Dietary profile of pediatric obstructive sleep apnea patients, effects of routine educational counseling, and predictors for outcomes.

Background: Dietary behavior is a main contributing yet modifiable factor to the body weight status of children and may be involved in the pathophysiology of childhood obstructive sleep apnea (OSA). This study aimed to investigate the dietary profile of pediatric OSA patients, effects of educational counseling after adenotonsillectomy, and predictor for disease resolution. Methods: This observational study included 50 pediatric OSA patients undergoing adenotonsillectomy with routine educational counseling (Group 1), 50 pediatric OSA patients undergoing adenotonsillectomy without formal educational counseling (Group 2), and 303 healthy children without OSA (Control). The three groups were matched by age. The consumption frequency of 25 food items/groups was assessed by the Short Food Frequency Questionnaire. Quality of life was evaluated by the OSA-18 questionnaire. Sleep architecture and OSA severity were measured by standard polysomnography. Between- and within-group comparisons were analyzed by non-parametric approaches and generalized estimating equations. Prediction of disease recovery was performed by multivariable logistic regression models. Results: Group 1 children consumed fruit drinks with sugar, vegetables, sweets, chocolate, rice, and noodles more frequently than Control Group children. At baseline, the distributions of sex, weight status, OSA-18 scores, and polysomnographic variables were comparable between Group 1 and Group 2. After a 12-month follow-up, Group 1 had better improvements in physical suffering, caregiver concerns, sleep architecture, and mean peripheral oxygen saturation compared to Group 2. Furthermore, Group 1 no longer had excessive consumption of fruit drinks with sugar, chocolate, and noodles; however, food consumption frequencies did not change significantly. Notably, younger age and reduced intake of butter/margarine on bread and noodles were independent predictors of cured OSA in Group 1. Conclusion: The present study preliminarily characterized an unhealthy dietary profile among pediatric OSA patients and suggested that routine educational counseling in addition to adenotonsillectomy yielded some clinical benefits. Certain items/groups of food frequencies may be associated with disease recovery and further investigations are warranted.

Physical fitness mediates and predicts for high blood pressure among children in relation to weight status.

Background: Pediatric hypertension contributes to adulthood hypertension and target organ damage. Obesity is a well-known predictor for pediatric hypertension; however, the relationship between physical fitness and blood pressure (BP) is unclear among children. This study aimed to compare the differences in demographics, anthropometrics, and physical fitness across BP subgroups and investigate whether physical fitness was related to pediatric hypertension independent of weight status. Methods: This quantitative, cross-sectional study investigated demographic, anthropometric, physical fitness, and BP measures among 360 healthy school-aged children. Continuous variables were compared across BP subgroups with the one-way analysis of variance. Mediation and moderation analyses were used to explore the mechanism. Multivariable regression models were used to assess independent associations for hypertension. Results: There were 177 (49.2%), 37 (10.3%), and 146 (40.6%) children in the normotensive, elevated BP, and hypertensive subgroups, respectively. The hypertensive subgroup had higher body mass index (BMI) and waist/height ratio percentiles and performed worse in 800-m run, standing long jump (SLJ), and 1-min sit-ups than the normotensive subgroup. Furthermore, the 800-m run percentile (total effect: ß = 0.308, standard error = 0.044, p < 0.001) and sit and reach percentile (total effect: ß = 0.308, standard error = 0.044, p < 0.001) mediated the relationship between the BMI percentile and systolic BP percentile; the SLJ percentile was directly associated with the diastolic BP percentile (ß,-0.197, 95% confidence interval,-0.298-0.097; p < 0.001). The parsimonious model of multivariable regression models revealed that the SLJ percentile (adjusted exp (ß), 0.992, 95% confidence interval, 0.985-0.999; p = 0.042) and BMI percentile (adjusted exp (ß), 1.024, 95% confidence interval, 1.016-1.032; p < 0.001) were two independent predictors for pediatric hypertension. Conclusion: Physical fitness mediates the relationship between anthropometric and BP measures. The SLJ percentile is associated with pediatric hypertension independent of the BMI percentile. Proactive screening and health promotion for not only healthy weight status but also good physical fitness may be beneficial for BP control among school-aged students.

The 3% Oxygen Desaturation Index is an Independent Risk Factor for Hypertension Among Children with Obstructive Sleep Apnea.

Background: Obstructive sleep apnea (OSA) and obesity are both directional risk factors of hypertension. Chronic intermittent hypoxemia (IH) is a commonly observed pathophysiological mechanism involved in multiple comorbidities of OSA. However, their interactions are not well understood in children. This study aimed to investigate the associations of IH indexes (oxygen desaturation index 3% [ODI3], mean peripheral oxygen saturation [SpO2], least SpO2, and time with SpO2 < 85%), apnea-hypopnea index, and weight status with hypertension in a sample of pediatric OSA patients. Methods: The medical records of 365 pediatric OSA patients were retrospectively reviewed in this cross-sectional study. Demographics, anthropometrics, standard in-laboratory polysomnography, and nocturnal blood pressure were collected. Multivariate logistic regression with forward selection was used to identify independent predictors of hypertension. Results: Multivariate logistic regression analysis showed that ODI3 (odds ratio [OR] = 1.02, 95% confidence interval [CI] = 1.01-1.03) and body mass index z-score (OR = 1.34, 95% CI = 1.12-1.60) were independent continuous predictors of pediatric hypertension, whilst severe OSA (OR = 2.62, 95% CI = 1.60-4.29) and overweight/obesity (OR = 2.63, 95% CI = 1.59-4.34) were independent categorical predictors. Traditional risk factors including male sex (OR = 2.33, 95% CI = 1.02-5.33), late childhood/adolescence (OR = 1.98, 95% CI = 1.01-3.88), and overweight/obesity (OR = 2.97, 95% CI = 1.56-5.67) combined with sleep hypoxemia (least SpO2 ≤ 95%) (OR = 2.24, 95% CI = 1.16-4.04) predicted hypertension (R 2 = 0.21) in the severe IH subgroup (n = 205), while the no/mild IH subgroup (n = 160) had an entirely different predictor, severe OSA (OR = 3.81, 95% CI = 1.49-9.74) (R 2 = 0.07). Conclusion: The close relationships among IH, overweight/obesity, and hypertension highlight the importance of reducing IH and body weight in children with OSA.

Can Anthropometry and Body Composition Explain Physical Fitness Levels in School-Aged Children?

Physical fitness (PF) is closely related to various health outcomes and quality of life among children. However, the associations between anthropometry, body composition (BC), and PF are not fully elucidated. This cross-sectional study aimed to investigate the associations between demographic metrics (age, sex), anthropometric measures (body mass index z-score (BMI z-score) waist/height ratio (WHtR)), BC parameters (body-fat percentage (BF%), muscle weight), and PF levels (800-m run, sit-and-reach, 1-min sit-ups, standing long jump) in school-aged children. Continuous variables were dichotomized by median splits. The results of 180 girls and 180 boys (mean age: 10.0 ± 0.7 years; mean BMI z-score: 0.366 ± 1.216) were analyzed. Multivariable linear regressions revealed that BF% (regression coefficient (B) = 3.4, 95% confidence interval (CI) = 2.5-4.3) was independently correlated with the 800-m run. Sex (B = 4.6, 95% CI = 3.0-6.3), age (B = 3.1, 95% CI = 1.9-4.3), and BMI z-score (B = -0.7, 95% CI = -1.4--0.1) were independently related to sit-and-reach. Age (B = 3.3, 95% CI = 2.0-4.7), BF% (B = -0.3, 95% CI = -0.4--0.2), and muscle weight (B = 0.7, 95% CI = 0.2-1.2) were independently associated with 1-min sit-ups. In addition to demography, anthropometry and BC provided additional information concerning some PF levels in school-aged children. Weight management and PF promotion should be addressed simultaneously in terms of preventive medicine and health promotion for children.

Are Body Composition Parameters Better than Conventional Anthropometric Measures in Predicting Pediatric Hypertension?

Body composition (BC) parameters are associated with cardiometabolic diseases in children; however, the importance of BC parameters for predicting pediatric hypertension is inconclusive. This cross-sectional study aimed to compare the difference in predictive values of BC parameters and conventional anthropometric measures for pediatric hypertension in school-aged children. A total of 340 children (177 girls and 163 boys) with a mean age of 8.8 ± 1.7 years and mean body mass index (BMI) z-score of 0.50 ± 1.24 were enrolled (102 hypertensive children and 238 normotensive children). Significantly higher values of anthropometric measures (BMI, BMI z-score, BMI percentile, waist-to-height ratio) and BC parameters (body-fat percentage, muscle weight, fat mass, fat-free mass) were observed among the hypertensive subgroup compared to their normotensive counterparts. A prediction model combining fat mass ≥ 3.65 kg and fat-free mass ≥ 34.65 kg (area under the receiver operating characteristic curve = 0.688; sensitivity = 66.7%; specificity = 89.9%) performed better than BMI alone (area under the receiver operating characteristic curve = 0.649; sensitivity = 55.9%; specificity = 73.9%) in predicting hypertension. In conclusion, BC parameters are better than anthropometric measures in predicting pediatric hypertension. BC measuring is a reasonable approach for risk stratification in pediatric hypertension.

High-Sensitivity C-Reactive Protein Elevation Is Independently Associated with Subclinical Renal Impairment in the Middle-Aged and Elderly Population-A Community-Based Study in Northern Taiwan.

This cross-sectional study aimed to investigate the associations between high-sensitivity C-reactive protein (hs-CRP) and renal impairment (RI) among middle-aged and elderly people. We collected and analyzed demographic, anthropometric, metabolic, and renal function data in a community-based population in Northern Taiwan. We excluded subjects with acute inflammation from this study and defined RI as the presence of urinary albumin-creatinine ratio 30-300 mg/g or an estimated glomerular filtration rate of <60 mL/min/1.73 m2. There were 131, 125, and 125 participants in the low (≤0.80 mg/L), middle (0.81-1.76 mg/L), and high (>1.77 mg/L) hs-CRP tertiles, respectively. hs-CRP exhibited significantly positive correlations with body mass index, waist circumference, systolic blood pressure, triglyceride, and fasting plasma glucose, and a negative correlation with high-density lipoprotein. The prevalence and odds ratio of RI significantly increased across hs-CRP tertiles from low to high, and this trend remained significant after adjusting for the conventional cardiometabolic risk factors. hs-CRP ≥ 1.61 mg/L in the total group and ≥2.03 mg/L in the elderly group accurately predicted RI (p = 0.01 and 0.03, respectively). These findings suggest that we should carefully evaluate the renal function for at-risk individuals with hs-CRP elevation.

Wide-Angle Coronary Bifurcation Stenotic Lesions Treated With One Drug-Eluting Stent and Sequential Balloon Technique: A Better Strategy?

BACKGROUND: Clinically significant bifurcation lesions account for up to 20% of percutaneous coronary intervention (PCI) procedures, and present technical challenges due to the potential for occlusion of the side branch vessel. Percutaneous coronary intervention using final kissing ballooning (FKB) plays a major role in treating bifurcation lesions, but sequential dilatation (SD) is a less complicated PCI technique with a shallower learning curve. Previous studies have shown no benefit of FKB over SD, but wide-angle (>70°) bifurcation lesions may respond differently to narrow-angle bifurcation lesions. METHODS: Retrospective analysis was carried out to compare outcomes of FKB and SD stenting specifically for wide-angle bifurcation lesions: 7,582 PCIs performed at a single medical centre between 1 January 2009 and 31 May 2016 were screened. This yielded 112 SD and 102 FKB cases for comparative analysis, which was conducted with respect to major adverse cardiac event (MACE)-free survival and target lesion revascularisation (TLR)-free survival rates. RESULTS: The comparative analysis was achieved using the log-rank test and presented as Kaplan-Meier curves. All baseline characteristics were balanced among the groups. The mean procedure and fluoroscopy times were significantly longer for patients with FKB than SD. Patients with SD had slightly better MACE and TLR rates than those with FKB in both the drug-eluting stent (DES) and bare metal stent (BMS) groups. In addition, patients with DES had slightly lower MACE and TLR rates than those with BMS in both the FKD and SD groups. Major adverse cardiac event-free survival and TLR-free survival rates were also slightly higher in patients with DES than those with BMS in both the FKD and SD groups. However, these differences were not statistically significant. CONCLUSIONS: These results suggest that the most applicable procedure for PCI of wide-angulated bifurcation stenosis would be a combination of DES and SD.

Effectiveness of a multi-faceted intervention among elementary school children.

Childhood obesity has been shown to be closely related to future obesity and comorbidities. As its prevalence and impact has increased significantly worldwide, researchers have focused on prevention and intervention. This study assessed a multifaceted intervention for elementary school children.A retrospective data collection with a cohort analysis was employed. A 16-week school-based intervention with nutritional intervention, physical activity, and behavioral education was designed and conducted by a multidisciplinary team for 1860 children aged 6 to 13 years. Basic information, anthropometrics, and physical fitness (PF) were recorded before and after the intervention. The differences compared with a reference group, and compared between subgroups, were analyzed.Significant favorable changes in body weight and composition were found. Children's height, weight, and muscle weight increased, whereas BMI, BMI z-score (zBMI), waist circumference, hip circumference, waist-hip ratio, waist-height ratio, body fat percentage, and visceral fat area decreased. Sit-ups and 800-m run time significantly improved. Girls exhibited a greater reduction in body weight outcomes; boys improved more in body composition and PF. Students with higher zBMI had a greater reduction in all anthropometrics; students with lower zBMI showed greater PF improvement, except for the 800-m run.The intervention improved weight measures, body composition, and PF. Subgroup differences suggested the need for sex- and weight-specific interventions.

Platelet MicroRNA 365-3p Expression Correlates with High On-treatment Platelet Reactivity in Coronary Artery Disease Patients.

PURPOSE: The expression level of platelet microRNAs (miRNAs) correlates with heart disease and may be altered by antiplatelet therapy. This study aims to assess whether certain miRNAs are associated with treatment response by platelets in patients who received percutaneous coronary intervention and antiplatelet therapy. The dynamic expression of certain miRNAs in patients receiving different antiplatelet regimens was also investigated. METHODS: Healthy subjects (N = 20) received no-stent or antiplatelet therapy (as control), and patients (N = 155) who underwent stent implant and received treatment regimens that included aspirin plus clopidogrel, ticagrelor, or cilostazol were included. The association of miR-96-5p, miR-495-3p, miR-107, miR-223-3p, miR-15a-5, miR-365-3p, and miR-339-3p levels with treatment response, SYNTAX score, and HTPR was determined. RESULTS: Of the different treatment regimens, ticagrelor was the most efficacious. At 24 h following drug administration, ROC analysis revealed that miR-339-3p and miR-365-3p had the highest sensitivity (74.3% and 90.0%, respectively) and specificity (71.4% and 93.3%) for detecting HTPR compared with the five other miRNAs. The SYNTAX score positively correlated with miR-223-3p and miR-365-3p levels at 24 h (P ≤ 0.006) and with miR-365-3p levels 7 days following drug administration (P = 0.014). The expression of all three miRNAs reached the highest levels in hyperresponsive (P2Y12 reaction unit < 85) followed by hyporesponsive (P2Y12 reaction unit ≥ 208) and then normoreactive. The normoreactive value was very close to that of controls. CONCLUSIONS: Our data suggest that miR-365-3p expression level correlates with the antiplatelet treatment response. CLINICAL TRIAL REGISTRATION: NCT02101437.

DAPT Plus Cilostazol is Better Than Traditional DAPT or Aspirin Plus Ticagrelor as Elective PCI for Intermediate-to-Highly Complex Cases: Prospective, Randomized, PRU-Based Study in Taiwan.

PURPOSE: Current treatment guidelines do not recommend different antiplatelet treatments for patients in different coronary risk categories; nor do they consider ethnic differences in responses to individual drugs. OBJECTIVES: We performed a prospective, single-blind, randomized, comparative study of Taiwanese patients with stable angina and scheduled stent implantation for intermediate-to-highly complex coronary lesions and compared the platelet reactivity unit (PRU) levels and 24-month outcomes of groups receiving three different antiplatelet treatments. METHODS: Patients (N = 334) were randomized into three treatment groups (aspirin + clopidogrel, aspirin + ticagrelor, or aspirin + clopidogrel + cilostazol) for 6 months of treatment and were then switched to aspirin only. PRU levels were determined 24 h, 7 days, and 1 month after stent implantation. Clinical outcomes and adverse events were recorded over 24 months. RESULTS: Clopidogrel treatment reached full effect after 1 month. Ticagrelor decreased PRU levels more than did clopidogrel but often to levels that increased the risk of hemorrhage. The addition of cilostazol to clopidogrel decreased PRU levels earlier and more strongly than clopidogrel alone but not as strongly as did ticagrelor. Ticagrelor treatment caused fewer major adverse cardiovascular events (MACEs) and more episodes of minor bleeding than the other two treatments. CONCLUSIONS: Clopidogrel appears safer than ticagrelor in Taiwanese patients with stable angina after stent implantation for intermediate-to-highly complex coronary lesions. The addition of cilostazol to clopidogrel may provide a more rapid decrease in PRU to therapeutic levels without increasing the risk of hemorrhage. CLINICAL TRIAL REGISTRATION NUMBER: NCT02101411.

Relation between fetuin-A levels and fibroblast growth factor 23 with the severity of coronary artery disease measured by SYNTAX scores.

Diagnosis of coronary artery disease requires invasive procedures that are typically not implemented until clinical warning signs are apparent. The goal of this study was to determine the relation between the severity of coronary artery disease, as measured by the SYNTAX scoring system, with serum levels of fetuin-A and fibroblast growth factor 23 (FGF23) in the general population. We enrolled 165 patients who had stable angina and positive results on treadmill testing or abnormal results on thallium myocardial perfusion scanning showing perfusion defects or who had acute coronary syndromes. Patients were hospitalized for evaluation with angiography, with or without simultaneous percutaneous coronary intervention. SYNTAX Scores were calculated on the basis of the results of coronary angiography using a computer-based questionnaire of sequential and interactive self-guided questions. Univariate analysis was used to assess the significance of fetuin-A and FGF23, as well as gender, age, body mass index, waist circumference, diabetes, hypertension, creatinine, total cholesterol, cholesterol, triglycerides, and high-sensitivity C-reactive protein in relation to cardiovascular disease severity. Multivariate analysis with stepwise regression was used to assess the utility of fetuin-A and FGF23 as predictors of SYNTAX Score. Multivariate analysis showed log fetuin-A to be a significant predictor of SYNTAX Score (p <0.0001) after controlling for the significant factors gender, cholesterol levels, and log high-sensitivity C-reactive protein. Log FGF23 values were also shown by multivariate regression to significantly predict SYNTAX Score (p = 0.0137) after controlling for gender, creatinine, cholesterol, and log high-sensitivity C-reactive protein. In conclusion, fetuin-A and FGF23 can be considered in combination with noninvasive test results as patient selection criteria for performing angiography.

An efficiency data envelopment analysis model reinforced by classification and regression tree for hospital performance evaluation.

As changes in the medical environment and policies on national health insurance coverage have triggered tremendous impacts on the business performance and financial management of medical institutions, effective management becomes increasingly crucial for hospitals to enhance competitiveness and to strive for sustainable development. The study accordingly aims at evaluating hospital operational efficiency for better resource allocation and cost effectiveness. Several data envelopment analysis (DEA)-based models were first compared, and the DEA-artificial neural network (ANN) model was identified as more capable than the DEA and DEA-assurance region (AR) models of measuring operational efficiency and recognizing the best-performing hospital. The classification and regression tree (CART) efficiency model was then utilized to extract rules for improving resource allocation of medical institutions.

A hybrid diagnosis model for determining the types of the liver disease.

The symptoms of liver diseases are not apparent in the initial stage, and the condition is usually quite serious when the symptoms are obvious enough. Most studies on liver disease diagnosis focus mainly on identifying the presence of liver disease in a patient. Not many diagnosis models have been developed to move beyond the detection of liver disease. The study accordingly aims to construct an intelligent liver diagnosis model which integrates artificial neural networks, analytic hierarchy process, and case-based reasoning methods to examine if patients suffer from liver disease and to determine the types of the liver disease.

An intelligent model for liver disease diagnosis.

OBJECTIVES: Liver disease, the most common disease in Taiwan, is not easily discovered in its initial stage; early diagnosis of this leading cause of mortality is therefore highly important. The design of an effective diagnosis model is therefore an important issue in liver disease treatment. This study accordingly employs classification and regression tree (CART) and case-based reasoning (CBR) techniques to structure an intelligent diagnosis model aiming to provide a comprehensive analytic framework to raise the accuracy of liver disease diagnosis. METHODS: Based on the advice and assistance of doctors and medical specialists of liver conditions, 510 outpatient visitors using ICD-9 (International Classification of Diseases, 9th Revision) codes at a medical center in Taiwan from 2005 to 2006 were selected as the cases in the data set for liver disease diagnosis. Data on 340 patients was utilized for the development of the model and on 170 patients utilized to perform comparative analysis of the models. This paper accordingly suggests an intelligent model for the diagnosis of liver diseases which integrates CART and CBR. The major steps in applying the model include: (1) adopting CART to diagnose whether a patient suffers from liver disease; (2) for patients diagnosed with liver disease in the first step, employing CBR to diagnose the types of liver diseases. RESULTS: In the first phase, CART is used to extract rules from health examination data to show whether the patient suffers from liver disease. The results indicate that the CART rate of accuracy is 92.94%. In the second phase, CBR is developed to diagnose the type of liver disease, and the new case triggers the CBR system to retrieve the most similar case from the case base in order to support the treatment of liver disease. The new case is supported by a similarity ratio, and the CBR diagnostic accuracy rate is 90.00%. Actual implementation shows that the intelligent diagnosis model is capable of integrating CART and CBR techniques to examine liver diseases with considerable accuracy. The model can be used as a supporting system in making decisions regarding liver disease diagnosis and treatment. The rules extracted from CART are helpful to physicians in diagnosing liver diseases. CBR can retrieve the most similar case from the case base in order to solve a new liver disease problem and can be of great assistance to physicians in identifying the type of liver disease, reducing diagnostic errors and improving the quality and effectiveness of medical treatment.