RESUMEN
AIM: This study aims to examine single nucleotide polymorphism (SNP) associations with cerebral palsy in a multi-variable analysis adjusting for potential clinical confounders and to assess SNP-SNP and SNP-maternal infection interactions as contributors to cerebral palsy. METHODS: A case control study including 587 children with cerebral palsy and 1154 control children without cerebral palsy. Thirty-nine candidate SNPs were genotyped in both mother and child. Data linkage to perinatal notes and cerebral palsy registers was performed with a supplementary maternal pregnancy questionnaire. History of known maternal infection during pregnancy was extracted from perinatal databases. RESULTS: Both maternal and fetal carriage of inducible nitric oxide synthase SNP rs1137933 were significantly negatively associated with cerebral palsy in infants born at less than 32 weeks gestation after adjustment for potential clinical confounders and correction for multiple testing (odds ratio 0.55, 95% confidence interval 0.38-0.79; odds ratio 0.57, 95% confidence interval 0.4-0.82, respectively). Analysis did not show any statistically significant SNP-SNP or SNP-maternal infection interactions after correction for multiple testing. CONCLUSIONS: Maternal and child inducible nitric oxide synthase SNPs are associated with reduced risk of cerebral palsy in infants born very preterm. There was no evidence for statistically significant SNP-SNP or SNP-maternal infection interactions as modulators of cerebral palsy risk.
Asunto(s)
Parálisis Cerebral/genética , Recien Nacido Prematuro , Óxido Nítrico Sintasa de Tipo II/genética , Polimorfismo de Nucleótido Simple , Factores de Confusión Epidemiológicos , Citocinas/genética , Femenino , Técnicas de Genotipaje , Edad Gestacional , Humanos , Recién Nacido , Masculino , Lectina de Unión a Manosa/genética , Metaloproteinasa 2 de la Matriz/genética , Metaloproteinasa 3 de la Matriz/genética , Madres , Análisis Multivariante , Trombofilia/genéticaRESUMEN
BACKGROUND: The incidence of severe perineal tears acquired during vaginal childbirth varies considerably across hospitals but its use as a safety and quality indicator is in jeopardy because of problems associated with accurate detection and recording. AIM: To understand and interpret time trends in the incidence of third- and fourth-degree perineal tears among women giving birth vaginally in 18 public maternity hospitals in South Australia, taking into account individualised risk factors for each birth. METHODS: The risk-adjusted probability of a third- and fourth-degree tear was estimated for each of 65,598 singleton vaginal births (2002-2008), using a previously published regression model. The risk factors for each birth included maternal age; parity and ethnicity; assistance with instruments and episiotomy; shoulder dystocia; and infant birthweight. Plots of 'excess' tears were generated to help identify maternity services where the observed incidence of severe trauma differed from the expectation estimated from the risk profiles. RESULTS: Three hospitals were identified at which there were systematically more tears than expected (given their risk profiles), and five hospitals were identified at which there were fewer tears. However, increased tearing at two hospitals coincided closely with improved advocacy for better detection and treatment of perineal tears (especially partial third-degree tears). CONCLUSION: Statistical process control methods provide a powerful means of investigating temporal variations in the incidence of outcomes like severe perineal tears. Third- or fourth- degree tears should be retained as a quality indicator of maternity services, but it is likely that many third-degree tears currently go undetected.
Asunto(s)
Canal Anal/lesiones , Maternidades/normas , Hospitales Públicos/normas , Laceraciones/epidemiología , Complicaciones del Trabajo de Parto/epidemiología , Perineo/lesiones , Indicadores de Calidad de la Atención de Salud/estadística & datos numéricos , Adulto , Femenino , Maternidades/estadística & datos numéricos , Hospitales Públicos/estadística & datos numéricos , Humanos , Incidencia , Laceraciones/etiología , Modelos Logísticos , Complicaciones del Trabajo de Parto/etiología , Evaluación de Procesos y Resultados en Atención de Salud , Embarazo , Estudios Retrospectivos , Ajuste de Riesgo , Factores de Riesgo , Australia del Sur/epidemiología , Índices de Gravedad del TraumaRESUMEN
BACKGROUND: The incidence of third- and fourth-degree perineal tears during vaginal childbirth is being increasingly used as an indicator of the safety and quality of maternity health care services. In order to make fair comparisons across hospitals it may be necessary to estimate a probability of severe perineal tears for every woman, taking into account her risk profile. METHODS: Logistic regression analysis was used to estimate the probabilities of third- and fourth-degree tears (n = 1582; 2.4%) in 65 598 vaginal births in publicly funded hospitals in South Australia, 2002-08. RESULTS: Maternal age ≥25 years, primiparity, instrument assistance, Asian or African ethnicity, shoulder dystocia and increasing birthweight were all identified as factors that are associated with an increased risk of perineal tears. In parous women, episiotomy, with or without instrument assistance, was associated with more tears; but among nulliparous women, episiotomy was associated with significantly fewer tears when forceps assistance was required, and showed little or no association with tearing in vacuum-assisted or unassisted (spontaneous) births. CONCLUSION: The probabilities of severe perineal tears in first-time mothers giving birth to a term singleton with cephalic presentation, may range from under 1% to over 40%, according to a minimalist model containing only predictors unrelated to clinical management. If instrument assistance and episiotomy are also incorporated into the modelling, the estimated probability of tearing may exceed 50% in high risk individuals. Such variation highlights the need for risk adjustment when comparing hospitals with respect to their incidence of third or fourth degree perineal tears.
Asunto(s)
Parto Obstétrico/efectos adversos , Episiotomía/efectos adversos , Complicaciones del Trabajo de Parto , Forceps Obstétrico/efectos adversos , Perineo/lesiones , Adolescente , Adulto , Benchmarking , Estudios Transversales , Femenino , Hospitales Públicos/normas , Humanos , Puntaje de Gravedad del Traumatismo , Edad Materna , Modelos Teóricos , Embarazo , Factores de Riesgo , Índice de Severidad de la Enfermedad , Australia del Sur , Adulto JovenRESUMEN
BACKGROUND: The Australian Carbohydrate Intolerance Study in Pregnant Women (ACHOIS) showed that treatment of pregnant women with mild gestational diabetes mellitus is beneficial for both women and their infants. It is still uncertain whether there are benefits of similar treatment for women with borderline gestational diabetes.This trial aims to assess whether dietary and lifestyle advice and treatment given to pregnant women who screen for borderline gestational diabetes reduces neonatal complications and maternal morbidities. DESIGN: Multicentre, randomised controlled trial. INCLUSION CRITERIA: Women between 240 and 346 weeks gestation with a singleton pregnancy, a positive oral glucose challenge test (venous plasma glucose ≥7.8 mmol/L) and a normal oral 75 gram glucose tolerance test (fasting venous plasma glucose <5.5 mmol/L and a 2 hour glucose <7.8 mmol/L) with written, informed consent.Trial entry and randomisation: Women with an abnormal oral glucose tolerance test (fasting venous plasma glucose ≥5.5 mmol/L or 2 hour glucose ≥7.8 mmol/L) will not be eligible and will be offered treatment for gestational diabetes, consistent with recommendations based on results of the ACHOIS trial. Eligible women will be randomised into either the 'Routine Care Group' or the 'Intervention Group'.Study groups: Women in the 'Routine Care Group' will receive routine obstetric care reflecting current clinical practice in Australian hospitals. Women in the 'Intervention Group' will receive obstetric care, which will include dietary and lifestyle advice, monitoring of blood glucose and further medical treatment for hyperglycaemia as appropriate.Primary study outcome: Incidence of large for gestational age infants. SAMPLE SIZE: A sample size of 682 women will be sufficient to show a 50% reduction in the risk of large for gestational age infants (alpha 0.05 two-tailed, 80% power, 4% loss to follow up) from 14% to 7% with dietary and lifestyle advice and treatment. DISCUSSION: A conclusive trial outcome will provide reliable evidence of relevance for the care of women with borderline glucose intolerance in pregnancy and their infants. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry - ACTRN12607000174482.
Asunto(s)
Diabetes Gestacional/terapia , Dieta , Macrosomía Fetal/prevención & control , Estilo de Vida , Educación del Paciente como Asunto/métodos , Adulto , Femenino , Prueba de Tolerancia a la Glucosa , Humanos , Recién Nacido , EmbarazoRESUMEN
BACKGROUND: A low-lying placenta detected at the mid-pregnancy ultrasound is commonly reported to warn against potential morbidity associated with placenta praevia. There is no information on what distance away from the internal cervical os is safe. AIMS: We examined whether a low-lying placenta not overlapping the cervical os in the second trimester increases the risk of obstetric complications and whether there is a cut-off point at which that increase occurs. METHODS: Adverse perinatal outcomes were examined prospectively in a cohort of women with a placenta 0-30 mm from the internal cervical os ('low-lying') at the routine mid-trimester ultrasound and compared to those with a placenta further away. Two composite outcomes of 'major' and 'minor' adverse events were predefined as primary outcome measures, requiring a sample size of 480 women with a low-lying placenta. Chi-square and Fisher's exact tests were used for statistical analysis. RESULTS: In 1662 pregnancies ('low-lying': n = 484; 'normal': n = 1178), there was no increase in composite adverse outcomes with a low-lying placenta and no cut-off distance within 30 mm from the cervical os at which risks increased. Postpartum haemorrhage ≥ 1000 mL was more frequent with a low-lying placenta (7.6% vs 4.7%, P < 0.05). CONCLUSIONS: Women with a low-lying placenta, not overlapping the cervical os, in mid-pregnancy are at no higher risk of adverse outcomes than those with a normally located placenta, except postpartum haemorrhage. This suggests that the high-risk label can be removed from pregnancies with a low-lying placenta not overlapping the cervical os in mid-pregnancy, reducing anxiety and resource utilisation.
Asunto(s)
Placenta Previa/diagnóstico por imagen , Resultado del Embarazo/epidemiología , Adulto , Femenino , Humanos , Placenta/diagnóstico por imagen , Embarazo , Segundo Trimestre del Embarazo , Estudios Prospectivos , Ultrasonografía Prenatal , Adulto JovenRESUMEN
BACKGROUND: Investment in strategies to promote 'a healthy start to life' has been identified as having the greatest potential to reduce health inequalities across the life course. The aim of this study was to examine social determinants of low birthweight in an Australian population-based birth cohort and consider implications for health policy and health care systems. METHODS: Population-based survey distributed by hospitals and home birth practitioners to >8000 women six months after childbirth in two states of Australia. Participants were women who gave birth to a liveborn infant in Victoria and South Australia in September/October 2007. Main outcome measures included stressful life events and social health issues, perceived discrimination in health care settings, infant birthweight. RESULTS: 4,366/8468 (52%) of eligible women returned completed surveys. Two-thirds (2912/4352) reported one or more stressful life events or social health issues during pregnancy. Women reporting three or more social health issues (18%, 768/4352) were significantly more likely to have a low birthweight infant (< 2500 grams) after controlling for smoking and other socio-demographic covariates (Adj OR = 1.77, 95% CI 1.1-2.8). Mothers born overseas in non-English speaking countries also had a higher risk of having a low birthweight infant (Adj OR = 1.85, 95% CI 1.2-2.9). Women reporting three or more stressful life events/social health issues were more likely to attend antenatal care later in pregnancy (OR = 2.06, 95% CI 1.3-3.1), to have fewer antenatal visits (OR = 2.17, 95% CI 1.4-3.4) and to experience discrimination in health care settings (OR = 2.69, 95% CI 2.2-3.3). CONCLUSIONS: There is a window of opportunity in antenatal care to implement targeted preventive interventions addressing potentially modifiable risk factors for poor maternal and infant outcomes. Developing the evidence base and infrastructure necessary in order for antenatal services to respond effectively to the social circumstances of women's lives is long overdue.
Asunto(s)
Recién Nacido de Bajo Peso , Acontecimientos que Cambian la Vida , Mujeres Embarazadas/psicología , Prejuicio , Atención Prenatal/organización & administración , Adulto , Estudios de Cohortes , Femenino , Política de Salud , Humanos , Recién Nacido , Sobrepeso/epidemiología , Embarazo , Atención Prenatal/psicología , Atención Prenatal/estadística & datos numéricos , Factores de Riesgo , Fumar/epidemiología , Australia del Sur/epidemiología , Victoria/epidemiología , Adulto JovenRESUMEN
OBJECTIVE: To compare the nature and prevalence of mental health problems, prevalence of suicidal ideation and behaviour, and health-related quality of life of 13-17-year-olds on remand with that of 13-17-year-olds in the general community. METHOD: Self reported questionnaires completed by 13-17-year-olds who were remanded in South Australia in 2008/9 (N = 159), 13-17-year-olds who participated in the Child and Adolescent Component of the National Survey of Mental Health and Well-being in Australia (N = 1283), and 13-17-year-olds who participated in the Western Australian Aboriginal Child Health Survey (N = 1100). Mental health problems were identified using the Youth Self-Report and the Strength and Difficulties Questionnaire. Health-related quality of life was assessed using the Child Health Questionnaire. RESULTS: A total of 50.0% (95% CI, 42.3-58.3) of adolescents on remand versus 18.9% of adolescents in the community scored above the recommended cut-off score on the Youth Self-Report. Among Indigenous adolescents, 55.8% (95% CI, 41.3-69.5) on remand versus 32.1% in the community scored above the recommended cut-off score on the Strength and Difficulties Questionnaire. Among those on remand, 19.1% (95% CI, 13.2-26.2) reported making a suicide attempt during the previous 12 months compared to 4.3% in the community. Health-related quality of life was significantly worse among adolescents on remand than adolescents in the community. These differences remained after adjusting for differences in the demographic characteristics of the two groups of adolescents. CONCLUSIONS: Compared with adolescents in the community, both Indigenous and non-Indigenous adolescents on remand experience a wide range of problems, including poorer mental and physical health, a higher prevalence of suicidal ideation and behaviour, greater family adversity, and poorer school attendance. This broad range of problems needs to be effectively addressed to enable adolescents on remand to become active and productive members of their communities.
Asunto(s)
Delincuencia Juvenil/estadística & datos numéricos , Trastornos Mentales/epidemiología , Prisioneros/estadística & datos numéricos , Calidad de Vida/psicología , Intento de Suicidio/estadística & datos numéricos , Adolescente , Niño , Comorbilidad , Femenino , Indicadores de Salud , Encuestas Epidemiológicas , Humanos , Delincuencia Juvenil/etnología , Delincuencia Juvenil/psicología , Masculino , Trastornos Mentales/diagnóstico , Trastornos Mentales/etnología , Trastornos Mentales/psicología , Grupos de Población/psicología , Grupos de Población/estadística & datos numéricos , Prisioneros/psicología , Psicometría/estadística & datos numéricos , Carencia Psicosocial , Valores de Referencia , Australia del Sur , Intento de Suicidio/etnología , Intento de Suicidio/psicología , Encuestas y Cuestionarios , Australia OccidentalRESUMEN
BACKGROUND: The federal government wants outcomes of hospital care to be made publicly available. League tables based on single clinical indicators are misleading, largely because of their inability to take case-complexity into account. AIM: To demonstrate the application of a graphical tool (the risk-adjusted funnel plot) to the comparison of clinical outcomes across hospitals; and its advantages over league tables. METHODS: We looked at publicly available data on intact lower genital tract (ILGT), for all hospitals in New South Wales at which more than 200 births occurred in 2005. The 'excess' percentage of women at each hospital with an ILGT following a vaginal birth, was calculated after adjustment for instrumental assistance, the use of epidural analgesia/anaesthesia, the use of induction/augmentation, and the number of births per annum. RESULTS: In 2005, ILGT ranged from 13.1 to 55.8%. A plot of ILGT against vaginal births per annum (a funnel plot) revealed huge heterogeneity among hospitals, and an inverse association with the number of births per annum. A residual funnel plot, constructed from the differences between observed and expected ILGT identified four hospitals (three public and one private) with consistently better ILGT than expected - and four public hospitals with ILGT consistently worse than expected. Some of these hospitals were not located at the extremes of the league table. CONCLUSION: The risk-adjusted funnel plot is a useful graphical tool which may overcome the shortcomings of league tables. We need to become more sophisticated in our use of clinical indicators for comparing hospital performances.
Asunto(s)
Parto Obstétrico/efectos adversos , Hospitales/normas , Modelos Estadísticos , Evaluación de Resultado en la Atención de Salud , Perineo/lesiones , Indicadores de Calidad de la Atención de Salud/estadística & datos numéricos , Parto Obstétrico/estadística & datos numéricos , Femenino , Humanos , Nueva Gales del Sur , EmbarazoRESUMEN
In the post-Diabetes Control and Complications Trial (DCCT) and Epidemiology of Diabetes Interventions and Complications (EDIC) era of type 1 diabetes mellitus (T1DM) care, glycosylated hemoglobin (A1C) has enjoyed primacy as the clinical outcome variable (1). Metabolic control as defined by A1C, however, only defines approximately 25% of the risk of subsequent microvascular pathology (2) and, hence, other glycemic outcome variables are also being canvassed as being of potential significance. Transcription-regulating actions of glucose and the phenomenon of "metabolic memory" have recently become recognized (3,4). Simultaneously, ambulant continuous glucose monitoring (CGM) technologies have become available. The convergence of these factors has increased the interest in the impacts of fluctuations in glycemia, otherwise known as glycemic variation (GV). Initially, this interest was focused upon the effects of post-prandial glycemic excursions (5), but more recently, associations of GV and oxidative stress, microvascular pathology (6), and GV prediction associated with closedloop insulin delivery (7) have evolved. Notwithstanding this emerging interest in GV, there still remains a lack of consensus as to the importance of GV, in what circumstances it can be measured, and what GV metrics are best suited for various purposes. The aim of this review is to discuss these 3 key areas: Why measure GV? When can GV be meaningfully assessed?; How to measure to GV?.
Asunto(s)
Glucemia/metabolismo , Diabetes Mellitus Tipo 1/metabolismo , Hemoglobina Glucada/metabolismo , Animales , Glucemia/análisis , Diabetes Mellitus Tipo 1/sangre , Hemoglobina Glucada/análisis , Humanos , Monitoreo Ambulatorio/métodos , Monitoreo Ambulatorio/normasRESUMEN
OBJECTIVE: To explore the experiences, expectations, and motivations of parents/caregivers of children with otitis media who were booked to undergo tympanostomy tube insertion. METHOD: A cross-sectional cohort study was conducted using semistructured interviews with 39 parents. Interviews were conducted via telephone and analyzed for key themes. RESULTS: Three themes emerged that incorporated a range of subthemes: (1) the impact of the child's underlying condition on the family, (2) the cues and prompts that influenced parents to seek intervention, and (3) the parents' expectations of the health-care system. The child's otitis media disrupted the day-to-day functioning of the family and the child's well-being, but despite this, the families found ways to adapt and cope. Parents were influenced by their friends, family, and medical practitioners when making treatment decisions and had differing expectations of the health-care system. CONCLUSION: Parents need support during their child's illness to help with pressures placed on the family and also in making health-care decisions for their child. Clinicians should consider these issues when discussing treatment options with parents.
RESUMEN
BACKGROUND: The association among gallbladder disease, cholecystectomy, and pancreatic cancer is unclear. Moreover, time interval between gallbladder disease or cholecystectomy and pancreatic cancer diagnosis is not considered in most previous studies. AIM: To quantify the association among gallbladder disease, cholecystectomy, and pancreatic cancer, considering time since first diagnosis of gallbladder disease or cholecystectomy. METHODS: We used data from nine case-control studies within the Pancreatic Cancer Case-Control Consortium, including 5760 cases of adenocarcinoma of the exocrine pancreas and 8437 controls. We estimated pooled odds ratios and the corresponding 95% confidence intervals by estimating study-specific odds ratios through multivariable unconditional logistic regression models, and then pooling the obtained estimates using fixed-effects models. RESULTS: Compared with patients with no history of gallbladder disease, the pooled odds ratio of pancreatic cancer was 1.69 (95% confidence interval, 1.51-1.88) for patients reporting a history of gallbladder disease. The odds ratio was 4.90 (95% confidence interval, 3.45-6.97) for gallbladder disease diagnosed <2 years before pancreatic cancer diagnosis and 1.11 (95% confidence interval, 0.96-1.29) when ≥2 years elapsed. The pooled odds ratio was 1.64 (95% confidence interval, 1.43-1.89) for patients who underwent cholecystectomy, as compared to those without cholecystectomy. The odds ratio was 7.00 (95% confidence interval, 4.13-11.86) for a surgery <2 years before pancreatic cancer diagnosis and 1.28 (95% confidence interval, 1.08-1.53) for a surgery ≥2 years before. CONCLUSIONS: There appears to be no long-term effect of gallbladder disease on pancreatic cancer risk, and at most a modest one for cholecystectomy. The strong short-term association can be explained by diagnostic bias and reverse causation.
Asunto(s)
Colecistectomía/efectos adversos , Enfermedades de la Vesícula Biliar/cirugía , Neoplasias Pancreáticas/etiología , Anciano , Estudios de Casos y Controles , Femenino , Enfermedades de la Vesícula Biliar/patología , Humanos , Agencias Internacionales , Masculino , Persona de Mediana Edad , Neoplasias Pancreáticas/patología , Pronóstico , Factores de RiesgoRESUMEN
We conducted a population-based case-control study on the relation of menstrual and reproductive factors and hormone use with pancreatic cancer risk among female participants of the SEARCH program study. We evaluated 367 cases of ductal adenocarcinoma and 821 controls for associations between pancreatic cancer and age at menarche, age at menopause, number of pregnancies, exogenous hormone use, and history of gynaecologic surgery. Among directly interviewed and proxy participants, we found a statistically significant association for having age of menarche at 11 years or younger compared with menarche at ages 12-13 years (OR = 1.8, 95% CI = 1.1-3.1). This result was consistent, but not statistically significant, among three of the four studies analyzed, and when the data were analyzed separately by response status (direct vs. proxy interviews). No other menstrual or reproductive factors were associated with pancreatic cancer risk in this study. In conclusion, earlier age at menarche may be weakly associated with pancreatic cancer, but it seems unlikely that menstrual and reproductive factors play more than only a minor role in pancreatic cancer. Additional analyses in large prospective study populations and in pooled studies may help to clarify remaining inconsistencies.
Asunto(s)
Carcinoma Ductal Pancreático/epidemiología , Menarquia , Neoplasias Pancreáticas/epidemiología , Historia Reproductiva , Adolescente , Adulto , Estudios de Casos y Controles , Niño , Femenino , Humanos , Menopausia , Ciclo Menstrual , Persona de Mediana Edad , Factores de Riesgo , Adulto JovenRESUMEN
OBJECTIVE: To assess the applicability of risk-adjusted sequential control charts using the Paediatric Index of Mortality version 2 for monitoring of the quality of paediatric intensive care. DESIGN: Observational study. SETTING: A registry of patient admissions to paediatric intensive care units (PICUs) in Australia and New Zealand. PATIENTS: A total of 10,710 patients admitted to eight PICUs during a 24-month period. MEASUREMENTS AND RESULTS: A series of risk-adjusted control charts was created for each PICU. Modified sequential probability ratio tests were used to test the hypothesis that the PICUs being monitored were 'out of control', where loss of control was arbitrarily defined as the odds of death exceeding twice the odds of dying as estimated by PIM2. In 24 months of monitoring, there was one alarm signal, suggesting the odds of deaths had doubled, and there was one signal, in another PICU, suggesting the odds of death had halved. CONCLUSIONS: The major advantage of risk-adjusted sequential control charts is that the technique allows unit performance to be monitored continuously over time, rather than intermittently, with the aim of rapidly detecting a change in performance as soon as possible after it occurs. This technique is suitable for continuously screening for a change in outcome within a PICU over time and complements other methods of monitoring the quality of paediatric intensive care.
Asunto(s)
Benchmarking/métodos , Mortalidad Hospitalaria , Unidades de Cuidado Intensivo Pediátrico/estadística & datos numéricos , Evaluación de Resultado en la Atención de Salud/estadística & datos numéricos , Australia , Preescolar , Humanos , Registros Médicos/estadística & datos numéricos , Nueva Zelanda , Sistema de Registros , Factores de RiesgoRESUMEN
This study examined the dynamic relationships between child, parenting, and family-related predictor variables and early childhood externalising behaviour problems. A community sample of 395 Australian children was followed longitudinally, and assessed at 4 and 6 years with the Child Behavior Checklist, Teacher Report Form, and standard measures of parenting, temperament, and familial adversity. Variables based on the average scores across the two assessments and the change in scores between assessments were utilised as predictors of parent-reported and teacher-reported externalising behaviour problems at age 6. It was hypothesised that both higher average scores and more detrimental changes in scores, would independently predict externalising problems at age 6. Multivariable analyses found that the presence of parent-reported child externalising problems in six-year-olds were predicted by: (i) the presence of parent-reported child externalising problems at age 4, (ii) higher average "teacher-reported child externalising behaviour," "inflexible temperament," "non-persistent temperament," and "over-reactive parenting," and (iii) an increased "inflexible temperament" score between age 4 and age 6. The presence of teacher-reported child externalising problems at age 6 was predicted by higher average "parent-reported child externalising behaviour," and "over-reactive parenting." The results provide further evidence of the adverse impact of continuing high levels of temperament difficulties and over-reactive parenting on externalising behaviour in early childhood. However, contrary to expectations, the contribution of including the dynamic change scores was limited.
Asunto(s)
Trastornos de la Conducta Infantil/psicología , Familia/psicología , Relaciones Padres-Hijo , Responsabilidad Parental , Trastornos de la Conducta Infantil/diagnóstico , Trastornos de la Conducta Infantil/epidemiología , Preescolar , Depresión/diagnóstico , Depresión/epidemiología , Depresión/psicología , Femenino , Humanos , Masculino , Estudios Prospectivos , Apoyo Social , Encuestas y Cuestionarios , Temperamento , Factores de TiempoRESUMEN
OBJECTIVES: We aimed to evaluate the relation between menstrual and reproductive factors, exogenous hormones, and risk of pancreatic cancer (PC). METHODS: Eleven case-control studies within the International Pancreatic Cancer Case-control Consortium took part in the present study, including in total 2838 case and 4748 control women. Pooled estimates of odds ratios (ORs) and their 95% confidence intervals (CIs) were calculated using a 2-step logistic regression model and adjusting for relevant covariates. RESULTS: An inverse OR was observed in women who reported having had hysterectomy (ORyesvs.no, 0.78; 95% CI, 0.67-0.91), remaining significant in postmenopausal women and never-smoking women, adjusted for potential PC confounders. A mutually adjusted model with the joint effect for hormone replacement therapy (HRT) and hysterectomy showed significant inverse associations with PC in women who reported having had hysterectomy with HRT use (OR, 0.64; 95% CI, 0.48-0.84). CONCLUSIONS: Our large pooled analysis suggests that women who have had a hysterectomy may have reduced risk of PC. However, we cannot rule out that the reduced risk could be due to factors or indications for having had a hysterectomy. Further investigation of risk according to HRT use and reason for hysterectomy may be necessary.
Asunto(s)
Neoplasias Pancreáticas , Estudios de Casos y Controles , Femenino , Humanos , Modelos Logísticos , Oportunidad Relativa , Factores de RiesgoRESUMEN
This study compared the latency of pattern reversal visual evoked potentials (VEP) of 36-month old children exposed to opioid pharmacotherapy in utero to that of a group of non-exposed children. Pregnant women were enrolled as part of an open-label non-randomised flexible dosing longitudinal study. Participants were 21 children whose mothers were treated with buprenorphine- (n=11) or methadone-pharmacotherapy (n=10) during pregnancy, and 15 children not exposed to opioids in pregnancy. One-way between groups analyses of variance (ANOVA) were conducted to test the statistical significance of differences between the mean latencies of the peak response to two different sized checkerboard patterns (48' and 69' of retinal arc). Standard multiple regression analyses were conducted to determine whether there was a significant relationship between group status and VEP latencies after adjusting for the effect of covariates. VEP latencies ranged from 98 to 112 milliseconds (ms) for checks of 48' arc, and from 95 to 113ms for checks of 69' arc. Latencies were comparable across groups. After adjusting for covariates children prenatally exposed to methadone or buprenorphine did not differ significantly from non-opioid exposed children in their responses to either check size. Nor were there any significant differences in VEP latencies between children prenatally exposed to methadone and children prenatally exposed to buprenorphine. Head circumference (HC) was significantly associated with P100 latencies for both check sizes. Data from this controlled, non-randomised study suggest that neither buprenorphine nor methadone appear to have any long-term effects on visual maturity assessed at 36months of age.
Asunto(s)
Buprenorfina/efectos adversos , Corteza Cerebral/efectos de los fármacos , Corteza Cerebral/fisiopatología , Potenciales Evocados Visuales/efectos de los fármacos , Metadona/efectos adversos , Narcóticos/efectos adversos , Efectos Tardíos de la Exposición Prenatal/fisiopatología , Preescolar , Femenino , Humanos , Lactante , Estudios Longitudinales , Masculino , Estimulación Luminosa , EmbarazoRESUMEN
Despite much discussion regarding the clinical relevance of glycemic variation (GV), little discourse has addressed the properties of the data set from which it is derived. We aimed to assess the minimum duration of data required using continuous glucose monitoring (CGM) that most closely approximates to a gold standard 90-day measure. Data from 20 children and adolescents with type 1 diabetes were examined. All participants had CGM data sets of 90 days duration, from which standard deviation (SD), coefficient of variation (CV), mean amplitude of glycemic action (MAGE), and continuous overlapping net glycemic action (CONGA1-8) were calculated for the overall period and then investigational periods of 2, 4, 6, 12, 18, 24, and 30 days. The percentage difference between each measure and the overall measure per time period was assessed. As the duration of the CGM data set increased, the percentage error continued to decrease, giving a metric approximating more closely toward the overall measure. Median SD and CV differed from the overall measure by <10% at 12 days duration. The frequency of interruptions to the CGM trace rendered MAGE and CONGA unreliable, hence SD and CV were reported. We suggest that data sets used to infer GV should be of a minimum duration of 12 days. MAGE and CONGA exhibit poor performance in the setting of frequent trace interruption.
RESUMEN
Several prospective cohort studies have demonstrated that childhood lead levels show small but statistically significant adjusted associations with subsequent development in later childhood and adolescence. The Port Pirie Cohort study is one of the few prospective cohort studies to follow participants into adulthood. This paper reviews all childhood and adulthood findings of the Port Pirie Cohort study to date. Cohort members (initially, 723 infants born in/around the lead-smelting town of Port Pirie) showed a wide range of childhood blood lead levels, which peaked around 2 years old (M=21.3µg/dL, SD=1.2). At all childhood assessments, postnatal lead levels - particularly those reflecting cumulative exposure - showed small significant associations with outcomes including cognitive development, IQ, and mental health problems. While associations were substantially attenuated after adjusting for several childhood covariates, many remained statistically significant. Furthermore, average childhood blood lead showed small significant associations with some adult mental health problems for females, including anxiety problems and phobia, though associations only approached significance following covariate adjustment. Overall, there did not appear to be any age of greatest vulnerability or threshold of effect, and at all ages, females appeared more susceptible to lead-associated deficits. Together, these findings suggest that the associations between early childhood lead exposure and subsequent developmental outcomes may persist. However, as the magnitude of these effects was small, they are not discernible at the individual level, posing more of a population health concern. It appears that the combination of multiple early childhood factors best predicts later development. As such, minimising lead exposure in combination with improving other important early childhood factors such as parent-child interactions may be the best way to improve developmental outcomes.
Asunto(s)
Discapacidades del Desarrollo/inducido químicamente , Exposición a Riesgos Ambientales , Intoxicación por Plomo/epidemiología , Intoxicación por Plomo/etiología , Preescolar , Estudios de Cohortes , Femenino , Humanos , Plomo/sangre , Intoxicación por Plomo/sangre , Masculino , Relaciones Padres-HijoRESUMEN
BACKGROUND: Given that relatively little is known about the development of resilience in early childhood, this longitudinal study aimed to identify preschool resource factors associated with young children's mental health resilience to family adversity. METHODS: A community sample of 474 young Australian children was assessed in preschool (mean age 4.59 years, 49% male), and again two years later after their transition into formal schooling. At each assessment, standard questionnaires were used to obtain ratings from both parents and teachers about the quality of children's relationships with parents and teachers, children's self-concept and self-control, mental health (Strengths and Difficulties Questionnaire), and family adversities (including stressful life events and socioeconomic disadvantage). RESULTS: Greater exposure to cumulative family adversities was associated with both greater teacher- and parent-reported child mental health difficulties two years later. Multiple methodologies for operationalizing resilience were used to identify resources associated with resilient mental health outcomes. Higher quality child-parent and child-teacher relationships, and greater child self-concept and self-control were associated with resilient mental health outcomes. With the exception of child-teacher relationships, these resources were also prospective antecedents of subsequent resilient mental health outcomes in children with no pre-existing mental health difficulties. Child-parent relationships and child self-concept generally had promotive effects, being equally beneficial for children facing both low- and high-adversity. Child self-control demonstrated a small protective effect on teacher-reported outcomes, with greater self-control conferring greater protection to children under conditions of high-adversity. CONCLUSIONS: Findings suggest that early intervention and prevention strategies that focus on fostering child-adult relationship quality, self-concept, and self-control in young children may help build children's mental health and their resilience to family adversities.
RESUMEN
Low-level environmental lead exposure during childhood is associated with poorer emotional/behavioural functioning in later childhood and adolescence. Scarce research has examined whether these apparent effects persist into adulthood. This study is the first to examine prospective associations between lead exposure across early childhood and several common adult mental health problems. Childhood data (including blood lead concentrations) and adult data (from mental health questionnaires and psychiatric interviews) were available for 210 participants (44% males, mean age=26.3 years) from the Port Pirie cohort study (1979-1982 birth cohort). Participants had a mean childhood (to 7 years) average blood lead concentration of 17.2µg/dL. Among females, childhood blood lead showed small significant positive associations with lifetime diagnoses of drug and alcohol abuse and social phobia, and with anxiety, somatic and antisocial personality problems. For example: for a 10µg/dL blood lead increase, females were 2.84 times (95% CI 1.10, 7.30) more likely to have an alcohol abuse diagnosis. However, adjustment for childhood covariates - particularly stimulation within the home environment - rendered these associations non-significant. No significant or sizeable unadjusted or adjusted associations were seen for males. The associations between early lead exposure and emotional/behavioural functioning in children might persist into adulthood, at least for females. However, it is unclear whether such results arise from residual confounding, or other mechanisms. Interventions that focus on improving the childhood home environment may have a long-term positive impact on adult mental health outcomes. However, more prospective research using large and representative samples is needed to substantiate these results.