Relationship between childhood obesity cut-offs and metabolic and vascular comorbidities: comparative analysis of three growth standards.

BACKGROUND: To compare the association between metabolic and vascular comorbidities and the body mass (BMI)-for-age cut-off criteria from three growth standards [Centers for Disease Control and Prevention (CDC), 2000; World Health Organization (WHO), 2007; Spanish Reference Criteria (Carrascosa Lezcano et al., 2008)] that are used to define being overweight and obese in childhood. METHODS: A prospective study was conducted in 137 children (aged 8-16 years). Based on BMI-for-age Z-scores according to WHO cut-offs, 59 participants were obese, 35 were overweight and 43 were normal-weight. All participating children were subsequently reclassified applying the CDC and Spanish Reference Criteria. Blood pressure (BP), biochemical variables and vascular parameters (stiffness and intima-media thickness) were analysed. RESULTS: According to WHO and CDC references, 48% and 43% of the children, respectively, were categorised as obese, whereas 16% were considered as obese using the Spanish Reference Criteria. Applying WHO criteria, obese children showed significantly higher levels of insulin, homeostasis model assessment index and most vascular parameters, as well as lower high-density lipoprotein (HDL)-cholesterol than overweight children. Moreover, overweight children showed higher BP, insulin and uric acid, and lower HDL-cholesterol than normal weight children. The CDC criteria yielded similar results, although with fewer differences between obese and overweight children. Applying Spanish criteria, the differences between obese and overweight children disappeared. CONCLUSIONS: WHO and CDC BMI-for-age references and cut-offs are useful for defining obesity and being overweight in children because they clearly identify metabolic and vascular comorbidities. The Spanish Reference Criteria underdiagnose obesity because overweight children show comorbidities typical of the obese.

Early decision of gastrostomy tube insertion in children with severe developmental disability: a current dilemma.

BACKGROUND: Healthcare professionals advise earlier gastrostomy tube (GT) placement in children with severe developmental disabilities, marked feeding disorders and risk of malnutrition. However, a delay in acceptance of the procedure by parents/guardians is the main issue of concern. The present study aimed to investigate: (i) parental satisfaction with GT feeding and whether parents/carers would have accepted earlier GT placement and (ii) subsequent nutritional outcome. METHODS: Twenty-six disabled children with GT feeding were recruited. A structured questionnaire by telephone was held to record parental perceptions of GT (mainly satisfaction with the procedure and patient management). A longitudinal study (0-6-12 months) was designed to investigate anthropometric outcome. Nutritional support mode and GT-related complications were also recorded. RESULTS: Parents/carers showed high satisfaction (91%). Furthermore, 87% recognised that they would have accepted an earlier placement of the GT had they anticipated the outcome. Patient management and family dynamics were acknowledged to have improved considerably. Nutritional assessment demonstrated a positive trend in weight. Height improved significantly 6 months post-implantation (P = 0.045) and body mass index improved after 12 months (P = 0.041). When comparing nutritional outcome between children in whom the GT was placed before 18 months of age and those in whom it was placed later, height was found to improve significantly in the first group (P = 0.04). CONCLUSIONS: Most parents/carers would have agreed to earlier GT feeding of their children had they acknowledged its benefits. Although nutritional response was positive, it was less so than the parental perception of children's overall improvement. Growth rates were significantly increased when GT was placed early in life.

Arteriovenous fistula of the vertebral artery in a female infant with hypotonia and cephalocorporal disproportion.

BACKGROUND: Congenital arteriovenous fistulas are exceptional in childhood and imply a therapeutic challenge. CASE REPORT: A 9-month-old female infant was studied for cephalocorporal disproportion, hypotonia, progressive muscular atrophy and hyperreflexia. Computed tomography of the brain and electroencephalography were normal. Electromyographic patterns suggested proximal myopathic involvement. A continuous murmur with systolic reinforcement was audible in the neck. Angioresonance detected intracranial aneurysmal dilatations behind the bulbo-medullary junction and cerebral panangiography evidenced a direct vertebrovertebral fistula with extra- and intra-cranial varices and extreme medullary compression. Occlusion of the afferent vessel to the aneurismal sack was successfully achieved with a mixture of Histoacryl and 75% lipiodol via a microcatheter. CONCLUSION: Clinical signs of an arteriovenous fistula may be atypical. Considerable cephalocorporal disproportion and a bruit in the cervical or retromastoidal regions must suggest its existence. Complete obliteration with endovascular embolization permits somatic and neurological recovery.

Prenatal and neonatal risk factors for the development of enamel defects in low birth weight children.

OBJECTIVE: To analyse the influence of several prenatal and neonatal risk factors in the development of enamel defects in low birth weight children. SUBJECTS AND METHODS: Children between 4 and 5 years of age (n = 102) were classified into: Group 1) 52 low birth weight (<2500 g); Group 2) 50 normal birth weight (>or=2500 g). Medical history, prenatal and neonatal variables were collected. Enamel defects were evaluated with the modified Developmental Defects of Enamel Index. RESULTS: The prevalence of hypoplasia and average number of affected teeth were significantly higher in group 1 than in group 2 (59.6%vs 16% and 1.6 vs 0.3 respectively). Low gestational age was linked to a higher prevalence of hypoplastic (P = 0.027) and combined defects (P = 0.001). Children with neonatal risk factors (low Apgar scores, parenteral nutrition, orotracheal intubation, mechanical ventilation and acidosis) developed defects more frequently (P < 0.05). Defects were symmetrically distributed in children who were not intubated; in those who required intubation they concentrated on the left maxillary teeth (P < 0.05). Smoking during pregnancy, young maternal age and multiple birth were significantly associated to developmental defects. CONCLUSIONS: The prevalence of enamel defects in primary dentition is significantly influenced by birth weight, gestational age and several systemic factors. Orotracheal intubation probably plays an important role as a result of laryngoscope trauma on the maxilla.

The effects on offspring of premature parturition.

The time of parturition defines the length of the intrauterine period of fetal life, a requisite to achieve adequate adaptation to the external environment. Immaturity, a condition whose severity is inversely related to the length of pregnancy, is the main determinant of the increased morbidity and mortality associated with preterm birth. Despite great advances in medical technology and expertise, mainly after the introduction of the neonatal intensive care units, only one- to two-thirds of infants from the subsets with lower birthweight/gestational age reach survival at discharge. Distinct major neurological and sensorial sequelae, including cerebral palsy, retinopathy of prematurity, and hearing loss, as well as reduced neuropsychological abilities, leading to deficient academic achievement and deterioration of several aspects of health status, are still highly prevalent among the most immature children. Interestingly, decreasing mortality rates, which are not followed by detectable increases of disability, are being observed in recent years. Future advances may be expected from clinical and basic research on uterine contractility and cervical softening. Also, changes in reproductive technology procedures, a main factor in the incidence of multiple pregnancies, and a more refined approach to obstetric care, compose some of the clinical interventions which may reduce the problem.

Copper, iron, and zinc contents in human milk during the first three months of lactation: a longitudinal study.

The aim of the study has been to analyze the evolution of copper, iron, and zinc contents in human milk, from colostrum to the third postpartum month, following a longitudinal design, under specific conditions of sample collection and to apply an analytical procedure previously optimized to reduce any variation outside physiological lactation. The copper, iron, and zinc concentrations in 144 milk samples from 39 healthy puerpera women, were analyzed in five stages by flame atomic absorption spectrometry, following a standardized protocol. Copper presented a gradual decrease from 0.38 mg/L to 0.19 mg/L by the 90th day; the particular analysis from colostrum to transitional milk manifested the following two tendencies. Whereas an increase from 0.19 to 0.42 mg/L was observed in some women, a decrease from 0.53 to 0.45 mg/L was detected in others; therefore, copper presented two significant behaviors in the evolution from colostrum to transitional milk. In both cases, the evaluated changes were significant. The iron content varied from 0.56 to 0.40 mg/L by the 30th day, remaining constant until the first trimester concluded. The average zinc concentration decreased sharply from 7.99 to 3.3 mg/L on d 15; the rate of decrease slowed down gradually until 1.05 mg/L.

A study of factors that may influence the determination of copper, iron, and zinc in human milk during sampling and in sample individuals.

The aim of this study was to establish the possible effects of the sampling protocol (between-breast, within-feed, and diurnal differences) and the mother's personal factors (age, parity, iron supplementation, smoking habits, and lactation period) on the copper, iron, and zinc contents in human milk. One hundred thirty-six human milk samples identified by their origin and sampling conditions were analyzed. The samples were obtained from the 2nd to 15th d postpartum from 62 women. The data on the individuals required for the study were available. Mineral determinations were analyzed by flame atomic absorption spectrometry following a standardized protocol. The results showed that iron contents were higher in hind-milk samples and at the nighttime feeding and depended on the breast from which the sample was taken. The copper and zinc concentrations showed no significant variations. There was no significant relationship among the mothers' age, parity, smoking habits, iron supplementation, and copper content. Milk from older women had lower zinc contents than that of younger women. Increased amounts of iron were found in multiparous women. Between colostrum and transitional milk, a sharp decrease in zinc content was observed, whereas copper and iron contents remained constant. All of these results make it clear that standardized sampling protocols are needed in order to obtain comparable values.

[Haemophilus influenza type b invasive disease in the Community of Valencia. Study Group on Invasive Diseases]. / Enfermedad invasora por Haemophilus influenzae tipo b en la Comunidad Valenciana. Group de Estudio de Enfermedades Invasoras.

The objective of this study was to estimate the incidence of systemic Haemophilus influenzae type b (Hib) disease in the Valencian Community, Spain, and to study the microbiological characteristics of the strains. Prospective, active surveillance of children in the Valencian Community. Data were obtained from microbiology laboratories and paediatricians. A case was considered when a child younger than 15 years of age had clinical invasive disease and a Haemophilus influenzae (Hi) was isolated from a normally sterile site, or when a positive capsular antigen was identified with a compatible Gram strain. In the first year of surveillance, starting on December 1, 24 cases were identified. Of the 20 strains studied in our laboratory, 19 were serotype b and one non typable. 75% of the strains were beta-lactamase positive. Meningitis was the most frequent clinical presentation. All children were less than five, and 51.2% were less than one year of age. The mortality was 8.3%. For unvaccinated children less than 5 years the estimated incidence of invasive disease was 18.2/100,000 and of meningitis 14.0/100,000. The incidence of Hib invasive disease in unvaccinated children justifies the universal Hib vaccine programme in the Valencian Community.

Injured workers' perceptions of case management services. A descriptive study.

This article describes the findings from a study of injured workers conducted as part of a multifaceted evaluation study of a case management program. The sample consisted of workers who filed a workers' compensation claim between January 1 and September 30, 1995. Data collection consisted of written surveys (n = 45), personal interviews (n = 27), and telephone interviews (n = 16). The findings from this study provided many insights into the injured workers' personal and work experiences, and, in particular, their perceptions of their experience with the nurse case management program. Workers satisfied with services described the nurse case manager (NCM) as having the ability to see the "big picture," to develop appropriate goals, and to anticipate client needs. Dissatisfied workers reported feeling unimportant in terms of service provision. They reported feeling that "the system" did not respond to their needs, and that the NCM was uninterested and disrespectful. This vivid portrayal of workers' experiences and perceptions of case management services provides valuable information about the world view of the injured worker.

Return to work experience of injured workers in a case management program.

A major goal of case management programs is the worker's timely return to work. Few studies have examined return to work from the perspective of the injured worker. This article describes the findings from the case management evaluation that describe the return to work experience of workers who sustained catastrophic injuries, or who had secondary conditions or complications following the injury occurrence. Among the factors determined to affect the return to work experience were structural factors (i.e., psychosocial variables including job satisfaction and relationship with employer and coworkers, financial pressures, and system issues such as securing benefits) and process factors (i.e., interaction with service providers and with the workers' compensation system). Outcomes are described in terms of satisfaction with services and return to work.

Case management services for injured workers. Providers' perspectives.

The perceptions of service providers involved in case management services are described here. The service providers included claims managers, occupational nurse consultants, attending physicians, and nurse case managers. The purposes of this phase of the study were to describe these providers' perceptions about the case management program; to organize findings according to the quality assessment model that guided this study (including structure, function, and outcomes); and to identify barriers and facilitators to satisfaction with case management services. Structural factors that affected services included the workers' compensation system, construction of the service team, roles within the program, and individual attributes of service providers. Process factors were conflicts among parties, role of communication, and interaction with workers. Outcomes were described in terms of program efficiency and effectiveness. Data are used to illustrate and explain each of these themes.

Case management for injured workers. A descriptive study using a record review.

A record review was used to examine case management services provided to 36 workers who sustained a catastrophic or medically complex injury, and who were referred to a case management program. The aims of this phase of the evaluation were to identify and describe: Workers' demographics and personal attributes, The structures and processes that affected the course of these cases, and The role of the nurse case manager (NCM). A data collection instrument was developed to collect quantitative and qualitative information. Structural factors that emerged as most consequential included the quality and quantity of the injured worker's social support and the employment situation, including the availability of a job post-injury, employer support, and worker motivation. Process variables identified included the interactions of service providers including communication, and collaboration. The NCM was described as a monitor, coordinator, supporter, and advocate for the worker. Additionally, the NCM served as a consultant to other service providers and played a key role in the implementation of cost containment strategies.

Long-term effects of delayed parenthood.

The present study aims to define, characterize and compare the long-term effects on offspring of delayed parenthood. Data published so far on this topic show that maternal and paternal ageing may affect offspring by different mechanisms. Delayed motherhood is characterized by increased probability of obstetric complications and/or fetal and perinatal problems which, in turn, may increase the risks of mortality and morbidity in newborns and later life. Furthermore, maternal ageing is distinguished by a decreased ratio of male to female infants and higher odds of conceiving a trisomic child and/or an individual suffering from mitochondrial DNA disorders. In contrast, delayed fatherhood is associated with higher risks of conceiving an individual suffering from new inheritable-mutation disorders. The different pattern of disease in offspring associated with maternal and paternal ageing may be explained, among other factors, by the fact that (i) oocytes of middle-aged women may suffer oxidative stress because their mitochondria produce higher amounts of reactive oxygen species; (ii) diplotene oocytes and to a lesser extent metaphase I and II oocytes have an efficient DNA repair system which is essentially independent of maternal age; and (iii) mitochondria are transmitted to the next generation along the matrilineal line. Moreover, (i) the activities of antioxidant enzymes within the seminal plasma and spermatozoa from older men may be reduced and so spermatozoa may be more vulnerable to mutational changes than spermatozoa from younger men; and (ii) late spermatids, and immature and mature spermatozoa do not have a DNA repair system.

Foetal erythrocytes exhibit an increased ability to scavenge for nitric oxide.

The presence of adult human whole blood inhibited in vitro relaxations of rat aortic rings by the nitric oxide (NO) donor S-nitroso-N-acetyl-DL-penicillamine (SNAP). Incubation with foetal blood containing the same concentration of haemoglobin produced a shift to the right of the relaxation curve. SNAP-induced vasorelaxations were more inhibited by dialysed solutions of haemoglobin than by the presence of erythrocytes in the organ bath, but there were no differences between the effect of adult or foetal haemoglobins. The presence of plasma from adult or foetal blood did not modify the effects of SNAP. Relaxations induced by endogenous, endothelium-derived, NO were more inhibited by foetal than by adult erythrocytes. These results suggest that foetal erythrocytes have a higher NO scavenging effect than those present in adult blood.

[Epidemiology of Haemophilus influenzae type b, Neisseria meningitidis, and Streptococcus pneumoniae in children in the Valencia Community, Spain. Acute diseases study group]. / Epidemiología de la meningitis producida por Haemophilus influenzae tipo b, Neisseria meningitidis y Streptococcus pneumoniae en niños de la Comunidad Valenciana, España. Grupo de Estudio de Enfermedades Invasoras.

OBJECTIVE: To asses the incidence of Haemophilus influenzae type b (Hib), Neisseria meningitidis and Streptococcus pneumoniae meningitis in children of de Valencian Community (VC), Spain, and to describe the microbiologic characteristics. MATERIAL AND METHODS: Prospective surveillance system with paediatrician and microbiologist participation of all public hospitals of the VC. Cases are children less than 15 with clinical meningitis and with isolation of Hib, N. meningitidis or S. pneumoniae from CSF of blood. RESULTS: From 1st December 1995 to 30th November 1996, 51 cases were declared, 33.3% were Hib, 49.0% N. meningitidis and 17.7% S. pneumoniae. The annual incidence of meningitis was 7.6 cases/100,000 < 15 years, 20.5/100,000 < 5 years and 56.2/100,000 < 1 year. 84.3% of the cases occurred in children younger than 5. S. pneumoniae had the highest mortality. CONCLUSIONS: Hib is a frequent cause of meningitis in spite of that one third of children are vaccinated. 43% of the N. meningitidis isolated in meningitis are serogroup C. S. pneumoniae meningitis are more frequent in children less than one, and has a high mortality rate.

[Application of the distortion products register in newborns. Preliminary results]. / Aplicación del registro de productos de distorsión en neonatos. Resultados preliminares.

Following the development of an up-to-date audiological technique--as it seems to be--the register of acoustic distortion products 2F1-F2, the AA. have undertaken the study of the characteristics of otoacoustic emissions in a new-born normal hearing group. They describe the features of distortion products audiogram (DP-gram) of the collective, the limitations of the test and its possible clinical appliances.

Distortion product otoacoustic emissions in healthy newborns: normative data.

Distortion product otoacoustic emissions (DPOAE) offer an alternative to transiently evoked otoacoustic emissions (TEOAE) as an audiological test. The former can be used as a screening technique, and may also provide frequency-specific information about the functional state of the cochlea. We recorded DPOAE in a group of healthy newborns to establish the characteristics of a DPOAE "audiogram" (DP-gram) in this population. The DP-gram can be obtained with characteristics quite similar to those observed in adults, with two sharp peaks of maximum amplitude at F2 frequencies of 2 kHz and 5-6 kHz, and a decline in DPOAE amplitude in midfrequencies. The results confirm the limitations of DPOAE recording for testing parts of the basilar membrane where lower frequencies are coded.

Prognostic factors in childhood asthma: a logistic regression analysis.

Thirty-two factors related to childhood asthma were studied in 200 asthmatic children. Remission of asthma was defined as a period of at least 2 years free of asthma while receiving no treatment. Univariate analysis showed significant associations between persistence of asthma and perennial symptoms with an odds ratio (OR) of 2.5 (95% confidence intervals 1.2 to 5.5); sensitization to house dust mites OR 3.5 (1.2 to 9.6); sensitization to molds, OR 7.9 (2.9 to 21.6); sensitization to pollen, OR 4.8 (1.4 to 16.3); and sensitization to milk protein, OR 5.4 (1.8 to 15.9). There was a positive association of remission of asthma with good treatment compliance, OR 12.1 (1.6 to 91.6). A stepwise logistic regression analysis selected the variables: perennial symptoms (S: 0 = no, 1 = yes), length of follow-up time (T: number of months), treatment compliance (C: 0 = poor, 1 = good), sensitization to fungi (F: 0 to 4), and sensitization to milk protein (M: 0 to 4). The analysis yielded the following formula for calculation of probability of asthma remission P(R): [formula: see text] where S indicates perennial symptoms; T, follow-up time in months; C, compliance; F, allergy to fungi; and M, allergy to milk.