Role of Insulin Resistance as a Mediator of the Relationship between Body Weight, Waist Circumference, and Systolic Blood Pressure in a Pediatric Population.

Excess weight and high waist circumference (WC) are associated with increased blood pressure (BP), starting from the pediatric age. Insulin resistance is associated with elevated BP in childhood. The aim of the study was to assess the role of insulin resistance in mediating the relationship between body mass index (BMI), WC, and BP values in a pediatric population referred to a cardio-pediatric center for the presence of one or more cardiovascular risk factors. In 419 children (mean age 10.7 [standard deviation, SD 2.5] years), the following parameters were collected both in basal conditions and after 18.6 (SD 9.3) months of follow-up during which a treatment based on lifestyle and dietary modifications was given: systolic and diastolic BP (SBP and DBP), WC, plasma glucose, and insulin values. The HOMA (Homeostasis Model Assessment)-index was considered as an expression of insulin resistance. At baseline there was a significant correlation between HOMA-index and SBP z-score (ß = 0.081, p = 0.003), and insulin resistance was a mediator of the relationship between BMI and SBP z-score (p = 0.015), and between waist circumference to height (WtHr) and SBP z-score (p = 0.008). The effect of BMI z-score modifications on SBP z-score changes from baseline to follow-up was totally mediated by HOMA-index changes (p = 0.008), while HOMA-index only partially mediated the effect of WtHr modifications on SBP z-score changes (p = 0.060). Our study strongly suggests that, in a pediatric population at cardiovascular risk, the HOMA-index is an important mediator of the relationship between BMI, WC and SBP.

Biosimilar erythropoiesis-stimulating agents are an effective and safe option for the management of myelofibrosis-related anemia.

OBJECTIVES: Erythropoiesis-stimulating agents (ESA) have an established role in treating anemia in hematological malignancies. However, their role, particularly biosimilar ESA (B-ESA), in myelofibrosis (MF) is not well established. METHODS: This study retrospectively collected data on 96 MF patients treated with B-ESA (alpha/zeta) for the management of anemia to assess safety, efficacy (anemia response [AR]), and survival. RESULTS: Seventy-seven patients (80%) obtained AR. The median time to AR was 2.5 months. In multivariate analysis, significant predictive factors of AR were transfusion independency (p = .006) and ferritin levels <200 ng/ml (p = .009) at baseline. After a median follow-up of 43.8 months from diagnosis, 38 patients (39%) died, 11 (28.9%) from leukemic evolution. Only two patients (2.5%) stopped B-ESA for toxicity. The 24-month survival was significantly affected by response to B-ESA (70.8% in AR vs. 55.3% in non-responder patients, p = .016). In multivariate analysis, age ≤ 70 years (p = .029) and Hb > 8.5 g/dl (p = .047) at baseline were significantly associated with improved survival, with a trend for longer survival in AR patients (p = .06). CONCLUSIONS: B-ESA seems to be an effective and well-tolerated option for anemia treatment in the MF setting. This strategy deserves further clinical investigation.

Uric acid and arterial stiffness in children and adolescents: Role of insulin resistance and blood pressure.

Several studies describe the association between serum uric acid (SUA) and arterial stiffness in adults. Uric acid contributes through several mechanisms to the increase in blood pressure (BP) and adversely affects the insulin signaling pathway. Moreover, SUA predict the development of hypertension and insulin resistance up to type 2 diabetes. Early arterial stiffening, estimated by carotid-femoral pulse wave velocity (PWV), may already be present in pediatric age. Aim of our study was to investigate the relationship between SUA and PWV in a pediatric population and its interaction with insulin resistance and BP. In 322 children and adolescents (56.2% male, mean age 11.3 [SD 2.8] years), we measured weight, height, waist circumference, BP and PWV. We also assayed SUA and estimated glomerular filtration rate (eGFR) and calculated HOMA-index as a marker of insulin resistance. Simple and multiple regression analyses were performed to assess variables associated with PWV. Mediation models were applied to identify the direct and indirect effects of individual variables on PWV. On univariate analysis, age (p < 0.001), waist circumference-to-height ratio (p = 0.036), systolic and diastolic BP (SBP and DBP) z-score (p < 0.001), heart rate (p = 0.028), SUA (p = 0.002), HOMA-index (p < 0.001), and eGFR (p = 0.014) were significantly associated with PWV. The multiple regression model showed that only age (p = 0.028), SBP z-score (p = 0.006), and heart rate (p = 0.001) were significantly associated with PWV. The results were superimposable when the DBP z-score replaced the SBP z-score in the model. Mediation models showed that the effect of eGFR on PWV was fully mediated by SUA (p = 0.015) and that the effect of SUA on PWV was totally mediated by HOMA-index (p < 0.001). Both SUA (p < 0.01) and HOMA-index (p < 0.01) had a significant association with higher SBP (DBP) z-scores. The double mediation model including both BP and HOMA-index showed that the SUA effect on PWV was totally mediated by both variables (p = 0.005, for HOMA-index, p = 0.004, for SBP z-score and p = 0.007, for combined effect). The results were superimposable when the DBP z-score replaced the SBP z-score in the model. In conclusion, insulin resistance and BP are both important mediators of the association between SUA and vascular stiffness in pediatric age.

Training in communication and emotion handling skills for students attending medical school: Relationship with empathy, emotional intelligence, and attachment style.

OBJECTIVE: To describe the Emoty-Com training, its impact on medical students' attitudes towards doctors' emotions and to explore the association between students' empathy, emotional intelligence (EI), and attachment style (AS) with post-training performance scores. METHODS: The 16-hour Emoty-Com training was delivered to all second-year medical students of Verona and Milan (Italy) Universities. At pre-training, students filled out three questionnaires assessing empathy, AS and EI and responded to three questions on attitudes towards doctors' emotions in the doctor-patient encounter. The same three questions and a final evaluation test were proposed at post-training. RESULTS: 264 students participated in the study. The training reduced students' worry about managing emotions during doctor-patient relationships. Gender was associated with specific subscales of empathy, EI, and AS. Final performance scores were associated with students' attitudes towards emotions but not with empathy, EI, and AS. CONCLUSION: The Emoty-Com training increased students' self-efficacy in handling their own emotions during consultations. Students' performance scores were related to their attitude towards doctors' emotions in clinical encounters. PRACTICE IMPLICATIONS: The Emoty-Com training suggests ways to teach and evaluate emotion-handling skills for medical students. Possible links between empathy, EI, AS, and the attitudes towards doctors' emotions during the years of education are highlighted.

Early factors associated with risk of developmental coordination disorder in very preterm children: A prospective area-based cohort study in Italy.

BACKGROUND: Developmental coordination disorder (DCD) is a motor disorder of unknown aetiology that may have long-term consequences on daily activities, and psychological and physical health. Studies investigating risk factors for DCD have so far provided inconsistent results. OBJECTIVES: To assess, using a parent-report screening tool, risk of DCD in school-age very preterm children born in Italy, and investigate the associated early biomedical and sociodemographic factors. METHODS: A prospective area-based cohort (804 children, response rate 73.4%) was assessed at 8-11 years of age in three Italian regions. Perinatal data were abstracted from medical records. DCD risk was measured using the Italian-validated version of the Developmental Coordination Disorder Questionnaire (DCDQ-IT). For this study, children with cognitive deficit (i.e. intelligence quotient <70), cerebral palsy, severe vision and hearing disabilities, and other impairments affecting movement were excluded. A total of 629 children were analysed. We used inverse probability weighting to account for loss to follow-up, and multilevel, multivariable modified Poisson models to obtain adjusted risk ratio (aRR) and 95% confidence interval (CI). Missing values in the covariates were imputed. RESULTS: 195 children (weighted proportion 31.8%, 95% CI 28.2, 35.6) scored positive on the DCDQ-IT, corresponding to the 15th centile of the reference Movement-ABC test. Factors associated with overall DCD risk were male sex (aRR 1.35, 95% CI 1.05, 1.73), intrauterine growth restriction (aRR 1.45, 95% CI 1.14, 1.85), retinopathy of prematurity (aRR 1.62, 95% CI 1.07, 2.45), and older maternal age at delivery (aRR 1.39, 95% CI 1.09, 1.77). Complete maternal milk feeding at discharge from the neonatal unit and higher parental socio-economic status were associated with decreased risk. CONCLUSIONS: Both biomedical and sociodemographic factors increase DCD risk. These findings can contribute to elucidating the origins of this disorder, and assist in the identification of children at risk for early referral and intervention.

Emotional intelligence as a mediator between attachment security and empathy in pre-clinical medical students: A multi-center cross-sectional study.

OBJECTIVE: To explore the association of emotional intelligence (EI) and attachment security (AS) with empathy dimensions in medical students by examining the mediating role of EI. METHODS: In a cross-sectional design, the Interpersonal Reactivity Index (IRI), the Emotional Quotient Inventory (EQ-i), the Attachment Style Questionnaire (ASQ), and demographic questions were administrated to second-year medical students of two medical schools in Northern Italy. RESULTS: 253 medical students (56.13% female), aged 19-29, participated in this study. AS positively correlated to Empathic Concern (r = 0.17, p = 0.008) and Perspective Taking (r = 0.24, p < 0.001), and negatively to Personal Distress (r = -0.33, p < 0.001). Individuals with the same level of AS and a higher score on EQ-i had a higher score (ß = 0.072, p = 0.033) on empathy latent factor (at the basis of Empathic Concern and Perspective Taking) and a lower score (ß = -0.290, p < 0.001) on Personal Distress than those with a lower EQ-i score. CONCLUSION: This study shows that EI completely mediated the relationship between AS and empathy dimensions among medical students. PRACTICE IMPLICATIONS: EI training and workshop should be considered when designing educational interventions and programs to enhance empathy and decrease interpersonal distress in medical students.