Linear growth after pediatric liver transplantation.

To determine growth patterns in a large cohort of unselected children undergoing liver transplantation, the outcomes of 294 orthotopic liver transplantations performed in 221 children at The University of Chicago between October 1984 and October 1992 were retrospectively reviewed; 66% were alive at the time of this analysis. The mean age at transplantation was 4.1 +/- 5.0 years; 44% of the children were male and 16% of the transplants were from living-related donors. The mean height z score at the time of transplantation was -1.6 +/- 1.8, and 39% of children had height z scores of < -2.0 at transplantation. When children with growth retardation at the time of transplantation (height z scores of < -2. 0) were compared with children with more normal growth, there were no significant differences in gender or re-transplantation rates, although children with growth retardation at transplantation were significantly younger than those with more appropriate growth (2.8 +/- 4.1 years vs 4.7 +/- 5.1 years, P <.05). The height z score of all children with biliary atresia at the time of transplantation was -1.9 +/- 1.7 compared with -1.2 +/- 2.0 in those children with underlying diseases other than biliary atresia. Catch-up growth was seen in 37% to 47% of children at any given time point after transplantation. Children with evidence of catch-up growth (growth velocity z score >0) 2 years after transplantation were more likely to be first-time transplant recipients, had more growth retardation at the time of transplantation, and were receiving lower doses of prednisone at 2 years after transplantation. Younger children were most likely to demonstrate catch-up growth after transplantation. In summary, a large proportion of children have growth retardation at the time of liver transplantation. This growth retardation is inversely correlated with age. Before transplantation, children with biliary atresia grow less well than children with other forms of liver disease. Up to one half of children demonstrate catch-up growth after liver transplantation. Growth after transplantation is proportional to the degree of growth retardation at transplantation and inversely correlated to age at transplantation. Children with poor growth after transplantation are more likely to be receiving higher doses of corticosteroid.

Ethnic differences in substance use and alcohol-use-related mortality among first generation migrants to England and Wales

Epidemiological studies among migrant ethnic groups are potentially important as a way to provide insight into the relative importance of genetic, cultural, and socioeconomic factors in the etiology of substance use disorders. This paper summarizes prior United Kingdom studies of the prevalence of substance-use-associated problems in different ethnic groups before analyzing trends in recent mortality data by country of birth. On this evidence, rates of alcohol-related mortality may be marginally higher for those born in the Caribbean than for the native British, but are substantially raised for those born in Ireland and the Indian subcontinent. There is some indication that rates for the Caribbean and possibly the Irish groups have risen more rapidly than for the national population over a 12-year period. These difference in mortality rates seem to have arisen for complex reasons.(AU)

Energy expenditure in children with Down syndrome: correcting metabolic rate for movement.

Children with Down syndrome (DS) have a high prevalence of obesity. To investigate the relation between energy expenditure and obesity, we measured body composition, resting metabolic rate (RMR), and total energy expenditure in 13 prepubescent children with DS and in 10 control subjects matched for age, weight, and percentage of fat, using indirect calorimetry and the doubly labeled water method. Measurement of RMR was complicated by excessive movement by both the DS and control subjects. We therefore developed a method of subtracting the energy expended in movement and calculated the corrected RMR. The corrected RMR was significantly lower in those with DS than in control subjects when expressed as a percentage of the basal metabolic rate, predicted by the World Health Organization: 79.5% +/- 10.4% and 96.8% +/- 7.8%, respectively (p < 0.001). No significant differences were detected in total daily energy expenditure or non-RMR expenditure between the subject groups. In the DS group, 60% of the variability in fat mass could be accounted for by non-RMR expenditure expressed per kilogram of body weight (p < 0.02). No relation was detected between fat mass and non-RMR expenditure in control subjects, nor were any measures of energy expenditure predictive of changes in fatness among the subjects with DS during a 1-year follow-up. The results of this study indicate that prepubescent children with DS have decreased RMR compared with control children.

Evaluation of an office- and hospital-based intervention to increase the use of cloth diapers.

To evaluate an office-based educational intervention to promote the use of cloth diapers, we randomly assigned parents of 193 infants either to the intervention group or to a control group. The intervention consisted of physician advice and written material on cloth and disposable diapers at the 2-week office visit. Midway through the study, one of the birth hospitals switched to the exclusive use of cloth diapers. The results indicate that the diapering decisions of parents can be influenced by practices in hospitals and by office-based physician and nurse counseling.

Experience with moderate intensity anticoagulation and aspirin after mechanical valve replacement. A retrospective, non-randomized study.

A selected group of patients who underwent valve replacement were analyzed to evaluate the feasibility, effectiveness and safety of combined treatment with moderate intensity anticoagulation plus aspirin. One hundred ninety-six patients who received a total of 204 mechanical valve prostheses between 1985 and 1991 were selected according to rigid criteria. The prostheses included 124 valves of caged ball design, 62 St. Jude valves and 18 others. The follow up of the whole population was 581.8 patient years, with an average of 2.97 patient years, and was complete by the definition criteria. All patients received moderate intensity anticoagulation with acenocoumarol (target International Normalized Ratio 2.5 to 3.5) and daily aspirin (100 mg or 325 mg). The incidence of thromboembolic events for the whole group was 3.26% per patient year, but only 1.6% in patients "compliant" with treatment. Preoperative embolism and non-compliance with treatment had a strong correlation with postoperative thromboembolism. The INR values had a strong correlation with both thromboembolic and hemorrhagic events. The incidence of serious hemorrhagic events was 4.12% patient years although only two cases (0.34%/pty) were fatal (cerebral hemorrhages). There was no difference in hemorrhagic incidence between patients receiving either 325 mg or 100 mg daily. A low incidence of thromboembolic complications was attained with the use of combined antithrombotic and antiplatelet therapy, even in the first generation caged ball type prostheses. However, the combination of moderate intensity anticoagulation with either 325 mg or 100 mg aspirin was associated with a risk of bleeding similar to high intensity anticoagulation alone. The risk of bleeding appeared to be greater in the presence of gastric pathology, and the combination of anticoagulants and aspirin should be avoided in patients with these conditions.

Intracranial injury following minor head trauma.

One hundred twelve patients presenting with a Glascow Coma Scale (GCS) score greater than or equal to 13 with a history of minor head trauma were prospectively studied to determine if certain historic or physical examination variables would predict which of these patients were at increased risk for intracranial injury. Patients either underwent cranial computed axial tomography (CT) or were followed up by phone at 4 weeks to determine major morbidity or mortality. Thirty-five patients underwent CT scanning of the head and eight demonstrated intracranial injury. Five patients were treated nonoperatively, and three patients had neurosurgical intervention. One patient died following surgery. At the 4-week follow-up no patient was found to have suffered any major morbidity or mortality. Stepwise logistic regression found age over 40 years (P = .05, odds ratio = 6.4, 95% confidence interval 1.0 to 38.8) and complaint of headache (P = .039, odds ratio 8.167, 95% confidence interval 1.074 to 62.09) to be significantly predictive of intracranial injury. All eight patients with positive CTs had a GCS score of 15. The authors conclude that intracranial injury does exist in patients suffering minor head trauma with a GCS score of 13 or above. Age over 40 years and complaint of headache are associated with an increased risk of intracranial injury.