Association of adipokines with blood pressure in rural Chinese adolescents.

Previous research has demonstrated that adipokines influence blood pressure (BP). Limited data exist in healthy adolescents, who are in a critical period for preventing the development of high BP. This study investigated the association of leptin, adiponectin and the leptin-to-adiponectin ratio (LAR) with BP in rural Chinese adolescents. This report included 1245 adolescents (average body mass index: 19.3 kg m(-2)) aged 13-21 years from an established twin cohort. We examined gender-specific associations between plasma adipokines and BP, with adjustment for measures of adiposity and insulin resistance (IR). We estimated the genetic contribution to adipokines using the twin design and Cholesky decomposition models. There was no correlation between leptin and adiponectin levels. Leptin was positively associated with systolic blood pressure (SBP) in males and diastolic blood pressure in females, but the association disappeared after adjusting for adiposity and IR. LAR was positively associated with SBP (ß(s.e.): 1.94(0.45)), P<0.01), adiponectin was negatively associated with SBP (ß(s.e.): -2.18(0.63)), P<0.001) only in males, and such associations were independent of adiposity and IR. A test of gender × adiponectin interaction was significant (P=0.01). Heritability estimation showed that both environmental and genetic factors contribute to variance in adipokines. In these relatively lean Chinese adolescents, leptin was positively associated with BP in both genders, but was adiposity/IR dependent. Adiponectin was negatively associated with SBP in males, independent of adiposity/IR.

Pediatricians' involvement in gun injury prevention.

BACKGROUND: Injuries from small arms are of concern internationally. The health perspective is an emerging aspect of international work to reduce these injuries. This aspect has been evident in US firearm injury prevention work for over a decade, exhibited by strong statements from the American Academy of Pediatrics (AAP) to remove firearms from children's environments. OBJECTIVES: To assess trends among US pediatricians related to firearm injury prevention counseling practices and attitudes toward gun legislation. DESIGN: National random sample, mailed surveys of AAP members: (1) 1994 (response rate = 68.9%, n = 982); (2) 2000 (response rate = 62.4%, n = 922). chi(2) Tests were used to assess bivariate relationships and logistic regression to assess multivariate relationships regarding counseling practices. RESULTS: Respondents in both years believed that violence prevention should be a priority for pediatricians (91.4% and 92.0%) and reported always or sometimes recommending handgun removal from the home (46.2% and 55.9%, respectively). In 2000, 74% of the respondents were comfortable discussing firearm safety; fewer thought they had sufficient training (32.7%) or time (27.5%) to discuss firearms. In 1994 and 2000, the likelihood of counseling on handgun removal was positively related to recent experience treating a gun injury, female sex and not owning a gun. In both years, >80% of pediatricians thought that gun control legislation or regulations would reduce injury and death. CONCLUSIONS: US pediatricians continue to adopt policies promoting gun injury prevention. The practices and attitudes of pediatricians may be important for public education strategies regarding firearm injury prevention in the US and internationally.

Are medical societies developing a standard for gun injury prevention?

CONTEXT: Following heightened gun violence in the 1990s, many medical societies in the United States adopted policies on the topic. OBJECTIVE: Identify points of firearm violence policy agreement among large medical organizations. DESIGN: Fourteen national medical societies-clinical focus, demonstrated interest in gun injury prevention, >2000 members-were selected for policy review in 2002. Policies were categorized on areas covered and items within these. Consensus areas were addressed by >/=7/14 societies. Consensus items were included by >/=7/14 societies, shared items by 5-6. RESULTS: There were five consensus areas: access prevention, gun commerce, research, public education, and clinical counseling. There were four consensus items: restricting gun access by enforcing existing laws, restricting access to all guns at the point of sale, restricting access to handguns at the point of sale, and creating a national database on gun injury and death. Shared items promote violence prevention, clinical education on risks of guns in the home, treating guns as consumer products, restricting gun access to children, bans on automatic weapons, and promoting trigger locks. CONCLUSIONS: Large medical societies in the United States agree on key approaches for reducing gun injury mortality and morbidity. Future research will be needed to track the evolution of this emerging standard for physician action, which now includes the consensus areas and items. It promises to be, in effect, a medical standard of care for gun injury prevention. The United States experience may be useful to others working on gun injury prevention.

Public health advocacy: process and product.

OBJECTIVES: In this article the author describes public health advocacy and proposes a conceptual framework for understanding how it works. METHODS: The proposed framework incorporates the image of an assembly line. The public health advocacy assembly line produces changes in societal resource allocation that are necessary for optimizing public health. The framework involves 3 main stages: information, strategy, and action. These stages are conceptually sequential but, in practice, simultaneous. The work at each stage is continually adjusted according to circumstances at the other stages. RESULTS: The framework has practical implications; for example, public health advocacy teams need members with complementary skills in distinct roles. Potential applications are illustrated via two public health advocacy efforts. CONCLUSIONS: The framework may be useful in assessing staffing and funding needs for public health advocacy endeavors, explaining common problems in these endeavors and suggesting solutions, and guiding decisions concerning effort allocation. Application of the framework to a variety of public health advocacy endeavors will clarify its strengths and weaknesses.

Health care providers' experience reporting child abuse in the primary care setting. Pediatric Practice Research Group.

OBJECTIVES: To describe (1) primary care providers' experiences identifying and reporting suspected child abuse to child protective services (CPS) and (2) variables affecting providers' reporting behavior. DESIGN AND METHODS: Health care providers (76 physicians, 8 nurse practitioners, and 1 physician assistant) in a regional practice-based network completed written surveys that collected information about the demographic characteristics of each provider and practice; the provider's career experience with child abuse; and the provider's previous year's experience identifying and reporting suspected child abuse, including experience with CPS. RESULTS: All providers (N = 85) in 17 participating practices completed the survey. In the preceding 1 year, 48 respondents (56%) indicated that they had treated a child they suspected was abused, for an estimated total of 152 abused children. Seven (8%) of 85 providers did not report a total of 7 children with suspected abuse (5% of all suspected cases). A majority of providers (63%; n = 29) believed that children who were reported had not benefited from CPS intervention, and 21 (49%) indicated that their experience with CPS made them less willing to report future cases of suspected abuse. Providers who had some formal education in child abuse after residency were 10 times more likely to report all abuse than were providers who had none. CONCLUSIONS: Primary care providers report most, but not all, cases of suspected child abuse that they identify. Past negative experience with CPS and perceived lack of benefit to the child were common reasons given by providers for not reporting. Education increases the probability that providers will report suspected abuse.

Prevalence of symptoms of gastroesophageal reflux during childhood: a pediatric practice-based survey. Pediatric Practice Research Group.

OBJECTIVES: To determine the prevalence of symptoms associated with gastroesophageal reflux (GER) in 3- to 17-year-old children, to describe the prevalence of factors associated with GER in these children, and to determine the percentage of symptomatic children who have been treated. DESIGN: A cross-sectional survey. SETTING: Sixteen pediatric practice research group practices in the Chicago, Ill, area (urban, suburban, and semirural). PARTICIPANTS: A total of 566 parents of 3- to 9-year-old children, 584 parents of 10- to 17-year-old children, and 615 children aged 10 to 17 years. INTERVENTION: None. MAIN OUTCOME MEASURE: Reported frequency of symptoms associated with GER. RESULTS: Parents of 3- to 9-year-old children reported that their children experienced a sensation of heartburn ("burning/painful feeling in middle of chest"), epigastric pain ("stomachache above belly button"), and regurgitation ("sour taste or taste of throw up") 1.8%, 7.2%, and 2.3% of the time, respectively. Parents of 10- to 17-year-old children reported that their children experienced the same symptoms 3.5%, 3.0%, and 1.4% of the time, while children aged 10 to 17 years reported the symptoms 5.2%, 5.0%, and 8.2% of the time, respectively. Complaints of abdominal pain ("stomachache") were most common, reported by 23.9% and 14.7% of parents of 3- to 9-year-old and 10- to 17-year-old children and by 27.9% of children aged 10 to 17 years. In those aged 10 to 17 years, heartburn reported by the children was associated with reported cigarette use (odds ratio, 6.5; 95% confidence interval, 2-21); no other complaint was associated with cigarette, alcohol, or caffeine consumption or passive smoking exposure. In 3- to 9-year-old children, no complaint was associated with caffeine consumption or passive smoking exposure. Reported treatment in the past week with antacids was 0.5% according to parents of children aged 3 to 9 years and 1.9% and 2.3% according to parents of children aged 10 to 17 years and children aged 10 to 17 years, respectively. Treatment with over-the-counter histamine receptor blockers was 0% for children aged 3 to 9 years and 10 to 17 years, as reported by their parents, and 1.3% for those aged 10 to 17 years, as reported by themselves. CONCLUSIONS: Symptoms suggestive of GER are not rare in childhood, yet only a fraction of children with symptoms are treated with over-the-counter antacids or histamine2 antagonists. Prospective longitudinal data are needed to determine which children with symptoms of GER actually have GER disease and are at risk of developing complications.

Rational service planning in pediatric primary care: continuity and change in psychopathology among children enrolled in pediatric practices.

OBJECTIVE: To examine the stability of the occurrence of psychiatric disorders in a nonpsychiatric sample of young children. METHOD: There were 510 children ages 2-5 years enrolled through pediatric practices, with 391 children participating in the second wave, and 344 in the third wave of data collection 42-48 months later. The assessment battery administered at each wave yielded best-estimate consensus DSM-III-R diagnoses and dimensional assessments of psychopathology. RESULTS: The prevalence of disruptive disorders (DDs) decreased, while emotional disorders (EDs), other disorders, and comorbid DD increased. The DDs were associated with lower family cohesion, more maternal negative affect, stressful life events, and male gender. Comorbid DDs were associated with increasing age and family cohesion. Older children, lower family cohesion, and maternal negative affect were associated with EDs. Time trends for the dimensional assessment of psychopathology was similar to DSM-III-R disorders, but correlates differed. CONCLUSIONS: We discuss implications for service planning in pediatric primary care.

Restructuring asthma care in a hospital setting to improve outcomes.

STUDY OBJECTIVES: To restructure asthma care as the pilot program in hospital-wide redesign aimed at providing better and more standardized care. We chose asthma care to begin our reorganization because it is the highest-volume diagnosis at our hospital and it involves a broad spectrum of services. DESIGN: Key elements of our restructuring included the following: (1) establishing a pulmonary unit with expanded bed capacity from 8 to 22 beds for asthma patients; (2) standardized treatment protocols; (3) availability of direct admission by primary care physicians who maintained management of their patients with the option of consultation with a specialist; and (4) use of case managers who helped patients and their families overcome obstacles to optimum care. SETTING: A hospital serving a high proportion of Medicaid patients. PATIENTS/PARTICIPANTS: Children with asthma and their families. INTERVENTIONS: Standardized care for asthma; use of case managers to facilitate adherence to treatment. RESULTS: With the restructured asthma care program, parent satisfaction with treatment was sustained; the average length of stay and use of the emergency department (ED) were reduced; observation unit use increased; and there were fewer readmissions to both the inpatient unit and the ED. CONCLUSIONS: We conclude that an inner-city hospital can provide optimum care for asthma patients by standardizing treatment, aggregating asthma patients in one location, and providing education and follow-up through the use of case managers. The protocol shifts some costs from expensive services such as the pediatric ICU and the ED to less costly case management and outreach personnel. In the long run, this allocation of resources should help to lower costs as well as improve quality of care.

Adapting the gang model: peer mentoring for violence prevention.

OBJECTIVES: This study assessed the effectiveness of an inner-city peer-mentoring program in modifying the attitudes and behaviors involving violence of preadolescent mentees. METHODS: In a case-matched cohort study involving 7- to 13-year-old children, 50 children enrolled in peer mentoring (case subjects) were compared with 75 control subjects. Case subjects were involved before enrollment in the community program in which the intervention occurred; control subjects lived in the same housing project and were matched with case subjects on age, sex, and census tract. A total of 19 community adolescents mentored the case subjects by designing and presenting violence prevention lessons. Two reliable self-report scales, Determining our Viewpoints of Violent Events and Normative Beliefs About Aggression Scale, were used to measure attitudinal change. Teachers completed the Revised Behavior Problem Checklist to assess changes in behavior. RESULTS: At baseline, the survey scores of the case and control subjects were not different. After the intervention period, the case scores indicated less support for violence than the control scores. Case behavior scores did not change, but control behavior scores worsened. CONCLUSIONS: The data suggest that peer mentoring for younger children may be an important component of efforts to reduce youth violence. A larger multisite trial is warranted.

Handguns as a pediatric problem. 1986.

Handgun injury is a major cause of morbidity and mortality in American society, particularly for young people. Large numbers of children are affected by handgun violence through the loss of fathers, brothers, and other relatives. Young children are injured and sometimes killed in handgun accidents. Some children and many adolescents are murdered with handguns. Because of their great lethality and very limited ability to provide personal protection, the great burden of handgun injury can best be reduced by making handguns less available. Handgun control cannot reduce rates of crime or interpersonal assault, but it can be expected to reduce the frequency and severity of injury which grows out of these situations, to levels closer to the much lower ones found in other countries. Pediatricians can contribute to this effort, as they have to the efforts to reduce the morbidity and mortality from poisonings and motor vehicle passenger injury.

Sleep and behavior problems among preschoolers.

This study described the relationship between amount of sleep and behavior problems among preschoolers. Participants were 510 children aged 2 to 5 years who were enrolled through 68 private pediatric practices. Parents reported on the amount of sleep their child obtained at night and in 24-hour periods. With demographic variables controlled, regression models were used to determine whether sleep was associated with behavior problems. The relationship between less sleep at night and the presence of a DSM-III-R psychiatric diagnosis was significant (odds ratio = 1.23, p = .026). Less night sleep (p < .0001) and less sleep in a 24-hour period (p < .004) were associated with increased total behavior problems on the Child Behavior Checklist; less night sleep (p < .0002) and less 24-hour sleep (p < .004) were also associated with more externalizing problems on that measure. Further research is needed to ascertain whether sleep is playing a causal role in the increase of behavior problems.

Psychiatric disorders with onset in the preschool years: I. Stability of diagnoses.

OBJECTIVE: To examine the stability of psychiatric disorders with onset in preschool years. METHOD: Five hundred ten children aged 2 through 5 years enrolled initially, with 344 participating in a third wave of data collection 42 through 48 months later. The test batteries used for diagnoses varied by child's age, but they included the Child Behavior Checklist, developmental evaluation, Rochester Adaptive Behavior Inventory and a play session (under age 7 years), and a structured interview (Diagnostic Interview for Children and Adolescents, for parent and child) (ages 7 and older). Consensus DSM-III-R diagnoses were assigned using best-estimate procedures. RESULTS: Intraclass correlations were 0.497 for emotional disorders, 0.718 for disruptive disorders, 0.457 for other diagnoses, and 0.544 for disruptive disorders comorbid with another disorder, indicating moderate stability for all groups of disorders. More than 50% of the children who were aged 2 through 3 years at wave 1 continued to have some psychiatric disorder at wave 2 or 3. Rates were higher for children aged 4 through 5 initially; approximately two thirds were cases subsequently. Odds ratios indicate that having an emotional or disruptive disorder is a strong risk factor for later diagnoses. CONCLUSIONS: While some preschool children in primary care "grow out of" their disorder, an equally large number do not; this finding supports the need for early detection and intervention.