RESUMO
Community coalitions have the potential to catalyze important changes in the health and well-being of populations. The authors demonstrate how communities can benefit from a multisector coalition to conduct a community-wide surveillance, coordinate activities, and monitor health and wellness interventions. Data from Summit County, Ohio are presented that illustrate how this approach can be framed and used to impact community health positively across communities nationwide. By jointly sharing the responsibility and accountability for population health through coalitions, communities can use the Health Impact Pyramid framework to assess local assets and challenges and to identify and implement programmatic and structural needs. Such a coalition is well poised to limit duplication and to increase the efficiency of existing efforts and, ultimately, to positively impact the health of a population.
Assuntos
Planejamento em Saúde Comunitária/organização & administração , Promoção da Saúde , Adolescente , Adulto , Idoso , Comportamento Cooperativo , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Ohio , Adulto JovemRESUMO
PURPOSE: The authors sought to describe longitudinal changes in Percentage of Consonants Correct-Revised (PCC-R) after severe pediatric traumatic brain injury (TBI), to compare the odds of normal-range PCC-R in children injured at older and younger ages, and to correlate predictor variables and PCC-R outcomes. METHOD: In 56 children injured between age 1 month and 11 years, PCC-R was calculated over 12 monthly sessions beginning when the child produced ≥ 10 words. At each session, the authors compared odds of normal-range PCC-R in children injured at younger (≤ 60 months) and older (> 60 months) ages. Correlations were calculated between final PCC-R and age at injury, injury mechanism, gender, maternal education, residence, treatment, Glasgow Coma Score, and intact brain volume. RESULTS: PCC-Rs varied within and between children. Odds of normal-range PCC-R were significantly higher for the older than for the younger group at all sessions but the first; odds of normal-range PCC-R were 9 to 33 times higher in the older group in sessions 3 to 12. Age at injury was significantly correlated with final PCC-R. CONCLUSION: Over a 12-month period, severe TBI had more adverse effects for children whose ages placed them in the most intensive phase of PCC-R development than for children injured later.
Assuntos
Lesões Encefálicas/complicações , Lesões Encefálicas/fisiopatologia , Escala de Coma de Glasgow , Fonética , Distúrbios da Fala/etiologia , Distúrbios da Fala/fisiopatologia , Fatores Etários , Transtornos da Articulação/etiologia , Transtornos da Articulação/fisiopatologia , Criança , Pré-Escolar , Feminino , Humanos , Lactente , Estudos Longitudinais , Masculino , Estudos Prospectivos , Recuperação de Função Fisiológica/fisiologia , Fala/fisiologia , Medida da Produção da FalaAssuntos
Atenção Primária à Saúde/organização & administração , Organizações de Assistência Responsáveis , Prática Avançada de Enfermagem , Humanos , Patient Protection and Affordable Care Act , Assistência Centrada no Paciente , Assistentes Médicos , Atenção Primária à Saúde/legislação & jurisprudência , Atenção Primária à Saúde/normas , Garantia da Qualidade dos Cuidados de Saúde , Estados Unidos , Recursos HumanosRESUMO
Animal and human studies indicate that neonatal seizures are detrimental to the developing nervous system. This study addressed whether parameters of seizure severity and treatment were predictive of outcome and influenced the incidence of epilepsy. The outcome of babies with neonatal seizures was assessed based on follow-up examination, record review, and school performance. Epilepsy was assessed relative to developmental outcome and imaging abnormalities. There was no association between response to therapy and outcome. Neonates with mild or moderate seizure severity and decreasing severity over time, prior to anticonvulsant treatment, were more likely to have normal or moderately abnormal development than a severe outcome or death. Babies who had the highest seizure severity following treatment were more likely to have adverse outcomes. Those with normal imaging studies were more likely to have better outcome than those with diffuse severe abnormalities. Children with epilepsy were more likely to have abnormal development and imaging.
Assuntos
Deficiências do Desenvolvimento/diagnóstico , Deficiências do Desenvolvimento/fisiopatologia , Convulsões/diagnóstico , Convulsões/fisiopatologia , Adolescente , Anticonvulsivantes/uso terapêutico , Criança , Pré-Escolar , Deficiências do Desenvolvimento/tratamento farmacológico , Feminino , Humanos , Lactente , Imageamento por Ressonância Magnética , Masculino , Avaliação de Resultados em Cuidados de Saúde , Valor Preditivo dos Testes , Convulsões/tratamento farmacológico , Tomografia Computadorizada por Raios XRESUMO
PURPOSE: Almost 17% of the US population exhibits a major depressive disorder in their lifetimes. Prevalence data show that whites experience depression earlier than African Americans, and women have a higher prevalence than men. Less is known regarding depression among underserved minority populations. The goal of our study was to examine the relationship of depression and associated self-reported conditions in participants enrolled in a community-based research registry, a substantial number of whom were underrepresented minorities. METHODS: This study used a research registry of community members who had expressed interest in participating in health education projects conducted by the Center for Primary Care Community-Based Research. The patients received care at 10 family health centers. Participants were surveyed regarding family history of depression/anxiety and associated symptoms. Descriptive analyses, univariate analyses, and logistic regressions were used. RESULTS: The population (N = 2421) included women (72.2%), African Americans (54.9%), and reported good or very good general health (68.9%). Comorbid pain was found, with headache as the predominant complaint. Compared with nonwhites, whites had a significantly higher prevalence of current depression (26.3% vs. 23.8%; P = .01), current anxiety (25.5% vs. 16.6%), and current headache (14.2% vs. 11.2%). Whites also had a higher prevalence of a family history of depression (38.4% vs. 32.1%) and anxiety (8.9% vs. 7.7%) and of taking depression (22.4% vs. 14.8%) and anxiety (15.8% vs. 7.8%) medications. However, nonwhites had a higher prevalence of leg pain (18.8% vs. 14.9%) but a lower prevalence of headache (11.2% vs. 14.2%). CONCLUSIONS: Pain was common in patients with comorbid behavioral conditions. Headache was more common in whites, whereas leg pain was more common in nonwhites. Physicians should screen for depression and anxiety in patients with headache and other pain symptoms.
Assuntos
Serviços de Saúde Comunitária/métodos , Transtorno Depressivo Maior/epidemiologia , Dor/epidemiologia , Atenção Primária à Saúde/métodos , Adolescente , Adulto , Negro ou Afro-Americano , Idoso , Idoso de 80 Anos ou mais , Criança , Estudos de Coortes , Serviços de Saúde Comunitária/organização & administração , Transtorno Depressivo Maior/diagnóstico , Transtorno Depressivo Maior/patologia , Feminino , Educação em Saúde , Humanos , Modelos Logísticos , Masculino , Área Carente de Assistência Médica , Pessoa de Meia-Idade , Dor/diagnóstico , Dor/patologia , Prevalência , Atenção Primária à Saúde/organização & administração , Psicometria , Curva ROC , Sistema de Registros , Autorrelato , Estados Unidos/epidemiologia , População Branca , Adulto JovemRESUMO
Young men's sexual experiences with men are different from their sexual experiences with women because of homophobia. Early sexual debut with another man could lead to tobacco use as a result. The study assessed 691 HIV-negative gay men recruited from southwestern Pennsylvania. Early sexual experiences with men and women were associated with participants' smoking behaviors. It is thought that the early sexual debut with men may place these individuals at risk for homophobia as well as for being socialized in environments that will influence their smoking behavior. To be effective, tobacco control programs need to be culturally competent regarding issues that affect gay men.
Assuntos
Homossexualidade Masculina/estatística & dados numéricos , Relações Interpessoais , Parceiros Sexuais , Fumar/epidemiologia , Tabagismo/epidemiologia , Adulto , Coito/psicologia , Homossexualidade Masculina/psicologia , Humanos , Masculino , Pennsylvania/epidemiologia , Assunção de Riscos , Fumar/psicologia , Inquéritos e Questionários , Tabagismo/psicologiaRESUMO
BACKGROUND: Thrombocytopenia-associated multiple organ failure (TAMOF) is a poorly understood syndrome in critically ill children. A disintegrin and metalloprotease with thrombospondin motifs (ADAMTS-13), formerly known as von Willebrand factor (VWF) cleaving protease, is decreased in adults with VWF-mediated thrombotic microangiopathy, and intensive plasma exchange (PEx) both replenishes ADAMTS-13 and improves outcome in these patients. OBJECTIVES: To determine whether: 1) critically ill children with TAMOF syndrome have decreased ADAMTS-13 activity, 2) ADAMTS-13 activity correlates with platelet counts and VWF antigen, 3) the autopsies from patients who died with reduced ADAMTS-13 activity have VWF-rich microthrombi, and 4) intensive PEx will restore ADAMTS-13 activity and facilitate organ failure resolution. DESIGN: First study: observational. Second study: randomized control trial. SETTING: Single center university pediatric intensive care unit. PATIENTS: First study: thirty-seven consecutive children (17 males and 20 females; ages ranging from 9 days to 23 years) identified with > or = 2 organs dysfunction were enrolled. Seventy-six percent of these children had thrombocytopenia (platelet counts < 100,000/mm3). Five additional critically ill children without MOF were also enrolled. In the second study, children with severe TAMOF (platelet counts < 100,000/mm3 and > 3 organ failure) were randomized to PEx or standard therapy. Primary physicians and parents agreed to enrollment in 10 of the 20 eligible patients with ages ranging from 1 year to 18 years. Five patients received PEx and 5 patients received standard therapy. RESULTS: First study: children with TAMOF (n = 28) had decreased ADAMTS-13 activity, but similar plasminogen activator inhibitor-1 activity and prothrombin time compared to children with MOF without thrombocytopenia (n = 9, p < 0.05). All non-survivors (n = 7) had TAMOF, reduced ADAMTS-13 activity, and VWF-rich microvascular thromboses at autopsy. In the second study, PEx (n = 5, median 12 days, 4-28 days) restored ADAMTS-13 activity and organ function, compared to standard therapy (n = 5, p < 0.05). CONCLUSIONS: Children with TAMOF syndrome can have VWF-mediated thrombotic microangiopathy. Similar to adult experience, PEx can replenish ADAMTS-13 activity and reverse organ failure.
Assuntos
Proteínas ADAM/sangue , Insuficiência de Múltiplos Órgãos/terapia , Troca Plasmática/métodos , Trombocitopenia/terapia , Proteínas ADAM/efeitos dos fármacos , Proteína ADAMTS13 , Adolescente , Adulto , Fatores Etários , Análise de Variância , Biomarcadores/sangue , Criança , Pré-Escolar , Estado Terminal/mortalidade , Estado Terminal/terapia , Feminino , Seguimentos , Humanos , Lactente , Recém-Nascido , Modelos Logísticos , Masculino , Insuficiência de Múltiplos Órgãos/sangue , Insuficiência de Múltiplos Órgãos/complicações , Insuficiência de Múltiplos Órgãos/mortalidade , Valores de Referência , Medição de Risco , Estatísticas não Paramétricas , Taxa de Sobrevida , Trombocitopenia/sangue , Trombocitopenia/complicações , Trombocitopenia/mortalidade , Resultado do TratamentoRESUMO
There is a dearth of evidence relative to the identification and the variability between the prevalence of chronic conditions in the greater geographic community and the prevalence of these chronic conditions reported through community-based primary care practices. Described is the content and context of a research registry and the variation in panels given the means of recruitment. Patients complete a medical form that includes their self-reported demographics, current and past medical conditions, current medications, family history of selected medical conditions, and a release for full access to their medical records. Two panels were examined, those patients served by community-based primary care practices and assessment of those citizens living in the greater underserved population. These results suggest that the recorded frequency of conditions is similar to those found in the most frequent diagnostic clusters reported in literature for primary care visits. Despite the equity of the demographic and geographical area for recruitment, the identified chronic conditions of those recruited from medical practices differed significantly than the participants from community venues. These findings are provocative in that they have an impact on the understanding of the content and context of a primary care community-based research registry, but also the possible variations in panels given the means of recruitment into a registry. These data are relevant not only as a measure of prevalence of conditions seen in primary care, but perhaps more importantly as a measure of the prevention of chronic diseases that disproportionately affect the underserved.
Assuntos
Participação da Comunidade/métodos , Atenção Primária à Saúde/organização & administração , Sistema de Registros , Pesquisa/organização & administração , Comportamentos Relacionados com a Saúde , Nível de Saúde , Humanos , Cobertura do Seguro/estatística & dados numéricos , Seguro Saúde/estatística & dados numéricos , Características de Residência/estatística & dados numéricos , Fatores SocioeconômicosRESUMO
BACKGROUND: Serum 25-hydroxyvitamin D (25(OH)D) is low in obese adults. OBJECTIVE: To examine serum 25(OH)D in obese (BMI >95th percentile for age) vs. non-obese (BMI = 5th-75th percentile for age) 6-10-year-old African American children and compare their differences in therapeutic response to vitamin D supplementation. METHODS AND PROCEDURES: In an open label non-randomized pre-post comparison 21 obese (OB) and 20 non-obese (non-OB) subjects matched for age, sex, skin color, and pubertal maturation were treated with 400 IU of vitamin D(3) daily for 1 month. Serum 25(OH)D, 1,25-dihydroxyvitamin D (1,25(OH)(2)D), parathyroid hormone (PTH), leptin, and markers of bone turnover (serum bone-specific alkaline phosphatase (BSAP), osteocalcin (OC), and urine n -telopeptide cross-links of type 1 collagen (urine NTX)) were measured. Vitamin D deficiency was defined as serum 25(OH)D < or =20 ng/ml and insufficiency as 21-29 ng/ml respectively. RESULTS: Vitamin D deficiency occurred in 12/21 (57%) OB vs. 8/20 (40%) non-OB at baseline (P = 0.35) and persisted in 5/21 (24%) OB vs. 2/18 (11%) non-OB (P = 0.42) after treatment. When the cohort was stratified by the baseline levels of 25(OH)D, there were differences in the response to treatment in the obese and non-obese cohorts. DISCUSSION: Vitamin D deficiency was common among OB and non-OB preadolescent African American children, and 400 IU of vitamin D(3) (2x the recommended adequate intake) daily for 1 month was inadequate to raise their blood levels of 25(OH)D to > or =30 ng/ml.
Assuntos
Negro ou Afro-Americano , Obesidade/metabolismo , Deficiência de Vitamina D/tratamento farmacológico , Vitamina D/uso terapêutico , Negro ou Afro-Americano/etnologia , Fosfatase Alcalina/sangue , Osso e Ossos/metabolismo , Criança , Colágeno Tipo I/urina , Suplementos Nutricionais , Relação Dose-Resposta a Droga , Feminino , Humanos , Leptina/sangue , Masculino , Obesidade/etnologia , Osteocalcina/sangue , Cooperação do Paciente , Peptídeos/urina , Prevalência , Vitamina D/administração & dosagem , Vitamina D/análogos & derivados , Vitamina D/sangue , Deficiência de Vitamina D/sangue , Deficiência de Vitamina D/etnologiaRESUMO
We measured the frequency and outcome of cervical cancer prevention failures that occurred in the Papanicolaou (Pap) and colposcopy testing phases involving 1,646,580 Pap tests in 4 American hospital systems between January 1, 1998, and December 31, 2004. We defined a screening failure as a 2-step or greater discordant Pap test result and follow-up biopsy diagnosis. A total of 5,278 failures were detected (0.321% of all Pap tests); 48% and 52% of failures occurred in the Pap test and colposcopy phases, respectively. Missed squamous cancers (1 in 187,786 Pap tests), glandular cancers (1 in 19,426 Pap tests), and high-grade lesions (1 in 6,870 Pap tests) constituted 4.1% of all failures. Unnecessary repeated tests or diagnostic delays occurred in 70.8% and 63.9% of failures involving high- and low-grade lesions, respectively. We conclude that cervical cancer prevention practices are remarkably successful in preventing squamous cancers, although a high frequency of failures results in low-impact negative outcomes.
Assuntos
Colposcopia/estatística & dados numéricos , Erros de Diagnóstico/estatística & dados numéricos , Programas de Rastreamento/estatística & dados numéricos , Teste de Papanicolaou , Valor Preditivo dos Testes , Neoplasias do Colo do Útero/diagnóstico , Esfregaço Vaginal/estatística & dados numéricos , Colposcopia/normas , Erros de Diagnóstico/normas , Feminino , Humanos , Programas de Rastreamento/normas , Estadiamento de Neoplasias , Administração dos Cuidados ao Paciente/estatística & dados numéricos , Reprodutibilidade dos Testes , Neoplasias do Colo do Útero/prevenção & controle , Esfregaço Vaginal/normasRESUMO
PURPOSE: Interpreting the rapidly changing speech skills of young children recovering from neurological injury is difficult because developmental expectations are generally available only at relatively lengthy intervals (e.g., 6 or 12 months). In this research note, the authors describe the process of generating a Percentage of Consonants Correct-Revised (PCC-R; L. D. Shriberg, D. Austin, B. A. Lewis, J. L. McSweeny, & D. L. Wilson, 1997a) performance curve and illustrate some of its applications for assessing change in performance over time. METHOD: The authors compiled mean PCC-R scores from 16 samples of typically developing children (18-172 months) and used curve fitting to test more than 11,000 statistical models of monthly growth in PCC-R. They selected a parsimonious and developmentally plausible model with R(2) = .9839 (p < .0005) and used it to generate the PCC-R, standard deviation, and standard error expected at each monthly age. RESULTS: The PCC-R performance curve distinguished among 65 children (37-57 months of age) diagnosed independently with normal or disordered speech with a high degree of success. More important, the PCC-R performance curve can be used to identify the points at which children (18-172 months) recovering from neurological injury achieve normal-range consonant production. CONCLUSION: The curve-fitting approach holds promise as a means of interpreting temporal variations in speech production at a finer grain than existing normative data currently allow.
Assuntos
Lesões Encefálicas/complicações , Testes de Articulação da Fala/métodos , Testes de Articulação da Fala/normas , Distúrbios da Fala/diagnóstico , Distúrbios da Fala/etiologia , Adolescente , Criança , Pré-Escolar , Feminino , Humanos , Lactente , Masculino , Fonética , Reprodutibilidade dos Testes , FalaRESUMO
OBJECTIVE: Describe the safety and efficacy of antithymocyte globulin or alemtuzumab preconditioning, steroid avoidance and reduced calcineurin inhibitor (CNI) immunosuppression in 34 children undergoing renal transplantation. METHODS: ATG (n=8) or alemtuzumab (n=26) were infused at the time of transplantation. This was followed by low-dose twice a day tacrolimus monotherapy with consolidation to once daily dosing by 6 months and once every other day dosing by 12 months. Follow-up ranged from 0.5-2.9 years (mean 1.33 years), with a minimum of 6 months. RESULTS: Both ATG and alemtuzumab were well tolerated. Lymphopenia occurred routinely and resolved after 3-6 months. Acute cellular rejection occurred in 9%; it was related to medical nonadherence in two patients and resulted in one graft loss at 1.5 years. Important adverse events included transient neutropenia in 10 children (none with serious infection), and autoimmune hemolytic anemia in two (resolved with a steroid course in both and conversion to sirolimus in one). Estimated glomerular filtration rate (e-GFR) was stable and averaged 88 mL/min/1.73 m2 at latest follow-up. Fifteen preadolescents had a greater increase in height Z-score at 1 year (1.3 vs. 0.5, P=0.001), and a higher e-GFR (94.8+/-21 vs. 76.6+/-20 ml/min/1.73 m2, P<0.05), when compared to case-matched historical controls who were weaned off steroids by 6 months after transplantation and received twice daily tacrolimus monotherapy. CONCLUSION: This simple regimen appears safe, has a low risk for acute cellular rejection or other adverse effects, and is associated with excellent growth and renal function. Such a regimen may also improve compliance and limit CNI nephrotoxicity.
Assuntos
Transplante de Rim/imunologia , Depleção Linfocítica/métodos , Tacrolimo/uso terapêutico , Condicionamento Pré-Transplante/métodos , Adolescente , Alemtuzumab , Anemia/epidemiologia , Anticorpos Monoclonais/uso terapêutico , Anticorpos Monoclonais Humanizados , Anticorpos Antineoplásicos/uso terapêutico , Soro Antilinfocitário/uso terapêutico , Criança , Pré-Escolar , Creatinina/sangue , Seguimentos , Taxa de Filtração Glomerular , Humanos , Imunossupressores/uso terapêutico , Lactente , Cuidados Intraoperatórios , Nefropatias/classificação , Nefropatias/cirurgia , Complicações Pós-Operatórias/epidemiologia , Resultado do TratamentoRESUMO
BACKGROUND: Developmental impairments in children have been attributed to persistent middle-ear effusion in their early years of life. Previously, we reported that among children younger than 3 years of age with persistent middle-ear effusion, prompt as compared with delayed insertion of tympanostomy tubes did not result in improved cognitive, language, speech, or psychosocial development at 3, 4, or 6 years of age. However, other important components of development could not be assessed until the children were older. METHODS: We enrolled 6350 infants soon after birth and evaluated them regularly for middle-ear effusion. Before 3 years of age, 429 children with persistent effusion were randomly assigned to undergo the insertion of tympanostomy tubes either promptly or up to 9 months later if effusion persisted. We assessed literacy, attention, social skills, and academic achievement in 391 of these children at 9 to 11 years of age. RESULTS: Mean (+/-SD) scores on 48 developmental measures in the group of children who were assigned to undergo early insertion of tympanostomy tubes did not differ significantly from the scores in the group that was assigned to undergo delayed insertion. These measures included the Passage Comprehension subtest of the Woodcock Reading Mastery Tests (mean score, 98+/-12 in the early-treatment group and 99+/-12 in the delayed-treatment group); the Spelling, Writing Samples, and Calculation subtests of the Woodcock-Johnson III Tests of Achievement (96+/-13 and 97+/-16; 104+/-14 and 105+/-15; and 99+/-13 and 99+/-13, respectively); and inattention ratings on visual and auditory continuous performance tests. CONCLUSIONS: In otherwise healthy young children who have persistent middle-ear effusion, as defined in our study, prompt insertion of tympanostomy tubes does not improve developmental outcomes up to 9 to 11 years of age. (ClinicalTrials.gov number, NCT00365092 [ClinicalTrials.gov].).
Assuntos
Desenvolvimento Infantil , Ventilação da Orelha Média , Otite Média com Derrame/cirurgia , Criança , Pré-Escolar , Feminino , Seguimentos , Humanos , Masculino , Testes PsicológicosRESUMO
Medical students, residents, postdoctoral fellows, and faculty commonly consult with biostatistical experts about study design and data analysis when conducting clinical research. The role of biostatistical training during these consultations is examined, and characterizations of the connections between biostatistical consultation and education are reviewed. The presence and kinds of teaching efforts during biostatistical consults at four academic research institutions over various periods of time between 1999 and 2005 (237 consultations in total) were recorded and are described. By site, 67, 70, 78, and 100 per cent of the consulting sessions included biostatistical training, with an overall 78 per cent (95 per cent CI: 73-83 per cent) of consultations including an educational component when all consultations were combined. Training covered a wide range of biostatistical topics. Seventy-five per cent of the consultations with faculty (120/161), 79 per cent with fellows and residents (31/39), and 100 per cent with medical students (10/10) included some degree of instruction in study design or statistical analysis topics. Results show that both the need and the opportunity exist for specialized biostatistical instruction during one-on-one sessions between a consulting biostatistician and physicians, medical students, and research staff. Academic researchers are ideally positioned to absorb this kind of training when they initiate a request for assistance with their own research project.
Assuntos
Biometria , Consultores , Educação Médica/métodos , Estatística como Assunto/educação , HumanosRESUMO
Immunoreactivity, immunosuppression requirement and liver graft function was assessed serially for its relationship to delayed/recurrent acute cellular rejection (ACR) after the first 60 days in 36 pediatric primary liver transplant (LTx) recipients. Subjects were classified as rejectors (n=20) or Non-Rejectors (n=16) based on the presence/absence of biopsy-proven ACR in the first 60 days. All children received anti-lymphocyte induction and steroid-free Tacrolimus or Sirolimus monotherapy, as reported previously. Median age was 4 years (0.45-18) and follow-up was 570 days (106-1144). Compared with non-rejectors, rejectors 1. took significantly longer to achieve reduced donor-specific alloreactivity by MLR (p=0.049), and "low" TAC/SRL whole blood requirements defined as TAC levels < or = 8 ng/ml (p=0.0048), 2. experienced significantly greater variation in time to achieve reduced donor-specific immunoreactivity (SEM 0.8 vs 3.85, p=0.0048), and 3. experienced greater ACR incidence during minimization of immunosuppression (35% versus 6%, p=0.032). Serial monitoring of immunoreactivity may increase the safety with which immunosuppression is minimized in pediatric LTx.
Assuntos
Rejeição de Enxerto/prevenção & controle , Imunossupressores/uso terapêutico , Transplante de Fígado , Adolescente , Criança , Pré-Escolar , Feminino , Rejeição de Enxerto/diagnóstico , Rejeição de Enxerto/epidemiologia , Humanos , Imunossupressores/sangue , Incidência , Lactente , Teste de Cultura Mista de Linfócitos , Recidiva , Sirolimo/sangue , Sirolimo/uso terapêutico , Tacrolimo/sangue , Tacrolimo/uso terapêutico , Doadores de Tecidos , Transplante HomólogoRESUMO
Pathologists exhibit very poor agreement in adjudicating the cause of cytologic-histologic correlation discrepancies, which contributes to problems in designing interventions to reduce discrepancy frequency. In this observational study, we developed a visual method of adjudicating discrepancy cause, termed the No-Blame Box method, which consisted of initially assessing specimen interpretability by separately evaluating specimen quality and the presence of tumor. Five pathologists blindly adjudicated the cause of discrepancy in pulmonary specimens from 40 patients. The kappa statistic of all pathologist pairs in adjudicating discrepancy cause using the No-Blame Box method ranged from 0.400 to 0.796, indicating acceptable to excellent agreement. Pathologists ranged in their assessment of specimen interpretability from 13% to 20%, and in no case did all 5 pathologists concur that a specimen was interpretable. Most discrepancies resulted from pathologists diagnosing noninterpretable samples. Pathologists who used the No-Blame Box showed significant agreement in the adjudication of discrepancy cause.
Assuntos
Consenso , Erros de Diagnóstico , Variações Dependentes do Observador , Patologia Cirúrgica/métodos , Garantia da Qualidade dos Cuidados de Saúde/métodos , Humanos , Modelos Estatísticos , Patologia Cirúrgica/normas , Reprodutibilidade dos Testes , Método Simples-CegoRESUMO
Cross-sectional studies have shown that 1) adolescents are insulin resistant compared with prepubertal children and adults, 2) pubertal insulin resistance is likely mediated by growth hormone (GH), and 3) pubertal insulin resistance is associated with increased fat oxidation and decreased glucose oxidation. The aim of this study was to assess the validity of these cross-sectional observations by performing a longitudinal study in normal children during the prepubertal and pubertal periods. Nine healthy, normal weight, prepubertal children underwent hyperinsulinemic-euglycemic and hyperglycemic clamp studies for evaluation of insulin sensitivity and insulin secretion. Children had repeat evaluations during puberty. Consistent with cross-sectional observations, this longitudinal study demonstrated that during puberty: 1) insulin sensitivity decreased by approximately 50%, 2) the decrease in insulin sensitivity was compensated by a doubling in insulin secretion, and 3) the decrease in insulin sensitivity was independent of changes in percentage of body fat. Puberty was associated with increased total body lipolysis and decreased glucose oxidation. A novel observation is the demonstration of approximately 50% decrease in adiponectin levels at the pubertal time point. These metabolic changes are proposed to be partially mediated by increased GH secretion and are consistent with the Randle cycle of competition between glucose and fat oxidation.
Assuntos
Glucose/metabolismo , Resistência à Insulina/fisiologia , Metabolismo dos Lipídeos/fisiologia , Puberdade/metabolismo , Adiponectina/metabolismo , Composição Corporal/fisiologia , Criança , Pré-Escolar , Feminino , Técnica Clamp de Glucose , Hormônio do Crescimento/metabolismo , Homeostase/fisiologia , Humanos , Fator de Crescimento Insulin-Like I/metabolismo , Leptina/metabolismo , Estudos Longitudinais , Masculino , Oxirredução , Puberdade/fisiologiaRESUMO
CONTEXT: Markers to identify overweight youth with insulin resistance are of clinical importance. OBJECTIVE: To determine if markers of dyslipidemia could identify overweight adolescents with insulin resistance. SETTING, PARTICIPANTS, AND STUDY DESIGN: We retrospectively examined the association between markers of dyslipidemia and insulin resistance in 35 overweight [body mass index (BMI) of > or =95th percentile], white adolescents [mean age 13.5 +/- (SD) 1.6 yr] who had participated in hyperinsulinemic-euglycemic clamp studies to evaluate insulin action. Total body fat was measured by dual-energy X-ray absorptiometry and abdominal fat with computed tomography. Using receiver-operating curves, cut-points for triglyceride (TG)/high-density lipoprotein (HDL) and TG level to identify overweight individuals in the lowest tertile for insulin sensitivity were determined. MAIN OUTCOME MEASURE: Difference in the values for insulin sensitivity among the groups. RESULTS: Of the markers examined (TG, TG/HDL, adiponectin, measures of adiposity and fasting insulin), fasting insulin was the strongest correlate of insulin sensitivity (r = 0.87, p < 0.001). Youth with TG/HDL level > or =3 had lower insulin sensitivity (50% lower median values, p < 0.01) and higher visceral fat (p < 0.05) despite BMI comparable to that of youth with TG/HDL level <3. Youth with TG/HDL > or =3 had a sensitivity of 61% and specificity of 82% for identifying participants with the greatest degree of insulin resistance. CONCLUSIONS: TG and TG/HDL are easily obtained markers associated with insulin resistance. Further research is needed to determine if a constellation of clinical findings, such as components of the metabolic syndrome along with other metabolic markers including adiponectin, better predicts insulin resistance in overweight youth.