How to develop a sustainable telemedicine service? A Pediatric Telecardiology Service 20 years on - an exploratory study.

BACKGROUND: Telemedicine services are promoting more access to healthcare. Portugal was an early adopter of telemedicine to overcome both its geological barriers and the shortage of healthcare professionals. The Pediatric Cardiology Service (PCS) at Coimbra University Hospital Centre (CHUC) has been using telemedicine to increase access and coverage since 1998. Their Pediatric Telecardiology Service has been daily connecting CHUC with 13 other Portuguese national hospitals, and regularly connecting with Portuguese-speaking African countries, through a teleconsultation platform. METHODS: This study aims at exploring the Pediatric Telecardiology Service's evolution, through a comprehensive assessment of the PCS's development, evolution and impact in public health, to better understand the critical factors for implementation and sustainability of telemedicine, in the context of healthcare services digitalization. A case study was performed, with cost-benefit, critical factors and organizational culture assessment. Finally, the Kingdon's framework helped to understand the implementation and scale-up process and the role of policy-making. RESULTS: With the total of 32,685 out-patient teleconsultations, growing steadily from 1998 to 2016, the Pediatric Telecardiology Service has reached national and international recognition, being a pioneer and an active promotor of telemedicine. This telemedicine service has saved significant resources, about 1.1 million euros for the health system (e.g. in administrative and logistic costs) and approximately 419 euros per patient (considering an average of 1777 patients per year). PCS presents a dominant "Clan" culture. The Momentum's critical factors for telemedicine service implementation enabled us to understand how barriers were overcome (e.g. political forces). Willingness, perseverance and teamwork, allied with partnership with key stakeholders, were the foundation for professionals' engagement and service networking development. Its positive results, new regulations and the increasing support from the hospital board, set up a window of opportunity to establish a sustainable telemedicine service. CONCLUSION: The Pediatric Telecardiology Service enables real-time communication and the sharing of clinical information, overcoming many barriers (from geographical ones to shortage of healthcare professionals), improving access to specialized care both in Portugal and Africa. Motivation and teamwork, and perseverance, were key for the Pediatric Telecardiology Service to tackle the window of opportunity which created conditions for sustainability.

Childhood adiposity: being male is a potential cardiovascular risk factor.

As the earliest atherosclerotic lesions begin during childhood, our aim was to correlate gender-related adiposity to classical cardiovascular risk factors in a group of children.An observational and transversal analysis was carried out in a cohort consisting of 161 children of both sexes, aged 6 to 17 years of age. Waist circumference was correlated to leptin, high-sensitivity C-reactive protein, systolic and diastolic blood pressure, plasma lipids, homeostasis model assessment-insulin resistance, and the left ventricular mass index. After adjusting for age, waist circumference in boys, compared to girls, correlated more strongly and directly to systolic (r = 0.538; p < 0.001) and diastolic blood pressure (ρ = 0.401; p < 0.01), ApoB/ApoA ratio (ρ = 0.515; p < 0.01), high-density lipoprotein cholesterol (r = -0.441; p < 0.001), low-density lipoprotein cholesterol (ρ = 0.280; p < 0.01), triglycerides (ρ = 0.420; p < 0.001), homeostasis model assessment-insulin resistance (ρ = 0.463; p < 0.001), and the left ventricular mass index (ρ = 0.286; p < 0.01). A similar pattern was observed regarding the correlations between leptin, high-sensitivity C-reactive protein, and the above parameters (except between high-sensitivity C-reactive protein and diastolic blood pressure), and also, particularly in boys. CONCLUSION: Although increased childhood adiposity is related to a more adverse metabolic and clinical profile in both genders, males appear to have a potentially greater cardiovascular risk. WHAT IS KNOWN: Obesity is characterized by a chronic low-grade inflammatory process. WHAT IS NEW: Increased adiposity is related to a more pronounced pro-inflammatory response in boys. Childhood male adiposity is a potentially greater cardiovascular risk factor. Arterial hypertension, insulin resistance, and dyslipidemia is more strongly correlated to waist circumference in boys.

[Infective endocarditis as a form of late presentation of congenital heart disease]. / Endocardite infecciosa como primeira manifestação de cardiopatia congénita de apresentação tardia.

A diagnosis of congenital heart disease is usually established at an early age, so infective endocarditis is a rare form of presentation. The authors describe the case of a male adolescent with a week-long history of intermittent fever and unquantified weight loss. Physical examination detected pansystolic and diastolic murmurs, and an associated precordial thrill. Laboratory tests showed evidence of an active infection. Etiological investigation revealed a perimembranous ventricular septal defect, aortic regurgitation, and aortic and mitral valve vegetations. A diagnosis of mitral-aortic infective endocarditis was made and he was started on intravenous antibiotics and anticongestive therapy. After initial clinical improvement, he developed symptoms and signs of congestive heart failure. Repeat echocardiography showed an extensive mitral-aortic paravalvular abscess. The antibiotics were changed and anticongestive therapy was intensified, and he subsequently underwent surgery. The outcome has been generally favorable, and at present he is asymptomatic under anticongestive therapy.

[Teleconsultation in the Portuguese National Health Service During the COVID-19 Pandemic: A Survey of Physicians' Views and Future Implications]. / Consulta Não Presencial no Serviço Nacional de Saúde Português Durante a Pandemia de COVID-19: Estudo da Opinião dos Médicos e Implicações para o Futuro.

INTRODUCTION: The COVID-19 pandemic led to the reorganization of healthcare services and teleconsultation emerged as a solution to facilitate patient appointments. The aim of this study was to characterize, from a physician perspective, the teleconsultations carried out in the Portuguese National Health Service (SNS) during the first phase of the pandemic and to identify factors that influence the experience of the teleconsultation. MATERIAL AND METHODS: A cross-sectional analytical study was conducted based on an online survey, between July-September 2020, aimed at SNS doctors. Data on demographics, practice, attitudes and perceptions associated with the teleconsultation was collected. The adjusted prevalence ratio (aPR) was calculated to identify demographic factors and determinants of teleconsultation associated with satisfaction, use of video calls and greater motivation to carry out teleconsultations in the future. RESULTS: 2225 valid responses were obtained. Teleconsultation was carried out by 93.8% of participants in this period, 99.0% used the telephone as a form of communication and only 8.0% used a video call. A high degree of satisfaction with the teleconsultation was significantly associated with perceiving the teleconsultation as providing care with equivalent quality to a face-to-face consultation (aPR = 1.472) and being motivated to do teleconsultation after the pandemic (aPR = 4.081). Reporting clinical (aPR = 0.763) or technical difficulties (aPR = 0.666) was negatively associated with satisfaction). 70.4% of doctors would like to continue doing follow-up teleconsultations and 53.3% consider that video call technologies should always or often be used during teleconsultations. CONCLUSION: Teleconsultation seems to have potential to to become a common practice in the future. However, it is important to address clinical, technical, organizational, and legal questions and, above all, to ensure that it is a safe and valuable practice for patients.

Introdução: A pandemia de COVID-19 impôs uma reorganização dos serviços de saúde e a teleconsulta surgiu como solução para manter o acompanhamento dos utentes. Este estudo caracterizou, pela perspetiva dos médicos, a consulta não presencial (CNP) realizada no Serviço Nacional de Saúde (SNS) durante a primeira fase da pandemia e identificou fatores que influenciam a experiência da consulta.Material e Métodos: Estudo transversal analítico com base num questionário online dirigido aos médicos do SNS entre julho e setembro de 2020. Recolheram-se dados demográficos e informação sobre a prática, atitudes e perceções relativas à CNP. Foram calculadas razões de prevalência através de regressões Poisson, ajustadas para identificar fatores associados a maior satisfação, utilização de videochamada e maior motivação para realizar teleconsultas no futuro.Resultados: Obtiveram-se 2225 respostas válidas. A CNP foi realizada por 93,8% dos inquiridos neste período, dos quais 99,0% utilizou o telefone como forma de comunicação e apenas 8,0% a videochamada. Registámos elevada satisfação com as CNP realizadas, com significativa associação à ideia de que a CNP providencia cuidados de saúde de qualidade equivalentes à consulta presencial [adjusted prevalence ratio (aPR) = 1,472], e adesão à realização de CNP após a pandemia (aPR = 4,081). A existência de dificuldades clínicas (aPR = 0,763) ou técnicas (aPR = 0,666) esteve associada a menor satisfação. Entre os médicos respondentes, 70,4% gostariam de continuar a realizar CNP subsequentes e 53,3% consideram que deve ser sempre ou muitas vezes utilizado suporte de vídeo na CNP.Conclusão: A teleconsulta parece ter potencial para se tornar uma prática comum no futuro. No entanto importa solucionar limitações de natureza clínica, técnica, organizacional e legal e, assegurar que é uma prática segura, benéfica e valorizada pelo utente.

[Asymptomatic cardiac tumor in a child: an incidental diagnosis]. / Tumor cardíaco em criança assintomática: um diagnóstico acidental.

Cardiac tumors in the pediatric population are rare, their incidence range between 0.001% and 0.003%. They are mostly benign, rhabdomyomas the most common type, followed by fibromas. The clinical features are being usually nonspecific and depend on the size and location of the tumor within the heart. We report the case of a previously healthy four-year-old boy referred for flu-like symptoms. A respiratory infection was suspected and a chest X-ray showed an increased cardiothoracic index. An echocardiogram revealed a single large heterogeneous mass in the left ventricle emerging from the lateral wall. Despite its size, the mass did not obstruct the left ventricular outflow tract or affect mitral valve function. Cardiac magnetic resonance imaging showed a large mass whose imaging features were suggestive of a fibroma. He became symptomatic during follow-up and was referred for surgical excision of the mass. Histological study confirmed a fibroma. At present the patient remains asymptomatic.

Left ventricular noncompaction: analysis of a pediatric population.

INTRODUCTION: Left ventricular noncompaction (LVNC) is a rare and potentially progressive cardiomyopathy, characterized by the persistence of multiple trabeculations and deep intratrabecular recesses in the ventricular myocardium. Although two-dimensional and color Doppler echocardiography are the most useful diagnostic modalities, cardiac magnetic resonance imaging has proved to have high sensitivity and specificity in the diagnosis of this anomaly. OBJECTIVE: To characterize the clinical and imaging features of LVNC in a pediatric population and to assess their evolution. METHODS AND RESULTS: We performed a retrospective chart review of five pediatric patients with LVNC, followed at Coimbra Pediatric Hospital between January 1999 and December 2007. Median age at presentation was five months (ranging from one day to 13 years), and they were mainly male (1.5:1). Two of the children had a family history of sudden death. In one case the clinical presentation was cardiac arrest due to ventricular fibrillation and in three others, congestive cardiac failure. None of the five cases had associated congenital cardiac anomalies. Involvement of the ventricular apical region was found in all cases. Four children additionally had ventricular dysfunction which improved with diuretic and vasodilator therapy. Mean follow-up was 34 months, ranging from six months to seven years. In one case a change in the morphological phenotype was noted, from a dilated to a hypertrophic form. In this case and in the child's father a mutation in the MYBPC3 gene was identified, which is associated with hypertrophic cardiomyopathy. No thromboembolic phenomena or deaths occurred during the study period. CONCLUSION: In the pediatric population, congestive cardiac failure is the most common clinical presentation of LVNC, which can coexist with other cardiomyopathies, particularly dilated and hypertrophic forms. The sample presented in this analysis is statistically non-significant due to its limited size and the authors highlight the need for larger prospective studies in the pediatric population in order to clarify this disease and its diagnostic criteria.

Unusual cause of left ventricular dysfunction in a child. / Causa rara de disfunção ventricular esquerda em idade pediátrica.

Anomalous Origin of the Left Coronary Artery from the Pulmonary Artery is a rare congenital heart disease and a cause of myocardial ischemia during childhood. Most undiagnosed cases die in the first year of life as an extensive collateral network is essential for survival. The diagnosis requires a high index of clinical suspicion. The authors present the case of an 8-year-old black asymptomatic child referred from Cape Verde Island in order to clarify left ventricular dilatation and dysfunction with systo-diastolic turbulent flows observed at the interventricular septum. At the age of 3 months, she was diagnosed with heart failure, in the context of showing dilated cardiomyopathy. She was managed and clinically improved with anticongestive therapy, which she was still taking at the time of admission to our Center. The echocardiogram findings suggested Anomalous Origin of the Left Coronary Artery from the Pulmonary Artery and the diagnosis was confirmed by computerized angiotomography and cardiac catheterization. The patient was successfully submitted to direct implantation of the left coronary artery into the aorta, allowing the creation of a double coronary perfusion system. This case illustrates an unusual presentation of a rare pathology that survived without a diagnosis after the first year of life. It also reinforces the importance of multimodality image screening in these cases.

Innocent heart murmurs.

Innocent heart murmur is a frequent auscultatory finding in children. The diagnosis is essentially clinical, without need for further investigation. However, excluding heart disease can be a difficult task. This review article describes some features of medical history and physical examination that help in this differentiation. The role of diagnostic tests is also examined.

Importance of ambulatory blood pressure monitoring in the diagnosis and prognosis of pediatric hypertension. / Importância da monitorização ambulatória da pressão arterial no diagnóstico e prognóstico da hipertensão arterial em idade pediátrica.

The prevalence of high blood pressure (BP) at pediatric age has increased progressively, one of the causes of which is obesity. However, the dominant etiology in this age group is renal and/or cardiovascular pathology. Ambulatory blood pressure monitoring (ABPM) is the method of choice for the diagnosis of hypertension, especially in children at high cardiovascular risk. Its use is limited to children from five years of age. Choosing appropriate cuff size is key to obtaining correct blood pressure. The main indication for ABPM is to confirm the diagnosis of hypertension. It also allows the diagnosis of white coat hypertension (which may represent an intermediate stage between the normotensive phase and hypertension), or masked hypertension, associated with progression to sustained hypertension and left ventricular hypertrophy (LVH). Children with isolated nocturnal hypertension should be considered as having masked hypertension. BP load is defined as the percentage of valid measurements above the 95th percentile for age, gender, and height. Values above 25-30% are pathological and those above 50% are predictive of LVH. ABPM correlates with target organ damage, particularly LVH and renal damage. It is useful in the differentiation of secondary hypertension, since these children show higher BP load and less nocturnal dipping, and confirmation of response to therapy. Thus ABPM allows the diagnosis and classification of hypertension, provides cardiovascular prognostic information and identifies patients with intermediate phenotypes of hypertension.

Abdominal pain of cardiovascular origin.

Infective endocarditis is a microbial infection of the endocardium and it is rare in the pediatric population. In children, congenital heart disease is one of the most important risk factors for developing infective endocarditis and can involve other structures in addition to cardiac valves. The prognosis is generally better than in other forms of endocarditis, although the average mortality rate in the pediatric population is 15-25%. Clinical manifestations can mimic other diseases such as meningitis and collagen-vascular disease or vasculitis. Therefore, a high degree of suspicion is required to make an early diagnosis. Gram-positive bacteria, specifically alpha-hemolytic streptococci, Staphylococcus aureus and coagulase-negative staphylococci, are the most commonly involved bacteria. Diagnosis is based on the modified Duke criteria, which rely mostly on clinical assessment, echocardiography and blood cultures. Antibacterial treatment should ideally be targeted. However, if no specific bacteria have been identified, patients should promptly be treated empirically with multiple drug regimens based on local resistance and the most common etiologies. The authors describe a case of a seven-year-old girl with classic clinical signs of endocarditis, with a clinical twist.

[Premature Atherosclerosis in HIV-Infected Pediatric Patients: Literature Review and Clinical Approach]. / Aterosclerose Precoce na População Pediátrica Infetada pelo VIH: Revisão da Literatura e Abordagem Clínica.

Human immunodeficiency virus infected children and adolescents are a pediatric group with increased risk of premature cardiovascular disease. The virus itself, the antiretroviral therapy and the lifestyle establish a complex interplay of factors that promotes an accelerated atherosclerosis. This process is probably mediated by dyslipidaemia, dysregulation of glucose metabolism, lipodystrophy, inflammation, endothelial dysfunction and a prothrombotic state. The clinical approach to this population in terms of cardiovascular prevention is mainly based on efficient treatment of the infection, reduction of the modifiable risk factors and promotion of lifestyle changes.

As crianças e adolescentes infetados pelo vírus da imunodeficiência humana representam um grupo pediátrico com risco acrescido de doença cardiovascular precoce. O próprio vírus, a terapêutica antirretrovírica e os estilos de vida estabelecem um complexo conjunto interatuante de fatores que promove a aterosclerose acelerada. Este processo é provavelmente mediado por dislipidémia, alterações do metabolismo glicídico, inflamação crónica com disfunção endotelial e um estado pro-trombótico. A abordagem clínica desta população para prevenção cardiovascular é baseada sobretudo num tratamento eficaz da infeção, na redução dos fatores de risco modificáveis e na promoção de hábitos saudáveis.

Five years of teleconsultation: experience of the Cardiology Department of Coimbra Pediatric Hospital.

BACKGROUND: Telemedicine is an excellent tool to expand specialized medical care, providing better access for patients and lowering costs for their families. The objective of this work was to evaluate the reliability of teleconsultation in pediatric cardiology, with similar results to traditional consultation. It can be a useful tool to upgrade technical skills among the staff involved and to improve the quality of life of patients and families. METHODS: The authors present their 5 years' experience of pediatric cardiology teleconsultation involving Coimbra Central Pediatric Hospital and district hospitals in the central region of Portugal. During this period 1761 consultations, involving 1056 patients, were given with a pre-established weekly schedule for each hospital and joint online reports were produced, with data confidentiality assured. RESULTS: Cardiac murmur was the most common reason for consultation (73%). No heart disease was diagnosed in 49% of the patients. Among septal defects, accounting for 43%, ventricular septal defect was the most frequent (20%). Only 10% of all patients had to be seen in the Pediatric Hospital Cardiology Department. Six emergency consultations were requested. CONCLUSIONS: Pediatric cardiology teleconsultation is a reliable procedure using the Medigraf platform, with a similar error rate to consultations by traditional methods. The costs are lower, especially for the families, who do not have to travel far from home or take time off work. The waiting time for a consultation is shorter and therapeutic decisions are faster. A pediatric cardiologist can cover a larger geographic area and the cooperative work during sessions is useful for exchanging knowledge and experiences.

[Obesity: Paradigm of Endothelial Dysfunction in Paediatric Age Groups]. / Obesidade: Paradigma da Disfunção Endotelial em Idade Pediátrica.

INTRODUCTION: Obesity is considered a global epidemic with important public health issues as it is an independent risk factor in the development of cardiovascular disorders. MATERIAL AND METHODS: Approximately 10% of the worldâÄôs paediatric population has excess weight or obesity and 40% of these will be obese adults. Obesity is characterized by a chronic, low grade, pro-inflammatory process that ultimately results in endothelial dysfunction, the trigger lesion leading to adult cardiovascular disease. This leads to an imbalance in the synthesis of mediators that normally regulate vascular homeostasis, particularly nitric oxide bioavailability, favoring a pro-atherosclerotic status, the hallmark of cardiovascular disorders. RESULTS: These changes begin early in childhood and anatomopathological studies in children with excess weight or obesity have shown endothelial changes that represent the precursors of the atherosclerotic lesion. DISCUSSION: Endothelial dysfunction is the earliest manifestation of the atherosclerotic lesion. It is evident in obese children and, as such, it potentially contributes towards cardiovascular disease in the adult. CONCLUSION: Although the clinical impact of these changes rarely manifest themselves in infancy, the presence of related biomarkers as well as vascular morphological changes can, at this early stage, be found and assessed.

Introdução: A obesidade é considerada pela Organização Mundial de Saúde como uma epidemia global sendo considerada um factor de risco cardiovascular independente.Material e Métodos: Estima-se que cerca de 10% da população pediátrica mundial apresente excesso de peso ou obesidade e que cerca de 40% sejam obesas na vida adulta. A obesidade caracteriza-se por um processo pró-inflamatório crónico que resulta na lesão do endotélio. O resultante desequilíbrio na produção de mediadores que normalmente regulam a homeostasia vascular, particularmente a biodisponibilidade do óxido nítrico, favorece um ambiente pró-aterosclerótico propício ao desenvolvimento da doença cardiovascular.Resultados: Estudos anátomo-patológicos em crianças com excesso de peso ou obesidade evidenciam lesões do endotélio que se traduzem nos precursores da lesão aterosclerótica.Discussão: A disfunção endotelial é a manifestação mais precoce da lesão aterosclerótica. Estas alterações evidenciam-se precocemente em crianças obesas, contribuindo para a doença cardiovascular no adulto.Conclusão: As repercussões clínicas destas alterações raramente se manifestam em idade pediátrica, sendo detectadas apenas através de biomarcadores, alterações morfológicas dos vasos ou modificações do tónus arterial periférico.

Insulin resistance, dyslipidemia and cardiovascular changes in a group of obese children.

INTRODUCTION: Obesity-related comorbidities are present in young obese children, providing a platform for early adult cardiovascular disorders. OBJECTIVES: To compare and correlate markers of adiposity to metabolic disturbances, vascular and cardiac morphology in a European pediatric obese cohort. METHODS: We carried out an observational and transversal analysis in a cohort consisting of 121 obese children of both sexes, between the ages of 6 and 17 years. The control group consisted of 40 children with normal body mass index within the same age range. Markers of adiposity, plasma lipids and lipoproteins, homeostasis model assessment-insulin resistance, common carotid artery intima-media thickness and left ventricular diameters were analyzed. RESULTS: There were statistically significant differences between the control and obese groups for the variables analyzed, all higher in the obese group, except for age, high-density lipoprotein cholesterol and adiponectin, higher in the control group. In the obese group, body mass index was directly correlated to left ventricular mass (r=0.542; p=0.001), the homeostasis model assessment-insulin resistance (r=0.378; p=<0.001) and mean common carotid artery intima-media thickness (r=0.378; p=<0.001). In that same group, insulin resistance was present in 38.1%, 12.5% had a combined dyslipidemic pattern, and eccentric hypertrophy was the most common left ventricular geometric pattern. CONCLUSIONS: These results suggest that these markers may be used in clinical practice to stratify cardiovascular risk, as well as to assess the impact of weight control programs.

Circulating endothelial progenitor cells in obese children and adolescents.

OBJECTIVE: This study aimed to investigate the relationship between circulating endothelial progenitor cell count and endothelial activation in a pediatric population with obesity. METHODS: Observational and transversal study, including 120 children and adolescents with primary obesity of both sexes, aged 6-17 years, who were recruited at this Cardiovascular Risk Clinic. The control group was made up of 41 children and adolescents with normal body mass index. The variables analyzed were: age, gender, body mass index, systolic and diastolic blood pressure, high-sensitivity C-reactive protein, lipid profile, leptin, adiponectin, homeostasis model assessment-insulin resistance, monocyte chemoattractant protein-1, E-selectin, asymmetric dimethylarginine and circulating progenitor endothelial cell count. RESULTS: Insulin resistance was correlated to asymmetric dimethylarginine (ρ=0.340; p=0.003), which was directly, but weakly correlated to E-selectin (ρ=0.252; p=0.046). High sensitivity C-reactive protein was not found to be correlated to markers of endothelial activation. Systolic blood pressure was directly correlated to body mass index (ρ=0.471; p<0.001) and the homeostasis model assessment-insulin resistance (ρ=0.230; p=0.012), and inversely correlated to adiponectin (ρ=-0.331; p<0.001) and high-density lipoprotein cholesterol (ρ=-0.319; p<0.001). Circulating endothelial progenitor cell count was directly, but weakly correlated, to body mass index (r=0.211; p=0.016), leptin (ρ=0.245; p=0.006), triglyceride levels (r=0.241; p=0.031), and E-selectin (ρ=0.297; p=0.004). CONCLUSION: Circulating endothelial progenitor cell count is elevated in obese children and adolescents with evidence of endothelial activation, suggesting that, during infancy, endothelial repairing mechanisms are present in the context of endothelial activation.

Pro-inflammatory triggers in childhood obesity: correlation between leptin, adiponectin and high-sensitivity C-reactive protein in a group of obese Portuguese children.

INTRODUCTION: Pediatric obesity is increasingly prevalent in the Portuguese population. Adipocyte dysfunction results in the expression of pro-inflammatory mediators that are responsible for the low-grade inflammatory process that characterizes obesity. OBJECTIVES: The aim of this study was to investigate the relationship between markers of adiposity, inflammation and adipokines in a Portuguese obese pediatric population. METHODS: One hundred and twenty children of both sexes, aged 6-17 years, were included in this study. The control group consisted of 41 healthy normal-weight children. The variables analyzed were age, gender, body mass index, waist circumference, fat mass percentage, high-sensitivity C-reactive protein (hs-CRP), leptin and adiponectin. RESULTS: There were significant differences between controls and obese children for all parameters analyzed. In the obese group, after controlling for age and gender, hs-CRP (p=0.041), adiponectin (p=0.019) and leptin (p<0.001) still showed significant statistical differences. A direct correlation was found between hs-CRP, leptin, body mass index and waist circumference, the strongest being with leptin (r=0.568; p<0.001). This trend remained statistically significant, regardless of gender or pubertal age. CONCLUSIONS: Considering the role of leptin, adiponectin and hs-CRP in the genesis of endothelial dysfunction, they may be used in clinical practice for risk stratification, as well as in the assessment of weight control programs.