Association between nutritional status and positive childhood disability screening using the ten questions plus tool in Sarlahi, Nepal

The study was conducted to examine the association between the indicators of malnutrition and disability of children as reported by caregivers. The Ten Questions Plus questionnaire was administered to caregivers of 1,902 children aged 1-9 years, during August 2007-March 2008, in rural Nepal. Height and weight of children were also measured. The main outcome was a positive response to one or more questions. In total, 514 (27%) children had a positive response to at least one question. Moderate stunting [odds ratio (OR)=1.47, 95% confidence interval (CI) 1.02-2.12) and severe (OR=2.39, 95% CI 1.60-3.57) stunting were independently associated with reported delay in sitting, standing, or walking. Severe stunting was also associated with report of delayed learning compared to other children of similar age (OR=2.01, 95% CI 1.27-3.20). Parental report of disability was quite prevalent in this setting, with over a quarter of the sample screening positive. Chronic malnutrition may be associated with delayed motor and mental development.

Human trophoblast responses to Porphyromonas gingivalis infection

Porphyromonas gingivalis is a periodontal pathogen that is also associated with preterm low-birthweight delivery. We investigated the transcriptional responses of human extravillous trophoblasts (HTR-8) to infection with P. gingivalis. Over 2000 genes were differentially regulated in HTR-8 cells by P. gingivalis. In ontology analyses of regulated genes, overpopulated biological pathways included mitogen-activated protein (MAP) kinase signaling and cytokine production. Immunoblots confirmed overexpression of the MAP kinase pathway components MEK3, p38 and Max. Furthermore, P. gingivalis infection induced phosphorylation and activation of MEK3 and p38. Increased production of interleukin (IL)-1beta and IL-8 by HTR-8 cells was demonstrated phenotypically by enzyme-linked immunosorbent assay of HTR-8 cell lysates and culture supernatants. Hence, infection of trophoblasts by P. gingivalis can impact signal transduction pathways and modulate cytokine expression, outcomes that could disrupt the maintenance of pregnancy.

Sub-Tenon's ropivacaine block for pain relief after primary strabismus surgery

PURPOSE

Pain is the main cause of patient distress/dissatisfaction after strabismus surgery. The aim of the study was to evaluate the effect of sub-Tenon's block with ropivacaine at the end of strabismus surgery on post-operative pain.

METHODS

A prospective trial was conducted in 79 patients (age 1.0-65 years) scheduled for outpatient primary strabismus surgery with fixed sutures under general anesthesia (GA) at a major tertiary hospital. Half the patients were randomly allocated to receive sub-Tenon's block with ropivacaine 0.2% at conclusion of the operation. Primary outcome measures were visual analog scale (VAS) scores at arrival to the post-anesthesia care unit (PACU), at discharge 3 hr later, 12-16 hr post-operatively, and 24 hr post-operatively. Supplemental analgesia requirements and patient satisfaction were recorded as well. Data were presented as median (range). Mann-Whitney test, Pearson chi(2)-test or Fisher's exact test was used for statistical analysis; p <or= 0.05 was considered significant.

RESULTS

There were no between-group differences in median VAS scores at arrival to the PACU and at discharge, with a borderline difference at 24 hr post-operatively (p = 0.06). At 12-16 hr post-operatively, the median score was 0.0 (range 0-5) in the study group and 4.0 (range 0-6) in the controls (p < 0.001). The lower VAS score in the study group was associated with a lower rate of supplemental analgesia use (21.9% versus 57.9%, p = 0.001), fewer doses of supplemental analgesia (10 doses versus 35, p = 0.03), and higher patient satisfaction (p < 0.001).

CONCLUSIONS

Sub-Tenon's block with ropivacaine 0.2% at the completion of outpatient primary strabismus surgery with fixed sutures under GA reduces pain 12-16 hr post-operatively and analgesia requirements 4-23 hr post-operatively.

The Development of an Assertiveness Self-Report Inventory

The development of a self-report measure of assertiveness is described. The Assertiveness Self-Report Inventory (ASRI) was devised with concern for endorsement frequency, internal consistency, and independence from social desirability response bias. The scale's reliability and convergent and discriminant validity are adequate. Further tests of validity support the use of the scale as a measure that taps behavior related to the construct of assertiveness.

Case report: Sanjad--Sakati syndrome: dental findings and treatment

BACKGROUND

Sanjad--Sakati syndrome (SSS) is a genetic disease confined to Arab populations in the Middle- East countries and characterized by hypoparathyroidism, hypocalcaemia and hyperphosphataemia, severe intrauterine and postnatal growth failure, respiratory infection susceptibility prone, dwarfism, mental retardation, seizures, craniofacial dysmorphic features as retromicrognathia and abnormal dentition.

CASE REPORT

A 12 year-old child was referred who needed dental treatment because of his oral and systemic condition. Radiographic findings showed agenesis of 12 permanent teeth (all canines and premolars).

TREATMENT

Because of the child's physical limitations and cooperation, treatment was under general anaesthesia. Plaque removal, restorations and extractions of infected teeth were performed.

FOLLOW-UP

The child was observed after one year, plaque removal was carried out and fluoride varnish was placed on all teeth. However, the patient died 18 months later as a result of pulmonary complications.

CONCLUSION

People with poor systemic conditions and physical limitations are prone to dental health neglect. Early professional advice and treatment, and periodical follow-up can improve quality of life of these patients.

Infectious complications of peripherally inserted central venous catheters in children

BACKGROUND

Peripherally inserted central venous catheters (PICCs) are frequently used in infants and children. However, only limited data are available on current infectious and noninfectious complications of PICCs in this patient population. The aim of the study is to define the current rate of infectious and noninfectious complications of PICCs, the causative agents, and to define possible risk factors associated with these complications.

METHODS

A prospective surveillance study was conducted at the Schneider Children Medical Center of Israel. All patients in whom a PICC was inserted between August 2004 and October 2006 were included. Demographic, clinical, and microbiologic data were collected by a questionnaire completed by the anesthesiologist at the time of insertion and removal of each catheter. Items covered epidemiologic, clinical, and microbiologic data.

RESULTS

A total of 279 PICCs were inserted in 221 patients. There were no complications at insertion. Mean dwell time was 30 days. One hundred seventy-seven (63%) of all PICC placements were free of complications. Twenty-six catheters (9.3%) were dislodged accidentally; 38 (13.6%) were removed for mechanical problems: tears in 5, leaks in 12, and obstructions in 21; 38 (13.6%) were removed for an infectious complication: phlebitis in 13 (4.6%, 1.5/1000 PICC days), exit-site infection in 10 (3.5%, 1.1/1000 PICC days), PICC-associated bloodstream infection in 12 (4.3%, 1.4/1000 PICC days), and PICC-related bloodstream infection in 4 (1.4%, 0.4/1000 PICC days); 15 more were removed for presumed infection (5.3%, 1.7/1000 PICC days). On multivariate analysis, composite indication for PICC use and older patient age were significantly associated with infectious complications.

CONCLUSIONS

PICCs are safe and may be used for prolonged periods. In our center, the rates of infectious complications are lower than for tunneled central venous catheters. Accidental dislodgement is not uncommon and may be prevented by use of sutures, occlusive dressing, and education of patients, families, and medical staff.

Socioeconomic Factors Influencing BRCA 1/2 Mutation Carriers To Choose Risk Reduction Surgery in Community Cancer Genetics Program

Background: Mutations in the BRCA 1/2 genes predispose women to increased risk of breast and ovarian cancer. Prophylactic mastectomy (PM) reduces the risk of breast cancer by approximately 90% while prophylactic salpingo-oophorectomy (PSO) reduces the risk of both breast and ovarian cancer. Yet, there is a paucity of data to determine if mutation carriers avail themselves of these risk reducing surgeries in the community setting.Purpose: This study evaluates if particular socioeconomic factors influence BRCA 1/2 mutation carriers to elect risk reduction surgery (RRS), either PM or PSO or both.Method: Of 129 BRCA1/2 positive patients identified by a community-based cancer genetics program outside Philadelphia from 1998 to 2008, 44 were excluded due to personal history of ovarian cancer, loss of follow-up, male gender, or deceased status. The 85 remaining patients were asked to complete a questionnaire addressing: age at diagnosis, ethnicity, religion, parity, education level, marital status, occupation, number of first degree relatives with breast or ovarian cancer, personal history of breast cancer, and use of oral contraceptives, tobacco, and alcohol. A chart review was performed on all responders.Results: Forty-nine patients (58%) completed the questionnaire. Of these, 68% (34/49) had RRS. Of those who did not have RRS, 63% (10/15) stated they definitely plan for RRS in the future. More than half of the women planning RRS in the future (6/10) were younger than 30 years old. Therefore, of all responders, 90% (44/49) stated they had or definitely plan to have RRS. The mean age of women with RRS versus those without was 43.9 and 35.6 years, respectively (p=.0102). Women age 40-64 had the highest rate of RRS (26/34; 84%; p=0.004). Most women (88%) with RRS had children (30/34; p=0.0493). Sixty-five percent (32/49) of women responders were college graduates; 24% were high school graduates (12/49). Of women who had RRS, 68% were college graduates. College graduates age &gt; 40 were the group most likely to have RRS (17/18; 94%; p= .00029). Only 63% of high school graduates age &gt; 40 (5/8; p=1.0) had RRS. Eight-five percent (11/13) of Ashkenazi Jewish women had RRS versus 67% (18/27) of non-Jewish Caucasian women. This was not statistically significant (p=0.2925). There was also no statistical difference for women choosing RRS with respect to occupation, birth control pill use, history of breast cancer, or family history of breast or ovarian cancer. Only 3/49 smoked cigarettes (&gt;more than 1 pack per week) and none drank alcohol (&gt;1 drink/day).Discussion: Women who presented to this community based genetics program had a high rate of RRS, were likely to be college educated, non-smokers, and non-drinkers. Age older than 40, completion of child bearing, and attainment of a college degree were the most significant factors associated with BRCA 1/2 mutation carriers having RRS. Further studies should explore barriers to genetic testing services, as well as evaluate reasons why BRCA1/2 mutation carriers decline RRS.

Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 4076.

Adding gabapentin to a multimodal regimen does not reduce acute pain, opioid consumption or chronic pain after total hip arthroplasty

BACKGROUND

Gabapentin (GPN) is effective in reducing post-operative pain and opioid consumption, but its effects with regional anesthesia for total hip arthroplasty (THA) are not known. We designed this study to determine whether (1) gabapentin administration reduces pain and opioid use after THA using a multimodal analgesic regimen including spinal anesthesia; (2) pre-operative administration of gabapentin is more effective than post-operative administration.

METHODS

After REB approval and informed consent, 126 patients were enrolled in a double-blinded, randomized-controlled study. Patients received acetaminophen 1 g per os (p.o.), celecoxib 400 mg p.o. and dexamethasone 8 mg intravenously, 1-2 h pre-operatively. Patients were randomly assigned to one of three treatment groups (G1: Placebo/Placebo; G2: GPN/Placebo; G3: Placebo/GPN). Patients received gabapentin 600 mg (G2) or placebo (G1 and G3) 2 h before surgery. All patients had spinal anesthesia [15 mg (3cc) of 0.5% hypobaric bupivacaine with 10 microg of fentanyl]. In the post-anesthetic care unit, patients received gabapentin 600 mg (G3) or placebo (G1 and G2). On the ward, patients received acetaminophen 1000 mg p.o. q6h, celecoxib 200 mg p.o. q12h and a morphine PCA device. Patients were interviewed 6 months post-surgery to determine the incidence and severity of chronic post-surgical pain.

RESULTS

Mean+/-SD cumulative morphine (mg) consumption (G1=49.4+/-24.8, G2=47.2+/-30.1 and G3=56.1+/-38.2) at 48 h and pain scores at 12, 24, 36 and 48 h post-surgery were not significantly different among the groups [G1 (n=38), G2 (n=38) and G3 (n=38)]. Side effect profiles were similar across groups. Six months after surgery, the number of patients who reported chronic post-surgical pain (G1=10, G2=12 and G3=9) and the severity of the pain (G1=4.2+/-2.9, G2=4.1+/-2.2 and G3=4.9+/-2.2) did not differ significantly among the groups (P>0.05).

CONCLUSIONS

A single 600 mg dose of gabapentin given pre-operatively or post-operatively does not reduce morphine consumption or pain scores in hospital or at 6 months after hip arthroplasty within the context of spinal anesthesia and a robust multimodal analgesia regimen.

Localization of P. gingivalis in preterm delivery placenta

Increasing evidence suggests an association between periodontal disease and adverse pregnancy outcomes. Although infection is considered as a risk factor for preterm delivery, the localization of oral bacteria or their antigens in chorioamnionitis placental tissue has never been demonstrated. This study was devised to test the hypothesis that periodontal pathogens may be present and affect human placenta in cases of chorioamnionitis. Using immunocytochemistry, we have identified the presence of Porphyromonas gingivalis antigens in placental tissues. The antigens were detected in the placental syncytiotrophoblasts, chorionic trophoblasts, decidual cells, and amniotic epithelial cells, as well as the vascular cells. There was a substantial increase in immunostaining intensity of the tissues sectioned from women with chorioamnionitis compared to those experiencing normalterm pregnancy, p < 0.019 (Mann-Whitney test). These results suggest that P. gingivalis may commonly colonize placental tissue, and that the presence of the organism may contribute to preterm delivery.

Traditional birth attendants in rural Nepal: knowledge, attitudes and practices about maternal and newborn health

Efforts to formalise the role of traditional birth attendants (TBAs) in maternal and neonatal health programmes have had limited success. TBAs' continued attendance at home deliveries suggests the potential to influence maternal and neonatal outcomes. The objective of this qualitative study was to identify and understand the knowledge, attitudes and practices of TBAs in rural Nepal. Twenty-one trained and untrained TBAs participated in focus groups and in-depth interviews about antenatal care, delivery practices, maternal complications and newborn care. Antenatal care included advice about nutrition and tetanus toxoid (TT) immunisation, but did not include planning ahead for transport in cases of complications. Clean delivery practices were observed by most TBAs, though hand-washing practices differed by training status. There was no standard practice to identify maternal complications, such as excessive bleeding, prolonged labour, or retained placenta, and most referred outside in the event of such complications. Newborn care practices included breastfeeding with supplemental feeds, thermal care after bathing, and mustard seed oil massage. TBAs reported high job satisfaction and desire to improve their skills. Despite uncertainty regarding the role of TBAs to manage maternal complications, TBAs may be strategically placed to make potential contributions to newborn survival.

Subcutaneous IGF-1 is not beneficial in 2-year ALS trial

BACKGROUND

Previous human clinical trials of insulin-like growth factor type I (IGF-1) in amyotrophic lateral sclerosis (ALS) have been inconsistent. This phase III, randomized, double-blind, placebo-controlled study was undertaken to address whether IGF-1 benefited patients with ALS.

METHODS

A total of 330 patients from 20 medical centers were randomized to receive 0.05 mg/kg body weight of human recombinant IGF-1 given subcutaneously twice daily or placebo for 2 years. The primary outcome measure was change in their manual muscle testing score. Secondary outcome measures included tracheostomy-free survival and rate of change in the revised ALS functional rating scale. Intention to treat analysis was used.

RESULTS

There was no difference between treatment groups in the primary or secondary outcome measures after the 2-year treatment period.

CONCLUSIONS

Insulin-like growth factor type I does not provide benefit for patients with amyotrophic lateral sclerosis.

Risk factors for sternal wound infection in children undergoing cardiac surgery: a case-control study

SUMMARY

Complex and prolonged cardiovascular operations are increasingly performed on young infants and children. The aims of this study were to define the incidence, causative bacterial pathogens and risk factors for sternal wound infections (SWIs) in infants and children undergoing cardiac surgery. The study group included all children who underwent cardiac surgery by median sternotomy at a tertiary paediatric centre from 1999 to 2003 and who were diagnosed with a postoperative SWI. Charts were reviewed for pre-, intra- and postoperative variables. The findings were compared with control patients operated on immediately before and after the cases and analysed by a stepwise logistic regression model. Of the 1821 children who underwent cardiac surgery, 49 (2.69%) had SWI; full data were available for 47. Twenty-nine (61.7%) had superficial wound infection and 18 (38.3%) deep wound infection. The main bacterial pathogens were Staphylococcus aureus in 14 patients (39%) and Pseudomonas aeruginosa in 12 (33%). Three variables emerged as significant independent risk factors for SWI: young age (odds ratio: 0.63; 95% confidence interval: 0.47-0.85; P<0.001 for each additional year), cyanotic heart disease (4.93; 1.98-12.3; P<0.001), and central venous catheter (CVC) dwell time (1.15; 1.06-1.24; P<0.001 for each additional day). Gram-negative infections were significantly associated with preoperative oxygen treatment (P=0.007) and prolonged urinary catheter dwell time (P=0.004). This study confirms younger age as risk factor for SWI and adds cyanotic heart disease and duration of CVC as new independent risk factors. Specific risks for Gram-negative infections are identified and should help to introduce new preventive strategies to decrease the incidence and severity of SWI.

Isoflavones and gamma irradiation inhibit cell growth in human salivary gland cells

We studied the effects of isoflavones and irradiation on cell cycle in a human salivary gland cell line (HSG). Genistein and a soy isoflavone conjugate (NS) inhibited DNA synthesis. Cells deconjugated the glucoside form of isoflavones in NS to the aglycones genistein and daidzein. NS, genistein and IR increased phosphorylation of p53 and p21 CIP1 at serine 15 (phos-p53). Irradiation and NS also increased levels of p21 CIP1. In a cologenic survival assay, cells in log phase growth had high radio-sensitivity with 2 Gy causing a reduction in survival (SF2=0.45).

CONCLUSION

isoflavones and radiation may interact to sensitize cancer cells to radiation.

Complex regional pain syndromes in children and adolescents

BACKGROUND

The purpose of the present paper was to assess efficiency of treatment and long-term functional outcome of complex regional pain syndromes (CRPS) in children who were treated in the chronic pain clinic at a major tertiary hospital in Israel.

METHODS

The files of 14 children with CRPS were analyzed retrospectively. Demographic data, initiating event, referring source, time needed for referral to pain clinic, clinical evaluation, treatment, recurrence and complications were recorded.

RESULTS

Fourteen children with CRPS types I and II were included in the study. Girls were affected in 71%. Lower extremities were affected in 57%. The median time from onset of symptoms to seeking medical help was 4.46 weeks (range 2-82 weeks). The median time to referral to pain clinic was 24.51 weeks (range 1.2-94). In 45% the referral source was the pediatrician. A total of 85.8% of patients were referred to various consultations before the pain clinic. Most children had reduced pain and improved function on non-invasive treatment approach. Invasive treatments were used in 28.5%. Full or partial recovery was accomplished in 93%. Recurrence was observed in 29%.

CONCLUSIONS

CRPS in children and adolescents is still underdiagnosed, although many of the epidemiologic features of pediatric CRPS are similar in different countries/cultures. Early recognition and management is the major factor in improving outcome and preventing resistant CRPS, but even children with delayed diagnosis still have a good outcome. The management of this disease by an experienced multidisciplinary team is recommended. Because psychosocial factors play an important role, it is recommended to provide psychological evaluation and cognitive behavioral treatment as soon as possible.

The effect of maternal micronutrient supplementation on early neonatal morbidity in rural Nepal: a randomised, controlled, community trial

OBJECTIVE

Micronutrient deficiencies during pregnancy may be linked to poor newborn health and poor host defences against infection. We assessed newborn morbidity to determine the effect of four combinations of antenatal micronutrient supplements.

DESIGN

Cluster-randomised, double-masked, controlled trial.

SETTING

Rural community in Nepal.

INTERVENTIONS

Women received daily supplements from early pregnancy through to 3 months postpartum of vitamin A alone (control) or vitamin A with folic acid, folic acid plus iron, folic acid plus iron plus zinc or a multiple micronutrient supplement containing these and 11 other nutrients.

MAIN OUTCOME MEASURES

Infants were visited in their home at birth (n = 3927) and for each of 9 days thereafter to elicit a 24-h history of nine infant morbidity symptoms, measure infant respiratory rate and axial temperature, and assess the infant for chest indrawing. At 6 weeks of age, infants were visited again in their homes to elicit a 30-day and 7-day history of 10 morbidity symptoms using parental recall.

RESULTS

Maternal micronutrient supplementation had no effect on 10-day morbidity or morbidity 30-day and 7-day morbidity assessed at 6 weeks of age all relative risks were close to 1. Symptoms of birth asphyxia increased by about 60% (p<0.05) in infants of women who received the multiple micronutrient supplement compared with the control. Symptoms of combinations of sepsis, preterm and birth asphyxia were associated with 8- to 14-fold increased odds of 6-month infant mortality.

CONCLUSIONS

None of the combinations of antenatal micronutrient supplements tested improved symptoms of neonatal morbidity in the first 10 days of life or at 6 weeks of age. Further research is needed to elucidate the association and mechanism of increased risk of birth asphyxia following maternal multiple micronutrient supplementation.

TRIAL REGISTRATION NUMBERS

NCT00115271.