Effective antenatal education: strategies recommended by expectant and new parents

Antenatal education is a crucial component of antenatal care, yet practice and research demonstrate that women and men now seek far more than the traditional approach of a birth and parenting program attended in the final weeks of pregnancy. Indeed, women and men participating in this study recommended a range of strategies to be provided during the childbearing year, comparable to a "menu in a restaurant." Their strategies included three program types: "Hearing Detail and Asking Questions," "Learning and Discussing," and "Sharing and Supporting Each Other." The characteristics of each type of program are identified in this article. The actual learning methods the study participants recommended to be incorporated into the programs were "Time to Catch Up and Focus," "Seeing and Hearing the Real Experience," "Practicing," and "Discovering."

Early mortality in EURODIAB population-based cohorts of type 1 diabetes diagnosed in childhood since 1989

AIMS/HYPOTHESIS

The aims of this study were to provide a contemporary picture of mortality and causes of death in Europe following a diagnosis of type 1 diabetes made before the 15th birthday, and to examine excess mortality by country for possible links to incidence level or national prosperity.

METHODS

Thirteen population-based EURODIAB registers in 12 countries followed-up 28,887 children diagnosed since 1989, either by record linkage to population registers or through contact with doctors providing care.

RESULTS

There were 141 deaths in the cohort during 219,061 person-years of follow-up compared with 69.1 deaths expected from national mortality rates, a standardised mortality ratio (SMR) of 2.0 (95% CI 1.7-2.4). The SMR varied from 0 to 4.7 between countries, but showed little relationship with the country's incidence rate or gross domestic product (US$ per capita). The SMR did not change significantly with attained age, calendar period or time since diagnosis. The female SMR (2.7; 95% CI 2.0-3.5) was greater than the male SMR (1.8; 95% CI 1.4-2.2), although absolute numbers of excess deaths were similar in the two sexes. One-third of deaths were classified as directly attributable to diabetes (many with mention of ketoacidosis) and half were unrelated to diabetes. There was a non-significant excess of accidental/violent deaths (48 observed vs 40.7 expected; SMR 1.2; 95% CI 0.9-1.6) but little excess in suicides (11 observed, 10.2 expected; SMR 1.1; 95% CI 0.5-1.9).

CONCLUSIONS/INTERPRETATION

Before the onset of late complications, significant excess mortality existed following the diagnosis of type 1 diabetes in childhood, even in recent years. Variation between countries in this excess could not be explained.

Randomised-controlled trial of two antenatal education programmes

OBJECTIVE

to determine whether a new antenatal education programme with increased parenting content could improve parenting outcomes for women compared with a regular antenatal education programme.

DESIGN

a randomised-controlled trial. Data were collected through self-report surveys.

SETTING

specialist referral maternity hospital in Sydney, Australia.

PARTICIPANTS

170 women birthing at the hospital. Ninety-one women attended the new programme and 79 the regular programme.

INTERVENTION

a new antenatal education programme ('Having a Baby' programme) developed from needs assessment data collected from expectant and new parents. One important feature of the programme was the recognition that pregnancy, labour, birth and early parenting were a microcosm of the childbearing experience, rather than separate topics.

MEASURES

the primary outcome measure was perceived maternal parenting self-efficacy. Worry about the baby, and perceived parenting knowledge, were secondary outcome measures. They were measured before the programme and after birth. Birth outcomes were also recorded.

FINDINGS

the postnatal perceived maternal parenting self-efficacy scores of women who attended the 'Having a Baby' programme were significantly higher than those who attended the regular programme. Perceived parenting knowledge scores of women who attended the 'Having a Baby' programme were also significantly higher than those who attended the regular programme. Worry scores were lower but they did not reach statistical significant. Birth outcomes were similar.

IMPLICATIONS FOR PRACTICE

the 'Having a Baby' programme improved maternal self-efficacy and parenting knowledge. Parenting programmes that continue in the early postnatal period may be beneficial.

A 10-year, prospective study of the metabolic effects of growth hormone replacement in adults

CONTEXT

Only a few studies have investigated the effects of GH replacement in adults for more than 5 yr.

OBJECTIVE/DESIGN/PATIENTS

In a prospective, open-label, single-center study, the effects of 10-yr GH replacement were determined. Eighty-seven consecutive patients (52 men and 35 women), with a mean age of 44.1 (range 22-74) yr with adult-onset GH deficiency (GHD) were included.

RESULTS

The initial mean dose of GH (0.98 mg/d) was reduced during the study and at yr 10 was 0.47 mg/d. The mean IGF-I sd score increased from -1.81 at baseline to 1.29 at study end. The absolute reduction in total body fat was transient. However, after correction for age and sex using a four-compartment model, the reduction in body fat was sustained during the 10-yr study period. There was a sustained improvement in serum lipid profile and after 10 yr, and blood glycosylated hemoglobin level was reduced. The treatment responses in IGF-I sd score, serum high-density lipoprotein cholesterol level, and body composition as measured using dual-energy x-ray absorptiometry were more marked in men, whereas women had a more marked reduction in blood glycosylated hemoglobin level.

CONCLUSION

The effect on the absolute amount of body fat was seen early and was transient, which could be due to the normal aging of the patients. The effects on metabolic indices were detected later, but they were sustained and even progressive throughout the study period.

Evidence for immunological priming and increased frequency of CD4+ CD25+ cord blood T cells in children born to mothers with type 1 diabetes

Maternal transmission of islet autoantibodies to children born to mothers with type 1 diabetes (T1D) has been shown to protect from autoantibodies and diabetes development later in life. However, the factors conferring disease protection are poorly understood. The aim of this study was to evaluate comparatively proinflammatory cytokines, autoantibodies and lymphocyte subsets in cord blood (CB) of children born to mothers with either T1D (n = 13), gestational diabetes (GDM) (n = 32) or healthy mothers (n = 81) in relation to transplacental passage of autoantibodies. The results are consistent with early priming of the fetal immune system only in children born to mothers with T1D. Levels of interleukin (IL)-1beta (P = 0.022), tumour necrosis factor (TNF)-alpha (P = 0.002) and IL-8 (P = 0.0012), as well as the frequency of CD4(+) CD25(+) T cells (P < 0.01) were significantly increased, and the increased levels correlated positively with anti-GAD65 autoantibody (GADA) levels. Moreover, CD4(+) CD25(+) T cells of children born to T1D mothers exhibited a more pronounced memory phenotype with increased CCR4 expression and down-regulation of CD62L. These data suggest that early activation of the fetal immune system as a consequence of maternal autoimmunity and transplacental passage of GADA may influence the generation and expansion of fetal regulatory T cells. This might induce an early antigen-specific immunological tolerance that could protect against T1D later in life.

Reduced field-of-view MRI using outer volume suppression for spinal cord diffusion imaging

A spin-echo single-shot echo-planar imaging (SS-EPI) technique with a reduced field of view (FOV) in the phase-encoding direction is presented that simultaneously reduces susceptibility effects and motion artifacts in diffusion-weighted (DW) imaging (DWI) of the spinal cord at a high field strength (3T). To minimize aliasing, an outer volume suppression (OVS) sequence was implemented. Effective fat suppression was achieved with the use of a slice-selection gradient-reversal technique. The OVS was optimized by numerical simulations with respect to T(1) relaxation times and B(1) variations. The optimized sequence was evaluated in vitro and in vivo. In simulations the optimized OVS showed suppression to <0.25% and approximately 3% in an optimal and worst-case scenario, respectively. In vitro measurements showed a mean residual signal of <0.95% +/- 0.42 for all suppressed areas. In vivo acquisition with 0.9 x 1.05 mm(2) in-plane resolution resulted in artifact-free images. The short imaging time of this technique makes it promising for clinical studies.

Ten-year GH replacement increases bone mineral density in hypopituitary patients with adult onset GH deficiency

There are few studies that have determined the effects of long-term GH replacement on bone mineral density (BMD) in GH-deficient (GHD) adults. In this study, the effects of 10 years of GH replacement on BMD were assessed in 87 GHD adults using dual energy X-ray absorptiometry (DEXA). The results show that GH replacement induced a sustained increase in BMD at all the skeletal sites measured.

INTRODUCTION

Little is known of the effect of more than 5 years of GH replacement therapy on bone metabolism in GHD adults.

PATIENTS AND METHODS

In this prospective, open-label, single-center study, which included 87 consecutive adults (52 men and 35 women; mean age of 44.1 (range 22-74) years) with adulthood onset GHD, the effect of 10 years of GH replacement on BMD was determined.

RESULTS

The mean initial dose of GH was 0.98 mg/day. The dose was gradually lowered and after 10 years the mean dose was 0.47 mg/day. The mean insulin-like growth factor-I (IGF-I) SDS increased from 1.81 at baseline to 1.29 at study end. The GH replacement induced a sustained increase in total, lumbar (L2-L4) and femur neck BMD, and bone mineral content (BMC) as measured by DEXA. The treatment response in IGF-I SDS was more marked in men, whereas women had a more marked increase in the total body BMC and the total body z-score. There was a tendency for women on estrogen treatment to have a larger increase in bone mass and density compared with women without estrogen replacement.

CONCLUSIONS

Ten years of GH replacement in hypopituitary adults induced a sustained, and in some variables even a progressive, increase in bone mass and bone density. The study results also suggest that adequate estrogen replacement is needed in order to have an optimal response in BMD in GHD women.

Daily physical activity in Swedish children aged 8-11 years

INTRODUCTION

Physical inactivity is hypothesized to be a contributing factor in the development of a variety of diseases. Recommendations for an adequate level of physical activity have been proposed. There are few studies in which the physical activity in children has been objectively assessed. The purpose of this study was to estimate objectively the level of physical activity in Swedish children.

MATERIALS AND METHODS

We studied 248 children (140 boys and 108 girls) aged 7.9-11.1 years from Malmö, Sweden. Physical activity was measured with accelerometers. Children were instructed to wear the accelerometers for 4 days. The mean daily activity was expressed as the mean counts per minute of recording. The time that the child spent performing moderate or vigorous activity was calculated by using previously established cutoff points.

RESULTS

The mean daily activity was higher in boys than in girls, 751+/-243 vs 618+/-154 counts/min (P<0.001). All children fulfilled the recommendation for moderate physical activity for 60 min or more per day. Ninety-two percent of the boys and 86% of the girls performed vigorous activity, for 20 min or more per day.

CONCLUSION

All children, aged 8-11 years, who participated in this study reached the recommended level of physical activity, with boys being more active than girls.

Sleep apnoea and quality of life in growth hormone (GH)-deficient adults before and after 6 months of GH replacement therapy

OBJECTIVE

To investigate the sleep architecture and breathing as well as quality of life (QoL) in adults with GH deficiency (GHD) before and 6 months after GH replacement therapy.

DESIGN

A prospective observational study.

PATIENTS

Nineteen consecutive adults with GHD (11 men, eight women; mean age 53, range 21-73 years) were studied.

MEASUREMENTS

An overnight sleep study was performed and the Minor Symptom Evaluation Profile (MSEP), Functional Outcome of Sleep Questionnaire (FOSQ), Short Form 36 (SF-36) and Epworth Sleepiness Scale (ESS) questionnaires were applied at baseline and after the treatment period.

RESULTS

For the whole group, there were no significant changes in mean total sleep time (TST; 370 min vs. 374 min), proportion of slow-wave sleep (SWS; 17.8%vs. 18.4%) and rapid eye movement (REM) sleep (12.1%vs. 13.9%) on GH replacement. Mean apnoea-hypopnoea index (AHI) was high and remained unchanged (28.2/h before vs. 28.0/h following GH replacement). Twelve patients (63%) were found to have obstructive sleep apnoea (OSA; AHI >or= 10/h) at baseline. Compared with GH-deficient patients without OSA (AHI 3.9/h), the OSA patients (AHI 42.4/h) had less SWS (11.4%vs. 28.6%, P = 0.010) and REM sleep (10.1%vs. 15.5%, P = 0.036). A marginal increase was observed in REM sleep time (10.1% before vs. 12.7% after GH; P = 0.048) while SWS was unchanged in this group. Moreover, MSEP for General Well-being and Responsiveness, FOSQ scores for General Productivity, Activity Level and Vigilance as well as SF-36 domains for Vitality and Mental Health were improved.

CONCLUSIONS

Contrary to some previous observations in a smaller group of patients, our data suggest that GH therapy does not induce or aggravate OSA in GH-deficient adults. Moreover, GH therapy may improve some of the QoL dimensions in these patients.

Endocrine, liver-derived IGF-I is of importance for spatial learning and memory in old mice

IGF-I is a neuroprotective hormone, and neurodegenerative disorders, including Alzheimer's disease, have been associated with decreased serum IGF-I concentration. In this study, IGF-I production was inactivated in the liver of adult mice (LI-IGF-I(-/-)), resulting in an approximately 80-85% reduction of circulating IGF-I concentrations. In young (6-month-old) mice there was no difference between the LI-IGF-I(-/-) and the control mice in spatial learning and memory as measured using the Morris water maze test. In old (aged 15 and 18 months) LI-IGF-I(-/-) mice, however, the acquisition of the spatial task was slower than in the controls. Furthermore, impaired spatial working as well as reference memory was observed in the old LI-IGF(-/-) mice. Histochemical analyses revealed an increase in dynorphin and enkephalin immunoreactivities but decreased mRNA levels in the hippocampus of old LI-IGF-I(-/-) mice. These mice also displayed astrocytosis and increased metabotropic glutamate receptor 7a-immunoreactivity. These neurochemical disturbances suggest synaptic dysfunction and early neurodegeneration in old LI-IGF-I(-/-) mice. The decline in serum IGF-I with increasing age may therefore be important for the age-related decline in memory function.

Liver-derived IGF-I is permissive for ovariectomy-induced trabecular bone loss

INTRODUCTION

Estrogen deficiency results in trabecular bone loss, associated with T-cell proliferation in the bone marrow. Insulin-like growth factor I (IGF-I) is involved in the regulation of both bone metabolism and lymphopoiesis. A major part of serum IGF-I is derived from the liver. The aim of the present study was to investigate the role of liver-derived IGF-I for ovariectomy (ovx)-induced trabecular bone loss.

MATERIALS AND METHODS

Mice with adult liver-specific IGF-I inactivation (LI-IGF-I-/-) and wild type mice (WT) were either ovx or sham operated. After 5 weeks, the skeletal phenotype was analyzed by pQCT and microCT. The bone marrow cellularity was analyzed using FACS technique, and mRNA levels were quantified using real-time PCR.

RESULTS

Ovx resulted in a pronounced reduction in trabecular bone mineral density (-52%, P < 0.001), number (-45%, P < 0.01) and thickness (-13%, P < 0.01) in WT mice while these bone parameters were unaffected by ovx in LI-IGF-I-/- mice. Furthermore, ovx increased the number of T-cells in the bone marrow of the femur in WT but not in LI-IGF-I-/- mice. Interleukin 7 (IL-7) has been reported to stimulate the formation and function of osteoclasts by inducing the expression of receptor activator of NF-kappaB ligand (RANKL) on T-cells. IL-7 mRNA levels and the RANKL/osteoprotegerin ratio in bone were increased by ovx in WT but not in LI-IGF-I-/- mice.

CONCLUSIONS

Liver-derived IGF-I is permissive for ovx-induced trabecular bone loss. Our studies indicate that IGF-I might exert this permissive action by modulation of the number of T-cells and the expression of IL-7, which in turn is of importance for the RANKL/OPG ratio and consequently osteoclastogenesis in the bone marrow.

Maximum oxygen uptake and objectively measured physical activity in Danish children 6-7 years of age: the Copenhagen school child intervention study

OBJECTIVES

To provide normative data on maximum oxygen uptake (Vo(2)max) and physical activity in children 6-7 years of age and analyse the association between these variables.

METHODS

Vo(2)max was measured in 366 boys (mean (SD) 6.8 (0.4) years of age) and 332 girls (6.7 (0.4) years of age) from preschool classes in two suburban communities in Copenhagen, during a progressive treadmill exercise. Habitual physical activity was measured with accelerometers.

RESULTS

Boys had higher Vo(2)max both in absolute values (1.19 (0.18) v 1.06 (0.16) litres/min (+11%), p<0.001) and relative to body weight (48.5 (6.0) v 44.8 (5.6) ml/kg/min (+8%); p<0.001) than girls. The difference in Vo(2)max between boys and girls decreased to +2% when expressed relative to lean body mass (LBM). Absolute Vo(2)max was related to LBM, body mass, and stature (all p<0.001). Boys were more physically active than girls (mean counts +9.4%, p<0.001), and even when boys and girls with the same Vo(2)max were compared, boys were more active. The difference in physical activity between the sexes was higher when sustained activity of higher intensity was compared.

CONCLUSIONS

Vo(2)max is higher in boys than girls (+11%), even when related to body mass (+8%) and LBM (+2%). Most of the difference in Vo(2)max relative to body mass was explained by the larger percentage body fat in girls. When boys and girls with the same Vo(2)max were compared, boys engaged in more minutes of exercise of at least moderate intensity.

Growth hormone and the cardiovascular function

In this review, the great importance of growth hormone (GH) for the maintenance of cardiac function in adult life is discussed. Physiological effects of GH are discussed as well as the cardiac dysfunction caused both by GH excess (acromegaly) and by GH deficiency in adult hypopituitary patients. In both acromegaly and adult GH deficiency, there is also increased cardiovascular morbidity and mortality. Finally, the effect of GH treatment in heart failure is discussed.

Malignant disease and cardiovascular morbidity in hypopituitary adults with or without growth hormone replacement therapy

A retrospective comparison was performed between 1411 hypopituitary adults without GH replacement [mean age, 56.9 (sd 18.6) yr] and the normal population in terms of fatal and nonfatal morbidity. A similar prospective comparison was then made in 289 hypopituitary patients on long-term GH replacement [mean age, 47.6 (sd 14.8) yr; mean duration of GH treatment, 60 months]. In the 1411 hypopituitary patients without GH replacement, overall mortality (P < 0.001), and the rates of myocardial infarctions (P < 0.01), cerebrovascular events (P < 0.001), and malignancies (P < 0.001) were increased compared with the normal population. Colorectal cancer was the most common malignancy in this cohort (P < 0.001 vs. the background population). In the 289 hypopituitary patients on GH replacement, overall mortality and the rate of malignancies were similar to the normal population. In the hypopituitary adults on GH therapy, the rate of myocardial infarctions was lower than that in the background population (P < 0.05), and there was a tendency toward an increased rate of cerebrovascular events. In conclusion, overall mortality and the rate of myocardial infarctions were increased in hypopituitary patients without GH replacement. An increased rate of malignancies was observed in the hypopituitary adults without GH therapy, with a predominance of colorectal cancer. GH replacement appeared to provide protection from myocardial infarctions. The rate of cerebrovascular events tended to be increased also in hypopituitary adults on GH therapy.

Cerebral perfusion assessment by bolus tracking using hyperpolarized13C

Cerebral perfusion was assessed with 13C MRI in a rat model after intravenous injections of the 13C-labeled compound bis-1,1-(hydroxymethyl)-1-13C-cyclopropane-D8 in aqueous solutions hyperpolarized by dynamic nuclear polarization (DNP). Since the tracer acted as a direct signal source, several of the problems associated with techniques based on traditional dynamic susceptibility contrast (DSC) MRI contrast agents were avoided. Maps of cerebral blood flow (CBF), cerebral blood volume (CBV), and mean transit time (MTT) were calculated. The MTT was determined to be 2.8 +/- 0.8 sec. However, arterial partial-volume effects in the animal model prevented accurate absolute quantification of CBF and CBV. It was demonstrated that depolarization of the hyperpolarized 13C tracer via relaxation and the imaging sequence had little influence on CBF assessment when the time resolution of the imaging sequence was short compared to the MTT. However, CBV and MTT were increasingly underestimated as MTT or the depolarization rate increased if depolarization was not taken into account. With a modified bolus-tracking theory depolarization could be compensated for, assuming that the depolarization rate was known. Three separate compensation methods were investigated experimentally and by numerical simulations.

Effects of GH and insulin-like growth factor-I on body composition

In this review, different methods to estimate body composition are discussed shortly. The effects by GH on total and visceral fat mass, lean mass, muscle strength and body water are described. Gender differences in the sensitivity to GH administration are reviewed. Finally, a short description of the effects of insulin-like growth factor-I (IGF-I) administration on body composition has been included.

Oral administration of the growth hormone secretagogue NN703 in adult patients with growth hormone deficiency

OBJECTIVE

Little is known of the usefulness of GH secretagogues (GHSs) in GH-deficient (GHD) adults. The objective of this study was to determine the number of responders to treatment with NN703 in GHD adults.

DESIGN

A multicentre, randomized, double-blind, and placebo-controlled study.

PATIENTS

Ninety-seven GHD adults were included.

MEASUREMENTS

The GH response before and after 1 week of oral treatment with NN703 (n = 83) or placebo (n = 14) was determined. The first and last dose of NN703 was 3 mg/kg, whereas the dose of NN703 was 1.5 mg/kg/day during the 6 days between the first and last doses. Furthermore, all 97 patients received 1 micro g/kg GH-releasing hormone (GHRH) 3 weeks after the last dose of NN703.

RESULTS

Serum GH peak and area under curve (AUC) values after the first NN703 administration were greater than those after placebo administration (P < 0.05). However, after correction for the lower body mass index (BMI) in the NN703 group, this difference lost statistical significance. After 1 week of therapy, GH peak and AUC values were similar following the final doses of NN703 and placebo. Serum peak and AUC values of other anterior pituitary hormones were similar between the NN703 and placebo groups both after the first and last administration of study drug. Nine of the 83 patients (11%) responded with a serum peak GH concentration >or= 5 micro g/l after the first and/or last NN703 administration, whereas no patient responded after placebo administration. Serum IGF-I was unaffected by 1-week NN703 treatment, whereas serum IGFBP-3 was increased (P < 0.05 vs. placebo) also after correction for BMI. Mean serum peak GH concentration after GHRH administration was 2.1 micro g/l (+/-0.3, SEM), which was higher than that after the first NN703 administration (1.32 +/- 0.3, P < 0.05).

CONCLUSION

NN703 administration was generally well tolerated. Eleven per cent of the GHD adult patients responded with a peak GH response >or= 5 micro g/l after the first and/or last administration of oral NN703. Although a majority of GHD adults will not respond to NN703, the present results suggest that oral NN703 treatment could be useful in some adult patients with moderately severe GHD. These patients may be identified by a test dose of GHS.

The effect of treatment with the oral growth hormone (GH) secretagogue MK-677 on GH isoforms

Growth hormone (GH) consists of several isoforms. We have studied the proportion, expressed as percentage of total GH concentration, of non-22kDa (non-22K) GH isoforms and 20K GH during 8-week oral treatment with MK-677 25mg daily in 12 obese males. The proportion of non-22K GH isoforms in peak total GH samples after the initial MK-677 administration was higher than that after 2 and 8 weeks (p<0.01 and p<0.05, respectively). In selected non-peak total GH samples after the initial MK-677 administration, however, the proportion of non-22K GH isoforms was similar to that in the peak total GH samples after 2 and 8 weeks. The proportion of 20K GH in 2-h samples after the initial MK-677 administration was lower than that after 2 and 8 weeks (p<0.01 and p<0.05, respectively). We concluded that the proportion of non-22K GH isoforms was higher in peak, but not in non-peak, total GH samples after the initial MK-677 administration than that observed after multiple doses. The proportion of 20K GH in 2-h samples after the initial MK-677 administration was lower than that after 2 and 8 weeks. These moderate changes in the proportion non-22K GH isoforms are likely of small importance for the clinical response to MK-677 treatment.

Gradient echo imaging of flowing hyperpolarized nuclei: theory and phantom studies on 129Xe dissolved in ethanol

The influence of flip angle and flow velocity on the signal intensity achieved when imaging a hyperpolarized substance with a spoiled gradient echo sequence was investigated. The study was performed both theoretically and experimentally using hyperpolarized xenon dissolved in ethanol. Analytical expressions regarding the optimal flip angle with respect to signal and the corresponding signal level are presented and comparisons with thermally polarized substances are made. Both experimentally and theoretically, the optimal flip angle was found to increase with increasing flow velocity. Numerical calculations showed that the velocity dependence of the signal differs between the cases of hyperpolarized and thermally polarized substances.

An MLP training algorithm taking into account known errors on inputs and outputs

A training algorithm is introduced that takes into account a priori known errors on both inputs and outputs in an MLP network. The new cost function introduced for this case is based on a linear approximation of the network function over the input distribution for a given input pattern. Update formulas, in the form of the gradient of the new cost function, is given for a MLP network, together with expressions for the Hessian matrix. This is later used to calculate error bars in a Bayesian framework. The error bars thus derived are discussed in relation to the more commonly used width of the target posterior predictive distribution. It will also be shown that the taking into account of known input uncertainties in the way suggested in this article will have a strong regularizing effect on the solution.