Prenatal ultrasound use and risk of autism spectrum disorder: Findings from the case-control Study to Explore Early Development

BACKGROUND

Studies evaluating the association between prenatal ultrasounds and autism spectrum disorder (ASD) have largely produced negative results. Concern remains due to the rising identification of children with ASD and ultrasound use.

OBJECTIVE

To evaluate the association between prenatal ultrasound use and ASD.

METHODS

We used data from the Study to Explore Early Development, a multisite case-control study of preschool-aged children with ASD implemented during 2007-2012. We recruited cases from children receiving developmental disability services and randomly selected population controls from birth records. ASD case status was based on in-person standardised assessments. We stratified analyses by pre-existing maternal medical conditions and pregnancy complications associated with increased ultrasound use (ultrasound indications) and used logistic regression to model case status by increasing ultrasound counts. For pregnancies with medical record data on ultrasound timing, we conducted supplementary tests to model associations by trimester of exposure.

RESULTS

Among 1524 singleton pregnancies, ultrasound indications were more common for ASD cases than controls; respectively, for each group, no indications were reported for 45.1% and 54.2% of pregnancies, while ≥2 indications were reported for 26.1% and 18.4% of pregnancies. The percentage of pregnancies with multiple ultrasounds varied by case status and the presence of ultrasound indications. However, stratified regression models showed no association between increasing ultrasound counts and case status, either for pregnancies without (aOR 1.01, 95% CI 0.92, 1.11) or with ultrasound indications (aOR 1.01, 95% CI 0.95, 1.08). Trimester-specific analyses using medical record data showed no association in any individual trimester.

CONCLUSIONS

We found no evidence that prenatal ultrasound use increases ASD risk. Study strengths included gold-standard assessments for ASD case classification, comparison of cases with controls, and a stratified sample to account for conditions associated both with increased prenatal ultrasound use and ASD.

Does Offloading with Felt Foot Plates Heal Diabetic Foot Ulcers?

OBJECTIVE

To determine (1) if offloading with a felt foot plate heals a diabetic foot ulcer, (2) the rate of healing with the felt foot plate, and (3) the impact on rate of healing from the confounding factors of patient weight and growth factors on healing times.

METHODS

The researchers conducted a retrospective chart cohort review over 3 years.

RESULTS

Using a multivariable linear and logistic regression model, the data showed a statistically significant reduction in the diabetic foot ulcer area over time. Confounding factors of patient weight and growth factors did not impact healing times.

CONCLUSIONS

Offloading a diabetic foot ulcer with a felt foot plate is adequate for healing.

Features that best define the heterogeneity and homogeneity of autism in preschool-age children: A multisite case-control analysis replicated across two independent samples

The heterogeneous nature of children with symptoms of autism spectrum disorder (ASD) makes it difficult to identify risk factors and effective treatment options. We sought to identify behavioral and developmental features that best define the heterogeneity and homogeneity in 2-5-year-old children classified with ASD and subthreshold ASD characteristics. Children were enrolled in a multisite case-control study of ASD. Detailed behavioral and developmental data were gathered by maternal telephone interview, parent-administered questionnaires, child cognitive evaluation, and ASD diagnostic measures. Participants with a positive ASD screen score or prior ASD diagnosis were referred for comprehensive evaluation. Children in the ASD group met study criteria based on this evaluation; children who did not meet study criteria were categorized as having subthreshold ASD characteristics. There were 1480 children classified as ASD (81.6% boys) and 594 children classified as having subthreshold ASD characteristics (70.2% boys) in the sample. Factors associated with dysregulation (e.g., aggression, anxiety/depression, sleep problems) followed by developmental abilities (e.g., expressive and receptive language skills) most contributed to heterogeneity in both groups of children. Atypical sensory response contributed to homogeneity in children classified as ASD but not those with subthreshold characteristics. These findings suggest that dysregulation and developmental abilities are clinical features that can impact functioning in children with ASD and other DD, and that documenting these features in pediatric records may help meet the needs of the individual child. Sensory dysfunction could be considered a core feature of ASD and thus used to inform more targeted screening, evaluation, treatment, and research efforts. LAY SUMMARY: The diverse nature of autism spectrum disorder (ASD) makes it difficult to find risk factors and treatment options. We identified the most dissimilar and most similar symptom(s) in children classified as ASD and as having subthreshold ASD characteristics. Factors associated with dysregulation and developmental abilities contributed to diversity in both groups of children. Sensory dysfunction was the most common symptom in children with ASD but not those with subthreshold characteristics. Findings can inform clinical practice and research.

Cancer Commons’ virtual tumor board program: A patient-centric advisory panel and real-world data registry

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Background: We initiated a nationwide Virtual Tumor Board (VTB) program for pancreatic cancer (PC) patients (pts). The VTB consists of oncology experts and serves as an advisory panel by providing information on treatment (Tx) options based on a comprehensive review of patients’ oncologic history. Personalized Tx options and their rationales are provided and outcomes tracked in a prospective registry (XCELSIOR). Methods: PC pts who participated in XCELSIOR shared access to their full medical records, which were collected, processed, and abstracted. The panel reviewed cases asynchronously through an interactive platform followed by a VTB which was held weekly through videoconferencing. Tx options were summarized into a written report and provided to patients and their physicians. Outcomes and quality of life are tracked longitudinally through an IRB-approved 21CFR11 compliant observational registry (XCELSIOR). Results: From 9/2020 to 8/2021, the VTB reviewed 79 unique cases; 56% were male; median age at diagnosis was 66 (50-87). At the time of VTB, 68 (87%) had metastatic disease and 8 (10%) had locally advanced disease. Median prior therapy lines was 2 (0-9), with 26 (35%), 24 (32%), 6 (8%), and 19 (25%) pts having received 1, 2, 3 and 4+ lines of therapy, respectively. Median time from diagnosis for pts presenting after 1, 2, and 3+ lines of prior Tx was 9.5, 11, and 17.5 months, respectively. First-line Tx was FOLFIRINOX in 40 (53%) pts and gemcitabine/nab-paclitaxel in 22 (29%) pts. At the time of VTB, 32 (37%) of patients had stable disease, 23 (26%) had disease progression, 18 (21%) had recently started a new Tx, 7 (8%) were responding to Tx, 3 (3%) had stable disease on imaging but rising CA 19-9, and 4 (4%) were others. Prior to VTB, 69 (87%) pts had molecular profiling results available. Collectively the VTB provided 375 Tx and diagnostic (NGS, imaging, etc.) options with a median of 4 (1-12) options per patient. As of 9/8/2021, 87 VTB reports were provided. Of 25 instances of ‘no Tx decision’, 10 (40%) are deceased, 10 (40%) are stable, and 5 (10%) had other reasons. Of the 25 people who started a subsequent Tx, 14 (56%) were identified by the VTB. These included 9 (64%) FDA-approved, 3 (21%) off-label, and 2 (14%) on-trial Tx. Tx not identified by the VTB included 3 (33%) FDA-approved, 2 (22%) off-label, 2 (22%) on-trial, and 2 (22%) local Tx. Conclusions: We present our experience of utilizing a platform for patients to receive a virtual tumor board review and utilize an IRB-approved registry as a learning system. Early data indicate successes in identifying treatment and clinical trial opportunities. Future steps include streamlining communication with primary oncologists and enhancing access to treatments. NCT03793088.

A Novel Method to Offload Neuropathic Ulcers of the Distal Phalanges in the Presence of First Ray Metatarsal Hypermobility: 3 Case Reports

BACKGROUND

The standard practice to heal neuropathic ulcers on the toes is to offload the affected areas with special types of therapeutic footwear including shoes and boots to reduce the amount of pressure on the wound. Once healed, the individual wears custom insoles to prevent the development of new wounds. In our practice, we found that some newly healed wounds will reulcerate despite wearing therapeutic footwear. We devised a method to prevent and offload neuropathic foot ulcers on the distal phalanges in the presence of first ray metatarsal hypermobility, a common problem associated with the development of wounds.

CASES

Three individuals with first ray metatarsal hypermobility and recurrent neuropathic ulcers demonstrated healing using a buttress constructed from a tampon placed under the plantar surface of the proximal interphalangeal joint. The buttress was successful in supporting the first ray metatarsal to keep it in proper alignment.

CONCLUSION

We found using a buttress was an effective nonsurgical intervention for these 3 individuals with first ray metatarsal hypermobility to prevent and offload neuropathic hallux ulcers.

CE: From the CDC: Understanding Autism Spectrum Disorder

Autism spectrum disorder (ASD) is a condition characterized by impaired social communication as well as restricted and repetitive behaviors. It is considered a neurodevelopmental disorder because it is associated with neurologic changes that may begin in prenatal or early postnatal life, alters the typical pattern of child development, and produces chronic signs and symptoms that usually manifest in early childhood and have potential long-term consequences. In past decades, autism was conceptualized as a strictly defined set of behaviors, usually accompanied by intellectual impairment. Today, it is recognized as a spectrum, ranging from mild to severe, in which behaviors vary substantially and the majority of children who fall on the spectrum have average to above average intellectual ability. Here, the authors discuss the risk factors for ASD, its epidemiology, common concurrent conditions, evaluation, diagnosis, treatments, and outcomes.

Disparities in Documented Diagnoses of Autism Spectrum Disorder Based on Demographic, Individual, and Service Factors

The objectives of our study were to (a) report how many children met an autism spectrum disorder (ASD) surveillance definition but had no clinical diagnosis of ASD in health or education records and (b) evaluate differences in demographic, individual, and service factors between children with and without a documented ASD diagnosis. ASD surveillance was conducted in selected areas of Arizona, Arkansas, Colorado, Georgia, Maryland, Minnesota, Missouri, New Jersey, North Carolina, Tennessee, and Wisconsin. Children were defined as having ASD if sufficient social and behavioral deficits and/or an ASD diagnosis were noted in health and/or education records. Among 4,498 children, 1,135 (25%) had ASD indicators without having an ASD diagnosis. Of those 1,135 children without a documented ASD diagnosis, 628 (55%) were not known to receive ASD services in public school. Factors associated with not having a clinical diagnosis of ASD were non-White race, no intellectual disability, older age at first developmental concern, older age at first developmental evaluation, special education eligibility other than ASD, and need for fewer supports. These results highlight the importance of reducing disparities in the diagnosis of children with ASD characteristics so that appropriate interventions can be promoted across communities. Autism Res 2020, 13: 464-473. © 2019 International Society for AutismResearch,Wiley Periodicals, Inc. LAY SUMMARY: Children who did not have a clinical diagnosis of autism spectrum disorder (ASD) documented in health or education records were more likely to be non-White and have fewer developmental problems than children with a clinical diagnosis of ASD. They were brought to the attention of healthcare providers at older ages and needed fewer supports than children with a clinical diagnosis of ASD. All children with ASD symptoms who meet diagnostic criteria should be given a clinical diagnosis so they can receive treatment specific to their needs.

Trends in documented co-occurring conditions in children with autism spectrum disorder, 2002-2010

BACKGROUND

Autism spectrumdisorder (ASD) commonly presents with co-occurring medical conditions (CoCs). Little is known about patterns in CoCs in a time of rising ASD prevalence.

AIMS

To describe trends in number and type of documented CoCs in 8-year-old children with ASD.

METHODS

We used Autism and Developmental Disabilities Monitoring Network (ADDM) data, a multi-source active surveillance system monitoring ASD prevalence among 8-year-old children across the US. Data from surveillance years 2002, 2006, 2008, and 2010 were used to describe trends in count, categories, and individual CoCs.

RESULTS

Mean number of CoCs increased from 0.94 CoCs in 2002 to 1.06 CoCs in 2010 (p < 0.001). The percentage of children with ASD with any CoC increased from 44.5% to 56.4% (p < 0.001). CoCs with the greatest increases were in general developmental disability (10.4% to 14.5%), language disorder (18.9% to 23.6%), and motor developmental disability (10.5% to 15.6%). Sex modified the relationship between developmental (P = 0.02) and psychiatric (P < 0.001) CoCs and surveillance year. Race/ethnicity modified the relationship between neurological conditions (P = 0.04) and surveillance year.

CONCLUSIONS

The increase in the percentage of children with ASD and CoCs may suggest the ASD phenotype has changed over time or clinicians are more likely to diagnose CoCs.

Comparison of autism spectrum disorder surveillance status based on two different diagnostic schemes: Findings from the Metropolitan Atlanta Developmental Disabilities Surveillance Program, 2012

For the first time, the Autism and Developmental Disabilities Monitoring Network (ADDM) at the Centers for Disease Control and Prevention (CDC) reported prevalence estimates based on two different diagnostic schemes in the 2014 surveillance period. Results found substantial agreement between surveillance case status based on Diagnostic and Statistical Manual of Mental Disorders-Fourth Edition-Text Revision (DSM-IV-TR) criteria and DSM-5 criteria ASD (kappa = 0.85). No study has replicated this agreement in another independent sample of surveillance records. The objectives of this study were to (1) replicate agreement between surveillance status based on DSM-IV-TR criteria and DSM-5 criteria for ASD, (2) quantify the number of children who met surveillance status based on only DSM-IV-TR criteria and only DSM-5 criteria for ASD, and (3) evaluate differences in characteristics of these latter two groups of children. The study sample was 8-year-old children who had health and education records reviewed for ASD surveillance in metropolitan Atlanta, GA in the 2012 surveillance year. Results found substantial agreement between child's surveillance status using DSM-IV-TR criteria and DSM-5 criteria for ASD (kappa = 0.80). There were no differences in child race/ethnicity, child sex, or intellectual disability between surveillance status defined by DSM-IV-TR criteria and that defined by DSM-5 criteria. Children who met surveillance status based on DSM-IV-TR criteria, but not DSM-5 criteria, were more likely to have developmental concerns and evaluations in the first three years. Children who met surveillance status based on DSM-5 criteria, but not DSM-IV-TR criteria, were more likely to have been receiving autism-related services or previously diagnosed with ASD. These results suggest that surveillance status of ASD based on DSM-5 criteria is largely comparable to that based on DSM-IV-TR criteria, and identifies children with similar demographic and intellectual characteristics.

Abstract P1-08-06: Not presented

This abstract was not presented at the symposium.

Brief Report: Estimated Prevalence of a Community Diagnosis of Autism Spectrum Disorder by Age 4 Years in Children from Selected Areas in the United States in 2010: Evaluation of Birth Cohort Effects

We compared early-diagnosed autism spectrum disorder (ASD) (defined as diagnosis by age 4 years) between the 2002 and 2006 birth cohorts, in five sites of the Autism and Developmental Disabilities Monitoring Network. In the 2002 cohort, the prevalence/1000 of early-diagnosed ASD was half the 8-year-old prevalence (7.2 vs. 14.7, prevalence ratio [PR] 0.5 [0.4-0.6]). Overall, the prevalence of early-diagnosed ASD did not differ between birth cohorts (PR 1.1 [0.9-1.3]). However, in three sites with complete case ascertainment, the prevalence of early-diagnosed ASD was higher for those born in 2006 versus 2002 (PR 1.3 [1.1-1.5]), suggesting possible improvement in early identification. The lack of change in two sites may reflect less complete case ascertainment. Studies in more recent cohorts are needed.

Autism Spectrum Disorder Among US Children (2002-2010): Socioeconomic, Racial, and Ethnic Disparities

OBJECTIVES

To describe the association between indicators of socioeconomic status (SES) and the prevalence of autism spectrum disorder (ASD) in the United States during the period 2002 to 2010, when overall ASD prevalence among children more than doubled, and to determine whether SES disparities account for ongoing racial and ethnic disparities in ASD prevalence.

METHODS

We computed ASD prevalence and 95% confidence intervals (CIs) from population-based surveillance, census, and survey data. We defined SES categories by using area-level education, income, and poverty indicators. We ascertained ASD in 13 396 of 1 308 641 8-year-old children under surveillance.

RESULTS

The prevalence of ASD increased with increasing SES during each surveillance year among White, Black, and Hispanic children. The prevalence difference between high- and low-SES groups was relatively constant over time (3.9/1000 [95% CI = 3.3, 4.5] in 2002 and 4.1/1000 [95% CI = 3.6, 4.6] in the period 2006-2010). Significant racial/ethnic differences in ASD prevalence remained after stratification by SES.

CONCLUSIONS

A positive SES gradient in ASD prevalence according to US surveillance data prevailed between 2002 and 2010, and racial and ethnic disparities in prevalence persisted during this time among low-SES children.

Prevalence of Cerebral Palsy among 8-Year-Old Children in 2010 and Preliminary Evidence of Trends in Its Relationship to Low Birthweight

BACKGROUND

The public health objective for cerebral palsy (CP) in the United States is to reduce the percentage of children with CP who were born low birthweight (LBW, <2500 g) by 10% between 2006 and 2020. This study reports the prevalence of CP in a constant surveillance area for the years 2006, 2008, and 2010 and describes initial progress towards the CP public health objective.

METHODS

Data on children with CP at age 8 years were ascertained by the Autism and Developmental Disabilities Monitoring (ADDM) Network, a population-based surveillance system that monitored CP in four areas of the United States.

RESULTS

CP prevalence in 2010 was 2.9 per 1000 [95% confidence interval (CI) 2.6, 3.2], down from 3.5 (95% CI 3.2, 3.9) in the same surveillance area in 2006. Among CP cases with no documented postneonatal aetiology, 49.1% (95% CI 42.9, 55.2) were born LBW in 2010 compared with 54.3% (95% CI 48.4, 60.1) in 2006. In 2010, 28.1% (95% CI 22.9, 30.4) were born very low birthweight (VLBW, <1500 g) compared with 35.4% (95% CI 30.0, 41.2) in 2006. The relative risks for associations between CP and both LBW and VLBW also declined, though not significantly, during the study period.

CONCLUSIONS

Declines in the associations between CP and LBW categories may have contributed to declines during the study period in both the prevalence of CP and the percentage of children with CP who were born LBW or VLBW. Ongoing monitoring of these trends is warranted.

Prevalence of cerebral palsy and intellectual disability among children identified in two U.S. National Surveys, 2011-2013

PURPOSE

Cerebral palsy (CP) and intellectual disability (ID) are developmental disabilities that result in considerable functional limitations. There are few recent and nationally representative prevalence estimates of CP and ID in the United States.

METHODS

We used two U.S. nationally representative surveys, the 2011-2012 National Survey of Children's Health (NSCH) and the 2011-2013 National Health Interview Survey (NHIS), to determine the prevalence of CP and ID based on parent report among children aged 2-17 years.

RESULTS

CP prevalence was 2.6 (95% confidence interval [CI]: 2.1-3.2) per 1000 in the NSCH and 2.9 (95% CI: 2.3-3.7) in the NHIS. ID prevalence was 12.2 (95% CI: 10.7-13.9) and 12.1 (95% CI: 10.8-13.7) in NSCH and NHIS, respectively. For both conditions, the NSCH and NHIS prevalence estimates were similar to each other for nearly all sociodemographic subgroups examined.

CONCLUSIONS

Despite using different modes of data collection, the two surveys produced similar and plausible estimates of CP and ID and offer opportunities to better understand the needs and situations of children with these conditions.

Hospitalizations Attributable to Respiratory Infections among Children with Neurologic Disorders

OBJECTIVES

To characterize respiratory infection hospitalizations in children with neurologic disorders and to compare them with those of the general pediatric population.

STUDY DESIGN

We analyzed claims data from commercial insurance and Medicaid enrollees < 19 years of age from July 2006 to June 2011 who had ≥ 1 visit with an International Classification of Diseases, Ninth Revision, diagnosis code for a neurologic disorder. We identified hospitalizations with primary diagnosis codes indicating a respiratory infection and compared hospitalization rates with random samples of children from the commercial and Medicaid databases (comparison groups).

RESULTS

Among 33,651923 children, 255,046 (0.76%) had ≥ 1 neurologic condition. Among children with neurologic conditions, 8249 of 68,717 hospitalizations (12%) were attributed to a respiratory infection (rate: 21/1000 person-years), although rates varied by disorder. Children with neurologic disorders had greater rates than children in comparison groups (relative rate: Commercial Claims 7.4 [95% CI 7.1-7.7]; Medicaid 5.0 [95% CI 4.8-5.2]). Children < 2 years were most likely to be hospitalized, although those 10-18 years were 14.5 (95% CI 13.3-16.7) times more likely to be hospitalized than age-matched comparison groups. Co-occurring deafness, blindness, and scoliosis were associated with increased respiratory hospitalization rates.

CONCLUSIONS

Children with neurologic disorders are at 5- to 7-fold greater risk for hospitalization from respiratory infections compared with all children, although rates vary widely by disorder type, age, and comorbidities. Children with specific neurologic disorders and those who had co-occurring conditions have the highest rates.

Birth Prevalence of Cerebral Palsy: A Population-Based Study

OBJECTIVE

Population-based data in the United States on trends in cerebral palsy (CP) birth prevalence are limited. The objective of this study was to examine trends in the birth prevalence of congenital spastic CP by birth weight, gestational age, and race/ethnicity in a heterogeneous US metropolitan area.

METHODS

Children with CP were identified by a population-based surveillance system for developmental disabilities (DDs). Children with CP were included if they were born in metropolitan Atlanta, Georgia, from 1985 to 2002, resided there at age 8 years, and did not have a postneonatal etiology (n = 766). Birth weight, gestational age, and race/ethnicity subanalyses were restricted to children with spastic CP (n = 640). Trends were examined by CP subtype, gender, race/ethnicity, co-occurring DDs, birth weight, and gestational age.

RESULTS

Birth prevalence of spastic CP per 1000 1-year survivors was stable from 1985 to 2002 (1.9 in 1985 to 1.8 in 2002; 0.3% annual average prevalence; 95% confidence interval [CI] -1.1 to 1.8). Whereas no significant trends were observed by gender, subtype, birth weight, or gestational age overall, CP prevalence with co-occurring moderate to severe intellectual disability significantly decreased (-2.6% [95% CI -4.3 to -0.8]). Racial disparities persisted over time between non-Hispanic black and non-Hispanic white children (prevalence ratio 1.8 [95% CI 1.5 to 2.1]). Different patterns emerged for non-Hispanic white and non-Hispanic black children by birth weight and gestational age.

CONCLUSIONS

Given improvements in neonatal survival, evidence of stability of CP prevalence is encouraging. Yet lack of overall decreases supports continued monitoring of trends and increased research and prevention efforts. Racial/ethnic disparities, in particular, warrant further study.

Development and validation of the Australian Aboriginal racial identity and self-esteem survey for 8-12 year old children (IRISE_C)

INTRODUCTION

In Australia, there is little empirical research of the racial identity of Indigenous children and youth as the majority of the current literature focuses on adults. Furthermore, there are no instruments developed with cultural appropriateness when exploring the identity and self-esteem of the Australian Aboriginal population, especially children. The IRISE_C (Racial Identity and Self-Esteem of children) inventory was developed to explore the elements of racial identity and self-esteem of urban, rural and regional Aboriginal children. This paper describes the development and validation of the IRISE_C instrument with over 250 Aboriginal children aged 8 to 12 years.

METHODS

A pilot of the IRISE C instrument was combined with individual interviews and was undertaken with 35 urban Aboriginal children aged 8-12 years. An exploratory factor analysis was performed to refine the survey and reduce redundant items in readiness for the main study. In the main study, the IRISE C was employed to 229 Aboriginal children aged 6-13 years across three sites (rural, regional and urban) in Western Australia. An exploratory factor analysis using Principal axis factoring was used to assess the fit of items and survey structure. A confirmatory factor analysis was then employed using LISREL (diagonally weighted least squares) to assess factor structures across domains. Internal consistency and reliability of subscales were assessed using Cronbach's co-efficient alpha.

RESULTS

The pilot testing identified two key concepts - children's knowledge of issues related to their racial identity, and the importance, or salience, that they attach to these issues. In the main study, factor analyses showed two clear factors relating to: Aboriginal culture and traditions; and a sense of belonging to an Aboriginal community. Principal Axis Factoring of the Knowledge items supported a 2-factor solution, which explained 38.7% of variance. Factor One (Aboriginal culture) had a Cronbach's alpha of 0.835; Factor 2 (racial identity) had a Cronbach's alpha of 0.800, thus demonstrating high internal reliability of the scales.

CONCLUSION

The IRISE_C has been shown to be a valid instrument useful of exploring the development of racial identity of Australian Aboriginal children across the 8-12 year old age range and across urban, rural and regional geographical locations.

The role of socio-economic status and perinatal factors in racial disparities in the risk of cerebral palsy

AIM

To determine whether racial disparities in cerebral palsy (CP) risk among US children persist after controlling for socio-economic status (SES) (here indicated by maternal education) and perinatal risk factors.

METHOD

A population-based birth cohort study was conducted using the Autism and Developmental Disabilities Monitoring Network surveillance and birth data for 8-year-old children residing in multi-county areas in Alabama, Georgia, Missouri, and Wisconsin between 2002 and 2008. The birth cohort comparison group included 458 027 children and the case group included 1570 children with CP, 1202 with available birth records. χ(2) tests were performed to evaluate associations and logistic regression was used to calculate relative risks (RR) and adjusted odds ratios (OR) with 95% confidence intervals (CI).

RESULTS

The risk of spastic CP was more than 50% higher for black versus white children (RR 1.52, 95% CI 1.33-1.73), and this greater risk persisted after adjustment for SES (OR 1.35, 95% CI 1.18-1.55), but not after further adjustment for preterm birth and size for gestational age. The protective effect of maternal education remained after adjustment for race/ethnicity and perinatal factors.

INTERPRETATION

Maternal education appears to independently affect CP risk but does not fully explain existing racial disparities in CP prevalence in the US.

Trends in the prevalence of autism spectrum disorder, cerebral palsy, hearing loss, intellectual disability, and vision impairment, metropolitan atlanta, 1991-2010

This study examined the prevalence and characteristics of autism spectrum disorder (ASD), cerebral palsy (CP), hearing loss (HL), intellectual disability (ID), and vision impairment (VI) over a 15-20 year time period, with specific focus on concurrent changes in ASD and ID prevalence. We used data from a population-based developmental disabilities surveillance program for 8-year-olds in metropolitan Atlanta. From 1991-2010, prevalence estimates of ID and HL were stable with slight increases in VI prevalence. CP prevalence was constant from 1993-2010. The average annual increase in ASD prevalence was 9.3% per year from 1996-2010, with a 269% increase from 4.2 per 1,000 in 1996 to 15.5 per 1,000 in 2010. From 2000-2010, the prevalence of ID without ASD was stable; during the same time, the prevalence of ASD with and without co-occurring ID increased by an average of 6.6% and 9.6% per year, respectively. ASD prevalence increases were found among both males and females, and among nearly all racial/ethnic subgroups and levels of intellectual ability. Average annual prevalence estimates from 1991-2010 underscore the significant community resources needed to provide early intervention and ongoing supports for children with ID (13.0 per 1,000), CP, (3.5 per 1,000), HL (1.4 per 1,000) and VI (1.3 in 1,000), with a growing urgency for children with ASD.

Hospitalizations for severe lower respiratory tract infections

BACKGROUND

Hospitalization for lower respiratory tract infections (LRTIs) among children have been well characterized. We characterized hospitalizations for severe LRTI among children.

METHODS

We analyzed claims data from commercial and Medicaid insurance enrollees (MarketScan) ages 0 to 18 years from 2007 to 2011. LRTI hospitalizations were identified by the first 2 listed International Classification of Diseases, Ninth Revision discharge codes; those with ICU admission and/or receiving mechanical ventilation were defined as severe LRTI. Underlying conditions were determined from out- and inpatient discharge codes in the preceding year. We report insurance specific and combined rates that used both commercial and Medicaid rates and adjusted for age and insurance status.

RESULTS

During 2007-2011, we identified 16797 and 12053 severe LRTI hospitalizations among commercial and Medicaid enrollees, respectively. The rates of severe LRTI hospitalizations per 100000 person-years were highest in children aged <1 year (commercial: 244; Medicaid: 372, respectively), and decreased with age. Among commercial enrollees, ≥ 1 condition increased the risk for severe LRTI (1 condition: adjusted relative risk, 2.68; 95% confidence interval, 2.58-2.78; 3 conditions: adjusted relative risk, 4.85; 95% confidence interval, 4.65-5.07) compared with children with no medical conditions. Using commercial/Medicaid combined rates, an estimated 31289 hospitalizations for severe LRTI occurred each year in children in the United States.

CONCLUSIONS

Among children, the burden of hospitalization for severe LRTI is greatest among children aged <1 year. Children with underlying medical conditions are at greatest risk for severe LRTI hospitalization.

Maternal infections during pregnancy and cerebral palsy: a population-based cohort study

BACKGROUND

Cerebral palsy (CP) is a common motor disability in childhood. We examined the association between maternal infections during pregnancy and the risk of congenital CP in the child.

METHODS

Liveborn singletons in Denmark between 1997 and 2003 were identified from the Danish National Birth Registry and followed from 1 year of life until 2008. Redemption of antibiotics from the National Register of Medicinal Product Statistics and maternal infections reported by the National Hospital Register were used as markers of maternal infection during pregnancy. CP diagnoses were obtained from the Danish Cerebral Palsy Registry. Adjusted hazard ratio (HR) and 95% confidence interval (CI) were estimated by Cox proportional hazard models.

RESULTS

Of the 440 564 singletons with follow-up data, 840 were diagnosed with congenital CP. Maternal genito-urinary tract infections (HR 2.1, 95% CI 1.4, 3.2) were associated with CP in all births, in term births (HR 1.9, 95% CI 1.1, 3.2), in children with spastic CP (HR 2.1, 95% CI 1.4, 3.3), and among first-born children (HR 1.9, 95% CI 1.4, 3.3). Overall, we found associations between redeemed nitrofurantoin (HR 1.7, 95% CI 1.1, 2.8) and CP. Among trimester-specific exposures, CP risk was associated with prescriptions redeemed in the first trimester for any antibacterials, beta-lactam antibacterials, and nitrofurantoin, an antibiotic commonly used to treat lower urinary tract infection, and genito-urinary tract infections in the third trimester.

CONCLUSION

Genito-urinary tract infections and antibiotic use during pregnancy were associated with increased risks of CP, indicating that some maternal infections or causes of maternal infections present in prenatal life may be part of a causal pathway leading to CP.

Congenital cerebral palsy and prenatal exposure to self-reported maternal infections, fever, or smoking

OBJECTIVE

The objective of the study was to investigate the association between maternal self-reported infections, fever, and smoking in the prenatal period and the subsequent risk for congenital cerebral palsy (CP).

STUDY DESIGN

We included the 81,066 mothers of singletons born between 1996 and 2003 who participated in the Danish National Birth Cohort. Children were followed up through December 2008. Information on maternal infections, fever, smoking, and other demographic and lifestyle factors during pregnancy were reported by mothers in computer-assisted telephone interviews in early and midgestation. We identified 139 CP cases including 121 cases of spastic CP (sCP) as confirmed by the Danish National Cerebral Palsy Register. Cox proportional hazards regression models were used to estimate adjusted hazard ratios (aHRs) and 95% confidence intervals (CIs).

RESULTS

Self-reported vaginal infections were associated with an increased risk of CP and sCP (aHR, 1.52; 95% CI, 1.04-2.24; and aHR, 1.73; 95% CI, 1.16-2.60, respectively) and particularly untreated vaginal infections were associated with an increased risk of sCP (aHR, 1.95; 95% CI, 1.16-3.26). Fever was associated with the risk of CP (aHR, 1.53; 95% CI, 1.06-2.21). Smoking 10 or more cigarettes per day during pregnancy was also associated with sCP (aHR, 1.80; 95% CI, 1.10-2.94). There was a modest excess in risk for children exposed to both heavy smoking and vaginal infections. No other self-reported infections were significantly associated with CP.

CONCLUSION

Self-reported vaginal infections, fever, and smoking 10 or more cigarettes per day during pregnancy were associated with a higher risk of overall CP and/or sCP.

Design and characterization of a laterally mounted phased-array transducer breast-specific MRgHIFU device with integrated 11-channel receiver array

PURPOSE

This work presents the design and preliminary evaluation of a new laterally mounted phased-array MRI-guided high-intensity focused ultrasound (MRgHIFU) system with an integrated 11-channel phased-array radio frequency (RF) coil intended for breast cancer treatment. The design goals for the system included the ability to treat the majority of tumor locations, to increase the MR image's signal-to-noise ratio (SNR) throughout the treatment volume and to provide adequate comfort for the patient.

METHODS

In order to treat the majority of the breast volume, the device was designed such that the treated breast is suspended in a 17-cm diameter treatment cylinder. A laterally shooting 1-MHz, 256-element phased-array ultrasound transducer with flexible positioning is mounted outside the treatment cylinder. This configuration achieves a reduced water volume to minimize RF coil loading effects, to position the coils closer to the breast for increased signal sensitivity, and to reduce the MR image noise associated with using water as the coupling fluid. This design uses an 11-channel phased-array RF coil that is placed on the outer surface of the cylinder surrounding the breast. Mechanical positioning of the transducer and electronic steering of the focal spot enable placement of the ultrasound focus at arbitrary locations throughout the suspended breast. The treatment platform allows the patient to lie prone in a face-down position. The system was tested for comfort with 18 normal volunteers and SNR capabilities in one normal volunteer and for heating accuracy and stability in homogeneous phantom and inhomogeneous ex vivo porcine tissue.

RESULTS

There was a 61% increase in mean relative SNR achieved in a homogeneous phantom using the 11-channel RF coil when compared to using only a single-loop coil around the chest wall. The repeatability of the system's energy delivery in a single location was excellent, with less than 3% variability between repeated temperature measurements at the same location. The execution of a continuously sonicated, predefined 48-point, 8-min trajectory path resulted in an ablation volume of 8.17 cm(3), with one standard deviation of 0.35 cm(3) between inhomogeneous ex vivo tissue samples. Comfort testing resulted in negligible side effects for all volunteers.

CONCLUSIONS

The initial results suggest that this new device will potentially be suitable for MRgHIFU treatment in a wide range of breast sizes and tumor locations.

The role of migration and choice of denominator on the prevalence of cerebral palsy

AIM

Differential migration and choice of denominator have been hypothesized to contribute to differences between period prevalence and birth prevalence of cerebral palsy (CP). The purpose of this study was to evaluate the effects of migration and choice of denominator on the prevalence of CP.

METHOD

Data from the Metropolitan Atlanta Developmental Disabilities Surveillance Program and census and birth certificate files were used to calculate various CP prevalence estimates for 2000.

RESULTS

The overall CP period prevalence was 3.2 (95% confidence interval [CI] 2.7-3.8) per 1000 8-year-olds and was similar for those born in Atlanta who resided there at age 8 years (3.3; 95% CI 2.7-4.1) and those born outside Atlanta who moved into Atlanta by age 8 years (3.0; 95% CI 2.3-3.9). CP prevalence in these two migration strata was similar by sex and race/ethnicity. CP birth prevalence of 8-year-olds in Atlanta in 2000 was 2.0 (95% CI 1.6-2.5) per 1000 live births in 1992.

INTERPRETATION

The authors found no evidence to support the hypothesis that differential in-migration explained higher period than birth prevalence of CP in Atlanta. Comparability of CP prevalence across geographic areas will be enhanced if future studies report both period and birth prevalence.

Early mental health morbidity and later smoking at age 17 years

BACKGROUND

We examined the relationship between the onset and pattern of childhood mental health disorders and subsequent current smoking status at age 17 years.

METHOD

Data were from a prospective cohort study of 2868 births of which 1064 supplied information about their current smoking at 17 years of age. The association between the onset and pattern of clinically significant mental health disorders in the child and subsequent smoking at age 17 years was estimated via multivariable logistic regression.

RESULTS

Relative to 17 year olds who never had an externalizing disorder, 17-year-olds who had an externalizing disorder at age 5, 8 or 14 years were, respectively, 2.0 times [95% confidence interval (CI) 1.24-3.25], 1.9 (95% CI 1.00-3.65) or 3.9 times (95% CI 1.73-8.72) more likely to be a current smoker. Children with an ongoing pattern of externalizing disorder were 3.0 times (95% CI 1.89-4.84) more likely to be smokers at the age of 17 years and those whose mothers reported daily consumption of 6-10 cigarettes at 18 weeks' gestation were 2.5 times (OR 2.46, 95% CI 1.26-4.83) more likely to report smoking at 17 years of age. Associations with early anxiety and depression in the child were not found.

CONCLUSIONS

Current smoking in 17-year-olds may be underpinned by early emergent, and then, ongoing, externalizing disorder that commenced as young as age 5 years as well as exposure to early prenatal maternal smoking. The associations documented in adults and adolescents that link tobacco smoking and mental health are likely to be in play at these early points in development.

Post-stroke fatigue and return to work: a 2-year follow-up

BACKGROUND

Post-stroke fatigue may affect the ability to return to work but quantitative studies are lacking.

METHOD

We included 83 first-ever stroke patients <60 years and employed either full-time (n = 77) or part-time (n = 6) at baseline. The patients were recruited from stroke units at Aarhus University Hospital between 2003 and 2005 and were followed for 2 years. Fatigue was assessed by the Multidimensional Fatigue Inventory. Pathological fatigue was defined as a score ≥12 on the General Fatigue dimension. Return to paid work was defined as working at least 10 h per week. Data were analyzed using multivariable logistic regression.

RESULTS

A total of 58% of patients had returned to paid work after 2 years. The adjusted Odds Ratio (OR) for returning to paid work was 0.39 (95% confidence interval (CI) 0.16-1.08) for patients with a General Fatigue score ≥12 at baseline. Persisting pathological fatigue after 2 years of follow-up was associated with a lower chance of returning to paid work [adjusted OR 0.29 (95% CI 0.11-0.74)]. Higher scores of General Fatigue at follow-up also correlated negatively with the chance of returning to paid work when analyzing fatigue on a continuous scale (adjusted OR 0.87, 95% CI 0.80-0.94 for each point increase in General Fatigue).

CONCLUSIONS

Post-stroke fatigue appears to be an independent determinant of not being able to resume paid work following stroke.

Clinical outcomes of osteomyelitis patients infected with methicillin-resistant Staphylococcus aureus USA-300 strains

Methicillin-resistant Staphylococcus aureus (MRSA) USA-300 strains have emerged as an important cause of community-acquired infections. These strains have been recognized as an etiology of osteomyelitis but data on their incidence and outcomes are limited. We retrospectively studied the incidence and clinical outcomes of MRSA USA-300 osteomyelitis in patients at the University of Louisville Hospital and the Henry Ford Health System between January 2007 and March 2008. Pulsed-field gel electrophoresis was used to determine USA type. Clinical outcomes were defined as management success versus failure at 12 months. Chi-square tests, Fisher exact tests, and Mann-Whitney tests were used to compare patient characteristics on the basis of clinical outcomes and USA type. Of the 50 patients with MRSA osteomyelitis, 27 (54%) had the USA-300 strain. Clinical failure was identified in 22% (6/27) of the patients with MRSA USA-300 and in 30% (7/23) of the patients with MRSA non-USA-300 osteomyelitis (P = .509). Our results showed that MRSA USA-300 is a significant etiology of MRSA osteomyelitis. With current surgical and medical management, outcomes of patients with MRSA USA-300 osteomyelitis are similar to those of patients with MRSA non-USA-300 osteomyelitis.

Volatile Fatty acids and hydrogen as substrates for sulfate-reducing bacteria in anaerobic marine sediment

The addition of 20 mM MoO(4) (molybdate) to a reduced marine sediment completely inhibited the SO(4) reduction activity by about 50 nmol g h (wet sediment). Acetate accumulated at a constant rate of about 25 nmol g h immediately after MoO(4) addition and gave a measure of the preceding utilization rate of acetate by the SO(4)-reducing bacteria. Similarly, propionate and butyrate (including isobutyrate) accumulated at constant rates of 3 to 7 and 2 to 4 nmol g h, respectively. The rate of H(2) accumulation was variable, and a range of 0 to 16 nmol g h was recorded. An immediate increase of the methanogenic activity by 2 to 3 nmol g h was apparently due to a release of the competition for H(2) by the absence of SO(4) reduction. If propionate and butyrate were completely oxidized by the SO(4)-reducing bacteria, the stoichiometry of the reactions would indicate that H(2), acetate, propionate, and butyrate account for 5 to 10, 40 to 50, 10 to 20, and 10 to 20%, respectively, of the electron donors for the SO(4)-reducing bacteria. If the oxidations were incomplete, however, the contributions by propionate and butyrate would only be 5 to 10% each, and the acetate could account for as much as two-thirds of the SO(4) reduction. The presence of MoO(4) seemed not to affect the fermentative and methanogenic activities; an MoO(4) inhibition technique seems promising in the search for the natural substrates of SO(4) reduction in sediments.

Prolactin release and response to vasoactive intestinal peptide in an opportunistic breeder, the zebra finch (Taeniopygia guttata)

Zebra finches in arid regions of Australia are opportunistic breeders that time their breeding cycles to coincide with nonseasonal rainfall. Hormonal profiles associated with reproductive behaviors may differ from those observed in seasonal breeders because these birds need to be reproductively competent on short notice. This study measured plasma prolactin (PRL) levels in nonbreeding and breeding zebra finches and in birds with and without prior reproductive experience. We also investigated the change in plasma PRL following injection with vasoactive intestinal peptide (VIP), the avian PRL-releasing hormone. PRL was lowest in non-paired birds, increased after pair bonds had formed, and was highest in incubating birds. No differences in PRL levels were found between males and females in these biparental care-givers. A single injection of VIP resulted in a rapid increase in plasma PRL in nonbreeding zebra finches, while PRL remained unchanged in incubating birds. When escalating doses of VIP were administered, nonbreeders responded with a maximal response in PRL release, but PRL levels in breeders remained unchanged following even the highest VIP dose. Among nonbreeders, inexperienced birds had significantly lower PRL levels than birds that had successfully reared a clutch, but both groups responded with an equally robust increase in PRL following a VIP challenge. This pattern differs from that observed in most photosensitive species in which only during a breeding cycle do birds secrete significant levels of PRL in response to exogenous VIP. Zebra finches, even when not actively breeding, must maintain competent pituitary lactotrophs that can secrete PRL at maximal rates. This is part of the suite of characters enabling these birds to respond to favorable breeding conditions at any time.