Financial responsibility, financial context, and ambulatory blood pressure in early middle-aged African-American women

BACKGROUND

African-American women have excess rates of elevated blood pressure (BP) and hypertension compared to women of all other racial/ethnic backgrounds. Several researchers have speculated that race and gender-related socioeconomic status (SES) stressors might play a role.

OBJECTIVE

To examine the association between a novel SES-related stressor highly salient among African-American women, financial responsibility for one's household, and 48-h ambulatory BP. We further examined whether aspects related to African-American women's financial context (e.g., single parenthood, household income, marital status) played a role.

METHODS

Participants were N = 345 employed, healthy African-American women aged 30-46 from diverse SES backgrounds who underwent 48-h ambulatory BP monitoring. Linear regression analyses were conducted to examine associations between self-reported financial responsibility and daytime and nighttime BP, adjusting for age, SES and other sociodemographics, cardiovascular risk factors, financial strain and depressive symptoms. Interactions between financial responsibility and single parenthood, household income, and marital/partnered status were tested.

RESULTS

In age-adjusted analyses, reporting financial responsibility was associated with higher daytime systolic (β = 4.42, S.E. = 1.36, p = 0.0013), and diastolic (β = 2.82, S.E. = 0.98, p = 0.004) BP. Associations persisted in fully adjusted models. Significant associations were also observed for nighttime systolic and diastolic BP. There were no significant interactions with single parenthood, household income, nor marital/partnered status.

CONCLUSION

Having primary responsibility for one's household may be an important driver of BP in early middle-aged African-American women, independent of SES, financial strain, and across a range of financial contexts. Future studies examining prospective associations are needed, and policy interventions targeting structural factors contributing to financial responsibility in African-American women may be warranted.

The association between Superwoman schema and subjective sleep quality among Black women

OBJECTIVES

Similar to women overall, Black women are socialized to be communal and "self-sacrificing," but unlike women from other racial/ethnic backgrounds, Black women are also socialized to be "strong" and "invulnerable." This phenomenon is labeled Superwoman schema. This study examined associations between Superwoman schema endorsement and subjective sleep quality.

METHODS

Participants included 405 Black women (ages 30-46). Superwoman schema was measured using a 35-item scale capturing five dimensions: obligation to present strength, suppress emotions, resistance to vulnerability, motivation to succeed, and obligation to help others. Superwoman schema overall and the five dimensions/subscales were analyzed. The Pittsburgh Sleep Quality Index (PSQI) was used to investigate overall subjective sleep quality (range: 0-19), poor sleep quality (PSQI >5), and specific sleep domains (eg, sleep duration, sleep disturbances). We fit linear and binary logistic regression models, adjusting for health-related and sociodemographic factors.

RESULTS

Superwoman schema dimension obligation to help others was associated with lower overall subjective sleep quality (β: .81, 95%CI=0.29, 1.32) and poor sleep quality (OR: 1.55, 95%CI=1.10, 2.19), as well as bad subjective sleep quality (OR: 1.76, 95%CI=1.18, 2.66), sleep disturbances (β: .73, 95%CI =0.07, 1.41), and daytime sleepiness (OR: 2.01, 95%CI=1.25, 3.26). Suppress emotions (OR: 1.41, 95%CI=1.01, 1.99) was associated with poor subjective sleep quality. Superwoman schema overall was associated with daytime sleepiness (OR: 2.01, 95%CI=1.06, 3.82).

CONCLUSION

Superwoman schema endorsement, especially obligation to help others and suppress emotions, may be important psychosocial risk factors for Black women's sleep health.

Superwoman Schema and self-rated health in black women: Is socioeconomic status a moderator?

BACKGROUND

The Superwoman Schema (SWS) construct elucidates Black women's socialization to be strong, suppress their emotions, resist vulnerability, succeed despite limited resources, and help others at their own expense. Drawing from intersectionality and social psychological research on self-schemas, this study examined the extent to which SWS was associated with Black women's self-rated health. We also investigated whether socioeconomic status (SES) moderated the association between SWS, its five dimensions, and self-rated health.

METHODS

Data were from the Mechanisms Underlying Stress and Emotions (MUSE) in African-American Women's Health Study, a cohort of African American self-identified women. SWS was assessed using Giscombé's 35-item Superwoman Schema Scale. Socioeconomic status was measured by household income and educational attainment. Ordered logistic regression models were used and statistical interactions were run to test for moderation (N = 408).

RESULTS

First, SWS dimension "obligation to help others" was associated with worse self-rated health (p < .05). Second, household income, but not education, moderated the association between SWS and self-rated health (p < .05): SWS overall was associated with worse self-rated health among higher income women but better self-rated health among lower income women. Third, income moderated the association between SWS dimension "obligation to present an image of strength" and self-rated health (p < .05): presenting strength was associated with better self-rated health for lower income women only. Fourth, moderation results revealed that SWS dimension "obligation to help others" was inversely associated with self-rated health particularly among higher income women.

CONCLUSIONS

Findings speak to the complex interplay between SES and SWS dimensions as they relate to Black women's perceived health.

Network stressors, personal stressors, and ambulatory blood pressure in African-American women-Does superwoman schema play a role?

OBJECTIVE

Life stressors have been linked to cardiovascular risk; however, studies typically focus on stressors that directly impact the individual, that is, personal stressors. Research suggests that women, particularly African-American women, may be more vulnerable to network stressors that involve family members and friends-potentially due to norms around needing to be a "Superwoman." Yet few studies have examined these phenomena.

METHOD

We examined associations between network, versus personal, stressors, and elevated blood pressure (BP) in N = 392 African-American women aged 30-46. Questionnaire-assessed negative life events were classified into upsetting network or personal stressors. BP was assessed in clinic and via 48-hr ambulatory monitoring. Linear and logistic regression models examined associations between type of stressors and 48-hr daytime and nighttime systolic BP (SBP) and diastolic BP (DBP), and sustained hypertension after adjusting for relevant covariates. Interactions with questionnaire-assessed superwoman schema (SWS) were tested in exploratory analyses.

RESULTS

In age and sociodemographic-adjusted models, network stressors were significantly associated with daytime SBP, β (SE) = 2.01 (0.51), p ≤ .0001, and DBP, β (SE) = 1.59 (0.37), p ≤ .0001, but personal stressors were not (p values > .10). Associations persisted after adjustment for cardiovascular and psychosocial risk factors. Patterns were similar for nighttime BP and sustained hypertension. There were no interactions with SWS.

CONCLUSIONS

Network, but not personal, stressors were associated with elevated rates of daytime SBP and DBP, as well as sustained hypertension in African-American women, irrespective of SWS endorsement. Future research is needed to determine whether stress-management interventions focused on network stressors might impact BP in this high-risk population. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Gendered Racial Microaggressions and Black Women's Sleep Health

Gendered racial microaggressions reflect historical and contemporary gendered racism that Black women encounter. Although gendered racial microaggressions are related to psychological outcomes, it is unclear if such experiences are related to sleep health. Moreover, the health effects of gendered racial microaggressions dimensions are rarely investigated. Using a cohort of Black women (N = 400), this study employs an intracategorical intersectional approach to (1) investigate the association between gendered racial microaggressions and sleep health, (2) assess whether gendered racial microaggressions dimensions are related to sleep health, and (3) examine whether the gendered racial microaggressions-sleep health association persists after accounting for depressive symptoms and worry. Gendered racial microaggressions were associated with poor sleep quality overall and four specific domains: subjective sleep quality, latency, disturbance, and daytime sleepiness. Two gendered racial microaggressions dimensions were especially detrimental for sleep: assumptions of beauty/sexual objectification and feeling silenced and marginalized. After accounting for mental health, the effect of gendered racial microaggressions on sleep was reduced by 47 percent. Future research implications are discussed.

Effects of pair housing on behavior, cortisol, and clinical outcomes during quarantine-like procedures for rhesus macaques (Macaca mulatta)

BACKGROUND

Compatible pair housing of macaques in research settings increases species-typical behaviors and facilitates beneficial social buffering. It is not yet established whether these benefits are maintained after intrafacility transfer and domestic quarantine, which are two stressors that can lead to behavioral and clinical abnormalities.

METHODS

We evaluated 40 adolescent male rhesus macaques who were single- or pair-housed immediately following an intrafacility transfer. We measured behavior, fecal cortisol, body weight, and diarrhea occurrence. Body weight and diarrhea occurrence were also retrospectively analyzed in an additional 120 adolescent rhesus who underwent a similar transfer.

RESULTS AND CONCLUSIONS

Pair-housed macaques exhibited less of some undesirable behaviors (e.g., self-clasping) and experienced less diarrhea than single-housed subjects; however, no significant differences in cortisol levels or alopecia measures were found. The demonstrated beneficial effects of pair housing for rhesus macaques following intrafacility transfer and adjustment suggest pairing upon arrival at a new facility will bolster animal welfare.

Monitoring Multiple U.S. Government-Supported Covid-19 Vaccine Trials

Monitoring U.S. Government-Supported Covid-19 Vaccine TrialsOperation Warp Speed was a partnership created to accelerate the development of Covid-19 vaccines. The National Institutes of Health oversaw one data and safety monitoring board to review/monitor all Operation Warp Speed trials. This article describes the challenges faced in monitoring these trials and provides ideas for future similar endeavors.

Safety and biomarker effects of candesartan in non-hypertensive adults with prodromal Alzheimer's disease

Observational studies suggest that angiotensin receptor blockers in hypertensive adults are associated with lower post-mortem indicators of Alzheimer's disease pathology. Candesartan, an angiotensin receptor blocker, has a positive cognitive effect in mild cognitive impairment with hypertension. However, its safety and effects in non-hypertensive individuals with Alzheimer's disease are unclear. This is the first double-blind randomized placebo-controlled trial aimed to assess safety and effects of 1-year therapy of candesartan on biomarkers and clinical indicators of Alzheimer's disease in non-hypertensive individuals with biomarker-confirmed prodromal Alzheimer's disease. Seventy-seven non-hypertensive participants 50 years or older (mean age: 68.1 years; 62% women; 20% African American) with mild cognitive impairment and biomarker confirmed Alzheimer's disease were randomized to escalating doses of once daily oral candesartan (up to 32 mg) or matched placebo. Main outcomes included safety and tolerability of candesartan, cerebrospinal fluid biomarkers (amyloid-β42, amyloid-β40, total tau and phospho-tau). Additional exploratory outcomes included PET imaging (Pittsburgh Compound-B (¹¹C-PiB) and ¹⁸F-flortaucipir), brain MRI (structural and connectivity measures) and cognitive functioning. Analyses used intention-to-treat approach with group comparisons of safety measures using Chi-square test, and repeated measures mixed effects models were used to assess candesartan effects on main and exploratory outcomes (ClinicalTrials.gov, NCT02646982). Candesartan was found to be safe with no significant difference in safety measures: symptoms of hypotension, renal failure or hyperkalemia. Candesartan was also found to be associated with increases in cerebrospinal fluid Aβ40 (between-group mean difference: 1211.95 pg/ml, 95% confidence interval: 313.27, 2110.63) and Aβ42 (49.51 pg/ml, 95% confidence interval: -98.05, -0.98) reflecting lower brain amyloid accumulation. Candesartan was associated with decreased ¹¹C-PiB in the parahippocampal region (-0.1104, 95% confidence interval: -0.19, -0.029) which remained significant after false discovery rate correction, and with an increase in functional network connectivity in the subcortical networks. Candesartan was further associated with improved executive function (Trail Making Test Part B) performance (-11.41 s, 95% confidence interval: -11.94, -10.89) and trended for an improved global cognitive functioning reflected by a composite cognitive score (0.002, 95% confidence interval: -0.0002, 0.005). We did not observe significant effects on tau levels, hippocampal volume or other cognitive measures (memory or clinical dementia rating scale-sum of boxes). In conclusion, among non-hypertensive prodromal Alzheimer's disease, candesartan is safe and likely decreases brain amyloid biomarkers, enhances subcortical brain connectivity and has favourable cognitive effects. These findings suggest that candesartan may have an important therapeutic role in Alzheimer's disease, and warrant further investigation given the lack of clear treatment options for this devastating illness.

Pain, Analgesic Use, and Patient Satisfaction With Spinal Versus General Anesthesia for Hip Fracture Surgery : A Randomized Clinical Trial

BACKGROUND

The REGAIN (Regional versus General Anesthesia for Promoting Independence after Hip Fracture) trial found similar ambulation and survival at 60 days with spinal versus general anesthesia for hip fracture surgery. Trial outcomes evaluating pain, prescription analgesic use, and patient satisfaction have not yet been reported.

OBJECTIVE

To compare pain, analgesic use, and satisfaction after hip fracture surgery with spinal versus general anesthesia.

DESIGN

Preplanned secondary analysis of a pragmatic randomized trial. (ClinicalTrials.gov: NCT02507505).

SETTING

46 U.S. and Canadian hospitals.

PARTICIPANTS

Patients aged 50 years or older undergoing hip fracture surgery.

INTERVENTION

Spinal or general anesthesia.

MEASUREMENTS

Pain on postoperative days 1 through 3; 60-, 180-, and 365-day pain and prescription analgesic use; and satisfaction with care.

RESULTS

A total of 1600 patients were enrolled. The average age was 78 years, and 77% were women. A total of 73.5% (1050 of 1428) of patients reported severe pain during the first 24 hours after surgery. Worst pain over the first 24 hours after surgery was greater with spinal anesthesia (rated from 0 [no pain] to 10 [worst pain imaginable]; mean difference, 0.40 [95% CI, 0.12 to 0.68]). Pain did not differ across groups at other time points. Prescription analgesic use at 60 days occurred in 25% (141 of 563) and 18.8% (108 of 574) of patients assigned to spinal and general anesthesia, respectively (relative risk, 1.33 [CI, 1.06 to 1.65]). Satisfaction was similar across groups.

LIMITATION

Missing outcome data and multiple outcomes assessed.

CONCLUSION

Severe pain is common after hip fracture. Spinal anesthesia was associated with more pain in the first 24 hours after surgery and more prescription analgesic use at 60 days compared with general anesthesia.

PRIMARY FUNDING SOURCE

Patient-Centered Outcomes Research Institute.

Antibodies to human leukocyte antigens and their association with blood product exposures in pediatric patients undergoing cardiac transplantation

BACKGROUND AND AIMS

Previous blood product exposures may result in the development of antibodies to human leukocyte antigens (HLA). Pediatric heart transplant recipients who have these antibodies experience increased morbidity and mortality after transplantation. In this study, our aims were to confirm the association of previous allogeneic blood product exposures with the formation of anti-HLA antibodies, determine which blood components pose the greatest risk of developing antibodies, and assess differences in outcomes after transplantation between patients who had anti-HLA antibodies and those who did not.

METHODS

This retrospective investigation included all children who underwent cardiac transplantation at Children's Healthcare of Atlanta from January 1, 2015 through December 31, 2018. Chart reviews were performed to collect pertinent data. Anti-HLA antibodies were detected by single antigen bead testing. Antibody burden was tabulated using the calculated panel reactive antibody (cPRA) score immediately prior to transplantation. Statistical analyses were conducted to examine differences based on HLA antibody status and identify associations with outcomes of interest.

RESULTS

Our results show a significant association between pretransplant blood product exposures and HLA antibody status. Children with a pretransplant blood product exposure had 7.98 times the odds of developing an anti-HLA antibody compared to those without a pretransplant blood product exposure (p = .01). We also found a significant association between a previous red blood cell (RBC) exposure and HLA antibody status (p = .01) which was not found for other blood component exposures. Patients who were HLA antibody positive were more likely to develop a donor-specific antibody (DSA) after transplantation (p = .04).

CONCLUSIONS

Exposure to previous allogeneic blood products affects the development of anti-HLA antibodies in children presenting for heart transplantation. Previous RBC exposures resulted in HLA antibody positivity more than other blood component exposures. Importantly, the presence of HLA antibodies was associated with the development of DSAs post-transplantation. Developing transfusion strategies to reduce allogeneic blood product exposures in children who may need future cardiac transplantation should be a high priority.

Association Between Business Travel, Health-Related Behaviors, and Adiposity

OBJECTIVE

To evaluate the associations between frequency of business travel and health behaviors and adiposity.

METHODS

Retrospective cross-sectional analysis of de-identified electronic medical records from 795 corporate physical exams.

RESULTS

Business travel frequency demonstrates a curvilinear relationship with body mass index and body composition in men and women, with domestic and international travel. Linear and quadratic term beta coefficients indicate stronger associations between the sum of domestic and international travel and BMI, body fat percentage, and visceral adipose tissue in women than men, after accounting for age, exercise, and sleep. Based on our male sample population, international travel frequency has a greater influence on adiposity than summed (mostly domestic) travel.

CONCLUSIONS

Frequent business travel adversely affects body composition, with differences by gender and type of travel.

Health care practitioners' experience-based opinions on providing care after a positive newborn screen for Pompe disease

The addition of Pompe disease (PD) and other conditions with later-onset forms to newborn screening (NBS) in the United States (US) has been controversial. NBS technology cannot discern infantile-onset PD (IOPD) from later-onset PD (LOPD) without clinical follow-up. This study explores genetic health care practitioners' (HCPs) experiences and challenges providing NBS patient care throughout the US and their resultant opinions on NBS for PD. An online survey was distributed to genetic counselors, geneticists, NBS follow-up care coordinators, and nurse practitioners caring for patients with positive NBS results for PD. Analysis of 78 surveys revealed the majority of participating HCPs support inclusion of PD on NBS. Almost all HCPs (93.3%) feel their state has sufficient resources to provide follow-up medical care for IOPD; however, only three-fourths (74.6%) believed this for LOPD. Common barriers included time lag between NBS and confirmatory results, insurance difficulties for laboratory testing, and family difficulties in seeking medical care. HCPs more frequently encountered barriers providing care for LOPD than IOPD (53.9% LOPD identified ≥3 barriers, 31.1% IOPD). HCPs also believe creation of a population of presymptomatic individuals with LOPD creates a psychological burden on the family (87.3% agree/strongly agree), unnecessary medicalization of the child (63.5% agree/strongly agree), and parental hypervigilance (68.3% agree/strongly agree). Opinions were markedly divided on the use of reproductive benefit as a justification for NBS. Participants believe additional education for pediatricians and other specialists would be beneficial in providing care for patients with both IOPD and LOPD, in addition to the creation of evidence-based official guidelines for care and supportive resources for families with LOPD.

Data and Safety Monitoring of COVID-19 Vaccine Clinical Trials

To speed the development of vaccines against SARS-CoV-2, the United States Federal Government has funded multiple phase 3 trials of candidate vaccines. A single 11-member data and safety monitoring board (DSMB) monitors all government-funded trials to ensure coordinated oversight, promote harmonized designs, and allow shared insights related to safety across trials. DSMB reviews encompass 3 domains: (1) the conduct of trials, including overall and subgroup accrual and data quality and completeness; (2) safety, including individual events of concern and comparisons by randomized group; and (3) interim analyses of efficacy when event-driven milestones are met. Challenges have included the scale and pace of the trials, the frequency of safety events related to the combined enrollment of over 100 000 participants, many of whom are older adults or have comorbid conditions that place them at independent risk of serious health events, and the politicized environment in which the trials have taken place.

Does eating in the absence of hunger extend to healthy snacks in children?

OBJECTIVES

To assess if eating in the absence of hunger (EAH) extends to healthier snacks and examine the relationship between the home food environment and EAH in children with normal weight (NW) or overweight/obesity (OB) who are at low risk (LR) or high risk (HR) for obesity based on maternal obesity.

METHODS

EAH was assessed after lunch and dinner when children received either low energy dense fruit snacks or high energy dense sweet/savoury snacks. The availability of obesogenic foods in the home was assessed by the Home Food Inventory.

RESULTS

Data showed significant main effects of risk group (P=.0003) and snack type (P < .001). EAH was significantly greater in HR-OB (284±8 kcal) than LR-NW (249±9 kcal) or HR-NW (251±8 kcal) children. Serving fruit rather than sweet/savoury snacks reduced energy intake, on average, by 60% (223 kcal) across risk groups. For each unit increase in the obesogenic home food environment, EAH of sweet/savoury snacks decreased by 1.83 calories.

CONCLUSIONS

Offering low energy dense snacks after a meal can moderate EAH and increase children's intake of healthy foods. Increased access to obesogenic foods in the home may reduce the salience of high energy dense snacks when they become available in other settings.

Creating and sustaining effective pipeline initiatives to increase diversity in biostatistics: the ENAR Fostering Diversity in Biostatistics Workshop

Biostatisticians with advanced degrees are highly sought after. Employment opportunities in the fields of mathematics and statistics are expected to increase dramatically by 2028. Underrepresentation of minorities in biostatistics has been a persistent problem, yielding a demographic landscape that differs substantially from the general US population. In some instances, students may have the appropriate quantitative skills, but are unaware of biostatistics and in other instances, students may not yet have the appropriate quantitative background, but are intellectually capable and willing to shore up those skills once they learn about biostatistics as a viable, exciting career option. Therefore, in order to ensure robust scientific advancement, there must be a concerted effort to increase the pipeline of intellectually talented persons available with exposure to the appropriate quantitative skills who are interested in careers in biostatistics. The overarching goal of this paper is to discuss the development, implementation, and impact of a federally funded pipeline initiative aimed at increasing the number of underrepresented minorities successful in graduate training and professional careers in biostatistics as well as establishing effective mentoring and networking relationships. Our findings provide a roadmap for the development of sustainable initiatives to promote diversity in biostatistics and STEM fields more broadly.

A Comparison of Ketamine or Etomidate Combined with Xylazine for Intraperitoneal Anesthesia in Four Mouse Strains

Intraperitoneal (IP) injection is a common route of anesthetic administration in mice. Ketamine-xylazine (KX) anesthesia is one of the most widely used IP protocols, but has limitations. Etomidate is an alternative to ketamine that has been used in both human and veterinary medicine yet has not been widely studied in mice. The purpose of this study was to evaluate etomidate-xylazine (EX) anesthesia as an alternative to KX. We hypothesized that EX would be as safe and effective as KX, with both sex- and strain-dependent differences. Male and female Crl:CD1(ICR), C57BL/6NCrl, BALB/cJ and NU/J mice were given a single IP dose of ketamine 100 mg/kg and xylazine 10 mg/kg or etomidate 20 mg/kg and xylazine 10 mg/kg. Sedation times were similar between KX and EX, with CD1 mice exhibiting shorter sedation times. Surgical anesthesia was achieved in 44% of EX mice, compared with 4% of KX mice. C57BL/6NCrl mice were significantly more likely to achieve surgical anesthesia when given EX (94%) or KX (18%) than were other strains. In all strains except C57BL/6NCrl mice, females were more likely to reach surgical anesthesia than males. Several mice experienced an adverse hyperexcitement response during induction, with BALB/cJ (79%) and NU/J (87%) mice given EX significantly more likely than other strains to experience hyperexcitement. EX and KX protocols had no overall differences in lowest respiration rate, lowest systolic blood pressure, lowest rectal temperature, or levels of acidosis, although the lowest heart rates were significantly higher with EX, indicating that EX and KX have similar safety profiles. Thus, EX and KX administration were associated with several significant physiologic differences when comparing sexes or individual strains. Our results indicate that EX is an equally effective sedative and a more effective surgical anesthetic than KX; however, EX is only recommended for invasive procedures in C57BL/6 mice due to the high rate of hyper-excitement and inconsistent surgical depth seen in other strains. Further study is needed to optimize EX for use in multiple mouse strains.

Increased parental anxiety and a benign clinical course: Infants identified with short-chain acyl-CoA dehydrogenase deficiency and isobutyryl-CoA dehydrogenase deficiency through newborn screening in Georgia

The long-term consequences and need for therapy in children with short-chain acyl-CoA dehydrogenase deficiency (SCADD) or isobutyryl-CoA dehydrogenase deficiency (IBDD) identified via newborn screening (NBS) remains controversial. Initial clinical descriptions were severe; however, while most cases identified through NBS have remained asymptomatic, clinical concerns have been raised in these populations. It is not clear whether these children are asymptomatic because of the success of NBS, or because the normal clinical course of these disorders is relatively benign. To evaluate these possibilities in our program, we evaluated the clinical outcomes of children with SCADD or IBDD identified by the Georgia NBS compared to the health status of a healthy age-matched control group. We also assessed parental anxiety during a phone interview both subjectively and objectively using the Pediatric Inventory for Parents (PIP), a validated measure of illness-related parental stress. The general health of 52 SCADD and nine IBDD cases from 2007 to 2016 were compared to the general health of unaffected control children obtained through the Centers for Disease Control and Prevention (CDC) parent listserv. We also collected statements from parents who participated in a phone survey regarding events they experienced during and after their diagnostic process. Overall, the children with SCADD and IBDD had no major health problems. There was no significant difference in cognitive development (p = .207). We identified a slightly higher incidence of reported neonatal hypoglycemia in the SCADD group; two of these occurred in the context of maternal diabetes. All interviewed parents reported extreme anxiety during the diagnostic period and current feelings of uncertainty about their child's future. PIP scores for all six caregivers who responded to that portion of the survey were consistent with some degree of parental stress. The greatest reported stressor was the unknown long-term impact of the illness. All children with SCADD and IBDD had no significant long-term sequelae. The phone interviews revealed substantial parental anxiety about the identification and follow-up of SCADD and IBDD. Based on our findings, the anxiety parents experience may be unwarranted given that we see no disease-associated morbidity or mortality in these children. Consideration should be given to the removal of these conditions from NBS panels, or if that is not possible, clinicians could educate parents on the benign nature of these diagnoses and release them from follow-up without treatment.

Levels of clinical condom failure for anal sex: A randomized cross-over trial

BACKGROUND

Men who have sex with men (MSM) face a 28-fold higher risk of HIV acquisition than men who have sex with women (MSW). Condoms are the most accessible prevention method, with billions produced annually. Due to potentially high clinical failure, international regulatory agencies do not approve condoms for anal sex. This trial sought to provide data regarding approval of condoms for anal sex.

METHODS

We conducted a blinded, crossover randomized trial among MSM and MSW in Atlanta, Georgia, USA. Crossover conditions were standard condoms, thin condoms, and condoms fitted to each user's penile dimensions. The primary outcome was total clinical failure (slippage and/or breakage), assessed using an intention-to-treat analysis. A mixed methods model assessed differences in odds of failure. The study is registered with ClinicalTrials.gov, NCT02753842, and is completed.

FINDINGS

We enrolled 252 MSM and 252 MSW between May 19, 2016 and May 2, 2017. Participants reported a total of 4884 anal or vaginal sex acts using study-provided condoms. For all crossover conditions, clinical failure was lower for anal sex (0•7%, 16/2351) than for vaginal sex (1•9%, 48/2533), (odds ratio 0•40, 95% confidence interval 0•21, 0•75, p < •001)00. There was no difference in odds of failure for anal sex acts between the different types of condoms. Due to study design, nearly all anal sex acts used condom-compatible lubricant (98•3%), yet only a minority of vaginal sex acts (41•6%) used lubricant. Sex acts for which lubricant was used had lower failure for both anal and vaginal sex, with no difference in odds of failure between them.

INTERPRETATION

In the largest trial of effectiveness of condoms for anal sex to date, we found remarkably low levels of failure. Condoms should be approved by regulatory agencies for anal sex. Clinicians may recommend condoms as a highly efficacious HIV and STD prevention tool for anal sex. Differences between failure for anal and vaginal sex were likely due to differential use of lubricant. Condom promotion programs should consider providing additional lubricant for all condoms distributed.

Utility of a US Food and Drug Administration (FDA) label indication for condoms for anal sex

Condoms are highly effective for HIV prevention, yet are not currently indicated by the US Food and Drug Administration (FDA) for anal sex. We surveyed a national sample of men who have sex with men to assess whether FDA label indication could affect anticipated condom use, and to determine levels of perceived condom failure for anal sex. We found that 69% of respondents anticipated that a label indication change would increase their likelihood of condom use. Median perceived failure was 15%. We anticipate that these results may aid the FDA in developing standards for a label indication for anal sex.

Double-Blind, Single-Center, Randomized Three-Way Crossover Trial of Fitted, Thin, and Standard Condoms for Vaginal and Anal Sex: C-PLEASURE Study Protocol and Baseline Data

Background

Male condoms are underused despite their ability to prevent transmission of HIV and other sexually transmitted infections. The perception of decreased sexual pleasure and poor condom fit are major contributors to condom nonuse.

Objective

The purpose of this study was to compare event-level performance and pleasure using fitted, thin, and standard condoms among men who have sex with men (MSM) and men who have sex with women (MSW). We also sought to assess condom type preference. We present the study design and enrollment data from the trial.

Methods

This study recruited sexually active men aged 18 to 54 years in Atlanta, Georgia, United States. We enrolled 252 MSM and 252 MSW in a double-blind, 3-way randomized crossover trial with conditions of fitted, thin, and standard condoms. A permuted block randomization scheme was used to assign each participant to the sequence in which they received each type of study condom. After a baseline screening and enrollment visit, randomized participants were followed for at least 6 and up to 12 weeks depending on their use of study condoms in each 2-week period between scheduled, in-person study visits. Participants were instructed to complete mobile-optimized coital logs as soon as possible after using condoms for anal or vaginal sex acts. The logs collected event-level pleasure and performance measures for the study condoms as well as other relevant data. A questionnaire was administered at the final study visit to assess overall study condom preference.

Results

The study enrolled 252 MSM and 252 MSW, a total of 504 participants. MSM and MSW study arms were similar for a number of key traits including race and ethnicity, marital status, self-rated condom experience, and recent experience of condom failure. Men in the MSM arm were older, however, and fewer MSM were students. The majority of participants in both arms rated themselves as very experienced with using condoms, and the majority had used condoms recently. Over one-third of participants in each arm reported experiencing condom failure in the last 6 months.

Conclusions

This is the first condom trial to compare the performance of standard, thin, and fitted condoms and to use pleasure and preference as primary outcomes. Given the disparate impact of HIV on MSM, equal enrollment of MSM and MSW was a key feature of this study. Trial results may inform an FDA label indication for anal sex and provide new information regarding the relative performance of different types of condoms.

Trial Registration

ClinicalTrials.gov NCT02753842; https://clinicaltrials.gov/ct2/show/NCT02753842 (Archived by WebCite at http://www.webcitation.org/76RLTFyf0)

International Registered Report Identifier (IRRID)

DERR1-10.2196/12205

Patients' reactions and follow-up testing decisions related to Tay-Sachs (HEXA) variants of uncertain significance results

JScreen is a national public health initiative based out of Emory University that provides reproductive carrier screening through an online portal and follow-up genetic counseling services. In 2014, JScreen began reporting to patients variants of uncertain significance (VUSs) in the gene that causes Tay-Sachs disease (HEXA). Genetic counseling was provided to discuss the VUS and patients were offered hexosaminidase A (HEXA) blood enzyme testing to assist with VUS reclassification. To identify patient reactions and factors influencing their follow-up testing decisions after receiving these results, we conducted a retrospective quantitative study by administering online surveys to 62 patients with HEXA VUSs. Participants who pursued enzyme testing and those who did not both experienced low levels of distress when receiving the VUS results. Perceptions of HEXA carrier status after genetic counseling, decisional conflict levels, plans to have children in the near future, time available to pursue enzyme testing, and eligibility for research were significant factors influencing decision-making to pursue or not pursue enzyme testing. Genetic counseling played an important role in helping patients understand the VUS and follow-up testing options. When discussing VUSs with patients, it would be beneficial for genetic counselors to focus on the patient's perception of the VUS, anxiety related to the uncertainty of their results, and follow-up options, when available.

Evaluation of 4 Presurgical Skin Preparation Methods in Mice

Mice routinely undergo surgical procedures for use in research; however, studies of skin preparation methods to achieve antisepsis are rare. The present study evaluated 4 skin preparation treatments: depilatory agent followed by povidone-iodine and alcohol scrub; depilatory agent followed by povidone-iodine and saline scrub; electric clippers followed by povidone-iodine and alcohol scrub; and electric clippers followed by povidone-iodine and saline scrub. Swabs for bacterial culture were obtained immediately after hair removal and after scrubbing to measure the reduction in bacterial load. Full-thickness incisions were assigned ASEPSIS wound scores and examined histologically on days 0, 1, and 7 after surgery. Neither bacterial load growth nor ASEPSIS wound scores differed among any of the treatments. Histopathology revealed statistically significant but biologically irrelevant differences. Overall all treatment methods achieved acceptable bacterial load reduction and surgical site healing.

Feasibility of autologous intraoperative blood collection and retransfusion in small children with complex congenital heart defects undergoing cardiopulmonary bypass

INTRODUCTION

Allogeneic blood product transfusion is common in pediatric patients undergoing cardiopulmonary bypass although it is associated with an increased risk for adverse events. Furthermore, numerous donor exposures may affect future blood transfusion needs and human leukocyte antigen matching for patients who may ultimately require cardiac transplantation. Autologous intraoperative blood collection and retransfusion is a known method of blood preservation, but has not been extensively practiced in pediatric patients. In this study we assess the feasibility of this blood conservation technique in small children with complex congenital heart defects undergoing cardiopulmonary bypass.

METHODS

After Institutional Review Board approval, we retrospectively reviewed the medical records of children weighing <10 kg who underwent cardiopulmonary bypass over a 2-year period. Eighteen patients underwent autologous intraoperative blood collection and retransfusion and comprised the study group. Eighteen control patients were chosen by a 1:1 matched design using preoperative hematocrit, surgical procedure, and body weight. Multiple corresponding demographic and surgical variables, transfusion data, and clinical outcomes were compared.

RESULTS

Patient demographics, operative parameters and preoperative laboratory, and coagulation values were similar between the two groups. Despite the removal of autologous blood, study patients did not require more inotropic support prior to cardiopulmonary bypass. They also did not experience a significant increase in bleeding as measured by 24-hour postoperative chest tube output. Study patients were exposed to significantly fewer donor units intraoperatively and within the first 24 hours postoperatively.

DISCUSSION

The use of autologous intraoperative blood collection and retransfusion is a feasible option for small children with complex congenital heart defects undergoing cardiopulmonary bypass. Study patients received significantly fewer donor exposures without an increase in postoperative bleeding. Children who require multiple cardiac surgeries or eventually transplantation could benefit from this blood conservation technique.

Identifying behavioral phenotypes for childhood obesity

Existing programs which aim to prevent and treat childhood obesity often do not take into account individual variation and the underlying mechanisms that impact child eating behavior. Individual differences in children's appetitive traits have been shown to appear as early as during infancy and become more pronounced as children grow older and become more exposed to the obesogenic food environment. Differences in genetic predispositions interacting with factors in children's early environment account in part for individual differences in appetitive traits. It is very likely that obesogenic eating phenotypes manifest themselves before the onset of childhood obesity. If so, identifying these phenotypes early is expected to move primary prevention strategies in a new direction and holds great potential to significantly enhance our ability to prevent childhood obesity. The aim of this narrative review is to discuss the role of behavioral phenotyping as an innovative approach for the development of more personalized obesity prevention and treatment interventions that are tailored to children's individual predispositions. We describe several examples of appetitive traits which have been linked to overeating and excess weight gain in children and thus may represent modifiable risk factors for future interventions. The review concludes with a comprehensive synthesis of opportunities for future human ingestive behavior research on identifying behavioral phenotypes for childhood obesity.

Assessing the Feasibility of a Social Media to Promote Weight Management Engagement in Adolescents with Severe Obesity: Pilot Study

Background

Severe obesity in adolescents has deleterious physical and psychological complications necessitating frequent multi-disciplinary clinic visits. Greater treatment engagement has been equated with weight-loss. However, traditional medical weight-loss programs for adolescents have high attrition rates. Social media is widely used by adolescents and may enhance medical weight management engagement and success.

Objective

The first objective was to examine the acceptability and feasibility of using a private social media group as an adjunct to medical weight management in youth ages 14 to 20 years with severe obesity [body mass index (BMI) ≥ 35 kg/m2]. The second objective was to pilot test the use of social media to improve treatment engagement and decrease attrition rates.

Methods

In this single arm, 12 week pre-post study, participants attended individual clinic visits and participated in a moderated private social media group that received nutrition, exercise, and behavior change social media communications or “posts” 3 to 4 times/week. Youth commented and/or liked posts from the moderator and each other. Social media engagement was measured with the number of likes and comments on social media. Clinic attrition was compared, measuring clinic visit attendance 12 weeks prior, during, and after the intervention with mixed linear regression models. Correlations of social media engagement with changes from baseline for BMI, BMI-z score, and psychosocial measures were fit.

Results

All 13 enrolled youth completed the study and reported that the group was enjoyable, helpful, reinforced their weight management program, and would recommend using social media to support other youth. The pilot trial was acceptable and feasible. Youth mean weekly engagement (likes + comments) in social media was greater than once a day (8.6 ±3.6). Compared to 12 weeks prior to the intervention, there was no significant decrease in clinic visit attendance at the end of the intervention (M=.231, P=.69) or 12 weeks at the conclusion of the intervention (M=.589, P=.28). Increased social media comments correlated with weight change (r=–.633, P=.04).

Conclusions

This pilot trial demonstrated that the use of social media as an adjunct to medical weight management was feasible and acceptable to adolescents with severe obesity. Based upon these preliminary findings, social media may be an effective way to mitigate attrition from obesity treatment programs, and improve health outcomes in this high-risk population.

Parent and child care provider partnerships: Protocol for the Healthy Me, Healthy We (HMHW) cluster randomized control trial

BACKGROUND

Formation of diet and physical activity habits begins during early childhood. However, many preschool-aged children in the United States do not achieve recommendations for a nutritious diet or active lifestyle. Two important spheres of influence, home and child care, could ensure that children receive consistent health messages. Innovative approaches that engage both parents and child care providers in a substantial way are needed. Social marketing, a promising approach for health promotion targeting children, uses principles that recognize the need to engage multiple stakeholders and to emphasize benefits and overcome barriers associated with behavior change. Yet, application of social marketing principles in interventions for preschool-age children is limited.

METHODS

Healthy Me, Healthy We (HMHW) is 2-arm, cluster randomized controlled trial to evaluate the effect of a 8-month social marketing campaign on the diet and physical activity behaviors of preschool children (3-4years old), their parents, and child care providers. The campaign is delivered by the child care center and includes branded classroom and at-home activities and materials. Primary outcomes are children's diet quality (assessed with Healthy Eating Index scores) and minutes of non-sedentary activity (measured via accelerometers). Secondary outcomes assess children's body mass index, nutrition and physical activity practices at the child care center and at home, and health behaviors of child care providers and parents.

CONCLUSION

HMHW is an innovative approach to promoting healthy eating and physical activity in preschool children. The campaign targets children during a key developmental period and leverages a partnership between providers and parents to affect behavior change.

Relationship between food insecurity, child weight status, and parent-reported child eating and snacking behaviors

PURPOSE

Prior studies showed that food insecurity may increase the odds of obesity in children and adults. We still know very little about the familial aggregation of obesity in food-insecure households or the mechanisms by which food insecurity confers an increased risk of obesity to children. The purpose of this study was to compare children and mothers from food-insecure and food-secure households in their weight status, child eating patterns/behaviors, and maternal feeding practices.

DESIGN AND METHODS

Fifty mothers of 8-10-year-old children were asked to complete questionnaires, including the U.S. Household Food Security survey, and had their own and their children's heights and weights measured.

RESULTS

The odds of a child being obese were five times higher for children from food-insecure households compared with children from food-secure households (95% confidence interval 1.15-20.8). In univariate analyses, children from food-insecure households showed significantly greater external eating, both past satiation and in the absence of hunger (p < .03), and mothers from food-insecure households expressed significantly greater concern about their children's weight and used restrictive feeding practices to a greater extent (p < .03) when compared with families from food-secure households. A greater proportion of children from food-secure households consumed three to four snacks per day (45.9 vs. 15.4%), while a higher proportion of children from food-insecure households consumed five or more snacks per day (15.4 vs. 0%; p = .02).

PRACTICE IMPLICATIONS

These findings provide further support for an association between food insecurity and childhood obesity and suggest that differences in external eating, child snacking patterns, and select maternal feeding practices may be implicated in food-insecure children's overconsumption of calories. When caring for food-insecure children, healthcare providers should screen for problematic eating patterns and feeding practices.

Cognitive Effects of Adenotonsillectomy for Obstructive Sleep Apnea

OBJECTIVE

Research reveals mixed evidence for the effects of adenotonsillectomy (AT) on cognitive tests in children with obstructive sleep apnea syndrome (OSAS). The primary aim of the study was to investigate effects of AT on cognitive test scores in the randomized Childhood Adenotonsillectomy Trial.

METHODS

Children ages 5 to 9 years with OSAS without prolonged oxyhemoglobin desaturation were randomly assigned to watchful waiting with supportive care (n = 227) or early AT (eAT, n = 226). Neuropsychological tests were administered before the intervention and 7 months after the intervention. Mixed model analysis compared the groups on changes in test scores across follow-up, and regression analysis examined associations of these changes in the eAT group with changes in sleep measures.

RESULTS

Mean test scores were within the average range for both groups. Scores improved significantly (P < .05) more across follow-up for the eAT group than for the watchful waiting group. These differences were found only on measures of nonverbal reasoning, fine motor skills, and selective attention and had small effects sizes (Cohen's d, 0.20-0.24). As additional evidence for AT-related effects on scores, gains in test scores for the eAT group were associated with improvements in sleep measures.

CONCLUSIONS

Small and selective effects of AT were observed on cognitive tests in children with OSAS without prolonged desaturation. Relative to evidence from Childhood Adenotonsillectomy Trial for larger effects of surgery on sleep, behavior, and quality of life, AT may have limited benefits in reversing any cognitive effects of OSAS, or these benefits may require more extended follow-up to become manifest.

Red Cell Flexibility and Platelet Aggregation in Patients with Chronic Obstructive Vascular Disease (COAD) and Study of Therapeutic Approaches

The red blood cell flexibility was studied in the blood of twenty patients with severe peripheral vascular disease and twenty matched controls. Patients exhibited significantly less red cell flexibility than controls. In both groups there was an inverse relationship between age and red cell flexibility. No correlation was found between red cell flexibility and sex or smoking history. Pentoxifylline, a xanthine derivative which inhibits phosphodiesterases and platelet aggregation, was found to increase red cell flexibility. This effect of the drug was greater on red cells with impaired flexibility than on normal cells. Various prostaglandins by contrast were found to decrease red cell flexibility, this could be compensated for by pentoxifylline. Forty patients with COAD were treated intravenously with PgE1. Significant inhibition of platelet aggregation and clinical improvement was noticed. It is suggested that combinations of PgE1 and pentoxifylline should be explored in clinical studies.

Computerized Detection of Mass Lesions in Digital Breast Tomosynthesis Images Using Two- and Three Dimensional Radial Gradient Index Segmentation

Initial results for a computerized mass lesion detection scheme for digital breast tomosynthesis (DBT) images are presented. The algorithm uses a radial gradient index feature for the initial lesion detection and for segmentation of lesion candidates. A set of features is extracted for each segmented partition. Performance of two- and three dimensional features was compared. For gradient features, the additional dimension provided no improvement in classification performance. For shape features, classification using 3D features was improved compared to the 2D equivalent features. The preliminary overall performance was 76% sensitivity at 11 false positives per exam, estimated based on DBT image data of 21 masses. A larger database will allow for further development and improvement in our computer aided detection scheme.

Effects of financial incentives for the purchase of healthy groceries on dietary intake and weight outcomes among older adults: A randomized pilot study

Providing financial incentives can be a useful behavioral economics strategy for increasing fruit and vegetable intake among consumers. It remains to be determined whether financial incentives can promote intake of other low energy-dense foods and if consumers who are already using promotional tools for their grocery purchases may be especially responsive to receiving incentives. This randomized controlled trial tested the effects of offering financial incentives for the purchase of healthy groceries on 3-month changes in dietary intake, weight outcomes, and the home food environment among older adults. A secondary aim was to compare frequent coupon users (FCU) and non-coupon users (NCU) on weight status, home food environment, and grocery shopping behavior. FCU (n = 28) and NCU (n = 26) were randomly assigned to either an incentive or a control group. Participants in the incentive group received $1 for every healthy food or beverage they purchased. All participants completed 3-day food records and a home food inventory and had their height, weight, and waist circumference measured at baseline and after 3 months. Participants who were responsive to the intervention and received financial incentives significantly increased their daily vegetable intake (P = 0.04). Participants in both groups showed significant improvements in their home food environment (P = 0.0003). No significant changes were observed in daily energy intake or weight-related outcomes across groups (P < 0.12). FCU and NCU did not differ significantly in any anthropometric variables or the level at which their home food environment may be considered 'obesogenic' (P > 0.73). Increased consumption of vegetables did not replace intake of more energy-dense foods. Incentivizing consumers to make healthy food choices while simultaneously reducing less healthy food choices may be important.

Comparison of the satiating properties of egg- versus cereal grain-based breakfasts for appetite and energy intake control in children

BACKGROUND

Few studies exist that have systematically examined the role of protein, and egg protein in particular, in appetite and energy intake regulation in children.

OBJECTIVE

The aim of this study was to compare the effects of three different types of breakfast on appetite and energy intake at subsequent meals in children.

DESIGN

Forty children, ages 8-10, were served a compulsory breakfast (egg, cereal, or oatmeal) and lunch, consumed ad libitum, once a week for three weeks. Children's appetite ratings were assessed repeatedly throughout the morning. On each test day, caregivers completed food records, which captured children's intake for the remainder of the day.

RESULTS

There was a significant main effect of breakfast condition on energy intake at lunch (P=0.02) indicating that children consumed ~70 fewer calories at lunch following the egg breakfast (696 ± 53 kcal) compared to the cereal (767 ± 53 kcal) and oatmeal (765 ± 53 kcal) breakfasts. Calories consumed for the remainder of the day and daily energy intake did not differ across conditions (P>0.30). There also were no significant differences in children's appetite ratings between conditions (P>0.43).

CONCLUSIONS

Consuming an egg-based breakfast significantly reduced short-term, but not longer-term, energy intake in children in the absence of differences in appetite ratings.

The use of clinical parameters to predict obstructive sleep apnea syndrome severity in children: the Childhood Adenotonsillectomy (CHAT) study randomized clinical trial

IMPORTANCE

It is important to distinguish children with different levels of severity of obstructive sleep apnea syndrome (OSAS) preoperatively using clinical parameters. This can identify children who most need polysomnography (PSG) prior to adenotonsillectomy (AT).

OBJECTIVE

To assess whether a combination of factors, including demographics, physical examination findings, and caregiver reports from questionnaires, can predict different levels of OSAS severity in children.

DESIGN, SETTING, AND PARTICIPANTS

Baseline data from 453 children from the Childhood Adenotonsillectomy (CHAT) study were analyzed. Children 5.0 to 9.9 years of age with PSG-diagnosed OSAS, who were considered candidates for AT, were included.

INTERVENTIONS

Polysomnography for diagnosis of OSAS.

MAIN OUTCOMES AND MEASURES

Linear or logistic regression models were fitted to identify which demographic, clinical, and caregiver reports were significantly associated with the apnea hypopnea index (AHI) and oxygen desaturation index (ODI).

RESULTS

Race (African American), obesity (body mass index z score > 2), and the Pediatric Sleep Questionnaire (PSQ) total score were associated with higher levels of AHI and ODI (P = .05). A multivariable model that included the most significant variables explained less than 3% of the variance in OSAS severity as measured by PSG outcomes. Tonsillar size and Friedman palate position were not associated with increased AHI or ODI. Models that tested for potential effect modification by race or obesity showed no evidence of interactions with any clinical measure, AHI, or ODI (P > .20 for all comparisons).

CONCLUSIONS AND RELEVANCE

This study of more than 450 children with OSAS identifies a number of clinical parameters that are associated with OSAS severity. However, information on demographics, physical findings, and questionnaire responses does not robustly discriminate different levels of OSAS severity.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT00560859.

Quality of life and obstructive sleep apnea symptoms after pediatric adenotonsillectomy

BACKGROUND AND OBJECTIVES

Data from a randomized, controlled study of adenotonsillectomy for obstructive sleep apnea syndrome (OSAS) were used to test the hypothesis that children undergoing surgery had greater quality of life (QoL) and symptom improvement than control subjects. The objectives were to compare changes in validated QoL and symptom measurements among children randomized to undergo adenotonsillectomy or watchful waiting; to determine whether race, weight, or baseline OSAS severity influenced changes in QoL and symptoms; and to evaluate associations between changes in QoL or symptoms and OSAS severity.

METHODS

Children aged 5 to 9.9 years with OSAS (N = 453) were randomly assigned to undergo adenotonsillectomy or watchful waiting with supportive care. Polysomnography, the Pediatric Quality of Life inventory, the Sleep-Related Breathing Scale of the Pediatric Sleep Questionnaire, the 18-item Obstructive Sleep Apnea QoL instrument, and the modified Epworth Sleepiness Scale were completed at baseline and 7 months. Changes in the QoL and symptom surveys were compared between arms. Effect modification according to race and obesity and associations between changes in polysomnographic measures and QoL or symptoms were examined.

RESULTS

Greater improvements in most QoL and symptom severity measurements were observed in children randomized to undergo adenotonsillectomy, including the parent-completed Pediatric Quality of Life inventory (effect size [ES]: 0.37), the 18-item Obstructive Sleep Apnea QoL instrument (ES: -0.93), the modified Epworth Sleepiness Scale score (ES: -0.42), and the Sleep-Related Breathing Scale of the Pediatric Sleep Questionnaire (ES: -1.35). Effect modification was not observed by obesity or baseline severity but was noted for race in some symptom measures. Improvements in OSAS severity explained only a small portion of the observed changes.

CONCLUSIONS

Adenotonsillectomy compared with watchful waiting resulted in significantly more improvements in parent-rated generic and OSAS-specific QoL measures and OSAS symptoms.

GLP-1 plays a limited role in improved glycemia shortly after Roux-en-Y gastric bypass: a comparison with intensive lifestyle modification

Rapid glycemic improvements following Roux-en-Y gastric bypass (RYGB) are frequently attributed to the enhanced GLP-1 response, but causality remains unclear. To determine the role of GLP-1 in improved glucose tolerance after surgery, we compared glucose and hormonal responses to a liquid meal test in 20 obese participants with type 2 diabetes mellitus who underwent RYGB or nonsurgical intensive lifestyle modification (ILM) (n = 10 per group) before and after equivalent short-term weight reduction. The GLP-1 receptor antagonist exendin(9-39)-amide (Ex-9) was administered, in random order and in double-blinded fashion, with saline during two separate visits after equivalent weight loss. Despite the markedly exaggerated GLP-1 response after RYGB, changes in postprandial glucose and insulin responses did not significantly differ between groups, and glucagon secretion was paradoxically augmented after RYGB. Hepatic insulin sensitivity also increased significantly after RYGB. With Ex-9, glucose tolerance deteriorated similarly from the saline condition in both groups, but postprandial insulin release was markedly attenuated after RYGB compared with ILM. GLP-1 exerts important insulinotropic effects after RYGB and ILM, but the enhanced incretin response plays a limited role in improved glycemia shortly after surgery. Instead, enhanced hepatic metabolism, independent of GLP-1 receptor activation, may be more important for early postsurgical glycemic improvements.

Role of child weight status and the relative reinforcing value of food in children's response to portion size increases

OBJECTIVE

Food portion size is an important determinant of intake in children. It remains unknown if children's weight status and relative reinforcing value of food (RRVF) interact with portion size to affect intake.

METHODS

In a randomized crossover design, 25 normal-weight and 25 obese children, ages 8-10 years, consumed dinner once a week for 3 weeks. At each dinner, the same meal was served, but the portion size of all foods (chicken nuggets, hash browns, ketchup, green beans, brownies) and a sugar-sweetened beverage (fruit punch) varied across conditions (100, 150, and 200%). Children's RRVF was assessed using a behavioral choice task.

RESULTS

There was a significant main effect of portion size condition (P = 0.003) and weight status (P = 0.0005) and a nonsignificant trend for a portion size-by-weight status interaction (P = 0.108) on intake. Mean intakes across conditions (100, 150, and 200%) were 801 ± 57, 964 ± 58, and 873 ± 57 kcal for normal-weight children and 1041 ± 57, 1129 ± 57, and 1210 ± 57 kcal for obese children, respectively. Neither the main effect of RRVF status nor the condition-by-RRVF status interaction was significant (P > 0.48).

CONCLUSIONS

Environments that offer large portions of palatable foods affect all children's intake irrespective of their weight status or how reinforcing they find food to be.

Maternal concern about child weight in a study of weight-discordant siblings

OBJECTIVE

This study examined concern about child weight in mothers of weight-discordant siblings and determined the accuracy of maternal self-report versus measured child height, weight, and corresponding body mass index (BMI; kg/m(2) ) z-score.

DESIGN AND SAMPLE

Discordant sibling design. Forty-seven mothers of 5- to 12-year-old, weight-discordant siblings.

MEASURES

Mothers self-reported their concern about child weight for each child separately and for a subset of children, self-reported their heights and weights. Siblings' height, weight, waist circumference, and adiposity were measured.

RESULTS

The majority (83%) of mothers expressed concern about their overweight/obese child's weight and 20% of mothers expressed concern about their normal-weight child's weight (p < .001). Difference scores in maternal concern about child weight were positively associated with difference scores in sibling BMI z-score (r = 0.42; p = .01) and percent body fat (r = 0.56; p < .001). For overweight/obese children only, maternal-reported child heights and weights were significantly lower compared to the measured values (p < .03).

CONCLUSIONS

One fifth of mothers of weight-discordant siblings were unconcerned about their overweight/obese child's weight and for overweight/obese children only, mothers tended to underreport children's height and weight. Mothers' concern for their overweight/obese child's weight was greater for sibling pairs who were more discordant in their weight.

Change in body composition during a weight loss trial in obese adolescents

What is already known about this subject Adolescence is an important period of physiological growth. Loss of central adiposity with preservation of lean mass during weight loss is optimal. There are discrepancies in the literature concerning changes in lean mass during weight loss in adolescents. What this study adds This study provides information of regional and total body composition change in adolescents during weight loss. This study controls for important factors that impact body composition in growing adolescents such as age, sex, height, baseline weight and race. This study provides correlations of changes in waist circumference and body mass index (BMI) with total and trunk fat mass during weight loss in adolescents.

SUMMARY

Background Changes in body composition during weight loss among obese adolescents are poorly understood. This study characterized the composition of weight loss and its association with changes in waist circumference (WC) in obese adolescents. Methods Total (Tot), trunk (Tr) and appendicular (Ap) fat mass (FM) and lean mass (LM) were measured by dual-energy X-ray absorptiometry in 61 obese adolescents (40 girls) who participated in a randomized controlled weight loss trial. Changes in body composition were assessed at 0, 6 and 12 months using mixed-effects regression models. Correlation analysis of change in WC and total and regional compartments of FM and LM were assessed. Results Weight loss for adolescents was 90.3% FM and 15.9% LM at 0-6 months, and 98.2% FM and 7% LM at 0-12 months. At 12 months, girls lost 2.67 kg more TotFM than boys in models adjusted for height, age, race and baseline weight. Boys gained LM in all compartments in all models. At 12 months, girls lost TotLM (2.23 ± 0.74, P < 0.004) and ApLM (0.69 ± 0.31, P = 0.03) and gained TrLM (0.37 ± 0.35, P = 0.29). The percentage LM, increased for boys and girls in all models. TotFM was correlated with body mass index (BMI) change with TotFM (R = 0.70-0.91, P = 0.001) and WC change (R = 0.53-0.55, P < 0.001). Conclusions Weight loss in obese adolescents during a weight loss trial using lifestyle management and sibutramine was primarily from trunk FM. Although absolute LM increased in boys and decreased in girls, the percentage of weight that is LM increased for both boys and girls. Changes in BMI were more reflective of changes in FM than changes in WC.

Relationship between sexual function and quality of life in obese persons seeking weight reduction

OBJECTIVE

This study investigated sexual functioning in persons with obesity and seeking weight loss, and the associations of sexual functioning with relevant demographic and clinical variables as well as quality of life were investigated.

DESIGN AND METHODS

Participants were enrolled in a two-year randomized clinical trial. Participants were obese and had at least two components of metabolic syndrome. Male and female sexual functioning was assessed by the International Index of Erectile Function (IIEF) and the Female Sexual Function Index (FSFI) respectively.

RESULTS

The rate of female sexual dysfunction was 29%. The rate of erectile dysfunction (ED) was 45%. Of the characteristics considered, FSD was associated with age (P = 0.002). ED was significantly associated with age and physical functioning (both P < 0.01).

CONCLUSIONS

A large minority of patients with obesity reported sexual dysfunction. The occurrence of sexual dysfunction was associated with age, but, surprisingly, not weight-related comorbidities. This may be the result of the nature of the study sample or the methods used to administer the questionnaires that assessed sexual functioning.

Threshold for improvement in insulin sensitivity with adolescent weight loss

OBJECTIVES

To assess the association of weight loss and insulin sensitivity, glucose tolerance, and metabolic syndrome (MS) in obese adolescents following weight loss treatment, and to determine the threshold amount of weight loss required to observe improvements in these measures.

STUDY DESIGN

A randomized, controlled behavioral weight loss trial was conducted with 113 obese adolescents. Changes in fasting insulin, homeostasis model assessment of insulin resistance, whole body insulin sensitivity index (WBISI), body mass index (BMI), and MS criteria were assessed at baseline and at month 4.

RESULTS

There was significant improvement in all measures of insulin sensitivity at month 4. Mean fasting insulin dropped from 22.3 to 16.6 μU/mL (P < .0001). Homeostasis model assessment of insulin resistance decreased significantly from 4.9 to 3.7 (P = .001) and WBISI increased significantly from 2.87 to 3.98 (P < .0001). An 8% reduction in BMI led to a significant improvement in WBISI (P = .03) and was the optimal threshold. Fewer individuals met criteria for MS after weight loss (P = .0038), although there were no significant changes in the individual features of the syndrome.

CONCLUSIONS

In this trial, weight loss at month 4 was associated with improved insulin sensitivity in obese adolescents. An approximate decrease in BMI of 8% was the threshold level at which insulin sensitivity improved. As more weight loss programs are designed for obese adolescents, it will be important to have reasonable weight loss goals that will yield improvements in metabolic and cardiovascular disease risk factors.

Changes in eating, physical activity and related behaviors in a primary care-based weight loss intervention

OBJECTIVE

To examine changes in eating behaviors and physical activity, as well as predictors of weight loss success, in obese adults who participated in a 2-year behavioral weight loss intervention conducted in a primary care setting.

DESIGN

A longitudinal, randomized controlled, multisite trial.

SUBJECTS

Three hundred ninety obese (body mass index, 30-50 kg m(-2)) adults, ≥ 21 years, in the Philadelphia region.

METHODS

Participants were assigned to one of three interventions: (1) Usual Care (quarterly primary care provider (PCP) visits that included education on diet and exercise); (2) Brief Lifestyle Counseling (quarterly PCP visits plus monthly lifestyle counseling (LC) sessions about behavioral weight control); or (3) Enhanced Brief LC (the previous intervention with a choice of meal replacements or weight loss medication).

RESULTS

At month 24, participants in both Brief LC and Enhanced Brief LC reported significantly greater improvements in mean (± s.e.) dietary restraint than those in Usual Care (4.4 ± 0.5, 4.8 ± 0.5 and 2.8 ± 0.5, respectively; both P-values ≤ 0.016). The percentage of calories from fat, along with fruit and vegetable consumption, did not differ significantly among the three groups. At month 24, both the Brief LC and Enhanced Brief LC groups reported significantly greater increases than usual care in energy expenditure (kcal per week) from moderately vigorous activity (+593.4 ± 175.9, +415.4 ± 179.6 and -70.4 ± 185.5 kcal per week, respectively; both P-values ≤ 0.037). The strongest predictor of weight loss at month 6 (partial R(2)=33.4%, P<0.0001) and at month 24 (partial R(2)=19.3%, P<0.001) was food records completed during the first 6 months. Participants who achieved a 5% weight loss at month 6 had 4.7 times greater odds of maintaining a ≥ 5% weight loss at month 24.

CONCLUSIONS

A behavioral weight loss intervention delivered in a primary care setting can result in significant weight loss, with corresponding improvements in eating restraint and energy expenditure. Moreover, completion of food records, along with weight loss at month 6, is a strong predictor of long-term weight loss.

The association between weight loss in caregivers and adolescents in a treatment trial of adolescents with obesity

OBJECTIVE

The relationship between weight change in caregivers and their adolescents was evaluated following a randomized trial of lifestyle modification for adolescents, which included either a conventional diet or meal replacements.

METHODS

Adolescents (N = 113) had an M ± SD age of 15.0 ± 1.3 years (62% African American; 26% Caucasian, 12% other; 81% female) and body mass index of 37.1 ± 5.1 kg/m(2).

RESULTS

Mixed effects models yielded a significant association between percentage change in body mass index of caregivers and adolescents from baseline to months 4 and 12 (p = .01). When caregivers lost above the median (-1.67%) at month 4, their adolescents achieved a significantly greater loss at month 12 (-9.1 ± 1.3%) compared with adolescents whose caregivers lost less than the median (-4.3 ± 1.3%) (p = .003).

CONCLUSION

Engaging caregivers in their own weight loss efforts during adolescent weight loss treatment may improve adolescent weight loss.

Fat and lean BMI reference curves in children and adolescents and their utility in identifying excess adiposity compared with BMI and percentage body fat

BACKGROUND

Body mass index (BMI) and percentage body fat (%BF) are widely used to assess adiposity. These indexes fail to account for independent contributions of fat mass (FM) and lean body mass (LBM) to body weight, which vary according to age, sex, pubertal status, and population ancestry in the pediatric population.

OBJECTIVE

The objective was to develop pediatric reference curves for fat mass index (FMI) and lean body mass index (LBMI) and evaluate the effects of population ancestry and LBM on measures of excess adiposity (BMI, %BF, and FMI).

DESIGN

Sex-specific FMI and LBMI reference curves relative to age for children and adolescents aged 8-20 y were generated from cross-sectional body-composition data measured by dual-energy X-ray absorptiometry from NHANES.

RESULTS

The mean LBMI z score was higher in blacks (males: 0.26; females: 0.45) than in whites (males: -0.07; females: -0.09) and Mexican Americans (males: 0.05; females: -0.09). The positive predictive value of overweight by BMI to identify excess adiposity defined by FMI was lower in blacks (males: 35.9%; females: 30.3%) than in whites (males: 65.4%; females: 52.2%) and Mexican Americans (males: 73.3%; females: 68.3%). Participants classified as having excess adiposity by FMI but normal adiposity by %BF had significantly higher BMI, LBMI, and height z scores than did those classified as having excess adiposity by %BF but normal adiposity by FMI.

CONCLUSIONS

Relative to FMI, the prevalence of excess adiposity is overestimated by BMI in blacks and underestimated by %BF in individuals with high LBM. The use of FMI and LBMI improves on the use of %BF and BMI by allowing for the independent assessment of FM and LBM.

A randomized trial of adenotonsillectomy for childhood sleep apnea

BACKGROUND

Adenotonsillectomy is commonly performed in children with the obstructive sleep apnea syndrome, yet its usefulness in reducing symptoms and improving cognition, behavior, quality of life, and polysomnographic findings has not been rigorously evaluated. We hypothesized that, in children with the obstructive sleep apnea syndrome without prolonged oxyhemoglobin desaturation, early adenotonsillectomy, as compared with watchful waiting with supportive care, would result in improved outcomes.

METHODS

We randomly assigned 464 children, 5 to 9 years of age, with the obstructive sleep apnea syndrome to early adenotonsillectomy or a strategy of watchful waiting. Polysomnographic, cognitive, behavioral, and health outcomes were assessed at baseline and at 7 months.

RESULTS

The average baseline value for the primary outcome, the attention and executive-function score on the Developmental Neuropsychological Assessment (with scores ranging from 50 to 150 and higher scores indicating better functioning), was close to the population mean of 100, and the change from baseline to follow-up did not differ significantly according to study group (mean [±SD] improvement, 7.1±13.9 in the early-adenotonsillectomy group and 5.1±13.4 in the watchful-waiting group; P=0.16). In contrast, there were significantly greater improvements in behavioral, quality-of-life, and polysomnographic findings and significantly greater reduction in symptoms in the early-adenotonsillectomy group than in the watchful-waiting group. Normalization of polysomnographic findings was observed in a larger proportion of children in the early-adenotonsillectomy group than in the watchful-waiting group (79% vs. 46%).

CONCLUSIONS

As compared with a strategy of watchful waiting, surgical treatment for the obstructive sleep apnea syndrome in school-age children did not significantly improve attention or executive function as measured by neuropsychological testing but did reduce symptoms and improve secondary outcomes of behavior, quality of life, and polysomnographic findings, thus providing evidence of beneficial effects of early adenotonsillectomy. (Funded by the National Institutes of Health; CHAT ClinicalTrials.gov number, NCT00560859.).

Treatment of adolescent obesity comparing self-guided and group lifestyle modification programs: a potential model for primary care

Lifestyle modification programs (LMP) for weight loss in adolescents with obesity are effective but not available. Primary care may be a setting for reaching more adolescents. Two models of LMP for use in primary care were examined. Adolescents and caregivers enrolled in a 1-year randomized trial comparing Group LMP with Self-Guided LMP. All participants (N = 169) received the same treatment recommendations and met with a health coach six times in clinic. Group LMP participants had an additional 17 group sessions; those in Self-Guided LMP followed the remainder of the program at home with parental support. The primary outcome was percentage change in initial body mass index. The mean (SE) 1.31% (0.95%) reduction in Group LMP did not differ significantly from the 1.17% (0.99%) decrease in the Self-Guided LMP (p = 0.92). Both treatments were significantly effective in reducing body mass index. Given its brevity, the Self-Guided LMP offers an innovative approach for primary care.

An open-label efficacy trial of escitalopram for night eating syndrome

OBJECTIVE

Night eating syndrome (NES) has become increasingly recognized as a disorder in need of effective treatments. Selective serotonin reuptake inhibitors have shown efficacy in previous trials, so we sought to expand our understanding of the efficacy of escitalopram in the current trial.

METHOD

Thirty-one adults with NES participated in a 12-week open-label trial of escitalopram. Outcome measures included the Night Eating Symptom Scale (NESS), percent of daily intake after the evening meal (% intake) and number of nocturnal ingestions/week (NI), weight, total awakenings/week, mood, and quality of life. Mixed-effects models were used to assess change over time.

RESULTS

Significant reductions were observed from week 0 to week 12 for the NESS (30.2 to 15.2), % intake (46% to 17%), NI (5.8 to 1.2), weight (90.2 to 88.6 kg), awakenings (8.1 to 2.7), and BDI-II (12.1 to 7.7). Outcomes did not differ significantly by gender, age, race, or psychiatric co-morbidity status. Eighteen of 31 completed 12 weeks of treatment.

DISCUSSION

This open-label trial of escitalopram showed significant reductions in symptoms associated with NES. Randomized controlled trials are warranted to test these findings.

TRIAL REGISTRATION

clinicaltrials.gov identifier: NCT01401595.

Influence of stress in parents on child obesity and related behaviors

OBJECTIVE

To assess associations of the number of parent stressors and parent-perceived stress with obesity and related behaviors in their children.

METHODS

This cross-sectional analysis used data from the 2006 Southeastern Pennsylvania Household Health Survey in which 2119 parents/caregivers answered questions about themselves and their children (ages 3-17 years). Survey data were used to assess the main exposure variables: the number of stressors (measured using a stressor index) and parent-perceived stress (the response to a general stress question); child covariates (age, race/ethnicity, health quality, and gender); adult covariates (education, BMI, gender, poor sleep quality) and study outcomes (child obesity, fast-food consumption, fruit and vegetable consumption, and physical activity). To account for developmental differences, analyses were also stratified by age group (3-5, 6-8, 9-12, and 13-17 years). Analyses used multiple logistic regression, with results expressed as odds ratios and 95% confidence intervals.

RESULTS

The number of parent stressors was related to child obesity in unadjusted (1.12, 1.03-1.22, P = .007) and adjusted models (1.12, 1.03-1.23, P = .010). Parent-perceived stress was related to fast-food consumption in unadjusted (1.07, 1.03-1.10, P < .001) and adjusted (1.06, 1.02-1.10, P < .001) models.

CONCLUSIONS

The number of parent stressors was directly related to child obesity. Parent-perceived stress was directly related to child fast-food consumption, an important behavioral indicator of obesity risk. Clinical care models and future research that address child obesity should explore the potential benefits of addressing parent stressors and parent-perceived stress.