Observational study to estimate the proportion of surgical site infection following excision of ulcerated skin tumours (OASIS study)

BACKGROUND

Ulceration is a recognized risk factor for surgical site infection (SSI); however, the proportion of patients developing SSI after excision of an ulcerated skin cancer is unknown.

AIM

To determine the proportion of participants with SSI after surgical excision of an ulcerated skin cancer. A secondary aim was to assess feasibility outcomes to inform the design of a randomized controlled trial to investigate the benefits and harms of perioperative antibiotics following excision of ulcerated tumours.

METHODS

This was a multicentre, prospective, observational study of patients undergoing excision of an ulcerated skin cancer between March 2019 and March 2020. Prior to surgical excision, surface swabs of the ulcerated tumours of participants recruited from one centre were undertaken to determine organism growth. At 4 weeks after surgery, all participants were e-mailed or posted the Wound Healing Questionnaire (WHQ) to determine whether they had developed SSI.

RESULTS

In total, 148 participants were recruited 105 (70.9%) males; mean ± SD age 77.1 ± 12.3 years. Primary outcome data were available for 116 (78.4%) participants, of whom 35 (30.2%) were identified as having an SSI using the WHQ with a cutoff score of 8, and 47 (40.5%) were identified with a cutoff score of 6. Using the modified WHQ in participants with wounds left to heal by secondary intention, 33 (28.4%) and 43 (37.1%) were identified to have SSI respectively.

CONCLUSION

This prospective evaluation of SSI identified with the WHQ following excision of ulcerated skin cancers demonstrated a high proportion with SSI. The WHQ was acceptable to patients; however, further evaluation is required to ensure validity in assessing skin wounds.

Sustainability in skin cancer surgery

Carbon emissions ascribed to medical instruments account for one of the largest proportions of the NHS carbon footprint.¹ Our aim was to evaluate the sustainable value of the main types of theatre packs used for skin surgery (single-use and reusable) based on their economic, environmental, and social sustainability, and determine which is more sustainable for long-term use.

Environmentally sustainable dermatology

In 2017, health and social care organizations contributed 6.3% of carbon emissions in England. Efforts to reduce the environmental footprint of the National Health Service (NHS) have been broadly focused on reducing demand, through prevention and patient empowerment, and modifying supply side factors by focusing on lean care systems and low carbon alternatives. This narrative review concentrates on supply side factors to identify sustainable practices with a focus on actions that could be implemented in dermatology departments. For this study, a literature review was conducted In MEDLINE in April 2020. The search terms included 'environmental sustainability' and 'climate change' with 'dermatology', 'telemedicine', 'NHS', 'surgery' and 'operating theatres'. Out of 95 results, 20 were deemed relevant to the review. Although the review showed that there is clearly growing interest in environmental sustainability, the identified literature lacked examples of comprehensive implementation and evaluation of initiatives. The literature discussed distinct areas including transport, waste management and procurement as part of a lean healthcare system. A number of papers highlighted the potential contribution of carbon-reducing actions without citing verifiable outcome data. This narrative review highlights the need for detailed environmental impact assessments of treatment options in dermatology, in tandem with economic analysis. In conclusion, we have identified a clear need for evidence-based guidance setting out implementable actions with identifiable benefits achievable within local clinical teams. This will require engagement between clinicians, patients and healthcare organizations.

Normative data from linear and nonlinear quantile regression in CANTAB: Cognition in mid-to-late life in an epidemiological sample

Introduction

Normative cognitive data can help to distinguish pathological decline from normal aging. This study presents normative data from the Cambridge Neuropsychological Test Automated Battery, using linear regression and nonlinear quantile regression approaches.

Methods

Heinz Nixdorf Recall study participants completed Cambridge Neuropsychological Test Automated Battery tests: paired-associate learning, spatial working memory, and reaction time. Data were available for 1349-1529 healthy adults aged 57-84 years. Linear and nonlinear quantile regression analyses examined age-related changes, adjusting for sex and education. Quantile regression differentiated seven performance bands (percentiles: 97.7, 93.3, 84.1, 50, 15.9, 6.7, and 2.3).

Results

Normative data show age-related cognitive decline across all tests, but with quantile regression revealing heterogeneous trajectories of cognitive aging, particularly for the test of episodic memory function (paired-associate learning).

Discussion

This study presents normative data from Cambridge Neuropsychological Test Automated Battery in mid-to-late life. Quantile regression can model heterogeneity in age-related cognitive trajectories as seen in the paired-associate learning episodic memory measure.

•

The study presents normative cognitive data from the Cambridge Neuropsychological Test Automated Battery in mid-to-late life.

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Most tasks showed similar decline across performance bands with increasing age.

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Quantile regression is sensitive for evaluating diverging trajectories with age.

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Episodic memory showed accelerated decline in the average performance range.

Do perioperative antibiotics reduce the risk of surgical-site infections following excision of ulcerated skin cancers? A Critically Appraised Topic

AIM

To review the efficacy of perioperative antibiotics in reducing the risk of surgical-site infections (SSIs) following excision of ulcerated skin cancers.

SETTING AND DESIGN

Study selection, data extraction and analysis were carried out independently by four authors. Only randomized controlled trials (RCTs) reported in the English language were included.

INCLUDED STUDIES

RCTs in the English language in which patients received perioperative topical, intralesional or oral antibiotics for dermatological surgery, including Mohs micrographic surgery in general practice, dermatology or plastic surgery departments, were included.

OUTCOME

The proportion of participants developing SSI following excision of skin lesions.

RESULTS

Thirteen RCTs were identified from our literature search of PubMed and Embase, which evaluated SSI following use of topical (n = 5), oral (n = 3), intramuscular (n = 2), intravenous (n = 1) and intralesional antibiotics (n = 2) in dermatological surgery. Two RCTs specifically investigated SSIs in ulcerated skin cancer excisions; one RCT investigated the SSI rate following surgical treatment specifically for ulcerated skin cancers in individuals randomized to topical antibiotics vs. oral cephalexin; and one RCT compared intravenous cefazolin with no antibiotic, demonstrating significant reduction in SSI rates for ulcerated tumours (P = 0·04).

CONCLUSIONS

The heterogeneity of the RCTs included in this study makes it difficult to make a direct comparison of the outcomes measured. High-quality evidence demonstrating a beneficial effect of the use of perioperative antibiotics to prevent SSI following excision of ulcerated skin cancers is lacking. In the absence of an evidence base, we propose that a well-designed multicentre RCT could evaluate the effect of perioperative antibiotics following excision of ulcerated tumours, and potentially reduce inappropriate antibiotic prescription.

Adolescent mental health and subsequent parenting: a longitudinal birth cohort study

Background

Adolescent mental health problems are associated with a range of adverse outcomes in adulthood but little is known about the effects on adult parenting practices. This study aimed to examine prospective associations between adolescent conduct and emotional problems and subsequent parenting behaviours in adulthood.

Methods

The study sample comprised 1110 members from the MRC National Survey of Health and Development. Prospective data were collected from teacher reports of conduct and emotional problems at age 13 and 15 years and adult outcome measures of parenting included intellectual environment, cognitive stimulation, coercive discipline, parental interest and parental aspiration.

Results

In regression models adjusted for the confounding effects of social background, cognition and education, adolescent conduct problems predicted coercive parenting behaviours in adulthood. The effects of adolescent emotional problems on the development of coercive discipline practices were explained by covariates. Likewise, the inability of parents who displayed conduct problems in adolescence to provide an intellectually stimulating home environment was fully explained by the adjustment for education.

Conclusions

Adolescents who exhibit conduct problems are more likely to develop coercive styles of parenting.

Subacute cutaneous lupus erythematosus associated with radioiodine treatment

Subacute cutaneous lupus erythematosus (SCLE) is characterized by nonscarring, photodistributed, annular or papulosquamous plaques with antibodies to Ro/SS-A antigen. We report a case of SCLE associated with radioiodine treatment.

General and specific components of depression and anxiety in an adolescent population

BACKGROUND

Depressive and anxiety symptoms often co-occur resulting in a debate about common and distinct features of depression and anxiety.

METHODS

An exploratory factor analysis (EFA) and a bifactor modelling approach were used to separate a general distress continuum from more specific sub-domains of depression and anxiety in an adolescent community sample (n = 1159, age 14). The Mood and Feelings Questionnaire and the Revised Children's Manifest Anxiety Scale were used.

RESULTS

A three-factor confirmatory factor analysis is reported which identified a) mood and social-cognitive symptoms of depression, b) worrying symptoms, and c) somatic and information-processing symptoms as distinct yet closely related constructs. Subsequent bifactor modelling supported a general distress factor which accounted for the communality of the depression and anxiety items. Specific factors for hopelessness-suicidal thoughts and restlessness-fatigue indicated distinct psychopathological constructs which account for unique information over and above the general distress factor. The general distress factor and the hopelessness-suicidal factor were more severe in females but the restlessness-fatigue factor worse in males. Measurement precision of the general distress factor was higher and spanned a wider range of the population than any of the three first-order factors.

CONCLUSIONS

The general distress factor provides the most reliable target for epidemiological analysis but specific factors may help to refine valid phenotype dimensions for aetiological research and assist in prognostic modelling of future psychiatric episodes.

Profiles of family-focused adverse experiences through childhood and early adolescence: the ROOTS project a community investigation of adolescent mental health

BACKGROUND

Adverse family experiences in early life are associated with subsequent psychopathology. This study adds to the growing body of work exploring the nature and associations between adverse experiences over the childhood years.

METHODS

Primary carers of 1143 randomly recruited 14-year olds in Cambridgeshire and Suffolk, UK were interviewed using the Cambridge Early Experiences Interview (CAMEEI) to assess family-focused adversities. Adversities were recorded retrospectively in three time periods (early and later childhood and early adolescence). Latent Class Analysis (LCA) grouped individuals into adversity classes for each time period and longitudinally. Adolescents were interviewed to generate lifetime DSM-IV diagnoses using the K-SADS-PL. The associations between adversity class and diagnoses were explored.

RESULTS

LCA generated a 4-class model for each time period and longitudinally. In early childhood 69% were allocated to a low adversity class; a moderate adversity class (19%) showed elevated rates of family loss, mild or moderate family discord, financial difficulties, maternal psychiatric illness and higher risk for paternal atypical parenting; a severe class (6%) experienced higher rates on all indicators and almost exclusively accounted for incidents of child abuse; a fourth class, characterised by atypical parenting from both parents, accounted for the remaining 7%. Class membership was fairly stable (~ 55%) over time with escape from any adversity by 14 years being uncommon. Compared to those in the low class, the odds ratio for reported psychopathology in adolescents in the severe class ranged from 8 for disruptive behaviour disorders through to 4.8 for depressions and 2.0 for anxiety disorders. Only in the low adversity class did significantly more females than males report psychopathology.

CONCLUSIONS

Family adversities in the early years occur as multiple rather than single experiences. Although some children escape adversity, for many this negative family environment persists over the first 15 years of life. Different profiles of family risk may be associated with specific mental disorders in young people. Sex differences in psychopathologies may be most pronounced in those exposed to low levels of family adversities.

Parental practices predict psychological well-being in midlife: life-course associations among women in the 1946 British birth cohort

BACKGROUND

Certain parenting styles are influential in the emergence of later mental health problems, but less is known about the relationship between parenting style and later psychological well-being. Our aim was to examine the association between well-being in midlife and parental behaviour during childhood and adolescence, and the role of personality as a possible mediator of this relationship.

METHOD

Data from 984 women in the 1946 British birth cohort study were analysed using structural equation modelling. Psychological well-being was assessed at age 52 years using Ryff's scales of psychological well-being. Parenting practices were recollected at age 43 years using the Parental Bonding Instrument. Extraversion and neuroticism were assessed at age 26 years using the Maudsley Personality Inventory.

RESULTS

In this sample, three parenting style factors were identified: care; non-engagement; control. Higher levels of parental care were associated with higher psychological well-being, while higher parental non-engagement or control were associated with lower levels of psychological well-being. The effects of care and non-engagement were largely mediated by the offspring's personality, whereas control had direct effects on psychological well-being. The psychological well-being of adult women was at least as strongly linked to the parenting style of their fathers as to that of their mothers, particularly in relation to the adverse effects of non-engagement and control.

CONCLUSIONS

This study used a prospective longitudinal design to examine the effects of parenting practices on psychological well-being in midlife. The effects of parenting, both positive and negative, persisted well into mid-adulthood.

An Evaluation of the Precision of Measurement of Ryff's Psychological Well-Being Scales in a Population Sample

The aim of this study is to assess the effective measurement range of Ryff's Psychological Well-being scales (PWB). It applies normal ogive item response theory (IRT) methodology using factor analysis procedures for ordinal data based on a limited information estimation approach. The data come from a sample of 1,179 women participating in a midlife follow-up of a national birth cohort study in the UK. The PWB scales incorporate six dimensions: autonomy, positive relations with others, environmental mastery, personal growth, purpose in life and self-acceptance. Scale information functions were calculated to derive standard errors of measurement for estimated scores on each dimension. Construct variance was distinguished from method variance by inclusion of method factors from item wording (positive versus negative). Our IRT analysis revealed that the PWB measures well-being most accurately in the middle range of the score distribution, i.e. for women with average well-being. Score precision diminished at higher levels of well-being, and low well-being was measured more reliably than high well-being. A second-order well-being factor loaded by four of the dimensions achieved higher measurement precision and greater score accuracy across a wider range than any individual dimension. Future development of well-being scales should be designed to include items that are able to discriminate at high levels of well-being.

Correcting physical activity energy expenditure for body size in children

Being able to compare the energy cost of physical activity across and between populations is important. However, energy expenditure is related to body size, so it is necessary to appropriately adjust for differences in body size when comparisons are made. This study examined the relationship between the daily energy cost of activity and body weight in 47 children aged 6-10 years. Log-log regression showed weight1.0 to be an inappropriate adjustment for activity energy expenditure in children, with a more valid adjustment being weight0.3. Clearly, both weight dependent and non-weight dependent activities are part of everyday living in children. This balance influences how energy expenditure is correctly adjusted for body size. Investigators interpreting data of energy expenditure in children from children of different body sizes need to take this into consideration.

Validity of BMI as a measure of obesity in Australian white Caucasian and Australian Sri Lankan children

BACKGROUND

Body mass index (BMI) is used to diagnose obesity. However, its ability to predict the percentage fat mass (%FM) reliably is doubtful. Therefore validity of BMI as a diagnostic tool of obesity is questioned.

AIM

This study is focused on determining the ability of BMI-based cut-off values in diagnosing obesity among Australian children of white Caucasian and Sri Lankan origin.

SUBJECTS AND METHODS

Height and weight was measured and BMI (W/H2) calculated. Total body water was determined by deuterium dilution technique and fat free mass and hence fat mass derived using age- and gender-specific constants. A %FM of 30% for girls and 20% for boys was considered as the criterion cut-off level for obesity. BMI-based obesity cut-offs described by the International Obesity Task Force (IOTF), CDC/NCHS centile charts and BMI-Z were validated against the criterion method.

RESULTS

There were 96 white Caucasian and 42 Sri Lankan children. Of the white Caucasians, 19 (36%) girls and 29 (66%) boys, and of the Sri Lankans 7 (46%) girls and 16 (63%) boys, were obese based on %FM. The FM and BMI were closely associated in both Caucasians (r=0.81, P<0.001) and Sri Lankans (r=0.92, P<0.001). Percentage FM and BMI also had a lower but significant association. Obesity cut-off values recommended by IOTF failed to detect a single case of obesity in either group. However, NCHS and BMI-Z cut-offs detected cases of obesity with low sensitivity.

CONCLUSIONS

BMI is a poor indicator of percentage fat and the commonly used cut-off values were not sensitive enough to detect cases of childhood obesity in this study. In order to improve the diagnosis of obesity, either BMI cut-off values should be revised to increase the sensitivity or the possibility of using other indirect methods of estimating the %FM should be explored.

Outcomes of conduct problems in adolescence: 40 year follow-up of national cohort

OBJECTIVE

To describe long term outcomes associated with externalising behaviour in adolescence, defined in this study as conduct problems reported by a teacher, in a population based sample.

DESIGN

Longitudinal study from age 13-53.

SETTING

The Medical Research Council National Survey of Health and Development (the British 1946 birth cohort).

PARTICIPANTS

3652 survey members assessed by their teachers for symptoms of externalising behaviour at age 13 and 15.

MAIN OUTCOME MEASURES

Mental disorder, alcohol abuse, relationship difficulties, highest level of education, social class, unemployment, and financial difficulties at ages 36-53.

RESULTS

348 adolescents were identified with severe externalising behaviour, 1051 with mild externalising behaviour, and 2253 with no externalising behaviour. All negative outcomes measured in adulthood were more common in those with severe or mild externalising behaviour in adolescence, as rated by teachers, compared with those with no externalising behaviour. Adolescents with severe externalising behaviour were more likely to leave school without any qualifications (65.2%; adjusted odds ratio 4.0, 95% confidence interval 2.9 to 5.5), as were those with mild externalising behaviour (52.2%; 2.3, 1.9 to 2.8), compared with those with no externalising behaviour (30.8%). On a composite measure of global adversity throughout adulthood that included mental health, family life and relationships, and educational and economic problems, those with severe externalising behaviour scored significantly higher (40.1% in top quarter), as did those with mild externalising behaviour (28.3%), compared with those with no externalising behaviour (17.0%).

CONCLUSIONS

Adolescents who exhibit externalising behaviour experience multiple social and health impairments that adversely affect them, their families, and society throughout adult life.

The relationship between early personality and midlife psychological well-being: evidence from a UK birth cohort study

BACKGROUND

Individual differences in personality influence the occurrence, reporting and outcome of mental health problems across the life course, but little is known about the effects on adult psychological well-being. The aim of this study was to examine long range associations between Eysenck's personality dimensions and psychological well-being in midlife.

METHODS

The study sample comprised 1,134 women from the 1946 British birth cohort. Extraversion and neuroticism were assessed using the Maudsley Personality Inventory in adolescence (age 16 years) and early adulthood (age 26). Psychological well-being was assessed at age 52 with a 42-item version of Ryff's Psychological Well-being Scale. Analyses were undertaken within a structural equation modelling framework that allowed for an ordinal treatment of well-being and personality items, and latent variable modelling of longitudinal data on emotional adjustment. The contribution of mental health problems in linking personality variations to later well-being was assessed using a summary measure of mental health (emotional adjustment) created from multiple time-point assessments.

RESULTS

Women who were more socially outgoing (extravert) reported higher well-being on all dimensions. Neuroticism was associated with lower well-being on all dimensions. The effect of early neuroticism on midlife well-being was almost entirely mediated through emotional adjustment defined in terms of continuities in psychological/ psychiatric distress. The effect of extraversion was not mediated by emotional adjustment, nor attenuated after adjustment for neuroticism.

CONCLUSIONS

Individual differences in extraversion and neuroticism in early adult life influence levels of well-being reported in midlife.

Improvements in social functioning reported by a birth cohort in mid-adult life: A person-centred analysis of GHQ-28 social dysfunction items using latent class analysis

The General Health Questionnaire is widely used to measure the health status of individuals. Most studies have focused on traditional score values for one or more dimensions of psychopathology. We introduce a new analysis model that is person-centred and uses a latent structure approach to group individuals by a discrete latent variable. Data were drawn from a midlife (age 53) follow up of a national birth cohort study (n = 3035). For both men and women, three groups (latent classes) were sufficient to summarise individuals’ reports of recent changes in social functioning. The groups differed in the number and nature of the reported changes. Furthermore, they were shown to differ in terms of: (1) reported general health, (2) in mean scores on the conventional GHQ factors and (3) in several other variables external to the GHQ (happiness in job, ability to express feelings and self-confidence). Latent Class Analysis of positively worded GHQ items defined groups who differ in perceptions of recent positive changes in social functioning. These groups extend the value of individual health profiles afforded by the GHQ by using distinctions between categories in the first and second responses that are usually combined.

Psychometric evaluation and predictive validity of Ryff's psychological well-being items in a UK birth cohort sample of women

Background

Investigations of the structure of psychological well-being items are useful for advancing knowledge of what dimensions define psychological well-being in practice. Ryff has proposed a multidimensional model of psychological well-being and her questionnaire items are widely used but their latent structure and factorial validity remains contentious.

Methods

We applied latent variable models for factor analysis of ordinal/categorical data to a 42-item version of Ryff's psychological well-being scales administered to women aged 52 in a UK birth cohort study (n = 1,179). Construct (predictive) validity was examined against a measure of mental health recorded one year later.

Results

Inter-factor correlations among four of the first-order psychological well-being constructs were sufficiently high (> 0.80) to warrant a parsimonious representation as a second-order general well-being dimension. Method factors for questions reflecting positive and negative item content, orthogonal to the construct factors and assumed independent of each other, improved model fit by removing nuisance variance. Predictive validity correlations between psychological well-being and a multidimensional measure of psychological distress were dominated by the contribution of environmental mastery, in keeping with earlier findings from cross-sectional studies that have correlated well-being and severity of depression.

Conclusion

Our preferred model included a single second-order factor, loaded by four of the six first-order factors, two method factors, and two more distinct first-order factors. Psychological well-being is negatively associated with dimensions of mental health. Further investigation of precision of measurement across the health continuum is required.

Habitual physical activity and physical activity intensity: their relation to body composition in 5.0–10.5-y-old children

BACKGROUND

Concerns of a decrease in physical activity levels (PALs) of children and a concurrent increase in childhood obesity exist worldwide. The exact relation between these two parameters however has as yet to be fully defined in children.

OBJECTIVE

This study examined the relation in 47 children, aged 5-10.5 y (mean age 8.4+/-0.9 y) between habitual physical activity, minutes spent in moderate, vigorous and hard intensity activity and body composition parameters.

DESIGN

Total energy expenditure (TEE) was calculated using the doubly labelled water technique and basal metabolic rate (BMR) was predicted from Schofield's equations. PAL was determined by PAL=TEE/BMR. Time spent in moderate, vigorous and hard intensity activity was determined by accelerometry, using the Tritrac-R3D. Body fatness and body mass index (BMI) were used as the two measures of body composition.

RESULTS

Body fat and BMI were significantly inversely correlated with PAL (r=-0.43, P=0.002 and r=-0.45, P=0.001). Times spent in vigorous activity and hard activity were significantly correlated to percentage body fat (r=-0.44, P=0.004 and r=-0.39, P=0.014), but not BMI. Children who were in the top tertiles for both vigorous activity and hard activity had significantly lower body fat percentages than those in the middle and lowest tertiles. Moderate intensity activity was not correlated with measures of body composition.

CONCLUSIONS

As well as showing a significant relation between PAL and body composition, these data intimate that there may be a threshold of intensity of physical activity that is influential on body fatness. In light of world trends showing increasing childhood obesity, this study supports the need to further investigate the importance of physical activity for children.

The use of body mass index to predict body composition in children

BACKGROUND

Simple anthropometric indices of body composition have particular appeal for use in children, and as such body mass index (BMI) has been used to predict percentage body fat in a number of studies.

AIM

To evaluate the relationship between BMI and percentage body fat (%body fat) and a proposed, more appropriate relationship between BMI and fat mass/height(2) in a cohort of young children.

SUBJECTS AND METHODS

Cross-sectional study of 109 children aged between 6 and 10 years residing in either Sydney or Brisbane, Australia. Weight and height were measured using standard methods. Body composition was measured using a stable isotope method to firstly determine total body water and subsequently fat free mass.

RESULTS

The correlation between BMI and fat mass/height(2) was markedly greater than that between BMI and percentage body fat. In the entire group of children the R(2) (x100%) value for the relationship between BMI and fat mass/height(2) was 73.3% compared with 46.5% for the relationship between BMI and percentage body fat.

CONCLUSIONS

We have shown that the use of BMI to predict fat mass/height(2), and consequently percentage body fat, is superior to the use of BMI to predict percentage body fat based directly upon the R(2) values of the above analysis.

Catch-up growth in small-for-gestational-age term infants: a randomized trial

BACKGROUND

Small-for-gestational-age (SGA) term infants are at risk of long-term growth deficits.

OBJECTIVE

The objectives were to test the hypothesis that postnatal growth in SGA term infants can be altered by dietary intervention and to examine whether there is a critical window for nutritional programming of the growth trajectory during the first 9 mo postnatally.

DESIGN

Healthy term (gestation > or =37 wk) infants with birth weights below the 10th centile were randomly assigned to receive standard term formula (TF; n = 147) or nutrient-enriched formula (EF; n = 152) for the first 9 mo; 175 breast-fed SGA term infants formed a reference group. The main outcome measures were weight, length, and occipitofrontal head circumference (OFC) at 9 and 18 mo.

RESULTS

The infants fed the EF showed greater gains in length by 9 (1.1 cm; 95% CI: 0.38, 1.79) and 18 (1.0 cm; 0.25, 1.83) mo and in OFC by 9 (0.5 cm; 0.1, 0.9) and 18 (0.6 cm; 0.2, 1.1) mo than did infants fed the TF; the differences were larger in females. The dietary effects were independent of the pattern of growth retardation. Breast-fed infants showed greater gains in weight and OFC by 18 mo than did infants fed the TF; however, these differences disappeared after adjustment for age, parental size, and birth order.

CONCLUSIONS

Linear growth and OFC gains in SGA term infants improve after nutritional intervention during the first 9 mo of life and the effects persist for > or =9 mo beyond the intervention period. Further information on whether catch-up growth is beneficial or detrimental to long-term outcomes is required before public health interventions can be recommended.

Randomized trial of nutrient-enriched formula versus standard formula for postdischarge preterm infants

OBJECTIVES

Preterm infants are frequently discharged from the hospital growth retarded and show reduced growth throughout childhood. In a large efficacy and safety trial, we tested the hypothesis that nutritional intervention in the first 9 months postterm would reverse postdischarge growth deficits and improve neurodevelopment without adverse safety outcomes.

PARTICIPANTS AND INTERVENTION

Two hundred eighty-four infants (mean gestation: 30.9 weeks) were studied; 229 were randomly assigned a protein, energy, mineral, and micronutrient-enriched postdischarge formula (PDF; N = 113) or standard term formula (TF; N = 116) from discharge (mean 36.5 weeks' postmenstrual age). A reference group (N = 65) was breastfed until at least 6 weeks' postterm. Outcome measures. Anthropometry was performed at 6 weeks and 3, 6, 9, and 18 months. Development was measured at 9 months (Knobloch, Passamanick, and Sherrard's developmental screening inventory) and 18 months (Bayley Scales of Infant Development II; primary outcome) postterm.

RESULTS

At 9 months, compared with the TF group, those fed PDF were heavier (difference 370 g; 95% confidence interval [CI]: 84-660) and longer (difference 1.1 cm; 95% CI: 0.3-1.9); the difference in length persisted at 18 months (difference 0.82 cm; 95% CI: -0.04-1.7). There was no effect on head circumference. The effect of diet was greatest in males; at 9 months length deficit with TF was 1.5cm (95% CI: 0.3-2.7), and this remained at 18 months (1.5cm [95% CI: 0.3-2.7]). There was no significant difference in developmental scores at 9 or 18 months, although PDF infants had a 2.8 (-1.3-6.8) point advantage in Bayley motor score scales. At 6 weeks' postterm, exclusively breastfed infants were already 513 g (95% CI: 310-715) lighter and 1.6cm (95% CI: 0.8-2.3) shorter than the PDF group, and they remained smaller up to 9 months' postterm.

CONCLUSIONS

1) Improving postdischarge nutrition in the first 9 months may "reset" subsequent growth-at least until 18 months for body length. We intend to follow-up the children at older ages. The observed efficacy of PDF was not associated with adverse safety outcomes. 2) We cannot reject the hypothesis that postdischarge nutrition benefits motor development and this requires additional study. 3) Our data raise the possibility that breastfed postdischarge preterm infants may require nutritional supplementation, currently under investigation.

Infant feeding and maternal concerns about stool hardness

From a questionnaire completed by 195 mothers of infants aged 3-12 weeks we found that significantly more formula than breast-feeding mothers had concerns about stool hardness and had sought professional advice, resulting in both increased use of health care resources and more dietary interventions.

Lack of association between vitamin A status and measures of conjunctival epithelial integrity in young children in northern Ghana

OBJECTIVE

To investigate the association between vitamin A status and conjunctival epithelial function in young children in rural northern Ghana and to consider whether impaired epithelial function was associated with increased measures of systemic infection in these children.

DESIGN

Children were selected from the Ghana Vitamin A Supplementation Trials' Child Health Study, a randomized, double-blind, placebo-controlled trial of the effect of vitamin A supplementation on morbidity. Treatment group and serum retinol concentrations were used as measures of vitamin A status, conjunctival impression cytology and tear IgA concentrations as measures of conjunctival epithelial integrity, and serum immunoglobulin and alpha 1-acid glycoprotein concentrations as indicators of chronic or acute systemic infection.

SUBJECTS

Children 13-64 months old.

INTERVENTION

60 mg retinol as retinyl palmitate every 4 months for 1 year.

RESULTS

Vitamin A status was not significantly associated with epithelial integrity nor with measures of systemic infection. Impaired conjunctival epithelial integrity was also not associated with increased systemic infection.

CONCLUSIONS

There was no evidence for a major role of improved epithelial integrity and function on the biochemical indices of chronic or acute systemic infection after vitamin A supplementation. These data support the observations in the main study that vitamin A supplementation did not improve conjunctival impression cytology nor decrease the prevalence of most morbidity symptoms.

Influence of morbidity on serum retinol of children in a community-based study in northern Ghana

Serum retinol concentrations decrease during illness and thus may not accurately reflect the vitamin A status of populations with a high prevalence of illness. To quantify the contribution of illness to low serum retinol in a field study of children aged 6-59 mo in northern Ghana, serum retinol values were compared with two indicators of recent illness; symptoms reported by parents and acute-phase protein concentrations in serum. Serum retinol was not associated with symptoms of illness but showed a significant negative correlation with both alpha 1-acid glycoprotein (AGP) and serum amyloid A (SAA). Elevated AGP was associated with a 24% decrease in mean serum retinol. A large proportion of asymptomatic children had elevated AGP or SAA concentrations, suggesting that subclinical infections may have had important effects on serum retinol. A significant negative correlation between malaria parasite density and serum retinol indicated that malaria may have been one of the subclinical infections responsible. Measurement of AGP may improve interpretation of serum retinol data from populations with a high prevalence of morbidity.

Diet, body size and micronutrient status in Parkinson's disease

Nutritional status was assessed in a group of patients with Parkinson's disease. Weight loss since the onset of disease occurred in 52% of the patients and 22% had lost more than 12.8 kg. Although 67% of patients experienced eating difficulties of some kind, dietary intakes of protein and energy were not significantly lower than recommended intakes. Plasma levels of albumin (44.2 g/l vs 45.7 g/l), vitamin A (2.61 vs 2.94 mumol/l), vitamin E (22.0 vs 32.0 mumol/l), iron (15.3 vs 18.3 mumol/l) and zinc (14.2 vs 18.7 mumol/l) were significantly lower (P < 0.05) in the patients than in healthy controls. Levels of ferritin, total iron-binding capacity and copper were similar between groups. The potential significance of low levels of vitamin E and zinc are discussed in relation to oxidative stress in the pathogenesis of this disease.

Cytochrome P-450-dependent mixed-function oxidase and glutathione S-transferase activities in spontaneous obesity-diabetes

The effect of non-insulin-dependent diabetes on the hepatic microsomal cytochrome P450-dependent mixed-function oxidase system and on cytosolic glutathione S-transferase activity was determined using the spontaneously obese-diabetic (ob/ob) mouse model. The activities of the xenobiotic-metabolizing cytochrome P450 proteins were monitored by the use of chemical probes. Non-insulin-dependent diabetes did not influence the hepatic metabolism of substrates associated with the P450 I, IIB, IIE, III and IV families of cytochromes. In contrast, cytosolic glutathione S-transferase activity was markedly reduced and glutathione levels were significantly lowered. These findings raise the possibility that patients suffering from this disease may be more susceptible to chemicals that rely on glutathione conjugation for their deactivation.

Abatement of exertional perceptions following dynamic exercise: physiological mediators

Perceptual and physiological congruity was examined during recovery from high-intensity dynamic exercise. Nine males (24.8 +/- 0.6 yr; VO2max; 52.3 +/- 1.5 ml.kg-1.min-1) undertook in random order four maximal treadmill protocols. Treadmill speed was held constant (5.3 km.h-1) while grade was incremented by 2, 4, 6, or 8% every 3 min for protocols A, B, C, and D, respectively. Ratings of perceived exertion (RPErec; Borg 15-point scale), ventilation (VE), respiratory rate (RR), oxygen uptake (VO2), and heart rate (HR) were measured preexercise and during each min of a 12-min supine postexercise period that immediately followed treadmill testing. Ratings were obtained for the peripheral perceptual signal arising from the legs (RPErec-L), the respiratory-metabolic signal from the chest (RPErec-C), and the overall body signal (RPErec-O). Blood pH was measured preexercise and during min 1, 6, and 12 of recovery. RPErec-L and RPErec-O were lower (P less than 0.05) and blood pH higher (p less than 0.05) following protocol A than D at all recovery time points. RPErec-C, VE, and RR were lower (P less than 0.05) for protocol A than D at all recovery time points. Differences among protocols were not noted for VO2 or HR at any recovery time point. The decay in signal strength for both RPErec-L and RPErec-O following high-intensity exercise reflected the abatement of metabolic acidosis. RPErec-O was influenced by the abatement of pulmonary ventilation during the postexercise period.

Dispositional optimism and recovery from coronary artery bypass surgery: the beneficial effects on physical and psychological well-being

The effect of dispositional optimism on recovery from coronary artery bypass surgery was examined in a group of 51 middle-aged men. Patients provided information at three points in time--(a) on the day before surgery, (b) 6-8 days postoperatively, and (c) 6 months postoperatively. Information was obtained relating to the patient's rate of physical recovery, mood, and postsurgical quality of life. Information was also gathered regarding the manner in which the patients attempted to cope with the stress of the surgery and its aftermath. As expected, dispositional optimism proved to be an important predictor of coping efforts and of surgical outcomes. More specifically, dispositional optimism (as assessed prior to surgery) correlated positively with manifestations of problem-focused coping and negatively with the use of denial. Dispositional optimism was also associated with a faster rate of physical recovery during the period of hospitalization and with a faster rate of return to normal life activities subsequent to discharge. Finally, there was a strong positive association between level of optimism and postsurgical quality of life at 6 months.

Effect of simulated altitude erythrocythemia in women on hemoglobin flow rate during exercise

The effect of simulated altitude erythrocythemia on hemoglobin flow rate and maximal O2 uptake (VO2max) was determined for nine women sea-level residents. Test conditions included normoxia and normobaric hypoxia (16% O2-84% N2). Cycle tests were performed under normoxia (T1-N) and hypoxia (T1-H) at prereinfusion control and under hypoxia 48 h after a placebo infusion (T2-H) and 48 h after autologous infusion of 334 ml of erythrocytes (T3-H). Hematocrit (38.1-44.9%) and hemoglobin concentration (12.7-14.7 g.dl-1) increased from control to postreinfusion. At peak exercise, VO2max decreased from T1-N (2.40 l.min-1) to T1-H (2.15 l.min-1) then increased at T3-H (2.37 l.min-1). Maximal arterial-mixed venous O2 difference decreased from T1-N to T1-H and increased at T3-H. Cardiac output (Q), stroke volume, heart rate, and total peripheral resistance during maximal exercise were unchanged from T1-N through T3-H. Hemoglobin flow rate (Hb flow) at maximum did not change from T1-N to T1-H but increased at T3-H. When compared with submaximal values for T1-N, VO2 was unchanged at T1-H and T3-H; Q increased at T1-H and decreased at T3-H; arterial-mixed venous O2 difference decreased at T1-H and increased at T3-H; Hb flow did not change at T1-N but increased at T3-H. For young women, simulated altitude erythrocythemia increased peak Hb flow and decreased physiological altitude (227.8 m) but did not affect maximum cardiac output (Qmax).

Hemoglobin concentration and aerobic work capacity in women following induced erythrocythemia

The effect of induced erythrocythemia on hemoglobin concentration ([Hb]) and aerobic work capacity was determined for nine women. Cycle tests were performed at prereinfusion (T1), 2 days after a placebo infusion (T2), 2 days postreinfusion of 334 ml of red blood cells (T3), 8 days postreinfusion (T4), and 14 days postreinfusion (T5). T1 and T2 responses did not differ, negating a placebo effect. [Hb] increased from 12.7 g X dl at T1 to 14.7 g X dl at T3 and then remained constant at T4 and T5. Hematocrit increased from 38.1% at T1 to 44.9% at T3 and then remained constant at T4 and T5. Submaximal O2 uptake (VO2) and stroke volume (SV) did not change from T1 through T5. Submaximal cardiac output (Q) and heart rate (HR) decreased from T1 to T3 and then remained constant at T4 and T5. Arteriovenous O2 difference increased from T1 to T3 and then remained constant at T4 and T5. Maximal VO2 was greater at T3 (2.65 l X min-1), T4 (2.66 l X min-1), and T5 (2.60 l X min-1) than at T1 (2.41 l X min-1). Physical work capacity was greater at T3 (10,740 kg X m), T4 (10,980 kg X m), and T5 (10,380 kg X m) than at T1 (8,747 kg X m). Maximal values for Q, HR, and SV were unchanged from T1 through T5. At maximum, arteriovenous O2 difference and Hb flow rate increased from T1 to T3 and then remained constant at T4 and T5. The greater postreinfusion [Hb] improved O2 transport capacity and appeared to regulate circulatory responses.

Effect of induced erythrocythemia on hypoxia tolerance during physical exercise

The effect of induced erythrocythemia on hypoxia tolerance during physical exercise was determined for five male mountain climbers. Treadmill testing was performed under four conditions: 1) prereinfusion, normoxia (Pre-N); 2) prereinfusion, hypoxia (Pre-H); 3) postreinfusion, normoxia (Post-N); and 4) postreinfusion, hypoxia (Post-H). An altitude of 3,566.2 m was simulated by having subjects breath a gas mixture of 13.5% O2-86.5% N2 at normal barometric pressure. Tests were administered immediately before and 24 h after autologous transfusion of 750 ml of red blood cells. Hematocrit increased from 43.3% at prereinfusion to 54.8% at postreinfusion. Hemoglobin concentration increased from 13.80 g X 100 ml-1 at prereinfusion to 17.63 g X 100 ml-1 at postreinfusion. Maximal O2 uptake (VO2 max, 1 X min-1) increased (P less than 0.05) by 12.8% (3.28 to 3.70) from Pre-N to Post-N and 13.0% (2.62 to 2.96) from Pre-H to Post-H. Treadmill performance time (s) increased (P less than 0.05) by 15.8% (793 to 918) from Pre-N to Post-N and 8.9% (687 to 748) from Pre-H to Post-H. VO2 max decreased by 20.1% from Pre-N to Pre-H and by 9.8% from Pre-N to Post-H. Treadmill time decreased by 13.4% from Pre-N to Pre-H and 5.7% from Pre-N to Post-H. The calculated change in hypoxia tolerance following reinfusion indicated that physiological altitude was improved by 463.6 m. It was concluded that induced erythrocythemia increased hypoxia tolerance during physical exercise.

Differentiated perceptions of exertion and energy cost of young women while carrying loads

Differentiated local ratings of perceived exertion from the legs and central ratings from the chest, and oxygen consumption, were determined during load carriage in seven young women. Subjects walked for 6 min at 3.22, 4.83, 6.44, or 8.05 km X h-1 carrying (1) no load, (2) a load equal to 7.5% of body weight (mean: 4.66 kg) or (3) a load equal to 15% of body weight (mean: 9.32 kg). Thus, each subject underwent 12 separate tests. The external loads were in the form of lead pellets carried in a plastic scuba belt worn around the waist. A differentiation threshold was found at 6.44 km X h-1 for the 0% and 7.5% loads and at 4.83 km X h-1 for the 15% load. At speeds below the threshold, the perception of exertion was similar in the legs, chest and overall. At higher speeds, exertion was perceived to be more intense in the legs than overall and less intense in the chest than overall, suggesting that the local legs signal was the dominant factor in shaping the overall sensation of exertion. The oxygen uptake was greater for the 15% load than for either the 0% or 7.5% loads, but was similar for the 0% and 7.5% loads. Findings suggested a critical weight limit for external loads that could be transported without increasing the metabolic cost beyond that required to move the body weight alone. This limit fell between 7.5% and 15% of the body weight. When oxygen uptake was expressed per kg of total weight transported, there was no loss of metabolic efficiency while carrying loads up to 15% of the body weight.