Severe obesity and global developmental delay in preschool children: Findings from a Canadian Paediatric Surveillance Program study

Background

The co-presentation of severe obesity (SO) and global developmental delay (GDD) in Canadian preschool children has not been examined. However, SO and GDD may require syndromic diagnoses and unique management considerations.

Objectives

To determine (1) minimum incidence; (2) age of onset and risk factors; and (3) health care utilization for co-presenting SO and GDD.

Methods

Through the Canadian Paediatric Surveillance Program (CPSP), a monthly form was distributed to participants from February 2018 to January 2020 asking for reports of new cases of SO and GDD among children ≤5 years of age. We performed descriptive statistics for quantitative questions and qualitative content analysis for open-ended questions.

Results

Forty-seven cases (64% male; 51% white; mean age: 3.5 ± 1.2 years) were included. Age of first weight concern was 2.5 ± 1.3 years and age of GDD diagnosis was 2.7 ± 1.4 years. Minimum incidence of SO and GDD was 3.3 cases per 100,000 for ≤5 years of age per year. Identified problems included school and/or behavioural problems (n = 17; 36%), snoring (n = 14; 30%), and asthma/recurrent wheeze (n = 10; 21%). Mothers of 32% of cases (n = 15) had obesity and 21% of cases (n = 10) received neonatal intensive care. Microarray was ordered for 57% (n = 27) of children. A variety of clinicians and services were accessed. As reported by CPSP participants, challenges faced by families and health service access were barriers to care.

Conclusion

Children with SO and GDD have multiple comorbidities, and require early identification and referral to appropriate services. These cases may also benefit from additional testing to rule out known genetic obesity syndromes.

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BACKGROUND/OBJECTIVE

Antipsychotic use in children is increasing. The purpose of the present article is to provide guidance to clinicians on the clinical management of extrapyramidal side effects of second-generation antipsychotics.

METHODS

Published literature, key informant interviews, and discussions with panel members and stakeholder partners were used to identify key clinical areas of guidance and preferences on format for the present recommendations. Draft recommendations were presented to a guideline panel. Members of the guideline panel evaluated the information gathered from the systematic review of the literature and used a nominal group process to reach a consensus on treatment recommendations. A description of the neurological abnormalities commonly seen with antipsychotic medications is provided, as well as recommendations on how to examine and quantify these abnormalities. A stepwise approach to the management of neurological abnormalities is provided.

RESULTS

Several different types of extrapyramidal symptoms can be seen secondary to antipsychotic use in children including neuroleptic-induced acute dystonia, neuroleptic-induced akathisia, neuroleptic-induced parkinsonism, neuroleptic-induced tardive dyskinesia, tardive dystonia and tardive akathisia, and withdrawal dyskinesias. The overwhelming majority of evidence on the treatment of antipsychotic-induced movement disorders is derived from adult patients with schizophrenia. Given the scarcity of paediatric data, recommendations were made with reference to both the adult and paediatric literature. Given the limitations in the generalizability of data from adult subjects to children, these recommendations should be considered on the basis of expert opinion, rather than evidence based.

CONCLUSION

Clinicians must be aware of the potential of second-generation antipsychotics to induce neurological side effects, and should exercise a high degree of vigilance when prescribing these medications.

Treatment recommendations for extrapyramidal side effects associated with second-generation antipsychotic use in children and youth

BACKGROUND/OBJECTIVE

Antipsychotic use in children is increasing. The purpose of the present article was to provide guidance to clinicians on the clinical management of extrapyramidal side effects of second-generation antipsychotics.

METHODS

Published literature, key informant interviews, and discussions with panel members and stakeholder partners were used to identify key clinical areas of guidance and preferences on format for the present recommendations. Draft recommendations were presented to a guideline panel. Members of the guideline panel evaluated the information gathered from the systematic review of the literature and used a nominal group process to reach a consensus on treatment recommendations. A description of the neurological abnormalities commonly seen with antipsychotic medications is provided, as well as recommendations on how to examine and quantify these abnormalities. A stepwise approach to the management of neurological abnormalities is provided.

RESULTS

Several different types of extrapyramidal symptoms can be seen secondary to antipsychotic use in children including neuroleptic-induced acute dystonia, neuroleptic-induced akathisia, neuroleptic-induced parkinsonism, neuroleptic-induced tardive dyskinesia, tardive dystonia and tardive akathisia, and withdrawal dyskinesias. The overwhelming majority of evidence on the treatment of antipsychotic-induced movement disorders comes from adult patients with schizophrenia. Given the scarcity of paediatric data, recommendations were made with reference to both the adult and paediatric literature. Given the limitations in the generalizability of data from adult subjects to children, these recommendations should be considered on the basis of expert opinion, rather than evidence based.

CONCLUSION

Clinicians must be aware of the potential of second-generation antipsychotics to induce neurological side effects, and should exercise a high degree of vigilance when prescribing these medications.

Ascorbic acid decreases the binding affinity of the AT1 receptor for angiotensin II

BACKGROUND

Ascorbic acid is an essential vitamin and a powerful antioxidant. Many studies have highlighted the benefits of ascorbic acid for chronic cardiovascular diseases such as hypertension in which angiotensin II (Ang II) plays an significant role. We therefore hypothesized that ascorbic acid could modify the pharmacological properties of the AT(1) receptor for Ang II.

METHODS

Binding studies and Ca(2+) mobilization studies were performed with HEK293 cells stably expressing the AT(1) receptor for Ang II. Smooth muscle contraction studies were performed with rabbit aorta strips that endogenously express the AT(1) receptor.

RESULTS

Scatchard analysis revealed that ascorbic acid decreased the binding affinity of the AT(1) receptor without modifying its maximal binding capacity. Ascorbic acid did not modify the binding affinity of the AT(2) receptor for Ang II or of the UT receptor for urotensin II. In single-cell Ca(2+) imaging assays, ascorbic acid reduced the frequency of intracellular Ca(2+) oscillations induced by a low dose of Ang II. In functional assays, ascorbic acid significantly diminished the contraction of rabbit aorta pre-contracted with Ang II but not those pre-contracted with urotensin II.

CONCLUSIONS

Ascorbic acid decreases the binding affinity of the AT(1) receptor. These results offer a mechanistic explanation for the reported blood pressure lowering effect of ascorbic acid.

Comparative analysis of xanafide cytotoxicity in breast cancer cell lines

Xanafide, a DNA-intercalating agent and topoisomerase II inhibitor, has previously demonstrated comparable cytotoxicity to the parent drug amonafide (NSC 308847). The current study was conducted to investigate further the anti-proliferative effects of xanafide in human breast cancer cell lines, in vitro and in vivo. The in vitro activity of xanafide against MCF-7, MDA-MB-231, SKBR-3 and T47D cell lines was compared to that of paclitaxel, docetaxel, gemcitabine, vinorelbine and doxorubicin. In MCF-7, xanafide demonstrated comparable total growth inhibition (TGI) concentrations to the taxanes and lower TGI values than gemcitabine, vinorelbine and doxorubicin. MCF-7 (oestrogen receptor (ER)+/p53 wild-type) was the most sensitive cell line to xanafide. MDA-MB-231 and SKBR-3 exhibited similar sensitivity to xanafide. T47 D (ER+/p53 mutated), showed no response to this agent. The in vivo activity of xanafide was further compared to that of docetaxel in MCF-7 and MDA-MB-231 cell lines using the hollow fibre assay. Xanafide was slightly more potent than docetaxel, at its highest dose in MCF-7 cell line, whereas docetaxel was more effective than xanafide in MDA-MB-231 cell line. Our results show that there is no relationship between sensitivity of these cell lines to xanafide and cellular levels of both isoforms of topoisomerase II and suggest that ER and p53 status and their crosstalk may predict the responsiveness or resistance of breast cancer patients to xanafide.

Expression of calcitonin gene-related peptide, substance P and protein kinase C in cultured dorsal root ganglion neurons following chronic exposure to mu, delta and kappa opiates

The mechanisms involved in morphine tolerance are poorly understood. It was reported by our group that calcitonin gene-related peptide (CGRP)-like immunoreactivity (IR) was increased in the spinal dorsal horn during morphine tolerance [Ménard et al. (1996) J. Neurosci. 16, 2342-2351]. More recently, we observed that it was possible to mimic these results in cultured dorsal root ganglion (DRG) neurons allowing for more detailed mechanistic studies [Ma et al. (2000) Neuroscience 99, 529-539]. The aim of the present series of experiments was to further validate the DRG cell culture model by establishing which subtypes of opioid receptors are involved in the induction of CGRP in cultured rat DRG neurons, and to examine the signaling pathway possibly involved in the induction of CGRP-like IR following repeated opiate treatments. Other neuropeptides known to be expressed in DRG neurons, such as substance P (SP), neuropeptide Y (NPY) and galanin, were investigated to assess specificity. Following treatment with any of the three opioid agonists (mu, DAMGO; delta, DPDPE; kappa, U50488H), the number of CGRP- and SP-IR cultured DRG neurons increased significantly, and in a concentration-dependent manner, with the effects of kappa agonist being less pronounced. NPY and galanin were not affected.Double-immunofluorescence staining showed that the three opioid receptors were co-localized with both CGRP- and SP-like IR.Protein kinase C (PKC)-like IR was found to be significantly increased following a repetitive treatment with DAMGO. Double-immunofluorescence staining showed the co-localization of PKCalpha with CGRP- and SP-IR in cultured DRG neurons. Moreover, a combined treatment with DAMGO and a PKC inhibitor (chelerythrine chloride or Gö 6976) was able to block the effects of the opioid on increased CGRP-like IR. These data suggest that the three opioid receptors may be involved in the induction of CGRP and SP observed following chronic exposure to opiates, and that PKC probably plays a role in the signaling pathway leading to the up-regulation of these neuropeptides. These findings further validate the DRG cell culture as a suitable model to study intracellular pathways that govern changes seen following repeated opioid treatments possibly leading to opioid tolerance.

Use of antenatal steroids to counteract the negative effects of tracheal occlusion in the fetal lamb model

Tracheal occlusion (TO) in fetal lambs induces pulmonary hyperplasia but has negative effects on type II cells. The purpose of this study was to determine whether antenatal steroids could reverse the adverse effects of TO on lung maturation in fetal lambs. Sixteen time-dated pregnant ewes (term, 145 d) and 24 of their fetuses were divided into six groups: 1) TO at 117 d gestation; 2) TO at 117 d with a single maternal intramuscular injection of 0.5 mg/kg betamethasone 24 h before delivery; 3) TO at 117 d and release of the occlusion 2 d before delivery; 4) TO and release of the occlusion with maternal steroids; 5) unoperated controls without antenatal steroid treatment; and 6) unoperated controls, littermates of groups 1-4, treated with antenatal steroids. All fetuses were killed at 137 d gestation. Outcome measurements consisted of lung weight-to-body weight ratio; lung morphometry determined by mean terminal bronchial density; and assessment of type II pneumocytes by in situ hybridization to the mRNA of surfactant proteins B and C. Lung weight-to-body weight ratio and mean terminal bronchial density were significantly different among groups with TO and controls, indicating increased lung growth and structural maturation. The density of type II pneumocytes was markedly decreased by TO. Release 2 d before sacrifice significantly increased the density and surfactant activity of type II pneumocytes, but to levels still far from controls. Steroids alone had an effect similar to release. An additive effect was noted with steroids and 2-d release resulting in type II cell density comparable to controls. After fetal TO, a single maternal intramuscular dose of 0.5 mg/kg of betamethasone 24 h before delivery allows partial recuperation of the type II pneumocytes, an effect that is potentiated by 2-d release.

Effects of amyloid peptides on cell viability and expression of neuropeptides in cultured rat dorsal root ganglion neurons: a role for free radicals and protein kinase C

Chronic pain caused by nerve injury and inflammation is more common in the elderly. However, mechanisms underlying this phenomenon are unclear. Higher sensitivity of sensory neurons to free radicals has been suggested as one possibility. The production of free radicals can be induced by various agents, including the highly toxic protein beta-amyloid (A beta), which is found in higher amounts in the brains of Alzheimer's Disease patients. In dorsal root ganglion (DRG) cultures exposed to A beta, we examined cellular toxicity and peptide expression, in particular calcitonin gene-related peptide (CGRP), a peptide which is abundantly expressed by nociceptive afferents and is known to be involved in pain processes. Exposure of cultured rat DRG neurons to A beta(25--35) or A beta(1--40) (10 or 20 microM for 24--96 h) increased trypan blue-stained cells in a concentration- and time-dependent manner, thus, indicating cellular toxicity. These treatments also increased the number of CGRP immunoreactive (IR) neurons while decreasing the number of neuropeptide Y- and galanin-IR neurons. The free radical scavenger, superoxide dismutase, attenuated both the toxicity and neuropeptide changes induced by A beta, thus, suggesting that oxidative stress probably contributes to these effects. Exposure of cultured DRG neurons to A beta also increased the number of protein kinase C alpha (PKC alpha)-IR neurons. The PKC inhibitors, chelerythrine chloride and Gö6976, significantly augmented A beta-induced cellular toxicity while attenuating the increases in CGRP-and PKC alpha-IR cells, supporting the notion of a protective role for PKC in A beta insults. These in vitro data suggest that A beta peptides may, in addition to causing neurotoxicity, regulate neuropeptide expression in primary afferents. This finding could be relevant to the higher incidence of neuropathic pain that occurs with ageing.

Effect of intradialytic parenteral nutrition on delivered Kt/V

The purpose of the study is to determine the effect of intradialytic parenteral nutrition (IDPN) and its components on delivered Kt/V (Kt/Vd). Nineteen patients undergoing routine outpatient hemodialysis and receiving IDPN were enrolled onto this prospective, crossover study. To reduce the confounding of time, assigned treatment in the first week was random, with patient crossover in the fourth week. Patients served as their own controls. In the successive 6 weeks, patients received IDPN solutions differing in whether amino acids (AAs), dextrose, or lipids were included or excluded. The primary end point was Kt/Vd, measured with a single-pool, variable-volume urea kinetic model. Other factors with the potential to impact on Kt/Vd were controlled and/or monitored. The administration of IDPN with all three components resulted in a significantly reduced mean Kt/Vd. When patients received AA-containing solutions, mean Kt/Vd was significantly less than when IDPN was withheld. Administration of solutions without AA resulted in a mean Kt/Vd not significantly different from mean Kt/Vd when IDPN was withheld. The mean prescribed Kt/V did not differ from mean Kt/Vd when IDPN was withheld. Simulation analyses of increased urea generation (Gu) showed an increase in patient urea volume and decreased Kt/V similar to the study findings. AA-containing IDPN solutions resulted in a significant reduction in Kt/Vd, possibly mediated by increased Gu. Administration of IDPN solutions may have important clinical and economic consequences that warrant further investigation.

Implementing and evaluating outcome indicators of performance for mental health agencies

Regulation-based processes for evaluating the performance of mental health agencies are gradually changing to focus on measuring the effectiveness of mental health services in obtaining the best possible outcomes. The decreased availability of resources for serving people with mental health problems has led to an emphasis on effectiveness, which is often expressed in terms of accountability. Thus, a singular reliance on compliance with practice standards has shifted to the need to be able to demonstrate that funds appropriated for mental health services are being used in ways that result in valued outcomes. In Colorado, this shift has led to the development of performance indicators that provide information reflecting stakeholder values about the performance outcomes of the mental health system. This article describes these performance indicators and presents the data that led to a decision to award monetary incentives to two community agencies. Potential benefits and pitfalls of Colorado's performance indicator process are also discussed.

Referring and reporting research participants at risk: views from urban adolescents

Researching developmental risks of urban youth raises ethical concerns when an investigator discovers a participant is in jeopardy. This study collected data on 147 seventh, ninth, and eleventh graders' views of 3 investigator options: (1) taking no action and maintaining confidentiality, (2) reporting the problem to a concerned parent or adult, and (3) facilitating adolescent self-referrals. Participants judged these options within the context of 5 risk domains: substance abuse, child maltreatment, life-threatening behaviors, delinquency, and shyness. Judgments of reporting options were related to grade and ratings of risk severity, but not to moral reasoning. Confidentiality was viewed favorably for risk behaviors of low perceived severity or for which the consequences of adult discovery might introduce greater risk. Confidentiality was viewed unfavorably and reporting to adults favorably for child maltreatment and threats of suicide. Self-referral was viewed favorably across all grades and risk behaviors. Implications of adolescent perspectives for research ethics are discussed.

[Monitoring neurotoxic effects among laboratory personnel working with organic solvents]

The relationship between organic solvent exposure and central nervous disorders make early detection of neurophysiologic et neuropsychologic alterations in organic solvent exposed workers a priority. Moreover, the variability in the frequency of exposure and the numerous organic solvents encountered in scientific laboratories render the environmental and biological measurements used in medical surveys almost impossible. The present study was undertaken to appreciate the potential neurotoxic effects of organic solvents handling in laboratory employees. Neurophysiological and neuropsychological tests batteries were used with each worker and data were adjusted for potential confounding factors (age and education level). A Principal Components Analysis were performed to reduce the information and the first five factors corresponded to: mood states, speed coding, contrast vision in high frequencies, manual dexterity and contrast vision in low frequencies. These five factors were compared between the daily manipulators of at least one solvent (n = 75) and the non or occasional solvent users (n = 35). The results from this study showed that subjects directly in contact with solvents had a poorer mood state than those who were not or rarely exposed (p < 0.01) and that independently of the "work activity". Mood state impairment in chronic solvent exposed workers has been shown by many authors, with or without psychomotor alteration, and may reflect possible over-exposure. Detection of this instability may lead to early neurophysiologic alteration in exposed workers and permit health services to intervene before the development of irreversible effects.

Implementation of Beam's Eye View into routine treatment planning and delivery

The use of oblique fields in the chest and abdomen is fraught with uncertainty, especially in the location of critical structures on simulator and port films. Targets near these structures may be underdosed because of the physician's uncertainty in shaping the treatment fields. To help alleviate this problem, we have found the Beam's Eye View option of the Theraplan Treatment Planning System to be a useful and effective tool. The Beam's Eye View program uses the external and internal contours we enter into the treatment planning system from CT scans. Once the necessary contours have been entered from the desired CT slices, the software will project the view that the beam would see as it passes through these structures. Using this "Beam's Eye View," we can determine the optimum angle and field shape to treat our target and minimize critical structure dose.

Women and technology

The introduction of microtechnology (in particular, word processing and data processing instruments and other computer-controlled equipment) has had dramatic effects on the nature, organization and rhythm of work in settings traditionally occupied by female workers (offices, service industries, telecommunications, etc.). This article describes some of these effects, with particular reference to organizational issues within the office setting. Symptoms of excessive stress among office workers are described; the motives for technological change and resistance to change are examined; and some suggestions for procedural reform are offered in the interest of safeguarding the mental health of female workers.

Effects of talker and of listener bias on stimulus dominance in dichotic listening

Stimulus dominance, wherein a higher score occurs for one member of a pair of syllables presented dichotically, was investigated in two experiments. The first examined effects due to talker. Six stop consonant-vowel syllables were spoken by two talkers. The pattern of stimulus dominance was not significantly different for the two talkers, and stimulus dominance was not related to articulatory feature-sharing categories. The second experiment investigated whether stimulus dominance reflects a true perceptual superiority of one syllable over another or whether attentional strategies or biases by listeners contribute to the outcome. Syllables were spoken by a single talker. For one group of listeners, tendencies to attend selectively to one ear or the other were uncontrolled. For the second group, maximum performance could be achieved only by attending exclusively to the monitored ear. The magnitude and frequency of stimulus dominance was significantly smaller with the single-ear monitoring task, but ear dominance was unaffected.