New Insights Into Accelerometer-Measured Habitual Physical Activity and Sedentary Time During Early Recovery in Pediatric Concussion

PURPOSE

Concussion management is shifting away from a rest-is-best approach, as data now suggest that exercise-is-medicine for this mild brain injury. Despite this, we have limited data on habitual physical activity following concussion. Therefore, our objective was to quantify accelerometer-measured physical activity and sedentary time in children with concussion (within the first month of injury) and healthy controls. We hypothesized that children with concussion would be less active than their healthy peers.

METHODS

We performed a secondary analysis of prospectively collected accelerometer data. Our sample included children with concussion (n = 60, 31 females) and historical controls (n = 60) matched for age, sex, and season of accelerometer wear.

RESULTS

Children with concussion were significantly more sedentary than controls (mean difference [MD], 38.3 min/d, P = .006), and spent less time performing light physical activity (MD, -19.5 min/d, P = .008), moderate physical activity (MD, -9.8 min/d, P < .001), and vigorous physical activity (MD, -12.0 min/d, P < .001); these differences were observed from 8:00 AM to 9:00 PM. Sex-specific analyses identified that girls with concussion were less active and more sedentary than both boys with concussion (P = .010) and healthy girls (P < .010).

CONCLUSION

There is an activity deficit observed within the first month of pediatric concussion. Physical activity guidelines should address this while considering sex effects.

Accelerometer techniques for capturing human movement validated against direct observation: a scoping review

INTRODUCTION

Accelerometers are devices commonly used to measure human physical activity and sedentary time. Accelerometer capabilities and analytical techniques have evolved rapidly, making it difficult for researchers to keep track of advances and best practices for data processing and analysis.

OBJECTIVE

The objective of this scoping review is to determine the existing methods for analyzing accelerometer data for capturing human movement which have been validated against the criterion measure of direct observation.

METHODS

This scoping review searched 14 academic and 5 grey databases. Two independent raters screened by title and abstract, then full text. Data were extracted using Microsoft Excel and checked by an independent reviewer.

RESULTS

The search yielded 1039 papers and the final analysis included 115 papers. 71 unique accelerometer models were used across a total of 4217 participants. While all studies underwent validation from direct observation, most direct observation occurred live (55%) or using recordings (42%). Analysis techniques included machine learning approaches (22%), the use of existing cut-points (18%), ROC curves to determine cut-points (14%), and other strategies including regressions and non-machine learning algorithms (8%).

DISCUSSION

Machine learning techniques are becoming more prevalent and are often used for activity identification. Cut-point methods are still frequently used. Activity intensity is the most assessed activity outcome; however, both the analyses and outcomes assessed vary by wear location.

CONCLUSIONS

This scoping review provides a comprehensive overview of accelerometer analysis and validation techniques using direct observation and is a useful tool for researchers using accelerometers.

Physical Activity in Pediatric Inflammatory Bowel Disease: A Scoping Review

BACKGROUND

Inflammatory bowel disease (IBD) is a chronic, systemic condition affecting the gastrointestinal tract. IBD can be severe and are associated with impairment in growth, school absences, abdominal pain, and fatigue. Physical activity (PA) could have an anti-inflammatory effect in addition to other benefits. It is important to address the possible risks, physiological effects of PA, and potential barriers, and facilitators for PA participation in pediatric IBD. However, potential barriers and facilitators to PA have yet to be adequately described.

METHODS

We conducted a scoping review to map and describe the current literature on PA in pediatric IBD populations between 1980 and April 2022 using Preferred Reporting Items for Systematic Reviews and Meta-analysis guidelines for Scoping reviews.

RESULTS

Nineteen articles were identified including 10 descriptive, 6 interventional, and 3 physiological responses to PA studies. Patients and healthy controls demonstrated similar responses to exercise. Barriers to participation were low self-esteem, body image, and active IBD symptoms. Facilitators included personal interest, activity with friends, and support from family.

CONCLUSION

This review highlighted that PA participation may reduce in children with IBD-related symptoms. Short- and medium-term impacts of PA on immune modulation require further study; it is possible that regular PA does not negatively affect biomarkers of disease activity.

A Pilot Study of Exercise Training for Children and Adolescents With Inflammatory Bowel Disease: An Evaluation of Feasibility, Safety, Satisfaction, and Efficacy

BACKGROUND

Children with inflammatory bowel disease (IBD) experience extraintestinal side effects including altered body composition, impaired muscle strength, and aerobic capacity. Exercise training may remedy these issues.

PURPOSE

To assess the feasibility, safety, participant satisfaction, and efficacy of a training program for youth with IBD.

METHODS

Children with IBD completed 16 weeks of training (2 supervised + 1 home sessions per week). Feasibility was assessed by tracking recruitment, adherence, and compliance rates. Safety was assessed by tracking symptoms and adverse events. Posttraining interviews gauged satisfaction. Circulating inflammatory markers, body composition, muscle strength, aerobic fitness, and habitual physical activity were measured at baseline, midtraining (8 wk), and posttraining.

RESULTS

Eleven youth were recruited and 10 completed the study. Participants adhered to 28 (1) of 32 prescribed supervised sessions and 8 (4) of 16 prescribed home sessions. There were no adverse events, and overall feedback on training was positive. Posttraining, we observed an increase in lean mass (+2.4 [1.1] kg), bone density (+0.0124 [0.015] g·cm-2), aerobic fitness (+2.8 [5.7] mL·kg LM-1· min-1), and vigorous physical activity levels (+13.09 [8.95] min·h-1) but no change in inflammation or muscle strength.

CONCLUSION

Supervised exercise training is feasible, safe, and effective for youth with IBD and should be encouraged.

The temporal and bi-directional relationship between physical activity and sleep in ambulatory children with cerebral palsy

PURPOSE

Exploring the temporal and bi-directional relationship between device-based measures of physical activity and sleep in ambulatory children with cerebral palsy (CP).

MATERIALS AND METHODS

24-hour activity data were collected from children with CP (n = 51, 43% girls, mean age (range); 6.8 (3-12) years; Gross Motor Function Classification System levels I to III). Nocturnal sleep parameters and daily physical activity were measured for seven consecutive days and nights using ActiGraph GT3X accelerometers. Linear mixed models were constructed to explore the relationships between sleep and activity.

RESULTS

Light and moderate-to-vigorous activity were negatively associated with sleep efficiency (SE) (resp. p = 0.04, p = 0.010) and total sleep time (TST) (resp. p = 0.007, p = 0.016) the following night. Sedentary time was positively associated with SE and TST the following night (resp. p = 0.014, p = 0.004). SE and TST were positively associated with sedentary time (resp. p = 0.011, p = 0.001) and negatively with moderate-to-vigorous physical activity (resp. p < 0.001, p = 0.002) the following day. Total bedtime and TST were negatively associated with light physical activity (resp. p = 0.046, p = 0.004) the following day.

CONCLUSIONS

The findings from this study suggest that ambulatory children with CP may not sleep better after physical activity, and vice versa, indicating that the relationship is complex and needs further investigation.

Does Sleep Quality Influence Recovery Outcomes After Postconcussive Injury in Children and Adolescents?

OBJECTIVE

To determine whether objective parameters of sleep quality differ throughout recovery between children and adolescents who experienced an early return to school (RTS) and those who had a delayed RTS or did not return at all during the study period.

SETTING

Sleep parameters reflective of sleep quality were evaluated in participants' natural sleeping habitat throughout 9 weeks postinjury.

PARTICIPANTS

Ninety-four children and adolescents (aged 5-18 years) with diagnosed concussion.

DESIGN

Prospective cohort. Participants followed RTS protocols.

MAIN MEASURES

Actigraphy-derived estimates of total sleep time (TST), sleep efficiency (SE), wake after sleep onset (WASO), average arousal length (AAL), and number of arousals (NOAs) per hour were assessed. The length of time from injury until RTS was determined for each participant. Participants were categorized into an early RTS or delayed RTS group based on their time to RTS.

RESULTS

Both TST and SE were significantly greater in the early RTS group. WASO duration, AAL, and NOAs were significantly greater in the delayed RTS group. Differences between RTS groups were most apparent during weeks 1 to 5 postinjury.

CONCLUSIONS AND CLINICAL IMPLICATIONS

Participants who returned to school earlier had significantly better objective sleep quality than participants who experienced a delayed RTS. This study provides evidence in support of a relationship between sleep quality and time to RTS in children and adolescents with concussion. Considering early monitoring of sleep, education regarding sleep hygiene, and access to age-appropriate sleep interventions may be helpful in pediatric concussion recovery.

Seasonal variation of eosinophil counts in histologically normal colonic mucosal biopsies

INTRODUCTION

The eosinophil counts in colonic biopsies are affected by geographical and possibly seasonal variations. This study aims to investigate the significance of seasonal variations of eosinophil counts in histologically normal colonic mucosal biopsies.

MATERIALS AND METHODS

This is a retrospective, cross sectional study that included 337 cases of normal colonic biopsies. The number of eosinophils per high power field was counted in the most densely populated area. The eosinophilic counts were compared among genders, age groups, biopsy sites and in various months and seasons. Two tailed T-test was used to compare means and a p value < 0.05 was considered significant.

RESULTS

173 (51%) of cases were from males. The age range was between 18-82 with the mean being 51.7 years (SD= 17.5). 181 (54%) biopsies were from the right colon and 156 (46%) from the left colon. There was a statistically significant difference between eosinophil counts in the right colon (mean 20.2, SD 13.2) and left colon (mean 13.8, SD10.1); p value <0.001. The mean eosinophil counts was highest in autumn (21.1) followed by spring (18.3). The counts in winter and summer were close (15.2 and 15.1 respectively). There was a statistically significant difference between counts in autumn and summer (p=0.013) and between autumn and winter (p=0.008). However, there was no statistically significant differences between autumn and spring counts (p=0.183). When stratified according to site, this pattern of statistical significance was observed in the right colon but not the left colonic mucosal biopsies.

CONCLUSION

There are significant seasonal variations of eosinophil counts in normal colonic biopsies which are more pronounced in the right colon. Pathologists and gastroenterologists need to be aware of these variations and to take them into account when determining if a patient has tissue eosinophilia.

Accelerometer-measured physical activity, sedentary behavior, and sleep in children with cerebral palsy and their adherence to the 24-hour activity guidelines

AIM

To measure and describe the 24-hour activities (i.e. physical activity, sedentary behavior, and sleep) and to examine adherence to the 24-hour activity guidelines among children with cerebral palsy (CP) using actigraphy.

METHOD

Children's 24-hour activities were recorded over 7 days using hip- and wrist-worn ActiGraph wGT3X-BT accelerometers.

RESULTS

In total, 362 days and 340 nights from 54 children with CP (Gross Motor Function Classification System [GMFCS] levels I-III; 44% females; median age [range] 6 years 6 months [3-12 years]) were included. Mean (SD) daily wear time was 746.2 (48.9) minutes, of which children spent on average 33.8% in light physical activity (251.6 [58.7] minutes per day), 5.2% in moderate-to-vigorous physical activity (38.5 [20.1] minutes per day), and the remaining 61.1% being sedentary (456.1 [80.4] minutes per day). Physical activity decreased while sedentary behavior increased with increasing GMFCS level. In total, 13% of all children met the physical activity recommendations, and 35% met the age-appropriate sleep duration recommendation. The proportion of children meeting the combined 24-hour guidelines for physical activity and sleep was low (5.9%), especially in those classified in GMFCS level III (0%).

INTERPRETATION

The observed low 24-hour guideline adherence rates emphasize the importance of considering the entire continuum of movement behaviors in the care of children with CP, in efforts to promote healthy lifestyle behaviors and prevent negative health outcomes.

Exploring the relationship between resting state intra-network connectivity and accelerometer-measured physical activity in pediatric concussion: A cohort study

Our objective was to explore the association between resting state functional connectivity and accelerometer-measured physical activity in pediatric concussion. Fourteen children with concussion (aged 14.54 ± 2.39 years, 8 female) were included in this secondary data analysis of a larger study. Participants had neuroimaging at 15.3 ± 6.7 days post-injury and subsequently a mean of 11.1 ± 5.0 days of accelerometer data. Intra-network connectivity of the default mode network (DMN), sensorimotor network (SMN), salience network (SN), and fronto-parietal network (FPN) was computed using resting state functional MRI. We found that per general linear models, only intra-network connectivity of the DMN was associated with physical activity levels. More specifically, increased intra-network connectivity of the DMN was significantly associated with higher levels of subsequent accelerometer-measured light physical activity (F(2, 11) = 7.053, p = 0.011, Ra2 = 0.562; β = 0.469), moderate physical activity (F(2, 11) = 7.053, p = 0.011, Ra2 = 0.562; β = 0.725), and vigorous physical activity (F(2, 11) = 10.855, p = 0.002, Ra2 = 0.664; β = 0.79). Intra-network connectivity of the DMN did not significantly predict sedentary time. Therefore, these preliminary findings suggest that there is a positive association between the intra-network connectivity of the DMN and device-measured physical activity in children with concussion.

Correlates of Moderate-to-Vigorous Physical Activity in Children With Physical Illness and Physical-Mental Multimorbidity

This study measured physical activity (PA) and explored its correlates among children with multimorbidity (co-occurring chronic physical and mental illness; MM) versus those with chronic physical illness only (PI). This study used baseline data from the Multimorbidity in Children and Youth Across the Life Course (MY LIFE) study, an on-going cohort study following 263 children with a PI 2 to 16 years of age (mean age: 9.8 years, SD = 4.0; 47.7% female). PA was measured using accelerometry, and demographic and psychosocial variables were collected using questionnaires. Of the 55 children with MM and the 85 with PI with valid accelerometer data, 38.1% and 41.2%, respectively, met average daily PA guidelines. Correlates of moderate-to-physical PA (MVPA) among children with MM were age, ρ(53) = -0.45, p = .001, body mass index (BMI), ρ(48) = -0.28, p = .04, self-perceived behavioral conduct, ρ(24) = -0.45, p = .02, physical health-related quality of life, ρ(51) = 0.56, p < .001, and peer support, ρ(52) = 0.27, p = .04. Correlates of MVPA among children with PI were age, ρ(83) = -0.40, p < .001, sex, ρ(83) = -0.26, p = .01, self-perceived social competence, ρ(31) = 0.42, p = .02, self-perceived athletic competence, ρ(31) = 0.48, p = .005, physical health-related quality of life, ρ(83) = 0.34, p = .001, participation in community sport, ρ(31) = 0.41, p = .02, and family functioning, ρ(83) = 0.26, p = .02. These results demonstrate that children with PI and MM are insufficiently active and their PA is correlated with demographic and psychosocial factors.

Examining the trajectory and predictors of post-concussion sleep quality in children and adolescents

OBJECTIVES

This study aimed to 1) determine if post-concussion sleep quality of children and adolescents differed from healthy sleep estimates; 2) describe the trajectory of parameters of sleep quality; 3) determine factors that predict sleep quality outcomes; and 4) compare sleep parameter outcomes between asymptomatic and symptomatic participants at 4 weeks post-concussion.

METHODS

Nightly actigraphy estimates of sleep in 79 children and adolescents were measured throughout 4 weeks post-concussion. Total sleep time (TST), sleep efficiency (SE), wake after sleep onset (WASO), number of arousals (NOA), and average arousal length (AAL) were measured.

RESULTS

Child and adolescent participants experienced significantly poorer SE and longer WASO duration throughout 4 weeks of recovery and adolescents experienced significantly longer TST. SE significantly improved with time post-injury (p = .047). Older age was associated with longer TST (p = .003) and female sex was associated with longer WASO (p = .025) and AAL duration (p = .044). Week 4 sleep parameter outcomes were not significantly different between asymptomatic and symptomatic participants.

CONCLUSIONS

The sleep quality of youth is adversely affected by concussion, particularly in females. Sleep quality appears to improve with time but may require more than 4 weeks to return to normal.

Deriving Normative Data on 24-Hour Ambulatory Blood Pressure Monitoring for South Asian Children (ASHA): A Clinical Research Protocol

Background:

The global prevalence of hypertension in children and adolescents has increased over the past 2 decades and is the strongest predictor of adult hypertension. South Asians have an increased prevalence of metabolic syndrome associated risk factors including abdominal obesity, diabetes, and hypertension. All these factors contribute to their increased cardiovascular disease burden. Accurate and early identification of hypertension in South Asian children is a necessary aspect of cardiovascular disease prevention. Ambulatory blood pressure monitoring (ABPM) is considered the gold-standard for pediatric blood pressure (BP) measurement. However, its utilization is limited due to the lack of validated normative reference data in diverse, multiethnic pediatric populations.

Objective:

The primary objective is to establish normative height-sex and age-sex-specific reference values for 24-h ABPM measurements among South Asian children and adolescents (aged 5-17 years) in Ontario and British Columbia, Canada. Secondary objectives are to evaluate differences in ABPM measurements by body mass index classification, to compare our normative data against pre-existing data from German and Hong Kong cohorts, and to evaluate relationships between habitual movement behaviors, diet quality, and ABPM measurements.

Design:

Cross-sectional study, quasi-representative sample.

Setting:

Participants will be recruited from schools, community centers, and places of worship in Southern Ontario (Greater Toronto and Hamilton area, including the Peel Region) and Greater Vancouver, British Columbia.

Participants:

We aim to recruit 2113 nonoverweight children (aged 5-17 years) for the primary objective. We aim to recruit an additional 633 overweight or obese children to address the secondary objectives.

Measurements:

Ambulatory BP monitoring measurements will be obtained using Spacelabs 90217 ABPM devices, which are validated for pediatric use. The ActiGraph GT3X-BT accelerometer, which has also been validated for pediatric use, will be used to obtain movement behavior data.

Methods:

Following recruitment, eligible children will be fitted with 24-h ABPM and physical activity monitors. Body anthropometrics and questionnaire data regarding medical and family history, medications, diet, physical activity, and substance use will be collected. Ambulatory BP monitoring data will be used to develop height-sex- and age-sex-specific normative reference values for South Asian children. Secondary objectives include evaluating differences in ABPM measures between normal weight, overweight and obese children; and comparing our South Asian ABPM data to existing German and Hong Kong data. We will also use compositional data analysis to evaluate associations between a child’s habitual movement behaviors and ABPM measures.

Limitations:

Bloodwork will not be performed to facilitate recruitment. A non-South Asian comparator cohort will not be included due to feasibility concerns. Using a convenience sampling approach introduces the potential for selection bias.

Conclusions:

Ambulatory BP monitoring is a valuable tool for the identification and follow-up of pediatric hypertension and overcomes many of the limitations of office-based BP measurement. The development of normative ABPM data specific to South Asian children will increase the accuracy of BP measurement and hypertension identification in this at-risk population, providing an additional strategy for primary prevention of cardiovascular disease.

Grip strength is lower in adults born with extremely low birth weight compared to term-born controls

BACKGROUND

Grip strength predicts long-term morbidity and mortality in adults. We compared grip strength in adults born with extremely low birth weight (ELBW; under 1 kg) and a normal birth weight control group (NBW) and describe change in grip strength over a 10-year period in a longitudinal cohort study of preterm birth.

METHODS

Grip strength, body composition, and device-measured physical activity were assessed in 95 mature adults (MA) born ELBW (age 31.6 (1.6) mean (SD) years, 59 females) and 88 born NBW (age 31.9 (1.4) years, 52 females). Regression models were used to examine the effect of perinatal factors, body composition, physical activity, and physical self-efficacy on grip strength.

RESULTS

Grip strength was lower in MA born ELBW compared to NBW (31.8 (10.0) vs. 39.8 (11.2) kg; p < 0.001). Birth weight group was associated with grip strength independent of sex, height, and lean mass index, but device-measured physical activity was not. The change in grip strength from mid-20s to MA was similar in ELBW and NBW participants.

DISCUSSION

Grip strength in MA born ELBW is low and is similar to a reference group 25-30 years older, suggesting higher risk for cardiovascular and all-cause mortality.

IMPACT

Adults born extremely preterm have reduced grip strength compared to control participants born at full term. Reduced grip strength is a predictor of frailty and increased cardiovascular disease risk. Change in grip strength from age in mid-20s to mid-30s is similar in those born preterm and full-term-born controls. Grip strength is related to lean mass and not to device-measured physical activity-and correlates of grip strength are similar in those born preterm and term-born controls. Grip strength is a simple measure that may provide information about the health of adults born preterm.

Automatically Identifying Financial Stress Information from Clinical Notes for Patients with Prostate Cancer

Background

Financial stress, one of the social determinants, is common among cancer patients because of high out-ofpocket costs for treatment, as well as indirect costs. The National Academy of Medicine (NAM) has advised providers to recognize and discuss cost concerns with patients in order to enhance shared decision-making for treatment and exploration of financial assistant programs. However, financial stress is rarely assessed in clinical practice or research, thus, under-coded and under-documented in clinical practice. Natural language processing (NLP) offers great potential that can automatically extract and process data on financial stress from clinical free text existing in the patient electronic health record (EHR).

Methods

We developed and evaluated an NLP approach to identify financial stress from clinical narratives for patients with prostate cancer. Of 4,195 eligible prostate cancer patients, we randomly sampled 3,138 patients (75%) as a training dataset (150,990 documents) to develop a financial stress lexicon and NLP algorithms iteratively. The remaining 1,057 patients (25%) were used as a test dataset (55,516 documents) to evaluate the NLP algorithm performance. The common terms representing financial stress were "financial concerns," "unable to afford," "insurance issue," "unemployed," and "financial assistance." Negations were used to exclude false mentions of financial stress.

Results

Applying both pre- and post-negation, the NLP algorithm identified 209 patients (6.0%) from the training sample and 66 patients (6.2%) with 161 notes from the test sample as having documented financial stress. Two independent domain experts manually reviewed all 161 notes with NLP identified positives and randomly selected 161 notes with NLP-identified negatives, the NLP algorithm yielded 0.86 for precision, 1 for recall, and 0.9.2 for F-score.

Conclusions

Financial stress information is not commonly documented in the EHR, neither in structured format nor in clinical narratives. However, natural language processing can accurately extract financial stress information from clinical notes when such narrative information is available.

Physical activity and sedentary behaviour in children with spina bifida

AIM

To describe active and sedentary time in children with spina bifida and to compare their physical activity on weekdays versus weekends.

METHOD

In this exploratory cross-sectional study, data from 13 Canadian and 22 Dutch children with spina bifida (14 females, 21 males; mean age 10y 11mo, standard deviation [SD] 3y 6mo, range 5y 6mo-18y; Hoffer classification distribution: community [n=28], household [n=3], non-functional [n=3], and non-ambulator [n=1]) were analysed. Objective measures of physical activity and sedentary behaviour were obtained by using ActiGraph or Actiheart activity monitors. Data for the participants wearing the ActiGraph were compared with age- and sex-matched controls that were developing typically using independent-samples t-tests. Activity data collected on weekdays was compared to those on weekends.

RESULTS

ActiGraph data demonstrated children with spina bifida spent more time sedentary (mean [SD] 49.5min/h [5.78]) and less time in moderate to vigorous physical activity (mean [SD] 2.33min/h [1.61]) compared with the typically developing group (mean [SD] 41.0min/h [5.76] and 5.46min/h [2.13], p=0.001 and p<0.001 respectively). For both ActiGraph- and Actiheart-derived data, physical activity and sedentary time were not significantly different between weekdays and weekends.

INTERPRETATION

Children with spina bifida have reduced levels of physical activity and increased sedentary behaviour, with no statistical differences seen between weekdays and weekends. Several methodological issues related to activity monitoring warrant consideration when choosing the appropriate method to quantify physical activity and sedentary behaviour.

WHAT THIS PAPER ADDS

Reduced levels of physical activity and sedentary time were quantified in children with spina bifida. Objective quantification of physical behaviour in ambulatory and non-ambulatory school-aged children with spina bifida is possible.

Exploring Accelerometer Versus Self-Report Sleep Assessment in Youth With Concussion

This study examines accelerometer-based and self-report assessment of sleep disturbance from a larger prospective cohort of youth 5 to 18 years of age with postconcussive injury. Twenty-one participants with self-reported sleep disturbance were evaluated using accelerometers. Participants completed the Pittsburgh Sleep Quality Index (PSQI) every 48 hours and also measured sleep via accelerometry. Correlations were conducted matching PSQI scores to accelerometry assessment. PSQI scores were significantly correlated only with “average number of awakenings” (r = −0.21; P = .049). Accelerometer-measured mean (standard deviation) sleep efficiency was 79.9% (5.20%), with normal sleep defined as >85%. The mean (standard deviation) PSQI global score was 10.5 (3.78) out of 21, where scores of >5 indicate subjective insomnia. Results suggest the PSQI and accelerometers may be measuring different attributes of sleep. Both may be needed as actual sleep is important but so is perception of good sleep. These findings call for further validity testing of objective sleep assessment measures and commonly used self-report tools.

Circulating Endothelial Progenitor Cells in Youth: Fitness, Physical Activity and Adiposity

Circulating endothelial progenitor cells (EPCs) are early markers of cardiovascular impairment. The role of EPCs in youth remains unclear, and is complicated by differences in how cells are identified. This study (1) described EPCs in pre- and late-pubertal males and females, (2) examined their association with fitness, activity and adiposity, and (3) compared EPCs to published cell definitions. 94 participants completed 2 sessions. During the first session, aerobic fitness (Wpeak) and moderate-to-vigorous physical activity (MVPA) were assessed. During the second session, percent body fat (%BF) was determined by DXA, and a fasted blood sample was collected to measure EPCs by flow cytometry. EPCs were identified as CD31(+)CD34(bright)CD45(dim)CD133(+). Samples were reanalyzed and cell counts were compared to 8 previously published EPC definitions. EPCs were similar in pre- and late-pubertal males and females (p>0.05). Neither EPC concentrations nor proportions were correlated with Wpeak (ρ=- 0.04 to-0.06), MVPA (ρ=- 0.09 to - 0.07) or %BF (ρ=0.20 to 0.14). Agreement between cell data analyzed according the different cell definitions ranged from Κ=-0.06 to 0.82. Our findings suggest that EPCs were not associated with fitness, MVPA or adiposity in youth. The overall poor agreement across definitions may be indicative of distinct EPC subpopulations.

Effects of acute exercise on circulating endothelial and progenitor cells in children and adolescents with juvenile idiopathic arthritis and healthy controls: a pilot study

BACKGROUND

Youth with juvenile idiopathic arthritis (JIA) may be at risk of poor cardiovascular health. Circulating endothelial progenitor cells (EPCs) and circulating endothelial cells (CECs) are markers of cardiovascular repair and damage, respectively, and respond to exercise. The objectives of this study were to compare resting levels of EPCs and CECs in JIA and controls, and to assess the effects of distinct types of exercise on EPCs and CECs in JIA and controls.

METHODS

Seven youth with JIA and six controls completed 3 visits. First, aerobic fitness was assessed. Participants then performed either moderate intensity, continuous exercise (MICE) or high intensity, intermittent exercise (HIIE) on separate days. Blood samples were collected at the beginning (REST), mid-point (MID) and end of exercise (POST) for determination of EPCs (CD31(+)CD34(bright)CD45(dim)CD133(+)) and CECs (CD31(bright)CD34(+)CD45(-)CD133(-)) by flow cytometry. Between group differences in EPCs and CECs were examined using two-way ANOVA, followed by Tukey's HSD post hoc, where appropriate. Statistical significance set at p ≤ 0.05.

RESULTS

Both EPCs and CECs were similar between groups at REST (p = 0.18-0.94). During MICE, EPCs remained unchanged in JIA (p = 0.95) but increased significantly at POST in controls (REST: 0.91 ± 0.55 × 10(6) cells/L vs. POST: 1.53 ± 0.36 × 10(6) cells/L, p = 0.04). Compared with controls, lower levels of EPCs were observed in JIA at MID (0.48 ± 0.50 × 10(6) cells/L vs. 1.10 ± 0.39 × 10(6) cells/L, p = 0.01) and POST (0.38 ± 0.34 × 10(6) cells/L vs. 1.53 ± 0.36 × 10(6) cells/L, p < 0.001) during MICE. No changes were detected in CECs with MICE in JIA and controls (p = 0.69). Neither EPCs nor CECs were modified with HIIE (p = 0.28-0.69).

CONCLUSION

Youth with JIA demonstrated a blunted EPC response to MICE when compared with controls. Future work should examine factors that may increase or normalize EPC mobilization in JIA.

Circulating endothelial cells in children: role of fitness, activity, and adiposity

PURPOSE

Circulating endothelial cells (CEC) are thought to be useful biomarkers of endothelial dysfunction and overall cardiovascular health. The extent to which CEC are influenced by fitness, physical activity, and adiposity in youth remains unknown, as they have seldom been examined in the pediatric population. This study assessed resting levels of CEC in boys and girls of different chronological and biological age and explored the relationship between these cells and aerobic fitness, physical activity, and adiposity.

METHODS

Seventy-five children (39 males; median [interquartile range], age = 14.4 [5.8]) completed two study visits. During the first visit, basic anthropometric data were collected and biological age was calculated. Peak mechanical power (Wpeak) was determined using the McMaster All-Out Continuous cycling test. Participants then wore an accelerometer over a 7-d period to assess habitual levels of moderate-to-vigorous physical activity. During visit 2, percent body fat (%BF) was assessed by dual-energy x-ray absorptiometry. A fasted blood sample was also collected from which concentrations of CEC, identified as CD31CD34CD45CD133, were quantified by flow cytometry.

RESULTS

No differences were seen in CEC by sex, chronological age, or biological age. The median (interquartile range) CEC concentration was 32.3 × 10 (63.0 × 10), representing 1.3% (2.7%) of collected peripheral blood mononuclear cells. CEC concentration was associated with Wpeak normalized to lean body mass (r = 0.36, P < 0.01) and time spent in moderate-to-vigorous physical activity (r = -0.27, P = 0.02). No relationship was observed between CEC and %BF.

CONCLUSION

Healthy children demonstrate relatively low concentrations of CECs. Because CEC represent a population of mature endothelial cells shed from the intima after irreversible damage, they may be more reflective of recent physical activity levels rather than fitness or level of adiposity.

Effects of acute exercise on markers of inflammation in pediatric chronic kidney disease: a pilot study

BACKGROUND

Children and adolescents with chronic kidney disease (CKD) are chronically exposed to high levels of inflammation, placing them at an increased risk of secondary health complications. Regular exercise may represent an effective therapy to reduce inflammation. The aims of this pilot study were to determine the effects of acute exercise on inflammation and immune cell counts in CKD.

METHODS

Nine children and adolescents (4 males) with CKD stages III-V performed a graded exercise test to determine peak oxygen uptake (VO2peak). Following a 10-min break, participants cycled for 20 min at 50 % of VO2peak. Blood samples were collected before and after the exercise period for the determination of complete blood counts, natural killer cells (NK(bright), NK(dim)) and circulating progenitor cell (CPC) counts, as well as interleukin-6 (IL-6), and tumor necrosis factor-α (TNF-α) concentrations.

RESULTS

Complete blood counts and NK(dim) cell and CPC counts were unchanged with exercise. Following exercise, NK(bright) cell counts increased (7.4 ± 4.3 vs. 12.2 ± 8.3 × 10(6) cells/L; p = 0.02), while trends were observed for an increase in IL-6 (2.1 ± 2.2 vs. 2.7 ± 2.6 pg/mL; p = 0.08), decrease in TNF-α (4.5 ± 1.2 vs. 4.2 ± 1.0 pg/mL; p = 0.08) and an increase in the IL-6:TNF-α ratio (0.6 ± 0.7 vs. 0.8 ± 0.8; p = 0.07).

CONCLUSIONS

Our findings suggest that acute exercise may create an anti-inflammatory environment in children and adolescents with CKD stages III-V.

Fitness and physical activity in youth with type 1 diabetes mellitus in good or poor glycemic control

BACKGROUND

Patients with type 1 diabetes mellitus (T1DM) may experience poor muscle health as a result of chronic hyperglycemia. Despite this, muscle function in children with T1DM with good or poor glycemic control has yet to be examined in detail.

OBJECTIVE

To assess differences in muscle-related fitness variables in children with T1DM with good glycemic control (T1DM-G), as well as those with poor glycemic control (T1DM-P), and non-diabetic, healthy controls.

SUBJECTS

Eight children with T1DM-G [glycosylated hemoglobin (HbA1c) ≤ 7.5% for 9 months], eight children with T1DM-P (HbA1c ≥ 9.0% for 9 months), and eight healthy controls completed one exercise session.

METHODS

Anaerobic and aerobic muscle functions were assessed with a maximal isometric grip strength test, a Wingate test, and an incremental continuous cycling test until exhaustion. Blood samples were collected at rest to determine HbA1c at the time of testing. Physical activity was monitored over 7 d using accelerometry.

RESULTS

Children with T1DM-P displayed lower peak oxygen consumption (VO2peak ) values (mL/kg/min) compared to healthy controls (T1DM-P: 33.2 ± 5.6, controls: 43.5 ± 6.3, p < 0.01), while T1DM-G (43.5 ± 6.3) had values similar to controls and T1DM-P. There was a negative relationship between VO2peak and HbA1c% (r = -0.54, p < 0.01). All groups were similar in all other fitness variables. There were no group differences in physical activity variables.

CONCLUSION

Children with T1DM-G did not display signs of impaired muscle function, while children with T1DM-P have signs of altered aerobic muscle capacity.

Effect of milk consumption on rehydration in youth following exercise in the heat

Low-fat milk is thought to be an effective postexercise rehydration beverage in adults; however, little is known about milk’s rehydration ability in children after exercising in the heat. This study tested the hypothesis that because of its electrolyte and protein content, skim milk (SM) would be more effective than both water (W) and a carbohydrate/electrolyte solution (CES) in replacing body fluid losses in children following exercise in the heat. Thirty-eight (19 females) heat-acclimated pre- to early pubertal (PEP, aged 7–11 years) and mid- to late-pubertal (MLP, aged 14–17 years) children performed 3 sessions in 34.5 °C, 47.3% relative humidity, consisting of 2 × 20-min cycling bouts at 60% peak oxygen uptake followed by consumption of either W, CES, or SM. Each beverage was consumed immediately after exercise in a volume equal to 100% of their body mass loss during exercise. Urine samples were collected before, during, and after exercise, as well as the 2-h period following beverage consumption. On average, children dehydrated 1.3% ± 0.4%. Children ingested 0.40 ± 0.11 L (PEP) and 0.74 ± 0.20 L (MLP) of fluid. The fraction of the ingested beverage retained at 2 h of recovery was greater with SM (74% ± 18%) than W (47% ± 26%) and CES (59% ± 20%, p < 0.001 for both), and greater in CES than W (p < 0.001). All participants were in a hypohydrated state after 2 h of recovery, following the pattern SM < CES < W. In both PEP and MLP children, SM is more effective than W and CES at replacing fluid losses that occur during exercise in the heat.

Postexercise protein ingestion increases whole body net protein balance in healthy children

Postexercise protein ingestion increases whole body and muscle protein anabolism in adults. No study has specifically investigated the combined effects of exercise and protein ingestion on protein metabolism in healthy, physically active children. Under 24-h dietary control, 13 (seven males, six females) active children (∼ 11 yr old; 39.3 ± 5.9 kg) consumed an oral dose of [(15)N]glycine prior to performing a bout of exercise. Immediately after exercise, participants consumed isoenergetic mixed macronutrient beverages containing a variable amount of protein [0, 0.75, and 1.5 g/100 ml for control (CON), low protein (LP), and high protein (HP), respectively] according to fluid losses. Whole body nitrogen turnover (Q), protein synthesis (S), protein breakdown (B), and protein balance (WBPB) were measured throughout exercise and the early acute recovery period (9 h combined) as well as over 24 h. Postexercise protein intake from the beverage was ∼ 0.18 and ∼ 0.32 g/kg body mass for LP and HP, respectively. Q, S, and B were significantly greater (main effect time, all P < 0.001) over 9 h compared with 24 h with no differences between conditions. WBPB was also greater over 9 h compared with 24 h in all conditions (main effect time, P < 0.001). Over 9 h, WBPB was greater in HP (P < 0.05) than LP and CON with a trend (P = 0.075) toward LP being greater than CON. WBPB was positive over 9 h for all conditions but only over 24 h for HP. Postexercise protein ingestion acutely increases net protein balance in healthy children early in recovery in a dose-dependent manner with larger protein intakes (∼ 0.32 g/kg) required to sustain a net anabolic environment over an entire 24 h period.

Effects of postexercise milk consumption on whole body protein balance in youth

In adults, adding protein to a postexercise beverage increases muscle protein turnover and replenishes amino acid stores. Recent focus has shifted toward the use of bovine-based milk and milk products as potential postexercise beverages; however, little is known about how this research translates to the pediatric population. Twenty-eight (15 girls) pre- to early pubertal (PEP, 7-11 yr) and mid- to late-pubertal (MLP, 14-17 yr) children consumed an oral dose of [(15)N]glycine prior to performing 2 × 20-min cycling bouts at 60% V̇O(2 peak) in a warm environment (34.5°C, 47.3% relative humidity). Following exercise, participants consumed either water (W), a carbohydrate-electrolyte solution (CES), or skim milk (SM) in a randomized, cross-over fashion in a volume equal to 100% of their body mass loss during exercise. Whole body nitrogen turnover (Q), protein synthesis (S), protein breakdown (B), and whole body protein balance (WBPB) were measured over 16 h. Protein intake from SM was 0.40 ± 0.10 g/kg. Over 16 h, Q and S were significantly greater (P < 0.01) with SM than W and CES. B demonstrated a trend for a main effect for beverage (P = 0.063). WBPB was more negative (P < 0.01) with W and CES than with SM. In the SM trial, WBPB was positive in PEP, although it remained negative in MLP. Boys exhibited significantly more negative WBPB than girls (P < 0.05). Postexercise milk consumption enhances WBPB compared with W and CES; however, additional protein intake may be required to sustain a net anabolic environment over 16 h.

The effects of resting and exercise serum from children with cystic fibrosis on C2C12 myoblast proliferation in vitro

Chronic systemic inflammation is a clinical symptom in children with cystic fibrosis (CF), but the effects on skeletal muscle development are unknown. The aims of this study were to determine (1) the effects of systemic factors from children with CF and healthy controls on myoblast proliferation, and (2) whether exercise serum can have an effect on proliferation in vitro. Eleven children with CF and 11 biological age-matched controls completed two 30-min bouts of cycling at an intensity set at 50% peak mechanical power. Serum samples were collected before exercise (REST), immediately following exercise (EX), and after 60 min of recovery (REC). Serum samples prepared in group-specific pools were used for cell culture experiments. C2C12 myoblasts were incubated in 5% serum and media for 1 h and then immediately harvested for protein and mRNA analysis, or incubated in growth media for 2 days to examine proliferation. C2C12 myoblasts treated with CF serum displayed greater proliferation phenotype than myoblasts treated with control serum. Proliferation did not change with EX or REC serum from children with CF compared to CF REST serum, while proliferation was increased with EX and REC serum from control compared to control REST serum. These findings suggest that systemic factors from children with CF at rest and after exercise can alter myoblast proliferation responses when compared to systemic factors from healthy children, which may have implications on skeletal muscle development.

Reliability and validity of short-term performance tests for wheelchair-using children and adolescents with cerebral palsy

AIM

To investigate the test-retest reproducibility of the Muscle Power Sprint Test (MPST), the 10 × 5-m sprint test, and the arm-cranking Wingate Anaerobic Test (WAnT) in children and adolescents with cerebral palsy (CP). A secondary objective was to assess the construct validity of the MPST.

METHOD

Twenty-three participants with spastic CP (mean age 13 y 3 mo, range 7-18 y, SD 3.6 y; 18 males, five females, two classified as having spastic unilateral CP, 21 as having spastic bilateral CP) using a manual wheelchair for at least part of the day were recruited and tested in different rehabilitation settings in the Netherlands. Participants were classified as in Gross Motor Function Classification System Expanded and Revised (GMFCS-E&R) levels III and IV.

RESULTS

Intraclass correlation coefficients (range 0.93-0.99; 95% confidence interval 0.82-1.0) for all variables indicated highly acceptable reproducibility. Limits of agreement analysis revealed satisfactory levels of agreement. The MPST variables demonstrated very strong significant positive correlations for peak power and mean power from both tests (peak power: r=0.91, p<0.001; mean power: r=0.88, p<0.001).

INTERPRETATION

The MPST, the 10 × 5-m sprint test, and the arm-cranking WAnT are reproducible tests for measuring anaerobic performance and agility in adolescents with spastic CP who self-propel a manual wheelchair. The MPST has been shown to be a valid test to measure anaerobic performance in this population.

Step count targets corresponding to new physical activity guidelines for the early years

PURPOSE

New physical activity guidelines recommend that children age 3–4 yr should accumulate at least 180 min of physical activity at any intensity spread throughout the day, including progression toward at least 60 min of energetic play by 5 yr of age. Step count targets corresponding to these recommendations will help practitioners and researchers monitor physical activity.

METHODS

One hundred thirty-three preschoolers were instructed to wear accelerometers for seven consecutive days. Activity and step count data were recorded in 3-s epochs. Step count targets equivalent to physical activity recommendations were derived using prediction equations from regression analyses. Receiver operating curve analyses were conducted to compare the sensitivity and specificity of the derived thresholds as well as a range of other targets.

RESULTS

The daily step count target derived for 180 min of physical activity of any intensity was 6013 +/- 88, whereas the target for 180 min of physical activity of any intensity including at least 60 min of moderate-to-vigorous physical activity was 6191 +/- 103. The smallest discrepancy between days meeting physical activity guidelines and step count targets was found with a 6000-step-per-day target. Receiver operating curves confirmed a balanced sensitivity and specificity of this target.

CONCLUSIONS

On the basis of our data, we suggest that a new step count target of 6000 steps per day should be used to determine whether 3- to 5-yr-old children are meeting physical activity recommendations.

Chemokine (C-C motif) Ligand 2 is a potential biomarker of inflammation & physical fitness in obese children: a cross-sectional study

BACKGROUND

Obesity is a global epidemic that is impacting children around the world. Obesity is a chronic inflammatory state with enhanced production of multiple cytokines and chemokines. Chemokine (C-C motif) Ligand 2 (CCL2) is produced by immune and metabolic cells and attracts immune cells into liver, muscle and adipose tissue, resulting in initiation and propagation of the inflammatory response in obesity. How obesity and fitness affect the production of this chemokine in children is unknown.This study tested the hypotheses that CCL2 levels are higher in obese children when compared to lean controls, and that fitness modulates CCL2 levels allowing its use as a biomarker of fitness.

METHODS

This was a cross sectional case-control study conducted in a Pediatric Tertiary care center in Hamilton, Ontario, Canada. Controls were recruited from the community. This study recruited overweight/obese children (BMI ≥ 85th percentile, n = 18, 9 female, mean age 14.0 ± 2.6 years) and lean controls (BMI < 85th percentile, n = 18, 8 female, mean age 14.0 ± 2.6 years) matched for age, sex and biological maturation.Aerobic fitness test was done using a cycle ergometer performing the McMaster All-Out Progressive Continuous Cycling test to exhaustion to determine peak oxygen uptake. Fasting CCL2 samples were taken prior to test. Categorical variables including subject categorization into different aerobic fitness levels in overweight/obese and lean children was reported based on the median split in each group.

RESULTS

Obese participants had significantly higher CCL2 levels when compared to lean group (150.4 ± 61.85 pg/ml versus 112.7 ± 38 pg/ml, p-value 0.034).To establish if CCL2 is a biomarker of fitness, we divided the groups based on their fitness levels. There was a main effect for group (F (3,32) = 3.2, p = 0.036). Obese high fitness group were similar to lean unfit and fit participants. Post-hoc analysis revealed that the overweight/obese low fitness group had significantly higher level of CCL2 compared to the lean low fitness group when adjusted to age, sex and maturity offset (F (3,29) = 3.1, p = 0.04).

CONCLUSIONS

CCL2 serves a dual role as a potential biomarker of inflammation and fitness in obese children.

Exercise and inflammation in pediatric Crohn's disease

We examined inflammatory cells, cytokines and growth factors in response to acute bouts of moderate intensity continuous exercise and high intensity intermittent exercise in youth with Crohn's disease and in healthy matched-controls. 15 patients and 15 controls performed 30 min of cycling at 50% of peak mechanical power (PMP) and 6 bouts of 4×15-s of cycling at 100% PMP. Blood was collected at rest, at the mid-point, at the end of exercise and at 30 and 60 min into recovery. In patients with CD, both types of exercise increased immune cells and GH and decreased IGF-I. Moderate intensity exercise induced a greater increase in leukocytes (p<0.05), neutrophils (p<0.05), lymphocytes (p<0.001), monocytes (p<0.05), IL-6 (p<0.05), IL-17 (p<0.05) and GH (p<0.05) and a similar decrease in IGF-I, compared with high intensity exercise. TNF-α did not change significantly with either exercise. Responses in patients were similar compared with controls; however, in patients monocytes remained elevated significantly longer in response to MICE. Youth with Crohn's disease can engage in distinctly different types of exercise without a significant acute exacerbation of inflammation.

Short-term muscle power and speed in preschoolers exhibit stronger tracking than physical activity

The purpose of this study was to examine the tracking of short-term muscle power, speed, and physical activity over a 15-month period in a sample of healthy Canadian preschool-aged children. Seventeen preschoolers (age, 4.4 ± 0.8 years) completed exercise testing and physical activity monitoring at baseline and follow-up separated by 14.6 ± 4.1 months. Short-term muscle power was measured using a modified 10-s Wingate test with peak power and mean power normalized to body mass. Speed was assessed with a 25-m dash. Physical activity was measured by accelerometry (Actigraph GT1M) using a 3-s epoch over 7 consecutive days. Total physical activity and moderate-to-vigorous physical activity, expressed as a percentage of accelerometer wear time, were examined. Tracking of the variables between year 1 and year 2 was analyzed using Spearman rank order correlations and Kappa statistics. Paired t-tests were used to assess differences in performance and physical activity between year 1 and year 2. Total physical activity was not significantly different at year 2 (p > 0.05) and showed fair tracking (r = 0.51, p = 0.05; ĸ = 0.30). Moderate-to-vigorous physical activity was increased at year 2 (p = 0.03) and exhibited poor tracking (r = 0.29, p = 0.28; ĸ = 0.00). Short-term muscle power and speed was increased at year 2 (p < 0.0001) and exhibited significant tracking: peak power (r = 0.72, p = 0.001; ĸ = 0.46), mean power (r = 0.83, p = 0.00004; ĸ = 0.82), and 25-m dash (r = 0.82, p = 0.0001; ĸ = 0.47). Moderate-to-vigorous physical activity increased in this sample of boys and girls during the preschool years, and short-term muscle power and speed exhibited stronger tracking than physical activity.

Reproducibility of computer-assisted joint alignment measurement in OA knee radiographs

OBJECTIVES

(1) To investigate the reproducibility of computer-assisted measurements of knee alignment angle (KA) from digitized radiographs of osteoarthritis (OA) participants requiring total knee arthroplasty (TKA) and (2) to determine whether landmark choice affects the precision of KA measurements on radiographs.

METHODS

Using a custom algorithm, femoral, central, and tibial measurement-guiding rules were interactively placed on digitized posteroanterior fixed-flexion knee radiographs by mouse control and positioned according to different anatomic landmarks. The angle subtended by lines connecting these guiding rules was measured by three readers to assess interobserver, intraobserver and experience-inexperience reproducibility. Test-retest reproducibility was evaluated with duplicate radiographs from a healthy cohort. Reproducibility was assessed using root-mean square coefficients of variation (RMSCV%). The Bland-Altman method was performed on data obtained from varying anatomic landmarks (confidence interval, CI= 95%).

RESULTS

From 16 healthy and 30 TKA participants, reproducibility analyses revealed a high degree of intraobserver (n=38, RMSCV=0.56%), interobserver (n=38, RMSCV=0.72%), test-retest (n=16, RMSCV=0.87%) and experience-inexperience (n=38, RMSCV=0.73%) reproducibility with variances below 1%. Varying the orientation of tibial and femoral rules according to anatomic landmarks produced a difference that exceeded an a priori limit of agreement of -1.11 degrees to +1.67 degrees.

CONCLUSION

Our custom-designed software provides a robust method for measuring KAs within digitized knee radiographs. Although test-retest analyses were only performed in a healthy cohort, we anticipate a similar degree of reproducibility in an OA sample. A standardized set of anatomic landmarks employed for KA measurement is recommended since arbitrary selection of landmarks resulted in imprecise KA measurement even with a computer-assisted technique.

Validation of the GALS musculoskeletal screening exam for use in primary care: a pilot study

Background

As the proportion of the Canadian population ≥65 grows, so too does the prevalence of musculoskeletal (MSK) conditions. Approximately 20% of visits to family physicians occur as a result of MSK complaints. The GALS (Gait, Arms, Legs, and Spine) screening examination was developed to assist in the detection of MSK abnormalities. Although MSK exams are primarily performed by rheumatologists or other MSK specialists, expanding their use in primary health care may improve the detection of MSK conditions allowing for earlier treatment. The primary goal of this study was to evaluate the use of the GALS locomotor screen in primary care by comparing the results of assessments of family physicians with those of rheumatologists. The secondary goal was to examine the incidence of MSK disorders and assess the frequency with which new diagnoses not previously documented in patients' charts were identified.

Methods

Patients ≥65 years old recruited from an academic family health centre were examined by a rheumatologist and a family physician who recorded the appearance of each participant's gait and the appearance and movement of the arms, legs and spine by deeming them normal or abnormal. GALS scores were compared between physicians with the proportion of observed (P_obs), positive (P_pos) and negative (P_neg) agreement being the primary outcomes. Kappa statistics were also calculated. Descriptive statistics were used to describe the number of "new" diagnoses by comparing rheumatologists' findings with each patient's family practice chart.

Results

A total of 99 patients consented to participate (92 with previously diagnosed MSK conditions). Results showed reasonable agreement between family physicians and rheumatologists; P_obs = 0.698, P_pos = 0.614 and P_neg = 0.752. The coefficient of agreement (estimated Kappa) was 0.3675 for the composite GALS score. For individual components of the GALS exam, the highest agreement between family physicians and rheumatologists was in the assessment of gait and arm movement.

Conclusion

Previously reported increases in undiagnosed signs and symptoms of musculoskeletal conditions have highlighted the need for a simple yet sensitive screening exam for the identification of musculoskeletal abnormalities. Results of this study suggest that family physicians can efficiently use the GALS examination in the assessment of populations with a high proportion of musculoskeletal issues.

Prenatal diagnosis for congenital adrenal hyperplasia in 532 pregnancies

Congenital adrenal hyperplasia (CAH) refers to a family of monogenic inherited disorders of adrenal steroidogenesis most often caused by enzyme 21-hydroxylase deficiency (21-OHD). In the classic forms of CAH (simple virilizing and salt wasting), androgen excess causes external genital ambiguity in newborn females and progressive postnatal virilization in males and females. Prenatal treatment of CAH with dexamethasone has been successfully used for over a decade. This article serves as an update on 532 pregnancies prenatally diagnosed using amniocentesis or chorionic villus sampling between 1978 and 2001 at New York Presbyterian Hospital-Weill Medical College of Cornell University. Of the 532 pregnancies, 281 were prenatally treated for CAH due to the risk of 21-hydroxylase deficiency. Follow-up telephone interviews with mothers, genetic counselors, endocrinologists, pediatricians, and obstetricians were performed in all cases. Of the pregnancies evaluated, 116 babies were affected with classic 21-OHD. Of these, 61 were female, 49 of whom were treated prenatally with dexamethasone. Dexamethasone administered at or before 9 wk gestation (in proper doses) was effective in reducing virilization. There were no statistical differences in the symptoms during pregnancy between mothers treated with dexamethasone and those not treated with dexamethasone, except for weight gain, edema, and striae, which were greater in the treated group. No significant or enduring side-effects were noted in the fetuses, indicating that dexamethasone treatment is safe. Prenatally treated newborns did not differ in weight from untreated, unaffected newborns. Based on our experience, prenatal diagnosis and proper prenatal treatment of 21-OHD are effective in significantly reducing or eliminating virilization in the newborn female. This spares the affected female the consequences of genital ambiguity, genital surgery, and possible sex misassignment.

Prenatal diagnosis for congenital adrenal hyperplasia in 532 pregnancies

Congenital adrenal hyperplasia (CAH) refers to a family of monogenic inherited disorders of adrenal steroidogenesis most often caused by enzyme 21-hydroxylase deficiency (21-OHD). In the classic forms of CAH (simple virilizing and salt wasting), androgen excess causes external genital ambiguity in newborn females and progressive postnatal virilization in males and females. Prenatal treatment of CAH with dexamethasone has been successfully used for over a decade. This article serves as an update on 532 pregnancies prenatally diagnosed using amniocentesis or chorionic villus sampling between 1978 and 2001 at New York Presbyterian Hospital-Weill Medical College of Cornell University. Of the 532 pregnancies, 281 were prenatally treated for CAH due to the risk of 21-hydroxylase deficiency. Follow-up telephone interviews with mothers, genetic counselors, endocrinologists, pediatricians, and obstetricians were performed in all cases. Of the pregnancies evaluated, 116 babies were affected with classic 21-OHD. Of these, 61 were female, 49 of whom were treated prenatally with dexamethasone. Dexamethasone administered at or before 9 wk gestation (in proper doses) was effective in reducing virilization. There were no statistical differences in the symptoms during pregnancy between mothers treated with dexamethasone and those not treated with dexamethasone, except for weight gain, edema, and striae, which were greater in the treated group. No significant or enduring side-effects were noted in the fetuses, indicating that dexamethasone treatment is safe. Prenatally treated newborns did not differ in weight from untreated, unaffected newborns. Based on our experience, prenatal diagnosis and proper prenatal treatment of 21-OHD are effective in significantly reducing or eliminating virilization in the newborn female. This spares the affected female the consequences of genital ambiguity, genital surgery, and possible sex misassignment.

Facilitating physician referrals on the World Wide Web: representation and appropriate utilization of clinical expertise

In highly integrated and increasingly complex health care systems, the identification and proper utilization of clinical staff expertise are key factors for efficiently delivering high quality patient care. To achieve these capabilities on an enterprise-wide scale, we have embarked on a multi-phased project to develop World Wide Web (WWW)-based physician referral capabilities for two large teaching hospitals. Currently, users may search for information concerning the education, training, board certifications, and self-designated clinical interests of staff members. Address, phone number, email address, and a photo are also presented. Our experience indicates that institutional changes are required to successfully deploy and maintain online physician referral services and that accurate and equitable representation of clinical expertise and the incorporation of referral guidelines require an incremental introduction of a carefully planned program that addresses the needs of clinicians, administrators, and health care policy-makers.

Genetic analysis of 11 beta-hydroxysteroid dehydrogenase

11 beta-Hydroxysteroid dehydrogenase (11 beta-OHSD) catalyzes the interconversion of cortisol and cortisone. This activity is postulated to protect the Type I (mineralocorticoid) receptor from excessive concentrations of cortisol, allowing aldosterone to function as a mineralocorticoid. An enzyme with 11 beta-OHSD activity was isolated from rat liver and the corresponding rat and human cDNA and genomic clones isolated. This enzyme is a member of the short-chain dehydrogenase family. Using site-directed mutagenesis, it was demonstrated that the amino terminus and two highly conserved residues, Tyr-179 and Lys-183, are required for enzymatic function. Examination of patients with apparent mineralocorticoid excess, a syndrome of juvenile hypertension thought to represent 11 beta-OHSD deficiency, did not reveal any mutations in the HSD11 gene. This disorder may involve an additional enzyme with 11 beta-OHSD activity or possibly another cortisol metabolizing enzyme.

The representation of time in clinical patient simulations

Simulated clinical scenarios are generally compressed in time to enhance educational effectiveness and to minimize testing time. Designers should consider how to best control potential sources of distortion in the perception of time and how to best communicate the passage of time to the user.