Growth assessment in infants and toddlers using three different reference charts

OBJECTIVE: To determine if the proportion of children < or =24 months old in a tertiary care facility defined as at risk of undernutrition or overnutrition differs according to different references used for assessment: the Centers for Disease Control and Prevention (CDC), National Center for Health Statistics (NCHS) or Tanner-Whitehouse (Tanner) growth charts for weight-for-age and length-for-age. METHODS: Lengths and weights were measured on infants (207 female, 341 male) aged < or =24 months admitted from or attending clinics in the General Pediatric or Respiratory Medicine Programs at The Hospital for Sick Children, Toronto. Weight-for-age and length-for-age percentiles and percent ideal body weight were electronically computed. RESULTS: The proportion of all children whose weight-for-age was <3rd percentile (at risk of undernutrition) was greatest using the CDC growth charts (22.5%) compared with the NCHS (15.9%) or Tanner (19.2%) growth charts. Likewise, the proportion of all infants/toddlers with percent ideal body weight <90 (at risk of undernutrition) was greatest using the CDC (32.3%) compared with the NCHS (22.1%) or Tanner (25.9%) growth charts. In contrast, the percentage of children whose percent ideal body weight was > or =110% (at risk of overnutrition) was least using the CDC (18.1%) compared with the NCHS (26.1%) or Tanner (22.4%) growth charts. CONCLUSION: More children aged < or =24 months will be defined as at risk of undernutrition and fewer at risk of overnutrition when using weight-for-age or percent ideal body weight and the CDC growth charts compared with the NCHS or Tanner growth charts. As a result, requests for a more detailed nutritional assessment for undernutrition will likely follow implementation of the CDC growth charts in a tertiary care setting. As the CDC, NCHS and Tanner growth charts are growth "references" rather than "standards," other than for screening purposes, they should not be used in isolation when assessing growth and nutritional status.     

Immunization Needs of Chronic Liver Disease Patients Seen in Primary Care Versus Specialist Settings

Chronic liver disease patients may benefit from certain vaccines, but their immunization coverage levels have not been widely studied. We examined the serologic and vaccination status of 693 chronic liver disease patients from 37 primary care and specialist centers. Patients in primary care had more often received influenza (47 versus 32%; P < .001) and pneumococcal (39 versus 19%; P < .001) vaccines. Among patients without documented prior exposure, those seeing specialists had more often completed hepatitis A (28 versus 5%; P < .001) and hepatitis B (29 versus 14%; P < .001) vaccination. Coverage was higher in centers with a policy of vaccinating on-site, among non-Hispanic whites, and among patients with hepatitis C and cirrhosis. In summary, most patients were unprotected against one or more vaccine preventable diseases. The higher coverage rates evident in centers vaccinating on-site suggests a breakdown may occur when patients are referred to alternative vaccination venues.     

Influence of chemical and mechanical polishing on water sorption and solubility of denture base acrylic resins

Influence of polishing methods on water sorption and solubility of denture base acrylic resins was studied. Eighty samples were divided into groups: Classico (CL), and QC 20 (QC) - hot water bath cured; Acron MC (AC), and Onda Cryl (ON) - microwave cured; and submitted to mechanical polishing (MP) - pumice slurry, chalk powder, soft brush and felt cone in a bench vise; or chemical polishing (CP) - heated monomer fluid in a chemical polisher. The first desiccation process was followed by storage in distilled water at 37 +/- 1 masculineC for 1 h, 1 day, 1, 2, 3 and 4 weeks. Concluding each period, water sorption was measured. After the fourth week, a second desiccation process was done to calculate solubility. Data were submitted to analysis of variance, followed by Tukey test (p<0.05). Means of water sorption (%) and solubility (%), respectively, were: CL-MP: 1.92 and 0.02; CL-CP: 1.98 and 0.52; QC-MP: 2.31 and -0.05; QC-CP: 2.32 and 0.25; AC-MP: 2.45 and -0.07; AC-CP: 2.43 and 0.41; ON-MP: 2.32 and -0.06; ON-CP: 2.34 and 0.27. Mechanical polishing promoted significantly lower solubility of acrylic resins; initially, water sorption values were higher for chemically polished samples, however, after 4 weeks all groups were similar.     

Kidney-bone, bone-kidney, and cell-cell communications in renal osteodystrophy

The relationship between bone and the kidney in renal osteodystrophy is a complex interplay of kidney to bone connections, bone to kidney connections, and cell to cell connections. In addition, such interactions have a profound effect on the vasculature. In this review, we discuss the role of the bone morphogenetic proteins (BMPs) in the skeleton, kidney, and vasculature. In addition, we propose that deficiencies of these BMPs seen in chronic kidney disease (CKD) result in decreased bone remodeling and a compensatory secondary hyperparathyroidism (high turnover state). Treatment of the hyperparathyroidism blocks this compensatory arm and thus decreased bone remodeling occurs (low turnover). We review animal models of CKD in which treatment with BMP-7 resulted in normalization of both high and low turnover states. Finally, we discuss vascular calcification as it relates to bone metabolism. We discuss the roles of BMP-7 and 2 other bone regulatory proteins, osteoprotegerin (OPG) and alpha2-HS glycoprotein (AHSG, human fetuin), in the human vasculature and their implications for vascular calcification.     

Exercise, depression, and mortality after myocardial infarction in the ENRICHD trial

PURPOSE: The large and well-characterized population of acute myocardial infarction (AMI) patients studied in the recently completed Enhancing Recovery in Coronary Heart Disease (ENRICHD) multicenter clinical trial provides a unique opportunity to examine the importance of self-reported regular physical exercise in a large cohort of patients with a recent AMI who are depressed or report low levels of social support. METHODS: We prospectively examined the association between self-reported physical exercise and all-cause mortality and cardiovascular morbidity among 2078 men (N = 1175; 56.5%) and women (N = 903; 43.5%) with an AMI participating in the ENRICHD Trial. Six months after suffering an AMI, patients were surveyed about their exercise habits and were then followed for up to 4 yr. RESULTS: During an average 2 yr of follow-up, 187 fatal events occurred. Patients reporting regular exercise had less than half the events (5.7%) of those patients reporting they did not regularly exercise (12.0%). After adjustment for medical and demographic variables, the hazard ratio for fatal events was 0.62 (95% CI = 0.44-0.86, P = 0.004). The rate of nonfatal AMI among the exercisers was 6.5% compared with 10.5% who reported no regular exercise. After adjustment for covariates, the hazard ratio for nonfatal AMI was 0.72 (95% CI = 0.52-0.99, P = 0.044). CONCLUSIONS: The present findings demonstrate the potential value of exercise in reducing mortality and nonfatal reinfarction in AMI patients at increased risk for adverse events by virtue of their either being depressed or having low social support.     

Primary prevention of cirrhosis. Public health strategies that can make a difference

Cirrhosis is associated with high morbidity and mortality and often affects persons during the most productive years of life. In the United States, alcoholic liver disease is the leading contributor to the overall prevalence of cirrhosis, followed by infection with hepatitis B virus (HBV) and hepatitis C virus (HCV). In this article, Drs Karsan, Rojter, and Saab examine lifestyle behaviors that can lead to cirrhosis and enumerate public health strategies aimed at primary prevention.     

Thalamic modulation of visceral nociceptive processing in adult rats with neonatal colon irritation

Visceral pain originates from visceral organs in response to a noxious stimulus which, if prolonged, may lead to chronic changes in the neural network mediating visceral nociception. For instance, colon inflammation enhances the responses of neurons in the thalamus to colorectal distension (CRD), whereas lesion in the dorsal column (DC) reverses this neuronal sensitization, suggesting that the thalamus and the DC play major roles in chronic visceral pain. In this study, we used adult rats sensitized with neonatal painful colon irritation to reveal the contribution of the thalamus and the DC to neuronal hyperexcitability in a model of chronic visceral pain. We recorded the responses of lumbosacral neurons to CRD in control rats and in rats with colon irritation following stimulation or inactivation of the thalamus, and after DC lesion. Our results show that, first, neuronal responses to CRD decreased following thalamic stimulation in control rats, whereas, in rats with colon irritation, responses either decreased or increased; second, DC lesion attenuated or enhanced these effects in the positively or in the negatively modulated group of neurons, respectively; third, lidocaine injection in the thalamus reduced the responses to CRD in some of the neurons recorded in rats with colon irritation, but had no effect on those in control rats. Therefore, it is reasonable to speculate that plasticity in rats with colon irritation that may underlie chronic pain is sustained by feedback loops ascending in the DC and engaging the thalamus.     

Sodium channel blockade with phenytoin protects spinal cord axons, enhances axonal conduction, and improves functional motor recovery after contusion SCI

Accumulation of intracellular sodium through voltage-gated sodium channels (VGSCs) is an important event in the cascade leading to anatomic degeneration of spinal cord axons and poor functional outcome following traumatic spinal cord injury (SCI). In this study, we hypothesized that phenytoin, a sodium channel blocker, would result in protection of axons with concomitant improvement of functional recovery after SCI. Adult male Sprague-Dawley rats underwent T9 contusion SCI after being fed normal chow or chow containing phenytoin; serum levels of phenytoin were within therapeutic range at the time of injury. At various timepoints after injury, quantitative assessment of lesion volumes, axonal degeneration, axonal conduction, and functional locomotor recovery were performed. When compared to controls, phenytoin-treated animals demonstrated reductions in the degree of destruction of gray and white matter surrounding the lesion epicenter, sparing of axons within the dorsal corticospinal tract (dCST) and dorsal column (DC) system rostral to the lesion site, and within the dorsolateral funiculus (DLF) caudal to the lesion site, and enhanced axonal conduction across the lesion site. Improved performance in measures of skilled locomotor function was observed in phenytoin-treated animals. Based on these results, we conclude that phenytoin provides neuroprotection and improves functional outcome after experimental SCI, and that it merits further examination as a potential treatment strategy in human SCI.     

Macrovesicular hepatic steatosis in living related liver donors: correlation between CT and histologic findings

PURPOSE: To assess degree of macrovesicular steatosis with unenhanced computed tomography (CT) and correlate it with histologic findings in potential donors for living related liver transplantation. MATERIALS AND METHODS: Forty-two candidates underwent unenhanced CT within 4 weeks of core liver biopsy. An experienced liver pathologist, blinded to both CT and surgical findings, retrospectively reviewed biopsy specimens and determined degree of macrovesicular steatosis. A radiologist blinded to histologic grading calculated mean hepatic attenuation in each donor liver by averaging 25 region-of-interest (ROI) measurements on five sections (five ROIs per section). Mean splenic attenuation was calculated with three separate ROI measurements. Liver attenuation index (LAI) was derived and defined as the difference between mean hepatic and mean splenic attenuation. Body mass index (BMI) was determined for each patient. Linear regression analysis was used to correlate degree of macrovesicular steatosis with both LAI and BMI. RESULTS: LAI correctly predicted degree of macrovesicular steatosis in 38 (90%) of 42 cases. In four of four livers, LAI below -10 HU correlated with greater than 30% macrovesicular steatosis (unacceptable for liver transplantation). In nine of 11 livers, LAI was between -10 and 5 HU and correctly predicted 6%-30% steatosis (relative contraindication). In two of 11 cases, LAI overestimated degree of hepatic steatosis. LAI above 5 HU correctly predicted 0%-5% steatosis in 25 of 27 livers. In two of 27 cases, parenchymal hemosiderin deposition led to an increase in LAI into the normal range, despite mild histologically confirmed steatosis. Degree of histologic macrovesicular steatosis correlated well with LAI (r = 0.92) and marginally with BMI (r = 0.45). Of 27 potential donors with normal livers at CT and acceptable LAI levels, four (15%) were deemed poor donor candidates because core biopsy revealed subtle hepatic necrosis and nonspecific hepatitis. CONCLUSION: Although unenhanced CT quantifies the degree of macrovesicular steatosis relatively well, it may preclude a liver biopsy only in a small percentage of potential donors with low LAI (unacceptable degree of steatosis). Core liver biopsy is still necessary in the majority of donors with normal LAI to identify those with both fatty liver and coexistent hemosiderin deposition or radiologically occult diffuse liver diseases.