Lack of Association of Household Income and Acute Gastroenteritis Disease Severity in Young Children: A Cohort Study

ObjectiveTo determine if low household income is associated with disease severity following emergency department (ED) discharge in children with acute gastroenteritis (AGE).MethodsWe conducted a secondary analysis employing data collected in 10 US-based tertiary-care, pediatric EDs between 2014 and 2017. Participants were aged 3 to 48 months and presented for care due to AGE. Income status was defined based on 1) home ZIP Code median annual home income and 2) percentage of home ZIP Code households below the poverty threshold. The primary outcome was moderate-to-severe AGE, defined by a post-ED visit Modified Vesikari Scale (MVS) score ≥9. Secondary outcomes included in-person revisits, revisits with intravenous rehydration, hospitalization, and etiologic pathogens.ResultsAbout 943 (97%) participants with a median age of 17 months (interquartile range 10, 28) completed follow-up. Post-ED visit MVS scores were lower for the lowest household income group (adjusted: -0.60; 95% confidence interval [CI]: -1.13, -0.07). Odds of experiencing an MVS score ≥9 did not differ between groups (adjusted odds ratio: 0.91; 95% CI: 0.54, 1.52). No difference in the post-ED visit MVS score or the proportion of participants with scores ≥9 was observed using the national poverty threshold definition. For both income definitions, there were no differences in terms of revisits following discharge, hospitalizations, and intravenous rehydration. Bacterial enteropathogens were more commonly identified in the lowest socioeconomic group using both definitions.ConclusionsLower household income was not associated with increased disease severity or resource use. Economic disparities do not appear to result in differences in the disease course of children with AGE seeking ED care.     

Association Between Workforce Gender Distribution and Lifetime Earning Potential in the Pediatric Subspecialties

ObjectiveExamine the relationship between the gender distribution of the pediatric subspecialty workforce and lifetime earning potential.MethodsWe estimated lifetime earning potential for pediatric academic subspecialists using mean debt and compensation data from national physician surveys for 2019 to 2020 and examined the relationship between the workforce gender composition and lifetime earning potential across the pediatric subspecialties using linear regression analysis.ResultsSubspecialties with a higher proportion of women had lower lifetime earning potential (-$55,215 in lifetime earning potential/1% increase in the percentage of female subspecialists; P value .002, 95% CI -$24,429 to -$86,000). Similarly, a higher proportion of female first-year fellows was associated with lower lifetime earning potential (-$61,808 in lifetime earning potential/1% increase in the percentage of female first-year fellows; P value .026, 95% CI -$9,210 to -$114,405).ConclusionsConsistent with patterns seen in other areas of adult medicine and surgery, pediatric subspecialties with higher proportions of women, such as adolescent medicine and endocrinology, tended to have lower lifetime earning potentials than subspecialties with higher proportions of men, such as cardiology and critical care. Lower earning subspecialties also tended to train higher proportions of women, suggesting that this trend may worsen over time as pediatrics in general and individual subspecialties in particular become increasingly female predominant.     

Medication-related osteonecrosis of the jaw: A literature review

BackgroundAntiresorptive agents such as bisphosphonates and denosumab, as well as angiogenesis inhibitors, may induce medication-related osteonecrosis of the jaw (MRONJ). However, the exact mechanisms of MRONJ are unclear and definitive treatment strategies have not yet been developed. Moreover, the aging population requiring antiresorptive agents and angiogenesis inhibitors has been increasing worldwide. Therefore, the aim of this literature review was to introduce the latest information on MRONJ. The epidemiology, triggering factors, risk factors, drug holiday, pathoetiology and treatment strategies for each drug-induced ONJ were investigated by conducting a PubMed search.HighlightThe prevalence and incidence of ONJ were very low. Some mechanisms of ONJ have been identified, although they were not definitive. Novel treatment strategies have been proposed in basic and clinical research. Several factors, including age and the administration duration of bisphosphonates, are risks for the development of bisphosphonate-related ONJ (BRONJ). Dental implant therapy and peri-implantitis could become risk factors of BRONJ, regardless of the onset timing of bisphosphonates. No reliable information about ONJ induced by denosumab and angiogenesis inhibitors was found.ConclusionCaution should be taken when dental treatment including implant therapy is performed in patients receiving bisphosphonates, denosumab, and angiogenesis inhibitors. There is limited scientific evidence regarding the relationship between MRONJ and older age. Further ONJ-related research on the aging population is required to manage the treatment of such diseases in older people in the future.     

Once-daily prandial lixisenatide versus once-daily rapid-acting insulin in patients with type 2 diabetes mellitus insufficiently controlled with basal insulin: analysis of data from five randomized,controlled trials

AimsTo compare the efficacy and safety of lixisenatide (LIXI), a once-daily prandial glucagon-like peptide-1 (GLP-1) receptor agonist, as add-on to basal insulin (Basal + LIXI) versus once-daily rapid-acting insulin (Basal + RAI) in patients with type 2 diabetes mellitus (T2DM).MethodsData were extracted from five randomized controlled trials assessing the efficacy and safety of basal insulin + insulin glulisine (n = 3) or basal insulin + LIXI (n = 2). Patients in the Basal + LIXI cohort were matched to patients in the Basal + RAI cohort using propensity score matching.ResultsIn the matched population, Basal + LIXI was twice as likely to reach composite outcomes of glycated haemoglobin (HbA_1c) < 7% and no symptomatic hypoglycaemia compared with the Basal + RAI group (odds ratio [OR]: 1.90; 95% confidence interval [CI]: 1.01, 3.55; P = 0.0455), as well as HbA_1c < 7% and no severe hypoglycaemia (OR: 1.97; 95 CI: 1.06, 3.66; P = 0.0311). Furthermore, Basal + LIXI was more than twice as likely to reach HbA_1c < 7%, no weight gain and no symptomatic hypoglycaemia (OR: 2.58; 95% CI: 1.23, 5.40; P = 0.0119).ConclusionsBoth basal + LIXI and Basal + RAI improved glycaemic control in patients with T2DM with inadequate glycaemic control on basal insulin. Basal + LIXI offers an effective therapeutic option to advance basal insulin therapy, improving glucose control without weight gain and with less risk of hypoglycaemia than prandial insulin.     

The influence of sex on cardiovascular outcomes associated with diabetes among older black and white adults

AimsIt is unknown whether sex differences in the association of diabetes with cardiovascular outcomes vary by race. We examined sex differences in the associations of diabetes with incident congestive heart failure (CHF) and coronary heart disease (CHD) between older black and white adults.MethodsWe analyzed data from the Cardiovascular Health Study (CHS), a prospective cohort study of community-dwelling individuals aged ≥ 65 from four US counties. We included 4817 participants (476 black women, 279 black men, 2447 white women and 1625 white men). We estimated event rates and multivariate-adjusted hazard ratios for incident CHF, CHD, and all-cause mortality by Cox regression and competing risk analyses.ResultsOver a median follow-up of 12.5 years, diabetes was more strongly associated with CHF among black women (HR, 2.42 [95% CI, 1.70–3.40]) than black men (1.39 [0.83–2.34]); this finding did not reach statistical significance (P for interaction = 0.08). Female sex conferred a higher risk for a composite outcome of CHF and CHD among black participants (2.44 [1.82–3.26]) vs. (1.44 [0.97–2.12]), P for interaction = 0.03). There were no significant sex differences in the HRs associated with diabetes for CHF among whites, or for CHD or all-cause mortality among blacks or whites. The three-way interaction between sex, race, and diabetes on risk of cardiovascular outcomes was not significant (P = 0.07).ConclusionsOverall, sex did not modify the cardiovascular risk associated with diabetes among older black or white adults. However, our results suggest that a possible sex interaction among older blacks merits further study.     

Common polymorphism in the cannabinoid type 1 receptor gene (CNR1) is associated with microvascular complications in type 2 diabetes

Endocannabinoids exert their biological effects via interaction with G-protein coupled cannabinoid receptors CB1 and CB2. Polymorphisms in the CNR1 gene (encoding CB1 receptor) were previously found to be associated with dyslipidemia and cardiovascular diseases. We investigated a role of the polymorphism in CNR1 gene in type 2 diabetes and its complications. The study involved 667 T2DM patients and 450 healthy individuals. All subjects were genotyped for G1359A polymorphism by PCR-RFLP procedure. Genotype frequencies did not differ significantly between patients and controls. The statistically significant differences were seen between T2DM patients with diabetic nephropathy (DN) and those without it (OR for risk allele 2.84, 95% CI 2.04–3.94, p < 0.0001). There were also differences between patients with diabetic retinopathy (DR) and those without DR (OR for risk allele 1.81, 95% CI 1.30–2.53, p = 0.0005). No differences were observed in diabetic neuropathy. The A allele was more frequent in patients with coexisting cardiovascular disease (CVD) compared to patients without CVD (p = 0.0044). The novel finding of our study is the association of the G1359A polymorphism with diabetic nephropathy and diabetic retinopathy in patients with T2DM. This polymorphism was also associated with cardiovascular disease in the patient group.     

Changes in bone mineral density following laparoscopic sleeve gastrectomy: 2-year outcomes

BackgroundEmerging evidence suggests that sleeve gastrectomy (SG) leads to significant bone mineral density (BMD) losses, but there is a paucity of studies evaluating skeletal consequences beyond 12-months post-operatively.ObjectivesTo evaluate BMD changes 2 years postoperatively.SettingA university hospital.MethodsThirty-three women (mean age: 34.4 ± 12.3 years) who underwent SG and completed 24 months of follow-up were evaluated prospectively at baseline and at 3 (M3), 6 (M6), 12 (M12), and 24 (M24) months postoperatively. Data collected included BMD at the total hip, femoral neck, and lumbar spine measured by dual-energy x-ray absorptiometry and anthropometrics, biochemical, nutritional, and physical activity parameters.ResultsAt M24, patients achieved a mean body mass index and excess weight loss of 32.4 ± 5.1 kg/m² and 64.5 ± 21.4%, respectively; however, weight stabilized at M12. Femoral neck BMD decreased significantly from baseline to M24 (.924 ± .124 versus .870 ± .129 g/cm², P < .001), with no change between M12 and M24 (P = .273). Total hip BMD decreased significantly from baseline to M24 (1.004 ± .105 versus .965 ± .132 g/cm², P < .001) but increased between M12 and M24 (P = .001). No significant changes were noted in lumbar spine BMD. The percentage of changes in the femoral neck and the total hip BMD from baseline to M24 positively correlated with postoperative excess weight loss (r = .352, P = .045, and r = .416, P = .018, respectively).ConclusionDespite notable weight loss, women who underwent SG experienced significant bone loss at the total hip and femoral neck more than 2 years postoperatively. Future studies should investigate intervention strategies to attenuate skeletal deterioration after SG.     

The National Osteoporosis Foundation’s position statement on peak bone mass development and lifestyle factors: a systematic review and implementation recommendations

Lifestyle choices influence 20–40 % of adult peak bone mass. Therefore, optimization of lifestyle factors known to influence peak bone mass and strength is an important strategy aimed at reducing risk of osteoporosis or low bone mass later in life. The National Osteoporosis Foundation has issued this scientific statement to provide evidence-based guidance and a national implementation strategy for the purpose of helping individuals achieve maximal peak bone mass early in life. In this scientific statement, we (1) report the results of an evidence-based review of the literature since 2000 on factors that influence achieving the full genetic potential for skeletal mass; (2) recommend lifestyle choices that promote maximal bone health throughout the lifespan; (3) outline a research agenda to address current gaps; and (4) identify implementation strategies. We conducted a systematic review of the role of individual nutrients, food patterns, special issues, contraceptives, and physical activity on bone mass and strength development in youth. An evidence grading system was applied to describe the strength of available evidence on these individual modifiable lifestyle factors that may (or may not) influence the development of peak bone mass (Table 1). A summary of the grades for each of these factors is given below. We describe the underpinning biology of these relationships as well as other factors for which a systematic review approach was not possible. Articles published since 2000, all of which followed the report by Heaney et al. [1] published in that year, were considered for this scientific statement. This current review is a systematic update of the previous review conducted by the National Osteoporosis Foundation [1].

Lifestyle Factor	Grade
Macronutrients
?Fat	D
?Protein	C
Micronutrients
?Calcium	A
?Vitamin D	B
?Micronutrients other than calcium and vitamin D	D
Food Patterns
?Dairy	B
?Fiber	C
?Fruits and vegetables	C
?Detriment of cola and caffeinated beverages	C
Infant Nutrition
?Duration of breastfeeding	D
?Breastfeeding versus formula feeding	D
?Enriched formula feeding	D
Adolescent Special Issues
?Detriment of oral contraceptives	D
?Detriment of DMPA injections	B
?Detriment of alcohol	D
?Detriment of smoking	C
Physical Activity and Exercise
?Effect on bone mass and density	A
?Effect on bone structural outcomes	B

Considering the evidence-based literature review, we recommend lifestyle choices that promote maximal bone health from childhood through young to late adolescence and outline a research agenda to address current gaps in knowledge. The best evidence (grade A) is available for positive effects of calcium intake and physical activity, especially during the late childhood and peripubertal years—a critical period for bone accretion. Good evidence is also available for a role of vitamin D and dairy consumption and a detriment of DMPA injections. However, more rigorous trial data on many other lifestyle choices are needed and this need is outlined in our research agenda. Implementation strategies for lifestyle modifications to promote development of peak bone mass and strength within one’s genetic potential require a multisectored (i.e., family, schools, healthcare systems) approach.