Food consumption of young stunted and non-stunted children in rural Zambia

OBJECTIVE: The aim of this study was to assess the quality of diet of rural Zambian pre-school children, and to compare the dietary intake of stunted and non-stunted children. DESIGN: Cross-sectional study, in which dietary intake was assessed with a 24-h recall method. Height and weight were measured according to standard procedures. SETTING: Twelve villages in Samfya District, Zambia. SUBJECTS: Children aged 6-9 months ('infants') and 14-20 months ('toddlers'), attending Mother-and-Child Health Clinics, were eligible for study. Excluded were: 12 wasted, and 18 for other reasons. In total 106 infants and 99 toddlers were included. RESULTS: In infants and toddlers, total daily intake of energy, calcium, iron, and vitamin A was insufficient compared to recommended daily intakes. Only infants had insufficient protein intake. Compared to intake from weaning foods, breast milk was the main source of energy and most nutrients for infants. For toddlers, weaning foods were more important. Stunted infants and toddlers tended to have lower intakes of energy compared to non-stunted age-mates. Daily energy intake per kg bodyweight showed no difference between stunted and non-stunted children. CONCLUSIONS: Overall quality of weaning foods was inadequate. Stunted infants and toddlers showed a tendency of lower energy intakes compared to non-stunted age-mates.     

‘Oh my God,I can't handle this!’: trainees’ emotional responses to complex situations

Context

Dealing with emotions is critical for medical trainees’ professional development. Taking a sociocultural and narrative approach to understanding emotions, we studied complex clinical situations as a specific context in which emotions are evoked and influenced by the social environment. We sought to understand how medical trainees respond to emotions that arise in those situations.

Methods

In an international constructivist grounded theory study, 29 trainees drew two rich pictures of complex clinical situations, one exciting and one frustrating. Rich pictures are visual representations that capture participants’ perceptions about the people, situations and factors that create clinical complexity. These pictures were used to guide semi‐structured, individual interviews. We analysed visual materials and interviews in an integrated way, starting with looking at the drawings, doing a ‘gallery walk’, and using the interviews to inform the aesthetic analysis.

Results

Participants’ drawings depicted a range of personal emotions in response to complexity, and disclosed unsettling feelings and behaviours that might be considered unprofessional. When trainees felt confident, they were actively participating, engaged in creative problem‐solving strategies, and emphasised their personal involvement. When trainees felt the situation was beyond their control, they described how they were running away from the situation, hiding themselves behind others or distancing themselves from patients or families.

Conclusions

A sense of control seems to be a key factor influencing trainees’ emotional and behavioural responses to complexity. This is problematic, as complex situations are by their nature emergent and dynamic, which limits possibilities for control. Following a social performative approach to emotions, we should help students understand that feeling out of control is an inherent property of participating in complex clinical situations, and, by extension, that it is not something they will ‘grow out of’ with expertise.

     

Invasiveness of fibroblast-like synoviocytes is an individual patient characteristic associated with the rate of joint destruction in patients with rheumatoid arthritis

OBJECTIVE: Rheumatoid arthritis (RA) is characterized by inflammation and destruction of synovial joints. Fibroblast-like synoviocytes (FLS) harvested from synovial tissue of patients with RA can invade normal human cartilage in severe combined immunodeficient (SCID) mice and Matrigel basement membrane matrix in vitro. This study was undertaken to investigate the association of these in vitro characteristics with disease characteristics in patients with RA. METHODS: Synovial tissue samples from 72 RA and 49 osteoarthritis (OA) patients were obtained. Samples of different joints were collected from 7 patients with RA. The FLS invasiveness in Matrigel was studied, and the intraindividual and interindividual differences were compared. From the patients with FLS who exhibited the most extreme differences in in vitro ingrowth (most and least invasive FLS), radiographs of the hands and feet were collected and scored according to the Sharp/van der Heijde method to determine the relationship between in vitro invasion data and estimated yearly joint damage progression. RESULTS: FLS from patients with RA were more invasive than FLS from patients with OA (P < 0.001). The mean intraindividual variation in FLS invasion was much less than the mean interindividual variation (mean +/- SD 1,067 +/- 926 and 3,845 +/- 2,367 for intraindividual and interindividual variation, respectively; P = 0.035), which shows that the level of FLS invasion is a patient characteristic. The mean +/- SEM Sharp score on radiographs of the hands or feet divided by the disease duration was 4.4 +/- 1.1 units per year of disease duration in patients with the least invasive FLS (n = 9), which was much lower compared with the 21.8 +/- 3.1 units per year of disease duration in patients with the most invasive FLS (n = 9) (P < 0.001). CONCLUSION: The ex vivo invasive behavior of FLS from RA patients is associated with the rate of joint destruction and is a patient characteristic, given the much smaller intraindividual than interindividual FLS variation.     

Selective dorsal rhizotomy: long-term experience from Cape Town

Introduction Given the large number of cerebral palsy patients who have undergone selective dorsal rhizotomy in the past two decades, it is clearly imperative that the clinical community be provided with objective and compelling evidence of the long-term sequelae of the procedure. Materials and methods In the early 1980s, Peacock in Cape Town shifted the site of the rhizotomy from the conus medullaris to the cauda equina, and in the past 25 years, more than 200 children have been operated on. We have studied the incidence of spinal deformities after multiple-level laminectomy and recorded a 20% incidence of isthmic spondylolysis or grade-I spondylolisthesis. We have also conducted a long-term prospective gait analysis study on a cohort of 14 ambulatory patients who were operated on in 1985. Results Ten years after surgery, our patients had increased ranges of motion that were within normal limits. Step length was significantly improved, although cadence was unchanged postoperatively and was significantly less than normal age-matched control subjects. Discussion We have recently tracked down all 14 patients from the original cohort and are currently completing a 20-year prospective follow-up analysis of their neuromuscular function and gait. Our preliminary data suggest that selective dorsal rhizotomy is not only an effective method for alleviating spasticity but it also leads to long-term functional benefits.     

A participatory and capacity-building approach to healthy eating and physical activity – SCIP-school: a 2-year controlled trial

The prevalence of obesity among preschool-aged children has increased, especially among those in low-income households. Two promising behavioral targets for preventing obesity include limiting children’s portion sizes and their intake of foods high in solid fats and/or added sugars, but these approaches have not been studied in low-income preschoolers in the home setting. The purpose of this study was to understand the contextual factors that might influence how low-income mothers felt about addressing these behavioral targets and mothers’ aspirations in feeding their children. We recruited 32 English-speaking women in Philadelphia, Pennsylvania who were eligible for the Supplemental Nutrition Assistance Program and who were the biologic mothers of children 36 to 66 months of age. Each mother participated in 1 of 7 focus groups and completed a brief socio-demographic questionnaire. Focus group questions centered on eating occasions, foods and drinks consumed in the home, and portion sizes. Each focus group lasted 90 minutes and was digitally recorded and transcribed verbatim. Three authors independently identified key themes and supporting quotations. Themes were condensed and modified through discussion among all authors. Thirty-one mothers identified themselves as black, 15 had a high school education or less, and 22 lived with another adult. Six themes emerged, with three about aspirations mothers held in feeding their children and three about challenges to achieving these aspirations. Mothers’ aspirations were to: 1) prevent hyperactivity and tooth decay by limiting children’s sugar intake, 2) use feeding to teach their children life lessons about limit setting and structure, and 3) be responsive to children during mealtimes to guide decisions about portions. Especially around setting limits with sweets and snacks, mothers faced the challenges of: 1) being nagged by children’s food requests, 2) being undermined by other adults in the family, and 3) having bad memories from childhood that made it hard to deny children’s food requests. Although the primary aspirations of low-income mothers in feeding their preschool-aged children were not focused on children’s weight, these aspirations were compatible with obesity prevention strategies to limit children’s portion sizes and their intake of solid fats and/or added sugars.     

Extreme dietary selectivity following liver transplantation in a 5-year-old girl; management via behavior therapy

In a 5.1-year-old girl who had been treated by surgical correction of biliary atresia and total orthotopic liver transplantation, extreme dietary selectivity was noted; this was treated by behaviour therapy. On entry in the rehabilitation centre, she manifested malnutrition along with a variety of gastro-enterologic complaints. The treatment consisted of a set of behavioural procedures such as stepwise expansion of the diet, verbal prompting, intermittent contingent attention and a list of agreements with a system of rewards; this led to the elimination of the dietary selectivity and to the consumption of a varied diet in a normal tempo.