L-dex ratio in detecting breast cancer-related lymphedema: reliability, sensitivity, and specificity.

Advances in bioelectrical impedance analysis (BIA) permit the assessment of lymphedema by directly measuring lymph fluid changes. The objective of the study was to examine the reliability, sensitivity, and specificity of cross-sectional assessment of BIA in detecting lymphedema in a large metropolitan clinical setting. BIA was used to measure lymph fluid changes. Limb volume by sequential circumferential tape measurement was used to validate the presence of lymphedema. Data were collected from 250 women, including healthy female adults, breast cancer survivors with lymphedema, and those at risk for lymphedema. Reliability, sensitivity, specificity and area under the ROC curve were estimated. BIA ratio, as indicated by L-Dex ratio, was highly reliable among healthy women (ICC=0.99; 95% CI = 0.99 - 0.99), survivors at-risk for lymphedema (ICC=0.99; 95% CI = 0.99 - 0.99), and all women (ICC=0.85; 95% CI = 0.81 - 0.87); reliability was acceptable for survivors with lymphedema (ICC=0.69; 95% CI = 0.54 to 0.80). The L-Dex ratio with a diagnostic cutoff of >+7.1 discriminated between at-risk breast cancer survivors and those with lymphedema with 80% sensitivity and 90% specificity (AUC=0.86). BIA ratio was significantly correlated with limb volume by sequential circumferential tape measurement. Cross-sectional assessment of BIA may have a role in clinical practice by adding confidence in detecting lymphedema. It is important to note that using a cutoff of L-Dex ratio >+7.1 still misses 20% of true lymphedema cases, it is important for clinicians to integrate other assessment methods (such as self-report, clinical observation, or perometry) to ensure the accurate detection of lymphedema.

Protection of the gastrointestinal tract epithelium against damage from low pH beverages.

Extensive consumption of low pH beverages such as citrus juices (pHs 2.3 to 4.3), alcoholic beverages (pHs 2.7 to 4.5), and soft drinks (pHs 2.3 to 4.2) has raised the question of whether exposure of the gastrointestinal (GI) tract to acidic beverages will cause damage to the epithelial lining. To evaluate the potential effects of low pH beverages on the GI tract epithelium, a detailed examination of the literature was undertaken. In some animal models, there is evidence of damage to GI epithelial cells following exposure to low pH beverages; however, in these studies there is no definitive relationship between acidity and the amount or severity of damage. Results from several other studies, conducted in both animals and humans, indicate a lack of adverse effects on epithelial cells. Furthermore, there is no evidence that damage is irreversible. Permanent damage from routine exposure to acidic beverages in humans would not be expected because of repair mechanisms that are available to maintain a healthy epithelium. Additionally, numerous physical, chemical, and biological mechanisms are in place to prevent damage to the epithelial cells. Finally, the safe history of consumption of low pH beverages, including various fruit juices, supports the conclusion that low pH beverage ingestion does not cause damage to the GI epithelium.

Diet, breakfast, and academic performance in children.

OBJECTIVE: To determine whether nutrient intake and academic and psychosocial functioning improve after the start of a universal-free school breakfast program (USBP). METHODS: Information was gathered from 97 inner city students prior to the start of a USBP and again after the program had been in place for 6 months. Students who had total energy intakes of <50% of the recommended daily allowance (RDA) and/or 2 or more micronutrients of <50% of RDA were considered to be at nutritional risk. RESULTS: Prior to the USBP, 33% of all study children were classified as being at nutritional risk. Children who were at nutritional risk had significantly poorer attendance, punctuality, and grades at school, more behavior problems, and were less likely to eat breakfast at school than children who were not at nutritional risk. Six months after the start of the free school breakfast programs, students who decreased their nutritional risk showed significantly greater: improvements in attendance and school breakfast participation, decreases in hunger, and improvements in math grades and behavior than children who did not decrease their nutritional risk. CONCLUSION: Participation in a school breakfast program enhanced daily nutrient intake and improvements in nutrient intake were associated with significant improvements in student academic performance and psychosocial functioning and decreases in hunger.

Immunoneutralization of somatostatin, insulin, and glucagon causes alterations in islet cell secretion in the isolated perfused human pancreas.

INTRODUCTION: In this study, immunoneutralization of endogenous insulin, glucagon, and somatostatin with specific antibodies was used in an isolated perfused human pancreas (IPHP) model. AIMS: To study intrapancreatic cellular interactions and pancreatic hormonal secretion. METHODOLOGY: Randomized, sequential 10-minute test intervals of single-pass perfusion with each antibody were performed at 3.9 mM or 11.5 mM steady-state glucose concentrations. Somatostatin, insulin, and glucagon levels were measured in the effluent during basal and immunoneutralization intervals. RESULTS: At 3.9 mM glucose concentration, somatostatin antibody (SS-Ab) stimulated insulin and glucagon secretion, insulin antibody (IN-Ab) inhibited glucagon secretion, and glucagon antibody (GN-Ab) stimulated insulin secretion. At 11.5 mM glucose concentration, SS-Ab stimulated insulin secretion, IN-Ab stimulated glucagon and inhibited somatostatin secretion, and GN-Ab stimulated insulin secretion. CONCLUSION: The variation in hormonal responses to immunoneutralization during stimulated and nonstimulated glucose conditions suggests that a dynamic association exists between the pancreatic cells.

The circulating hormonal milieu of the endocrine pancreas in healthy individuals, organ donors, and the isolated perfused human pancreas.

Although basal circulating levels of individual islet cell hormones have been measured, few studies compared the molar ratios of the major hormones secreted by the endocrine pancreas. This study examined the basal levels of four major islet hormones: insulin, C-peptide (C-P), glucagon (G), and pancreatic polypeptide (PP) in normal subjects, in organ donors with brain death, and in the isolated perfused human pancreas. Basal blood samples were taken from normal, fasted control subjects (NCs). Pancreata were obtained from 17 organ donors (ODs) with donor portal vein (DPV) and radial arterial (DRA) blood samples taken before organ procurement. Single-pass perfusion was performed on the procured pancreata, and after rewarming and equilibration, basal samples were collected from the splenic vein (SV) for 30 min. Radioimmunoassays of insulin, C-P, G, and PP were performed on all samples, and basal levels of all hormones were expressed as a common unit, femtomoles per milliliter. The data suggest that in the basal state, these four major islet hormones circulate in a relatively constant molar ratio. The ratio of the hormones is altered in brain death and with in vitro perfusion of the pancreas. The isolated perfused human pancreas secretes a relatively constant molar ratio of these hormones; however, this ratio is markedly different from the circulating ratio seen in either the NC group or the OD group. We conclude that a relatively constant hormonal milieu is secreted from the normal endocrine pancreas, and this hormonal milieu is altered after brain death and with isolation and perfusion of the human pancreas.

Liver failure attributable to hepatitis A virus infection in a developing country.

In young children hepatitis A virus (HAV) infections are usually subclinical events. However, HAV is also associated with progressive hepatic failure and even death in some patients. This study was undertaken to characterize the course of hepatitis A-related acute liver failure in children from a developing country where hepatitis A is endemic and produces significant morbidity. Patients <15 years of age with confirmed hepatitis A, seen at the Aga Khan University Hospital between January 1991 and August 1998 were identified using the patient registry. Of the 2735 patients seen with hepatitis A, 232 were admitted to the hospital. Of these 30 patients developed progressive hepatic dysfunction and liver failure. During this period, 45 children were admitted with liver failure attributable to other causes. Of the patients admitted with hepatitis A-related liver failure, 25 (83.3%) were encephalopathic at presentation and 36.7% of the patients died. The prothrombin time was the most significant predictor of survival. There was a significant difference between those who survived and those who died on discriminant analysis with respect to age, grade of hepatic encephalopathy, duration of hospitalization, prothrombin time, and duration of jaundice when taken as a group. There is a striking prevalence of liver dysfunction progressing to hepatic failure among children seen at a hospital in Karachi, Pakistan. This study demonstrates the significant morbidity and mortality that can attend HAV infections in children in a developing country despite tertiary medical facilities. The risk of HAV and its sequelae could probably be effectively reduced in these settings with improved sanitation and universal immunization.

Differential inhibition of insulin and islet amyloid polypeptide secretion by intraislet somatostatin in the isolated perfused human pancreas.

Islet amyloid polypeptide (IAPP) and insulin are co-stored and generally secreted in parallel; however, studies have demonstrated that the IAPP/insulin molar secretory ratio may be altered in response to certain stimuli. Because we previously demonstrated that intraislet somatostatin is an inhibitory regulator of basal insulin secretion in the isolated perfused human pancreas, this study was designed to determine the relative influence on the regulation of IAPP versus insulin secretion. Single-pass perfusion was performed in pancreata obtained from cadaveric organ donors with continuous perfusion of a modified Krebs media with the glucose level maintained at constant 3.9 mM. Intraislet somatostatin was immunoneutralized by the infusion of either a highly sensitive monoclonal somatostatin antibody (SAb) or its FAb fragment (SFAb). Sequential test periods separated by basal periods were performed by infusion of either of the following: glucose, SAb, SFAb, or appropriate controls. IAPP/insulin molar secretory ratio decreased by 33% in response to infusion of either SAb or the SFAb, respectively (p < 0.01), and decreased by 67% in response to glucose infusion (p < 0.01). An alteration of the IAPP/insulin secretory ratio is seen in response to infusion of exogenous glucose or in response to the neutralization of intraislet somatostatin.

Oral rehydration solution for acute diarrhea prevents subsequent unscheduled follow-up visits.

BACKGROUND: Oral rehydration solutions (ORS) for the treatment of acute diarrhea remain an underutilized therapy in the United States, despite multiple clinical trials confirming their efficacy and safety. Economic barriers to their use have been identified. OBJECTIVE: To determine whether providing ORS to patients at the time of their office visit for acute diarrhea can increase ORS utilization and reduce unscheduled follow-up visits. DESIGN: Randomized, controlled clinical trial. SETTING: Seven health centers of a large health maintenance organization. PARTICIPANTS: Children (N = 479) 0 to 60 months of age with acute diarrhea (at least three watery or loose stools in the previous 24 hours for

The relationship of school breakfast to psychosocial and academic functioning: cross-sectional and longitudinal observations in an inner-city school sample.

OBJECTIVE: To determine if a relationship exists between participation in a school breakfast program and measures of psychosocial and academic functioning in school-aged children. METHODS: Information on participation in a school breakfast program, school record data, and in-depth interviews with parents and children were collected in 1 public school in Philadelphia, Pa, and 2 public schools in Baltimore, Md, prior to the implementation of a universally free (UF) breakfast program and again after the program had been in place for 4 months. One hundred thirty-three low-income students had complete data before and after the UF breakfast program on school breakfast participation and school-recorded measures, and 85 of these students had complete psychosocial interview data before and after the UF breakfast program. Teacher ratings of behavior before and after the UF breakfast program were available for 76 of these students. RESULTS: Schoolwide data showed that prior to the UF breakfast program, 240 (15%) of the 1627 students in the 3 schools were eating a school-supplied breakfast each day. Of the 133 students in the interview sample, 24 (18%) of the students ate a school-supplied breakfast often, 26 (20%) ate a school-supplied breakfast sometimes, and 83 (62%) ate a school-supplied breakfast rarely or never. Prior to the UF breakfast program, students who ate a school-supplied breakfast often or sometimes had significantly higher math scores and significantly lower scores on child-, parent-, and teacher-reported symptom questionnaires than children who ate a school-supplied breakfast rarely or never. At the end of the school term 4 months after the implementation of the UF breakfast program, school-supplied breakfast participation had nearly doubled and 429 (27%) of the 1612 children in the 3 schools were participating in the school breakfast program each day. In the interview sample, almost half of the children had increased their participation. Students who increased their participation in the school breakfast program had significantly greater increases in their math grades and significantly greater decreases in the rates of school absence and tardiness than children whose participation remained the same or decreased. Child and teacher ratings of psychosocial problems also decreased to a significantly greater degree for children with increased participation in the school breakfast program. CONCLUSION: Both cross-sectional and longitudinal data from this study provide strong evidence that higher rates of participation in school breakfast programs are associated in the short-term with improved student functioning on a broad range of psychosocial and academic measures.

Feeding problems in cystinosis.

Nephropathic cystinosis, a rare autosomal recessive storage disease characterized by intracellular storage of free cystine due to a defect in lysosomal cystine transport, is the most common cause of Fanconi syndrome in childhood. Although manifestations of extrarenal organ involvement during the course of the disease are diverse, the spectrum of gastrointestinal (GI) problems has not yet been examined. In responses to a questionnaire from 70 (35%) of the 200 registered members of the Cystinosis Foundation, we found that GI symptoms are more common, more diverse, and occur at a younger age in patients with cystinosis than previously recognized. Ninety-three percent of interviewed subjects had GI symptoms at initial presentation, and the overall lifetime prevalence of GI problems in this group was 100%. Thirty percent have received gastric/jejunal tube feedings, and 7% required continuous or intermittent total parenteral nutrition. Fifty percent have been formally tested for GI abnormalities, and among these 77% have documented functional abnormalities (reflux/dysmotility, pseudo-obstruction, swallowing dysfunction). Early recognition and aggressive therapy of GI problems in cystinotic patients may ameliorate or prevent the development of disabling symptoms.

Relationship between hunger and psychosocial functioning in low-income American children.

OBJECTIVE: Using large-scale surveys from nine states, the Community Childhood Hunger Identification Project (CCHIP) estimates that 8% of American children under the age of 12 years experience hunger each year. CCHIP operationalizes child hunger as multiple experiences of parent-reported food insufficiency due to constrained resources. The current study examined the relationship between food insufficiency and school-age, low-income children's psychosocial functioning. The study also assessed the interinformant (parent versus child) reliability and time-to-time reliability of the CCHIP measure. METHOD: Two hundred four school-age children and their parents from four inner-city public schools were interviewed using parent, teacher, and clinician report measures of psychosocial functioning. Ninety-six children and their parents were reinterviewed 4 months later. RESULTS: Hungry and at-risk for hunger children were twice as likely as not-hungry children to be classified as having impaired functioning by parent and child report. Teachers reported higher levels of hyperactivity, absenteeism, and tardiness among hungry/at-risk children than not-hungry children. Parent and child reports of hunger were significantly related to each other, and time-to-time reliability of the CCHIP measure was acceptable. CONCLUSIONS: Results of this study suggest that intermittent experiences of food insufficiency and hunger as measured by CCHIP are associated with poor behavioral and academic functioning in low-income children. The current study also supports the validity and reliability of the CCHIP measure for assessing hunger in children.

Hunger in children in the United States: potential behavioral and emotional correlates.

OBJECTIVE: Results from a recent series of surveys from 9 states and the District of Columbia by the Community Childhood Hunger Identification Project (CCHIP) provide an estimate that 4 million American children experience prolonged periodic food insufficiency and hunger each year, 8% of the children under the age of 12 in this country. The same studies show that an additional 10 million children are at risk for hunger. The current study examined the relationship between hunger as defined by the CCHIP measure (food insufficiency attributable to constrained resources) and variables reflecting the psychosocial functioning of low-income, school-aged children. METHODS: The study group included 328 parents and children from a CCHIP study of families with at least 1 child under the age of 12 years living in the city of Pittsburgh and the surrounding Allegheny County. A two-stage area probability sampling design with standard cluster techniques was used. All parents whose child was between the ages of 6 and 12 years at the time of interview were asked to complete a Pediatric Symptom Checklist, a brief parent-report questionnaire that assesses children's emotional and behavioral symptoms. Hunger status was defined by parent responses to the standard 8 food-insufficiency questions from the CCHIP survey that are used to classify households and children as "hungry," "at-risk for hunger," or "not hungry." RESULTS: In an area probability sample of low-income families, those defined as hungry on the CCHIP measure were significantly more likely to have clinical levels of psychosocial dysfunction on the Pediatric Symptom Checklist than children defined as at-risk for hunger or not hungry. Analysis of individual items and factor scores on the Pediatric Symptom Checklist showed that virtually all behavioral, emotional, and academic problems were more prevalent in hungry children, but that aggression and anxiety had the strongest degree of association with experiences of hunger. CONCLUSION: Children from families that report multiple experiences of food insufficiency and hunger are more likely to show behavioral, emotional, and academic problems on a standardized measure of psychosocial dysfunction than children from the same low-income communities whose families do not report experiences of hunger. Although causality cannot be determined from a cross-sectional design, the strength of these findings suggests the importance of greater awareness on the part of health care providers and public health officials of the role of food insufficiency and hunger in the lives of poor children.