Misclassification of stunting, underweight and wasting in children 0-5 years of South Asian and Dutch descent: ethnic-specific v. WHO criteria.

OBJECTIVE: Several authors have questioned the suitability of WHO Child Growth Standards (WHO-CGS) for all ethnic groups. The aim of this study was to identify potential misclassification of stunting, underweight and wasting in children of Surinamese Asian Indian, South Asian (Pakistan/India) and Dutch descent. DESIGN: A series of routine cross-sectional measurements, collected 2012-2015. South Asian-specific normative growth references for weight-for-age and weight-for-length/height were constructed using the LMS method based on historic growth data of Surinamese Asian Indians born between 1974 and 1976. WHO-CGS and ethnic-specific references were applied to calculate z-scores and prevalence of stunting, underweight and wasting. SETTING: Youth HealthCare, providing periodical preventive health check-ups. PARTICIPANTS: 11 935 children aged 0-5 years. RESULTS: Considerable deviations from WHO-CGS were found, with higher-than-expected stunting rates, especially in the first 6 months of life. Surinamese Asian Indian children showed stunting rates up to 16·0 % and high underweight and wasting over the whole age range (up to 7·2 and 6·7 %, respectively). Dutch children consistently had mean WHO-CGS z-scores 0·3-0·5 sd above the WHO baseline (>6 months). The application of ethnic-specific references showed low rates for all studied indicators, although South Asian children were taller and larger than their Surinamese Asian Indian counterparts. CONCLUSIONS: WHO-CGS misclassify a considerable proportion of children from all ethnic groups as stunted in the first 6 months of life. Underweight and wasting are considerably overestimated in Surinamese Asian Indian children. Ethnic-specific growth references are recommended for Surinamese Asian Indian and Dutch children. The considerable differences found between South Asian subpopulations requires further research.

Effect of neighbourhood socioeconomic status on overweight and obesity in children 2-15 years of different ethnic groups.

BACKGROUND: Studies on the influence of neighbourhood socioeconomic status (N-SES) on overweight and obesity rates in children from different ethnic backgrounds are scarce. This study investigated the differential effect of N-SES on overweight (including obesity) and obesity prevalence in different ethnic groups, and if N-SES explains ethnic differences in the prevalence of overweight and obesity. DESIGN: A population based study of 109 766 body mass index (BMI) measurements of 86 209 children 2-15 years of Dutch, Turkish, Moroccan and South Asian descent. BMI class was determined with The International Obesity Task Force, and South Asian specific BMI cut-offs. WHO BMI criteria were applied for reference purposes. The effect of N-SES on prevalence rates was studied with generalized linear mixed models. RESULTS: Neighbourhood SES was negatively associated with overweight and obesity. However, the effect of N-SES on overweight was stronger in Dutch children (OR 0.75, 95% CI 0.73-0.77) than in Turkish (OR 0.86, 95% CI 0.82-0.90), Moroccan (OR 0.91, 95% CI 0.86-0.97) and South Asian (OR 0.90, 95% CI 0.84-0.96) children. The influence of N-SES on obesity showed a similar pattern, except for Moroccan children in whom obesity prevalence remained stable over the whole N-SES range. At the same N-SES, overweight and obesity prevalence was significantly higher in Turkish, Moroccan and especially South Asian children compared with Dutch children. Adjusting for N-SES attenuated the ethnic differences. CONCLUSIONS: Neighbourhood SES was negatively associated with overweight and obesity rates in all ethnic groups, but only partly explained the ethnic differences in overweight and obesity prevalence.

Tracking of thinness and overweight in children of Dutch, Turkish, Moroccan and South Asian descent from 3 through 15 years of age: a historical cohort study.

BACKGROUND: Overweight is shown to track (= to maintain a relative position in a distribution) from childhood to adulthood, but is mostly studied in preobesogenic cohorts and in single ethnic groups. Little is known about tracking of thinness by ethnicity. OBJECTIVES: to determine (differences in) tracking of BMI (class) from 3 through 15 years and the prediction of BMI class at 13-15 years of age in contemporary Dutch, Turkish, Moroccan and South Asian children living in the Netherlands. METHODS: Historical cohort of 7625 children, born 1994-1997, with 24,376 measurements of BMI. BMI z-score and BMI class was analysed using universal criteria. South Asian children were also assessed using ethnic specific BMI criteria. Diagnostic odds ratios (OR) and test properties were calculated to estimate the ability of BMI class at 3-4 years to predict BMI class at 13-15 years. RESULTS: Tracking of thinness between 3 and 15 years was stronger than that of overweight, as indicated by a generally higher diagnostic OR. BMI trajectories between 3 and 15 years of age of thin, normal weight and overweight adolescents were, although significantly different, quite similarly shaped in children of Dutch, Turkish and Moroccan descent. The South Asian BMI trajectory deviated considerably from the other ethnic groups, but the differences disappeared when South Asian specific BMI criteria were applied. A substantial proportion of overweight developed between 5-10 years, after which less children shifted to other BMI classes. A total of 55-78% of children with overweight at 3-4 years retained their overweight at 13-15 years, and 10-20% of 3-4 year olds with thinness remained thin. CONCLUSIONS: In all ethnic groups, overweight and especially thinness highly tracked into adolescence. South Asian children differed from the other ethnic groups when universal BMI criteria were applied, but with South Asian specific BMI criteria tracking patterns became more concordant.

BMI-for-age in South Asian children of 0-20 years in the Netherlands: secular changes and misclassification by WHO growth references.

BACKGROUND: South Asians are prone to cardiometabolic disease at lower BMI levels than most other ethnic groups, starting in childhood. The magnitude of BMI misclassifications is unknown. AIM: To compare the BMI distribution of contemporary South Asian 0-20 year olds in the Netherlands with: (1) The South Asian norm reference (secular trends); and (2) The WHO child growth standard and reference. SUBJECTS AND METHODS: The BMI-for-age distribution of 6677 routine measurements of 3322 South Asian children, aged 0-20 years, was described with the LMS method and BMI z-scores. RESULTS: The BMI distribution in South Asian 0-4 year olds was almost similar to the norm reference (mean BMI z-score = 0.11, skewness = 0.31, SD = 1.0), whereas in 5-19 year olds the distribution had shifted upwards (mean = 0.53) and widened (skewness = -0.12, SD = 1.08). Overweight (incl. obesity) and obesity peaked at 8-10 years, at 45-48% and 35-37%, respectively. Relative to the WHO references, the BMI distribution was left-shifted at ages 0-4 years (mean BMI z-score = -0.46, skewness = 0.23, SD = 0.98) and widened at ages 5-20 years (mean = 0.05; skewness = -0.02, SD = 1.40). At most ages, thinness rates were significantly higher and obesity rates lower than based on South Asian norms. CONCLUSIONS: A secular change of BMI-for-age in South Asian children mostly affected children >4 years. WHO references likely under-estimate overweight and obesity rates in South Asian children.

[Large part of The Hague children taking too little vitamin D]. / Groot deel Haagse jeugd slikt onvoldoende vitamine D.

OBJECTITVE: To investigate the extent to which 0-15-year-old children in The Hague are complying with Dutch Health Council vitamin D supplementation advice, and whether there are differences between ethnic groups. DESIGN: Cross-sectional study. METHOD: From November 2014 up to and including October 2015, The Hague organisations for youth health care (YHC) have recorded intake of vitamin D supplementation during standard consultations. YHC 0-4 recorded whether vitamin D supplementation intake was sufficient. YHC 4-18 recorded whether vitamin D supplementation was recommended for the child (aged 4 and older, in case of coloured skin or insufficient time spent outdoors) and whether this child took sufficient vitamin D supplementation. Information on ethnic origin was taken from the digital YHC records. RESULTS: A large majority of those aged 0-3 received sufficient vitamin D supplementation. Intake was unknown for most 4-year-olds. Vitamin D supplementation was recommended for half of the children aged 5 or older, but a substantial number of them received no (50%) or insufficient (18%) supplementation. Among children for whom extra vitamin D was recommended, there was little difference in vitamin D use between ethnic groups. CONCLUSION: The Dutch Health Council recommendation on vitamin D supplementation is intended to prevent vitamin D deficiencies, but there is insufficient compliance by children in The Hague, especially those aged five and older.

Declining and stabilising trends in prevalence of overweight and obesity in Dutch, Turkish, Moroccan and South Asian children 3-16 years of age between 1999 and 2011 in the Netherlands.

OBJECTIVE: In many developed countries, overweight and obesity prevalence seems to stabilise. The aim of this study was to determine trends between 1999 and 2011 in overweight and obesity prevalence, and mean Body Mass Index (BMI) z-score in Dutch, Turkish, Moroccan and Surinamese South Asian children in the Netherlands. DESIGN: A cross-sectional population-based study with 136 080 measurements of height and weight of 73 290 children aged 3-16 years. BMI class and BMI z-score were determined with the latest International Obesity Taskforce (IOTF) criteria, with overweight defined as an adult BMI equivalent ≥ 25 and obesity ≥ 30. Time trends per year were analysed using logistic and linear regression analyses. RESULTS: The prevalence of overweight in Dutch children declined from 13% to 11% (OR 0.960; 95% CI 0.954 to 0.965), but increased in Turkish children from 25% to 32% (OR 1.028; 95% CI 1.020 to 1.036). In Moroccan and Surinamese South Asian children, overweight rates were stable, but obesity prevalence decreased (OR 0.973; 95% CI 0.957 to 0.989, OR 0.964; 95% CI 0.943 to 0.985, respectively) as well as the mean BMI z-score (B=-0.010; 95% CI -0.014 to -0.006, B=-0.010; 95% CI -0.016 to -0.004). In Turkish children, trends limited to the period 2007-2011 showed no statistically significant relationship for all outcome measures. CONCLUSIONS: The decrease in obesity prevalence in Dutch, Moroccan and Surinamese South Asian children suggests that overweight children became less adipose. The stabilising trend in overweight and obesity prevalence in Turkish children since 2007 may signify a levelling off for this ethnic group.

Trends in overweight and obesity prevalence in Dutch, Turkish, Moroccan and Surinamese South Asian children in the Netherlands.

OBJECTIVE: To determine trends in the prevalence of overweight and obesity in children in The Hague (the Netherlands) from 1999 through 2007. DESIGN: Population-based study of a series of cross-sectional assessments of height and weight from electronic health records. SETTING: Child Health Care (Municipal Health Service), The Hague. PARTICIPANTS: 50,961 children aged 3-16 years, with Dutch (59%), Turkish (17%), Moroccan (13%) or Surinamese South Asian (11%) ethnicity, representative of the four major ethnic groups in The Hague, with 85,234 weight and height measurements recorded in 1999-2007. MAIN OUTCOME MEASURES: (Trends in) the prevalence of overweight (excluding obesity) and obesity as defined by the International Obesity Taskforce cut-off points, using logistic regression with year as independent variable. RESULTS: From 1999 through 2007 there was a decrease in the prevalence of overweight in Dutch girls from 12.6% to 10.9% (OR 0.96; 95% CI 0.95 to 0.98) and an increase in Turkish boys from 14.6% to 21.4% (OR 1.08; 95% CI 1.04 to 1.11). Obesity prevalence rose significantly in Turkish boys from 7.9% to 13.1% (OR 1.04; 95% CI 1.01 to 1.06) and in Turkish girls from 8.0% to 10.7% (OR 1.04; 95% CI 1.01 to 1.08). Dutch boys, and Moroccan and Surinamese South Asian boys and girls showed no significant trends. CONCLUSIONS: The declining prevalence of overweight in Dutch girls may indicate reversal of previous trends in the Netherlands. However, in Turkish children overweight prevalence and obesity is high and increasing. Further public health action is necessary, especially for Turkish children.

[What is the management for foot ulcers in diabetic patients?]. / Que faire devant un ulcère du pied chez un patient diabétique?

The "diabetic foot" covers the spectrum of neurological, arterial and infectious foot problems that occur as a consequence of diabetes. The wounds, often due to minor injuries, may lead to amputations if not quickly treated. The treatment consists of efficiently alleviating mechanical pressure from the wound (i.e. prevention of repeated trauma by walking on the ulcer) on the one hand, and using adequate local care on the other. In addition, the patient's vascular status needs to be assessed and corrected. If present, infections must be quickly and aggressively treated. The infection may be either superficial or deep and the presence of bone contact at clinical examination is suggestive of osteitis. Optimal care is provided in diabetic foot centers by multidisciplinary teams. These teams include a diabetologist, dermatologist, vascular surgeon, infectiologist, radiologist, podologist, shoemaker and specialized nurses. The main aim is to reduce the number of amputations. The best treatment, however, aims at prevention of foot wounds. It requires knowledge of the physiopathological mechanisms of diabetic foot, the screening for feet at risk, and the education of the patient, family and health care providers.

Attitudes of Flemish secondary school students towards euthanasia and other end-of-life decisions in minors.

BACKGROUND: The aim of the study was to investigate attitudes of secondary school students towards acceptability of requests by minors for end-of-life decisions (ELDs) with a possible life-shortening effect: non-treatment decisions, potentially life-shortening alleviation of pain and symptoms (APS) and euthanasia. METHODS: A cross-sectional survey was conducted among second and fourth grades students in 20 secondary schools in Flanders, Belgium. An anonymous structured questionnaire was administered to measure attitudes towards acceptability of requests for euthanasia and other ELDs, towards the right to be informed about terminal prognosis and their own desire to be informed. RESULTS: In total, 1769 students participated. In case of a terminal patient, 61% found a request for euthanasia acceptable, 60% a request for APS and 69% a request for non-treatment decision, compared with 18% (euthanasia) and 50% (APS) in case of a non-terminal patient. Acceptance was highest among: boys, participants older than 14 years and participants from general as opposed to technical and vocational education. Sixty-six per cent said the parents' opinion not being asked was a circumstance that should hold back a physician from administering a lethal drug. Ninety per cent of participants thought a minor has the right to be informed about terminal prognosis of a disease while 78% would like to be informed themselves. CONCLUSIONS: Attitudes towards ELD requests varied with case and participant characteristics and type of ELD. The studied adolescents have a clear wish to be informed about terminal prognosis. Physicians and caregivers should adequately involve adolescents in decision making and tailor prognosis-related information to their needs and level of competency.

Temperature increase in the fetus due to radio frequency exposure during magnetic resonance scanning.

This letter uses data from the literature to estimate the temperature rise in the fetus due to RF deposition within normal SAR limits for the pregnant woman. The results suggest that caution should be exercised when performing fetal MRI at high SAR levels until further data are available. It makes several recommendations related to fetal MRI and fetal SAR modelling.

[The Dutch Child Health Care guideline 'early detection of congenital heart disease in the age group 0-19 years']. / De standaard 'Vroegtijdige opsporing van aangeboren hartafwijkingen 0-19 jaar' van de jeugdgezondheidszorg.

The Dutch Child Health Care guideline on the early detection of congenital heart disease was developed according to the principles for evidence-based guideline development and contains recommendations for the conduct of the examination during routine check-ups and for referral criteria. Most congenital heart diseases can be detected in the first year of life if physicians and nurses work according to this guideline. Important early times for screening are the home visit to infants at the age of two weeks by the child health nurse and the routine check-up of infants at the age of four weeks by the child health care physician. A routine cardiac screening is carried out in every child by the nurse and the physician at times specified in the basic list of professional responsibilities. A more extensive examination is carried out when indicated. Routine cardiac check-ups are recommended until the age of four, after which they should be done only when indicated on medical grounds. A feasibility study showed that physicians and nurses can apply the guideline effectively, provided that they take part in prior specific training.

Characteristics and profile of boys and girls with emotional and behavioural disorders in Flanders mental health institutes: a quantitative study.

BACKGROUND: In this article, we search for gender differences and outline a detailed gender profile for children and youngsters with emotional and behavioural disorders who are placed in Flemish residential care institutes. METHODS: Data were collected of all placements (517 children) in six residential and semi-residential mental health care centres for children and youngsters with emotional and behavioural disorders in East Flanders, Belgium. File data (gender, age, retention, current treatment, type of referral, education, intelligence, Diagnostic and Statistical Manual IV-diagnoses and medication use) were gathered. The Child Behaviour Check List (CBCL) was implemented and completed for each child. On the basis of the CBCL, a behaviour profile was developed by means of correlation tables (Pearson correlation coefficient) and cross tabulations. Finally, the profile was compared with the file data of the boys and the girls. RESULTS: Significant gender differences were found for type of referral, intelligence and diagnoses. The same profile was developed for both genders separately, based on variables Externalizing and Social Problems. The file data associated with the profile groups differ for boys and girls. CONCLUSIONS: The results of our study show the complexity and diversity of the needs of boys and girls with disruptive behaviour in Flemish residential care institutes. Flemish government has to be aware of the fact that the current referral system selects the children with outspoken externalizing and problematic behaviour towards special health care and special schools. They are relegated because the mainstream system is not equipped well enough to cope with their disruptive, aggressive behaviour. Even if governments are in favour of inclusive education, it seems that in practice a rest group is created, in which girls are selected through the same mechanisms as boys, in this case for the same reasons of negative externalizing behaviour and social problems. For this it seems appropriate that school and (semi)-residential institutes apply a specific and adapted methodology.

A review of the current use of magnetic resonance imaging in pregnancy and safety implications for the fetus.

This paper presents an overview of the application of and risks of exposure to Magnetic Resonance Imaging (MRI) in pregnancy. It reviews the risks to the fetus by considering the hazards in terms of the three main components of an MRI system. These are the static magnetic field, the time-varying magnetic gradient fields and the pulsed radio frequency fields. The hazards discussed are biological effects, miscarriage, heating effects and acoustic noise exposure. This paper also presents a survey of MRI sites within the United Kingdom to ascertain the extent of MRI usage in pregnancy. To validate the situation of MRI in pregnancy a survey was sent to 352 MR units throughout the United Kingdom. The questions were grouped to assess (a) maternal MRI diagnosis (b) fetal MRI and (c) work practices for pregnant MRI staff. The results showed that 91% of sites were imaging pregnant women in need of diagnosis in the second and third trimester. This paper highlights that MRI can add information for fetal central nervous system abnormalities identified by ultrasound screening, however within the UK direct fetal imaging was only performed in 8% of sites. This paper indicates the need for research to be undertaken for specific MRI clinical conditions. It also advises that risk assessment for pregnant staff working in MRI is performed, and that there is a clear need for further research into the effects of MRI in pregnancy as there is a need for clear authoritive advice.

A serine protease is involved in the initiation of DNA damage-induced apoptosis.

Caspases are considered to be the key effector proteases of apoptosis. Initiator caspases cleave and activate downstream executioner caspases, which are responsible for the degradation of numerous cellular substrates. We studied the role of caspases in apoptotic cell death of a human melanoma cell line. Surprisingly, the pancaspase inhibitor zVAD-fmk was unable to block cleavage of poly(ADP-ribose) polymerase (PARP) after treatment with etoposide, while it did prevent DEVDase activity. It is highly unlikely that caspase-2, which is a relatively zVAD-fmk-resistant caspase, is mediating etoposide-induced PARP cleavage, as a preferred inhibitor of this caspase could not prevent cleavage. In contrast, caspase activation and PARP degradation were blocked by pretreatment of the cells with the serine protease inhibitor 4-(2-aminoethyl)benzenesulfonyl fluoride (AEBSF). We therefore conclude that a serine protease regulates an alternative initiation mechanism that leads to caspase activation and PARP cleavage. More importantly, while zVAD-fmk could not rescue melanoma cells from etoposide-induced death, the combination with AEBSF resulted in substantial protection. This indicates that this novel pathway fulfills a critical role in the execution of etoposide-induced programmed cell death.

Investigation of acoustic noise on 15 MRI scanners from 0.2 T to 3 T.

Acoustic noise levels for fast MRI pulse sequences were surveyed on 14 systems with field strengths ranging from 0.2 T to 3 T. A microphone insensitive to the magnetic environment was placed close to the magnet isocenter and connected via an extension cable to a sound level meter outside the scan room. Measured noise levels varied from 82.5 +/- 0.1 dB(A) for a 0.23 T system to 118.4 +/- 1.3 dB(A) for a 3 T system. Further measurements on four of the closed-bore systems surveyed showed that: 1) pulse sequence parameters (particularly FOV and TR) were more influential in determining noise level than field strength, 2) the noise level was found to vary along the z-direction with a maximum near the bore entrance, and 3) in one of two systems tested there was a significant increase in noise with a volunteer present instead of a test object. The results underline the importance of hearing protection for patients and for staff spending extended periods in the scan room.

Absence of direct relationship between intraperitoneal cellular influx and resistance to experimental peritonitis.

Intraperitoneal inflammation is an essential defence mechanism against microbial invasion of the abdominal cavity. We have recently demonstrated that a single contact with heat killed E. Coli or Staphylococcus aureus increased the intraabdominal leukocyte influx in rats later challenged by these microorganisms. The aim of the present study was to investigate some of the mechanisms of this phenomenon and to determine its effect on rats survival in an experimental model of peritonitis. The intraabdominal influx of leukocytes following intraperitoneal injection of E. coli, Pseudomonas aeruginosa or Staphylococcus was stimulated by previous intraperitoneal injection of heat killed microbes. The phenomenon was not specific, pretreatment with E. Coli enhanced the intraperitoneal inflammatory reaction against Pseudomonas and vice versa. On the contrary, pretreating the rats with heat killed microorganisms specifically improved their survival after induction of peritonitis with live bacteria, there was no cross-protection. Heat killed staphylococcus aureus which stimulated a subsequent inflammatory reaction against heat killed E. Coli had no effect on the mortality rates of E. Coli peritonitis. In conclusion, there is no direct relationship between resistance to peritonitis and the amount of leukocytes migrating into the abdominal cavity.

Surgical trauma does not decrease resistance to infection.

OBJECTIVE: To investigate the effect on survival of two operations done at various intervals before the induction of monobacterial or multibacterial peritonitis in rats. DESIGN: Laboratory study. SETTING: Teaching hospital, Belgium. MATERIAL: Inbred male white wistar R/A rats. INTERVENTIONS: Posterolateral laparotomy, hindleg amputation, or control (anaesthetic only) (n=90 animals in each group), followed by induction of Escherichia coli or Staphylococcus aureus peritonitis at 1, 7 or 14 days. Further groups of rats were similarly operated on (50 in each group), but peritonitis was induced by caecal ligation and puncture. MAIN OUTCOME MEASURE: Survival 7 days after induction of peritonitis. RESULTS: Of the rats in which E. coli was used to induce peritonitis 27/28 (96%), 29/29 (100%), and 21/30 (70%) had survived 7 days after induction of peritonitis in the group that underwent posterolateral laparotomy, compared with 18/30 (60%), 20/28 (71%), and 18/28 (64%) in the control group; p 0.001, 0.002, and 0.78, respectively. The figures for hindleg amputation were 21/27 (78%), 23/27 (85%), and 17/30 (57%). The corresponding figures for S. aureus peritonitis were for posterolateral laparotomy 28/30 (93%), 20/30 (67%), and 24/29 (83%) compared with controls 21/30 (70%), 9/30 (30%), and 20/29 (69%); p 0.04, 0.009, and 0.75, respectively. The figures for hindleg amputation were 21/30 (70%), 12/30 (40%), and 23/30 (77%). Similar results were obtained with peritonitis induced by caecal ligation and puncture. CONCLUSIONS: Although surgical trauma may depress various aspects of the immune response in rats, it does not decrease their resistance to intraperitoneal microbial infections. The previous opening of the peritoneal cavity seemed to improve survival in our model.

Information in magnetic resonance images: evaluation of signal, noise and contrast.

The assessment of diagnostic image quality for MRI is considered. The assessment of three key image quality determinants is addressed: signal, noise and contrast. There is a distinction between random noise evaluation, for the calculation of the SNR, and structured noise evaluation for the assessment of image artefacts. Specific methods used are correlation techniques and the Wiener spectrum. Contrast is assessed by comparison of experimental data and theoretical predictions. For each assessment, the theory and method of the evaluation strategy are discussed. The discussion is illustrated with analysis results from commercial MR systems. The choice of analysis method and the subsequent derivation of quality indices are shown to be critical in respect of robustness and accuracy.