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Background: Problematic Internet use (PIU) remains a significant social concern in Japan and across the globe. Numerous studies have been conducted to examine the prevalence of PIU, and its association with lifestyle habits and mental health status. To the best of our knowledge, few studies have examined the association between parental attachment and PIU in Japan. Furthermore, preventive measures in Japan have primarily targeted adolescents via education. Therefore, in this study we explored the association between PIU and attachment styles among adolescents to seek a new approach for the development of appropriate, effective measures. Methods: A self‐administered survey was conducted at one private (in 2018) and two public junior high schools (in 2020) in Kagawa Prefecture, western Japan. We used the Internet Addiction Test (IAT), the Experiences in Close Relationships–Relationship Structures (ECR–RS) questionnaire, and the Birleson Depression Self‐Rating Scale for Children (DSRS‐C). Multiple regression analysis was performed to examine the association between IAT scores and attachment styles. Results: Of 1,413 participants (grades 7–9; 700 boys and 713 girls), 39% of the students showed possible PIU and 3% showed PIU. Students with PIU tended to sleep for shorter durations, access the Internet for long hours, and have a poor mental health status (p < 0.01). PIU was significantly associated with insecure attachment (p < 0.0001). Conclusions: The findings of our study imply that improving attachment styles and developing secure attachment between the child and parent might help mitigate and/or prevent PIU. [ABSTRACT FROM AUTHOR]

Background Infant flow biphasic nasal continuous positive airway pressure (Bi-NCPAP) and regular NCPAP (Re-NCPAP) are equally useful with respect to the rate of successful weaning from mechanical ventilation. It remains unclear, however, whether Bi-NCPAP or Re-NCPAP is more effective for reducing apnea of prematurity (AOP). Methods A multicenter randomized controlled study was conducted of 66 infants assigned to receive Bi-NCPAP and 66 assigned to receive Re-NCPAP for respiratory support after extubation. Primary outcome was the number of AOP events during the 48 h observation period after successful extubation, defined as no reintubation and no adverse events associated with the use of NCPAP during the observation period. The secondary outcome was successful extubation. Reintubation was at the discretion of the attending physician. Results Baseline characteristics were similar between the two groups. The number of AOP events during the 48 h observation period was significantly lower in infants with Bi-NCPAP than in those with Re-NCPAP (5.2 ± 6.5 vs 10.3 ± 10.9 per infant, respectively; P = 0.002). The rate of successful extubation tended to be greater in those with Bi-NCPAP than in those with Re-NCPAP (92.4%, 61/66 vs 80.3%, 53/66, respectively; P = 0.074). Adverse events occurred in only one of 132 infants: erosive dermatitis developed on the nose after application of Re-NCPAP. The risk of reintubation did not differ significantly between the two groups (7.6%, 5/66 for Bi-NCPAP vs 18.2%, 12/66 for Re-NCPAP; P = 0.117). Conclusions Bi-NCPAP was superior to Re-NCPAP for reduction of AOP following extubation. [ABSTRACT FROM AUTHOR]

Background Neuraminidase inhibitors have been reported to decrease mortality in patients infected with influenza A ( H1 N1) pdm 2009 ( H1 N1 pdm09), but it is not clear whether they are effective against H1 N1pdm09 in apparently healthy children. Methods The effect of early treatment with neuraminidase inhibitors on 70 otherwise healthy children with possible H1 N1 pdm09 ( pH1 N1pdm09) infection was investigated. The children were simultaneously treated with a neuraminidase inhibitor (oseltamivir or zanamivir) and maoto, a Japanese traditional herbal medicine, which had been reported to be effective against seasonal influenza. Clinical severity was assessed using patient history, namely the worst values for clinical vital signs and laboratory data on admission. After refining these parameters with univariate, decision tree and multiple regression analysis, mean covariance structure equation analysis was used to investigate the association of estimated clinical severity to the selected parameters. Results Total path analysis using a Bayesian method indicated that the estimated clinical severity of pH1 N1pdm09 was positively associated with maximum body temperature, pulse rate, respiration rate, duration necessary for defervescence, admission duration and log urinary β2-microglobulin/creatinine level, and negatively associated with age and the presence and duration of treatment with the neuraminidase inhibitor in the outpatient clinic. Conclusions This study provides the first clinical evidence that early treatment with neuraminidase inhibitors in outpatient clinic decreased the estimated clinical severity of pH1 N1pdm09 in apparently otherwise healthy pediatric inpatients. [ABSTRACT FROM AUTHOR]

Background Several studies have suggested that i.v. atropine has a potential role in treating infantile hypertrophic pyloric stenosis ( IHPS). It remains unclear, however, whether surgery can be replaced by i.v. therapy. Methods Data were extracted on infants with IHPS who were treated with atropine and/or surgery, from a nationwide administrative database through 2006-2008. Patient demographic data, treatment effects and length of hospital stay were analyzed in each treatment group. Results A total of 585 infants met the criteria for IHPS; 188 patients (32%) were initially treated with atropine ( i.v. form, n = 180; oral form, n = 8), while 397 were treated with surgery as a first-line therapy. Of the 180 infants receiving i.v. atropine, 38 were withdrawn from medical management and subsequently underwent surgery. Thus, the overall success rate of i.v. atropine was 78.9% (142/180). Surgery had a success rate of 100%, and postoperative complications were found in 2.8% of patients (12/435). Medical management required longer hospital stay than surgery (mean, 13.5 days vs 8.0 days; P < 0.001). Conclusion Surgery remains the suitable standard management option for IHPS, with its high success rate, minimal complications and shorter hospital stay compared with i.v. atropine therapy. [ABSTRACT FROM AUTHOR]

Background Appropriate nutrition during childhood is important for preventing future development of lifestyle-related diseases. The effect of feeding choice on infant growth in Japan is not known. Methods Data from 204 healthy schoolchildren (age, 6-9 years) were obtained retrospectively from their parents by questionnaires. Breast-fed ( BF) and formula-fed ( FF) groups were defined as those fed only breast milk or formula milk at 4 months of age, respectively. There were 71 children (M/F, 31/40) in BF and 30 (M/F, 19/11) in FF. Anthropometric data at birth, and at 1, 4, 7, 10, 18, and 36 months of age in male and female infants were compared between the groups. Results In male infants, height was significantly lower at 4 months, bodyweight was lower from 4 to 18 months, and body mass index ( BMI) was lower from 10 to 36 months in BF than in FF. The standard deviation scores ( SDS) for height, weight and BMI had a similar pattern. No significant differences were observed for these variables for female infants in BF compared with FF. Multiple regression analysis showed that birthweight, mother's pre-pregnancy weight, and infant feeding choice were significant factors associated with weight- SDS at 18 and 36 months. Feeding choice was the only factor associated with BMI-SDS at 18 months. Conclusions Infant feeding choice had a gender-associated effect on growth during infancy. When evaluating infant growth, not only birthweight and mother's pre-pregnancy weight, but also infant feeding choice and gender should be considered. [ABSTRACT FROM AUTHOR]

Aim Postural tachycardia syndrome ( POTS) is one of the most frequent forms of chronic orthostatic intolerance in children and adolescents. The aim of the present study was to examine the influence of a genetic background on POTS. Methods A total of 96 children and adolescents with orthostatic dysregulation were studied. The polymorphism of the G protein β3 subunit ( GNB3) C825T and G protein α subunit ( GNAS1) T131C of genes encoding components of the autonomic nervous system were determined and compared with circulatory responses to active standing. Results In the GNB3 gene C825T polymorphism, the CT and TT genotype had a significant lower supine heart rate and a larger increase of heart rate by standing than the CC, associated with evaluated power of the high-frequency component of heart rate variability. According to the criteria of the Japanese clinical guidelines, 48 children were diagnosed as POTS and 30 were as normal responder with somatoform disorder (SD). In GNB3 C825T polymorphism, the TT genotype was more frequently found in the POTS group (45.8%) than in the SD group (25.0%; P = 0.036). In the GNAS1 T393C, the genotype frequencies for the T393C polymorphisms of GNA1 did not differ significantly between the groups. Conclusion The gene polymorphisms GNB3 C825T might be a risk factor for POTS through the enhanced vagal withdrawal of the heart in children and adolescents. [ABSTRACT FROM AUTHOR]

Background: The aim of this study was (i) to determine the incidence and risk factors of severe leaky lung syndrome (sLLS), persistent pulmonary edema characterized by massive tracheal secretions and resistance to surfactant therapy, in extremely low gestational age newborns requiring ventilatory support; and (ii) to evaluate the effects of hydrocortisone (HC) therapy for sLLS on tracheal aspirate fluid (TAF) volume and β2-microglobulin levels in TAF. Methods: Infants born at <28 weeks gestation requiring ventilation beyond day of life (DOL) 7 were included. Daily TAF volume changes were assessed using a TAF scoring system. Levels of TAF β2-microglobulin, an indicator of capillary leakage, were measured at DOL0, 7, before, and 4 days after starting HC therapy (started at 4 mg/kg/day; tapered for 1-3 weeks). Results: Of the 54 infants enrolled, 24 (44%) were diagnosed with sLLS. Lower gestational age, lower birthweight, and higher TAF β2-microglobulin levels at DOL7 were independent risk factors for sLLS. Seventeen infants with sLLS received HC therapy starting at DOL17 (median), with subsequent decreases in TAF volume and β2-microglobulin levels. Conclusions: The incidence of sLLS, as defined in this study, was 44% in extremely low gestational age newborns requiring ventilator support beyond a week. HC therapy effectively reduced TAF volume and β2-microglobulin levels, suggesting suppression of increased permeability of pulmonary capillaries in infants with sLLS. [ABSTRACT FROM AUTHOR]

Background: The aim of the present cross-sectional study was to use objective methods to assess the association between maternal smoking and body composition in offspring. Methods: A total of 2508 grade 4 school children were enrolled; all underwent lifestyle disease and passive smoking screening. Children were classified into four groups according to their urinary cotinine level and maternal smoking status during or before pregnancy. Items measured on lifestyle disease screening were compared among the four groups. Results: Only degree of obesity (DO) and body mass index (BMI) were significantly associated with maternal smoking during pregnancy. The prevalence of both DO >20% and DO >30%, and BMI >22% and BMI >25% was highest in children of mothers who smoked during pregnancy. These children had a tendency toward shorter height and increased weight although it was not statistically significant. There were no significant differences between maternal smoking status and lipid profile among groups. Confounders such as food, exercise and sleep were able to be eliminated Conclusion: Maternal smoking during pregnancy may be an independent risk factor of changing body composition in offspring, that is, shorter height and increased weight. [ABSTRACT FROM AUTHOR]

Background: The aim of this study was to determine the time-course effect of a single dose of hydrocortisone (HC) on arterial blood pressure in extremely low gestational age newborns (ELGAN) with refractory hypotension during the first 3 days of life. Methods: We carried out a matched case-control study of a cohort of 116 infants born between 23 and 27 weeks' gestation at a tertiary center. Twelve infants (10%) were treated with HC for refractory hypotension (HC group). HC was administered at a dose of 2 mg/kg when mean arterial pressure (MAP) was below 30 mmHg (25 mmHg for infants <25 weeks of gestational age) despite the use of inotropes and volume expanders. Changes in the MAP after the HC administration were compared with those in the infants who were not treated with HC and matched for gestational age (Control group). Results: The mean MAP before administration of HC was significantly lower in the HC group than that in the control group (24.0 ± 3.2 vs 33.3 ± 4.8 mmHg; P < 0.01). The mean MAP in the HC group increased significantly at 2 h after HC treatment, and then reached levels comparable to those in the Control group at 5 h (31.3 ± 4.0 vs 33.9 ± 4.7 mmHg; P= 0.18), and remained at normal levels until 12 h after HC treatment. Conclusion: A single dose of HC treatment induces a rapid and sustained improvement in blood pressure in ELGAN with refractory hypotension. [ABSTRACT FROM AUTHOR]

Background: This study analyzed the change in liver fibrosis markers after the Fontan operation and investigated their clinical usefulness as an index of congestive liver fibrosis. Methods: The study enrolled 24 patients who underwent the Fontan operation between January 1994 and December 2008. We subdivided the postoperative period into four intervals and then compared the hepatological markers during each. Eighteen patients underwent postoperative cardiac catheterization and the correlation between hepatological markers and the inferior vena cava (IVC) pressure was analyzed. Results: The mean age of the patients was 138.6 months and the mean interval between the Fontan operation and the examination was 97.8 months. Type IV collagen was extremely high in every interval (I, 286 ± 93; II, 265 ± 93; III, 305 ± 143; IV, 206 ± 70), while none of the laboratory variables changed significantly in each interval. A significant positive correlation was observed between type IV collagen and the IVC pressure, but no significant correlation with any other hepatological marker was detected. Conclusions: No specific parameter that reflects the progress in liver fibrosis was identified in this study. The possibility exists that type IV collagen reflects the degree of hepatic congestion. [ABSTRACT FROM AUTHOR]

Background: Vancomycin is frequently used for the treatment of methicillin-resistant Staphylococcus aureus (MRSA) infections; however, determining the optimal dosage for neonates is difficult because of their immature renal function. Methods: Serum creatinine-based dosing was introduced in Kumamoto City Hospital Neonatal Medical Center. Serum trough concentration and therapeutic efficacy of vancomycin were evaluated before and after the introduction of the creatinine-based dosing. Results: When the therapeutic range of serum trough concentration of vancomycin at steady state was set to 5-15 µg/mL, 20 trough concentrations (48.8%) were within the therapeutic range and 21 trough concentrations were outside the therapeutic range before the introduction of the serum creatinine-based dosing. After the introduction of serum creatinine-based dosing, 18 trough concentrations (81.8%) were within the therapeutic range and 4 trough concentrations were not, and there was an increase in the number of patients with trough concentrations in the therapeutic range ( P= 0.01; Fisher's exact test). Conclusions: The serum creatinine-based dosing of vancomycin is useful in maintaining the appropriate serum level of vancomycin in neonates. [ABSTRACT FROM AUTHOR]

Background: Self-administered questionnaires about physical activity are useful for collecting data to develop public health policies. There is currently no validated physical activity questionnaire, however, for Japanese children and adolescents. The purpose of the present study was to evaluate the validity and reliability of self-administered, physical activity questionnaires for Japanese students. Methods: Fifth- and eighth-grade students were asked to complete two questionnaires that estimated the intensity and time of moderate-to-vigorous physical activities in which they participated, and the frequency and duration spent performing sports activities. Students also wore triaxial accelerometers to compare their actual activity levels to their estimates, to investigate the validity and reliability of the questionnaires. Results: The intensity and time spent performing moderate-to-vigorous physical activity that were estimated from the questionnaire were higher than those measured by accelerometry (9-161% of accelerometry). Questionnaire data were highly correlated with accelerometer data for eighth graders (Spearman correlation, 0.642-0.754), but the correlations were lower for fifth graders (≤0.331). Furthermore, there was higher repeatability in the data collected from eighth graders (intraclass correlation, 0.625-0.645) than from fifth graders (0.136-0.194). Conclusions: Questionnaires may be useful in epidemiological studies for ranking physical activity levels of adolescents, such as a confounding factor for other lifestyle surveys, but these surveys are less accurate for younger children. [ABSTRACT FROM AUTHOR]

Background: Type and volume of infant feeding determines infant growth, hematological parameters, and serum lipids. Methods: Study subjects consisted of 103 infants who were born vaginally at term, with birthweight >2200 g. Milk feeding amount, type, and anthropometry were measured at 1 and 6 months. Hematological tests and serum lipid profile were assessed at 1 and 6 months. Thirty-four infants were breast-fed and 36 were formula-fed at 6 months. Results: Breast-fed infants demonstrated similar growth patterns compared with partially breast-fed or formula-fed infants, despite the lower milk intake. Infants with higher breast milk intake at 6 months, however, tended to have lower hemoglobin levels. In contrast, higher formula intake at 6 months was related to lower serum total cholesterol. Conclusions: Japanese breast-fed infants were more likely to be anemic at 6 months, while formula-fed infants were likely to have low serum lipid levels. Iron-fortified infant foods may be useful to prevent anemia in breast-fed infants. Fat quality of infant formulas should be improved to enhance lipid status of formula-fed infants. [ABSTRACT FROM AUTHOR]

Background: Owing to advances in neonatal intensive care, many infants who are hospitalized in neonatal intensive care units (NICU) can survive and grow, and are referred to as NICU survivors. However, social development in NICU survivors has not been fully explored. Methods: To examine the social development of NICU survivors, a questionnaire consisting of the Modified Checklist for Autism in Toddlers (M-CHAT) was used. The M-CHAT was completed by the parents of either NICU survivors ( n= 117) or normally delivered children (control group, n= 112) during their regular medical checkups at a corrected age of 12 months. Results: Ninety percent of NICU survivors and 63% of control children did not pass the M-CHAT screen. As it was originally designed for children aged 18-30 months, failed M-CHAT items could have been due to developmental issues and not due to autistic spectrum disorders. However, there was a significant difference in the total number of items failed between the two groups. In particular, many NICU survivors did not pass on M-CHAT items, such as oversensitivity to noise, unusual finger movements, and attempts to attract attention. Concerning perinatal complications, infants with low birthweight and/or the need for respiratory support tended to have a higher number of failures on all M-CHAT items. Conclusions: NICU survivors may have distinct developmental patterns of social communication, and should be followed up for assessment of social skills and neurological development. [ABSTRACT FROM AUTHOR]

Background: The influence of central nervous system (CNS)-directed chemotherapy on intelligence remains controversial. In this study, we investigated the influence of treatment on intellectual development in acute lymphoblastic leukemia (ALL) and brain tumor patients undergoing CNS-directed treatments. Methods: Among patients treated in the Department of Pediatrics, St Luke's International Hospital between April 2000 and March 2009, the subjects were 38 patients with ALL or brain tumors who underwent regular Wechsler intelligence tests. Results: The subjects consisted of 26 patients with ALL and 12 with brain tumors. Prophylactic cranial irradiation was not performed in patients with ALL, whereas it was done for all those with brain tumor. In patients with ALL, the IQ 1 year later was not changed from the start of treatment. In those with brain tumors, the verbal IQ 1 year later was significantly lower than that at the start of treatment. In patients with ALL, intelligence tests were performed 3 years after the start of treatment and there were no marked changes between the two time-points ( n= 11). In those with a brain tumor, intellectual functions further decreased after the completion of treatment to as late as 5 years after the initiation of treatment ( n= 7). Conclusions: There is no intellectual impairment in any patient with ALL at post-treatment follow-up 3 years after the start of treatment, while intelligence is serially reduced in brain tumor patients. An innovative intervention may be needed for this group of patients. [ABSTRACT FROM AUTHOR]

The aim of this study was to investigate the association between plasma glucose (PG), HbA1c and plasma glucagons levels in children with type 1 diabetes to determine the influence of plasma glucagon on their glycemic control. The study was conducted in 60 Japanese children, aged 13.3 ± 4.6 years, with type 1 diabetes for at least 3 years of diabetes. Most of the subjects had absent pancreatic β-cell function. We compared the glucagon levels among patient groups stratified according to the 2-hour postprandial levels (<50, 50-99, 100-199, 200-299, and ≥300 mg/dL), and the HbA1c levels (<7.0, 7.0-7.9, 8.0-8.9, and ≥9%). The mean 2-hour postprandial PG, HbA1c and plasma glucagon levels were 174 ± 97 mg/dL, 7.7 ± 1.3% and 84.0 ± 32.6 pg/mL, respectively. The glucagon levels were highly correlated with the PG levels (r = 0.553, P < 0.0001) and mildly correlated with the HbA1c levels (r = 0.301, P = 0.0192). Patients with high PG levels had significantly higher levels of glucagon as compared with those with lower PG levels (139.4 ± 47.2, 78.4 ± 17.3, 82.4 ± 21.0, 98.3 ± 29.2 and 93.8 ± 18.3 pg/mL, P = 0.0009). On the other hand, there were no significant differences in plasma glucagon levels among patient groups stratified according to HbA1c levels ( P = 0.1566), however, patients with HbA1c levels ≥ 9% had significantly higher levels of glucagon than those with HbA1c levels < 7% (113.3 ± 53.4 vs 80.8 ± 18.4 pg/mL, P = 0.0291). These results suggest that patients with high PG are likely to have high concentrations of plasma glucagon, which may aggravate glycemic control progressively, leading to elevation of HbA1c levels. [ABSTRACT FROM AUTHOR]

Background: Enteral feeding is known to be effective on the development of gut hormone secretion and pancreatic exocrine function. The aim of the present study was to examine the effects of extremely early enteral feedings on the development in very low-birthweight (VLBW) infants. Methods: Fecal elastase 1 and plasma secretin concentrations were measured at four different periods during the first 28 days of life in VLBW infants, with extremely early enteral feeding starting within 24 h of birth, as well as in control infants. Results: Fecal concentrations of elastase 1 at 7, 14 and 28 days after birth were significantly higher than those at 1 or 2 days in both the early feeding and control groups. Fecal elastase 1 levels in the early feeding group were significantly higher than those in the control group at 7 and 14 days after birth. The plasma concentration of secretin at 14 days after birth was significantly higher than that at 1 or 2 days and 7 days after birth in the early feeding group. No significant differences in plasma secretin levels were detected between the early feeding and control groups at 1 or 2 days, 7 days and 28 days after birth, but a significant difference in secretin level was observed between the two groups at 14 days after birth. Conclusions: Extremely early enteral feedings may play an important role in the development of pancreatic exocrine function and secretin secretion in the early period of life in VLBW infants. [ABSTRACT FROM AUTHOR]

Background: Ghrelin has effects on appetite and growth. Recent reports suggest effects on cardiac function, but no study has evaluated the ghrelin levels of congenital heart disease (CHD) infants with heart failure. The purpose of the present study was therefore to investigate the relationship between ghrelin level and growth and cardiac function in CHD infants. Methods: Twenty-eight infants with CHD were eligible for the study. Blood samples were obtained at the time of insertion of intracardiac catheter and correlation was examined between ghrelin plasma level and anthropometric parameters, including z score of height and weight, body mass index (BMI), and %bodyweight gain rate, severity of heart failure, and the levels of leptin and insulin-like growth factor-1. Results: In the CHD group, active ghrelin (A-Ghr) had a significant negative correlation with z score of bodyweight, and a significant positive correlation with cardiac function. There were no correlations, however, with height and BMI. A-Ghr levels were significantly higher in the high heart failure index score group. Significant correlation between A-Ghr and desacyl-ghrelin in the CHD group was observed. Conclusions: A-Ghr is involved in cardiac function and has little effect on their physique in infants with CHD. [ABSTRACT FROM AUTHOR]

Background: The aim of the present study was to examine the putative familial risk factors and evaluate the pharmacological effects in children and adolescents of attention-deficit–hyperactivity disorder (ADHD) with comorbid disruptive behavior disorders (DBD) and normal IQ. Methods: The retrospective study included 144 Japanese subjects (age, 5–18 years) with ADHD, of whom 35 subjects (24%) met the diagnostic criteria for DBD. Using multiple regression analysis, the familial background risk factors that might increase any comorbid antisocial behaviors were assessed. Furthermore, the 20 methylphenidate (MPH)-resistant DBD subjects were divided into three treatment groups: MPH plus risperidone ( n= 8); MPH plus carbamazepine ( n= 5); and MPH plus lithium carbonate ( n= 4). The effectiveness of the treatment was evaluated both before and after the add-on therapy using the Clinical Global Impressions–Improvement (CGI-I) and CGI-Severity (CGI-S) scale. Results: The putative familial risk factors were child abuse (odds ratio [OR], 19.48; P= 0.013) and maternal psychiatric disorders (OR, 15.59; P= 0.027). The addition of risperidone had the strongest tendency to improve the CGI-S score ( P= 0.063) and the highest rate of responses (50%) among the three treatment groups, albeit with no significant differences. Very few remarkable adverse clinical symptoms were observed. Conclusions: Child abuse and maternal psychiatric disorders are suggested to be significant risk factors in influencing the development of comorbid DBD in offspring. The use of risperidone appears to be well tolerated and is moderately effective in MPH-resistant aggression in ADHD children and adolescents with comorbid DBD. [ABSTRACT FROM AUTHOR]

The purpose of the present study was to verify that there are regional variations in the detection rate of postpartum depressive symptoms in mothers. A population-based survey of all women who gave birth in Fushimi Ward, Kyoto City during the period 1 December 2008-31 October 2010 was carried out. The Edinburgh Postnatal Depression Scale (EPDS) was completed by 2567 mothers of infants to measure postpartum depressive symptoms. The detection rate of postpartum depressive symptoms was compared between five localities. A significant difference was found between the lowest detection rate of postpartum depressive symptoms (8.4%) and the highest (18.1%; P < 0.001). A significant positive correlation was found between the proportion of houses in the locality receiving public assistance and the detection rate of postpartum depressive symptoms. The detection rate of postpartum depressive symptoms shows regional variations, suggesting a relationship with the poverty rate. [ABSTRACT FROM AUTHOR]