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Background. Poststroke guidelines recommend moderate-intensity, continuous aerobic training (MCT) to improve aerobic capacity and mobility after stroke. High-intensity interval training (HIT) has been shown to be more effective than MCT among healthy adults and people with heart disease. However, HIT and MCT have not been compared previously among people with stroke. Objective. The purpose of this study was to assess the feasibility and justification for a definitive randomized controlled trial (RCT) comparing HIT and MCT in people with chronic stroke. Design. A preliminary RCT was conducted. Setting. The study was conducted in a cardiovascular stress laboratory and a rehabilitation research laboratory. Patients. Ambulatory people at least 6 months poststroke participated. Intervention. Both groups trained 25 minutes, 3 times per week, for 4 weeks. The HIT strategy involved 30-second bursts at maximum-tolerated treadmill speed alternated with 30to 60-second rest periods. The MCT strategy involved continuous treadmill walking at 45% to 50% of heart rate reserve. Measurements. Measurements included recruitment and attendance statistics, qualitative HIT acceptability, adverse events, and the following blinded outcome variables: peak oxygen uptake, ventilatory threshold, metabolic cost of gait, fractional utilization, fastest treadmill speed, 10-Meter Walk Test, and Six-Minute Walk Test. Results. During the 8-month recruitment period, 26 participants consented to participate. Eighteen participants were enrolled and randomly assigned to either the HIT group (n= 13) or the MCT group (n=5). Eleven out of the 13 HIT group participants attended all sessions. Participants reported that HIT was acceptable and no serious adverse events occurred. Standardized effect size estimates between groups were moderate to very large for most outcome measures. Only 30% of treadmill speed gains in the HIT group translated into overground gait speed improvement. Limitations. The study was not designed to definitively test safety or efficacy. Conclusions. Although further protocol optimization is needed to improve overground translation of treadmill gains, a definitive RCT comparing HIT and MCT appears to be feasible and warranted., Stroke rehabilitation guidelines recommend moderate-intensity, continuous aerobic training (MCT) to improve mobility, aerobic capacity, and cardiovascular health. (1) However, accumulating evidence suggests that higher-intensity exercise may be significantly more effective [...]

IMPORTANCE: For walking rehabilitation after stroke, training intensity and duration are critical dosing parameters that lack optimization. OBJECTIVE: To assess the optimal training intensity (vigorous vs moderate) and minimum training duration (4, 8, or 12 weeks) needed to maximize immediate improvement in walking capacity in patients with chronic stroke. DESIGN, SETTING, AND PARTICIPANTS: This multicenter randomized clinical trial using an intent-to-treat analysis was conducted from January 2019 to April 2022 at rehabilitation and exercise research laboratories. Survivors of a single stroke who were aged 40 to 80 years and had persistent walking limitations 6 months or more after the stroke were enrolled. INTERVENTIONS: Participants were randomized 1:1 to high-intensity interval training (HIIT) or moderate-intensity aerobic training (MAT), each involving 45 minutes of walking practice 3 times per week for 12 weeks. The HIIT protocol used repeated 30-second bursts of walking at maximum safe speed, alternated with 30- to 60-second rest periods, targeting a mean aerobic intensity above 60% of the heart rate reserve (HRR). The MAT protocol used continuous walking with speed adjusted to maintain an initial target of 40% of the HRR, progressing up to 60% of the HRR as tolerated. MAIN OUTCOMES AND MEASURES: The main outcome was 6-minute walk test distance. Outcomes were assessed by blinded raters after 4, 8, and 12 weeks of training. RESULTS: Of 55 participants (mean [SD] age, 63 [10] years; 36 male [65.5%]), 27 were randomized to HIIT and 28 to MAT. The mean (SD) time since stroke was 2.5 (1.3) years, and mean (SD) 6-minute walk test distance at baseline was 239 (132) m. Participants attended 1675 of 1980 planned treatment visits (84.6%) and 197 of 220 planned testing visits (89.5%). No serious adverse events related to study procedures occurred. Groups had similar 6-minute walk test distance changes after 4 weeks (HIIT, 27 m [95% CI, 6-48 m]; MAT, 12 m [95% CI, −9 to 33 m]; mean difference, 15 m [95% CI, −13 to 42 m]; P = .28), but HIIT elicited greater gains after 8 weeks (58 m [95% CI, 39-76 m] vs 29 m [95% CI, 9-48 m]; mean difference, 29 m [95% CI, 5-54 m]; P = .02) and 12 weeks (71 m [95% CI, 49-94 m] vs 27 m [95% CI, 3-50 m]; mean difference, 44 m [95% CI, 14-74 m]; P = .005) of training; HIIT also showed greater improvements than MAT on some secondary measures of gait speed and fatigue. CONCLUSIONS AND RELEVANCE: These findings show proof of concept that vigorous training intensity is a critical dosing parameter for walking rehabilitation. In patients with chronic stroke, vigorous walking exercise produced significant and meaningful gains in walking capacity with only 4 weeks of training, but at least 12 weeks were needed to maximize immediate gains. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT03760016

Tyrosine kinase inhibitors that target vascular endothelial growth factor receptor [VEGFR-TKI] are a class of targeted therapies approved for treatment of several malignancies and are increasingly used in the pediatric population. Development of hypothyroidism during VEGFR-TKI therapy is well described in adults; however, there are no available data in children. Importantly, hypothyroidism during childhood can negatively impact growth and neurodevelopment. This retrospective study is the first to document frequency and severity of VEGFR-TKI induced hypothyroidism in pediatric and young adult patients. Patients included were ≤25 years of age and treated with at least one VEGFR-TKI between 2010 and 2018 at Cincinnati Children’s Hospital Medical Center. After review of clinical and demographic data, 69 patients were identified. Of these, 19 (27.5%) developed thyroid dysfunction defined as Thyroid-stimulating hormone≥5 mIU/mL during therapy. Twelve of those patients had overt hypothyroidism with documentation of low free thyroxine and/or levothyroxine initiation. Mean exposure time to VEGFR-TKI before thyroid dysfunction was 2.8 (0.5-10.4) months. These results suggest moderate risk of developing thyroid dysfunction during VEGFR-TKI therapy in pediatric and young adult patients. Baseline thyroid hormone screening should be performed and repeated frequently during the first year of therapy in the pediatric population.

Abstract: Smoking is an independent risk factor for stroke. The purpose of this prospective study was to determine whether significant changes in smoking behavior occurred in a cohort of stroke [...]

Abstract Rates of breastfeeding are increasing, but the methods by which human milk is fed to infants is not well described. Using a retrospective survey design, the authors collected information [...]

OBJECTIVE--Diabetes is a well known risk factor for stroke, but the impact of diabetes on stroke incidence rates is not known. This study uses a population-based study to describe the [...]

Background: Vitamin K has been suggested to have a role in bone metabolism, and low vitamin K intake has been related to low bone density and increased risk of osteoporotic fracture. Objective: The objective of this study was to determine whether phylloquinone (vitamin [K.sub.1]) intake and biochemical indicators of vitamin K status are related to bone mineral content (BMC) and markers of bone formation and bone resorption in girls. Design: Vitamin K status [plasma phylloquinone concentration and percentage of undercarboxylated osteocalcin (%ucOC)] was measured at baseline in a study of 245 healthy girls aged 3-16 y. Cross-linked N-telopeptide of type 1 collagen (NTx) breakdown, osteocalcin, and bone-specific alkaline phosphatase were measured to reflect bone resorption and formation. BMC of the total body, lumbar spine, and hip and dietary phylloquinone intake were measured annually for 4 y. Results: Phylloquinone intake (median: 45 [micro]g/d) was not consistently associated with bone turnover markers or BMC. Better vitamin K status (high plasma phylloquinone and low %ucOC) was associated with lower bone resorption and formation. Plasma phylloquinone was inversely associated with NTx and osteocalcin concentrations (P < 0.05), and %ucOC was positively associated with NTx and bone-specific alkaline phosphatase concentrations (p < 0.05). Indicators of vitamin K status were not consistently associated with current BMC or gain in BMC over the 4-y study period. Conclusions: Better vitamin K status was associated with decreased bone turnover in healthy girls consuming a typical US diet. Randomized phylloquinone supplementation trials are needed to further understand the potential benefits of phylloquinone on bone acquisition in growing children. KEY WORDS Vitamin K, phylloquinone, osteocalcin, under-carboxylated osteocalcin, bone density, bone turnover, bone resorption, girls, dietary intake

Background: Calcium supplements increase bone mass in children, but the effect does not persist once supplementation is discontinued. Objective: The objective of this study was to determine whether milk intake during childhood and adolescence, when controlled for current calcium intake, is associated with adult bone mass (ie, bone mineral content), bone mineral density, and the incidence of osteoporotic fracture. Design: We used data from the third National Health and Nutrition Examination Survey of 3251 non-Hispanic, white women age [greater than or equal to] 20 y. Bone density was measured at the hip. History of fracture of the hip, spine, or forearm was classified as a lifetime fracture (occurring after age 13 y) or an osteoporotic fracture (occurring after age 50 y). Subjects reported frequency of milk consumption during childhood (aged 5-12 y) and during adolescence (aged 13-17 y). Regression models controlled for weight, height, age, menopause and use of estrogen, physical activity, smoking, and current calcium intake. Results: Among women aged 20-49 y, bone mineral content was 5.6% lower in those who consumed < 1 serving of milk/wk (low intake) than in those who consumed > 1 serving/d (high intake) during childhood (P < 0.01). Low milk intake during adolescence was associated with a 3% reduction in hip bone mineral content and bone mineral density (P < 0.02). Among women aged [greater than or equal to] 50 y, there was a nonlinear association between milk intake during childhood and adolescence and hip bone mineral content and bone mineral density (P < 0.04). Low milk intake during childhood was associated with a 2-fold greater risk of fracture (P < 0.05). Conclusion: Women with low milk intake during childhood and adolescence have less bone mass in adulthood and greater risk of fracture. KEY WORDS Bone density, milk intake during childhood and adolescence, calcium intake, osteoporosis, peak bone mass, fracture, women

A decrease in blood flow through the uterus of pregnant sheep causes greater than normal resistance in the umbilical blood vessels. This could explain why decreases in uterine blood flow have been linked to fetal growth restriction.

Endothelin-A appears to regulate the flow of blood in the uterus, according to a study in sheep. Endothelin-A is a natural substance in the body that causes blood vessels to contract.

Giving pregnant women at risk of premature delivery corticosteroids and antibiotics does not increase the risk of bacterial infection in the newborn baby. These drugs are used to prevent respiratory distress syndrome and group B streptococcal infections in newborn babies. However, corticosteroids can suppress the immune system and antibiotics can kill protective bacteria.

A vaginal suppository containing misoprostol is more effective than oral misoprostol in inducing labor, according to a study of 330 pregnant women. However, vaginal misoprostol can adversely affect the uterus.

Leptin appears to be involved in regulating the growth of the fetus, especially during intrauterine growth restriction. Leptin is a hormone produced by fat cells that regulates body weight and the amount of fat in the body.

Taking a small sample of uterine tissue at the time of a cesarean delivery does not adversely affect the woman, according to a study of 118 women who had this procedure and 236 who did not. Uterine tissue samples are needed for research purposes to determine exactly how the uterus changes during labor.

The use of insulin lispro by 12 pregnant women with diabetes did not cause the formation or progression of diabetic retinopathy. In fact, 14% of 42 pregnant women who used regular insulin either developed retinopathy or experienced a progression of the disease.

Fetuses with a ventral wall defect can be delivered vaginally unless there is another reason to perform a cesarean. This was the conclusion of a study of 102 fetuses with a prenatal diagnosis of ventral wall defect, which is an abdominal hernia.

Byline: Rashmi Kothari, Edward Jauch, Joseph Broderick, Thomas Brott, Laura Sauerbeck, Jane Khoury, Tiepu Liu Abstract: Study objective: To document prehospital and inhospital time intervals from stroke onset to emergency department evaluation and to identify factors associated with presentation to the ED within 3 hours of symptom onset, the current time window for thrombolytic therapy. Methods: Patients admitted through the ED with a diagnosis of stroke were identified through admitting logs. Time intervals were obtained from EMS runsheets and ED records. Information regarding first medical contact, education, and income was obtained by patient interview. Baseline variables were analyzed to assess association with ED arrival within 3 hours of symptom onset; variables significant on univariate analysis were placed in a multivariable model. Results: There were 151 stroke patients (59% white and 41% black). Time of stroke onset and time to ED arrival were documented for 119 patients (79%). The median time from stroke onset to ED arrival was 5.7 hours; 46 patients (30%) presenting within 3 hours. Of those with times recorded, the median time from stroke onset to EMS arrival was 1.7 hours. Multivariable logistic regression identified use of EMS (odds ratio [OR], 4.0; 95% confidence interval [CI], 1.3 to 12.1) and white race (OR, 3.5; 95% CI, 1.3 to 10) as being independently associated with ED arrival within 3 hours of symptom onset. Median time from ED arrival to physician evaluation was 20 minutes. Median time from ED arrival to computed tomographic evaluation was 72 minutes. When patients were asked the main reason they sought medical attention, 40% (60/141) of those able to be interviewed said that they themselves did not decide to seek medical attention, but rather a friend or family member told them they should go to the hospital. Conclusion: The median time from stroke onset to ED evaluation was 5.7 hours, with almost a third of patients presenting within 3 hours. Use of EMS and white race were independently associated with arrival within 3 hours. [Kothari R, Jauch E, Broderick J, Brott T, Sauerbeck L, Khoury J, Liu T: Acute stroke: Delays to presentation and emergency department evaluation. Ann Emerg Med January 1999;33:3-8.] Author Affiliation: From the Departments of Emergency Medicine,.sup.* Neurology,.sup.a and Environmental Health,.sup.As. University of Cincinnati Medical Center Cincinnati, OH Article History: Received 20 April 1998; Revised 16 July 1998; Accepted 29 July 1998 Article Note: (footnote) [star] Supported by a Young Investigators Award from the American Heart Association, Ohio Affiliate (SW-93944-YI)., [star][star] Address for reprints: Rashmi Kothari, MD, Department of Emergency Medicine, University of Cincinnati, PO Box 670769,Cincinnati, OH 45267-0769;E-mail rashmikant.kothari@uc.edu. , a 0196-0644/99/$8.00 + 0, aa 47/1/94119

Pregnancy may not cause women with insulin-dependent diabetes to have an increased risk or increased progression of kidney disease. Researchers studied 182 pregnant women with insulin-dependent diabetes mellitus (IDDM) whose pregnancies continued for at least 20 weeks and followed them up for at least three years. Neither pregnancy nor having many children were found to be risk factors for kidney disease. Significant risk factors for kidney disease were protein in the urine and poor blood sugar control during pregnancy. Women with kidney disease were more likely to have complications of pregnancy, including newborn complications. No significant predictors of kidney disease progressing to end-stage kidney disease were found.

Purpose: The ‘5-2-1-0’ guidelines recommend that children: eat ≥5 servings of fruits/vegetables (‘5’), have ≤2 hours of screen-time (‘2’), have ≥1 hour of activity (‘1’), and drink 0 sugar-sweetened beverages (‘0’) daily. The pediatric emergency department (PED) treats children at risk for obesity and tobacco smoke exposure (TSE). We examined body mass index (BMI), overweight, obesity, TSE, and ‘5-2-1-0’ rates in children with TSE in the PED.Design: Cross-sectional study of PED children.Setting: The PED of a children’s hospital.Sample: Children with TSE >6 months-5 years old (N = 401).Measures: Sociodemographics, ‘5-2-1-0’ behaviors, BMI, and cotinine-confirmed TSE.Analysis: Associations between ‘5-2-1-0’ and sociodemographics were examined with logistic regression.Results: Mean (SD) age = 2.4 (1.6) years; 53.1% were Black; 65.8% had low-income; and 93.4% had TSE. Of 2-5-year-olds, mean (SD) BMI percentile was 66.2 (30.1), 16.1% were overweight and 20.6% were obese. In total, 10.5% attained ‘5’, 72.6% attained ‘2’, 57.8% of 2-5-year-olds attained ‘1’, and 9.8% attained ‘0’. Compared to White children, “other” race children were more likely to meet ‘5’ (aOR(95% CI):4.67(1.41, 5.45)); 2-5-years-olds (aOR(95%CI):0.60(0.38, 0.95)) and Black children (aOR(95%CI):0.36(0.21, 0.60)) were at decreased odds to meet ‘2’ compared to younger or White children, respectively. Compared to younger children, 2-5-year-olds were at decreased odds to meet ‘0’ (aOR(95%CI):0.08(0.02, 0.26)).Conclusion: Racially diverse, low-income children with TSE had low ‘5-2-1-0’ attainment. Interventions are needed to improve lifestyle habits in this population.

OBJECTIVE: To test the hypothesis that women with insulin-dependent diabetes and chronic or pregnancy-induced hypertensive disorders are at increased risk for developing retinopathic complications during pregnancy. STUDY DESIGN: One hundred fifty-four women with insulin-dependent diabetes were prospectively followed in an intensive program of diabetes in pregnancy. Ophthalmologic evaluations were obtained through pregnancy and at 6 to 12 weeks post partum, and findings were graded by a standard scale. Association of retinopathic progression with risk factors was tested with [X.sup.2] and multiple logistic regression analysis. RESULTS: Fifty-one women had progression of retinopathy during pregnancy; postpartum regression was observed in 13 women. Changes in glycemic control early in pregnancy, chronic hypertension, and pregnancy-induced hypertension were significantly associated with progression of retinopathy. CONCLUSION: Women with insulin-dependent diabetes who have hypertensive disorders in pregnancy are at increased risk for progression of retinopathy. (Am J Obstet Gynecol 1992;166:1214-8.)

En cancérologie, la place des patients a une légitimité naturelle et forte. Le cancer est une maladie fréquente, avec de nombreuses singularités mais aussi des traits communs entre pathologies, aux enjeux allant de la prévention jusqu’aux éventuelles phases palliatives ou à l’après-cancer, et propice à des prises de décision tant individuelles que collectives, à tout stade. L’engagement des patients s’impose aujourd’hui à tous les niveaux du système de soin, de la simple information jusqu’à l’implication réelle (co-construction). Gustave-Roussy, centre de lutte contre le cancer à Villejuif, a mis en place depuis 20 ans une réflexion et des actions spécifiques, incarnées par la création d’un comité de patients et aidants et complétées par un organe de pilotage institutionnel qui illustre la transformation du « travailler pour » en un « travailler avec ». À l’échelle des soins directs, les principaux travaux promus concernent la prise de décision partagée entre patient et professionnel, et la « pair-aidance » (ou pair-accompagnement). À l’échelle institutionnelle, on retrouve l’expertise de projets de l’hôpital ou de services, l’élaboration de documents institutionnels (information et formulaire de directives anticipées, etc.), et l’évaluation interne (audit). À l’échelle politique, la participation au groupe de travail expérience-patient d’Unicancer a permis un déploiement mieux coordonné avec d’autres centres. Avec Unicancer a été élaboré un guide lexical définissant les « patients ressources », « pairs-aidants », formateurs, évaluateurs et coordonnateurs. Cette approche partenariale est profitable pour les patients, leurs proches, les soignants, et doit s’amplifier et donner lieu à de nouveaux travaux de recherche.

Diabetics tend to develop infection easily, and this is related to alterations in immune cell activity, especially in subjects with poorly controlled elevated glucose levels. Pregnancy is also associated with increased risk for infection, as immune system function is altered during that time. Thus, pregnant diabetic women are highly likely to develop infections. The risk of infection associated with diabetes was evaluated in 65 diabetic and 65 nondiabetic pregnant women, and the association of infection rate with poor glycemic control in diabetic patients was studied. Eighty-five percent of diabetic women developed infections during pregnancy, compared with an infection rate of only 26 percent in nondiabetic women. Postpartum rates of infection were also higher in diabetic women. Infection rates at all sites were elevated. No particular bacterial species was implicated, but diabetic women did tend to have more infections caused by a common fungus (or yeast), Candida. The results suggested that glycemic control may have been poorer preceding the development of infections in diabetic women. Further research is needed to determine if improved metabolic control will result in a lower risk of infection in diabetic pregnant women. (Consumer Summary produced by Reliance Medical Information, Inc.)

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IMPORTANCE: Intracerebral hemorrhage (ICH) is a devastating stroke type that lacks effective treatments. An imaging biomarker of ICH expansion—the computed tomography (CT) angiography spot sign—may identify a subgroup that could benefit from hemostatic therapy. OBJECTIVE: To investigate whether recombinant activated coagulation factor VII (rFVIIa) reduces hemorrhage expansion among patients with spot sign–positive ICH. DESIGN, SETTING, AND PARTICIPANTS: In parallel investigator-initiated, multicenter, double-blind, placebo-controlled randomized clinical trials in Canada (“Spot Sign” Selection of Intracerebral Hemorrhage to Guide Hemostatic Therapy [SPOTLIGHT]) and the United States (The Spot Sign for Predicting and Treating ICH Growth Study [STOP-IT]) with harmonized protocols and a preplanned individual patient–level pooled analysis, patients presenting to the emergency department with an acute primary spontaneous ICH and a spot sign on CT angiography were recruited. Data were collected from November 2010 to May 2016. Data were analyzed from November 2016 to May 2017. INTERVENTIONS: Eligible patients were randomly assigned 80 μg/kg of intravenous rFVIIa or placebo as soon as possible within 6.5 hours of stroke onset. MAIN OUTCOMES AND MEASURES: Head CT at 24 hours assessed parenchymal ICH volume expansion from baseline (primary outcome) and total (ie, parenchymal plus intraventricular) hemorrhage volume expansion (secondary outcome). The pooled analysis compared hemorrhage expansion between groups by analyzing 24-hour volumes in a linear regression model adjusted for baseline volumes, time from stroke onset to treatment, and trial. RESULTS: Of the 69 included patients, 35 (51%) were male, and the median (interquartile range [IQR]) age was 70 (59-80) years. Baseline median (IQR) ICH volumes were 16.3 (9.6-39.2) mL in the rFVIIa group and 20.4 (8.6-32.6) mL in the placebo group. Median (IQR) time from CT to treatment was 71 (57-96) minutes, and the median (IQR) time from stroke onset to treatment was 178 (138-197) minutes. The median (IQR) increase in ICH volume from baseline to 24 hours was small in both the rFVIIa group (2.5 [0-10.2] mL) and placebo group (2.6 [0-6.6] mL). After adjustment, there was no difference between groups on measures of ICH or total hemorrhage expansion. At 90 days, 9 of 30 patients in the rFVIIa group and 13 of 34 in the placebo group had died or were severely disabled (P = .60). CONCLUSIONS AND RELEVANCE: Among patients with spot sign–positive ICH treated a median of about 3 hours from stroke onset, rFVIIa did not significantly improve radiographic or clinical outcomes. TRIAL REGISTRATION: ClinicalTrials.gov identifier: NCT01359202 and NCT00810888

To link to full-text access for this article, visit this link: http://dx.doi.org/10.1016/j.ajog.2008.06.066 Byline: Sina Haeri (a), Jane Khoury (b), Oormila Kovilam (c), Menachem Miodovnik (a) Keywords: diabetes; fetal growth restriction; pregnancy; vasculopathy Abstract: The purpose of this study was to test whether vasculopathy in type 1 diabetes mellitus (DM) is associated with fetal growth abnormalities. Author Affiliation: (a) Department of Obstetrics and Gynecology, Washington Hospital Center, Washington, DC (b) Center for Epidemiology and Biostatistics, Cincinnati Children's Hospital Medical Center, University of Cincinnati School of Medicine, Cincinnati, OH (c) Department of Obstetrics and Gynecology, University of Cincinnati School of Medicine, Cincinnati, OH Article History: Received 1 March 2008; Revised 2 May 2008; Accepted 21 June 2008 Article Note: (footnote) Cite this article as: Haeri S, Khoury J, Kovilam O, et al. The association of intrauterine growth abnormalities in women with type 1 diabetes mellitus complicated by vasculopathy. Am J Obstet Gynecol 2008;199:278.e1-278.e5.

IMPORTANCE: Childhood lead exposure is associated with neurobehavioral deficits. The effect of a residential lead hazard intervention on blood lead concentrations and neurobehavioral development remains unknown. OBJECTIVE: To determine whether a comprehensive residential lead-exposure reduction intervention completed during pregnancy could decrease residential dust lead loadings, prevent elevated blood lead concentrations, and improve childhood neurobehavioral outcomes. DESIGN, SETTING, AND PARTICIPANTS: This longitudinal, community-based randomized clinical trial of pregnant women and their children, the Health Outcomes and Measures of the Environment (HOME) Study, was conducted between March 1, 2003, and January 31, 2006. Pregnant women attending 1 of 9 prenatal care clinics affiliated with 3 hospitals in the Cincinnati, Ohio, metropolitan area were recruited. Of the 1263 eligible women, 468 (37.0%) agreed to participate and 355 women (75.8%) were randomized in this intention-to-treat analysis. Participants were randomly assigned to receive 1 of 2 interventions designed to reduce residential lead or injury hazards. Follow-up on children took place at 1, 2, 3, 4, 5, and 8 years of age. Data analysis was performed from September 2, 2017, to May 6, 2018. MAIN OUTCOMES AND MEASURES: Residential dust lead loadings were measured at baseline and when children were 1 and 2 years of age. At 1, 2, 3, 4, 5, and 8 years of age, the children’s blood lead concentrations as well as behavior, cognition, and executive functions were assessed. RESULTS: Of the 355 women randomized, 174 (49.0%) were assigned to the intervention group (mean [SD] age at delivery, 30.1 (5.5) years; 119 [68.3%] self-identified as non-Hispanic white) and 181 (50.9%) to the control group (mean [SD] age at delivery, 29.2 [5.7] years; 123 [67.9%] self-identified as non-Hispanic white). The intervention reduced the dust lead loadings for the floor (24%; 95% CI, –43% to 1%), windowsill (40%; 95% CI, –60% to –11%), and window trough (47%; 95% CI, –68% to –10%) surfaces. The intervention did not statistically significantly reduce childhood blood lead concentrations (–6%; 95% CI, –17% to 6%; P = .29). Neurobehavioral test scores were not statistically different between children in the intervention group than those in the control group except for a reduction in anxiety scores in the intervention group (β = –1.6; 95% CI, –3.2 to –0.1; P = .04). CONCLUSIONS AND RELEVANCE: Residential lead exposures, as well as blood lead concentrations in non-Hispanic black children, were reduced through a comprehensive lead-hazard intervention without elevating the lead body burden. However, this decrease did not result in substantive neurobehavioral improvements in children. TRIAL REGISTRATION: ClinicalTrials.gov identifier: NCT00129324

Context: An estimated 40 million school-aged children (age range 5−18 years) participate annually in sports in the United States, generating approximately 4 million sport-related injuries and requiring 2.6 million emergency department visits at a cost of nearly $2 billion.Objective: To determine the effects of a school-based neuromuscular training (NMT) program on sport-related injury incidence across 3 sports at the high school and middle school levels, focusing particularly on knee and ankle injuries.Design: Randomized controlled clinical trial.Setting: A total of 5 middle schools and 4 high schools in a single-county public school district.Patients or Other Participants: A total of 474 girls (222 middle school, 252 high school; age 14.0 ± 1.7 years, height 161.0 ± 8.1 cm, mass 55.4 ± 12.2 kg) were cluster randomized to an NMT (CORE; n 259 athletes) or sham (SHAM; n 215 athletes) intervention group by team within each sport (basketball, soccer, and volleyball).Intervention(s): The CORE intervention consisted of exercises focused on the trunk and lower extremity, whereas the SHAM protocol consisted of resisted running using elastic bands. Each intervention was implemented at the start of the season and continued until the last competition. An athletic trainer evaluated athletes weekly for sport-related injuries. The coach recorded each athlete-exposure(AE), which was defined as 1 athlete participating in 1 coach-directed session (game or practice).Main Outcome Measure(s): Injury rates were calculated overall, by sport, and by competition level. We also calculated rates of specific knee and ankle injuries. A mixed-model approach was used to account for multiple injuries per athlete.Results: Overall, the CORE group reported 107 injuries (rate 5.34 injuries/1000 AEs), and the SHAM group reported 134 injuries (rate 8.54 injuries/1000 AEs; F1,578 18.65, P< .001). Basketball (rate 4.99 injuries/1000 AEs) and volleyball (rate 5.74 injuries/1000 AEs) athletes in the CORE group demonstrated lower injury incidences than basketball (rate 7.72 injuries/1000 AEs) and volleyball (rate 11.63 injuries/1000 AEs; F1,275 9.46, P .002 and F1,149 11.36, P .001, respectively) athletes in the SHAM group. The CORE intervention appeared to have a greater protective effect on knee injuries at the middle school level (knee-injury incidence rate 4.16 injuries/1000 AEs) than the SHAM intervention (knee-injury incidence rate 7.04 injuries/1000 AEs; F1,261 5.36, P .02). We did not observe differences between groups for ankle injuries (F1,578 1.02, P .31).Conclusions: Participation in an NMT intervention program resulted in a reduced injury incidence relative to participation in a SHAM intervention. This protective benefit of NMT was demonstrated at both the high school and middle school levels.

The recent article by Geraghty et al (J Hum Lact. 2006;21:413-420) documents that mothers of presumably healthy singletons are just as likely to use breast pumps as are mothers of [...]

We aimed to determine the risk factors associated with the depletion of large HDL particles and enrichment of small HDL particles observed in adolescents with T2D. Four groups of adolescents were recruited: 1) lean insulin-sensitive (L-IS), normal BMI and no insulin resistance; 2) lean insulin-resistant (L-IR), normal BMI but insulin resistance (fasting insulin levels ≥ 25 mU/ml and homeostatic model assessment of insulin resistance ≥ 6); 3) obese insulin-sensitive (O-IS), BMI ≥ 95th percentile and no insulin resistance; and 4) obese insulin-resistant (O-IR), BMI ≥ 95th percentile and insulin resistance. Plasma was separated by using gel-filtration chromatography to assess the HDL subspecies profile and compared with that of obese adolescents with T2D (O-T2D). Large HDL subspecies were significantly lower across groups from L-IS > L-IR > O-IS > O-IR > O-T2D (P< 0.0001); small HDL particles were higher from L-IS to O-T2D (P< 0.0001); and medium-sized particles did not differ across groups. The contributions of obesity, insulin resistance, and diabetes to HDL subspecies profile were between 23% and 28%, 1% and 10%, and 4% and 9%, respectively. Obesity is the major risk factor associated with the altered HDL subspecies profile previously reported in adolescents with T2D, with smaller contributions from insulin resistance and diabetes.

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A significant number of severely obese adolescents undergoing bariatric surgery have evidence of early kidney damage. To determine if kidney injury is reversible following bariatric surgery, we investigated renal outcomes in the Teen-Longitudinal Assessment of Bariatric Surgery cohort, a prospective multicenter study of 242 severely obese adolescents undergoing bariatric surgery. Primary outcomes of urine albumin-to-creatinine ratio and cystatin C-based estimated glomerular filtration rate (eGFR) were evaluated preoperatively and up to 3 years following bariatric surgery. At surgery, mean age of participants was 17 years and median body mass index (BMI) was 51 kg/m2. In those with decreased kidney function at baseline (eGFR under 90 mL/min/1.73m2), mean eGFR significantly improved from 76 to 102 mL/min/1.73m2at three-year follow-up. Similarly, participants with albuminuria (albumin-to-creatinine ratio of 30 mg/g and more) at baseline demonstrated significant improvement following surgery: geometric mean of ACR was 74 mg/g at baseline and decreased to 17 mg/g at three years. Those with normal renal function and no albuminuria at baseline remained stable throughout the study period. Among individuals with a BMI of 40 kg/m2and more at follow-up, increased BMI was associated with significantly lower eGFR, while no association was observed in those with a BMI under 40 kg/m2. In adjusted analysis, eGFR increased by 3.9 mL/min/1.73m2for each 10-unit loss of BMI. Early kidney abnormalities improved following bariatric surgery in adolescents with evidence of preoperative kidney disease. Thus, kidney disease should be considered as a selection criteria for bariatric surgery in severely obese adolescents who fail conventional weight management.

ObjectiveResidential injury is a leading cause of morbidity and mortality in US children. Rates and types of injury vary by child age but little is known about injury risk based on child cognitive and motor abilities. The objective of this study was to determine whether cognitive or motor development in young children is associated with residential injury.MethodsWe employed data from Health Outcomes and Measures of the Environment (HOME) Study. Parent report of medically attended injury was obtained at regular intervals from 0 to 42 months. Child development was assessed at 12, 24 and 36 months using Bayley Scales of Infant and Toddler Development, 2nd edition, which generates both mental developmental index (MDI) and a psychomotor developmental index (PDI). Injury risk was modelled using multivariable logistic regression as function of child's MDI or PDI. Effects of MDI and PDI on injury risk were examined separately and jointly, adjusting for important covariates.ResultsChildren with cognitive delay (MDI <77) were at significantly higher risk of injury than children without cognitive delay (OR=3.7, 95% CI 1.4 to 10.5, p=0.012). There was no significant association of PDI with injury. There was, however, significant interaction of MDI and PDI (p=0.02); children with cognitive delay but normal motor development were at significantly higher risk of injury than children with normal cognitive and motor development (OR=9.6, 95% CI 2.6 to 35.8, p=0.001).ConclusionsChildren with cognitive delays, especially those with normal motor development, are at elevated risk for residential injuries. Injury prevention efforts should target children with developmental delays.Clinical trials numberNCT00129324; post-results.

Background:Ischemic stroke is the 5thleading cause of death in the US. As a measure of stroke severity, initial NIHSS has been used to predict clinical outcome. We sought to identify the optimal cut-points of NIHSS at initial presentation that are associated with higher 30-day mortality.Methods:In 2005, 2010, and 2015 all hospitalized, first acute ischemic stroke events occurring within the Greater Cincinnati area were ascertained. Potential ischemic stroke cases underwent chart abstraction and physician adjudication, including retrospective NIHSS score (range 0 - 42) based on clinical findings at initial presentation. Descriptive statistics for NIHSS were estimated by study year, demographics, and medical history. Data regarding mortality was obtained from the National Death Index. The Contal and O’Quigley method based on a modified log-rank test statistic was used to determine cut-points of the NIHSS score associated with 30-day mortality, and hazard ratios were obtained from Cox models with adjustment for sex, race, and age.Results:In 2005, 2010, and 2015 there were 1704, 1818 and 1852 ischemic stroke events with 30-day mortality rates of 10.5%, 9.6% and 9.0%, respectively. Optimal cut-points of NIHSS <9, 9-16 and >16 were identified. Across all 3 periods, 3431 (84.5%) cases had NIHSS 0-8, 352 (8.7%) had NIHSS 9-16 and 274 (6.8%) >16. Kaplan Meier Survival Curves for the 3 NIHSS groups are shown in the Figure. Strokes with NIHSS >16 at initial presentation were associated with a 15-fold (HR with 95% CI: 13, 19) increase in the risk of death at 30-days compared to those with NIHSS <9.Discussion:NIH Stroke Scale scores are a reliable predictor of mortality, with higher NIHSS scores having higher risk of death. The cut points reported identify subgroups of stroke patients with dramatically different prognoses. Future studies should assess if this excess mortality risk among severe strokes persists after the more widespread implementation of thrombectomy beyond 2015.

Introduction:Primary prevention reduces the burden of acute ischemic stroke (AIS), yet cerebrovascular risk factors (RF) remain underdiagnosed in certain populations. We aimed to identify predictors of undiagnosed RF among patients with cerebrovascular ischemic events in a large bi-racial population.Methods:Individuals 20 years and older with an incident TIA or AIS from the population-based Greater Cincinnati/Northern Kentucky 2015 stroke study period were screened for inclusion. We included all hospital ascertained, physician-verified cases of AIS and TIAs. Outpatient and ED-only cases were excluded. Abstracted medical record data included determination of newly diagnosed hypertension (HTN), diabetes mellitus (DM), hyperlipidemia (HLD) or atrial fibrillation (AF). Multivariable models were used to identify predictors for each undiagnosed RF. Model variables included: age, sex, race, insurance status and number of cerebrovascular RF (additionally including coronary artery disease and smoking).Results:A total of 1604 ischemic events were included (1485 stroke, 119 TIA) with 52.9% female; 22.4% Black; median age 70 (IQR 59, 82)). Only 6% (n=102) had no history of RF. The prevalence of each undiagnosed RF was: HTN 4.1%; HLD 7.9%; DM 3.1%; AF 3.2%. In unadjusted bivariate analysis, uninsured/unknown status was predictive of undiagnosed HTN (OR = 3.97, 95% CI 1.48, 10.68; p=.006) and HLD (OR=5.53, 95% CI 2.68, 11.4; p<.0001). After adjustment, insurance status remained a predictor for only undiagnosed HLD (Table 1). No relationship was found with race.Conclusions:The most consistent predictor for an undiagnosed RF was absence of other RF and lack of insurance, both suggestive of suboptimal cardiovascular screening in this population. Further studies assessing known but undertreated RF and socioeconomic factors could be of benefit.