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Background Controversy exists as to whether the threshold for blood pressure-lowering treatment should differ between people with and without type 2 diabetes. We aimed to investigate the effects of blood pressure-lowering treatment on the risk of major cardiovascular events by type 2 diabetes status, as well as by baseline levels of systolic blood pressure. Methods We conducted a one-stage individual participant-level data meta-analysis of major randomised controlled trials using the Blood Pressure Lowering Treatment Trialists' Collaboration dataset. Trials with information on type 2 diabetes status at baseline were eligible if they compared blood pressure-lowering medications versus placebo or other classes of blood pressure-lowering medications, or an intensive versus a standard blood pressure-lowering strategy, and reported at least 1000 persons-years of follow-up in each group. Trials exclusively on participants with heart failure or with short-term therapies and acute myocardial infarction or other acute settings were excluded. We expressed treatment effect per 5 mm Hg reduction in systolic blood pressure on the risk of developing a major cardiovascular event as the primary outcome, defined as the first occurrence of fatal or non-fatal stroke or cerebrovascular disease, fatal or non-fatal ischaemic heart disease, or heart failure causing death or requiring hospitalisation. Cox proportional hazard models, stratified by trial, were used to estimate hazard ratios (HRs) separately by type 2 diabetes status at baseline, with further stratification by baseline categories of systolic blood pressure (in 10 mm Hg increments from Findings We included data from 51 randomised clinical trials published between 1981 and 2014 involving 358 533 participants (58% men), among whom 103 325 (29%) had known type 2 diabetes at baseline. The baseline mean systolic/diastolic blood pressure of those with and without type 2 diabetes was 149/84 mm Hg (SD 19/11) and 153/88 mm Hg (SD 21/12), respectively. Over 4·2 years median follow-up (IQR 3·0–5·0), a 5 mm Hg reduction in systolic blood pressure decreased the risk of major cardiovascular events in both groups, but with a weaker relative treatment effect in participants with type 2 diabetes (HR 0·94 [95% CI 0·91–0·98]) compared with those without type 2 diabetes (0·89 [0·87–0·92]; pinteraction=0·0013). However, absolute risk reductions did not differ substantially between people with and without type 2 diabetes because of the higher absolute cardiovascular risk among participants with type 2 diabetes. We found no reliable evidence for heterogeneity of treatment effects by baseline systolic blood pressure in either group. In keeping with the primary findings, analysis using stratified network meta-analysis showed no evidence that relative treatment effects differed substantially between participants with type 2 diabetes and those without for any of the drug classes investigated. Interpretation Although the relative beneficial effects of blood pressure reduction on major cardiovascular events were weaker in participants with type 2 diabetes than in those without, absolute effects were similar. The difference in relative risk reduction was not related to the baseline blood pressure or allocation to different drug classes. Therefore, the adoption of differential blood pressure thresholds, intensities of blood pressure lowering, or drug classes used in people with and without type 2 diabetes is not warranted. Funding British Heart Foundation, UK National Institute for Health Research, and Oxford Martin School.

Moyamoya is a progressive cerebrovascular arteriopathy that affects children of any age. The goal of this study was to determine imaging and clinical outcomes as well as complication rates in a pediatric cohort undergoing either a combined direct/indirect or indirect-only revascularization approach. Patients with moyamoya disease or syndrome≤18years of age at the time of initial surgery were identified, and clinical data were collected retrospectively. Over a 12-year period, 26 patients underwent revascularization procedures on 49 hemispheres with a median follow-up of 2.6years from surgery. Median age at surgery was 7.3years (range 1.4-18.0years). Thirty-three hemispheres (67.3%) underwent combined revascularization with a direct bypass and encephalomyosynangiosis, and sixteen hemispheres (32.7%) underwent indirect-only revascularization. The rate of 30-day perioperative complication was 10.2%, and the rate of postoperative clinical stroke by end of follow-up was 10.2% by hemisphere. There was a 5.7% rate of intraoperative bypass failure requiring conversion to an indirect revascularization approach. On follow-up imaging, 96.9% of direct bypasses remained patent. On multivariate analysis, higher preoperative Pediatric Stroke Outcome Measure (PSOM) scores were associated with lower rates of good clinical outcome on follow-up (unit OR 0.03; p=0.03). Patients with age&nbsp

The pediatric stroke outcome measure (PSOM) is a standardized, disease-specific outcome measure. We aimed to validate the overall classification of neurological deficit severity using PSOM.We identified 367 neonates/children with arterial ischemic stroke (AIS) (Derivation Cohort). We analyzed the PSOM subscales (scored as 0 [no deficit], 0.5 [minimal/mild deficit; normal function], 1 [moderate deficit; slowing function], or 2 [severe deficit; missing function]) to derive severity levels using latent class analysis (LCA). We validated a severity classification scheme (PSOM-SCS) in: (a) children who had Pediatric Evaluation of Disability Inventory (PEDI; n = 63) and/or the Pediatric Quality-of-Life Inventory (PedsQL; n = 97) scored; and (b) an external cohort (AIS; n = 102) with concurrently scored modified Rankin Scale (mRS), King's Outcome Scale for Childhood Head-Injury (KOSCHI) and PSOM.Within the Derivation Cohort, LCA identified three severity levels: "normal/mild," "moderate," and "severe" (83.7%, 13.3%, and 3%, respectively). We developed severity classification based on PSOM subscale scores: "normal/mild"-normal function in all domains or slowing in one domain, "moderate"-slowing in ≥2 domains or missing function in one domain, and "severe"-missing function in ≥2 domains or slowing in ≥1 plus missing in one domain. PEDI and PedsQL both differed significantly across the severity groups. PSOM-SCS displayed high concordance with mRS (agreement coefficient [AC2] = 0.88) and KOSCHI (AC2 = 0.79).The PSOM-SCS constitutes a valid tool for classifying overall neurological severity emphasizing function and encompassing the full range of severity in pediatric stroke.Arithmetic summing of the PSOM subscales scores to assess severity classification is inadequate.The prior severity classification using PSOM overestimates poor outcomes.Three distinct severity profiles using PSOM subscales are identified.The PSOM-SCS is in moderate to excellent agreement with other disability measures.PSOM-SCS offers a valid tool for classifying the overall neurological deficit severity.

Aim: We assessed reproducibility of endothelial microparticles (EMPs) enumeration among youth. Methods & results: Four microparticle (MP) indices – total MP per microliter platelet free plasma (PFP), total EMPs per microliter PFP, percent activated EMPs and percent lactadherin positive (LACT[+]) of total EMPs – were measured at two visits (baseline and 7 ± 3 days follow-up) to determine reproducibility overall and by obesity status. We examined CD31+ or CD144+ with CD41-EMP events of size 0.3–1.0 μm. No statistically significant differences were observed between visits for any of the four MP indices. The within-participant and between-participant coefficient of variation was acceptable (range: 1.13–2.37) with good intraclass-correlation coefficient for all indices except total MP per microliter (range: 0.10–1.00). Conclusion: Total EMPs per microliter PFP, percent-activated EMPs and percent LACT(+) of total EMPs are reproducible among youth.

OBJECTIVE: We sought to evaluate the effect of 52 weeks of exenatide extended release (XR) on maintenance of meal replacement therapy induced BMI reduction in adolescents with severe obesity. METHODS: In this randomized, double-blind, placebo-controlled trial, 100 participants aged 12

BACKGROUND: There are limited data comparing the relative associations of various BMI metrics with adiposity and cardiometabolic risk factors in youth. OBJECTIVE: Examine correlations of 7 different BMI metrics with adiposity, cardiometabolic risk factors, and biomarkers (i.e. blood pressure, waist circumference, cholesterol, leptin, insulin, high molecular weight adiponectin, high-sensitivity c-reactive protein (hsCRP)). METHODS: This was a cross-sectional analysis of youth in all BMI categories. BMI metrics: BMI z-score (BMIz), extended BMIz (ext. BMIz), BMI percentile (BMIp), percent of the BMI 95th percentile (%BMI(p95)), percent of the BMI median (%BMI(p50)), triponderal mass index (TMI), and BMI (BMI). Correlations between these BMI metrics and adiposity, visceral adiposity, cardiometabolic risk factors and biomarkers were summarized using Pearson’s correlations. RESULTS: Data from 371 children and adolescents ages 8–21 years old were included in our analysis: 52% were female; 20.2% with Class I obesity, 20.5% with Class II, and 14.3% with Class III obesity. BMIp consistently demonstrated lower correlations with adiposity, risk factors, and biomarkers (r = 0.190–0.768) than other BMI metrics. The %BMI(p95) and %BMI(p50) were marginally more strongly correlated with measures of adiposity as compared to other BMI metrics. The ext.BMIz did not meaningfully outperform BMIz. CONCLUSION: Out of all the BMI metrics evaluated, %BMI(p95) and %BMI(p50) were the most strongly correlated with measures of adiposity. %BMI(p95) has the benefit of being used currently to define obesity and severe obesity in both clinical and research settings. BMIp consistently had the lowest correlations. Future research should evaluate the longitudinal stability of various BMI metrics and their relative associations with medium to long-term changes in adiposity and cardiometabolic outcomes in the context of intervention trials.

Background To investigate whether common variants in EPHB4 and RASA1 are associated with cerebral cavernous malformation (CCM) disease severity phenotypes, including intracranial hemorrhage (ICH), total and large lesion counts. Methods Familial CCM cases enrolled in the Brain Vascular Malformation Consortium were included (n = 338). Total lesions and large lesions (≥5 mm) were counted on MRI; clinical history of ICH at enrollment was assessed by medical records. Samples were genotyped on the Affymetrix Axiom Genome‐Wide LAT1 Human Array. We tested the association of seven common variants (three in EPHB4 and four in RASA1) using multivariable logistic regression for ICH (odds ratio, OR) and multivariable linear regression for total and large lesion counts (proportional increase, PI), adjusting for age, sex, and three principal components. Significance was based on Bonferroni adjustment for multiple comparisons (0.05/7 variants = 0.007). Results EPHB4 variants were not significantly associated with CCM severity phenotypes. One RASA1 intronic variant (rs72783711 A>C) was significantly associated with ICH (OR = 1.82, 95% CI = 1.21–2.37, p = 0.004) and nominally associated with large lesion count (PI = 1.17, 95% CI = 1.03–1.32, p = 0.02). Conclusion A common RASA1 variant may be associated with ICH and large lesion count in familial CCM. EPHB4 variants were not associated with any of the three CCM severity phenotypes., We investigated whether common variants in EPHB4 and RASA1 are associated with familial cerebral cavernous malformation (CCM) disease severity phenotypes, including intracranial hemorrhage (ICH), total and large lesion counts. EPHB4 variants were not associated with any of the three CCM severity phenotypes. However, an intronic RASA1 variant was significantly associated with ICH and large lesion count in familial CCM, suggesting that the Ras‐Erk pathway may play a role in CCM disease severity.

We describe the risk factors for peri-procedural and spontaneous arterial ischemic stroke (AIS) in children with cardiac disease.We identified children with cardiac causes of AIS enrolled in the International Pediatric Stroke Study registry from January 2003 to July 2014. Isolated patent foramen ovale was excluded. Peri-procedural AIS (those occurring during or within 72 hours of cardiac surgery, cardiac catheterization, or mechanical circulatory support) and spontaneous AIS that occurred outside of these time periods were compared.We identified 672 patients with congenital or acquired cardiac disease as the primary risk factor for AIS. Among these, 177 patients (26%) had peri-procedural AIS and 495 patients (74%) had spontaneous AIS. Among non-neonates, spontaneous AIS occurred at older ages (median 4.2 years, interquartile range 0.97 to 12.4) compared with peri-procedural AIS (median 2.4 years, interquartile range 0.35 to 6.1, P 0.001). About a third of patients in both groups had a systemic illness at the time of AIS. Patients who had spontaneous AIS were more likely to have a preceding thrombotic event (16 % versus 9 %, P = 0.02) and to have a moderate or severe neurological deficit at discharge (67% versus 33%, P = 0.01) compared to those with peri-procedural AIS.Children with cardiac disease are at risk for AIS at the time of cardiac procedures but also outside of the immediate 72 hours after procedures. Many have acute systemic illness or thrombotic event preceding AIS, suggesting that inflammatory or prothrombotic conditions could act as a stroke trigger in this susceptible population.

Background: Food insecurity may trigger eating behaviors that contribute to pediatric obesity. The aim of this study is to identify eating behaviors among a pediatric population with obesity and household food insecurity. Methods: A cross-sectional study analyzed Child Eating Behavior Questionnaire (CEBQ) and household food insecurity screener responses, and BMI measurements from pediatric participants with obesity (BMI ≥95th percentile) from a weight management clinic between 2013 and 2017. Multivariate linear regression was performed to evaluate associations between CEBQ eating domains [Food Responsiveness, Emotional Overeating, Enjoyment of Food, Desire to Drink (DD), Satiety Responsiveness, Slowness in Eating, Emotional Undereating (EUE), and Food Fussiness] and household food insecurity, adjusting for age, sex, race/ethnicity, SNAP participation, and BMI percentile. A sub-group analysis was performed on participants from food insecure (FI) households to evaluate the associations between SNAP participation and eating domains. Results: Eight hundred twenty-two participants were included in the final analysis. Participants from FI households had significantly higher BMI percentiles even after adjustment for age, sex, race/ethnicity, and SNAP status (p = 0.000). Household food insecurity was associated with increased DD beverages (p = 0.000). Among participants from FI households, SNAP participation was significantly positively associated with the EUE (p = 0.009). Conclusions: Youth from FI households have higher BMIs even among a population with obesity. DD is positively associated with household food insecurity and may contribute to obesity in this population. Results suggest that providers treating pediatric patients with obesity should consider regularly screening for household food insecurity and associated eating behaviors as part of their medical management of obesity.

Learning objectives After reviewing this article, the participant should be able to: 1. Understand the anatomy and pathophysiology of spinal cord injury and the resulting upper and lower motor neuron syndromes. 2. Recognize who may benefit from nerve transfers. 3. Understand the role of history, examination, imaging, and electrodiagnostics in the determination of time-sensitive lower motor neuron injury versus non-time-sensitive upper motor neuron injury. 4. Outline the surgical options and perioperative care for those undergoing nerve transfer and the expected outcomes in restoring shoulder, elbow, wrist, and hand function. Summary This article outlines how to localize and differentiate upper motor neuron from combined upper and lower motor neuron injury patterns in spinal cord injury by means of detailed history, physical examination, imaging, and electrodiagnostic studies to formulate appropriate surgical plans to restore function in this complex population.

There are well-established disparities in cancer incidence and outcomes by race/ethnicity that result from the interplay between structural, socioeconomic, socio-environmental, behavioural and biological factors. However, large research studies designed to investigate factors contributing to cancer aetiology and progression have mainly focused on populations of European origin. The limitations in clinicopathological and genetic data, as well as the reduced availability of biospecimens from diverse populations, contribute to the knowledge gap and have the potential to widen cancer health disparities. In this review, we summarise reported disparities and associated factors in the United States of America (USA) for the most common cancers (breast, prostate, lung and colon), and for a subset of other cancers that highlight the complexity of disparities (gastric, liver, pancreas and leukaemia). We focus on populations commonly identified and referred to as racial/ethnic minorities in the USA—African Americans/Blacks, American Indians and Alaska Natives, Asians, Native Hawaiians/other Pacific Islanders and Hispanics/Latinos. We conclude that even though substantial progress has been made in understanding the factors underlying cancer health disparities, marked inequities persist. Additional efforts are needed to include participants from diverse populations in the research of cancer aetiology, biology and treatment. Furthermore, to eliminate cancer health disparities, it will be necessary to facilitate access to, and utilisation of, health services to all individuals, and to address structural inequities, including racism, that disproportionally affect racial/ethnic minorities in the USA. Fil: Zavala, Valentina A.. University of California; Estados Unidos Fil: Bracci, Paige M.. University of California; Estados Unidos Fil: Carethers, John M.. University of Michigan; Estados Unidos Fil: Carvajal Carmona, Luis. University of California at Davis; Estados Unidos Fil: Coggins, Nicole B.. University of California at Davis; Estados Unidos Fil: Cruz Correa, Marcia R.. Universidad de Puerto Rico; Puerto Rico Fil: Davis, Melissa. No especifíca; Fil: de Smith, Adam J.. University of California; Estados Unidos Fil: Dutil, Julie. Ponce Research Institute; Puerto Rico Fil: Figueiredo, Jane C.. Cedars Sinai Medical Center; Estados Unidos Fil: Fox, Rena. University of California; Estados Unidos Fil: Graves, Kristi D.. University Of Georgetown; Estados Unidos Fil: Gomez, Scarlett Lin. University of California; Estados Unidos Fil: Llera, Andrea Sabina. Consejo Nacional de Investigaciones Científicas y Técnicas. Oficina de Coordinación Administrativa Parque Centenario. Instituto de Investigaciones Bioquímicas de Buenos Aires. Fundación Instituto Leloir. Instituto de Investigaciones Bioquímicas de Buenos Aires; Argentina Fil: Neuhausen, Susan L.. No especifíca; Fil: Newman, Lisa. No especifíca; Fil: Nguyen, Tung. University of California; Estados Unidos Fil: Palmer, Julie R.. National Institutes of Health; Estados Unidos Fil: Palmer, Nynikka R.. University of California; Estados Unidos Fil: Pérez Stable, Eliseo J.. National Institutes of Health; Estados Unidos Fil: Piawah, Sorbarikor. University of California; Estados Unidos Fil: Rodriquez, Erik J.. National Institutes of Health; Estados Unidos Fil: Sanabria Salas, María Carolina. Instituto Nacional de Cancerología; Colombia Fil: Schmit, Stephanie L.. University of Southern California; Estados Unidos Fil: Serrano Gomez, Silvia J.. Instituto Nacional de Cancerología; Colombia Fil: Stern, Mariana Carla. University of Southern California; Estados Unidos Fil: Weitzel, Jeffrey. No especifíca; Fil: Yang, Jun J.. St. Jude Children’s Research Hospital; Estados Unidos Fil: Zabaleta, Jovanny. No especifíca; Fil: Ziv, Elad. University of California; Estados Unidos Fil: Fejerman, Laura. University of California; Estados Unidos

Background Circulating endothelial cells (CECs) reflect early changes in endothelial health; however, the degree to which CEC number and activation is related to adiposity and cardiovascular risk factors in youth is not well described. Methods and Results Youth in this study (N=271; aged 8–20 years) were classified into normal weight (body mass index [BMI] percentage P >0.05). Youth with severe obesity had a higher degree of CEC activation compared with normal weight youth (8.3%; 95% CI, 1.1–15.6 [ P =0.024]). Higher CEC number was associated with greater body fat percentage (0.02 per percentage; 95% CI, 0.00–0.03 [ P =0.020]) and systolic blood pressure percentile (0.01 per percentage; 95% CI, 0.00–0.01 [ P =0.035]). Higher degree of CEC activation was associated with greater visceral adipose tissue (5.7% per kg; 95% CI, 0.4–10.9 [ P =0.034]) and non–high‐density lipoprotein cholesterol (0.11% per mg/dL; 95% CI, 0.01–0.21 [ P =0.039]). Conclusions Methods of CEC quantification are associated with adiposity and cardiometabolic risk factors and may potentially reflect accelerated atherosclerosis as early as childhood.

OBJECTIVE: Severe complications of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) include arterial ischemic stroke (AIS) in adults and multisystem inflammatory syndrome in children. Whether stroke is a frequent complication of pediatric SARS-CoV-2 is unknown. This study aimed to determine the proportion of pediatric SARS-CoV-2 cases with ischemic stroke and the proportion of incident pediatric strokes with SARS-CoV-2 in the first 3 months of the pandemic in an international cohort. METHODS: We surveyed 61 international sites with pediatric stroke expertise. Survey questions included: numbers of hospitalized pediatric (≤ 18 years) patients with SARS-CoV-2; numbers of incident neonatal and childhood ischemic strokes; frequency of SARS-CoV-2 testing for pediatric patients with stroke; and numbers of stroke cases positive for SARS-CoV-2 from March 1 to May 31, 2020. RESULTS: Of 42 centers with SARS-CoV-2 hospitalization numbers, 8 of 971 (0.82%) pediatric patients with SARS-CoV-2 had ischemic strokes. Proportions of stroke cases positive for SARS-CoV-2 from March to May 2020 were: 1 of 108 with neonatal AIS (0.9%), 0 of 33 with neonatal cerebral sinovenous thrombosis (CSVT; 0%), 6 of 166 with childhood AIS (3.6%), and 1 of 54 with childhood CSVT (1.9%). However, only 30.5% of neonates and 60% of children with strokes were tested for SARS-CoV-2. Therefore, these proportions represent 2.9, 0, 6.1, and 3.0% of stroke cases tested for SARS-CoV-2. Seven of 8 patients with SARS-CoV-2 and stroke had additional established stroke risk factors. INTERPRETATION: As in adults, pediatric stroke is an infrequent complication of SARS-CoV-2, and SARS-CoV-2 was detected in only 4.6% of pediatric patients with ischemic stroke tested for the virus. However, < 50% of strokes were tested. To understand the role of SARS-CoV-2 in pediatric stroke better, SARS-CoV-2 testing should be considered in pediatric patients with stroke as the pandemic continues. ANN NEUROL 2021.

Background and Purpose: Do children have an increased risk for brain arteriovenous malformation (AVM) recurrence compared with adults and does this risk vary depending on initial presentation with AVM rupture? Methods: We retrospectively studied 115 patients initially presenting with brain AVM under age 25 years who underwent complete surgical resection of the AVM as documented by digital subtraction angiography (DSA) and had delayed follow-up DSA to evaluate for AVM recurrence after apparent initial cure. Results: The mean time from baseline DSA to follow-up DSA was 2.3 years, ranging from 0 to 15 years. Twelve patients (10.4% of the 115 patient cohort and 16.7% of 72 patients with hemorrhage at initial presentation) demonstrated AVM recurrence on follow-up DSA. All patients with recurrence initially presented with intracranial hemorrhage, and intracranial hemorrhage was a significant predictor of recurrence (log rank P =0.037). Among patients with initial hemorrhage, the 5-year recurrence rate was 17.8% (95% CI, 8.3%–35.7%). All recurrences occurred in patients who were children at the time of their initial presentation; the oldest was 15 years of age at the time of initial AVM surgery. The 5-year recurrence rate for children (0–18 years of age) with an initial presentation of hemorrhage was 21.4% (95% CI, 10.1%–41.9%). Using Cox regression, we found the risk of AVM recurrence decreased by 14% per each year increase in age at the time of initial surgical resection (hazard ratio=0.86 [95% CI, 0.75–0.99]; P =0.031). Conclusions: There is a high rate of recurrence of apparently cured brain AVMs in children who initially present with AVM rupture. Imaging follow-up is warranted to prevent re-rupture.

Lack of food preparation knowledge, time to prepare meals and concerns about fruit and vegetable spoilage before consumption are the potential barriers to home cooking. These barriers may be addressed by meal kits (bundles of recipes and ingredients). We described home cooking barriers and evaluated acceptability of meal kits, using semi-structured focus groups with caregivers and adolescent patients of an outpatient paediatric weight management clinic. One meal kit per family, containing non-perishable food, a $20 gift card to a grocery store and recipes designed by clinic dietician for two meals, were given at clinic appointments. Two in-person semi-structured focus groups were conducted within 2 weeks of meal kit receipt. Four adolescent participants (75% female; 12.7 ± 0.9 years) and eight caregivers (88% female) participated in the focus groups. Four barriers to home cooking were identified: (a) healthy food cost, (b) preparation time, (c) food preparation knowledge and (d) picky eaters. Participants felt the meal kits addressed the time and lack of food preparation knowledge barriers to home cooking. A clinical meal kit programme was acceptable to a treatment-seeking adolescent population with obesity and their caregivers.

The Child and Adult Eating Behavior Questionnaires (CEBQ, AEBQ) are established measures of eating behaviors. However, no similar measure is available for adolescents. Prior research has validated the AEBQ in adult samples, and one study has explored using the measure with adolescents. However, no studies to date have examined the validity of the AEBQ in adolescent clinical populations. Furthermore, no studies have examined associations between the AEBQ and indicators of health status in adolescents.A total of 280 adolescents (12-17 years old, 60% female) seen in a pediatric weight management clinic completed the AEBQ at intake. Confirmatory factor analysis (CFA) was conducted with AEBQ items to evaluate the model fit of one-, two-, seven-, and eight-factor structures. Intercorrelations between scale scores from AEBQ Food Approach and Food Avoidance domains were calculated. Associations of AEBQ scales with body mass index (BMI) and binge-eating behaviors were examined using Spearman Rho correlations and independent t-tests.CFAs revealed that the best fitting model was a seven-factor structure excluding the Hunger scale, although overall model fit was only marginally acceptable (XThe seven-factor structure of AEBQ demonstrates a marginally acceptable fit for treatment-seeking adolescents with obesity. The Food Approach scales demonstrated more convergent validity than the Food Avoidance scales. The Food Approach scales also exhibited some clinical utility for identifying patients with increased risk for binge eating, which is a common target for behavioral intervention. Implications for maximizing the AEBQ's potential for assessing eating behaviors in adolescents with obesity are discussed.

Background Surgical videos are increasingly common, although their role in residency curricula remains unclear. The aim of this study was to evaluate the impact of an educational surgical video on resident performance of an open carpal tunnel release through an Objective Structured Assessment of Technical Skills and serial questionnaires. Methods Twenty-two residents representing six postgraduate years were randomized to receive text-based materials with or without a surgical video before performing a carpal tunnel release on human cadavers. Procedures were video recorded, anonymized, and independently evaluated by three hand surgeons using the Objective Structured Assessment of Technical Skills global rating scale, a procedure-specific technical rating scale, a record of operative errors, and pass/fail designation. Residents completed questionnaires before and after the procedure to track confidence in their technical skills. Results Residents in their first and second postgraduate years (n = 10) who watched the surgical video committed fewer operative errors (median, 4 versus 1.3; p = 0.043) and were more confident in their abilities following the procedure (median, 75 versus 32; p = 0.043) than those receiving text resources alone. There were no significant differences in Objective Structured Assessment of Technical Skills performance or questionnaire responses among more senior residents (n = 12). The technical rating scale was internally consistent (Cronbach α = 0.95; 95 percent CI, 0.91 to 0.98), reliable (intraclass correlation coefficient, 0.73; 95 percent CI, 0.40 to 0.88), and correlated with surgical experience (Spearman ρ = 0.57; p = 0.006). Conclusion Watching an educational surgical video to prepare for a cadaveric procedure significantly reduced operative errors and improved confidence among junior trainees performing a carpal tunnel release.

Background: Postoperative care is essential to optimizing patient outcome. We sought to determine the incidence and associated demographic and surgical factors of postoperative patient loss to follow-up following hand and upper extremity surgery. Methods: In all, 2834 surgical cases (2467 patients) were retrospectively reviewed. All surgical cases from July 2014 to June 2015 at a single practice with five surgeons were assessed. Charts were reviewed for compliance with postoperative follow-up. Variables were described with proportions and compared using logistic regression analysis. Results: In total, 2563 cases (2388 patients) met the inclusion criteria. Overall loss to follow-up rate was 26%. Patients lost to follow-up based on insurance type were 13% for worker’s compensation, 22% for private insurance, 21% for Medicare, 38% for Medicaid, and 44% for self-pay. Patients with expected short-term follow-up were lost at a 23% rate. Expected mid- and long-term follow-up patients were lost at 34% and 20% rates, respectively. Patients below 30 years old were lost to follow-up at a 42% rate compared to patients 30 to 64 years old (26%) and greater than or equal to 65 years (13%). Males had a higher rate of loss to follow-up, 32%, compared with females (22%). Patients living greater than 50 miles from our surgery center were lost to follow-up at a rate of 31%, compared with those who lived less than 50 miles (25%). Conclusions: We have identified demographic variables associated with patients being lost to follow-up after hand and upper extremity surgery. With this knowledge, we hope to develop methods of either improving in-office follow-up rates or discover new avenues to deliver postoperative care.

Background & Aims Little is known about provider and health system factors that affect receipt of active therapy and outcomes of patients with hepatocellular carcinoma (HCC). We investigated patient, provider, and health system factors associated with receipt of active HCC therapy and overall survival. Methods We performed a national, retrospective cohort study of all patients diagnosed with HCC from January 1, 2008 through December 31, 2010 (n = 3988) and followed through December 31 2014 who received care through the Veterans Administration (128 centers). Outcomes were receipt of active HCC therapy (liver transplantation, resection, local ablation, transarterial therapy, or sorafenib) and overall survival. Results In adjusted analyses, receiving care at an academically affiliated Veterans Administration hospital (odds ratio [OR], 1.97; 95% confidence interval [CI], 1.60–2.41) or a multi-specialist evaluation (OR, 1.60; 95% CI, 1.15–2.21), but not review by a multidisciplinary tumor board (OR, 1.19; 95% CI, 0.98–1.46), was associated with a higher likelihood of receiving active HCC therapy. In time-varying Cox proportional hazards models, liver transplantation (hazard ratio [HR], 0.22; 95% CI, 0.16–0.31), liver resection (HR, 0.38; 95% CI, 0.28–0.52), ablative therapy (HR, 0.63; 95% CI, 0.52–0.76), and transarterial therapy (HR, 0.83; 95% CI, 0.74–0.92) were associated with reduced mortality. Subspecialist care by hepatologists (HR, 0.70; 95% CI, 0.63–0.78), medical oncologists (HR, 0.82; 95% CI, 0.74–0.91), or surgeons (HR, 0.79; 95% CI, 0.71–0.89) within 30 days of HCC diagnosis, and review by a multidisciplinary tumor board (HR, 0.83; 95% CI, 0.77–0.90), were associated with reduced mortality. Conclusions In a retrospective cohort study of almost 4000 patients with HCC cared for at VA centers, geographic, provider, and system differences in receipt of active HCC therapy are associated with patient survival. Multidisciplinary methods of care delivery for HCC should be prospectively evaluated and standardized to improve access to HCC therapy and optimize outcomes.

Background: Epidemiologic observations have raised hypotheses regarding increased potato consumption as a correlate of weight gain, adiposity and diabetes risk, while nut consumption has been associated with weight control and metabolic health Furthermore, human diets are complex with phytochemicals potentially impacting the digestion and absorption of macro-and micronutrients We asked whether increased daily consumption of potatoes influences energy balance relative to almonds Methods: A randomized, controlled trial (30-day) of adult humans (n=180) prescribed daily, calorie-matched (300 kcal/day, n=60 subjects/group) consumption of either 1) almonds, 2) white potato French fries, or 3) white potato French fries with spices selected for alpha-glucosidase inhibitory properties Subjects were measured at baseline and completion (30-days) for primary (body fat measured by dual-energy x-ray absorptiometry, DXA) and secondary outcomes (body weight and markers of carbohydrate metabolism and insulin resistance) Results: A total of n=180 subjects were randomized to treatment groups, with sex (67 78% female), age (mean±SD, 30 35±8 74 years), BMI (26 11±4 15 kg/m2) and weight (75 56±15 44 kg) at baseline There were n=12 dropouts and n=3 terminations due to COVID19 follow-up limitations Change (completion minus baseline) in total fat mass by DXA was not significantly different among groups (mean (95% CI);Almonds: 214 88g (-5 15,434 92);Potatoes: 18 55g (-207 40,244 51);Potatoes+Spice mix: 231 05g (-1 33,463 43);p=0 347), nor change in fasting glucose (p=0 413), insulin (p=0 301) or HbA1c (p=0 234) Change in body weight was significantly different among groups (p=0 013;Almonds: 0 46kg (0 09,0 84);Potatoes: -0 26kg (-0 65,0 13);Potatoes+Spice mix: 0 45kg (0 06,0 85) Conclusions: There was no significant difference in the primary outcome of body fat change with 30 days of consumption of potatoes versus almonds

Pediatric obesity is a serious public health concern affecting almost 16% of two- to five-year-olds. Prior research has not sufficiently addressed how various factors combine to contribute to the heterogeneous condition of obesity. The goal of this study was to assess multiple individual factors to determine how they collectively contribute to weight status in young children, as this information could lead to tailored interventions. This was a cross-sectional, population-based study of three- to five-year-olds. Child height and weight were measured. Parents completed a demographic survey and validated questionnaires regarding these child characteristics: internalizing and externalizing behaviors, sleep problems, executive functions, and food approach and food avoid behaviors. Data for 154 participants (mean age: 4.4 ± 0.8 years; mean body mass index- z: .28 ± 1.0; 50% male) were analyzed using linear and logistic regression and a stepwise regression procedure. In the stepwise selection procedure for the binary outcome of obese/overweight versus normal weight, food avoid ( p = .151), food approach ( p = .017), and the White demographic variable ( p = .117) were identified as important predictors. In conclusion, when considering various cognitive, emotional, and behavioral factors, only food approach and food avoid eating behaviors predicted weight status in young children, suggesting prevention and intervention efforts should specifically address these aspects in young children.

Background and Purpose— Sickle cell disease (SCD) and arteriopathy are pediatric stroke risk factors that are not mutually exclusive. The relative contributions of sickled red blood cells and arteriopathy to stroke risk are unknown, resulting in unclear guidelines for primary and secondary stroke prevention when both risk factors are present. We hypothesized that despite similarities in clinical presentation and radiographic appearance of arteriopathies, stroke evaluation and management differ in children with SCD compared with those without SCD. Methods— We compared presentation and management of children with and without SCD enrolled in the IPSS (International Pediatric Stroke Study) with acute arterial ischemic stroke, according to SCD and arteriopathy status. Regression modeling determined relative contribution of SCD and arteriopathy in variables with significant frequency differences. Results— Among 930 childhood arterial ischemic strokes, there were 98 children with SCD, 67 of whom had arteriopathy, and 466 without SCD, 392 of whom had arteriopathy. Arteriopathy, regardless of SCD status, increased likelihood of hemiparesis (odds ratio [OR], 1.94; 95% CI, 1.46–2.56) and speech abnormalities (OR, 1.67; 95% CI, 1.29–2.19). Arteriopathy also increased likelihood of headache but only among those without SCD (OR, 1.89; 95% CI, 1.40–2.55). Echocardiograms were less frequently obtained in children with SCD (OR, 0.58; 95% CI, 0.37–0.93), but the frequency of identified cardiac abnormalities was similar in both groups ( P =0.57). Children with SCD were less likely to receive antithrombotic therapy, even in the presence of arteriopathy (OR, 0.14; 95% CI, 0.08–0.22). Arteriopathy was associated with a significantly higher likelihood of antithrombotic therapy in children without SCD (OR, 5.36; 95% CI, 3.55–8.09). Conclusions— Arteriopathy, and not SCD status, was most influential of stroke presentation. However, SCD status influenced stroke management because children with SCD were less likely to have echocardiograms or receive antithrombotic therapy. Further work is needed to determine whether management differences are warranted.

Bedding is an important source of teat end exposure to environmental mastitis pathogens. To better control environmental mastitis, we need an improved understanding of the relationships among bedding selection and management, bedding bacteria counts (BBC), and udder health (UH). The objectives of this cross-sectional observational study were (1) to describe BBC, bedding characteristics, udder hygiene scores, bulk tank milk (BTM) quality, and UH in US dairy herds using 1 of 4 bedding materials; (2) describe the relationship between BBC and herd measures of UH; and (3) identify benchmarks for monitoring bedding hygiene. Local dairy veterinarians and university researchers enrolled and sampled 168 herds from 17 states. Herds were on a Dairy Herd Improvement Association (DHIA) testing program and used 1 of 4 bedding types for lactating cows: new sand, reclaimed sand, manure solids (MNS), or organic non-manure materials. Each herd was sampled twice (winter and summer) in 2016. Samples and data collected included unused and used bedding, BTM samples, udder hygiene scores, DHIA test data, and descriptions of facilities and herd management practices. Bedding was cultured to determine the total bacteria count and counts of Bacillus spp., coliforms, Klebsiella spp., non-coliform gram-negative organisms, streptococci or streptococci-like organisms (SSLO), and Staphylococcus spp. Bedding dry matter, organic matter, and pH were also measured. Bulk tank milk samples were cultured to determine counts of coliforms, NAS, SSLO, Staphylococcus aureus, and Mycoplasma spp. Udder health measures included DHIA test-day average linear score (LS); the proportion of cows with an intramammary infection (IMI), where infection was defined as LS ≥4.0; the proportion of cows with a new IMI, where new IMI was defined as LS changing from

Author(s): Coffin, Phillip O; Santos, Glenn-Milo; Behar, Emily; Hern, Jaclyn; Walker, John; Matheson, Tim; Kinnard, Elizabeth N; Silvis, Janelle; Vittinghoff, Eric; Fox, Rena; Page, Kimberley | Abstract: AimsThe advent of direct-acting antivirals for hepatitis C virus (HCV) and limited effectiveness of prevention have generated interest in "Treatment as Prevention" (TasP), in which those most likely to transmit HCV (i.e. people who inject drugs [PWID]) are treated to reduced secondary transmission. However, there are scant data regarding the feasibility of treating PWID at high risk for secondary transmission or the optimal approach to treatment delivery.MethodsWe conducted a 2:1 randomized trial of modified directly-observed (mDOT) versus unobserved HCV treatment with ledipasvir-sofosbuvir daily for 8 weeks among PWID with 36 weeks of follow-up in San Francisco from 2015-2017. We evaluated recruitment-enrollment, treatment completion, end-of-treatment and 12-week response, and reinfection rate.ResultsOf 83 individuals eligible for screening, 72 (87.6%) attended the screening visit, 33 were eligible, and 31 enrolled; mean age was 42 years, 81% were male, 74% white. All but one participant (in the mDOT arm) completed treatment and 89.4% of mDOT and 96.6% of unobserved arm visits were attended. HCV was undetectable for 96.8% (30/31) at end of treatment and 89.7% (26/29) 12 weeks later (1 relapse, 1 reinfection), with no differences by arm. Two additional reinfections were subsequently identified, for a reinfection rate of 16.3 (95% CI 5.3-50.5) per 100 person-years of observation.ConclusionsIt was feasible to recruit active PWID for HCV treatment and achieve high retention, viral response, and satisfaction with either mDOT or unobserved protocols, supporting treatment of PWID at risk of transmitting HCV to others. The reinfection rate suggests we successfully reached a high-risk population and that successful HCV TasP initiatives may aim to be sufficient in scope to significantly lower prevalence in the community.Trial registrationclinicaltrials.gov NCT02609893.

Hepatocellular carcinoma (HCC) is a leading cause of morbidity and mortality in cirrhosis patients. This provides an opportunity to target the highest-risk population, yet surveillance rates in the United States and Europe range from 10% to 40%. The goal of this study was to identify barriers to HCC surveillance, using data from the Veterans Health Administration, the largest provider of liver-related health care in the United States. We included all patients 75 years of age or younger who were diagnosed with cirrhosis from January 1, 2008, until December 31, 2010. The primary outcome was a continuous measure of the percentage of time up-to-date with HCC surveillance (PTUDS) based on abdominal ultrasound (secondary outcomes included computed tomography and magnetic resonance imaging). Among 26,577 patients with cirrhosis (median follow-up = 4.7 years), the mean PTUDS was 17.8 ± 21.5% (ultrasounds) and 23.3 ± 24.1% when any liver imaging modality was included. The strongest predictor of increased PTUDS was the number of visits to a specialist (gastroenterologist/hepatologist and/or infectious diseases) in the first year after cirrhosis diagnosis; the association between visits to a primary care physician and increasing surveillance was very small. Increasing distance to the closest Veterans Administration center was associated with decreased PTUDS. There was an inverse association between ultrasound lead time (difference between the date an ultrasound was ordered and requested exam date) and the odds of it being performed: odds ratio = 0.77, 95% confidence interval 0.72-0.82 when ordered 180 days ahead of time; odds ratio = 0.90, 95% confidence interval 0.85-0.94 if lead time 91-180 days.The responsibility for suboptimal surveillance rests with patients, providers, and the overall health care system; several measures can be implemented to potentially increase HCC surveillance, including increasing patient-specialist visits and minimizing appointment lead time. (Hepatology 2017;65:864-874).

Bovine mastitis caused by mycoplasmas, in particular Mycoplasma bovis, is a major problem for milk production and animal welfare in large dairy herds in the USA and a serious, although sporadic, disease in Europe and the Middle East. It causes severe damage to the udder of cattle and is largely untreatable by chemotherapy. Mycoplasma mastitis has a distinct epidemiology and a unique set of risk factors, the most important of which is large herd size. The disease is often self-limiting, disappearing within months of outbreaks, sometimes without deliberate intervention. Improved molecular diagnostic tests are leading to more rapid detection of mycoplasmas. Typing tests, such as multi-locus sequence typing, can help trace the source of outbreaks. An approach to successful control is proposed, which involves regular monitoring and rapid segregation or culling of infected cows. Serious consideration should be given by owners of healthy dairy herds to the purchase of M. bovis-free replacements. Increased cases of disease could occur in Europe and Israel if the trend for larger dairy herds continues.

The purposes of this study were to characterize the impact of depression and anxiety on the severity of obesity among youth seeking weight management treatment and to determine the extent to which emotional eating mediates the relationship between depression and/or anxiety and degree of obesity. This cross-sectional, retrospective chart review of 102 adolescent patients from a weight management clinic analyzed demographics, body mass index, depression (Patient Health Questionnaire-9), and anxiety (Generalized Anxiety Disorder Scale-7) screens and the Child Eating Behavior Questionnaire, Emotional Over-Eating subscale. After adjusting for demographics and emotional eating, the odds of having severe obesity versus obesity were 3.5 times higher for patients with depression compared with those without (odds ratio [OR] = 3.5; 95% CI = 1.1, 11.3; P = .038) and nearly 5 times higher for those with anxiety (OR = 4.9; CI = 1.2, 20.9; P = .030). Emotional eating, however, was not a mediator between depression/anxiety and degree of adiposity.

Introduction: We examined the reproducibility of circulating endothelial cells (CEC) enumeration and activation among youth. Materials and methods: CECs from 151 youth were measured at baseline and 1 week follow-up. Enumeration of CEC in fresh whole blood was determined by direct assessment of buffy coat smears (CD146+ nucleated cells) and activated CEC (%VCAM-1 expression) was determined after immunomagnetic enrichment and co-staining of nuclei, plus positivity for P1H12 and VCAM-1. Results: No statistically significant difference in CEC enumeration (1.2 ± 2.5 vs 1.3 ± 2.2 CEC/milliliter of whole blood, p = 0.745) or activated CEC (57.1 ± 24.4 vs 58.0 ± 21.3 %VCAM-1, p = 0.592) between baseline and 1 week follow-up. Conclusion: On a cohort basis, CEC enumeration and activation are reproducible in youth. Relatively high individual biological variability may limit its clinical utility.

It has been assumed that the presence of udder hair can interfere with safe milking practices and reduce the wholesomeness of milk relative to bacterial content. This study determined the effect of removal by singeing udder hair on the microflora of teat skin (total bacteria, coliform, and esculin-positive and esculin-negative streptococci) and milk (total bacteria, coliform, psychrotrophic, and thermoduric counts) as opposed to not singeing udder hair, using different pre-and postmilking disinfection (predip, postdip, or both) combinations. The 4 different pre-and postmilking disinfection combinations were predip and postdip, postdip only, predip only, and no predip and no postdip. Differences in bacterial numbers recovered from teat skin and milk in singed and not singed glands were not significantly affected by treatment. Findings of this trial do not support the concept that udder hair removal results in improved milk quality as measured by bacterial content.

Little data are available regarding individual patients’ risk of surgical site infection (SSI) following mastectomy with or without immediate reconstruction. Our objective was to develop a risk prediction model for mastectomy-related SSI. Using commercial claims data, we established a cohort of women

Background Epilepsy is a common complication of pediatric stroke. Aim In this study, we aim to measure the association between epilepsy and neurologic outcome after childhood arterial ischemic stroke. Methods Prospective cohort study of children (29 days–19 years) enrolled after an acute arterial ischemic stroke at 21 international pediatric stroke centers and followed to identify epilepsy. One year post-stroke, outcomes were scored using the examination-based Pediatric Stroke Outcome Measure (range = 0–10); higher values reflect greater disability. Ordinal logistic regression was used to measure the association of Pediatric Stroke Outcome Measure scores (categorized as 0–1, 1.5–3, 3.5–6, 6.5–10) with epilepsy. Results Investigators enrolled 86 children (median age = 6.1 years, interquartile range (IQR) = 1.4–12.2 years) with acute stroke. At 1 year, 18/80 (23%) remained on an anticonvulsant including 8/80 (10%) with epilepsy. Among the 70 with Pediatric Stroke Outcome Measure scored, the median was 0.5 (IQR = 0–1.5) for children without epilepsy ( n = 63), and 6 (IQR = 0.5–10) for children with epilepsy ( n = 7). In univariable analyses, poorer 1-year outcome was associated with middle cerebral artery stroke, cortical infarcts, hemorrhagic transformation, hospital disposition not to home, and epilepsy. In multivariable analysis, middle cerebral artery stroke (odds ratio (OR) = 4.9, 95% confidence intervals (CI) = 1.1–21.3) and epilepsy (OR = 24.1, CI = 1.5–380) remained associated with poorer outcome. Conclusions Children who developed epilepsy during the first year post-stroke had poorer neurologic outcomes than those without epilepsy.

OBJECTIVE This study aimed to examine whether 1-month BMI improvement is predictive of superior 6- and 12-month BMI changes in a national sample of youth in pediatric weight management treatment. METHODS Participants were 4- to 18-year-olds from the Pediatric Obesity Weight Evaluation Registry, a prospective study collecting data from 31 pediatric weight management programs across the United States. Response at 1 month was defined as ≥ 3% BMI reduction; success at 6 and 12 months was defined as ≥ 5% BMI reduction from baseline. Analyses used linear and logistic regression with robust variance estimation. RESULTS Primary analyses were completed with 687 participants (mean age 12.2 years). One-month responders demonstrated significant improvements in BMI compared with nonresponders at 6 months (BMI, -2.05 vs. 0.05; %BMI, -5.81 vs. 0.23; P

ObjectiveTo determine whether lower socioeconomic status (SES) is associated with worse 1-year neurologic outcomes and reduced access to rehabilitation services in children with arterial ischemic stroke (AIS).MethodsFrom 2010 to 2014, the Vascular effects of Infection in Pediatric Stroke (VIPS) observational study prospectively enrolled and confirmed 355 children (age 29 days–18 years) with AIS at 37 international centers. SES markers measured via parental interview included annual household income (US dollars) at the time of enrollment, maternal education level, and rural/suburban/urban residence. Receipt of rehabilitation services was measured by parental report. Pediatric Stroke Outcome Measure scores were categorized as 0 to 1, 1.5 to 3, 3.5 to 6, and 6.5 to 10. Univariate and multivariable ordinal logistic regression models examined potential predictors of outcome.ResultsAt 12 ± 3 months after stroke, 320 children had documented outcome measurements, including 15 who had died. In univariate analysis, very low income (p = 0.004). In multivariable analysis, including adjustment for stroke etiology, this association persisted (OR 3.17, 95% CI 1.18–8.47, p = 0.02). Income did not correlate with receiving rehabilitation services at 1 year after stroke; however, quality and quantity of services were not assessed.ConclusionsIn a large, multinational, prospective cohort of children with AIS, low income was associated with worse neurologic outcomes compared to higher income levels. This difference was not explained by stroke type, neurologic comorbidities, or reported use of rehabilitation services. The root causes of this disparity are not clear and warrant further investigation.

Background: Immunosuppression is encountered in patients with oncologic, transplant, and autoimmune disorders. The purpose of this study is to provide guidance for physicians treating surgical hand and upper extremity (UE) infections in immunosuppressed (IS) patients. Methods: We retrospectively reviewed our database of patients presenting with UE infections over 3 years. IS patients were matched randomly to non-IS patients. Patient background, infection presentation, surgical evaluation, and microbiology variables were recorded. Infection variables included mechanism, location, and type. Outcomes included inpatient length of stay (LOS) and need for repeat drainage. Results: We identified 35 IS and 35 non-IS out of 409 UE infection patients. Patients most commonly had a hematologic malignancy (34%) as their IS class, and the most frequent immunosuppressive medication was glucocorticoids (57%). IS patients were more likely to be older and less likely to have a history of drug abuse or hepatitis C virus infections. IS infections were more likely to have idiopathic mechanisms, more likely to involve deeper anatomy such as joints, bone, tendon sheath, or muscle/fascia, and less likely to present with leukocytosis. IS cultures more commonly exhibited atypical Mycoplasma or fungus. There was no difference between IS and non-IS patients regarding LOS or recurrent drainage. Conclusions: Mechanism and white blood cell count are less reliable markers of infection severity in IS patients. Physicians treating infections in IS patients should maintain a higher suspicion for deeper involved anatomy and atypical microbiology. Nonetheless, with careful inpatient management and closer surveillance, outcomes in IS patients can approach that of non-IS patients.

OBJECTIVE: To evaluate the relationships of depression and anxiety symptoms with CVD risk factors and measures of vascular health in youth. Major Depressive Disorder and Bipolar Disorder are considered cardiovascular disease (CVD) risk factors in youth. STUDY DESIGN: Participants (n=202) were 8-18-year-olds from a cross-sectional study evaluating cardiovascular health across a wide range of BMI values (normal weight to severe obesity). CVD risk measurement included blood pressure, fasting lipids, glucose, insulin, carotid artery intima-media thickness, compliance and distensibility, brachial artery flow-mediated dilation, carotid-radial artery pulse wave velocity, body fat percentage, and a metabolic syndrome cluster score. Anxiety and depression symptoms were self-reported on the Screen for Child Anxiety Related Disorders and Center of Epidemiological Studies Depression Scale for Children. Two sets of adjustment variables were used in evaluation of differences between those with and without anxiety or depression symptomatology for the CVD risk factor and vascular outcomes. The first set included adjustment for Tanner stage, sex, and race; the second additionally adjusted for percent body fat. RESULTS: Anxiety was not significantly associated with CVD risk factors or vascular health in either model. Depression was associated with HDL cholesterol, triglycerides, and metabolic syndrome cluster score; these relationships were attenuated when accounting for percent body fat. CONCLUSIONS: When accounting for body fat, we found no clear relationship of self-reported depression or anxiety symptoms with CVD risk factors or vascular health in youth.

Background The American Heart Association set 2020 Strategic Impact Goals that defined cardiovascular risk factors to be included in the concept of ideal cardiovascular health ( ICH ). The prevalence of ICH among differing levels of adiposity in youth, especially severe obesity, is uncertain. Methods and Results The cross‐sectional study measured ICH metrics in 300 children and adolescents stratified by adiposity: normal weight, overweight/obese, and severely obese. ICH incorporates 7 behavioral and health metrics, and was characterized as poor, intermediate, or ideal. Individual ICH metrics were transformed into standardized sample z ‐scores; a summary ICH sample z ‐score was also calculated. Multivariable linear regression models were used to estimate differences in ICH sample z ‐scores by adiposity status. Of the 300 participants, 113 were classified as having normal weight, 87 as having overweight/obesity, and 100 as having severe obesity (mean age 12.8 years, SD 2.7; 48% female). No participants met the criteria for ICH ; 80% of those classified as having normal weight, 81% of those with overweight/obesity, and all of those with severe obesity were in poor cardiovascular health. After multivariable adjustment, those with overweight/obesity (sample z ‐score: −1.35; 95% confidence interval, −2.3, −1.1) and severe obesity (sample z ‐score: −1.45; 95% confidence interval, −2.9, −0.92) had lower overall ICH sample z ‐scores compared with participants with normal weight. Results were similar for individual ICH metrics. Conclusions Poor cardiovascular health was highly prevalent in youth; ICH sample z ‐scores increased across levels of adiposity. Youth with obesity, particularly those with severe obesity, remain a rich target for primary prevention efforts. Clinical Trial Registration URL : http://www.clinicaltrials.gov . Unique identifier: NCT 01508598.

Cervical spinal cord injury can result in profound loss of upper extremity function. Recent interest in the use of nerve transfers to restore volitional control is an exciting development in the care of these complex patients. In this article, the authors review preliminary results of nerve transfers in spinal cord injury.Review of the literature and the authors' cases series of 13 operations in nine spinal cord injury nerve transfer recipients was performed. Representative cases were reviewed to explore critical concepts and preliminary outcomes.The nerve transfers used expendable donors (e.g., teres minor, deltoid, supinator, and brachialis) innervated above the level of the spinal cord injury to restore volitional control of missing function such as elbow extension, wrist extension, and/or hand function (posterior interosseous nerve or anterior interosseous nerve/finger flexors reinnervated). Results from the literature and the authors' patients (after a mean postsurgical follow-up of 12 months) indicate gains in function as assessed by both manual muscle testing and patients' self-reported outcomes measures.Nerve transfers can provide an alternative and consistent means of reestablishing volitional control of upper extremity function in people with cervical level spinal cord injury. Early outcomes provide evidence of substantial improvements in self-reported function despite relatively subtle objective gains in isolated muscle strength. Further work to investigate the optimal timing and combination of nerve transfer operations, the combination of these with traditional treatments (tendon transfer and functional electrical stimulation), and measurement of outcomes is imperative for determining the precise role of these operations.Therapeutic, IV.

OBJECTIVEThe National Healthcare Safety Network classifies breast operations as clean procedures with an expected 1%–2% surgical site infection (SSI) incidence. We assessed differences in SSI incidence following mastectomy with and without immediate reconstruction in a large, geographically diverse population.DESIGNRetrospective cohort studyPATIENTSCommercially insured women aged 18–64 years with ICD-9-CM procedure or CPT-4 codes for mastectomy from January 1, 2004 through December 31, 2011METHODSIncident SSIs within 180 days after surgery were identified by ICD-9-CM diagnosis codes. The incidences of SSI after mastectomy with and without immediate reconstruction were compared using the χ2 test.RESULTSFrom 2004 to 2011, 18,696 mastectomy procedures among 18,085 women were identified, with immediate reconstruction in 10,836 procedures (58%). The incidence of SSI within 180 days following mastectomy with or without reconstruction was 8.1% (1,520 of 18,696). In total, 49% of SSIs were identified within 30 days post-mastectomy, 24.5% were identified 31–60 days post-mastectomy, 10.5% were identified 61–90 days post-mastectomy, and 15.7% were identified 91–180 days post-mastectomy. The incidences of SSI were 5.0% (395 of 7,860) after mastectomy only, 10.3% (848 of 8,217) after mastectomy plus implant, 10.7% (207 of 1,942) after mastectomy plus flap, and 10.3% (70 of 677) after mastectomy plus flap and implant (PP=.001) than without (6.1% vs 4.7%, P=.021) immediate reconstruction.CONCLUSIONSSSI incidence was twice that after mastectomy with immediate reconstruction than after mastectomy alone. Only 49% of SSIs were coded within 30 days after operation. Our results suggest that stratification by procedure type facilitates comparison of SSI rates after breast operations between facilities.Infect Control Hosp Epidemiol 2015;36(8):907–914

It is well established that exposure either to elevated levels of glucocorticoids, or to Mycoplasma bovis (M. bovis), has a negative effect on bovine neutrophil function. The objective of this research was to determine whether in vitro treatment of bovine neutrophils by M. bovis strains (n=4) and glucocorticoids would additively impair phagocyte function. Twenty, healthy, dairy cows were enrolled. Whole blood was collected from all cows for neutrophil isolation. Phagocytosis and the generation of superoxide anion (O2(-)) were tested in vitro by incubation of neutrophils with FITC labeled Escherichia coli (E. coli) and cytochrome c after treatment. Treatments included: NM1-4D (neutrophils treated with dexamethasone and exposed to one of the four M. bovis strains); NM1-4 (neutrophils exposed to one of the four M. bovis strains only); ND (neutrophils treated with dexamethasone only); and N (non-treated control neutrophils). The overall percentages of neutrophils phagocytizing E. coli were: 32%, 51%, 37%, and 53% ± 5.25% for treatments NM1-4D, NM1-4, ND, and N, respectively. The overall statistically transformed means of phagocytized E. coli per neutrophil were: 1.37, 1.72, 1.33, and 1.67 ± 0.057 for treatments NM1-4D, NM1-4, ND, and N, respectively. The overall statistically transformed means of neutrophil O2(-) production were: 8.60, 11.91, 9.01, and 12.21 ± 0.21 nmol/10(6) for treatments NM1-4D, NM1-4, ND, and N, respectively. Exposure of neutrophils to M. bovis plus dexamethasone had an additive effect on generation of reactive oxygen species (p=0.0057), but not on the percentage of neutrophils phagocytizing E. coli (p=0.0817) or number of E. coli phagocytized per neutrophil (p=0.2946). Only one of the four M. bovis strains had a negative effect on neutrophil phagocytic function. Dexamethasone treatment consistently decreased neutrophil function as indicated by decreased percentage of neutrophils phagocytizing E. coli, decreased number of E. coli phagocytized per neutrophil, and decreased neutrophil O2(-) production, compared to controls (p

Background and Purpose— A better understanding of the stroke risk factors in children with congenital heart disease (CHD) could inform stroke prevention strategies. We analyzed pediatric stroke associated with CHD in a large community-based case–control study. Methods— From 2.5 million children (aged Results— CHD was identified in 15 of 412 cases (4%) versus 7 of 1236 controls (0.6%). Cases of childhood stroke (occurring between ages 29 days to 20 years) with CHD had 19-fold (odds ratio, 19; 95% confidence interval 4.2–83) increased stroke risk compared to controls. History of CHD surgery was associated with >30-fold (odds ratio, 31; confidence interval 4–241) increased risk of stroke in children with CHD when compared with controls. After excluding perioperative strokes, the history of CHD surgery still increased the childhood stroke risk (odds ratio, 13; confidence interval 1.5–114). The majority of children with stroke and CHD were outpatients at the time of stroke, and almost half the cases who underwent cardiac surgery had their stroke >5 years after the most recent procedure. An estimated 7% of ischemic and 2% of hemorrhagic childhood strokes in the population were attributable to CHD. Conclusions— CHD is an important childhood stroke risk factor. Children who undergo CHD surgery remain at elevated risk outside the perioperative period and would benefit from optimized long-term stroke prevention strategies.

Objective:To quantify the incidence, timing, and risk of ischemic stroke after trauma in a population-based young cohort.Methods:We electronically identified trauma patients (Results:From 1,308,009 trauma encounters, we confirmed 52 trauma-related ischemic strokes. The 4-week stroke incidence was 4.0 per 100,000 encounters (95% confidence interval [CI] 3.0–5.2). Trauma was multisystem in 26 (50%). In 19 (37%), the stroke occurred on the day of trauma, and all occurred within 15 days. In 7/28 cases with cerebrovascular angiography at the time of trauma, no abnormalities were detected. In unadjusted analyses, head, neck, chest, back, and abdominal injuries increased stroke risk. Only head (OR 4.1, CI 1.1–14.9) and neck (OR 5.6, CI 1.03–30.9) injuries remained associated with stroke after adjusting for demographics and trauma severity markers (multisystem trauma, motor vehicle collision, arrival by ambulance, intubation).Conclusions:Stroke risk is elevated for 2 weeks after trauma. Onset is frequently delayed, providing an opportunity for stroke prevention during this period. However, in one-quarter of stroke cases with cerebrovascular angiography at the time of trauma, no vascular abnormality was detected.

Previously we had reported that exposure to high levels of glucocorticoids, and to unopsonized Mycoplasma bovis, has a negative interactive effect on bovine neutrophil function in vitro, and this interactive effect was a function of M. bovis strain differences. Here we hypothesized that in vitro treatment of bovine neutrophils by glucocorticoid would impair phagocytosis of opsonized M. bovis compared to non-treated neutrophils and such impairment would be a function of M. bovis strain differences. Neutrophils isolated from 20 mid-lactation cows were treated with immunosuppressive dose of 5 × 10−4 M dexamethasone or placebo and incubated with one of four opsonized M. bovis strains that had been isolated from bovine origin. After incubation neutrophil function measured included: percentage reduction in log10 of M. bovis CFU/ml, percentage of phagocytizing neutrophils, phagocytized M. bovis per neutrophil, and killed M. bovis per neutrophil. Least square means of all neutrophil groups were contrasted using linear mixed–effects models. Effects due to strain, treatment, and their interaction on neutrophil function measured by the number of phagocytized M. bovis per neutrophil and number of killed M. bovis per neutrophil were different (P

Bariatric surgery produces robust weight loss, however, factors associated with long-term weight-loss maintenance among adolescents undergoing Roux-en-Y gastric bypass surgery are unknown. Fifty adolescents (mean±s.d. age and body mass index (BMI)=17.1±1.7 years and 59±11 kg m−2) underwent Roux-en-Y gastric bypass surgery, had follow-up visits at 1 year and at a visit between 5 and 12 years following surgery (Follow-up of Adolescent Bariatric Surgery at 5 Plus years (FABS-5+) visit; mean±s.d. 8.1±1.6 years). A non-surgical comparison group (n=30; mean±s.d. age and BMI=15.3±1.7 years and BMI=52±8 kg m−2) was recruited to compare weight trajectories over time. Questionnaires (health-related and eating behaviors, health responsibility, impact of weight on quality of life (QOL), international physical activity questionnaire and dietary habits via surgery guidelines) were administered at the FABS-5+ visit. Post hoc, participants were split into two groups: long-term weight-loss maintainers (n=23; baseline BMI=58.2 kg m−2; 1-year BMI=35.8 kg m−2; FABS-5+ BMI=34.9 kg m−2) and re-gainers (n=27; baseline BMI=59.8 kg m−2; 1-year BMI=36.8 kg m−2; FABS-5+ BMI=48.0 kg m−2) to compare factors which might contribute to differences. Data were analyzed using generalized estimating equations adjusted for age, sex, baseline BMI, baseline diabetes status and length of follow-up. The BMI of the surgical group declined from baseline to 1 year (−38.5±6.9%), which, despite some regain, was largely maintained until FABS-5+ (−29.6±13.9% change). The BMI of the comparison group increased from baseline to the FABS-5+ visit (+10.3±20.6%). When the surgical group was split into maintainers and re-gainers, no differences in weight-related and eating behaviors, health responsibility, physical activity/inactivity, or dietary habits were observed between groups. However, at FABS-5+, maintainers had greater overall QOL scores than re-gainers (87.5±10.5 vs 65.4±20.2, P

Childhood obesity is a significant public health concern, and scholars and academicians have proposed the use of successful marketing and advertising tactics as a means of influencing healthy behaviors. This research investigates product placement to assess its potential effects on attitudes and behavior when utilized in an animated children’s television show. Results from an experiment suggest that multiple product placements may affect children’s attitudes toward certain drinks, but also suggest that a child’s existing favorite drink is a stronger predictor of actual beverage choice. Implications are provided.

Objectives We aim to describe our experiences and identify patients who may benefit from referral to a peripheral nerve surgeon for removal of contraceptive subdermal implants in which neurovascular injury may occur, and describe a treatment pathway for optimal care. Study design We reviewed the charts of 22 patients who were referred to the Division of Family Planning for difficult removal of etonogestrel contraceptive implants between January 1, 2014, and April, 1 2016. Of these, five were referred to a peripheral nerve surgeon due to pain or location of the implant. We evaluated and described these cases and, from our findings, developed recommendations for care in a multidisciplinary team approach. Results Two patients reported pain, including one with four previous failed removal attempts. In the two patients with pain, the implants were adherent to a sensory nerve. In another, the implant was within the biceps muscle and difficult to locate. In all cases, ultrasound imaging, general anesthesia and a wide exposure allowed for safe removal and good outcomes. Our multidisciplinary care approach has elucidated important referral and technical considerations that improve patient care and safety. Conclusion When necessary, multidisciplinary care with a Family Planning expert and possibly a peripheral nerve surgeon may be beneficial in safely removing etonogestrel contraceptive implants that would be difficult or risky to remove in an ambulatory setting.

Background Nerve transfer surgery to restore upper extremity function in cervical spinal cord injury (SCI) is novel and may transform treatment. Determining candidacy even years post-SCI is ill defined and deserves investigation. Objective To develop a diagnostic algorithm, focusing on electrodiagnostic (EDX) studies, to determine eligibility for nerve transfer surgery. Design Retrospective descriptive case series. Setting Tertiary university-based institution. Patients Individuals with cervical SCI (n = 45). Methods The electronic medical records of people referred to the Plastic Surgery Multidisciplinary Upper Extremity Surgery in SCI clinic from 2010-2015 were reviewed. People were considered for nerve transfers to restore elbow extension or finger flexion and/or extension. Data including demographic, clinical evaluation, EDX results, surgery, and outcomes were collected and analyzed. Main Outcome Measurements EDX data, including nerve conduction studies and electromyography, for bilateral upper extremities of each patient examined was used to assess for the presence of lower motor neuron injury, which would preclude late nerve transfer. Results Based on our criteria and the results of EDX testing, a substantial number of patients presenting even years post-SCI were candidates for nerve transfers. Clinical outcome results are heterogeneous but promising and suggest that further refinement of eligibility, long-term follow-up, and standardized assessment will improve our understanding of the role of nerve transfer surgery to restore function in people with midcervical SCI. Conclusions Many patients living with SCI are candidates for nerve transfer surgery to restore upper extremity function. Although the ultimate efficacy of these surgeries is not yet determined, this study attempts to report the criteria we are using and may ultimately determine the timing for intervention and which transfers are most useful for this heterogeneous population. Level of Evidence IV

There is a worldwide problem of disease caused by Mycoplasma (M.) bovis in cattle; it has a significant detrimental economic and animal welfare impact on cattle rearing. Infection can manifest as a plethora of clinical signs including mastitis, pneumonia, arthritis, keratoconjunctivitis, otitis media and genital disorders that may result in infertility and abortion. Current diagnosis and control information are reviewed and analysed to identify gaps in knowledge of the causative organism in respect of the disease pathology, diagnosis and control methods. The main considerations are as follows: no vaccines are commercially available; antimicrobial resistance is increasing; diagnostic and antimicrobial sensitivity testing needs to be improved; and a pen-side test would facilitate more rapid diagnosis and implementation of treatment with antimicrobials. More data on host susceptibility, stress factors, immune response and infectious dose levels are required. The impact of asymptomatic carriers, M. bovis survival in the environment and the role of wildlife in transmitting the disease also needs investigation. To facilitate development of vaccines, further analysis of more M. bovis genomes, its pathogenic mechanisms, including variable surface proteins, is required, along with reproducible disease models.

The National Mastitis Council was founded in 1961 based on the desire of a forward-thinking group of individuals to bring together "all forces of organized agriculture in the United States to combat, through every practical device, the mastitis threat to the Nation's health and food safety". What started as a small organization focused on mastitis of dairy cattle in the United States has grown into a global organization for mastitis and milk quality. Over the last 50-plus years the concerted efforts of the membership have led to the synthesis and dissemination of a considerable body of knowledge regarding udder health, milk quality, and food safety which has improved dairy cattle health and well-being and farm productivity.

Background and Purpose— Although arteriopathies are the most common cause of childhood arterial ischemic stroke, and the strongest predictor of recurrent stroke, they are difficult to diagnose. We studied the role of clinical data and follow-up imaging in diagnosing cerebral and cervical arteriopathy in children with arterial ischemic stroke. Methods— Vascular effects of infection in pediatric stroke, an international prospective study, enrolled 355 cases of arterial ischemic stroke (age, 29 days to 18 years) at 39 centers. A neuroradiologist and stroke neurologist independently reviewed vascular imaging of the brain (mandatory for inclusion) and neck to establish a diagnosis of arteriopathy (definite, possible, or absent) in 3 steps: (1) baseline imaging alone; (2) plus clinical data; (3) plus follow-up imaging. A 4-person committee, including a second neuroradiologist and stroke neurologist, adjudicated disagreements. Using the final diagnosis as the gold standard, we calculated the sensitivity and specificity of each step. Results— Cases were aged median 7.6 years (interquartile range, 2.8–14 years); 56% boys. The majority (52%) was previously healthy; 41% had follow-up vascular imaging. Only 56 (16%) required adjudication. The gold standard diagnosis was definite arteriopathy in 127 (36%), possible in 34 (9.6%), and absent in 194 (55%). Sensitivity was 79% at step 1, 90% at step 2, and 94% at step 3; specificity was high throughout (99%, 100%, and 100%), as was agreement between reviewers (κ=0.77, 0.81, and 0.78). Conclusions— Clinical data and follow-up imaging help, yet uncertainty in the diagnosis of childhood arteriopathy remains. This presents a challenge to better understanding the mechanisms underlying these arteriopathies and designing strategies for prevention of childhood arterial ischemic stroke.