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Objectives Hypoparathyroidism is a rare disease in children that occurs as a result of autoimmune destruction of the parathyroid glands, a defect in parathyroid gland development or secondary to physical parathyroid gland disturbance. Typical symptoms of hypoparathyroidism present as hypocalcaemia and hyperphosphatemia due to decreased parathyroid hormone secretion and may lead to nerve and muscles disturbances resulting in clinical manifestation of tetany, arrhythmias and epilepsy. Currently, there is no conventional hormone replacement treatment for hypoparathyroidism and therapeutic approaches include normalising mineral levels using an oral calcium supplement and active forms of vitamin D. Case presentation We present the case of a 10-year-old girl with primary hypoparathyroidism who had no prior history of autoimmune disorders, but who subsequently developed systemic lupus erythematosus.

Beneficial effects of physical activity (PA) are confirmed in patients with all types of long-lasting diabetes. The possibility of PA to be a factor prolonging remission phase in children with new-onset type 1 diabetes (T1D) has not yet been thoroughly studied.The aim of the study was to elucidate the influence of regular PA on prevalence of partial remission (PR), metabolic control, daily insulin requirement (DIR), and C-peptide secretion in children newly diagnosed with T1D.A total of 125 children diagnosed with T1D were studied prospectively for 2 years. Patients were controlled every 3 months and advised with PA according to ISPAD recommendations. Anthropometric parameters, HbA1c, C-peptide level and DIR were analyzed. Patients' PA level was assessed using a self-designed questionnaire.We classified 43% of participants as physically-active. In this group, lower HbA1c after 2 years, lower DIR after 3, 6 months, and after 2 years (all P .05) were found. At discharge from hospital, the prevalence of DIR 0.5 U/kg/24 h with near normoglycemia was similar in both groups. Then, we observed higher PR prevalence in active group lasting over time and resulting in 44% vs 13% after 2 years (P .001). C-peptide after 2 years was comparable in both groups, with higher prevalence of clinically significant levels (0.2 nmoL/L) in active group: 79.6% vs 61.4% (P = .029).These data support the view that regular PA may essentially contribute to extending PR time in pediatric diabetes, and may therefore lead to a better long-term metabolic control of the disease.

Low bone mineral density (BMD) was diagnosed in 24% of childhood cancer survivors (CCS), whereas very low BMD was relatively uncommon at 8%. We suggest that low BMD in CCS may become alleviated over time. Stem cell transplantation, radiotherapy, and underweight were the strongest independent predictors of decreased BMD. Childhood cancer survivors (CCS) are at risk of premature bone loss, although published studies are inconsistent. The objective of this study was to evaluate the prevalence and pattern of low bone mineral density (BMD) in short- and long-term CCS, and to determine clinical factors affecting skeleton after anticancer treatment. This retrospective study was conducted in a cohort of 326 children and young adult CCS (147 females) who completed anticancer treatment. BMD was determined by dual-energy X-ray absorptiometry (DXA). Low BMD was defined as a Z-score ≤ − 1.0, and the very low BMD as a Z-score ≤ − 2.0. Additionally, the changes in BMD over time were studied in 123 CCS who had been re-examined by DXA during follow-up. Median age at diagnosis was 7.27 years (range, 4.4–10.6); median time between end of treatment and DXA was 6.12 (range, 4.0–22.0). Low BMD was found in 24% of CCS, while very low BMD was relatively uncommon (8%). Based on multivariate analysis, the following were significantly associated with low BMD at the follow-up: hematopoietic stem cell transplantation (OR 3.13, 95% CI 1.02–9.63), head and neck radiotherapy (OR 2.54, 95% CI 1.32–4.90), and body weight below the standard reference (OR 3.57, 95% CI 1.24–10.23). The time-related trajectory showed an improvement (BMDLS) or stabilization (BMDTB) in Z-scores values. These data based on serial DXA measurements, encompassing a long-lasting observation period, show that CCS may not be at risk of premature bone loss in young adulthood. However, it is unknown how the scenario for skeletal mass is until the CCS will achieve older or postmenopausal age.

Purpose To evaluate the extent to which the population of Polish preadolescents is vitamin D deficient and to assess seasonal variations in vitamin D status. Participants and methods A total of 720 healthy children aged 9–13 years (409 girls, 311 boys) residing in 6 representative geographical locations in Poland were studied. A parental-assisted questionnaire provided data on nutritional habits, vitamin D supplements and sun exposure. Serum concentration of 25-hydroxyvitamin was determined twice, after the winter in March and after the summer in October. Results In March, vitamin D deficiency (25–50 nmol/L) was found in 64%, and severe deficiency (

It is reported that alterations in protein glycosylation are present in adult rheumatic diseases; however, the data related to pediatric rheumatic conditions are very scarce. The aim of this study was to assess the effect of juvenile idiopathic arthritis (JIA) on the serum glycosylation profile of transferrin isoforms. Twenty-five patients with different clinical forms of an active JIA and 22 healthy controls were studied. Serum samples were analyzed by capillary electrophoresis on MINICAP electrophoretic system (Sebia, France) to determine the levels of transferrin isoforms. In patients with JIA, tetrasialotransferrin (median 82.6%; range 68.8–99.5) concentration was lower (P = 0.032), and pentasialotransferrin (median 14%; range 0.5–31.2) was higher (P = 0.020) in comparison to controls (median 84.45; range 79.8–87.4; median 11.55; range 9.7–16.1, respectively). No significant correlations between concentration of transferrin isoforms and disease activity score (JADAS 27) or the degree of disability (VAS and CHAQ) were found. Erythrocyte sedimentation rate and CRP levels correlated positively with disialotransferrin (R = 0.493, P = 0.017; R = 0.850, P

Osteoarthritis (OA) is characterized by deterioration of the joints and associated with considerable pain and disability. OA is a chronic disease that requires intervention with both non-pharmacological and pharmacological treatment modalities and, inevitably, disease progression may necessitate successive treatments throughout the course of the disease. There is increasing data on the shortfalls of current pharmacological treatment of OA, and safety concerns associated with analgesic therapy use in OA arising from increasing evidence of gastrointestinal, cardiovascular, hepatic and renal adverse events with paracetamol and non-steroidal anti-inflammatory drugs (NSAIDs). Consequently, symptomatic slow-acting drugs for OA (SYSADOAs) may now be considered as a first-line treatment for knee OA, with a particular emphasis placed on the outstanding benefit: risk ratio of pharmaceutical-grade glucosamine and chondroitin sulfate formulations. In this short communication we review recent publications concerned with the safety of paracetamol, NSAIDs and SYSADOAs. Greater understanding of the benefits and limitations of current medications will lead to better disease management in OA. Furthermore, adherence to guideline recommendations across Europe and internationally, such as those from the European Society for Clinical and Economic Aspects of Osteoporosis, Osteoarthritis and Musculoskeletal Diseases (ESCEO), will promote evidence-based medicine and patient-centric care, ultimately leading to greater physician and patient satisfaction.

Objectives The aim of this study was to determine how pediatric patients and their parents perceive health care during hospital stays, what are their expectations of doctor behaviors, and which components of care do they consider to be the most important. Methods A qualitative descriptive study was carried out using the open interview technique. Twenty-six parents and 22 children undergoing hospital treatment participated. Results Our analysis identified two major themes: (1) doctor verbal and non-verbal behaviors, which included informing and explaining, conversations on topics other than the illness, tone of voice and other behaviors; and (2) perceived strategies used by doctors. This category included claims of doctors' intentional use of medical jargon to avoid addressing parental questions directly. Parents admitted that they did not understand medical vocabulary, but they also thought they might understand more of the medical issues if the doctor spoke using terms comprehensible to them. Conlcusions Our study shows the importance of interpersonal relationship affecting patient perception of quality of pediatric care. Parents of pediatric patients perceive that doctors behave in ways that deflect parents' questions and avoid providing them with medical information. Such behaviors include doctors excusing themselves by saying they are busy and using medical jargon. Medical students and doctors should be trained to communicate effectively with patients and their parents and develop skills to convey information in a simple and comprehensible way.

The aim of this study was to evaluate levels of osteocalcin (OC), osteoprotegerin (OPG) and total soluble receptor activator of nuclear factor-&kappa, B ligand (RANKL), and bone mineral density (BMD) in patients on long-term acenocoumarol (AC) treatment. The cross-sectional study was carried out in 42 patients treated long-term with AC and 28 control subjects. Serum concentrations of OC, OPG, and sRANKL were measured using enzyme linked immunosorbent assay (ELISA) kits, and BMD at the femoral neck and lumbar spine were assessed by dual energy X-ray absorptiometry. A significantly decreased concentration of OC was found in AC users compared to control subjects (4.94 &plusmn, 2.22 vs. 10.68 &plusmn, 4.5, p &lt, 0.001). Levels of OPG, sRANKL logarithm (log), sRANKL/OPG log ratio, and BMD were comparable between. In female AC users, positive correlations between OC and RANKL log, and between OC and RANKL/OPG log ratio (p = 0.017, p = 0.005, respectively), and a negative correlation between OC and OPG (p = 0.027) were found. Long-term AC anticoagulation significantly decreases OC concentration, but does not affect other bone metabolism markers or BMD. Our results also suggest the possibility that long-term treatment with AC may alleviate bone resorption in postmenopausal women.

Introduction: Vitamin D deficiency is an important public health problem worldwide. Vitamin D deficiency confers a significant risk for both skeletal and non-skeletal disorders and a number of lifelong negative health outcomes. The objectives of this evidence-based guidelines document are to provide health care professionals in Poland an updated recommendations for the prevention, diagnosis, and treatment of vitamin D deficiency. Methods: A systematic literature search examining the prevention and treatment strategies for vitamin D deficiency was conducted. Updated recommendations were developed using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) system describing the strength of the recommendation and the quality of supporting evidence. Twenty-seven contributors representing different areas of expertise and medical specialties, including pediatricians, geriatricians, endocrinologists, epidemiologists, nephrologists, gynecologists and obstetricians evaluated available published evidence related to vitamin D, formulated the goals of this document, and developed a common consolidated position. The consensus group, representing 6 national specialists consultants and 8 Polish and international scientific organizations/societies, participated in the process of grading evidence and drawing up the general and specific recommendations. Results: The updated recommendations define the diagnostic criteria for the evaluation of vitamin D status and describe the prevention and treatment strategies of vitamin D deficiency in the general population and in groups at increased risk of the deficiency. Age- and weight-specific recommendations for prevention, supplementation and treatment of vitamin D deficiency are presented, and detailed practice guidance is discussed regarding the management in primary and specialized health care. Conclusion: Vitamin D deficiency remains still highly prevalent in Poland, in all age groups. Currently, there is a great necessity to implement a regular supplementation with recommended doses, and to develop an effective strategy to alleviate vitamin D deficiency in the population. These updated recommendations are addressed to health professionals and the authorities pursuing comprehensive health policies, and should be also included in public health programs aimed at preventing a broad spectrum of chronic diseases.

Дослідження, які були проведені протягом останніх двох десятиліть, розширили уявлення про роль вітаміну D у регулюванні абсорбції кальцію та фосфату і метаболізму кісток та низки плейотропних ефектів в органах і тканинах тіла. Більшість спостережних та екологічних досліджень повідомляють про зв’язок між підвищеною концентрацією 25-гідроксивітаміну D [25(OH)D] у сироватці крові з поліпшенням результатів деяких хронічних, інфекційних та неінфекційних захворювань. Отже, численні установи та наукові організації розробили керівництва щодо використання вітаміну D та рекомендації щодо оптимальних сироваткових концентрацій 25(OH)D. Згідно з рекомендаціями керівництва, орієнтованого на здоров’я кісток, цільова концентрація 25(OH)D має становити 20 нг/мл (50 нмоль/л), а дози вітаміну D – 400–800 МО залежно від віку. Рекомендації, орієнтовані на плейотропні ефекти вітаміну D, радять досягати концентрації 25(OH)D 30 нг/мл (75 нмоль/л), а дози вітаміну D мають варіюватися у діапазоні від 400 до 2000 МО на добу залежно від віку, маси тіла, стану захворювання та етнічного походження. Розумний і збалансований вибір рекомендацій зумовлений такими факторами, як стан здоров’я, вік, маса тіла, регіон проживання, харчові та культурні звички, що робить регіональні або державні рекомендації більш придатними для застосування у клінічній практиці. У той самий час як отримання вітаміну D з природних джерел, тобто раціону харчування та регіону проживання, може сприяти підвищенню концентрації 25(ОН)D у певних підгрупах, для загальної популяції ці джерела вважають неефективними для підтримання цілорічної концентрації 25(ОН)D у діапазоні 30‑50 нг/мл (75–125 нмоль/л). Побічні ефекти вітаміну D, пов’язані з його самостійним вживанням, такі, як гіперкальціємія та гіперкальціурія, виникають рідко, і, як правило, є результатом застосування надзвичайно високих доз вітаміну D протягом тривалого часу.

In the Original Publication, the e-mail address of the author Milan Petronijevic is incorrect. The correct e-mail address is milanpetronijevic@yahoo.com.

Objective Both vitamin D and K2 are involved in a number of metabolic processes, including bone metabolism; however, associations between the vitamins are not fully understood. The aim of the study was to evaluate serum concentrations of 25-hydroxyvitamin D [25(OH)D] in adult patients receiving long-term acenocoumarol (AC) treatment. Participants and methods In this cross-sectional study 58 Caucasian patients (31 women, 27 men) with a median age of 65 years receiving long-term AC therapy were evaluated and compared with thirty-five age- and gender-matched healthy controls. The AC treatment was used due to recurrent venous thromboembolism (34.5%), atrial fibrillation (31%), or mechanical heart valve prostheses (34.5%). Medical records and a questionnaire were used to obtain information about chronic diseases, smoking habits, and the duration of therapy and weekly dose of AC. Anthropometric measurements were performed, and serum concentration of 25(OH)D and total ALP activity were measured. Results Among the 58 patients receiving long-term AC treatment, a high proportion (46.6%) demonstrated significant vitamin D deficiency with concentrations of 25(OH)D lower than 20 ng/mL. The median concentration of 25(OH)D in subjects receiving AC was significantly lower compared to the control group [20.4 (17.4; 26.1) vs. 28.2 (24; 32.7); p < 0.001]. No differences were found between women and men receiving AC therapy. In patients receiving AC, a negative correlation was found between the concentration of 25(OH)D and the weekly dose of AC (r = -0.337, p = 0.01). Patients with concentrations of 25(OH)D < 20 ng/mL were found to have a significantly higher median dose of AC, compared to those with concentrations of 25(OH)D ≥ 20 ng/mL [21 (17; 31) vs. 17 (12; 28); p = 0.045]. Conclusion In conclusion, treatment with acenocoumarol is associated with low 25-hydroxyvitamin D levels, although the path leading to this phenomenon is not entirely clear. Long-term administration of acenocoumarol in adults may increase the risk of chronic vitamin D deficiency, thus, effective supplementation of vitamin D in these individuals needs careful consideration.

The study objective was to assess the prevalence of cardiovascular disease risk factors in patients treated for childhood cancer (N=101) and to determine the involvement of clinical (cancer type and therapy) and/or genetic (FTO gene rs9939609 polymorphism) factors. Anthropometric features, laboratory findings, and standardized osteodensitometric indices (fat and lean mass) were considered. Overweight/obesity was found in 17.82% of the patients; however, central adiposity was found in as many as 42.5%. At least one abnormality in lipid metabolism was observed in 35.6%. Densitometry revealed elevated levels of fat mass in 44.55% of the patients. None of the parameters studied were associated with the FTO gene polymorphism. Standardized waist circumference was significantly higher in patients treated for leukemia than those treated for solid tumors (p=0.04). Our findings indicate a high rate of central adiposity among childhood cancer survivors, especially leukemia patients. The prevalence of risk factors of cardiovascular disease after anticancer therapy is not FTO gene polymorphism-dependent.

Introduction During the last years, changes in the diagnosis and treatment have caused a significant increase of the number of young adults who experienced cancer in childhood. This enlarging population is affected by many health problems, including multiple hormone deficiencies and bone mineral deficits. This is the first polish study assessing bone mineral density and endocrine status in young adult cancer survivors. Material and methods A total of 76 long-term survivors treated for pediatric cancer were identified. The mean age at the time of study was 24.1 ±3.5 years. Bone mineral density and TSH, fT3, fT4, FSH, LH, estradiol and testosterone level were assessed for each patient. Results Nine subjects were diagnosed with subclinical hypothyroidism. We found higher level of TSH in the study group, in comparison with control group (p = 0.015). Eighteen patients had increased level of FSH. In the study group higher number of patients with high FSH level was found in comparison with the control group (p = 0.049). A low BMD was observed in 7 patients whereas mild BMD deficits were found in 19 participants. Conclusions In conclusion, our data show that young adult cancer survivors might experienced various hormonal problems including low bone mass, thyroid impairment and gonadal dysfunction. Some of the patients required treatment, but they were not diagnosed before this study. There is the lack of proper clinical assessment among adult childhood cancer survivors in Poland. Therefore, we demonstrated the need for a comprehensive plan for longitudinal follow-up for late effects in these population.

We present a natural history of a 32-year-old man with Hajdu-Cheney syndrome (HJCYS), because of the de novo truncating mutation in the exon 34 of NOTCH2 (c.6424-6427delTCTG, p.Ser2142ArgfsX4), who has been followed up for a period of 23 years (between 9 and 32 years). During follow-up, we observed abnormalities of vision, hearing, voice, and progression of craniofacial features in the form of skeletal dysplasia with affected skull, dentition, spine, limbs, fingers, and toes. Low bone mineral density and history of fragility fractures also suggested primary osteoporosis being a clinical manifestation. According to Stengel-Rutkowski, Schimanek, and Wernheimer (1984; Human Genetics, 6, 272-295), systematic data acquisition has been used for quantitative analysis of anthropological, radiographic, and clinical features at childhood, adolescence, and young adulthood separately. A detailed phenotype description together with the results of reanalysis of 14 reports so far published on patients with HJCYS and NOTCH2 mutation showed similar phenotype evolution with age. The spectrum of observed features may improve diagnostic tools for HJCYS at different periods of the lifespan.

A qualitative descriptive design using an interview guide approach was adopted to investigate the patient-nurse relationship and paediatric ward amenities from the perspective of parents and hospitalised children in Poland. The study included 26 parents or caregivers of hospitalised children (between 13 months and 15 years old) and 22 children (from 10 to 16 years old). Qualitative content analysis was used to analyse the recorded verbal data. Data from patients’ transcripts were coded and classified in terms of topics on the patient-nurse relationship and hospital care. We identified five main topics. 1. Nurse qualities; 2. Nurse verbal behaviour; 3. Nurse tone of voice and non-verbal behaviour; 4. Hospital amenities; 5. Parents’ expectations towards nurses. Our study contributes to increased understanding of parents’ and children’s experiences of paediatric hospital care.

Purpose To assess skeletal mass in survivors of childhood Hodgkin disease (HD) and non-Hodgkin lymphoma (NHL) 1–5 years after treatment, and to identify potential risk factors influencing bone mineral density (BMD). Patients/methods This cross-sectional study was conducted in a cohort of 43 survivors (HD = 31; NHL = 12); mean age: 16.21 ± 4.4. Total body bone mineral content (TBMC) and density (TBBMD), and lumbar spine density (LSBMD) were determined using dual-energy X-ray absorptiometry. Results Three of all 43 patients developed low BMD. No significant differences in height, weight, and/or BMD Z -scores were found between HD and NHL survivors, children who received and did not receive radiotherapy, and the groups with different chemotherapeutic blocks. No differences were noted between the Z -scores of BMC (mean ± SD: 0.31 ± 1.29 vs. −0.089 ± 0.61, p = 0.165), TBBMD (mean ± SD: −0.32 ± 1.21 vs. −0.27 ± 0.91, p = 0.76), or the LSBMD (mean ± SD: −0.183 ± 1.54 vs. −0.17 ± 0.87, p = 0.637) in subgroups, in accordance with time after therapy (subgroup I 2 years after treatment). In HD survivors, age at diagnosis only affected the TBBMD Z -score (a decrease of 0.127 in total BMD Z -score per each year, R 2 = 0.999, p Conclusions Childhood lymphoma survivors demonstrate no significant deficits in bone mass and tend to maintain their BMD within the normal range when presenting during one to five years’ follow-up. However, this specific group requires longitudinal investigation to assess the pattern of peak bone mass achievement and the risk of future bone loss.

Background Hypocitraturia is considered a major risk factor for calcium stone formation. However, there is no widely accepted reference database of urinary citrate excretion in children. The aim of our study was to determine the amount of citrate eliminated in the urine over a 24-h period in a pediatric cohort and to determine an optimal unit reflecting excretion. Methods The study cohort comprised 2,334 healthy boys and girls aged 2–18 years. The levels of urinary citrate were assessed by an enzymatic method in 24-hour urine and expressed in absolute values, as urinary concentration, citrate/creatinine ratio, per kilogram of body weight, in relation to 1.73 m2, and as the calcium/citrate index. Results Similar incremental age-related citraturia rates were observed in both male and female subjects until puberty during which time citrate excretion became significantly higher in girls. Urinary citrate adjusted for creatinine and for body weight showed a significantly decreasing trend with increasing age in both sexes. Urinary citrate corrected for body surface was weakly correlated with age. Thus, the assumption of 180 mg/1.73 m2/24 h for males and 250 mg/1.73 m2/24 h for females as lower cut-off values appeared to be reliable from a practical perspective. Conclusions We found distinct sex-dependent differences in citraturia at the start of puberty, with significantly higher values of urinary citrate in girls than in boys. Further prospective studies are warranted to elucidate whether this difference represents a differentiated risk of urolithiasis.

The serum levels of matrix metalloproteinase-9 (MMP-9) in neuropsychiatric disorders of adults have been widely investigated. So far, no studies have been conducted on the relationship of MMP-9 and cognitive domains in children with two phenotype models, attention deficit/hyperactivity disorder and hyperkinetic disorder (ADHD/HKD). The aim of this research was to evaluate and test the hypothesis that serum MMP-9 levels are associated with the severity of symptoms in children with ADHD/HKD and to compare the results in two models of this disorder. The study group comprised 37 Caucasian boys aged 7–12 years with HKD, being a subset of the combined ADHD subtype. Intellectual functions were measured using Wechsler Intelligence Scale for Children-Revised. The analysis of serum concentrations of MMP-9 was based on a quantitative sandwich ELISA. The statistical regression analysis revealed a correlation between increased serum MMP-9 levels and severity of symptoms in the ADHD (β = 0.33; p = 0.043) and HKD (β = 0.34, p = 0.037) model. According to the results, elevated levels of serum MMP-9 in boys with HKD may be associated with clinical impulsivity domain (β = 0.38; p = 0.019).

The definition and classification of Osteogenesis imperfecta (OI) have been transformed over the last two decades. In the past, it has been described as a type I collagenopathy due to identified mutations in COL1A1 and COL1A2 genes encoding collagen type I which led to all OI cases. At least 10 genes involved in the process of type I collagen biosynthesis have been described until now. COL1A1 / 2 genes are responsible for almost 90% of OI prevalence. However, there is a number of newly discovered genes which encode proteins involved in posttranslational modification of procollagen, whereas mutations in these genes lead to approximately 10% types of OI inherited recessively. In this review, we provide an update on the traditional Sillence classification of the disease and we also report recent developments in understanding of underlying mechanisms responsible for OI. The paper discusses currently published modification of the OI classification (new types of the disease: V–XV) and a new approach to the diagnostic methods focusing mainly on phenotypic manifestation, independent of the genetic or molecular background. We point out the importance of clinical symptoms and severity of the disorder of which both appear the most useful criteria for management of OI patients in everyday practice.

Perhaps the role of Vitamin D supplementation has been most exhaustively studied in calcium absorption, skeletal wellbeing, muscular potency, balance and risk of falling. Nonetheless, new data has emerged and the recent research on sarcopenia makes the topic increasingly interesting. Given the socioeconomic burden of the musculoskeletal consequences of hypovitaminosis D it is vital to keep abreast with the latest literature in the field. The recommended Vitamin D supplementation dose should suffice to increase the serum 25 hydroxyvitamin D level to 30 ng/mL (75 nmol/L) and this level should be optimally maintained with a maintenance dose, particularly for those diagnosed with osteoporosis.

Objective. We aimed to determine the prevalence of excess body mass in juvenile idiopathic arthritis (JIA) children and to investigate the influence of obesity into the early, subclinical changes in cardiovascular system in these patients.Methods. Fifty-eight JIA patients, aged median 13 years, were compared to 36 healthy controls. Traditional cardiovascular risk factors and inflammatory markers (hsCRP, IL-6, TNFα, adiponectin) were studied together with IMT (intima-media thickness), FMD (flow mediated dilation), and LVMi (left ventricle mass index) as surrogate markers of subclinical atherosclerosis.Results. Thirteen JIA children (22%) were obese and had increased systolic blood pressure, cholesterol, triglycerides, insulin, HOMA, hsCRP, and IL-6 compared to nonobese JIA and controls. FMD was decreased compared to nonobese JIA and controls, whereas IMT and LVMi were increased. In multivariate regression analysis, TNFα, SDS-BMI, and systolic blood pressure were independent predictors of early CV changes in JIA.Conclusions. Coincident obesity is common in JIA children and is associated with insulin resistance, dyslipidemia, and increased levels of inflammatory markers leading to early changes in cardiovascular system. Thus, medical care of children with JIA should include strategies preventing cardiovascular disease by maintenance of adequate body weight.

Background/Aim: Girls with anorexia nervosa (AN) demonstrate severe depletion of body fat. The aim of this study was to determine an accurate anthropometric measurement for clinical assessment of fat depletion in girls with AN in connection with body composition measured by dual-energy X-ray absorptiometry (DXA). Methods: In 64 female AN patients aged 12.8–23.1 years (mean 16.0 ± 1.8), body mass index (BMI), skinfold thickness (subscapular, abdominal and triceps), mid-upper arm and thigh circumference, fat mass (FM) and lean mass were determined and compared with the data of 71 controls. Results: Girls with AN had lower anthropometric traits and were fat depleted compared to controls (14.9 ± 7.3 vs. 27.4 ± 6.4% of FM using DXA; all p < 0.001). BMI, thigh circumference and subscapular skinfold thickness demonstrated a very similar predictive value for DXA assessment of body fat. Based on the receiver-operating characteristic curve analysis and the determination of the positive predictive value, thigh circumference appeared the most specific and sensitive anthropometric predictor of fatness discriminating between AN and healthy girls, with the AUC value reaching 0.95 (95% CI = 0.92–0.97). Using a cutoff value of 49.6 cm, accuracy was 90.6%, sensitivity 93% and specificity 88.7%. Conclusions: Thigh circumference strongly correlates with DXA-FM and demonstrates a slight clinical advantage over BMI. This simple measurement might also serve as a useful predictor of body fatness in adolescent girls with AN and should therefore be further evaluated in independent cohort studies.

The Bonn Risk Index has been used to evaluate the risk of urinary calcium oxalate stone formation. According to the original method, risk should be determined based on 24-hour urine collection. We studied whether the Bonn Risk Index could be measured in spot urine samples and which part of the day is most suitable for this purpose.We collected total and fractionated 24-hour urine (in a 6-hour nocturnal portion and 9 consecutive 2-hour diurnal samples) in 42 children and adolescents with calcium oxalate urolithiasis and 46 controls. Bonn Risk Index values determined from each of the urine fractions were compared to those obtained from related 24-hour urine collections.Both groups exhibited similar circadian patterns of Bonn Risk Index values. Median Bonn Risk Index for the nighttime portion of urine in the stone group was 1.4 times higher than that obtained from the total 24-hour urine. The morning hours between 08:00 and 10:00 showed the peak lithogenic risk, and this fraction had the highest sensitivity and selectivity regarding discrimination between stone formers and healthy subjects. The afternoon hours demonstrated lower and less fluctuating crystallization risk. Despite diurnal fluctuations in Bonn Risk Index, there was still a well-defined cutoff between the groups.Bonn Risk Index determined from urine samples collected between 08:00 and 10:00 appears optimal in separating stone formers from healthy subjects, and appears as useful as the value determined from 24-hour urine collection. Investigation of this diurnal sample simplifies diagnosis in pediatric stone disease without loss of clinical information.

Purpose: The Bonn Risk Index has been used to evaluate the risk of urinary calcium oxalate stone formation. According to the original method, risk should be determined based on a 200 ml urine sample taken from a 24-hour collection. We evaluated whether the Bonn Risk Index can also be effectively determined in small urine samples. Materials and Methods: We studied 190 children and adolescents with nocturia and calcium oxalate urolithiasis. Initially Bonn Risk Index was determined according to the original method of Laube. Subsequently Bonn Risk Index was calculated using a computer program controlling a specially designed system to define the time point of induced crystallization based on consecutive urine samples of 1.5, 2.0 and 3.0 ml. Results: No significant differences were found in Bonn Risk Index between values obtained from 200 ml samples and those based on the micromethod with urine samples of 2 and 3 ml. Conclusions: Assessment of risk of urinary calcium oxalate stone formation with Bonn Risk Index in small urine volumes, based on prototype equipment controlled by specialized computer software, is comparable to the original method. This finding facilitates the procedure and improves Bonn Risk Index determination in children.

Home visits by doctors and nurses are considered an important indicator of the quality of healthcare. Published data are scarce regarding the role of family nurses in providing professional home care in Central and Eastern European countries that have recently introduced reforms to their primary care systems. The objective of the present study was to describe the involvement of family nurses in home visits in the context of organizational and legal changes in service provision, that is, to analyse the role of the family nurses employed by family doctors (1998) versus family nurses working in autonomous positions (2002 and 2006). The proportion of patients in the community receiving a home visit from a family nurse, the purpose of the family nurse's home visit and patient expectations towards the family nurse were studied. A series of cross-sectional studies were conducted in a small town in northeastern Poland, based on three consecutive surveys taken at 4-year intervals (1998, 2002, 2006, surveys I, II and III, respectively). During each survey, 1000 patients were interviewed (face to face) with structured questionnaires. In 1998, family nurses were employed by family doctors, but by 2002, nurses had established their own practices and held direct contracts with the National Health Fund. A significant increase in the percentage of patients receiving home visits from a family nurse was observed between surveys I and II (12.8% and 30.0%); however, the number of respondents reporting a home visit in survey III decreased to 23.9%. Patients over 75 years of age were the major demographic group receiving family nursing at home. This study suggests that reform of the primary healthcare system in Poland has produced changes in the family nursing system. Independence, contractual obligations and self-employment of Polish family nurses have resulted in their greater participation in home visits.

Objective. The aim of the study was to determine how the time factor affected the patients' perception of the acceptability of the primary health care system and to assess their satisfaction with family physician care. Design. A series of cross-sectional studies was conducted in 1998, 2002 and 2006, using face-to-face interviews with struc- tured questionnaires. Setting. The study was performed in Gizycko, Poland, where family physician services were introduced in 1995. Study participants. Three surveys were conducted, each involving 1000 subjects. Every time, random sample was taken, after selecting a subgroup of patients using medical service within the previous week. Main measures. Acceptability of the primary health care system (accessibility, the patient - practitioner relationship, the ame- nities of care, patient's preferences), perception of the changes in primary care and overall satisfaction with family physician care. Results. Between 1998 and 2002, an improvement was noted, lasting till 2006, in such accessibility components as the possi- bility of making an appointment by phone or at a definite hour. Some aspects of the patient - doctor relationship indicate that family physician care is directed at illness rather than health-oriented. The level of patient satisfaction was high. Conclusions. Generally, patients are satisfied with primary care reform and implementation of the family physician system. However, it is easier to improve accessibility of services than physician's personal qualities and the patient- practitioner relationship. Expressive functions of a physician (listening and reassuring) and activities regarding health promotion require special attention in the process of education of family physicians.

Cel W ciągu minionych 30 lat wzrosla czestośc wystepowania otylości u dzieci. Celem pracy byla ocena czestości wystepowania nadwagi i otylości u dzieci w okresie wczesnoszkolnym, w zalezności od stosowanych metod. Metody W losowo wybranych szkolach podstawowych Bialegostoku przeprowadzono przekrojowe badanie 1304 dzieci (604 dziewcząt, 700 chlopcow) w wieku 7–9 lat. Na podstawie zmierzonych cech antropometrycznych wyliczono BMI. Czestośc wystepowania nadwagi i otylości określono za pomocą dwoch niezaleznych metod interpretacji BMI: wg norm Instytutu Matki i Dziecka w Warszawie oraz kryteriow International Obesity Task Force (IOTF) opracowanymi przez Cole’a i wsp. Wyniki Stwierdzono istotne roznice w czestości wystepowania nadwagi i otylości w zalezności od przyjetych definicji. Przyjmując kryteria IOTF czestośc wystepowania nadwagi i otylości byla wieksza w porownaniu z polskimi wartościami referencyjnymi (odpowiednio 21,9% i 16,8%). Stwierdzono nieznacznie czestsze ich wystepowanie u chlopcow niz u dziewcząt: odpowiednio 22,9% (w tym otylośc 6,0%) vs 20,7% (w tym otylośc 4,5%) wg kryteriow IOTF. Wnioski Nadwaga i otylośc w okresie wczesnoszkolnym wśrod dzieci bialostockich wystepują cześciej niz w podobnych badaniach przeprowadzonych w innych miastach Polski. Ocena skali zjawiska zalezy w znacznym stopniu od zastosowanych kryteriow oceny BMI. Obowiązujące w Polsce normy diagnostyczne otylości u dzieci, opartych na siatkach BMI, niedoszacowują jej wystepowania w porownaniu z kryteriami IOTF. Moze to skutkowac istotnymi rozbieznościami w ocenie ryzyka populacyjnego otylości.

Bonn Risk Index (BRI) is being used for the assessment of urinary calcium oxalate (CaOx) crystallization. There are no published data regarding BRI during growth. The objective of this study was to establish age- and sex-dependent BRI values in healthy children and adolescents. A total of 1,050 Caucasian subjects aged 3–18 years (525 males, 525 females) without a history of kidney stone disease were enrolled in the cross-sectional study. The study group was divided into 15 ranges according to age, each comprising 70 subjects. Urinary ionized calcium [Ca2+] was measured using a selective electrode while the onset of spontaneous crystallization was determined using a photometer and titrating with 40 mmol/L ammonium oxalate (Ox2−). The calculation of BRI value was based on the ratio of [Ca2+] to the required amount of ammonium oxalate added to 200 ml of urine to induce crystallization. The median BRI was 0.26 1/L and the values of the 5th and 95th percentiles were 0.06 1/L and 1.93 1/L, respectively. BRI correlated positively with body-area-related BRI (1/L × 1.73 m2) (R = 0.18; P

Background The number of survivors of childhood cancer has increased. Several studies in children and adults have shown relationships between lean mass (LM), fat mass (FM), and bone mineral content (BMC). The objective of the study was to examine the association between body composition and bone mass in young survivors of childhood cancer. Methods Sixty-eight postpubertal participants (31 females and 37 males) aged between 15.5 and 27 years who were at least 5 years after completion of treatment for leukemia (n = 30), lymphoma (n = 28), or solid tumors (n = 10) were studied. Anthropometry was performed and dual energy X-ray absorptiometry (DXA) was used to assess BMC in the total body (T) and lumbar spine (S), FM, and LM. Results There were no observed differences in age or time for cessation of treatment. Body mass index (BMI) was a strong determinant of bone mass in both sexes. TBMC correlated positively with LM (males r = 0.9 and females r = 0.76; P

The aim of the study was to identify associations between fractures in childhood and family, anthropometric and lifestyle factors. Among 1,246 subjects aged 16.3-20.6 years (539 boys, 707 girls), based on a questionnaire, 869 were fracture-free while 377 (30.26%) had fractures. Of those reporting fractures, 146 reported multiple fractures (12% of studied population, 39% of all fractures). More boys had fractures than girls (35.6% vs 24.9%, p < 0.001). Fracture sites included: forearm (37%), fingers (23%) wrist (16%), ankle (14%), humerus (10%), tibia (8%) clavicle (7%) and femoral shaft / neck (3%). Among adolescents with multiple fractures, 52% also reported fractures in at least one family member, compared with 29% of those without a fracture history. Fractures in siblings and mothers (but not fathers) accounted for 44% of the liability in adolescents' fractures. Subjects with multiple fractures reported more time at the computer than those without fractures and reported more time participating in team sports, and 18.6% avoided milk, whereas 12.4% of those without fractures reported milk-free diets. Using a logistic regression model, none of the lifestyle factors, except for computer use, were independently associated with fractures. Fractures, particularly multiple fractures, are common in childhood and adolescence. Familial clustering of fractures suggests shared genetic and environmental factors are responsible.

Childhood cancer survivors are in augmented risk for developing obesity. For many factors leptin and leptin receptor gene polymorphism play an important role in the development and metabolism not only of fat, but also, bone tissue. The aim of the analysis was to find the relationships between Q223R, leptin levels, and anthropometric parameters.Patients and Methods. In the study 74 cancer survivors participated (ALLn=64, lymphomasn=10), and the control group consisted of 51 healthy peers. Leptin blood concentration was determined by ELISA method. To estimate leptin receptor gene polymorphism, RFLP method was used. Bone mineral density (BMD) and content (BMC), fat, and lean tissue measurements were obtained by DXA.Results. We found no correlations between serum leptin concentrations and anthropometric parameters nor BMD. Serum leptin concentrations were significantly lower in the group of cancer survivors compared to controls; however, in those overweight from examined group we found leptin levels higher than those in nonoverweight. Genotype Q223R was not associated with higher leptin levels, BMI, BMD, body fat or lean tissue.Conclusion. To our knowledge, this is the first report describing the relationship between BMD and Q223R polymorphism in childhood cancer survivors. Further analysis, based on a larger group of patients, is needed to confirm these findings.

Wstep: Wyniki badan z ostatnich lat dokumentują wiele korzyści wynikających z dzialania witaminy D na organizm czlowieka na wszystkichetapach jego zycia. Wiekszośc badan epidemiologicznych sugeruje, ze niedobor witaminy D jest powszechny wśrod mieszkancow EuropyŚrodkowej. Naturalną konsekwencją tej sytuacji jest koniecznośc ciąglego uświadamiania spoleczenstwu oraz środowisku medycznemu,jaką role odgrywa witamina D w rozwoju i funkcjonowaniu organizmu ludzkiego. Metody: Na podstawie przeglądu danych literaturowych Polski Zespol Wielodyscyplinarny opracowal tezy dotyczące zasad suplementacjiwitaminą D, ktore przeslano do czlonkow Komitetu Naukowego konferencji „Witamina D — minimum, maksimum, optimum”,19–20 Październik, 2012, Warszawa. W trakcie powyzszej konferencji z udzialem 550 delegatow oraz Ekspertow roznych dziedzin medycynyomowiono i przedyskutowano propozycje wytycznych suplementacji witaminą D populacji Europy Środkowej. Wyniki: W efekcie przeprowadzonych dyskusji Zespol Ekspertow opracowal wytyczne suplementacji witaminą D dla wszystkich grupwiekowych populacji Europy Środkowej. Określono rowniez kryteria diagnostyczne charakteryzujące stan zaopatrzenia organizmu w witamine D: deficyt witaminy D ustalono jako stezenie 25(OH)D < 20 ng/mL (< 50 nmol/L)], suboptymalne zaopatrzenie jako stezenie25(OH)D wynoszące 20–30 ng/mL (50–75 nmol/L), a stezenie 30–50 ng/mL (75–125 nmol/L) uznano za docelowe dla zapewnienia efektuplejotropowego witaminy D. Wnioski: Poprawa obecnego stanu zaopatrzenia witaminy D w grupach dzieci, mlodziezy, osob aktywnych zawodowo i seniorowpowinna zostac wlączona do priorytetow polityki zdrowotnej spoleczenstw Europy Środkowej.

The objective of this study was to investigate the vascular status, left-ventricular mass and biomarkers of endothelial activation in hypertensive (HT) adolescents, with particular attention to comparing nonobese with obese patients. Seventy-nine newly diagnosed HT adolescents aged 15.1±2.1 years (divided into 34 nonobese and 45 obese) were compared with 35 healthy volunteers. Intima-media thickness (IMT), flow-mediated dilation (FMD) and left-ventricular mass index (LVMi) were determined using ultrasound. Adhesion molecules and inflammatory interleukins (ILs), together with lipids and insulin resistance (HOMA), were also studied. HT obese adolescents had higher triglycerides, HOMA, and elevated levels of interleukin-6, tumor necrosis factor-α, soluble intercellular adhesion molecule-1 and soluble E-selectin compared with controls and nonobese HT patients. FMD was lower in HT groups (8.5±4.5% in nonobese, P=0.004; 8.1±4.9%, P=0.01 in obese vs 12.5±4.9%; in control), and IMT was higher (0.52±0.06 mm, P

Childhood acute lymphoblastic leukemia (ALL) survivors represent a specific group at risk for many health problems, including skeletal complications and osteoporosis. The objective of this study was to assess the risk of osteoporosis associated with the prevalence of low bone mass (according to the guidelines of the Pediatric Official Positions of the International Society for Clinical Densitometry 2007) in survivors of childhood ALL. The cross-sectional study was conducted in a cohort of 69 Caucasian children and adolescents (46 boys and 23 girls) aged 12.15 ± 0.5yr diagnosed with ALL and screened up to 5 yr after cessation of the treatment. Total body bone mineral content (TB BMC, g), total body bone mineral density (TB BMD, g/cm(2)), and lumbar spine BMD (LS BMD, g/cm(2)) were determined using dual-energy X-ray absorptiometry. Time interval from the completion of the treatment to the beginning of this study (subgroup I2 yr or subgroup II2 yr after treatment), methotrexate (MTX) doses (subgroup I-MTX ranging from 0.5 to 1.0g/m(2); subgroup II-MTX2.0 g/m(2)), cranial irradiation (subgroup I-without radiotherapy (RTX) and subgroup II receiving RTX of 12-18 Gy), cumulative steroid dose, and impaired endocrine function were considered as potential factors affecting bone metabolism and included in the analysis. No differences were found in bone traits (BMC, TB BMD, LS BMD) in relation to examined risk factors. In multiple regression model that included therapeutical factors, a risk group and central nervous system irradiation were of an important influence on bone mass, and risk group predicted TB BMD in small degree. Risk group and irradiation status lost their significance after the inclusion of anthropometric, age-connected, and time-connected factors. This study suggests that ALL survivors are not at increased risk for low bone mass. However, from the clinical perspective all patients after childhood ALL should be screened for clinical signs, fracture history, and lifestyle risk factors for low bone mass and osteoporosis. They should be referred to bone density evaluation only as often as may be necessary from the clinical evaluation.

Background: Although autistic spectrum disorders (ASD) are a strongly genetic condition certain metabolic disturbances may contribute to clinical features. Metabolism of oxalate in children with ASD has not yet been studied. Aim: The objective was to determine oxalate levels in plasma and urine in autistic children in relation to other urinary parameters. Method: In this cross-sectional study, plasma oxalate (using enzymatic method with oxalate oxidase) and spontaneous urinary calcium oxalate (CaOx) crystallization (based on the Bonn-Risk-Index, BRI) were determined in 36 children and adolescents with ASD (26 boys, 10 girls) aged 2e18 years and compared with 60 healthy non-autistic children matched by age, gender and anthropometric traits. Results: Children with ASD demonstrated 3-fold greater plasma oxalate levels [5.60 (5the95th percentile: 3.47e7.51)] compared with reference [(1.84 (5the95th percentile: 0.50e4.70) mmol/L ( p < 0.05)] and 2.5-fold greater urinary oxalate concentrations ( p < 0.05). No differences between the two groups were found in urinary pH, citraturia, calciuria or adjusted CaOx crystallization rates based on BRI. Despite significant hyperoxaluria no evidence of kidney stone disease or lithogenic risk was observed in these individuals. Conclusions: Hyperoxalemia and hyperoxaluria may be involved in the pathogenesis of ASD in children. Whether this is a result of impaired renal excretion or an extensive intestinal absorption, or both, or whether Ox may cross the blood brain barrier and disturb CNS function in the autistic children remains unclear. This appears to be the first report of plasma and urinary oxalate in childhood autism.

Chronic liver disease in adults is a risk factor of osteoporosis, but little is known about risk of fractures in children with non-cholestatic liver disease. The aim of this study was to investigate associations among the severity of liver fibrosis, bone mass and low-energy fractures in children. History of fractures, anthropometry, and bone mass and size were examined in 39 Caucasian children (25 boys, 14 girls) aged 7.1–18 years (mean 11.9 ± 3.1) with chronic hepatitis B and liver fibrosis evidenced by liver biopsy. Severity of liver fibrosis was based on histological classification according to the method of Batts and Ludwig (mild, 1–2 scores; advanced, 3 scores) and Ishak (1–3 and 4–5 scores, respectively). Bone mineral content (BMC), density (BMD) and body composition were determined in the total body and lumbar spine using dual energy X-ray absorptiometry. Seven subjects (4 girls, 3 boys; 18% of the sample) had low BMD in the total body and lumbar spine region (Z-scores below −2.0). No associations were found among BMC, BMD, bone size and the severity of liver fibrosis. Nine boys (36% of all boys) and one girl reported repeated fractures (forearm, wrist, tibia, ankle, humerus), showing trends similar to the prevalence in general population. Fractures were neither associated with lower BMD/BMC nor with scores of liver fibrosis. Deficits in BMD in children with chronic hepatitis B are not associated with the severity of liver fibrosis. This study suggests that non-cholestatic liver disease does not increase the risk of low-energy fractures during growth. From the practical perspective, however, children with chronic liver disease should be screened for history and clinical risk factors for fractures rather than referred to bone density testing.

Cancer disease and its therapy (e.g., chemotherapeutic agents such as glucocorticoids, methotrexate, antymetabolities, cranial and local irradiation) may severely disturb normal growth, bone mineral acquisition, and skeletal development because most individuals go through the stages of rapid growth when childhood cancer is diagnosed.To identify factors associated with reduced bone mineral density (BMD) in survivors of childhood cancer the authors examined 114 patients (70 males) who had been treated for acute lymphoblastic leukemia (ALL; n = 43), Hodgkin disease (HD; n = 35), and solid tumors (ST; n = 36) twice. Median age at diagnosis was 8.4 years; at the consecutive examinations it was 12.8 and 16.3 years, respectively. To assess bone density we used dual-energy x-ray absorptiometry (DXA).In the first examination, patients with a history of steroid therapy had higher total and spine BMD and higher BMI (body mass index) than those who were not given steroids. At the end of the follow-up, no differences were found in BMD between subgroups, although BMI was still higher in both ALL and HD patients than in those with ST.Patients treated for solid tumors have reduced bone mass. Low BMI and local irradiation seem to be the factors responsible for reduced BMD in children treated for ST. The use of steroids does not disturb bone mass accumulation in patients treated for childhood malignancies. However, a long-term effect of cancer treatment on osteoporosis risk remains to be determined.

Purpose: Our objective was to assess bone and muscular mass in children with meningomyelocele (MMC), and to analyze risk factors for osteoporosis and fractures based on densitometric examination. Material and Methods: The study group included 30 patients (15 girls and 15 boys) with MMC, aged 6–17 years, treated in the Department of Pediatric Rehabilitation, University Hospital. Physiotherapeutic assessment and laboratory tests (serum parathormone, alkaline phosphatase levels, calcium, and phosphate levels, and urine calcium levels) were performed. Densitometry was measured by dual energy X-ray absorptiometry using a Lunar DPX-L apparatus. Lean mass (fat-free tissue content) and fat mass (% fat content) was evaluated. Results: Femur fractures were the most common 12/30 (40%); 5/30 (17%) of the children with MMC had multiple fractures. The incidence of fractures correlated significantly with BMI and body fat content (p = 0.03) Children with MMC and fractures had a tendency toward higher BMI, despite the same absolute value of body mass, compared to those without fractures. Body fat levels were higher in MMC patients with fractures than in those without fractures (BMI R = 0.393, p = 0.03). Children with MMC and fractures had significantly higher 24 h calcuria values, despite normal renal function indices (p = 0.03). Conclusions: Low-energetic fractures in MMC children may result from metabolic disturbances that are a consequence of excessive renal calcium loss or excessive fatty tissue content.

Idiopathic hypercalciuria is the most important predisposing risk factor for calcium oxalate (CaOx) renal stone formation. We assessed the associations between spontaneous CaOx crystallization based on the Bonn Risk Index (BRI), urinary pH, calciuria, oxaluria, and citraturia in 140 Caucasian patients with hypercalciuria, aged 4-17 years, and compared the findings with those in 210 normocalciuric controls. Of the 140 hypercalciuric patients, 58 had renal stones, and 82 had recurrent erythrocyturia, renal colic, or urinary obstructive symptoms-but without stones. Urinary ionized calcium ([Ca(2+)]) levels were measured using a selective electrode, while the onset of crystallization was determined using a photometer and titration with 40 mmol/L ammonium oxalate (Ox(2-)). The calculation of the BRI was based on the [Ca(2+)]:Ox(2-) ratio. The BRI values were 12-fold higher in hypercalciuric children than in healthy controls, but no differences were found in the BRI between subjects with urinary stones and those with urolithiasis-like symptoms. An increased BRI suggested an association with hypercalciuria, lower urinary pH, hypocitraturia, and hypooxaluria. These data indicate that hypercalciuria is an important factor associated with increased urinary CaOx crystallization, although the causal pathways need further investigation. Determination of the BRI in children with hypercalciuria may improve the risk assessment of kidney stones.