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1.  Low sensitivity of the metabolic syndrome to identify adolescents with impaired glucose tolerance: an analysis of NHANES 1999–2010 
Background
The presence of impaired glucose tolerance (IGT) and metabolic syndrome (MetS) are two risk factors for Type 2 diabetes. The inter-relatedness of these factors among adolescents is unclear.
Methods
We evaluated the sensitivity and specificity of MetS for identifying IGT in an unselected group of adolescents undergoing oral glucose tolerance tests (OGTT) in the National Health and Nutrition Evaluation Survey 1999–2010. We characterized IGT as a 2-hour glucose ≥140 mg/dL and MetS using ATP-III-based criteria and a continuous sex- and race/ethnicity-specific MetS Z-score at cut-offs of +1.0 and +0.75 standard deviations (SD) above the mean.
Results
Among 1513 adolescents, IGT was present in 4.8%, while ATP-III-MetS was present in 7.9%. MetS performed poorly in identifying adolescents with IGT with a sensitivity/specificity of 23.7%/92.9% for ATP-III-MetS, 23.6%/90.8% for the MetS Z-score at +1.0 SD and 35.8%/85.0 for the MetS Z-score at +0.75 SD. Sensitivity was higher (and specificity lower) but was still overall poor among overweight/obese adolescents: 44.7%/83.0% for ATP-III-MetS, 43.1%/77.1% for the MetS Z-score at +1.0 SD and 64.3%/64.3% for MetS Z-score at +0.75 SD.
Conclusion
This lack of overlap between MetS and IGT may indicate that assessment of MetS is not likely to be a good indicator of which adolescents to screen using OGTT. These data further underscore the importance of other potential contributors to IGT, including Type 1 diabetes and genetic causes of poor beta-cell function. Practitioners should keep these potential causes of IGT in mind, even when evaluating obese adolescents with IGT.
doi:10.1186/1475-2840-13-83
PMCID: PMC4000320  PMID: 24755002
Insulin resistance; Metabolic syndrome; Impaired glucose tolerance; Type 2 diabetes; Adolescents
2.  Developing Clinical Strength-of-Evidence Approach to Define HIV-Associated Malignancies for Cancer Registration in Kenya 
PLoS ONE  2014;9(1):e85881.
Background
Sub-Saharan Africa cancer registries are beset by an increasing cancer burden further exacerbated by the AIDS epidemic where there are limited capabilities for cancer-AIDS match co-registration. We undertook a pilot study based on a “strength-of-evidence” approach using clinical data that is abstracted at the time of cancer registration for purposes of linking cancer diagnosis to AIDS diagnosis.
Methods/Findings
The standard Nairobi Cancer Registry form was modified for registrars to abstract the following clinical data from medical records regarding HIV infection/AIDS in a hierarchal approach at time of cancer registration from highest-to-lowest strength-of-evidence: 1) documentation of positive HIV serology; 2) antiretroviral drug prescription; 3) CD4+ lymphocyte count; and 4) WHO HIV clinical stage or immune suppression syndrome (ISS), which is Kenyan terminology for AIDS. Between August 1 and October 31, 2011 a total of 1,200 cancer cases were registered. Of these, 171 cases (14.3%) met clinical strength-of-evidence criteria for association with HIV infection/AIDS; 69% (118 cases were tumor types with known HIV association – Kaposi’s sarcoma, cervical cancer, non-Hodgkin’s and Hodgkin’s lymphoma, and conjunctiva carcinoma) and 31% (53) were consistent with non-AIDS defining cancers. Verifiable positive HIV serology was identified in 47 (27%) cases for an absolute seroprevalence rate of 4% among the cancer registered cases with an upper boundary of 14% among those meeting at least one of strength-of-evidence criteria.
Conclusions/Significance
This pilot demonstration of a hierarchal, clinical strength-of-evidence approach for cancer-AIDS registration in Kenya establishes feasibility, is readily adaptable, pragmatic, and does not require additional resources for critically under staffed cancer registries. Cancer is an emerging public health challenge, and African nations need to develop well designed population-based studies in order to better define the impact and spectrum of malignant disease in the backdrop of HIV infection.
doi:10.1371/journal.pone.0085881
PMCID: PMC3900436  PMID: 24465764
3.  Predictors of Retention and BMI Loss or Stabilization in Obese Youth Enrolled in a Weight Loss Intervention 
Objective
To evaluate predictors for intervention dropout and successful reduction of metabolic syndrome risk factors among obese children enrolled in a short-term, clinic-based weight-loss intervention.
Design, Setting, Subjects
Retrospective database review of 1080 children 8 months-17 y.o. seen a a pediatric obesity clinic.
Interventions
Behavior modification counseling to induce change in dietary and exercise choices.
Main Outcome Measures
1). Pre-/post-intervention change in body mass index (BMI), waist circumference, blood pressure, glucose, insulin, and cholesterol (LDL, HDL, & total). 2) Predictors of successful decrease in BMI and clinic drop-out.
Analysis
Paired t-tests for pre-/post-intervention comparisons. Linear regression to assess predictors of success and predictors of drop-out, with adjustment for age, gender, race, insurance status, and service area.
Results
Among children evaluated, adolescent females were most likely to achieve successful decrease in BMI, insulin level, and LDL cholesterol post-intervention. Nearly 40% of children dropped out early in the intervention. Predictors of drop out included age <6y, public insurance status, follow-up scheduled during summer months, and residence in a tertiary service area.
Conclusions
Clinic-based weight loss interventions can lead to successful improvements in BMI and other metabolic parameters in pediatric populations and may be more likely among adolescent females than in younger children or males. Drop-out is common, particularly among younger children, children with public insurance and children scheduled for follow-up in the summer. Identification of these drop-out predictors in individual patients may help in targeting children likely to succeed in short-term, clinic-based, weight-loss interventions.
doi:10.1016/j.orcp.2011.08.157
PMCID: PMC3501750  PMID: 23181148
obesity; weight loss; child; adolescent
4.  Avoiding bias in mixed model inference for fixed effects 
Statistics in Medicine  2011;30(22):2696-2707.
Analysis of a large longitudinal study of children motivated our work. The results illustrate how accurate inference for fixed effects in a general linear mixed model depends on the covariance model selected for the data. Simulation studies have revealed biased inference for the fixed effects with an underspecified covariance structure, at least in small samples. One underspecification common for longitudinal data assumes a simple random intercept and conditional independence of the within-subject errors (i.e., compound symmetry). We prove that the underspecification creates bias in both small and large samples, indicating that recruiting more participants will not alleviate inflation of the Type I error rate associated with fixed effect inference. Enumerations and simulations help quantify the bias and evaluate strategies for avoiding it. When practical, backwards selection of the covariance model, starting with an unstructured pattern, provides the best protection. Tutorial papers can guide the reader in minimizing the chances of falling into the often spurious software trap of nonconvergence. In some cases, the logic of the study design and the scientific context may support a structured pattern, such as an autoregressive structure. The sandwich estimator provides a valid alternative in sufficiently large samples. Authors reporting mixed-model analyses should note possible biases in fixed effects inference because of the following: (i) the covariance model selection process; (ii) the specific covariance model chosen; or (iii) the test approximation.
doi:10.1002/sim.4293
PMCID: PMC3396027  PMID: 21751227
compound symmetry; longitudinal data; random effects; type I error
5.  Long-term Cognition, Achievement, Socioemotional, and Behavioral Development of Healthy Late-Preterm Infants 
Objective
To compare healthy late-preterm infants with their full-term counterparts from age 4 through 15 years for numerous standard cognitive, achievement, socioemotional, and behavioral outcomes.
Design
Prospective cohort study.
Setting
National Institute of Child Health and Development Study of Early Child Care and Youth Development, 1991–2007.
Participants
A total of 1298 children (53 born at 34–36 weeks’ gestational age), and their families, observed from birth through age 15 years. None of the infants had major health problems before or immediately following birth, and all the infants were discharged from the hospital within 7 days.
Main Exposure
Preterm status: children born late pre-term (34–36 weeks) vs those born full term (37–41 weeks).
Main Outcome Measures
Eleven standard outcomes measuring cognition, achievement, social skills, and behavioral/emotional problems using the Woodcock-Johnson Psycho-Educational Battery–Revised and the Child Behavior Checklist, administered repeatedly through age 15 years.
Results
No consistent significant differences were found between late-preterm and full-term children for these standard measures from ages 4 to 15 years. Through age 15 years, the mean difference of most of these outcomes hovered around 0, indicating, along with small confidence intervals around these differences, that it is unlikely that healthy late-preterm infants are at any meaningful disadvantage regarding these measures.
Conclusion
Late-preterm infants born otherwise healthy seem to have no real burdens regarding cognition, achievement, behavior, and socioemotional development throughout childhood.
doi:10.1001/archpediatrics.2010.83
PMCID: PMC3287072  PMID: 20530302
6.  Racial/Ethnic and Gender Differences in the Relationship between Uric Acid and Metabolic Syndrome in Adolescents: An Analysis of NHANES 1999–2006 
Metabolism  2011;61(4):554-561.
Background
Among adolescents uric acid is associated with insulin resistance, hypertension and the metabolic syndrome (MetS) and in adults high uric acid levels are an independent risk factor for cardiovascular disease and diabetes.
Objective
Determine whether the relationship of uric acid with MetS varies in adolescents by race/ethnicity and gender.
Methods
We used linear regression to evaluate associations between uric acid and other MetS-associated clinical and laboratory measures among 3,296 non-Hispanic-white, non-Hispanic-black and Hispanic adolescents age 12–19y participating in the National Health and Nutrition Evaluation Survey (1999–2006).
Results
Overall, non-Hispanic-white males and females had the highest uric acid levels among the three racial/ethnic groups. In each racial/ethnic group there were higher uric acid levels for those adolescents with vs. without MetS. However, the extent of the MetS-related increase in uric acid level varied by race and gender. Among males, MetS was associated with the greatest increases in uric acid among non-Hispanic whites. However, among females, the MetS-related increase in uric acid was greatest among non-whites. Non-Hispanic-white females exhibited the lowest degrees of correlation between levels of uric acid and MetS-associated variables. Uric acid levels did not correlate with insulin levels in non-Hispanic-white females.
Conclusions
These data suggest the relationship between uric acid and MetS varies by race/ethnicity and gender. In particular, non-Hispanic-white males exhibit a strong relationship and non-Hispanic-white females exhibit a relatively poor correlation between uric acid and MetS-related factors. These data may have implications for the use of uric acid as a marker of future risk among adolescents.
doi:10.1016/j.metabol.2011.09.003
PMCID: PMC3262070  PMID: 22000606
obesity; insulin resistance; hypertension
7.  Low Sensitivity for the Metabolic Syndrome to Detect Uric Acid Elevations in Females and Non-Hispanic-Black Male Adolescents: An Analysis of NHANES 1999-2006 
Atherosclerosis  2011;220(2):575-580.
Background
Uric acid is tightly linked to the metabolic syndrome (MetS) and among adults higher uric acid levels are associated with future risk for diabetes, cardiovascular disease, hypertension and renal disease.
Objective
Evaluate the sensitivity of MetS to identify adolescents with elevated uric acid levels on a race/ethnicity and gender-specific basis.
Methods
We evaluated 3,296 males and female adolescents 12-19y participating in the National Health and Nutrition Evaluation Survey ‘99-’06, comprised of 67.6% non-Hispanic whites, 15.1% non-Hispanic blacks, and 17.3% Hispanics. We used a definition of MetS modified for use in adolescents and evaluated the sensitivity of a diagnosis of MetS to identify individuals with uric acid elevations (approximately the 95th percentile of uric acid by gender among normal-weight adolescents).
Results
When used as a screening test to identify individuals with uric acid elevations MetS performed more poorly among females (18.0%) than among males (37.0%)(p<0.001). Among males, MetS exhibited a lower sensitivity among non-Hispanic blacks (17.8%) compared to Hispanics (45.9%)(p<0.01) and non-Hispanic whites (37.4%)(p<0.05). There were no race/ethnicity differences in detecting elevated uric acid levels among females (non-Hispanic-white 15.5%, non-Hispanic-black 19.4%, Hispanic 26.5%, p>0.05).
Conclusion
Current criteria to diagnose MetS exhibit racial/ethnic and gender differences in the ability to identify adolescents with elevated uric acid levels, performing poorly among non-Hispanic-black males and among females. Given emerging data regarding the ability of uric acid elevations for predicting future disease, these data may have implications regarding the use of MetS as a marker of risk among all gender and racial/ethnic groups.
doi:10.1016/j.atherosclerosis.2011.11.033
PMCID: PMC3321243  PMID: 22178428
metabolic syndrome; uric acid; adolescents; insulin resistance; cardiovascular disease risk
8.  Hypothermia increases interleukin-6 and interleukin-10 in juvenile endotoxemic mice 
Objective
To develop a juvenile mouse model to establish effects of in vivo hypothermia on expression of the inflammation-modulating cytokines tumor necrosis factor-α, interleukin-1β, interleukin-6, and interleukin-10. Although induced hypothermia is neuroprotective in some patients, the mechanisms of protection are not well understood and concerns remain over potential detrimental effects, particularly in the setting of infection. We previously showed that in vitro hypothermia increases production of tumor necrosis factor-α and interleukin-1β in lipopolysaccharide-treated monocytes.
Design
Laboratory investigation.
Setting
Research laboratory.
Subjects
Juvenile (4-wk) male C57BL/6 mice.
Interventions
Mice were given chlorpromazine to suspend thermoregulation and lipopolysaccharide to stimulate cytokine production. Core temperature was maintained at 32°C or 37°C for 6 hrs by adjusting environmental temperature. In separate experiments, lipopolysaccharide-treated mice were kept in a cooling chamber without chlorpromazine treatment.
Measurements and Main Results
Plasma and organs were collected for cytokine quantitation. Chlorpromazine-treated hypothermic mice had 2.3-fold and 1.8-fold higher plasma interleukin-6 and interleukin-10 levels at 6 hrs compared with identically treated normothermic mice (p < .05), whereas plasma tumor necrosis factor-α and interleukin-1β were not significantly different at 2 hrs or 6 hrs. Liver tumor necrosis factor-α and interleukin-6 were significantly higher in hypothermic vs. normothermic mice, but lung and brain cytokines were not different. Lipopolysaccharide-treated mice kept in a cooling chamber without chlorpromazine treatment developed varying degrees of hypothermia with associated increases in plasma interleukin-6 and interleukin-10. A nonspecific marker of stress (plasma corticosterone) was not affected by hypothermia in lipopolysaccharide-treated mice.
Conclusion
Further studies are necessary to determine the mechanism and physiologic consequences of augmented systemic interleukin-6 and interleukin-10 expression during induced hypothermia.
doi:10.1097/PCC.0b013e3181b01042
PMCID: PMC3552185  PMID: 19602992
hypothermia; cytokines; interleukin-10; interleukin-6; endotoxin
9.  Risk of Childhood Asthma in Relation to the Timing of Early Child Care Exposures 
The Journal of pediatrics  2009;155(6):781-787.e1.
Objective
To examine whether early child care exposure influences the risk of developing asthma.
Study design
Longitudinal data from 939 children and their families from the National Institute of Child Health and Development (NICHD) Study of Early Child Care and Youth Development (SECCYD) were analyzed. Exposure to other children in the primary child care setting as an infant (before 15 months) and as a toddler (16–36 months) were assessed as risk factors for persistent or late-onset asthma by age 15 via logistic regression.
Results
The number of children in the child-care environment when the child was a toddler was significantly associated with odds of asthma, even after adjusting for respiratory illnesses and other risk factors (p<.05). The fewer the children exposed to as toddlers, the higher the probability of persistent or late-onset asthma by age 15.
Conclusions
This study supports the theory of a protective effect of exposure to other children at an early age, especially as a toddler, on the risk of asthma. This effect appears to be independent of the number of reported respiratory tract illnesses, suggesting that other protective mechanisms related to the number of children in the child care environment may be involved.
doi:10.1016/j.jpeds.2009.06.035
PMCID: PMC2783908  PMID: 19683726
10.  Racial/ethnic and sex differences in the ability of metabolic syndrome criteria to predict elevations in fasting insulin in adolescents 
The Journal of pediatrics  2011;159(6):975-981.e3.
Objective
To evaluate racial/ethnic and sex differences in the relationship between metabolic syndrome (MetS) diagnosis and fasting insulin among adolescents.
Study design
We analyzed data from the National Health and Nutrition Evaluation Survey 1999–2008 for 3,693 non-Hispanic-white, non-Hispanic-black and Hispanic adolescents (12–19y). We used linear regression to evaluate differences in fasting insulin between those with and without an adolescent adaptation of ATPIII-MetS in a sex- and race/ethnicity-specific basis.
Results
Females had higher insulin levels than males and non-Hispanic blacks and Hispanics had higher levels than non-Hispanic whites. Adolescents with MetS had higher insulin levels than those without MetS. The difference in insulin levels between those with and without MetS was greater among non-Hispanic blacks compared with non-Hispanic whites (p<0.05) but not Hispanics (p=0.10). The sensitivity of MetS for detecting elevated insulin levels was lower among non-Hispanic blacks and females compared with other ethnicities and males, respectively. Correlations between insulin and individual MetS components were similar among ethnicities.
Conclusion
MetS diagnosis performed more poorly in predicting elevated insulin levels among non-Hispanic blacks and among females. These data support the hypothesis that non-Hispanic blacks do not meet current criteria for MetS until they have reached a more advanced degree of insulin resistance.
doi:10.1016/j.jpeds.2011.05.023
PMCID: PMC3202665  PMID: 21784441
Metabolic syndrome; ethnicity; insulin resistance; adolescents
11.  Assessment and correction of skinfold thickness equations in estimating body fat in children with cerebral palsy 
AIM
To assess the accuracy of skinfold equations in estimating percentage body fat in children with cerebral palsy (CP), compared with assessment of body fat from dual energy X-ray absorptiometry (DXA).
METHOD
Data were collected from 71 participants (30 females, 41 males) with CP (Gross Motor Function Classification System [GMFCS] levels I–V) between the ages of 8 and 18 years. Estimated percentage body fat was computed using established (Slaughter) equations based on the triceps and subscapular skinfolds. A linear model was fitted to assess the use of a simple correction to these equations for children with CP.
RESULTS
Slaughter’s equations consistently underestimated percentage body fat (mean difference compared with DXA percentage body fat −9.6/100 [SD 6.2]; 95% confidence interval [CI] −11.0 to −8.1). New equations were developed in which a correction factor was added to the existing equations based on sex, race, GMFCS level, size, and pubertal status. These corrected equations for children with CP agree better with DXA (mean difference 0.2/100 [SD=4.8]; 95% CI −1.0 to 1.3) than existing equations.
INTERPRETATION
A simple correction factor to commonly used equations substantially improves the ability to estimate percentage body fat from two skinfold measures in children with CP.
doi:10.1111/j.1469-8749.2009.03474.x
PMCID: PMC2859115  PMID: 19811518
12.  A confirmatory factor analysis of the metabolic syndrome in adolescents: an examination of sex and racial/ethnic differences 
Objective
The metabolic syndrome (MetS) is a cluster of clinical indices that signals increased risk for cardiovascular disease and Type 2 diabetes. The diagnosis of MetS is typically based on cut-off points for various components, e.g. waist circumference and blood pressure. Because current MetS criteria result in racial/ethnic discrepancies, our goal was to use confirmatory factor analysis to delineate differential contributions to MetS by sub-group.
Research Design and Methods
Using 1999–2010 data from the National Health and Nutrition Examination Survey (NHANES), we performed a confirmatory factor analysis of a single MetS factor that allowed differential loadings across sex and race/ethnicity, resulting in a continuous MetS risk score that is sex and race/ethnicity-specific.
Results
Loadings to the MetS score differed by racial/ethnic and gender subgroup with respect to triglycerides and HDL-cholesterol. ROC-curve analysis revealed high area-under-the-curve concordance with MetS by traditional criteria (0.96), and with elevations in MetS-associated risk markers, including high-sensitivity C-reactive protein (0.71), uric acid (0.75) and fasting insulin (0.82). Using a cut off for this score derived from ROC-curve analysis, the MetS risk score exhibited increased sensitivity for predicting elevations in ≥2 of these risk markers as compared with traditional pediatric MetS criteria.
Conclusions
The equations from this sex- and race/ethnicity-specific analysis provide a clinically-accessible and interpretable continuous measure of MetS that can be used to identify children at higher risk for developing adult diseases related to MetS, who could then be targeted for intervention. These equations also provide a powerful new outcome for use in childhood obesity and MetS research.
doi:10.1186/1475-2840-11-128
PMCID: PMC3489601  PMID: 23062212
Metabolic syndrome; Factor analysis, Statistical; Insulin resistance; Pediatrics; Adolescents; Epidemiology; Clinical studies; Obesity; Risk factors
13.  Diagnosis of the Metabolic Syndrome Is Associated With Disproportionately High Levels of High-Sensitivity C-Reactive Protein in Non–Hispanic Black Adolescents 
Diabetes Care  2011;34(3):734-740.
OBJECTIVE
Whereas it is known that the metabolic syndrome (MetS) has a paradoxically lower prevalence in non–Hispanic black adolescents than in non–Hispanic whites or Hispanics, the relative severity of MetS by race/ethnicity is unknown. Inflammation, indicated by high-sensitivity C-reactive protein (hsCRP), is a key factor linking MetS to cardiovascular disease and type 2 diabetes. Our goal was to determine whether elevations of hsCRP vary by race/ethnicity among adolescents with MetS.
RESEARCH DESIGN AND METHODS
We used the National Health and Nutrition Examination Survey (1999–2008) and evaluated adolescents (age 12–19 years) using a pediatric/adolescent adaptation of the ATP III definition of MetS. We used linear regression to evaluate the interaction between MetS status and ethnicity with respect to hsCRP concentration.
RESULTS
For male and female adolescents, MetS was associated with elevated hsCRP levels compared with adolescents without MetS. However, the elevation in hsCRP between adolescents with and without MetS was greater in non–Hispanic blacks compared with that in non–Hispanic whites (P = 0.04) but not that in Hispanics (P = 0.18). hsCRP concentrations correlated with individual MetS components similarly among all ethnicities. In an evaluation of adolescents diagnosed with MetS, non–Hispanic blacks had higher BMI and more hypertension than other ethnicities but there were no other racial/ethnic differences in the features of MetS.
CONCLUSIONS
Non–Hispanic black adolescents have a greater differential in hsCRP between those with and those without MetS than the differential in non–Hispanic whites but not that in Hispanics. Therefore, even though MetS has a low prevalence in non–Hispanic blacks, MetS is a particularly good indicator of inflammation in non–Hispanic black adolescents.
doi:10.2337/dc10-1877
PMCID: PMC3041218  PMID: 21285387
14.  Ability Among Adolescents for the Metabolic Syndrome to Predict Elevations in Factors Associated with Type 2 Diabetes and Cardiovascular Disease: Data from the National Health and Nutrition Examination Survey 1999–2006 
Objective
The aim of this study was to compare currently proposed sets of pediatric metabolic syndrome criteria for the ability to predict elevations in “surrogate” factors that are associated with metabolic syndrome and with future cardiovascular disease and type 2 diabetes mellitus. These surrogate factors were fasting insulin, hemoglobin A1c (HbA1c), high-sensitivity C-reactive protein (hsCRP), and uric acid.
Methods
Waist circumference (WC), blood pressure, triglycerides, high-density lipoprotein cholesterol (HDL-C), fasting glucose, fasting insulin, HbA1c, hsCRP, and uric acid measurements were obtained from 2,624 adolescent (12–18 years old) participants of the 1999–2006 National Health and Nutrition Examination Surveys. We identified children with metabolic syndrome as defined by six commonly used sets of pediatric metabolic syndrome criteria. We then defined elevations in the surrogate factors as values in the top 5% for the cohort and calculated sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) for each set of metabolic syndrome criteria and for each surrogate factor.
Results
Current pediatric metabolic syndrome criteria exhibited variable sensitivity and specificity for surrogate predictions. Metabolic syndrome criteria had the highest sensitivity for predicting fasting insulin (40–70%), followed by uric acid (31–54%), hsCRP (13–31%), and HbA1c (7–21%). The criteria of de Ferranti (which includes children with WC >75 th percentile, compared to all other sets including children with WC >90 th percentile) exhibited the highest sensitivity for predicting each of the surrogates, with only modest decrease in specificity compared to the other sets of criteria. However, the de Ferranti criteria also exhibited the lowest PPV values. Conversely, the pediatric International Diabetes Federation criteria exhibited the lowest sensitivity and the highest specificity.
Conclusions
Pediatric metabolic syndrome criteria exhibit moderate sensitivity for detecting elevations in surrogate factors associated with metabolic syndrome and with risk for future disease. Inclusion of children with more modestly elevated WC improved sensitivity.
doi:10.1089/met.2010.0008
PMCID: PMC3046372  PMID: 20698802
15.  Ability Among Adolescents for the Metabolic Syndrome to Predict Elevations in Factors Associated with Type 2 Diabetes and Cardiovascular Disease: Data from the National Health and Nutrition Examination Survey 1999–2006 
Abstract
Objective
The aim of this study was to compare currently proposed sets of pediatric metabolic syndrome criteria for the ability to predict elevations in “surrogate” factors that are associated with metabolic syndrome and with future cardiovascular disease and type 2 diabetes mellitus. These surrogate factors were fasting insulin, hemoglobin A1c (HbA1c), high-sensitivity C-reactive protein (hsCRP), and uric acid.
Methods
Waist circumference (WC), blood pressure, triglycerides, high-density lipoprotein cholesterol (HDL-C), fasting glucose, fasting insulin, HbA1c, hsCRP, and uric acid measurements were obtained from 2,624 adolescent (12–18 years old) participants of the 1999–2006 National Health and Nutrition Examination Surveys. We identified children with metabolic syndrome as defined by six commonly used sets of pediatric metabolic syndrome criteria. We then defined elevations in the surrogate factors as values in the top 5% for the cohort and calculated sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) for each set of metabolic syndrome criteria and for each surrogate factor.
Results
Current pediatric metabolic syndrome criteria exhibited variable sensitivity and specificity for surrogate predictions. Metabolic syndrome criteria had the highest sensitivity for predicting fasting insulin (40–70%), followed by uric acid (31–54%), hsCRP (13–31%), and HbA1c (7–21%). The criteria of de Ferranti (which includes children with WC >75th percentile, compared to all other sets including children with WC >90th percentile) exhibited the highest sensitivity for predicting each of the surrogates, with only modest decrease in specificity compared to the other sets of criteria. However, the de Ferranti criteria also exhibited the lowest PPV values. Conversely, the pediatric International Diabetes Federation criteria exhibited the lowest sensitivity and the highest specificity.
Conclusions
Pediatric metabolic syndrome criteria exhibit moderate sensitivity for detecting elevations in surrogate factors associated with metabolic syndrome and with risk for future disease. Inclusion of children with more modestly elevated WC improved sensitivity.
doi:10.1089/met.2010.0008
PMCID: PMC3046372  PMID: 20698802
16.  Cognitive Skills of Young Children with and without Autism Spectrum Disorder Using the BSID-III 
Autism Research and Treatment  2011;2011:759289.
Objective. The purpose of the study was to compare the cognitive skills of young children diagnosed with autism spectrum disorder (ASD) to same-aged peers referred for possible developmental delays or behavioral concerns using the Bayley Scales of Infant Development-Third Edition. Method. A retrospective chart review was conducted of 147 children ages 16 to 38 months who were referred to a diagnostic clinic for developmental evaluation. Children with ASD were compared to those without ASD with respect to cognition and language outcomes, both overall and by age. Results. While language skills in children with ASD were more significantly delayed than language skills in children without ASD, there was less discrepancy in the cognitive skills of children with and without ASD. Conclusion. Formal cognitive assessment of children with ASD can provide guidance for developmental expectations and educational programming. Cognitive skills of children with ASD may be underappreciated.
doi:10.1155/2011/759289
PMCID: PMC3428618  PMID: 22937256
17.  Puberty, statural growth, and growth hormone release in children with cerebral palsy 
Objective
Children with cerebral palsy (CP) are smaller than normally growing children.. The association between the growth hormone (GH) axis and growth in children with CP during puberty is unknown. We compared growth and markers of the GH axis in pre-pubertal and pubertal children with moderate to severe CP and without CP over a three-year period.
Study design
Twenty children with CP, ages 6–18, Gross Motor Function Classification System levels III–V, were compared to a group of sixty-three normally growing children of similar age. Anthropometry, Tanner stage, bone age, and laboratory analyses were performed every six months for three years. Laboratory values included spontaneous overnight GH release, fasting IGF-1 and IGFBP-3. Repeated measures models were used to evaluate interactions among Tanner stage and group (children with CP vs. reference children), taking into account gender, age, and nutritional status.
Results
Children with CP grew more slowly than those without CP at all Tanner stages (p<0.01). Patterns of IGF-1 and GH secretion in children with CP were similar to those of the reference group; however, the concentrations of IGF-1 (p<0.01) and GH (p<0.01) were lower in girls with CP, with a similar trend for boys (p=0.10 and 0.14, respectively).
Conclusions
Diminished circulating IGF-1 and GH concentrations may explain the differences in growth between the two groups.
doi:10.3233/PRM-2009-0072
PMCID: PMC2834315  PMID: 20216931
cerebral palsy; growth; growth hormone; stature
18.  Surgical vs. non-surgical treatment in women with pelvic floor dysfunction: Patient-centered goals at one year 
The Journal of urology  2008;179(6):2280-2285.
Objective
In women with pelvic floor dysfunction (PFD), we assessed the degree to which treatment (surgical vs. non-surgical) was associated with achievement of patient-centered goals, satisfaction with care, and quality of life.
Study design
Prospective cohort. Between September 2003 and December 2004 we recruited women during their first referral visit for PFD treatment at our outpatient Urogynecology Clinic. At the first visit, women enumerated up to five personal treatment goals, and “anchored” each goal by anticipating best and worst possible outcomes. At 12 month follow-up, women were asked to indicate their level of goal attainment (−2, worst outcome; +2, best outcome). At baseline and follow-up, women completed short forms of the Incontinence Impact Questionnaire (IIQ-7) and Urogenital Distress Inventory (UDI-6) (range 0–100, high scores indicating greater impact or distress). Patients indicated level of treatment satisfaction on a 4 level ordinal scale.
Results
Of the 127 study participants with complete data, 46 (36.2 %) were managed surgically and 81 (63.8%) non surgically. There were no major demographic differences between the two groups in terms of age, race, weight, prior PFD surgery, and vaginal parity. The surgical group was more likely to have received baseline diagnosis of pelvic organ prolapse (80 % vs 60 %, p = 0.0259), and be post-menopausal (89 % vs 72 %, p = 0.0261). There were no significant differences in the distribution of goal type (symptom relief, activity, self image, general health) by treatment status (p = 0.1074). Using logistic regression to adjust for age and baseline diagnosis, surgically managed patients at one year were significantly more likely to report complete primary goal attainment (odds ratio (OR) = 4.42; p = 0.0154) and complete treatment satisfaction (OR = 6.12; p = 0.0109). For all participants, one-year IIQ-7 and UDI-6 scores were significantly correlated with primary goal attainment scores.
Conclusions
In this non-randomized, prospective analysis, surgically managed patients with PFD had higher one-year self-described complete goal attainment and satisfaction scores compared with non-surgically managed patients. Goal attainment scores correlated with disease-specific quality of life. Patient-centered outcomes should be incorporated in multi-center prospective research trials for pelvic floor disorders, and incorporated into clinical practice to inform treatment plans.
doi:10.1016/j.juro.2008.01.147
PMCID: PMC2745736  PMID: 18423762
pelvic floor dysfunction; treatment outcomes; patient satisfaction; quality of life; urinary incontinence; pelvic organ prolapse

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