Cognitive functioning in adolescents with severe obesity undergoing bariatric surgery or intensive non-surgical treatment in Sweden (AMOS2): a multicentre, open-label, randomised controlled trial

Background

Severe obesity during childhood is associated with cognitive deficits. Studies in adults have suggested improvements in executive functioning and memory after bariatric surgery. Our aim was to explore changes in cognitive function in adolescents over two years after bariatric surgery or intensive non-surgical treatment.

Methods

The Adolescent Morbid Obesity Surgery 2 (AMOS2) is a multicentre, open-label, randomised controlled trial in which adolescents (aged 13-16 years) with severe obesity (defined as body mass index (BMI) ≥35 kg/m2) at three specialised obesity centres in Sweden, were randomly assigned to receive bariatric surgery or intensive non-surgical treatment. Herein we report the results of the prespecified exploratory endpoint of change in cognitive functioning. Inclusion in AMOS2 required Tanner pubertal stage ≥3, previous participation in lifestyle obesity treatment for at least one year, and passed assessment form a paediatrician and a paediatric psychologist. Adolescents with severe intellectual disability or other severe, pervasive developmental disorder were excluded. Participants underwent baseline assessment of general intellectual ability, executive functioning, and memory before randomisation. Tests were administrated by clinical psychologists and repeated at one- and two-year follow-up timepoints. Differences in means between groups during follow-up are provided with confidence intervals. The trial is registered at ClinicalTrials.gov, NCT02378259.

Findings

Between October 28 2015 and June 7 2017, 46 adolescents (74% girls), with a mean age of 15.8 (±0.92) years and a mean BMI of 42.8 (±5.4) kg/m2, were included and randomised (23 to bariatric surgery and 23 to intensive non-surgical treatment). At baseline 23/46 (50%) of the adolescents had general intellectual functioning classified as borderline or below. For 15/18 (83%) aspects of cognitive functioning, no significant differences in change over two years were identified between groups; Immediate (average difference during follow-up 1.0 [95% CI: -2.6 to 4.6]) and Delayed (0.5 [95% CI: -0.6 to 1.6]) Verbal Recall, Category Fluency (1.1 [95% CI: -1.6 to 3.8]) and Switching (1.5 [95% CI: -0.0 to 2.9]), Number (-6.0 [95% CI: -12.3 to 0.3]) and Letter (0.1 [95% CI: -5.2 to 5.3]) Sequencing, Number-Letter Switching (-10.3 [95% CI: -26.4 to 5.8]), Motor Speed (-8.3 [95% CI: -17.5 to 0.9]), Colour Naming (-1.9 [95% CI: -4.2 to 0.3]), Inhibition (-3.6 [95% CI: -9.6 to 2.5]), Inhibition Switching (-6.7 [95% CI: -15.3 to 1.9]), Mazes (-0.5 [95% CI: -4.9 to 3.9]), Digit Span Forward (0.1 [95% CI: -0.6 to 0.9 ]) and Backward (0.6 [95% CI: -0.4 to 1.6 ]), and Estimated IQ (0.4 [95% CI: -3.9 to 4.8]; all p > 0.05). Three sub-tests assessing fundamental cognitive skills improved more over two years in operated adolescents than in intensive non-surgical treatment; Letter Fluency (average difference during follow-up 3.8 [95% CI: 0.1-7.5]; p = 0.046), Visual Scanning (-6.5 [95% CI: -11.6 to -1.5]; p = 0.011), and Word Reading (-1.9 [95% CI: -3.3 to -0.4]; p = 0.011).

Interpretation

In contrast to non-randomised studies in adults, we could not demonstrate an association of bariatric surgery and its accompanying significant weight loss with overall greater improvement in executive functions and memory in adolescents over two years compared with a non-surgical group without weight loss. However, lack of statistical power is a potential limitation. The clinical relevance of greater improvements in basic cognitive skills needs to be explored.

Funding

Sweden's innovation agency (VINNOVA), Swedish Research Council, Joanna Cocozza foundation for paediatric research, The Skane University Hospital Psychology Research and Development Grant, Tore Nilsson's Foundation, SUS Foundations and Donations, and Mary von Sydow's Foundation.

Significant effects of childhood obesity treatment with a web-based component in a randomised controlled study (Web-COP)

AIM

We evaluated the effect on body mass index standard deviation score (BMI-SDS) of a combined treatment (Web-COP) for children with obesity, including a web-based component targeting their parents.

METHODS

This randomised controlled trial recruited children 5-12 years of age with obesity (International Obesity Task Force BMI [IOTF-BMI] ≥30 kg/m2 ) from school health care and outpatient paediatric clinics in in Northern Sweden from 1 June 2019 to 21 June 2020. The children were randomised to Web-COP, an intervention with group sessions and a 12-week web-based component, or standard care. The primary outcome was the change in IOTF BMI-SDS after 6 months.

RESULTS

In total, 75 children (33 girls), mean age 9.5 years, were randomised, and 65/75 (87%) children and their parents completed the study, 35/39 (90%) in the Web-COP intervention and 30/36 (83%) in the standard care group. BMI-SDS at 6 months was changed from 3.08 to 2.81 in the intervention group compared to an increase from 3.07 to 3.16 in the standard care group, representing a significant difference between groups (p < 0.001). In the intervention group, 14/30 (47%) reduced their BMI-SDS ≥0.25, compared to none in the standard care group.

CONCLUSION

The parent-focused intervention significantly improved BMI-SDS in children with obesity as compared to children in standard care.

Long-term Outcomes Following Adolescent Metabolic and Bariatric Surgery

Severe obesity in adolescence negatively impacts upon health and wellbeing. Lifestyle modifications do not usually achieve a sufficient degree or durability of weight loss to mitigate the risk of medical complications. In recent years, metabolic and bariatric surgery (MBS), already a well-established treatment for adults with severe obesity, has emerged as an option in adolescents. Controlled studies in this age group have demonstrated substantial and sustained weight loss, improvements in associated health parameters, and a safety profile surpassing that observed in adult patients. This review aims to present published data on the results of MBS in adolescents with a focus on long-term outcomes. Indications for bariatric surgery and aspects of timing in the young person's life are also presented, along with safety considerations and factors influencing patient selection for surgery. We conclude, predominantly from short- to medium-term outcomes data, that MBS is a safe and valuable therapeutic option for adolescents with severe obesity. Considering the poor health and social wellbeing prognosis in this group, MBS appears to be underutilized. The need for continued research, multiprofessional specialist provision, coherent contemporary clinical guidelines, and routine long-term follow-up in adolescents undergoing MBS is highlighted.

Metabolic and bariatric surgery versus intensive non-surgical treatment for adolescents with severe obesity (AMOS2): a multicentre, randomised, controlled trial in Sweden

BACKGROUND

Severe obesity in adolescents has a profound impact on current and future health. Metabolic and bariatric surgery (MBS) is increasingly used in adolescents internationally. However, to our knowledge, there are no randomised trials examining the currently most used surgical techniques. Our aim was to evaluate changes in BMI and secondary health and safety outcomes after MBS.

METHODS

The Adolescent Morbid Obesity Surgery 2 (AMOS2) study is a randomised, open-label, multicentre trial done at three university hospitals in Sweden (located in Stockholm, Gothenburg, and Malmö). Adolescents aged 13-16 years with a BMI of at least 35 kg/m2, who had attended treatment for obesity for at least 1 year, passed assessments from a paediatric psychologist and a paediatrician, and had a Tanner pubertal stage of at least 3, were randomly assigned (1:1) to MBS or intensive non-surgical treatment. Exclusion criteria included monogenic or syndromic obesity, major psychiatric illness, and regular self-induced vomiting. Computerised randomisation was stratified for sex and recruitment site. Allocation was concealed for both staff and participants until the end of the inclusion day, and then all participants were unmasked to treatment intervention. One group underwent MBS (primarily gastric bypass), while the other group received intensive non-surgical treatment starting with 8 weeks of low-calorie diet. The primary outcome was 2-year change in BMI, analysed as intention-to-treat. The trial is registered at ClinicalTrials.gov, NCT02378259.

FINDINGS

500 people were assessed for eligibility between Aug 27, 2014, and June 7, 2017. 450 participants were excluded (397 did not meet inclusion criteria, 39 declined to participate, and 14 were excluded for various other reasons). Of the 50 remaining participants, 25 (19 females and six males) were randomly assigned to receive MBS and 25 (18 females and seven males) were assigned to intensive non-surgical treatment. Three participants (6%; one in the MBS group and two in the intensive non-surgical treatment group) did not participate in the 2-year follow-up, and in total 47 (94%) participants were assessed for the primary endpoint. Mean age of participants was 15·8 years (SD 0·9) and mean BMI at baseline was 42·6 kg/m2 (SD 5·2). After 2 years, BMI change was -12·6 kg/m2 (-35·9 kg; n=24) among adolescents undergoing MBS (Roux-en-Y gastric bypass [n=23], sleeve gastrectomy [n=2]) and -0·2 kg/m2 (0·4 kg; [n=23]) among participants in the intensive non-surgical treatment group (mean difference -12·4 kg/m2 [95% CI -15·5 to -9·3]; p<0·0001). Five (20%) patients in the intensive non-surgical group crossed over to MBS during the second year. Adverse events (n=4) after MBS were mild but included one cholecystectomy. Regarding safety outcomes, surgical patients had a reduction in bone mineral density, while controls were unchanged after 2 years (z-score change mean difference -0·9 [95% CI -1·2 to -0·6]). There were no significant differences between the groups in vitamin and mineral levels, gastrointestinal symptoms (except less reflux in the surgical group), or in mental health at the 2-year follow-up.

INTERPRETATION

MBS is an effective and well tolerated treatment for adolescents with severe obesity resulting in substantial weight loss and improvements in several aspects of metabolic health and physical quality of life over 2 years, and should be considered in adolescents with severe obesity.

FUNDING

Sweden's Innovation Agency, Swedish Research Council Health.

Metabolic and Bariatric Surgery in Adolescents: For Whom, When, and How?

Severe obesity in adolescence profoundly impacts health and social well-being. Lifestyle modifications are seldom successful in maintaining sufficient weight loss to mitigate the risk of complications. Metabolic and bariatric surgery (MBS) is a standard treatment for adult patients and has emerged as an option for adolescent patients. Several high-quality studies of adolescent MBS show substantial and sustained improvements both in weight and cardiometabolic parameters, as well as a safety profile similar to that seen in adult patients. Patients report improvements in health- and weight-related quality of life. Concerns around adolescent MBS can be attributed to a fear of side effects on growth and puberty, risk of nutritional deficiencies and osteoporosis, alcohol abuse, psychosocial vulnerability, and the ability to consent in the decision process. Guidelines give somewhat different recommendations, but the most comprehensive guidelines from the American Society for Metabolic and Bariatric Surgery recommend MBS for class III obesity or class II obesity with comorbidity. This mini-review aimed to pre-sent published data on MBS in adolescents. We discuss indications for MBS and the optimal timing in the young person's life, the choice of surgical method, and MBS in relation to the new anti-obesity medications. Based on data primarily from the USA and Sweden, we conclude that MBS is a valuable treatment option for adolescents with severe obesity that appears underutilized against the backdrop of the poor prognosis of severe obesity. We argue for continued research, development of guidelines, multi-professional teamwork, long-term follow-up, and centralization of adolescent MBS.

Exploring data quality and use of the routine health information system in Ethiopia: a mixed-methods study

OBJECTIVE

A routine health information system (RHIS) enables decision making in the healthcare system. We aimed to analyse data quality at the district and regional level and explore factors and perceptions affecting the quality and use of routine data.

DESIGN

This was a mixed-methods study. We used the WHO toolkit for analysing data quality and interviewed staff at the point of data generation and along with the flow of data. Data were analysed using the Performance of Routine Information System Management framework.

SETTING

This study was performed in eight districts in four regions of Ethiopia. The study was nested within a 2-year programme of the Operational Research and Coaching for government Analysts.

PARTICIPANTS

We visited 45 health posts, 1 district hospital, 16 health centres and 8 district offices for analysis of routine RHIS data and interviewed 117 staff members for the qualitative assessment.

OUTCOME MEASURES

We assessed availability of source documents, completeness, timeliness and accuracy of reporting of routine data, and explored data quality and use perceptions.

RESULTS

There was variable quality of both indicator and data element. Data on maternal health and immunisation were of higher quality than data on child nutrition. Issues ranged from simple organisational factors, such as availability of register books, to intricate technical issues, like complexity of indicators and choice of denominators based on population estimates. Respondents showed knowledge of the reporting procedures, but also demonstrated limited skills, lack of supportive supervision and reporting to please the next level. We saw limited examples of the use of data by the staff who were responsible for data reporting.

CONCLUSION

We identified important organisational, technical, behavioural and process factors that need further attention to improve the quality and use of RHIS data in Ethiopia.

Adapting pediatric obesity care to better suit adolescent patients: Design of a treatment platform and results compared with standard care in the national patient quality register

BACKGROUND

Obesity constitutes a critical risk for adolescent health. This study aimed at identifying youth-friendly components of obesity treatment.

METHODS

In this feasibility study, an adolescent obesity treatment platform was implemented at two Pediatric outpatient clinics in Sweden. Body mass index (BMI), BMI z-score, and the category of obesity (International Obesity Task Force) were compared before and after the intervention and with data on standard care from the Swedish Childhood Obesity Treatment Register.

RESULTS

The study included 99 participants (49 females) aged 13-18 years from 1 September 2014, to 31 December 2016. A pediatric nurse met the participants on average 6.5 times in the average inclusion period of 15 months. Physical activity sessions attracted 63 participants. Acceptance Commitment Therapy and In Real Life groups attracted 24 participants. At inclusion, 62 participants had obesity and 37 severe obesity, and 71/99 (72%) remained in the same category. The mean BMI increased from 32.0 to 33.4 kg/m2 (p < 0.01), but 56/94 (60%) participants lowered their BMI or increased less than 1 kg/m2 and 73% stayed to the end of the study. Participants who were new to treatment and participants coming for more than eight visits to the nurse did not increase in BMI. BMI did not change for the 221 out of 641 register patients who had two recordings of BMI in the study period.

CONCLUSIONS

The platform was successful in increasing retention, and 60% of participants lowered or maintained their BMI. Still, seven out of ten adolescents with obesity or severe obesity remained in the same weight category.

The Association of Low Blood Glucose and Low Serum Cortisol Levels in Severely Ill Children Admitted to Tertiary Referral Hospitals in Malawi: A Case-Control Study

Low blood glucose concentrations < 5 mmol/L in severely ill children presenting to hospitals in low-income countries are associated with mortality. Adrenal insufficiency with low cortisol levels may contribute to low blood glucose concentrations. Understanding the association between low cortisol and low blood glucose may assist in improving guidelines for management of severely ill children. The study aimed to determine the association between low serum cortisol and low blood glucose in severely ill children. A matched case-control study of children aged 1 month to 15 years was conducted at two tertiary hospitals in Malawi. Cases were children with blood glucose <  5 mmol/L. Two age-matched controls with blood glucose of ≥  5–15 mmol/L were enrolled per case. Low cortisol was defined as serum cortisol of < 25 µg/dL (690 nmol/L) and adrenal insufficiency as serum cortisol of < 10 µg/dL (276 nmol/L). A total of 54 cases and 108 controls were enrolled with, median age of 2.8 years (interquartile range [IQR]: 1.7–4.4). The median cortisol level was 58.7 µg/dL (IQR: 42.3–61.8) in cases and 40.9 µg/dL (IQR: 33.7–51.2) in controls (P = 0.911). The proportion of low cortisol was 4/54 (7.4%) in cases and 9/108 (8.3%) in controls. Logistic regression shows no association between low cortisol and low blood glucose (adjusted odds ratio: 0.33; 95% confidence interval, 0.04–3.02). Results suggest that there is no association between low cortisol and low blood glucose among severely ill children presenting to hospitals in Malawi. The reason for low blood glucose needs further investigation.

Strengthening routine health data analysis in Ethiopia: the Operational Research and Coaching for Analysts (ORCA) experience

Many routine health information systems (RHIS) show persistent gaps between recording and reporting data and their effective use in solving problems. Strengthening RHIS has become a global priority to track and address national health goals. In Ethiopia, the Ministry of Health and Bill & Melinda Gates Foundation introduced the Operational Research and Coaching for Analysts (ORCA) capacity development project, co-designed with the London School of Hygiene & Tropical Medicine, which delivered training, coaching and mentoring support. We present the development, experiences, and perceptions of ORCA as a mechanism to enhance data quality, analysis, interpretation and use. ORCA integrated capacity development activities into national data analysts’ routine workload over a period of 2 years. Participating analysts were drawn from across the Ministry of Health directorates and two of its closely aligned agencies: the Ethiopian Public Health Institute and the Ethiopian Pharmaceutical Supply Agency. We used mixed methods (knowledge questionnaire, semi-structured interviews, programme records) to document the fidelity, feasibility, reach, and acceptability of ORCA and identify early signs of improved knowledge and changing institutional practices. Thirty-six participants completed the programme. Working in interdisciplinary groups on specific national health indicators, they received training workshops and support for study design, fieldwork, and analysis to build skills in assessing data quality and interpreting findings relevant to policy. Personal development grants and laptops provided incentives for sustained engagement. Participants appreciated ORCA’s applied and practical approach as well as good communication from administrators and clear links to national strategy. They also expressed frustration with delays, difficulties prioritising project work over routine responsibilities, and lack of formal accreditation. Knowledge and analytic skills increased and participants were able to integrate experiences from the project into their future work. Health system managers saw potential in longer-term improvements in data analysis and application to policy, although no clear changes were observed yet.

'Now she prefers jeans, like everyone else…' - Parents' experiences of group- and web-based treatment of children's obesity

AIM

Web-based interventions have shown promising results in paediatric obesity treatment with the potential to increase coverage of care. This study aimed to explore parental experiences about participating in an intervention to improve healthy behaviours and lower BMI-SDS in children with obesity.

METHODS

This was an interview study with an inductive qualitative approach. Data were collected from individual interviews with 14 parents of 5- to 13-year-old children with obesity. The respondents had participated in a family-based treatment intervention consisting of four group sessions followed by 12-week web-based support. The interviews were analysed using qualitative manifest and latent content.

RESULTS

The overarching theme 'A transformative journey of lifestyle changes for the whole family' described how the participation impacted the lifestyle of the whole family. Four categories: parental awareness, introducing new routines, negotiating family battles and a feeling of support, represented various experiences made by respondents. The parents shared predominantly positive experiences of the intervention but also expressed feelings of guilt and struggled to address their child's obesity.

CONCLUSION

Parents who participated in a study for children with obesity with a web-based component found the programme helpful for achieving healthier lifestyles for the whole family.

High prevalence of neurodevelopmental problems in adolescents eligible for bariatric surgery for severe obesity

Aim

To assess the prevalence of neurodevelopmental problems in adolescents with severe obesity and their associations with binge eating and depression.

Methods

Data were collected at inclusion in a randomised study of bariatric surgery in 48 adolescents (73% girls; mean age 15.7 ± 1.0 years; mean body mass index 42.6 ± 5.2 kg/m²). Parents completed questionnaires assessing their adolescents’ symptoms of attention‐deficit/hyperactivity disorder and autism spectrum disorder and reported earlier diagnoses. Patients answered self‐report questionnaires on binge eating and depressive symptoms.

Results

The parents of 26/48 adolescents (54%) reported scores above cut‐off for symptoms of the targeted disorders in their adolescents, but only 15% reported a diagnosis, 32% of adolescents reported binge eating, and 20% reported symptoms of clinical depression. No significant associations were found between neurodevelopmental problems and binge eating or depressive symptoms. Only a third of the adolescents reported no problems in either area.

Conclusion

Two thirds of adolescents seeking surgical weight loss presented with substantial mental health problems (reported by themselves or their parents). This illustrates the importance of a multi‐professional approach and the need to screen for and treat mental health disorders in adolescents with obesity.

Routine health management information system data in Ethiopia: consistency, trends, and challenges

Background: Ethiopia is investing in the routine Health Management Information System. Improved routine data are needed for decision-making in the health sector. Objective: To analyse the quality of the routine Health Management Information System data and triangulate with other sources, such as the Demographic and Health Surveys. Methods: We analysed national Health Management Information System data on 19 indicators of maternal health, neonatal survival, immunization, child nutrition, malaria, and tuberculosis over the 2012-2018 time period. The analyses were conducted by 38 analysts from the Ministry of Health, Ethiopia, and two government agencies who participated in the Operational Research and Coaching for Analysts (ORCA) project between June 2018 and June 2020. Using a World Health Organization Data Quality Review toolkit, we assessed indicator definitions, completeness, internal consistency over time and between related indicators, and external consistency compared with other data sources. Results: Several services reported coverage of above 100%. For many indicators, denominators were based on poor-quality population data estimates. Data on individual vaccinations had relatively good internal consistency. In contrast, there was low external consistency for data on fully vaccinated children, with the routine Health Management Information System showing 89% coverage but the Demographic and Health Survey estimate at 39%. Maternal health indicators displayed increasing coverage over time. Indicators on child nutrition, malaria, and tuberculosis were less consistent. Data on neonatal mortality were incomplete and operationalised as mortality on day 0-6. Our comparisons with survey and population projections indicated that one in eight early neonatal deaths were reported in the routine Health Management Information System. Data quality varied between regions. Conclusions: The quality of routine data gathered in the health system needs further attention. We suggest regular triangulation with data from other sources. We recommend addressing the denominator issues, reducing the complexity of indicators, and aligning indicators to international definitions.

Microalbuminuria and retinopathy in adolescents and young adults with type 1 and type 2 diabetes

AIM

To estimate the occurrence of complications related to early-onset type 2 diabetes compared with type 1 diabetes.

METHODS

All individuals registered in the Swedish Pediatric Quality Diabetes Register and the Swedish National Diabetes Register with type 2 diabetes diagnosis at 10 to 25 years of age between 1996 and 2014 (n = 1413) were included. As controls, individuals with type 1 diabetes were randomly selected from the same registers and were matched for age, sex, and year-of-onset (n = 3748).

RESULTS

Of the adolescents with type 2 diabetes in the pediatric register, 7.7% had microalbuminuria and 24.6% had signs of retinopathy 5 years after diagnosis, whereas the adolescents with type 1 diabetes 3.8% had microalbuminuria and 19.2% had retinopathy. Among the young adults with type 2 diabetes from the adult diabetes register 10 years after diagnosis 15.2% had microalbuminuria and 39.7% retinopathy, whereas the young adults with type 1 diabetes 4.8% had microalbuminuria and 43.8% retinopathy. After adjustment for established risk factors measured over time in the whole combined cohort, individuals with type 2 diabetes had significantly higher risk of microalbuminuria with a hazard ratio (HR) of 3.32 (95% confidence interval, CI 2.86-3.85, P < .001), and retinopathy with a HR of 1.17 (95% CI 1.06-1.30, P 0.04).

CONCLUSIONS

The prevalence of complications and comorbidities was higher among those with type 2 diabetes compared with type 1 diabetes, although prevalent in both groups. Early monitoring and more active treatment of type 2 diabetes in young individuals is required.

Development, implementation and early results of a 12-week web-based intervention targeting 51 children age 5-13 years and their families

Background

Internet-based treatments have proven effective for various health issues. There is a need to scale up interventions targeting children with obesity, also in less densely populated areas where the prevalence in many countries is higher than in urban areas. The aim of this study was to design and implement an internet-based program as an add-on to standard treatment for childhood obesity.

Methods

Web-Childhood Obesity Prevention (Web-COP) was a prospective feasibility study with a pre- post- design. The intervention consisted of four group-based education sessions at the clinic, physical activity on prescription, and a new 12-week internet-based program. Web-COP was offered to children with obesity (International Obesity Task Force Body Mass Index (IOTF-BMI) ≥ 30 kg/m2) and their parents in two counties in Northern Sweden from August 2018 to June 2019. The primary outcome was change in BMI standard deviation score (BMI-SDS).

Results

The study included 55 children 5-13 years of age. The internet-based component was well received, and retention rate was 51/55 (92.7%). Data was analysed for 51 children. Mean BMI-SDS was 3.3 at start and decreased by 0.2, 0.3, and 0.4 at two, four, and six months from baseline. Using a continuous algorithm, 42/51 (81%), children lowered their BMI-SDS and 33/51 (65%) lowered their BMI.

Conclusion

Adding group sessions and an internet-based program to standard care was feasible and two thirds of included children with obesity reduced their BMI.

Improving quality and use of routine health information system data in low- and middle-income countries: A scoping review

BACKGROUND

A routine health information system is one of the essential components of a health system. Interventions to improve routine health information system data quality and use for decision-making in low- and middle-income countries differ in design, methods, and scope. There have been limited efforts to synthesise the knowledge across the currently available intervention studies. Thus, this scoping review synthesised published results from interventions that aimed at improving data quality and use in routine health information systems in low- and middle-income countries.

METHOD

We included articles on intervention studies that aimed to improve data quality and use within routine health information systems in low- and middle-income countries, published in English from January 2008 to February 2020. We searched the literature in the databases Medline/PubMed, Web of Science, Embase, and Global Health. After a meticulous screening, we identified 20 articles on data quality and 16 on data use. We prepared and presented the results as a narrative.

RESULTS

Most of the studies were from Sub-Saharan Africa and designed as case studies. Interventions enhancing the quality of data targeted health facilities and staff within districts, and district health managers for improved data use. Combinations of technology enhancement along with capacity building activities, and data quality assessment and feedback system were found useful in improving data quality. Interventions facilitating data availability combined with technology enhancement increased the use of data for planning.

CONCLUSION

The studies in this scoping review showed that a combination of interventions, addressing both behavioural and technical factors, improved data quality and use. Interventions addressing organisational factors were non-existent, but these factors were reported to pose challenges to the implementation and performance of reported interventions.

A randomized controlled trial comparing intensive non-surgical treatment with bariatric surgery in adolescents aged 13-16 years (AMOS2): Rationale, study design, and patient recruitment

Background

Previous non-randomized studies show similar outcomes in adolescents and adults after bariatric surgery. We describe the study protocol, recruitment, and selected baseline data of patients in a randomized multi-center study, the Adolescent Morbid Obesity Surgery 2 (AMOS2).

Methods

Three clinics in Sweden collaborated in designing the study and recruitment of patients from August 1, 2014 to June 30, 2017. Patients were selected among adolescents 13–16 years of age attending third-level obesity care for at least one year. Patients were randomized 1:1 to bariatric surgery (predominantly Roux-en-Y gastric bypass) or intensive non-surgical treatment starting with an eight-week low-calorie-diet.

Results

Fifty adolescents (37 girls) were randomized, 25 (19 girls) to bariatric surgery. Mean age was 15.7 years (range 13.3–16.9), weight 122.6 kg (range 95–183.3), Body Mass Index (BMI) 42.6 kg/m² (range 35.7–54.9) and BMI-SDS 3.45 (range 2.9–4.1). One patient had type 2 diabetes mellitus, and 12/45 (27%) had elevated liver enzymes. There were no significant differences between the groups. For the 39 eligible patients who were offered but declined inclusion, BMI was not different from included patients. However, patients who declined were younger, 15.2 years (p = 0.021). A sex difference was also noted with more of eligible girls, 37/53 (69.8%), than boys, 13/36 (36.1%), wanting to participate in the study (p = 0.002).

Conclusions

This clinical trial, randomizing adolescents with severe obesity to bariatric surgery or intensive non-surgical treatment, aims at informing about whether it is beneficial to undergo bariatric surgery in early adolescence. It will also enlighten the outcome of comprehensive non-surgical treatment. The study was registered at www.clinicalTrials.gov number NCT02378259.

•

Bariatric surgery is already a treatment option for adolescents with severe obesity in many countries.

•

We recruited 50 patients 13-16 years of age to a randomized controlled trial.

•

We aimed at investigating the optimal time point for bariatric surgery.

•

Adolescents and their families seemed to make well considered decisions to participate in the study.

Successful treatment of a cohort of infants with neonatal diabetes using insulin pumps including data on genetics and estimated incidence

AIM

Neonatal diabetes is rare, and treatment is challenging. We present aspects on treatment, genetics and incidence.

METHOD

This was a prospective cohort study including all cases in our study area in Sweden. We compared with data from the National Diabetes Registry, the Neonatal Quality Register and the National Patient Register.

RESULTS

In the 19-year study period January 1, 1998 to December 31, 2016, we treated seven infants, five of them boys. Six patients used a subcutaneous insulin pump, and the smallest patient started at a weight of 938 g. Most important was for the pump to deliver minute doses of insulin and the design of cannulas and tubing. All patients could stop insulin treatment at 17-145 days of age. One patient relapsed at age 4.5 years. Four patients used the insulin pump after discharge. A mutation was identified in five patients, and this included all patients born after 30 weeks of gestation. The incidence of neonatal diabetes was 2/1 00 000, higher than previously estimated for Europe. Similar but lower incidences were reported in the registries.

CONCLUSION

Insulin pumps were safe in neonatal diabetes. All seven cases were transient. Neonatal diabetes was more common in our area than reported from Europe.

Initial low-dose oral levothyroxine in a child with Down syndrome, myxedema, and cardiogenic shock

Myxedema is extremely rare in children, and guidelines are lacking. We treated a 12-year-old girl with myxedema and cardiogenic shock with initial low dose (0.3-2.5 μg/kg body weight/day) of oral levothyroxine and intensive care. Oral administration may safely revert children's myxedema in a dosage resembling that for hypothyroidism.

Clinical and Immunological Characteristics of Autoimmune Addison Disease: A Nationwide Swedish Multicenter Study

CONTEXT

Studies of the clinical and immunological features of autoimmune Addison disease (AAD) are needed to understand the disease burden and increased mortality.

OBJECTIVE

To provide upgraded data on autoimmune comorbidities, replacement therapy, autoantibody profiles, and cardiovascular risk factors.

DESIGN, SETTING, AND PARTICIPANTS

A cross-sectional, population-based study that included 660 AAD patients from the Swedish Addison Registry (2008-2014). When analyzing the cardiovascular risk factors, 3594 individuals from the population-based survey in Northern Sweden, MONICA (monitoring of trends and determinants of cardiovascular disease), served as controls.

MAIN OUTCOME MEASURES

The endpoints were the prevalence of autoimmune comorbidities and cardiovascular risk factors. Autoantibodies against 13 autoantigens were determined.

RESULTS

The proportion of 21-hydroxylase autoantibody-positive patients was 83%, and 62% of patients had ≥1 associated autoimmune diseases, more frequently coexisting in females (P < 0.0001). AAD patients had a lower body mass index (P < 0.0001) and prevalence of hypertension (P = 0.027) compared with controls. Conventional hydrocortisone tablets were used by 89% of the patients, with a mean dose of 28.1 ± 8.5 mg/d. The mean hydrocortisone equivalent dose normalized to the body surface was 14.8 ± 4.4 mg/m2/d. A greater hydrocortisone equivalent dose was associated with a greater incidence of hypertension (P = 0.046).

CONCLUSIONS

Careful monitoring of AAD patients is warranted to detect associated autoimmune diseases. Contemporary Swedish AAD patients did not have an increased prevalence of overweight, hypertension, type 2 diabetes mellitus, or hyperlipidemia. However, high glucocorticoid replacement doses could be a risk factor for hypertension.

Identification of genomic deletions spanning the PCDH19 gene in two unrelated girls with intellectual disability and seizures

Recently, missense and truncating mutations in the gene PCDH19 have been reported to cause female-restricted epilepsy with mental retardation (EFMR). EFMR (MIM#300088) is an X-linked disorder characterized by early onset seizures and intellectual disability (ID). Interestingly, unlike typical X-linked mode of inheritance, the phenotype is restricted to females, and males are unaffected carriers. PCDH19 is highly expressed in brain, and the encoded protein belongs to the cadherin superfamily. Here we report two unrelated female patients with deletions spanning PCDH19 identified by copy number variation (CNV) analysis and validated by qPCR. In one, we have identified a 3 Mb interstitial deletion at Xq21.33-q22.1 which spans PCDH19, LOC442459 & TNMD. This patient had her first seizure at 8 months old, and also has ID and aggressive behavior. In another female patient we identified a de novo 603 kb heterozygous deletion in a female patient with fits (since 1 year of age), ID, hyperactivity and aggressive behavior. The deletion spans the entire PCDH19 gene (also TNMD, SRPX2, TSPAN6 and SYTL4). In conclusion, our results suggest that deletions at PCDH19 also cause EFMR.

Malaria rapid testing by community health workers is effective and safe for targeting malaria treatment: randomised cross-over trial in Tanzania

Background

Early diagnosis and prompt, effective treatment of uncomplicated malaria is critical to prevent severe disease, death and malaria transmission. We assessed the impact of rapid malaria diagnostic tests (RDTs) by community health workers (CHWs) on provision of artemisinin-based combination therapy (ACT) and health outcome in fever patients.

Methodology/Principal Findings

Twenty-two CHWs from five villages in Kibaha District, a high-malaria transmission area in Coast Region, Tanzania, were trained to manage uncomplicated malaria using RDT aided diagnosis or clinical diagnosis (CD) only. Each CHW was randomly assigned to use either RDT or CD the first week and thereafter alternating weekly. Primary outcome was provision of ACT and main secondary outcomes were referral rates and health status by days 3 and 7. The CHWs enrolled 2930 fever patients during five months of whom 1988 (67.8%) presented within 24 hours of fever onset. ACT was provided to 775 of 1457 (53.2%) patients during RDT weeks and to 1422 of 1473 (96.5%) patients during CD weeks (Odds Ratio (OR) 0.039, 95% CI 0.029–0.053). The CHWs adhered to the RDT results in 1411 of 1457 (96.8%, 95% CI 95.8–97.6) patients. More patients were referred on inclusion day during RDT weeks (10.0%) compared to CD weeks (1.6%). Referral during days 1–7 and perceived non-recovery on days 3 and 7 were also more common after RDT aided diagnosis. However, no fatal or severe malaria occurred among 682 patients in the RDT group who were not treated with ACT, supporting the safety of withholding ACT to RDT negative patients.

Conclusions/Significance

RDTs in the hands of CHWs may safely improve early and well-targeted ACT treatment in malaria patients at community level in Africa.

Trial registration

ClinicalTrials.gov NCT00301015

Autoimmune polyglandular syndrome type 2 shows the same HLA class II pattern as type 1 diabetes

Autoimmune polyglandular syndrome (APS) type 2 is defined by the manifestation of at least two autoimmune endocrine diseases. Only few data exist on genetic associations of APS type 2. In this controlled study, 98 patients with APS type 2, 96 patients with type 1 diabetes (T1D), and 92 patients with autoimmune thyroid disease, both as a single autoimmune endocrinopathy, were tested for association with alleles of the human leukocyte antigen (HLA) class II loci DRB1, DQA1, and DQB1. Patients with APS type 2 had significantly more often the alleles DRB1*03 (P(c) < 0.0001), DRB1*04 (P(c) < 0.000005), DQA1*03 (P(c) < 0.0001), and DQB1*02 (P(c) < 0.05), when compared with controls. Less frequent in APS were DRB1*15 (P(c) < 0.05), DQA1*01 (P(c) < 0.0005), and DQB1*05 (P(c) < 0.005). With regard to frequency and linkage of these alleles, the susceptible haplotypes DRB1*0301-DQA1*0501-DQB1*0201 and DRB1*0401/04-DQA1*0301-DQB1*0302 were deduced. Protective haplotypes in this study were DRB1*1501-DQA1*0102-DQB1*0602 and DRB1*0101-DQA1*0101-DQB1*0501. Comparing APS patients with vs without AD, no significant differences regarding HLA class II alleles were noted in our collective. Patients with T1D as a singular disease had the same susceptible and protective HLA alleles and haplotypes. The prevalence of DRB1*03 and DRB1*04 in APS patients was not because of the presence of diabetes, as the APS type 2 patients without diabetes had the same allele distribution. In conclusion, these data suggest a common immunogenetic pathomechanism for T1D and APS type 2, which might be different from the immunogenetic pathomechanism of other autoimmune endocrine disease.

Impact sibutramine therapy in children with hypothalamic obesity or obesity with aggravating syndromes

OBJECTIVE

Behavioral treatment of children suffering from hypothalamic obesity or uncomplicated obesity in combination with syndromes that aggravate this condition has proven to be ineffective. The combination of comorbidities and severe obesity lower the quality of these children's lives drastically. The present goal was to determine whether treatment with sibutramine has a beneficial effect on such children.

DESIGN AND SUBJECTS

A double-blind, placebo-controlled, cross-over study (20 + 20 wk), followed by a 6-month open phase, was performed. The primary indicator of efficacy was the body mass index (BMI) sd score (SDS) value, which was analyzed using an ANOVA repeated-measures design [intention to treat (ITT)]. The 50 children (7-20 yr of age) involved included 22 with hypothalamic obesity and 28 with uncomplicated obesity plus aggravating syndromes. Forty-five patients completed the first phase, and 42 participated in the entire study.

RESULTS

The group that initially received the placebo demonstrated an insignificant decrease (-0.06) in BMI SDS during this treatment but a significant decrease (-0.68; P < 0.001) when treated with sibutramine. The other group demonstrated a reduction in their BMI SDS of -0.72 during administration of sibutramine and a rebound of +0.43 when placed on the placebo (P < 0.001 in both cases). The response of children with hypothalamic obesity was also significant but was less pronounced than that of children with nonhypothalamic obesity. During the open phase, a continuous reduction in weight was observed. The treatment was tolerated well.

CONCLUSION

The clinically and statistically significant weight reduction caused by sibutramine in this short-term study indicates that treatment of hypothalamic and syndromal obesity with this drug may be beneficial.

Shed some light on darkness: will Tanzania reach the millennium development goals?

The overall picture of health in sub-Saharan Africa can easily be painted in dark colours. The aim of this viewpoint is to discuss epidemiological data from Tanzania on overall health indicators and the burden of malaria and HIV. Is the situation in Tanzania improving or deteriorating? Are the health-related millennium development goals (MDG) on reducing under-five mortality, reducing maternal mortality and halting HIV and malaria within reach?

CONCLUSION

Child mortality and infant mortality rates are decreasing quite dramatically. Malaria prevention strategies and new effective treatment are being launched. The MDG 4 on child mortality is clearly within reach, and the same optimism may apply to MDG 6 on combating malaria.

SmiNet-2: Description of an internet-based surveillance system for communicable diseases in Sweden

Electronic systems for communicable diseases surveillance enhance quality by simplifying reporting, improving completeness, and increasing timeliness. In this article we outline the ideas and technologies behind SmiNet-2, a new comprehensive regional/national system for communicable disease surveillance in Sweden. The system allows for reporting from physicians (web form) and laboratories (direct from lab data system) over the internet. Using a unique personal identification number, SmiNet-2 automatically merges clinical and laboratory notifications to case records. Privileged users, at national and county level, work against a common central server containing all notifications and case records. In addition, SmiNet-2 has separate county servers with tools for outbreak investigations, contact tracing and case management. SmiNet-2 was first used in September 2004. Individual counties receive up to 90% of all notifications electronically. In its first year, SmiNet-2 received 54 980 clinical notifications and 32 765 laboratory notifications, which generated 58 891 case records. Since most clinicians in Sweden have easy access to the internet, a general web-based reporting has been feasible, and it is anticipated that within a few years all reporting to SmiNet-2 will be over the internet. In this context, some of the major advantages of SmiNet-2 when compared with other systems are timeliness in the dataflow (up to national level), the full integration of clinical and laboratory notifications, and the capability to handle more than 50 diseases with tailor-made notification forms within one single system.

Prevalence of obesity in Sweden

Although the prevalence of obesity in Sweden still is low in an international perspective, the development during the last decades is alarming in adults, adolescents and children alike. The prevalence of obesity [body mass index (BMI) > 30 kg m-2] in adults has doubled during the last two decades and is now approximately 10% in both men and women, according to estimates based on self-reported BMI from repeated random samples of the population. However, prevalence estimates based on measured BMI from the WHO MONICA study indicate that the self-reported data result in underestimates. In military conscripts, the prevalence of obesity (BMI > 30 kg m-2) almost quadrupled to 3.2% from 1971 to 1995, while the overweight fraction (BMI > 25 kg m-2) more than doubled to 16.3%. The development in younger age groups seems to be similar; the prevalence of overweight [International Obesity Task Force (IOTF)/Cole] in children aged 10 years in Gothenburg has doubled to 18% (2.9% obese) during the last decade, and similar figures have been reported in other studies. However, most reports on childhood overweight stem from the larger metropolitan areas, and hence may be underestimates because of the urban-rural influence on obesity-status. Recent data from non-urban areas in the northern part of Sweden estimate the prevalence of overweight (BMI > 20 kg m-2) in 10-year-olds to above 30%. In the most comprehensive study in children, including both rural and urban areas, BMI was measured among all children aged 10 years (n = 5517; 92.7% of the population) in the county of Ostergotland, and the prevalence of overweight (IOTF/Cole) was 22% in both boys and girls, of which 4% and 5% were obese respectively.

Autosomal-dominant non-autoimmune hyperthyroidism presenting with neuromuscular symptoms

AIM

Neuromuscular presentations are common in thyroid disease, although the mechanism is unclear. In the present study, we investigated the pathogenesis in a boy with autosomal-dominant hyperthyroidism presenting with neuromuscular symptoms.

METHODS

The TSHr gene was investigated by direct sequencing. Functional properties of the mutant TSHr were investigated during transient expression in COS-7 cells. Family members were investigated by clinical and biochemical examinations.

RESULTS

Sequence analysis revealed a previously reported heterozygous missense mutation Glycine 431 for Serine in the first transmembrane segment, leading to an increased specific constitutive activity. Three additional affected family members carried the same mutation. There was no indication of autoimmune disorder. All symptoms disappeared upon treatment with thacapzol and L-thyroxine and subsequent subtotal thyroidectomy.

CONCLUSION

The data imply that neuromuscular symptoms can be caused by excessive thyroid hormone levels rather than by autoimmunity.

Hexafluorine vs. Standard Decontamination to Reduce Systemic Toxicity After Dermal Exposure to Hydrofluoric Acid

INTRODUCTION

Dermal exposure to hydrofluoric acid (HF) may cause severe burns and systemic toxicity. Hexafluorine (Prevor, France) is a product marketed as an emergency decontamination fluid for HF skin and eye exposures. Documentation concerning Hexafluorine is scanty, and a recent study indicates that its ability to reduce HF burns is at most equal to that of water.

OBJECTIVE

The present study was conducted to evaluate Hexafluorine's capacity to reduce HF-induced systemic toxicity.

METHODS

Sprague Dawley rats were anesthetized, catheterized in the left femoral artery, and shaved on their back. A filter paper (3.5 x 6 cm) was soaked in 50% HF and applied on the back of each rat for 3 min. Thirty seconds after removal of the paper, a 3-min rinsing with either 500 mL Hexafluorine (group H), 500 mL water (group W), or 500 mL water followed by a single application of 2.5% calcium gluconate gel (group Ca) was carried out. Blood samples were analyzed for ionized calcium and potassium (before injury and 1, 2, 3, and 4 h after) and also for ionized fluoride (1, 2, and 4 h after injury).

RESULTS

The animals developed hypocalcemia, hyperkalemia, and hyperfluoridemia after the HF exposure. The only significant difference observed among the groups was in serum potassium at 1 h between group Ca and group W. However, there was a constant trend toward milder hypocalcemia and less pronounced hyperkalemia in group Ca compared to the other groups. There were no differences in the electrolyte disturbances between the Hexafluorine-treated animals and those treated with water only. Five of 39 animals died before completion of the experiment as a result of the HF exposure, one from group Ca and two from each of the other two groups.

CONCLUSION

In this experimental study, decontamination with Hexafluorine was not more effective than water rinsing in reducing electrolyte disturbances caused by dermal exposure to hydrofluoric acid.

Weak evidence of thyrotropin receptors in primary cultures of human osteoblast-like cells

Extra-thyroidal thyrotropin (TSH) receptors (TSHRs) have been demonstrated in several tissues and cells, including human and rat osteosarcoma cell lines. We have explored whether human TSHR (hTSHRs) also are present in primary cultures of human osteoblast-like (hOB) cells. [(125) I]TSH binding was limited in hOB cells, but somewhat higher in UMR 106-01 cells and considerably higher in hTSHR-transfected CHO cells. In hOB cells, the basal intracellular cAMP levels increased 282% after stimulation with 10 U/L TSH. In the hTSHR-transfected CHO cells, the cAMP increase was 3030% in response to 10 U/L TSH and 1240% after 1 U/L TSH. Free cytoplasmic calcium did not change in response to TSH in hOB cells. HTSHR mRNA was detected in hOB cells from 3/4 bone by reverse transcriptase polymerase chain reaction RT-PCR and nucleotide sequencing HTSHR mRNA, but could not be demonstrated with the RNase protection technique in hOB cells from 5 different donors. In conclusion, even after the use of several methods, we have found only weak evidence for expression and presence of functionally active hTSHR in hOB cells. Given the low level of expression, specific binding and cAMP signaling, we suggest that it is unlikely that circulating TSH plays a physiological role for bone metabolism mediated through osteoblasts.

[Cooperation reduces the risks of thyroid disease in pregnancy. Also mild maternal hypothyroidism can threaten the neurological development of the fetus]

A history of thyroidal disease in a pregnant mother requires special attention. Untreated, or not adequately treated, hypothyreosis in a pregnant mother is likely to affect the neurological development of the fetus negatively. The authors refer the discussion on the need for screening for hypothyroidism in early pregnancy, but stress the need for everybody dealing with these patients (general practitioners, midwives, gynecologists, pediatricians and endocrinologists), to recognize women at risk and inform their patients on the need of careful monitoring of thyroid supplementation in case of pregnancy. On the other hand, women with Graves' disease should be carefully assessed for the presence of TRAK-antibodies, and be subject to specialist maternal care. Their babies risk neonatal thyreotoxicosis and need careful attention.

High mobility group 1 protein (HMG-1) stimulates proinflammatory cytokine synthesis in human monocytes

Lipopolysaccharide (LPS) is lethal to animals because it activates cytokine release, causing septic shock and tissue injury. Early proinflammatory cytokines (e.g., tumor necrosis factor [TNF] and interleukin [IL]-1) released within the first few hours of endotoxemia stimulate mediator cascades that persist for days and can lead to death. High mobility group 1 protein (HMG-1), a ubiquitous DNA-binding protein, was recently identified as a "late" mediator of endotoxin lethality. Anti-HMG-1 antibodies neutralized the delayed increase in serum HMG-1, and protected against endotoxin lethality, even when passive immunization was delayed until after the early cytokine response. Here we examined whether HMG-1 might stimulate cytokine synthesis in human peripheral blood mononuclear cell cultures. Addition of purified recombinant HMG-1 to human monocyte cultures significantly stimulated the release of TNF, IL-1alpha, IL-1beta, IL-1RA, IL-6, IL-8, macrophage inflammatory protein (MIP)-1alpha, and MIP-1beta; but not IL-10 or IL-12. HMG-1 concentrations that activated monocytes were within the pathological range previously observed in endotoxemic animals, and in serum obtained from septic patients. HMG-1 failed to stimulate cytokine release in lymphocytes, indicating that cellular stimulation was specific. Cytokine release after HMG-1 stimulation was delayed and biphasic compared with LPS stimulation. Computer-assisted image analysis demonstrated that peak intensity of HMG-1-induced cellular TNF staining was comparable to that observed after maximal stimulation with LPS. Administration of HMG-1 to Balb/c mice significantly increased serum TNF levels in vivo. Together, these results indicate that, like other cytokine mediators of endotoxin lethality (e.g., TNF and IL-1), extracellular HMG-1 is a regulator of monocyte proinflammatory cytokine synthesis.

Presence of thyrotropin receptor in infant adipocytes

In healthy infants, the levels of TSH are known to peak at 50-100 times adult values during the first days of life. In studies of isolated human infant adipocytes, we have earlier shown that bovine TSH (bTSH) has a strong lipolytic effect, accompanied by a blunted response of adipocytes to catecholamines. In this study, we used human recombinant TSH (hTSH), and incubation of adipocytes with hTSH induced a lipolytic response similar to that obtained with the beta-adrenergic receptor agonist isoprenaline in adipocytes isolated from three infants. The lipolytic effect of hTSH was completely blocked by inhibitory TSH receptor (TSHR) antibodies. The TSHR mediates the effects of TSH in the thyroid, and it has been detected in some extrathyroid tissues, but not in isolated human adipocytes or childhood adipose tissue. In this study, we found TSHR RNA in infant and adult adipose tissues and isolated adipocytes with reverse transcriptase-PCR. The sequence of the amplified PCR product agreed with the published sequence. Northern blot hybridization on RNA prepared from infant adipose tissue showed a transcript of the expected size, and the expression of TSHR seemed higher in infant than in adult adipose tissue. In conclusion, this study indicates that TSH plays an active role in the metabolic adaptation after birth.

The lipolytic effects of thyrotropin and isoprenaline are not affected by growth hormone in infant adipocytes

The lipolytic effects of growth hormone (GH) in children are not fully clarified. In this study, no lipolytic effect of GH on isolated adipocytes obtained at surgery on healthy infants aged 2-5 months and children 3-6 years was observed. Furthermore, GH did not enhance isoprenaline-induced lipolysis, as in adults. The TSH-induced lipolysis which is prominent in neonatal adipocytes was not affected by incubation of adipocytes with GH. Assuming that GH alters adipocyte metabolism primarily by increasing the sensitivity, but not the maximum response, of the beta 2-adrenergic receptor population, it follows that GH, in this sense, should be a less important co-actor in children where beta 2-adrenergic receptors are more abundant.

Incidence of falls in three different types of geriatric care. A Swedish prospective study

The incidence and consequences of falls were investigated in three different types of Swedish geriatric care clinics: a geriatric rehabilitation clinic, a psychogeriatric clinic and a nursing home. Falls were prospectively registered by the nursing staff. The incidence rate (and 95% confidence interval) of falls per 10,000 patient days of the psychogeriatric clinic was 171 (146-196), compared with 92 (72-112) at the geriatric rehabilitation clinic, and 31 (22-41) at the nursing home. Most falls (62%) did not result in injury, while major injuries occurred in 5%. We conclude that accidental falls are a major problem in geriatric care in Sweden, but there is a considerable difference in incidence rates between different types of institutions.

Evidence for the presence of functional thyrotropin receptor in cardiac muscle

There is increasing evidence that the membrane-bound thyrotropin receptor (TSHR) may be mediating clinically important direct effects of thyrotropin (TSH) and of TSHR antibodies (TSHRab) in extra-thyroidal tissues. TSHR mRNA has formerly been detected in thyroid, retroorbital muscle and fibroblasts, peripheral lymphocytes and rodent fat. It is well known that thyroid disease may aggravate or induce heart disease, but the pathophysiological role of TSH and TSHRab is not clear. The aim of this study was to investigate if TSHR is present in cardiac muscle. Reverse transcriptase polymerase chain reactions revealed TSHR in human heart and Northern blot on extracted RNA showed a RNA species of 4.4 kb. TSH stimulation of cultured mouse AT-1 cardiomyocytes elevated the levels of intracellular second messenger 3',5'-cyclic AMP. This effect of TSH could be inhibited by TSHR antibodies. In solution hybridization levels of TSHR mRNA in AT-1 cells were 50% of mRNA in crude mouse heart. In conclusion functional TSHR is present in cardiomyocytes.

Effects of stimulatory and inhibitory thyrotropin receptor antibodies on lipolysis in infant adipocytes

TSH is a potent lipolytic hormone for isolated human adipocytes from neonatal subjects. Crude immunoglobulin fractions from sera of patients with Graves' disease, containing stimulatory TSH receptor (TSHR) autoantibodies, significantly increased lipolysis in fat cells from infants, whereas immunoglobulin fraction from a patient with inhibitory TSHR autoantibodies (TBab) blocked TSH-induced lipolysis in a dose-dependent manner. Although TBab totally blocked the maximum lipolysis induced by TSH (10(5) mU/L), no effect was seen on isoprenaline-induced lipolysis. The maximum lipolytic response to TSH was similar to that seen with the beta-adrenoceptor agonist isoprenaline, and there was a similar cAMP increase in response to both stimulators. From these results, it is concluded that the TSHR in infant adipocytes is likely to be coupled to the adenylate cyclase system, and the lipolytic effect of TSH can be simulated by stimulatory TSHR autoantibodies or inhibited by TBab.

Characterization of a Mycobacterium leprae antigen related to the secreted Mycobacterium tuberculosis protein MPT32

Secreted proteins may serve as major targets in the immune response to mycobacteria. To identify potentially secreted Mycobacterium leprae antigens, antisera specific for culture filtrate proteins of Mycobacterium tuberculosis were used to screen a panel of recombinant antigens selected previously by leprosy patient sera. Four potentially secreted antigens were identified by this approach, and one was recognized by antibodies specific for MPT32, a secreted M. tuberculosis protein. The DNA coding for the M. leprae antigen, which we have designated 43L, was isolated and characterized and found to encode a 25.5-kDa protein that is preceded by a consensus signal peptide of 39 amino acids. The N-terminal amino acid sequence of 43L shows 50% homology with the 20 known N-terminal amino acids of MPT32, and 47% homology was found with the N terminus of a 45/47-kDa antigen complex identified in Mycobacterium bovis BCG. These findings indicate that 43L represents an antigen related to MPT32 and the M. bovis BCG 45/47-kDa complex and that 43L is likely to be a protein secreted by M. leprae. Purified recombinant 43L protein is recognized by antibodies and T cells from healthy contacts and leprosy patients, illustrating that secreted proteins are of importance in the immune response to M. leprae.

Molecular mapping of interactions between a Mycobacterium leprae-specific T cell epitope, the restricting HLA-DR2 molecule, and two specific T cell receptors

A systematic series of 89 single residue substitution analogs of the Mycobacterium leprae 65-kDa protein-derived peptide LQAAPALDKL were tested for stimulation of two HLA-DR2 restricted 65 kDa-reactive T cell clones from a tuberculoid leprosy patient. Some analogs with substitutions outside a "core" region showed enhanced stimulation of the T cell clones. This core region of seven or eight residues was essential for recognition, whereas substitution of amino acids outside this region did not affect T cell recognition although these residues could not be omitted. Thus these core residues interact directly with the presenting HLA-DR2 molecule and/or the TCR. Except for analogs of position 419 for clone 2B6, the majority of the nonstimulatory substitution analogs did not inhibit the presentation of LQAAPALDKL and thus probably failed to bind to the HLA-DR2 molecule. Unless all of the core residues are physically involved in binding to DR2, substitution at a position not directly involved in binding appears to have an influence on other residues that do bind to the DR2 molecule. Active peptide analogs with two or more internal prolines suggest that not all analogs need be helical for activity with clone 2F10.