Does a Split-Week Gestational Age Model Provide Valuable Information on Neurodevelopmental Outcomes in Extremely Preterm Infants?

Our primary objective for this follow-up study was to compare the neurodevelopmental outcomes of a surviving cohort of infants using a split-week gestational model (early versus late) gestational age (GA) and the standard completed GA categorization. Neurodevelopmental outcomes using a split-week GA model defined as early (X, 0–3) and late (X, 4–6), with X being 23–26 weeks GA, were compared to outcomes using completed weeks GA. In total, 1012 infants were included in the study. Statistically significant differences were noted in outcomes between the early and late split of the gestational week at 23 weeks (early vs. late), with 13.3% vs. 54.5% for no neurodevelopmental impairment, and 53.3% vs. 22.7% for significant impairment (p = 0.034), respectively. There were no differences seen in the split week model for 24, 25, and 26 weeks. A trend towards improved neurodevelopmental outcomes was seen with each increasing gestation week. The split-week model did not provide additional information for pregnancies and infants between 24 and 26 weeks gestation. It did, however, provide information for counsel for infants at 23 weeks gestation, showing benefits in the late versus early half of the week.

Split-week gestational age model provides valuable information on outcomes in extremely preterm infants

AIM

To compare composite outcomes of neonatal mortality or morbidity using a split-week gestational age (GA) model to completed weeks GA maturity at 23-26 weeks gestation.

METHODS

This was a retrospective cohort study of infants born at 23-26 weeks GA. Outcomes using a split-week GA model defined as early (X, 0-3) and late (X, 4-6) with X being 23-26 weeks GA were compared to outcomes using completed weeks GA, with a similar comparison between the late split of the preceding week (X, 4-6) and early split of the subsequent week (X + 1, 0-3).

RESULTS

A total of 1345 infants were included in the study. Statistically significant differences were noted in outcomes between the early and late split of the gestational week at 24 (early vs late, 85.6% vs 73.0%), 25 (69.6% vs 56.6%) and 26 weeks (55.9% vs 37.4%), but not at 23 weeks GA (95.2% vs 94.5%). No statistically significant differences were noted between the late vs early part of the subsequent week (23, 4-6) vs (24, 0-3), and (24, 4-6) vs (25, 0-3) GA.

CONCLUSION

Neonatal outcome estimates using a split week model differs from that based on the use of completed weeks of gestational maturity.

Abstract P1-11-02: Identifying women at high-risk for breast cancer in the primary care setting

Background: Breast cancer risk assessment and available interventions for prevention, such as chemoprevention, are underutilized in the U.S. Reasons for low uptake include inability to routinely identify high-risk women in the primary care setting, inadequate time for counseling, and insufficient knowledge about risk-reducing strategies among primary care providers (PCPs) and patients. Our goal is to expand breast cancer risk counseling to a broader population of high-risk women identified in the primary care setting by developing a novel breast cancer risk navigation (BNAV) tool integrated into the electronic health record (EHR).

Methods: We propose to design the BNAV tool for PCPs, by integrating the Gail breast cancer risk assessment tool into the EHR. Our goal is to facilitate clinic workflow for the identification of high-risk women (5-year risk ≥1.7% or lifetime risk ≥20%), who may be referred for specialized risk counseling. We conducted recorded focus groups and individual interviews of PCPs (N = 20-25) at Columbia University Medical Center (CUMC), including internists, family practitioners, and gynecologists who use an EHR and see female patients, age 40-70 years, in the outpatient setting. We performed user analyses of PCPs on the characteristics of their practice and their clinic workflow. Information about the aims of BNAV and the development process were provided and PCPs were given an opportunity to ask questions and discuss the relative merits of BNAV and its potential application to clinical practice. Providers also completed a questionnaire to provide quantitative and qualitative feedback on BNAV. Verbal and written qualitative responses were condensed into themes using a qualitative approach based on grounded theory.

Results: In terms of breast cancer risk assessment, few providers routinely assessed for breast cancer risk factors apart from family history. Although some were familiar with the Gail model, no one used the risk calculator in their practice. Many PCPs were concerned about the added burden of incorporating the Gail model into the clinic visit. Potential solutions included screening for high-risk women during mammography and having patients complete the Gail model while in the waiting rooms. Most PCPs preferred referring high-risk women for specialized risk counseling, rather than directly discussing chemoprevention with their patients. Results from our interviews informed the selection of electronic resources to configure the BNAV tool. Using an open application programming interface within the EHR, the BNAV tool will incorporate the following approaches to workflow integration: 1) external decision support plug-ins for risk calculation; 2) dashboards with informatics-enabled summaries of patient history and breast cancer risk factors; 3) extracting data already available in the EHR for the Gail model breast cancer risk calculation; 4) alerts indicating high-risk patients should be referred for specialized risk counseling; 5) semi-structured referral orders for high-risk consultations.

Discussion: PCPs are on the front lines of preventive medicine and initiating the appropriate high-risk referrals. We propose to use health information technology methods to overcome barriers to breast cancer chemoprevention in the primary care setting.

Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr P1-11-02.

Dramatic pain relief and resolution of bone inflammation following pamidronate in 9 pediatric patients with persistent chronic recurrent multifocal osteomyelitis (CRMO)

BACKGROUND

Chronic recurrent multifocal osteomyelitis (CRMO) is an inflammatory, non-infectious osteopathy that affects predominantly patients </= 18 years of age. There is no uniformly effective treatment. Our objective is to describe clinical, magnetic resonance imaging (MRI), and bone resorption response to intravenous pamidronate in pediatric CRMO.

METHODS

We report our prospectively documented experience with all CRMO patients treated with pamidronate between 2003 and 2008 at a tertiary pediatric centre. Pamidronate was administered as intravenous cycles. The dose of pamidronate varied among subjects but was given as monthly to every 3 monthly cycles depending on the distance the patient lived from the infusion center. Maximum cumulative dose was </= 11.5 mg/kg/year. Pamidronate treatment was continued until resolution of MRI documented bone inflammation. Visual analog scale for pain (VAS) and bone resorption marker urine N-telopeptide/urine creatinine (uNTX/uCr) were measured at baseline, preceding each subsequent pamidronate treatment, at final follow-up, and/or at time of MRI confirmed CRMO flare. MRI of the affected site(s) was obtained at baseline, preceding every 2nd treatment, and with suspected CRMO recurrence.

RESULTS

Nine patients (5 F: 4 M) were treated, with a median (range) age at treatment of 12.9 (4.5-16.3) years, and median (range) duration of symptoms of 18 (6-36) months. VAS decreased from 10/10 to 0-3/10 by the end of first 3-day treatment for all patients. The mean (range) time to complete MRI resolution of bone inflammation was 6.0 (2-12) months. The mean (confidence interval (CI)) baseline uNTX/uCr was 738.83 (CI 464.25, 1013.42)nmol/mmol/creatinine and the mean (CI) decrease from baseline to pamidronate discontinuation was 522.17 (CI 299.77, 744.56)nmol/mmol/creatinine. Median (range) of follow-up was 31.4 (24-54) months. Four patients had MRI confirmed CRMO recurrence, which responded to one pamidronate re-treatment. The mean (range) uNTX/uCr change as a monthly rate from the time of pamidronate discontinuation to flare was 9.41 (1.38-19.85)nmol/mmol/creatinine compared to -29.88 (-96.83-2.01)nmol/mmol/creatinine for patients who did not flare by the time of final follow-up.

CONCLUSION

Pamidronate resulted in resolution of pain and MRI documented inflammation in all patients. No patient flared while his/her uNTX/uCr remained suppressed. We propose that pamidronate is an effective second-line therapy in persistent CRMO.

On the Superradiance of Spin-1 Waves in an Equatorial Wedge around a Kerr Hole

Recently Van Putten has suggested that superradiance of magnetosonic waves in a toroidal magnetosphere around a Kerr black hole may play a role in the central engine of gamma-ray bursts. In this context, he computed (in the WKB approximation) the superradiant amplification of scalar waves confined to a thin equatorial wedge around a Kerr hole and found that the superradiance is higher than for radiation incident over all angles. This Letter presents calculations of both spin-0 (scalar) superradiance (integrating the radial equation rather than using the WKB method) and spin-1 (electromagnetic/magnetosonic) superradiance in Van Putten's wedge geometry. In contrast to the scalar case, spin-1 superradiance decreases in the wedge geometry, decreasing the likelihood of its astrophysical importance.

Measurement of low dietary fiber intake as a risk factor for chronic constipation in children

BACKGROUND

Scarce information exists regarding dietary fiber intake in children with chronic constipation. The objective of this case-control study was to evaluate the intake of fiber as a risk factor for chronic constipation.

METHODS

Fifty-two children with a mean age of 6.8+/-3.2 years who had chronic constipation were age and gender matched with 52 children with normal intestinal habits. The fiber content of the diet was evaluated with a 24-hour dietary recall. Two tables of fiber composition in foods were used: a Brazilian table, and a table based on the method of the Association of Official Agricultural Chemists (AOAC).

RESULTS

According to the Brazilian table, the median intake of fiber (in grams per day) by the constipated and the control groups was 13.8 and 17.3, respectively, for total fiber (p = 0.020), 6.8 and 9.7 for insoluble fiber (p = 0.004), and 6.5 and 7.6 for soluble fiber (p = 0.104). According to the AOAC table, the constipation group (9.7 g/day) also had lower (p = 0.0022) intake of total fiber than the control group (12.6 g/day). The coefficient of correlation between the two tables on fiber content of food was +0.82 (p < 0.001) in the constipation group and +0.86 (p < 0.001) in the control group. The intake of fiber was less than the minimum recommendation (age + 5 g) and statistically associated (p = 0.001) with the constipation group (75.0%) in comparison with the controls (42.5%). The odds ratio was 4.1 (95% confidence limits, 1.64-10.32).

CONCLUSION

Intake of fiber below the minimum recommendation is a risk factor for chronic constipation in children.

[Estimated dietary fiber intake in children according to different food composition reference tables]

The importance of dietary fiber intake in the prevention and treatment of adult diseases has been widely emphasized in the literature for several years. Recommendations for fiber intake by children have only recently began to be published. The present study estimated the fiber intake by children with or without constipation according to five food composition tables. We studied 114 children under 12 years of age, of whom 56 were constipated and 58 had normal bowel movements. We used a 24 hour recall questionnaire and fiber consumption was analysed by five food composition tables: 1. Association of Official Agricultural Chemist-AOAC, 2. Southgate, 3. Mendez, 4. Englyst and 5. crude fiber. The statistical analysis showed significant differences between the medians of the estimated fiber consumption calculated using all tables, except the AOAC and Southgate tables. The median value and percent is 25th and 75th presented between parenthesis were (grams/day): Mendez--15.4 (11.9-19.6); Southgate--10.5 (7.8-13.5); AOAC--10.2 (7.3-14.0); Englyst--4.5 (3.0-6.0) and crude fiber--2.1 (1.4-2.9). There were statistical significant correlations between all pairs of tables but the best correlation was observed between Mendez and Southgate (r = +0.90), AOAC and Southgate (r = +0.88); and Mendez and AOAC (r = +0.84). Constipated children presented lower estimated fiber intake than those with normal bowel movements, with statistical significance according to all tables. In conclusion, it is important to determine which reference table should be utilized when recommending dietary fiber.

[Intake of dietary fiber and other nutrients by children with and without functional chronic constipation]

The aim of this study was to evaluate the dietary fiber intake and the dietary habits of children with and without functional chronic constipation. We enrolled 58 children with functional chronic constipation and 58 controls without constipation matched for sex and age. Food and fiber intake were evaluated by 24 hour dietary recall and a complete clinical history was performed. The age of onset of constipation occurred during the first year of life in 55.4% of the patients while the median age of evaluation was 78 months. Soiling was found in 41.7% of patients. The median period of exclusive breast feeding was shorter (P = 0.002) in the constipation group (one month) than in the control group (three month). The proportion of constipation was similar for mothers of children of both groups as well as for siblings in both groups. The fathers of children with constipation presented higher frequency of constipation (12.3%) than the fathers of children in control group (1.8%), but the difference did not reach statistical significance (P = 0.06). The amount of food measured by 24 hour recall was similar in both groups. The calorie intake of constipated children (1526 +/- 585 calories/day) was lower (P = 0.07) than in the control group (1712 +/- 513 calories/day) but the difference did not reach statistical significance. The intake of protein, fat and iron was lower in the constipation group than in the control group. The volume of cow's milk intake was similar in both groups. The median of total dietary fiber intake in the constipation group (13.5 g/day) was statistically (P = 0.009) lower than in the control group (16.8 g/day). The daily intake of insoluble dietary fiber was also statistically lower (P = 0.001) in the constipation group (6.3 g) than in the control group (9.4 g). The intake of soluble dietary fiber was similar in both groups. The intake of dietary fiber per 1,000 calories of diet was 10.3 g in the constipation group and 10.4 in the control group (P = 0.41). There was a considerable intersection of individual values in fiber intake of the constipation and control groups, suggesting that low fiber intake acts in association with others factors on the genesis of constipation in children. However, the low intake of insoluble fiber, suggests that it plays an important role on the pathogenesis of chronic constipation in children.