International Cut-offs Research Articles

Impact on survival of sarcopenia, systemic inflammatory response and anthropometric factors after pancreatectomy for resectable pancreatic adenocarcinoma

IntroductionPancreatic adenocarcinoma (PDAC) is becoming a public health issue with a 5-years survival rate around 10%. Patients with PDAC are often sarcopenic, which impacts postoperative outcome. At the same time, overweight population is increasing and adipose tissue promotes tumor related-inflammation. With several studies supporting independently these data, we aimed to assess if they held an impact on survival when combined.MethodsWe included 232 patients from two university hospitals (CHU de Lille, Institut Paoli Calmette), from January 2011 to December 2018, who underwent Pancreaticoduodenectomy (PD) for resectable PDAC. Preoperative CT scan was used to measure sarcopenia and visceral fat according to international cut-offs. Neutrophil to lymphocyte (NLR) and platelet to lymphocyte ratios (PLR) were used to measure inflammation. For univariate and multivariate analyses, the Cox proportional-hazard model was used. P-values below 0.05 were considered significant.ResultsSarcopenic patients with visceral obesity were less likely to survive than the others in multivariate analysis (OS, HR 1.65, p= 0.043). Cutaneous obesity did not influence survival. We also observed an influence on survival when we studied sarcopenia with visceral obesity (OS, p= 0.056; PFS, p = 0.014), sarcopenia with cutaneous obesity (PFS, p= 0.005) and sarcopenia with PLR (PFS, p= 0.043). This poor prognosis was also found in sarcopenic obese patients with high PLR (OS, p= 0.05; PFS, p= 0.01).ConclusionSarcopenic obesity was associated with poor prognosis after PD for PDAC, especially in patients with systemic inflammation. Pre operative management of these factors should be addressed in pancreatic cancer patients.

Abstract 6079: Comparison of FIT and cell-free DNA analyses for detection of individuals with colorectal cancer in population based screening

Abstract Background The fecal immunochemical test (FIT) is widely used in population based colorectal cancer (CRC) screening programs. Recently, circulating cell-free DNA (cfDNA) analyses have emerged as a new avenue for early cancer detection. The performance of cfDNA methods in comparison with FIT is currently unknown. The present study compared pre-operative cfDNA analyses to FIT for detection of patients with CRC who participated in a population-based screening program. Methods In the Dutch national CRC screening program, individuals aged 55-75 years are biennially invited to perform a single FIT. The database of the Dutch CRC screening program was queried to identify individuals with FIT data who also participated in two cfDNA studies, PLCRC-MEDOCC and PLCRC-PROVENC3 (AACR abstract C. Rubio Alarcón). Sensitivities with 95% confidence intervals (CI) for detecting individuals with CRC were determined for FIT, tumor-informed cfDNA analyses, as well as both tests combined. For FIT, sensitivities were determined at 20 µg and 47 µg hemoglobin (Hb)/g feces positivity cut-offs as these represent the most commonly used international and Dutch cut-offs, respectively. Liquid biopsy analyses were performed using next generation sequencing of cfDNA. Tumor-specific alterations were identified through parallel next generation sequence analysis of resected tumor tissues. Results The query identified 120 individuals with stage I (n=3, 2.5%), stage II (n= 57, 47.5%) and stage III (n=60, 50.0%) CRC who had participated in the Dutch CRC screening program and either PLCRC-MEDOCC or PLCRC-PROVENC3. All FIT samples were collected at a median time of 38 days before diagnosis (IQR 27-112 days). FIT sensitivity for detection of individuals with CRC was 83.3% (100/120 CRCs, 95% CI 75.4-89.5%) at a 20 µg Hb/g feces cut-off and 80.0% (96/120, 95% CI 71.7-86.7%) at a 47 µg Hb/g feces cut-off. Tumor-informed cfDNA analyses detected 75.8% (91/120, 95% CI 67.2-83.2%) of individuals with CRC in this population. The combination of cfDNA analyses and and FIT (20 µg Hb/g feces cut-off) identified almost all individuals with CRCs (119/120, sensitivity 99.2%, 95% CI 97.0-100%). The individual who was missed had a cancer that was a T3N0 microsatellite stable moderately differentiated adenocarcinoma in the ascending colon. Discussion While both FIT and cfDNA analyses identified most CRC cases (75-83%) in this series, both tests also demonstrated a substantial level of complementarity, indicating that in principle combining FIT with cell-free DNA testing would allow to increase sensitivity of CRC screening. Since the cell-free DNA tests used here are tumor-informed, which in real life screening practice is not feasible, it remains to be determined to what extent this result can be reached using non-tumor-informed approaches. Citation Format: Pieter Henk Abraham Wisse, Carmen Rubio-Alarcon, Suzanna J. Schraa, Adria C. Mosquera, Mark Sausen, Remond J. Fijneman, Geraldine R. Vink, Meike de Wit, Jillian Phallen, Victor E. Velculescu, Beatriz Carvalho, Gerrit A. Meijer. Comparison of FIT and cell-free DNA analyses for detection of individuals with colorectal cancer in population based screening [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2024; Part 1 (Regular Abstracts); 2024 Apr 5-10; San Diego, CA. Philadelphia (PA): AACR; Cancer Res 2024;84(6_Suppl):Abstract nr 6079.

Gross motor coordination and physical fitness in overweight and obese primary school children compared with normal weight peers

The epidemic of childhood obesity, the decline in the level of motor competence and health-related fitness, and simultaneously the increase in physical inactivity have been the subject of global professional and scientific discourse in the last two decades. This study is focused on the analysis of the level of gross motor coordination and physical fitness in primary school children in terms of their weight status. Data were collected from 219 primary school children (50.68% girls) with an average age of 9.48 years (SD = 0.47 years). Gross motor coordination was assessed with the KTK test. The children's physical fitness was assessed using six items of the Eurofit test. The body mass index (BMI) of the participants was assessed based on the international childhood BMI cut-offs suggested by the International Obesity Task Force (IOTF). Differences in the examined motor indicators between overweight/obese children and normal weight children were evaluated using independent samples t-test. Pearson correlations were performed to explore the associations between motor coordination indicators and BMI. The results of this study revealed overweight or obesity in more than one fifth of the participants (25.2% of girls and 21.3% of boys). Our study provides evidence that excessive body weight is negatively reflected both in gross motor coordination and in a worse physical fitness profile of children. Weak to moderate inverse correlations (−0.17 ≤ r ≤ −0.39) were found between most of the gross motor coordination, physical fitness parameters and BMI, for both sexes. Considering the role of gross motor coordination and health-related fitness in the mechanism of shaping children's active lifestyle, early detection and intervention is necessary, especially in children with excessive body weight.

Establishing international optimal cut-offs of waist-to-height ratio for predicting cardiometabolic risk in children and adolescents aged 6–18 years

BackgroundWaist-to-height ratio (WHtR) has been proposed as a simple and effective screening tool for assessing central obesity and cardiometabolic risk in both adult and pediatric populations. However, evidence suggests that the use of a uniform WHtR cut-off of 0.50 may not be universally optimal for pediatric populations globally. We aimed to determine the optimal cut-offs of WHtR in children and adolescents with increased cardiometabolic risk across different countries worldwide.MethodsWe used ten population-based cross-sectional data on 24,605 children and adolescents aged 6–18 years from Brazil, China, Greece, Iran, Italy, Korea, South Africa, Spain, the UK, and the USA for establishing optimal WHtR cut-offs. We performed an external independent test (9,619 children and adolescents aged 6–18 years who came from other six countries) to validate the optimal WHtR cut-offs based on the predicting performance for at least two or three cardiometabolic risk factors.ResultsBased on receiver operator characteristic curve analyses of various WHtR cut-offs to discriminate those with ≥ 2 cardiometabolic risk factors, the relatively optimal percentile cut-offs of WHtR in the normal weight subsample population in each country did not always coincide with a single fixed percentile, but varied from the 75th to 95th percentiles across the ten countries. However, these relatively optimal percentile values tended to cluster irrespective of sex, metabolic syndrome (MetS) criteria used, and WC measurement position. In general, using ≥ 2 cardiometabolic risk factors as the predictive outcome, the relatively optimal WHtR cut-off was around 0.50 in European and the US youths but was lower, around 0.46, in Asian, African, and South American youths. Secondary analyses that directly tested WHtR values ranging from 0.42 to 0.56 at 0.01 increments largely confirmed the results of the main analyses. In addition, the proposed cut-offs of 0.50 and 0.46 for two specific pediatric populations, respectively, showed a good performance in predicting ≥ 2 or ≥ 3 cardiometabolic risk factors in external independent test populations from six countries (Brazil, China, Germany, Italy, Korea, and the USA).ConclusionsThe proposed international WHtR cut-offs are easy and useful to identify central obesity and cardiometabolic risk in children and adolescents globally, thus allowing international comparison across populations.

Sarcopenia Prevalence and Influence on the Development of Toxicity and Length of Stay in Patients with Relapsed and Refractory Myeloma Treated with Commercial Anti-BCMA CART Cells

Background Sarcopenic muscle loss has well-documented adverse impacts on treatment outcomes and mortality across cancer types and is particularly prevalent in patients with multiple myeloma, reported in 54% of newly diagnosed patients (Nandakumar ASCO 2022). Two chimeric antigen receptor T-cell (CAR-T) constructs have been FDA approved for relapsed/refractory multiple myeloma (RRMM) after exposure to at least 4 prior lines of therapy. MM Treatment combinations frequently incorporate high dose dexamethasone, well known to cause muscle atrophy, and patients may be on therapy for many years prior to becoming eligible for commercial products with associated detrimental effects from cumulative toxicities. We sought to determine the prevalence of sarcopenia in a real-world cohort of patients with RRMM presenting for commercial CAR-T. Methods We identified all patients presenting to our center treated with commercially approved CAR-T with available restaging imaging performed prior to lymphodepleting chemotherapy (LD-chemo). Cross-sectional area (CSA) of skeletal muscle were measured using Sliceomatic software (v6, Tomovision, 2022), abdominal images obtained from low-dose CT of PET/CT scans, standardized to the midpoint of of the L3 vertebrae. CSA was standardized to the square of patient height to compute skeletal muscle index (SMI, cm2/m2). Patients were categorized as sarcopenic according to international gender-specific consensus cutoffs for SMI, male: < 55.4 cm2/m2 and female: < 38.9 cm2/m2 (Mourtzakis et al, 2008) Patients with the following FISH cytogenetics were considered high risk: t(4;14), t(14;16) and deletion 17p/monosomy 17 whereas the remainder were standard risk. All variables were summarized with descriptive statistics, Mann-Whitney U test, students t-test, chi-squared or Fisher's exact were used where appropriate. Analyses were conducted in Stata (16.1, StataCorp LLC, College Station, TX). Results The cohort consisted of 61 patients, 55 (90%) received ide-cel and 6 (10%) received cilta-cel. Baseline characteristics are summarized in Table 1. Of these 16 (26%) were ≥70 years at the time of treatment and 36 (59%) had co-morbidity index >2 at the time of therapy (Sorror, Blood 2005). All scans were performed a median of 16 days prior to CAR-T administration (range 2-90). Prior to CAR-T administration 47 (77%) of patients met criteria for sarcopenia based on their pre-LD chemo restaging imaging. Male patients were more likely than women to meet criteria for sarcopenia (89% vs 62%, p=0.01) and 31 (50%) met criteria for sarcopenic overweight or obesity. Sarcopenic patients had poorer baseline performance status ECOG >=2 (23% vs 7%, p=0.17), higher baseline ferritin (p=0.08) and higher baseline tumor burden as defined by >50% marrow involvement (40% vs 14%, p=0.08) when compared to non-sarcopenic patients, although not significant at the P=0.05 level. The majority (63%) of sarcopenic patients did not meet criteria for registration trials. No significant relationship was found between the presence of sarcopenia and the development of cytokine release syndrome, but all patients who developed neurotoxicity (any grade) had underlying sarcopenia (any grade ICANS 12/47, 26% vs 0%, p=0.04). A greater proportion of sarcopenic patients had extended lengths of stay >=9 days 51% vs 21%, p=0.05). In total 24/61 (39%) were recommended for post-discharge rehab/physical therapy, of whom the majority (N=20) had baseline sarcopenia. Similarly, 13/61 (21%) required additional supports at home on discharge, N=10 with baseline sarcopenia. Conclusion Sarcopenia is highly prevalent, found in 77% of patients attending for BCMA-directed CAR-T therapy in the commercial setting. We have shown that analysis of body habitus is straightforward to perform using images acquired as standard and could inform practice. In the real-world setting, sarcopenic patients appear to be at higher risk of developing neurotoxicity, although this merits further investigation. Although high prevalence of sarcopenia in this sample may preclude statistical detection of its adverse clinical impacts, it is clearly a significant clinical issue for patients undergoing complex immunotherapies for MM and warrants further research and intervention. Pre-habilitation strategies may be beneficial while patients are awaiting apheresis availability, or during cell manufacturing. Figure 1View largeDownload PPTFigure 1View largeDownload PPT Close modal

Influence of Overweight and Obesity on Morbidity and Mortality among Hospitalized Patients in Sri Lanka: A Single-Center Analysis.

Background Current evidence regarding the association between overweight and obesity and in-hospital morbidity and mortality is inconsistent and South Asian populations are underrepresented. Methods Data relevant to anthropometry, hospital outcomes, complications, and medical diagnoses of all acute medical admissions to the National Hospital of Sri Lanka were collected over a period of 3 months. Analysis was performed with WHO international (ICs) and Asian obesity cut-offs (ACs). Results Sample size was 2,128 (median age: 57 years [IQR: 42, 67], males: 49.7%). High prevalence of overweight (23.5%), generalized obesity (10.4%), central obesity (28.5%), and underweight (15.4%) was observed (ICs). Patients with either generalized or central obesity had significantly higher in-hospital mortality (4.8% versus 2.5%, p = 0.031) and acute kidney injury (AKI) (3.9% versus 1.2%) (p = 0.001) compared to normal weight. With ACs, overweight and obesity prevalence increased, without any significant increment in morbidity and mortality, but median length of hospital stay was significantly reduced in patients with generalized obesity compared to normal (3 [IQR: 2, 5] versus 4 [IQR: 2, 6], p = 0.014). Infections (44.4%) and cardiovascular diseases (CVDs) (25.9%) were the most common causes of admission. Overweight and generalized obesity or central obesity were associated with increased prevalence of acute CVDs and CVD risk factors and lower prevalence of acute infections, whilst underweight showed an inverse association. Conclusion A double burden of malnutrition and diseases were noted among hospital admissions, with obesity being a risk factor for in-hospital all-cause mortality and AKI. Overweight and obesity were associated with increased CVDs and reduced infections. Larger prospective studies are required to characterize these associations among South Asians.

Sarcopenia identified by computed tomography (CT) imaging using a machine learning–based convolutional neural network (CNN) algorithm impacts survival in patients with newly diagnosed multiple myeloma (NDMM).

110 Background: Sarcopenia or a loss of muscle mass increases with aging and is associated with increased overall mortality in patients with cancer. Recent advances in machine learning–based CNN algorithms have allowed for the rapid processing of digital images to produce image classifications of body composition. Since incidence of MM is highly associated with aging, we sought to determine if the presence of sarcopenia, as determined by utilizing this machine learning–based CNN algorithm on CT images, had prognostic value in patients with NDMM. Methods: We identified all patients with NDMM from January 2003 to July 2019 who had a standard-dose CT scan that included the L3 vertebral level performed within 6 months of diagnosis. Using a machine learning–based CNN-algorithm, abdominal CT images were analyzed to measure muscle area. These measurements were normalized by dividing the area values by the height of the patient squared (m2) to obtain skeletal muscle index (SMI) values. Patients were categorized as sarcopenic according to international gender-specific consensus cutoffs for SMI (male: &lt; 55 cm2/m2 and female: &lt; 39 cm2/m2). Patients with the following FISH cytogenetics were considered high risk (HR): t(4;14), t(14;16), t(14;20), and deletion 17p/monosomy 17 whereas the remainder were standard risk (SR). Survival analysis was performed using the Kaplan-Meier method and compared via the log-rank method. Results: The study cohort consisted of 344 patients. 68 (20%) were categorized as HR based on FISH cytogenetics.187 (54%) patients were sarcopenic based on their peri-diagnosis standard-dose CT scan. Sarcopenic patients were more likely to have ISS-3 disease (45% vs. 30%; p =.023), be male (73% vs. 48%; p &lt;.001), and be ≥ age 75 (27% vs. 14%; p =.002) compared to non-sarcopenic patients. The median OS for patients with HR FISH and ISS 2 / 3 disease was 40 months and 57 months respectively compared to 90 months and 119 months for those with SR FISH and ISS-1 disease respectively (FISH: p &lt;.004; ISS: p &lt;.001). The median OS for sarcopenic patients was 44 months compared to 90 months for those not sarcopenic (p &lt;.001). The time to next therapy (TTNT) for sarcopenic patients was 39 months compared to 45 months for those not sarcopenic (p =.05). In a multivariable model, the presence of sarcopenia (HR 1.64, 95% CI, 1.05–2.56; p =.03) retained significance in the presence of HR FISH, ISS 2 / 3 disease, and age ≥ 75. Conclusions: Gender-specific sarcopenia identified by a machine learning–based CNN algorithm significantly affects OS in patients with NDMM and is independent of age, ISS stage, and cytogenetic status. Future studies utilizing this machine learning–based methodology of assessing sarcopenia in larger prospective clinical trials are required to validate these findings.

Eating Patterns in Children, an Issue for Future Health Policy

Background: Obesity and overweight have increased prevalence in children during the last decades all over the world. Objectives: The aim of this study was to determine the prevalence of overweight/obesity through the 12-18 year old schoolchildren in Brasov district and to describe eating patterns and the possible relationship between overweight/obesity and eating pattern. Material and Method: There were recruted 250 children for a cross-sectional study in Brasov district, Romania. Alimentary habit, snaking, meal frequencies were declared by the subjects using a retrospective questionnaire. Parents were asked to give information about family history regarding the presence of cardio-vascular risk factors. There were measured weight and height for all children and it was calculated body mass index calculated using international standard cutoff points (International Obesity Task Force values). It was also evaluated the level of phisical activityfor each children. Results: Positive family hystory for cardio-vascular risk factor, eating pattern and physical activity were associated with overweight. Healthy eating pattern including fresh fruits and vegetables loses ground in favour of fast-food as the age increases. Conclusions: The main finding was that, eating pattern in schoolchildren should worry both parents and school authorities. The family influence on children̓s eating pattern decreases as the age grow, the busy school program determine lack of phisical activities and failure of and the healthy alimentation. The prevalence of overweight was high and connected with dietary behaviour, independent associations were evident between eating patterns and overweight, indicating the need of the need for a common intervention on nutrition both from the family and from the educators.

Equitable Distribution of Poor Quality of Care? Equity in Quality of Reproductive Health Services in Ethiopia

The Ethiopian health system faces persistent inequities in health-care utilization and outcomes, despite continued efforts to expand health service coverage. There is little evidence in the literature describing the status of equity in the quality of healthcare. This paper aims to understand the disparities in quality of antenatal care (ANC) and family planning (FP) among the poor and non-poor communities. We used the 2016 Ethiopia Demographic and Health Survey (DHS) data to compute a Multidimensional Poverty Index (MPI), and the 2014 Service Provision Assessment (SPA) data to assess quality of ANC and FP services—defined as the level of adherence to World Health Organization (WHO) clinical and service guidelines. We merged the two datasets using geographical coordinates, and aggregated service users into facility catchment area clusters using a 2-km radius for urban and 10-km radius for rural facilities. We computed ANC and FP quality and MPI indices for each facility and assigned these to catchment areas. Using the international cutoff point for deprivation (MPI = 33.3%), we evaluated whether the quality of ANC and FP services varies by poor and non-poor catchment areas. We found that most of catchment areas (75.7%) were deprived. While the overall quality of ANC and FP services are low (33% and 34% respectively), we found little variation in the distribution of the quality of these services between poor and non-poor areas, urban and rural settings, or regionally. The short-term focus needs to be on improving the overall quality of services rather than on its distribution.

The Association Between Sedentary Screen Time, Non-screen-based Sedentary Time, and Overweight in Chinese Preschool Children: A Cross-Sectional Study.

Introduction: Less is known about the effects of the different domains of sedentary behaviors on healthy weight in young children. This cross-sectional study examined the association between sedentary screen time (SST), non-screen-based sedentary time (NSST), and overweight (and obesity) in Chinese preschoolers.Methods: Data were collected from the Physical Activity and Health in Tianjin Chinese Children study (PATH-CC), involving healthy children 3–6 years old and their families. Children's overweight status was classified according to the international (IOTF) childhood BMI cut-offs. SST and NSST were reported in minutes/day by parents using the leisure-time sedentary behaviors questionnaire. Logistic regression models adjusted by sex, age, socioeconomic status, outdoor play, and sleep duration were used.Results: In a total of 971 children (55.4% boys), 11.8% were overweight. Generally, children spent 1 h/day in SST and 1 h/day in NSST. Multiple models showed that children who spent more time in SST were more likely to be overweight [OR and 95% CI: 1.22 (1.03–1.45)]. No correlation between time spent on NSST and children with overweight was found (P > 0.05).Conclusions: This study indicated that children who spent more time in SST were more likely to be overweight, but a null correlation between NSST and overweight was found. Longitudinal studies designed to identify associations between exposures to screen media and changes in metabolic parameters during a child's early years are needed.

Child Poverty and Health in the United States: Introduction and Executive Summary.

Child Poverty and Health in the United States: Introduction and Executive Summary.

Ideal cardiovascular health at age 5\u20136\u2009years and cardiometabolic outcomes in preadolescence

BackgroundThe American Heart Association (AHA) developed a definition of ideal cardiovascular health (ICH) based on the presence of both ideal health behaviours (diet, physical activity, weight status and smoking) and ideal health factors (glucose, total cholesterol and blood pressure levels). However, research of ICH in the paediatric population is scarce. We aimed to study ICH at age 5–6 years by extending the original ICH score with the health behaviours: sleep duration, screen time and prenatal smoke exposure, and to evaluate its association with cardiometabolic outcomes at age 11–12.MethodsA total of 1666 children aged 5–6 years were selected from the database of the ABCD-study, a prospective cohort study on the health and development of children born in Amsterdam, the Netherlands. Of these, 846 (50.8%) were boys and 1460 (87.6%) had a healthy weight. Data on self-reported health behaviours and health factors were used to calculate the ICH scores (original and extended) by adding the frequency of scoring ‘healthy’ on each indicator, based on international cut-offs. The children were followed up for 6 years and cardiometabolic outcomes (carotid intima-media thickness (CIMT), blood pressure, glucose and lipids) were measured. Associations between ICH (both original and extended) and cardiometabolic outcomes were examined using multivariable regression models.ResultsAt age 5–6 years, 11% scored poor (score 1–5), 56% intermediate (score 6–7) and 33% good (score 8–9) on extended ICH. Healthy diet and normal total cholesterol concentrations were the least prevalent. Neither the original nor the extended ICH scores were associated with CIMT at age 11–12. A higher score on the extended ICH was associated with lower total cholesterol (p for trend < 0.001), lower systolic (p for trend = 0.012) and diastolic blood pressure (p for trend = 0.011), and lower body mass index (BMI) (p < 0.001) at age 11–12. The original ICH score was associated with lower total cholesterol (p < 0.001) and BMI (p < 0.001) only.ConclusionOur findings suggest that extending the ICH score in young children with additional health behaviours improves prediction of some cardiometabolic outcomes, but not CIMT in preadolescence, compared to the original ICH score. We would recommend other researchers to incorporate objective measures of health behaviours and longer follow-up to find out whether associations persist into adulthood.

411 - Implementing the STrAtegies for RelaTives (START) intervention in Portugal – preliminary findings

IntroductionAs in other countries, Portuguese family caregivers have unmet needs regarding information and distress. START (STrAtegies for RelaTives) is a manual-based coping intervention for families of people with dementia, including coping strategies and stress-management components, by Livingston and colleagues (https://www.ucl.ac.uk/psychiatry/research/mental-health-older-people/projects/start). In the UK, START has been clinically effective, immediately and continuing even after 6-years, without increasing costs. Clinical training and supervision ensures treatment fidelity. In Portugal, these kind of interventions are less available and, when provided, are mostly supportive and fail to address coping strategies. Paradoxically, recruitment may also prove challenging.ObjectivesWe describe the development of the Portuguese translation of START, incorporating guidance from the UK team, and a pilot study of delivery to family caregivers of people with dementia. We will also discuss the challenges of recruiting participants and delivering the intervention.MethodWe translated the START intervention and recruited family caregivers from neurology and psychiatry outpatients, in a central hospital in Lisbon. Our baseline assessment included the Hospital Anxiety and Depression Scale and the Zarit Burden Interview. The pilot is still ongoing at time of submitting, so we focus on recruitment, baseline assessments and process issues.ResultsDuring a three-month period, we recruited six caregivers. Five were primary caregivers (spouses or adult children) who had been caring for their relatives for 2 up to 10 years. Two caregivers met the international cutoff for clinically relevant affective disorder . The most frequent motivators for taking part were learning to communicate with their relatives and increasing knowledge to build community resources. Overall, the subjective impression of the therapist in charge is that the intervention seems acceptable and promising.Discussion/ConclusionsThis pilot study will eventually lead to an improved version of the Portuguese version of the START manual. So far, the intervention seems appropriate for selected caregivers in Portugal. However, response to striking unmet needs, particularly basic home support, may need to precede interventions like START. We look forward to concluding the intervention study and analyzing the implementation challenges, as a basis to inform a wider-scale trial.

Trunk-to-peripheral fat ratio predicts a subsequent blood pressure in normal-weight pubertal boys: a 3-year follow-up of the Kitakata Kids Health Study

BackgroundLimited evidence exists regarding the relationship between central-to-peripheral fat ratio measured by dual-energy X-ray absorptiometry (DXA) and subsequent cardiometabolic risk in both pediatric and adult populations.MethodsThe present cohort study investigated the relationship between DXA-measured body fat distribution and cardiometabolic parameters. The source population was 275 4th–6th graders (aged 9.6–12.6 years) in the northeast region of Japan (Shiokawa area in Kitakata). A 3-year follow-up was conducted to obtain complete information from 155 normal-weight children (87 boys and 68 girls). Normal-weight children were identified using sex- and age-specific international cut-offs for body mass index (BMI) based on adult BMI values of 25 kg/m2 and 18.5 kg/m2, respectively. Body fat distribution was assessed using the trunk-to-appendicular fat ratio (TAR) and trunk-to-leg fat ratio (TLR) measured by DXA.ResultsIn boys, systolic blood pressure (SBP) at follow-up showed a significant relationship with TAR at baseline after adjusting for age, height, pubic hair appearance, SBP, and whole body fat at baseline (β = 0.24, P < 0.05), and SBP also showed a significant relationship with TLR after adjusting for confounding factors including whole body fat (β = 0.25, P < 0.05). In girls, there were no significant relationships between blood pressure and TAR/TLR.ConclusionBody fat distribution in normal-weight boys predicted subsequent blood pressure levels in adolescence. The relationship between fat distribution and blood pressure was independent of fat volume.

TSH Levels in Subclinical Hypothyroidism in the 97.5th Percentile of the Population.

The debate regarding the cutoff point in the treatment of patients with subclinical hypothyroidism (Shypo) is ongoing. Generally, two different groups are identified for treatment by levels of 10 and 20 mIU/L. Nevertheless, the question remains, “what cutoff point should be chosen?” We have written a selective nonsystematic review focused on the 97.5 percentile reference value reported in healthy subjects in a number of countries and observed important disparities, which partly show the challenge of identifying a single cutoff point for those patients needing medication. We identified studies of TSH on the natural history of subclinical hypothyroidism from population-based prospective cohort studies, which follow up patients for several years. The evolution of TSH levels in these patients is variable. Some cases of TSH may return to lower levels at different stages over the years, but others may not, possibly even developing into overt thyroid failure, also variable. We analyzed factors that may explain the normalization of serum TSH levels. In addition, we found that thorough population-based prospective cohort studies following up on TSH levels, thyroid antibodies, and ultrasonography are important in decisions made in the treatment of patients. However, the 97.5 percentile reference value varies in different countries; therefore, an international cutoff point for subclinical hypothyroidism cannot be recommended.

Prevalence of overweight and underweight in schoolchildren in Constantine, Algeria: comparison of four reference cut-off points for body mass index.

Algeria is experiencing a nutritional transition and increasing overweight in children. This study aimed to determine the prevalence of overweight and underweight in children aged 6-10 years in Constantine city, Algeria using four international reference cut-offs for body mass index. A cross-sectional study was conducted between February and May 2015 with a sample of 509 schoolchildren aged 6-10 years. Height and weight were measured according to World Health Organization (WHO) recommendations. The body mass index cut-offs of WHO, International Obesity Task Force, Centers for Disease Control and Prevention (CDC) and French national references were used to classify the sample as underweight and overweight according to age and sex. The kappa coefficient was used to assess agreement between the reference cut-offs. Based on the of different reference cut-offs, the prevalence of underweight in the children varied from 1.4% to 8.8%. The prevalence of overweight varied from 22.8% to 28.3%. The WHO cut-off gave a significantly higher prevalence of overweight in boys than girls (32.6% versus 24.0%, P = 0.03). The kappa values (between 0.251 and 0.954) indicated a fair to excellent agreement between the different reference cut-offs. The prevalence of overweight and underweight differs in the Constantine children depending on the reference cut-off used, suggesting international references should be used with care to avoid potential misclassification of children's nutritional status.

International Waist Circumference Percentile Cutoffs for Central Obesity in Children and Adolescents Aged 6 to 18 Years.

No universal waist circumference (WC) percentile cutoffs used have been proposed for screening central obesity in children and adolescents. To develop international WC percentile cutoffs for children and adolescents with normal weight based on data from 8 countries in different global regions and to examine the relation with cardiovascular risk. We used pooled data on WC in 113,453 children and adolescents (males 50.2%) aged 4 to 20 years from 8 countries in different regions (Bulgaria, China, Iran, Korea, Malaysia, Poland, Seychelles, and Switzerland). We calculated WC percentile cutoffs in samples including or excluding children with obesity, overweight, or underweight. WC percentiles were generated using the general additive model for location, scale, and shape (GAMLSS). We also estimated the predictive power of the WC 90th percentile cutoffs to predict cardiovascular risk using receiver operator characteristics curve analysis based on data from 3 countries that had available data (China, Iran, and Korea). We also examined which WC percentiles linked with WC cutoffs for central obesity in adults (at age of 18 years). WC measured based on recommendation by the World Health Organization. We validated the performance of the age- and sex-specific 90th percentile WC cutoffs calculated in children and adolescents (6-18 years of age) with normal weight (excluding youth with obesity, overweight, or underweight) by linking the percentile with cardiovascular risk (area under the curve [AUC]: 0.69 for boys; 0.63 for girls). In addition, WC percentile among normal weight children linked relatively well with established WC cutoffs for central obesity in adults (eg, AUC in US adolescents: 0.71 for boys; 0.68 for girls). The international WC cutoffs developed in this study could be useful to screen central obesity in children and adolescents aged 6 to 18 years and allow direct comparison of WC distributions between populations and over time.

Does the Severity of Obesity Influence Bone Mineral Density Values in Premenopausal Women?

The aim of this study was to compare bone mineral content (BMC), bone mineral density (BMD), and geometric indices of hip bone strength among 3 groups of adult obese premenopausal women (severely obese, morbidly obese, and super morbidly obese). This study included 65 young adult premenopausal women whose body mass index (BMI) > 35 kg/m2. They were divided into 3 groups using international cut-offs for BMI. Body composition and bone variables were measured by DXA. DXA measurements were completed for the whole body (WB), lumbar spine, total hip (TH), and femoral neck (FN). Geometric indices of FN strength (cross-sectional area, cross-sectional moment of inertia [CSMI], section modulus [Z], strength index [SI], and buckling ratio) were calculated by DXA. Results showed that age and height were not significantly different among the 3 groups. WB BMC values were higher in super morbidly obese women compared to severely and morbidly obese women. WB BMD, L1-L4 BMD, total hip BMD, FN BMD, cross-sectional area, CSMI, Z, and buckling ratio values were not significantly different among the 3 groups. SI values were lower in super morbidly obese compared to morbidly and severely obese women. In the whole population (n = 65), body weight, BMI, lean mass, fat mass, and trunk fat mass were positively correlated to WB BMC and negatively correlated to SI. Weight and lean mass were positively correlated to WB BMD and CSMI. Our findings suggest that the severity of obesity does not influence BMD values in premenopausal women.

Proposed achievable levels of dose and impact of dose-reduction systems for thrombectomy in acute ischemic stroke: an international, multicentric, retrospective study in 1096 patients

International dose reference levels are lacking for mechanical thrombectomy in acute ischemic stroke patients with large vessel occlusions. We studied whether radiation dose-reduction systems (RDS) could effectively reduce exposure and propose achievable levels. We retrospectively included consecutive patients treated with thrombectomy on a biplane angiography system (BP) in five international, high-volume centers between January 2014 and May 2017. Institutional Review Board approvals were obtained. Technical, procedural, and clinical characteristics were assessed. Efficacy, safety, radiation dose, and contrast load were compared between angiography systems with and without RDS. Multivariate analyses were adjusted according to Bonferroni's correction. Proposed international achievable cutoff levels were set at the 75th percentile. Out of the 1096 thrombectomized patients, 520 (47%) were treated on a BP equipped with RDS. After multivariate analysis, RDS significantly reduced dose-area product (DAP) (91 vs 140Gycm2, relative effect 0.74 (CI 0.66; 0.83), 35% decrease, p < 0.001) and air kerma (0.46 vs 0.97Gy, relative effect 0.63 (CI 0.56; 0.71), 53% decrease, p < 0.001) with 75th percentile levels of 148Gycm2 and 0.73Gy, respectively. There was no difference in contrast load, rates of successful recanalization, complications, or clinical outcome. Radiation dose-reduction systems can reduce DAP and air kerma by a third and a half, respectively, without affecting thrombectomy efficacy or safety. The respective thresholds of 148Gycm2 and 0.73Gy represent achievable levels that may serve to optimize current and future radiation exposure in the setting of acute ischemic stroke treatment. As technology evolves, we expect these values to decrease. • Internationally validated achievable levels may help caregivers and health authorities better assess and reduce radiation exposure of both ischemic stroke patients and treating staff during thrombectomy procedures. • Radiation dose-reduction systems can reduce DAP and air kerma by a third and a half, respectively, without affecting thrombectomy efficacy or safety in the setting of acute ischemic stroke due to large vessel occlusion.

Pattern of Body Mass Index in Students of a Private Medical College of Bangladesh

Objectives: To determine the BMI status of the students of Rajshahi Islami Bank Medical College and to calculate frequency of different BMI categoriesMethodology: A cross-sectional questionnaire based study was carried out in medical students of Rajshahi Islami Bank Medical College, Rajshahi. Body weight and height were measured and body mass index (BMI) values were calculated by dividing weight with (height) 2. Overweight and obesity were defined using WHO international standard BMI cut-offs.Results: The overall prevalence of underweight students was 29.9% out of which 9.6% fell under the category of severely underweight (BMI of &lt;16.5). In overweight category there were 8%. The frequency of students falling in Obese Class I, II &amp; III was 2.7%, 0.6% &amp; 0.0% respectively. It was found that more female students compared to male students were underweight. In the overweight and obese categories there was a preponderance of male students. A positive correlation was found between perception of obesity amongst parents and overweight obese students.Conclusion: According to this study, underweight, especially in girls, should be considered a serious health problem among adolescent students which needs to be addressed. Obesity on the other hand does not seem to be a major issue amongst them.TAJ 2014; 27(2): 1-5