Cardiovascular risk factors and the metabolic syndrome in pediatric nonalcoholic fatty liver disease

BACKGROUND: Nonalcoholic fatty liver disease (NAFLD), the most common cause of liver disease in children, is associated with obesity and insulin resistance. However, the relationship between NAFLD and cardiovascular risk factors in children is not fully understood. The objective of this study was to determine the association between NAFLD and the presence of metabolic syndrome in overweight and obese children. METHODS AND RESULTS: This case-control study of 150 overweight children with biopsy-proven NAFLD and 150 overweight children without NAFLD compared rates of metabolic syndrome using Adult Treatment Panel III criteria. Cases and controls were well matched in age, sex, and severity of obesity. Children with NAFLD had significantly higher fasting glucose, insulin, total cholesterol, low-density lipoprotein cholesterol, triglycerides, systolic blood pressure, and diastolic blood pressure than overweight and obese children without NAFLD. Subjects with NAFLD also had significantly lower high-density lipoprotein cholesterol than controls. After adjustment for age, sex, race, ethnicity, body mass index, and hyperinsulinemia, children with metabolic syndrome had 5.0 (95% confidence interval, 2.6 to 9.7) times the odds of having NAFLD as overweight and obese children without metabolic syndrome. CONCLUSIONS: NAFLD in overweight and obese children is strongly associated with multiple cardiovascular risk factors. The identification of NAFLD in a child should prompt global counseling to address nutrition, physical activity, and avoidance of smoking to prevent the development of cardiovascular disease and type 2 diabetes.

Mental health and quality of life after genetic testing for Huntington disease: a long-term effect study in Germany

Predictive genetic testing for Huntington disease (HD) might cause severe short-term psychological reactions in patients with poor mental health. Very few studies exist on the long-term effects of genetic HD testing. The aim of this study was to assess mental health and quality of life in persons who were tested for HD mutation, to compare mental health depending on the result of the genetic test (non-carriers, gene carriers, and patients with HD) and to identify predictors of mental health and quality of life via linear regression. The data were collected by self-report questionnaires. In total, 121 individuals participated in this study: 52 were non-carriers, 54 were gene carriers, and 15 were gene carriers suffering from HD. Non-carriers and gene carriers showed better mental health and quality of life than HD-patients but did not differ from each other. In non-carriers four variables predicted increased depression and low mental quality of life: low perceived social support, no intimate relationship, female sex and younger age. For gene carriers three predictors were found: low perceived social support, the expectation of an unfavorable genetic test result before the testing procedure and being childless. To prevent detrimental effects of HD testing on mental health and mental quality of life, specific attention should be paid to persons with limited social networks during genetic counseling. Assessment of expectations related to the test result and mental health prior to a genetic testing procedure may help to identify gene carriers at risk of poor coping after an unfavorable test result.

Persistent symptoms after elective sigmoid resection for diverticulitis

PURPOSE: Despite technically successful surgery for diverticular disease, a significant group of patients who experience persistent or recurrent symptoms remains. This study was designed to determine the incidence and pattern of persistent symptoms and their association with peroperative parameters. METHODS: Follow-up (33 (range, 4-72) months) through structured interviews with patients who had surgery for diverticulitis in our department from December 1999 to November 2004 was conducted. Of 162 patients, 124 (76.5 percent) were available for follow-up. Nonparametric tests were used for comparison of patients who had undergone elective (n = 68) or emergency (n = 56) procedures. RESULTS: Of patients who had elective surgery, 25 percent suffered persistent symptoms, including painful constipation, painful abdominal distension, abdominal cramps, and frequent painful diarrhea. Neither the stage of disease (complicated or uncomplicated) nor the surgical technique (laparotomy or laparoscopy) were significantly related to the occurrence of symptoms. Recurrent diverticulitis was not observed. Similar results were obtained from comparisons with emergency patients. CONCLUSIONS: The prevalence of persistent symptoms after successful surgery for diverticular disease may be an additional reason to carefully discuss the indication for prophylactic surgery. In any case, preoperative counseling and informed consent regarding the possibility of persistent symptoms after prophylactic elective surgery is essential.

Do patients respect the line? Transgression of boundaries reported by Swiss general practitioners

OBJECTIVE: Transgression of boundaries in the relationship between physician and patient is commonly studied with patient as victim and physician as transgressor. A recent survey in the U.S. reported that almost 90% of physicians face transgression by patients over one year. Incidents happened mainly through verbal abuse, disregarding privacy, and overly affectionate behavior. Since this incidence seems to be alarmingly high, we were interested to analyze how often general practitioners in Switzerland experience transgression by patients. METHODS: 24% of the members of the Swiss Society of Internal Medicine (SGIM) and of the Swiss Society of General Medicine (SGAM) (n=675/2781) responded to an internet-based survey which asked for experiences of transgression by patients and for physicians' responses to transgression in the last 12 months. RESULTS: 81% of responding physicians experienced transgression over the period of one year. Analyzing the frequency of incidents per physician per year, the most common forms of transgression were 'use of physician's first name' (7.7/y), 'asking personal questions' (1.8/y), 'being verbally abusive' (1.5/y), and 'being overly affectionate' (1.4/y). Calculated incidence of transgression was 3 per 1000 patient contacts. 39% of physicians decided to ignore the incident, 37% discussed the event openly. Transgression led to dismissal of patients in 13% of events. CONCLUSION: Transgression even in mild and modest form is a rare phenomenon in Swiss practices. PRACTICE IMPLICATION: The Swiss data do not suggest that there is a specific risk for Swiss practitioners to be exposed to major transgression for which they should specifically be prepared for example in communication skills trainings.

Internet information and medical consultations: experiences from patients' and physicians' perspectives

OBJECTIVE: Many patients use the Internet to obtain health-related information. It is assumed that health-related Internet information (HRII) will change the consultation practice of physicians. This article explores the strategies, benefits and difficulties from the patients' and physicians' perspective. METHODS: Semi-structured interviews were conducted independently with 32 patients and 20 physicians. Data collection, processing and analysis followed the core principles of Grounded Theory. RESULTS: Patients experienced difficulties in the interpretation of the personal relevance and the meaning of HRII. Therefore they relied on their physicians' interpretation and contextualisation of this information. Discussing patients' concerns and answering patients' questions were important elements of successful consultations with Internet-informed patients to achieve clarity, orientation and certainty. Discussing HRII with patients was appreciated by most of the physicians but misleading interpretations by patients and contrary views compared to physicians caused conflicts during consultations. CONCLUSION: HRII is a valuable source of knowledge for an increasing number of patients. Patients use the consultation to increase their understanding of health and illness. Determinants such as a patient-centred consultation and timely resources are decisive for a successful, empowering consultation with Internet-informed patients. PRACTICAL IMPLICATIONS: If HRII is routinely integrated in the anamnestic interview as a new source of knowledge, the Internet can be used as a link between physicians' expertise and patient knowledge. The critical appraisal of HRII during the consultation is becoming a new field of work for physicians.

Two cases of trisomy 16 mosaicism ascertained postnatally

Postnatally ascertained trisomy 16 mosaicism is a rare diagnosis, with only three reported cases to date with no defined clinical phenotype. Trisomy 16 mosaicism diagnosed prenatally is common and associated with variable pregnancy outcomes ranging from stillbirth with multiple congenital abnormalities to an apparently normal newborn, making the genetic counseling very challenging. It is not clear whether uniparental disomy (UPD) 16 contributes to the phenotype, although it has been suggested that maternal UPD 16 affects the rate of intra-uterine growth retardation (IUGR) and congenital anomalies. We report on two further cases of trisomy 16 mosaicism confined to fibroblasts diagnosed postnatally. Patient 1 presented at birth with severe hypospadias, unilateral postaxial polydactyly, and different hair color with midline demarcation. His growth and development were normal at 11 months of age. Patient 2 was born with IUGR, significant craniofacial and body asymmetry, asymmetric skin hyperpigmentation, unilateral hearing loss, scoliosis, VSD, unexplained dilated cardiomyopathy, feeding difficulties, failure to thrive, and recurrent respiratory tract infections. She died at 7 months of age from respiratory failure. These two further cases of postnatally diagnosed trisomy 16 mosaicism highlight the variability of clinical features and outcome in this diagnosis. While Patient 2 presented with typical features of chromosomal mosaicism, Patient 1 had mild and transient features with essentially normal outcome, suggesting that trisomy 16 mosaicism may be under-diagnosed.

Prospective effects of emotion regulation on emotional adjustment

Deficits in emotion-regulation skills have widely been shown to be associated with poor emotional adjustment. However, it is still unclear whether these deficits are a cause or a consequence of poor adjustment. The purpose of the present research was to clarify the reciprocal effects between these 2 concepts. In 2 studies (Ns = 446 and 635), self-reports of emotion regulation and emotional adjustment were assessed twice with a 2-week interval. Cross-lagged regression analyses demonstrated that self-reports of emotion regulation predicted subsequent adjustment, over and above the effects of previous adjustment, whereas emotional adjustment did not predict subsequent emotion regulation. Thus, a focus on emotion-regulation skills may be important in the prevention and treatment of affect-related mental health problems.

Do childhood cancer survivors with physical performance limitations reach healthy activity levels?

BACKGROUND The extent to which physical performance limitations affect the ability of childhood cancer survivors to reach healthy activity levels is unknown. Therefore this study aims to describe the effect of different types of limitations on activity levels in survivors. PROCEDURE Within the Swiss Childhood Cancer Survivor Study we sent a questionnaire to all survivors (≥16 years) registered in the Swiss Childhood Cancer Registry, who survived >5 years and were diagnosed 1976-2005 aged <16 years. We measured healthy activity levels using international guidelines and assessed different kinds of performance limitations (visual impairment, weight and endurance problems, cardiorespiratory, musculoskeletal, and neurological problems, pain and fatigue syndromes). RESULTS The sample included 1,560 survivors (75% response rate), of whom 209 (13.5%) reported they have performance limitations. Forty-two percent of survivors with limitations reached healthy activity levels, compared to 57% of survivors without limitations. Least active were survivors with vision impairments (25% active), weight and endurance problems (27.3%), cardiorespiratory problems (36.4%), and musculoskeletal problems (43.1%). After adjusting for socio-demographic variables and type of cancer, we found that survivors with limitations were 1.4 (95%CI 1.0-2.0; P = 0.047) times more likely to be inactive. CONCLUSIONS Although many survivors with physical performance limitations maintain healthy activity levels, there is room for improvement. Adapted and targeted physical activity counseling for survivors with performance limitations might help them to raise level of activity and pursue a healthy lifestyle.

Pelvic lymph node dissection in the context of radical cystectomy: a thorough insight into the connection between patient, surgeon, pathologist and treating institution

Pelvic lymph node dissection (PLND) in patients with bladder cancer varies widely in extent, technique employed, and pathological workup of specimens. The present paper provides an overview of the existing evidence regarding the effectiveness of PLND and elucidates the interactions between patient, surgeon, pathologist, and treating institution as well as their cumulative impact on the final postoperative lymph node (LN) staging. Bladder cancer patients undergoing radical cystectomy with extended PLND appear to have better oncologic outcomes compared to patients undergoing radical cystectomy and limited PLND. Attempts have been made to define and assess the quality of PLND according to the number of lymph nodes identified. However, lymph node counts depend on multiple factors such as patient characteristics, surgical template, pathological workup, and institutional policies; hence, meticulous PLND within a defined and uniformly applied extended template appears to be a better assurance of quality than absolute lymph node counts. Nevertheless, the prognosis of the patients can be partially predicted with findings from the histopathological evaluation of the PLND specimen, such as the number of positive lymph nodes, extracapsular extension, and size of the largest LN metastases. Therefore, particular prognostic parameters should be addressed within the pathological report to guide the urologist in terms of patient counseling.

Dose–effect relationship in routine outpatient psychotherapy: Does treatment duration matter?

Objective: There is an ongoing debate concerning how outcome variables change during the course of psychotherapy. We compared the dose–effect model, which posits diminishing effects of additional sessions in later treatment phases, against a model that assumes a linear and steady treatment progress through termination. Method: Session-by-session outcome data of 6,375 outpatients were analyzed, and participants were categorized according to treatment length. Linear and log-linear (i.e., negatively accelerating) latent growth curve models (LGCMs) were estimated and compared for different treatment length categories. Results: When comparing the fit of the various models, the log-linear LGCMs assuming negatively accelerating treatment progress consistently outperformed the linear models irre- spective of treatment duration. The rate of change was found to be inversely related to the length of treatment. Conclusion: As proposed by the dose–effect model, the expected course of improvement in psychotherapy appears to follow a negatively accelerated pattern of change, irrespective of the duration of the treatment. However, our results also suggest that the rate of change is not constant across various treatment lengths. As proposed by the “good enough level” model, longer treatments are associated with less rapid rates of change.

Toward individualized cholesterol-lowering treatment in end-stage renal disease.

There is broad evidence that lowering low-density lipoprotein (LDL) cholesterol will reduce cardiovascular risk. However, in patients on maintenance hemodialysis treatment, lowering LDL cholesterol is not as effective in preventing cardiovascular complications as in the general population. Cholesterol is either endogenously synthesized or absorbed from the intestine. It has been suggested that the benefit of using statins to prevent atherosclerotic complications is less pronounced in people with high absorption of cholesterol. Recent data indicate that patients on hemodialysis have high absorption of cholesterol. Therefore, these patients may benefit from dietary counseling to reduce cholesterol intake, from functional foods containing plant sterols and stanols, and from drugs that interfere with intestinal absorption of sterols (i.e., ezetimibe, bile acid resins, and sevelamer). This review discusses cholesterol homeostasis and the perspective of personalized treatment of hypercholesterolemia in hemodialysis.

Practices of pediatric oncology and hematology providers regarding fertility issues: A European survey.

BACKGROUND Fertility is impaired in many survivors of childhood cancer following treatment. Preservation of fertility after cancer has become a central survivorship concern. Nevertheless, several doctors, patients, and families do not discuss fertility and recommendations for fertility preservation in pediatrics are still lacking. Recommendations based on scientific evidence are needed and before their development we wanted to assess the practice patterns of fertility preservation in Europe. PROCEDURES On behalf of the PanCare network, we sent a questionnaire to pediatric onco-hematology institutions across Europe. The survey consisted of 21 questions assessing their usual practices around fertility preservation. RESULTS One hundred ninety-eight institutional representatives across Europe received the survey and 68 (response rate 34.3%) responded. Pre-treatment fertility counseling was offered by 64 institutions. Counseling was done by a pediatric onco-hematologist in 52% (33/64) and in 32% (20/64) by a team. The majority of institutions (53%) lacked recommendations for fertility preservation. All 64 centers offered sperm banking; eight offered testicular tissue cryopreservation for pre-pubertal males. For females, the possibility of preserving ovarian tissue was offered by 40 institutions. CONCLUSIONS There is a high level of interest in fertility preservation among European centers responding to our survey. However, while most recommended sperm cryopreservation, many also recommended technologies whose efficacy has not been shown. There is an urgent need for evidence-based European recommendations for fertility preservation to help survivors deal with the stressful topic of fertility. Pediatr Blood Cancer 2014;9999:1-5. © 2014 Wiley Periodicals, Inc.

Assessing Difficulties in Career Decision Making Among Swiss Adolescents with the German My Vocational Situation Scale

Assessing problems in career decision making among adolescents is important for career guidance and research. The present study is the first to investigate among Swiss adolescents the factor structure and convergent validity in relation to personality of the German-language adaptation of the My Vocational Situation Scale. Two preliminary studies (N = 217) suggested that using a 5-point Likert scale response format would increase scale reliability. The confirmatory factor analyses in the main study with two cohorts (n = 341, eighth grade; n = 303, eleventh grade) confirmed that four main factors, which assess problems with identity, decision making, information, and perceived barriers, underlie the data. The barriers factor was differentiated into aspired vocation and personal situation. Construct validity was supported by significant relationships between favorable personality characteristics (emotional stability, extraversion, agreeableness, conscientiousness, generalized self-efficacy, and internal locus of control) and fewer problems. The results suggest that the vocational identity and barriers scales can be fruitfully applied to research on and the practice of career counseling with adolescents.