Rheumatic heart disease: pilot study for a population-based evaluation of prevalence and cardiovascular outcomes among schoolchildren in Nepal

To evaluate a protocol for a population-based programme targeting the prevention of rheumatic heart disease (RHD) progression by early echocardiographic diagnosis of valvular lesions and timely implementation of secondary prevention.

Protocol for a population-based study of rheumatic heart disease prevalence and cardiovascular outcomes among schoolchildren in Nepal

Rheumatic heart disease (RHD) remains a major contributor to morbidity and mortality in developing countries. The reported prevalence rates of RHD are highly variable and mainly attributable to differences in the sensitivity of either clinical screening to detect advanced heart disease or echocardiographic evaluation where disease is diagnosed earlier across a continuous spectrum. The clinical significance of diagnosis of subclinical RHD by echocardiographic screening and early implementation of secondary prevention has not been clearly established. METHODS AND ANALYSIS: The authors designed a cross-sectional survey to determine the prevalence of RHD in children from private and public schools between the age of 5 and 15 years in urban and rural areas of Eastern Nepal using both cardiac auscultation and echocardiographic evaluation. Children with RHD will be treated with secondary prevention and enrolled in a prospective cohort study. The authors will compare the prevalence rates by cardiac auscultation and echocardiography, determine risk factors associated with diagnosis and progression of RHD, investigate social and economic barriers for receiving adequate cardiac care and assess clinical outcomes with regular medical surveillance as a function of stage of disease at the time of diagnosis. Prospective clinical studies investigating the impact of secondary prevention for subclinical RHD on long-term clinical outcome will be of central relevance for future health resource utilisation in developing countries. ETHICS AND DISSEMINATION: The study was considered ethically uncritical and was given an exempt status by the ethics committee at University of Bern, Switzerland. The study has been submitted to the National Nepal Health Research Council and was registered with http://www.ClinicalTrials.gov (NCT01550068). The study findings will be reported in peer-reviewed publications. CLINICALTRIALS.GOV IDENTIFIER: NCT01550068.

Wheeze and asthma prevalence and related health-service use in white and south Asian pre-schoolchildren in the United Kingdom

BACKGROUND: Epidemiological data for south Asian children in the United Kingdom are contradictory, showing a lower prevalence of wheeze, but a higher rate of medical consultations and admissions for asthma compared with white children. These studies have not distinguished different asthma phenotypes or controlled for varying environmental exposures. OBJECTIVE: To compare the prevalence of wheeze and related health-service use in south Asian and white pre-schoolchildren in the United Kingdom, taking into account wheeze phenotype (viral and multiple wheeze) and environmental exposures. METHODS: A postal questionnaire was completed by parents of a population-based sample of 4366 white and 1714 south Asian children aged 1-4 years in Leicestershire, UK. Children were classified as having viral wheeze or multiple trigger wheeze. RESULTS: The prevalence of current wheeze was 35.6% in white and 25.5% in south Asian 1-year-olds (P<0.001), and 21.9% and 20.9%, respectively, in children aged 2-4 years. Odds ratios (ORs) (95% confidence interval) for multiple wheeze and for viral wheeze, comparing south Asian with white children, were 2.21 (1.19-4.09) and 1.43 (0.77-2.65) in 2-4-year-olds after controlling for socio-economic conditions, environmental exposures and family history. In 1-year-olds, the respective ORs for multiple and viral wheeze were 0.66 (0.47-0.92) and 0.81 (0.64-1.03). Reported GP consultation rates for wheeze and hospital admissions were greater in south Asian children aged 2-4 years, even after adjustment for severity, but the use of inhaled corticosteroids was lower. CONCLUSIONS: South Asian 2-4-year-olds are more likely than white children to have multiple wheeze (a condition with many features of chronic atopic asthma), after taking into account ethnic differences in exposure to some environmental agents. Undertreatment with inhaled corticosteroids might partly explain their greater use of health services.

Oral hygiene indirect instruction and periodic reinforcements: effects on index plaque in schoolchildren

The aim of this study was to evaluate the effectiveness of the indirect instruction and the influence of the periodic reinforcement on the plaque index in schoolchildren. Forty schoolchildren aged from 7 to 9 years old were selected from a public school. After determining the initial O'Leary Plaque Index all schoolchildren were submitted to a program for oral hygiene through indirect instruction -"The Smiling Robot". The schoolchildren were divided into 2 groups: with and without motivation reinforcement. The index plaque exam was performed in both groups after 30, 60 and 90 days of the educational program. Comparing the groups, the plaque index decreasing could be observed in the group with reinforcement with statistically significant difference. For the group with reinforcement, statistically significant difference among the evaluations was found. For the group without reinforcement, significant decrease in the plaque index was found after 30 days when compared to the first, third and fourth evaluations. The indirect instruction with "The Smiling Robot "promoted a positive initial impact on the decrease of plaque index in the schoolchildren. The periodic reinforcements showed more suitable results and significant reduction of the plaque index in the course of the evaluations.

Prevalence, incidence and distribution of erosion

There is some evidence that the presence of erosion is growing steadily. Because of different scoring systems, samples and examiners, it is difficult to compare and judge the outcome of the studies. Preschool children aged between 2 and 5 years showed erosion on deciduous teeth in 6-50% of the subjects. Young schoolchildren (aged 5-9) already had erosive lesions on permanent teeth in 14% of the cases. In the adolescent group (aged between 9 and 17) 11-100% of the young people examined showed signs of erosion. Incidence data (= increase of subjects with erosion) evaluated in three of these studies were 12% over 2 years, 18% over 5 years and 27% over 1.5 years. In adults (aged between 18 and 88), prevalence data ranged between 4 and 82%. Incidence data are scarce; only one study was found and this showed an incidence of 5% for the younger and 18% for the older examined group (= increase of tooth surfaces with erosion). Prevalence data indicated that males had somewhat more erosive tooth wear than females. The distribution of erosion showed a predominance of occlusal surfaces (especially mandibular first molars), followed by facial surfaces (anterior maxillary teeth). Oral erosion was frequently found on maxillary incisors and canines. Overall, prevalence data are not homogeneous. Nevertheless, there is already a trend for more pronounced rate of erosion in younger age groups. Therefore, it is important to detect at-risk patients early to initiate adequate preventive measures.

Catch-up alveolarization in ex-preterm children: evidence from (3)He magnetic resonance

RATIONALE Histologic data from fatal cases suggest that extreme prematurity results in persisting alveolar damage. However, there is new evidence that human alveolarization might continue throughout childhood and could contribute to alveolar repair. OBJECTIVES To examine whether alveolar damage in extreme-preterm survivors persists into late childhood, we compared alveolar dimensions between schoolchildren born term and preterm, using hyperpolarized helium-3 magnetic resonance. METHODS We recruited schoolchildren aged 10-14 years stratified by gestational age at birth (weeks) to four groups: (1) term-born (37-42 wk; n = 61); (2) mild preterm (32-36 wk; n = 21); (3) extreme preterm (<32 wk, not oxygen dependent at 4 wk; n = 19); and (4) extreme preterm with chronic lung disease (<32 wk and oxygen dependent beyond 4 wk; n = 18). We measured lung function using spirometry and plethysmography. Apparent diffusion coefficient, a surrogate for average alveolar dimensions, was measured by helium-3 magnetic resonance. MEASUREMENTS AND MAIN RESULTS The two extreme preterm groups had a lower FEV1 (P = 0.017) compared with term-born and mild preterm children. Apparent diffusion coefficient was 0.092 cm(2)/second (95% confidence interval, 0.089-0.095) in the term group. Corresponding values were 0.096 (0.091-0.101), 0.090 (0085-0.095), and 0.089 (0.083-0.094) in the mild preterm and two extreme preterm groups, respectively, implying comparable alveolar dimensions across all groups. Results did not change after controlling for anthropometric variables and potential confounders. CONCLUSIONS Alveolar size at school age was similar in survivors of extreme prematurity and term-born children. Because extreme preterm birth is associated with deranged alveolar structure in infancy, the most likely explanation for our finding is catch-up alveolarization.

Promoting a functional physical self-concept in physical education: Evaluation of a 10-week intervention

Most physical education intervention studies on the positive effect of sports on self-concept development have attempted to increase schoolchildren’s self-concept without taking the veridicality of the self-concept into account. The present study investigated whether a 10-week intervention in physical education would lead to an increase not only in the general level of self-concept of endurance and self-concept of strength but also in its veridicality in those who had previously under- or overestimated their abilities. A total of 464 primary schoolchildren (246 boys, 218 girls, Mage = 11.9) either participated in the intervention or served as controls. The intervention group received endurance and strength training during physical education lessons carried out with a consistent individualized teacher frame of reference (iTFR). Results showed that this specific intervention was associated with increases not only in the general level of self-concept but also in its veridicality in under- and overestimators. Results are discussed in terms of didactic methods to promote functional self-concepts in physical education.

Asthma and allergies: is the farming environment (still) protective in Poland? The GABRIEL Advanced Studies

BACKGROUND Evidence exists that a farming environment in childhood may provide protection against atopic respiratory disease. In the GABRIEL project based in Poland and Alpine regions of Germany, Austria and Switzerland, we aimed to assess whether a farming environment in childhood is protective against allergic diseases in Poland and whether specific exposures explain any protective effect. METHODS In rural Poland, 23 331 families of schoolchildren completed a questionnaire enquiring into farming practices and allergic diseases (Phase I). A subsample (n = 2586) participated in Phase II involving a more detailed questionnaire on specific farm exposures with objective measures of atopy. RESULTS Farming differed between Poland and the Alpine centres; in the latter, cattle farming was prevalent, whereas in Poland 18% of village farms kept ≥1 cow and 34% kept ≥1 pig. Polish children in villages had lower prevalences of asthma and hay fever than children from towns, and in the Phase II population, farm children had a reduced risk of atopy measured by IgE (aOR = 0.72, 95% CI 0.57, 0.91) and skin prick test (aOR = 0.65, 95% CI 0.50, 0.86). Early-life contact with grain was inversely related to the risk of atopy measured by IgE (aOR = 0.66, 95% CI 0.47, 0.92) and appeared to explain part of the farming effect. CONCLUSION While farming in Poland differed from that in the Alpine areas as did the exposure-response associations, we found in communities engaged in small-scale, mixed farming, there was a protective farming effect against objective measures of atopy potentially related to contact with grain or associated farm activities.

Prevalence, incidence and distribution of erosion.

There is evidence that the presence of erosion is growing steadily. Due to different scoring systems, samples and examiners, it is difficult to compare the different studies. Preschool children from 2 to 5 years showed erosion on deciduous teeth in 1 to 79% of the subjects. Schoolchildren (aged from 5 to 9 years) already had erosive lesions on permanent teeth in 14% of the cases. In the adolescent group (aged between 9 and 20 years), 7 to 100% of the persons examined showed signs of erosion. Incidence data (the increase in the number of subjects presenting signs of dental erosion) was evaluated in four of these studies and presented average annual values between 3.5 and 18%, depending on the initial age of the examined sample. In adults (aged from 18 to 88 years) prevalence data ranged between 4 and 100%. Incidence data are scarce in this age group, and only one study was found analysing the increase of affected surfaces, showing an incidence of 5% for the younger and 18% for older age groups. In general, males present more erosive tooth wear than females. The distribution showed a predominance of affected occlusal surfaces (mandibular first molars) followed by facial surfaces (anterior maxillary teeth). Oral erosion was frequently found on maxillary incisors and canines. Overall, prevalence data are not homogeneous. Nevertheless, there is a trend towards a more pronounced rate of erosion in younger age groups. Furthermore, a tendency was found for more erosive lesions with increasing age and these erosions progressed with age.

Relationship between the objectively-assessed neighborhood area and activity behavior in Swiss youth

Background Neighborhood attributes are modifiable determinants of physical activity (PA) and sedentary behavior (SB). We tested whether the objectively-assessed built and social environment was associated with PA and SB in Swiss youth and whether sex, age and the socioeconomic position (Swiss-SEP) modified such associations. Methods We combined data of 1742 youth (ages 4 to 17) from seven studies conducted within Switzerland between 2005–2010. All youth provided accelerometer data and a home address, which was linked to objective environmental data and the Swiss-SEP-index. Associations between neighborhood attributes and PA were analyzed by multivariable multilevel regression analyses. Results The extent of green areas and building density was positively associated with PA in the total sample (p < 0.05). Factors representing centrally located areas, and more schoolchildren living nearby tended to increase PA in secondary schoolchildren, boys and those from lower-ranked socioeconomic areas. In primary schoolchildren, the extent of green areas was positively associated with PA (p = 0.05). Associations between neighborhood attributes and PA were more pronounced in youth from low socioeconomic areas. Conclusions The results indicate that some associations between neighborhood attributes and PA differ by age, sex and socioeconomic area. This should be taken into account when planning interventions to increase childhood PA.

Reactivity to Accelerometer Measurement of Children and Adolescents

PURPOSE: Awareness of being monitored can influence participants' habitual physical activity (PA) behavior. This reactivity effect may threaten the validity of PA assessment. Reports on reactivity when measuring the PA of children and adolescents have been inconsistent. The aim of this study was to investigate whether PA outcomes measured by accelerometer devices differ from measurement day to measurement day and whether the day of the week and the day on which measurement started influence these differences. METHODS: Accelerometer data (counts per minute [cpm]) of children and adolescents (n = 2081) pooled from eight studies in Switzerland with at least 10 h of daily valid recording were investigated for effects of measurement day, day of the week, and start day using mixed linear regression. RESULTS: The first measurement day was the most active day. Counts per minute were significantly higher than on the second to the sixth day, but not on the seventh day. Differences in the age-adjusted means between the first and consecutive days ranged from 23 to 45 cpm (3.6%-7.1%). In preschoolchildren, the differences almost reached 10%. The start day significantly influenced PA outcome measures. CONCLUSIONS: Reactivity to accelerometer measurement of PA is likely to be present to an extent of approximately 5% on the first day and may introduce a relevant bias to accelerometer-based studies. In preschoolchildren, the effects are larger than those in elementary and secondary schoolchildren. As the day of the week and the start day significantly influence PA estimates, researchers should plan for at least one familiarization day in school-age children and randomly assign start days.

Physical activity interventions in schools for improving lifestyle in European countries

Background: In the last decades, children’s and adolescents’ obesity and overweight have increased in European Countries. Unhealthy eating habits and sedentary lifestyle have been recognized to determine such an epidemic. Schools represent an ideal setting to modify harmful behaviors, and physical activity could be regarded as a potential way to avoid the metabolic risks related to obesity. Methods: A systematic review of the literature was carried out to summarize the evidence of school-based interventions aimed to promote, enhance and implement physical activity in European schools. Only randomized controlled trials were included, carried out in Europe from January 2000 to April 2014, universally delivered and targeting pupils aged between 3 and 18 years old. Results: Forty-seven studies were retrieved based either on multicomponent interventions or solely physical activity programs. Most aimed to prevent obesity and cardiovascular risks among youths. While few studies showed a decrease in BMI, positive results were achieved on other outcomes, such as metabolic parameters and physical fitness. Conclusion: Physical activity in schools should be regarded as a simple, non-expensive and enjoyable way to reach all the children and adolescents with adequate doses of moderate to vigorous physical activity.

Screening for Rheumatic Heart Disease among Peruvian Children: A Two-Stage Sampling Observational Study.

BACKGROUND The objective of the study was to evaluate the implications of different classifications of rheumatic heart disease on estimated prevalence, and to systematically assess the importance of incidental findings from echocardiographic screening among schoolchildren in Peru. METHODS We performed a cluster randomized observational survey using portable echocardiography among schoolchildren aged 5 to 16 years from randomly selected public and private schools in Arequipa, Peru. Rheumatic heart disease was defined according to the modified World Health Organization (WHO) criteria and the World Heart Federation (WHF) criteria. FINDINGS Among 1395 eligible students from 40 classes and 20 schools, 1023 (73%) participated in the present survey. The median age of the children was 11 years (interquartile range [IQR] 8-13 years) and 50% were girls. Prevalence of possible, probable and definite rheumatic heart disease according to the modified WHO criteria amounted to 19.7/1000 children and ranged from 10.2/1000 among children 5 to 8 years of age to 39.8/1000 among children 13 to 16 years of age; the prevalence of borderline/definite rheumatic heart disease according to the WHF criteria was 3.9/1000 children. 21 children (2.1%) were found to have congenital heart disease, 8 of which were referred for percutaneous or surgical intervention. CONCLUSIONS Prevalence of RHD in Peru was considerably lower compared to endemic regions in sub-Saharan Africa, southeast Asia, and Oceania; and paralleled by a comparable number of undetected congenital heart disease. Strategies to address collateral findings from echocardiographic screening are necessary in the setup of active surveillance programs for RHD. TRIAL REGISTRATION ClinicalTrials.gov identifier: NCT02353663.

Prevalence of Subclinical Rheumatic Heart Disease in Eastern Nepal

Importance: Although rheumatic heart disease has been nearly eradicated in high-income countries, 3 in 4 children grow up in parts of the world where it is still endemic. Objectives: To determine the prevalence of clinically silent and manifest rheumatic heart disease as a function of age, sex, and socioeconomic status and to estimate age-specific incidence. Design, Setting, and Participants: In this school-based cross-sectional study with cluster sampling, 26 schools in the Sunsari district in Eastern Nepal with 5467 eligible children 5 to 15 years of age were randomly selected from 595 registered schools. After exclusion of 289 children, 5178 children were enrolled in the present study from December 12, 2012, through September 12, 2014. Data analysis was performed from October 1, 2014, to April 15, 2015. Exposures: Demographic and socioeconomic characteristics were acquired in a standardized interview by means of a questionnaire customized to the age of the children. A focused medical history was followed by a brief physical examination. Cardiac auscultation and transthoracic echocardiography were performed by 2 independent physicians. Main Outcomes and Measures: Rheumatic heart disease according to the World Heart Federation criteria. Results: The median age of the 5178 children enrolled in the study was 10 years (interquartile range, 8-13 years), and 2503 (48.3%) were female. The prevalence of borderline or definite rheumatic heart disease was 10.2 (95% CI, 7.5-13.0) per 1000 children and increased with advancing age from 5.5 (95% CI, 3.5-7.5) per 1000 children 5 years of age to 16.0 (95% CI, 14.9-17.0) in children 15 years of age, whereas the mean incidence remained stable at 1.1 per 1000 children per year. Children with rheumatic heart disease were older than children without rheumatic heart disease (median age [interquartile range], 11 [9-14] years vs 10 [8-13] years; P = .03), more commonly female (34 [64.2%] vs 2469 [48.2%]; P = .02), and more frequently went to governmental schools (40 [75.5%] vs 2792 [54.5%]; P = .002). Silent disease (n = 44) was 5 times more common than manifest disease (n = 9). Conclusions and Relevance: Rheumatic heart disease affects 1 in 100 schoolchildren in Eastern Nepal, is primarily clinically silent, and may be more common among girls. The overall prevalence and the ratio of manifest to subclinical disease increase with advancing age, whereas the incidence remains stable at 1.1 per 1000 children per year. Early detection of silent disease may help prevent progression to severe valvular damage.