Management of recurrent epithelial ovarian carcinoma

Despite the standardisation of surgical techniques and significant progress in chemotherapeutics over the last 30 years, advanced epithelial ovarian cancer remains the most lethal gynaecological malignancy in the western world. Although the majority of women achieve a remission following primary therapy, most patients with advanced stage disease will eventually relapse and become candidates for 'salvage' therapy. The chances of a further remission depend on factors such as the 'treatment-free interval', and there are now a large number of chemotherapy agents with activity in ovarian cancer available to the oncologist. Recent randomised studies have reported on survival benefits for chemotherapy in recurrent disease, and therefore careful and appropriate selection of treatments has assumed a greater importance. This article reviews the most current data, and discusses the factors involved in making individualised treatment decisions.

From complexity to category: Responding to diagnostic uncertainties of autistic spectrum disorders

Objective: Recent data from Education Queensland has identified rising numbers of children receiving diagnoses of autistic spectrum disorder (ASD). Faced with funding diagnostic pressures, in clinical situations that are complex and inherently uncertain, it is possible that specialists err on the side of a positive diagnosis. This study examines the extent to which possible overinclusion of ASD diagnosis may exist in the presence of uncertainty and factors potentially related to this practice in Queensland. Methods: Using anonymous self-report, all Queensland child psychiatrists and paediatricians who see paediatric patients with development/behavioural problems were surveyed and asked whether they had ever specified an ASD diagnosis in the presence of diagnostic uncertainty. Using logistic regression, elicited responses to the diagnostic uncertainty questions were related to other clinical- and practice-related characteristics. Results: Overall, 58% of surveyed psychiatrists and paediatricians indicated that, in the face of diagnostic uncertainty, they had erred on the side of providing an ASD diagnosis for educational ascertainment and 36% of clinicians had provided an autism diagnosis for Carer's Allowance when Centrelink diagnostic specifications had not been met. Conclusion: In the absence of definitive biological markers, ASD remains a behavioural diagnosis that is often complex and uncertain. In response to systems that demand a categorical diagnostic response, specialists are providing ASD diagnoses, even when uncertain. The motivation for this practice appears to be a clinical risk/benefit analysis of what will achieve the best outcomes for children. It is likely that these practices will continue unless systems change eligibility to funding based on functional impairment rather than medical diagnostic categories.

Diagnosis of autistic spectrum disorders in Queensland: Variations in practice

Objective: For both paediatricians and child psychiatrists, referrals to assess possible autistic spectrum disorders (ASD) are increasing. This study examines current practices of medical specialists in the assessment of these disorders. Methods: An anonymous, self-report questionnaire was sent to all Queensland paediatricians and child psychiatrists. The survey elicited frequencies of consultation for ASD, diagnostic method, advice provided and perceived adequacy of training for this work. Results: Responses were received from 79 (85%) eligible paediatricians and 26 (58%) eligible child psychiatrists. For one-third of all clinicians, new consultations for possible ASD occurred as often as 2-3 times per week. Most specialists approached the clinical diagnosis of ASD by considering history from different sources and professional assessments. Paediatricians (86%) were more likely than child psychiatrists (62%) to request genetic studies for children with severe autism (P = 0.01). Both general paediatricians and developmental paediatricians perceived level of training for possible ASD consultations was significantly worse than child psychiatrists (P < 0.001 and P = 0.02, respectively), but no difference was found between paediatric groups (P = 0.27). Perceived adequacy of specialist training was not associated with length of experience in clinical practice. Conclusion: Medical practice in Queensland around diagnosis of ASD is characterized by considerable variability. There is still a long way to go if we are to achieve consistency around medical issues of organic diagnosis and practices impacting on health as well as consideration of differential developmental diagnoses. The finding that recently trained paediatricians felt just as unprepared for this work as their older colleagues suggests that the graduate training response to this 'new morbidity' has not been adequate.

Eating disorders in children and adolescents: an update

Purpose of review Children and adolescents with eating disorders frequently present to child mental health and paediatric services and have significant morbidity, psychosocial impairment and mortality. Efforts to treat these individuals have been hampered by a poor evidence base for effective interventions. This article reviews research published during 2004 with a primary focus on this challenging clinical area. Recent findings Research published during 2004 has replicated past epidemiological findings and expanded our understanding of the relationship of family meal structure and disordered eating. Research has provided assistance in the well known clinical conundrums of excessive exercising in anorexia nervosa and predicting when return of menses will occur. There has also been clarification of adolescent bingeing. Potential advances include a new, noninvasive method of measuring body composition and investigations in adolescents on leptin, neuro and gastrointestinal peptides. Importantly, further evidence of the effectiveness of family therapy for anorexia nervosa and short-term benefits from intervention programs have been published. Summary The research base that will influence clinical practice in child and adolescent eating disorders is increasing. More research is required in all areas of intervention.

Predictive regression equations and clinical uses of peripheral pulse timing characteristics in children

Studies have shown that increased arterial stiffening can be an indication of cardiovascular diseases like hypertension. In clinical practice, this can be detected by measuring the blood pressure (BP) using a sphygmomanometer but it cannot be used for prolonged monitoring. It has been established that pulse wave velocity (PWV) is a direct measure of arterial stiffening but its usefulness is hampered by the absence of non-invasive techniques to estimate it. Pulse transit time (PTT) is a simple and non-invasive method derived from PWV. However, limited knowledge of PTT in children is found in the present literature. The aims of this study are to identify independent variables that confound PTT measure and describe PTT regression equations for healthy children. Therefore, PTT reference values are formulated for future pathological studies. Fifty-five Caucasian children (39 male) aged 8.4 +/- 2.3 yr (range 5-12 yr) were recruited. Predictive equations for PTT were obtained by multiple regressions with age, vascular path length, BP indexes and heart rate. These derived equations were compared in their PWV equivalent against two previously reported equations and significant agreement was obtained (p < 0.05). Findings herein also suggested that PTT can be useful as a continuous surrogate BP monitor in children.

Age-related factors that confound peripheral pulse timing characteristics in Caucasian children

Characteristics obtained from peripheral pulses can be used to assess the status of cardiovascular system of subjects. However, nonintrusive techniques are preferred when prolonged monitoring is required for their comfort. Pulse transit time ( PTT) measurement has showed its potentials to monitor timing changes in peripheral pulse in cardiovascular and respiratory studies. In children, the common peripheries used for these studies are fingers or toes. Presently, there is no known study conducted on children to investigate the possible physiologic parameters that can confound PTT measure at these sites. In this study, PTT values from both peripheral sites were recorded from 55 healthy Caucasian children ( 39 male) with mean age of 8.4 +/- 2.3 years ( range 5 - 12 years). Peripheries' path length, heart rate, systolic blood pressure, diastolic blood pressure ( DBP) and mean arterial pressure ( MAP) were measured to investigate their contributions to PTT measurement. The results reveal that PTT is significantly related to all parameters ( P< 0.05), except for DBP and MAP. Age is observed to be the dominant factor that affects PTT at both peripheries in a child. Regression equations for PTT were derived for measuring from a finger and toe, ( 6.09 age + 189.2) ms and ( 6.70 age + 243.0) ms, respectively.

Cardiorespiratory monitoring equipment interferes with whole body impedance measurements

Bioelectrical impedance measurements are widely used for the study of body composition. Commonly measurements are made at 50 kHz to estimate total body water or at low frequencies (< 10 kHz) to estimate extracellular fluid volume. These measurements can be obtained as single measurements at discrete frequencies, or as fitted data interpolated from plots of measurements made at multiple frequencies. This study compared single frequency and multiple frequency (MF) measurements taken in the intensive care environment. MF bioimpedance (4-1000 kHz) was measured on an adult with and without cardiorespiratory monitoring, and on babies in the neonatal intensive care unit. Measurements obtained at individual frequencies were plotted against frequency and examined for the presence of outlying points. Fitted data for measurements obtained at 5 kHz and 50 kHz with and without cardiorespiratory monitoring were compared. Significant artefacts were detected in measurements at approximately 50 kHz and at integral divisions of this frequency as a result of interference from cardiorespiratory monitors. Single frequency measurements taken at these frequencies may be subject to errors that would be difficult to detect without the aid of information obtained from MF measurements.

Eating disorders and oral health: A review of the literature

This article is a review of the recent literature pertaining to the oral sequelae of eating disorders (EDs). Dentists are recognized as being some of the first health care professionals to whom a previously undiagnosed eating disorder patient (EDP) may present. However, despite the prevalence (up to 4 per cent) of such conditions in teenage girls and young adult females, there is relatively little published in the recent literature regarding the oral sequelae of EDs. This compares unfavourably with the attention given recently in the dental literature to conditions such as diabetes mellitus, which have a similar prevalence in the adult population. The incidence of EDs is increasing and it would be expected that dentists who treat patients in the affected age groups would encounter more individuals exhibiting EDs. Most of the reports in the literature concentrate on the obvious clinical features of dental destruction (perimolysis), parotid swelling and biochemical abnormalities particularly related to salivary and pancreatic amylase. However, there is no consistency in explanation of the oral phenomena and epiphenomena seen in EDs. Many EDPs are nutritionally challenged; there is a relative lack of information pertaining to non-dental, oral lesions associated with nutritional deficiencies.

Nutritional status and energy expenditure in children pre-bone-marrow-transplant

The aims of this study were to establish the nutritional status of children pre- BMT and to determine whether predictive methods of assessing nutritional status and resting energy expenditure ( REE) are accurate in this population. We analysed the body cell mass ( BCM) ( n = 26) and REE ( n = 24) in children undergoing BMT. BCM was adjusted for height ( BCM/ HTp) and expressed as a Z score to represent nutritional status. To determine whether body mass index ( BMI) was indicative of nutritional status in children undergoing BMT, BMI Z scores were compared to the reference method of BCM/ HTp Z scores. Schofield predictive equations of basal metabolic rate ( BMR) were compared to measured REE to evaluate the accuracy of the predictive equations. The mean BCM/ HTp Z score for the subject population was -1.09 +/- 1.28. There was no significant relationship between BCM/ HTp Z score and BMI Z score ( r = 0.34; P > 0.05); however there was minimal difference between measured REE and predicted BMR ( bias = -11 +/- 149 kcal/ day). The results of this study demonstrate that children undergoing BMT may have suboptimal nutritional status and that BMI is not an accurate indication of nutritional status in this population. However, Schofield equations were found to be suitable for representing REE in children pre- BMT.

Impact of ethnicity upon body composition assessment in Sri Lankan Australian children

Objectives: Obesity is a disease with excess body fat where health is adversely affected. Therefore it is prudent to make the diagnosis of obesity based on the measure of percentage body fat. Body composition of a group of Australian children of Sri Lankan origin were studied to evaluate the applicability of some bedside techniques in the measurement of percentage body fat. Methods: Height (H) and weight (W) was measured and BMI (W/H-2) calculated. Bioelectrical impedance analysis (BIA) was measured using tetra polar technique with an 800 mu A current of 50 Hz frequency. Total body water was used as a reference method and was determined by deuterium dilution and fat free mass and hence fat mass (FM) derived using age and gender specific constants. Percentage FM was estimated using four predictive equations, which used BIA and anthropometric measurements. Results: Twenty-seven boys and 15 girls were studied with mean ages being 9.1 years and 9.6 years, respectively. Girls had a significantly higher FM compared to boys. The mean percentage FM of boys (22.9 +/- 8.7%) was higher than the limit for obesity and for girls (29.0 +/- 6.0%) it was just below the cut-off. BMI was comparatively low. All but BIA equation in boys under estimated the percentage FM. The impedance index and weight showed a strong association with total body water (r(2)= 0.96, P < 0.001). Except for BIA in boys all other techniques under diagnosed obesity. Conclusions: Sri Lankan Australian children appear to have a high percentage of fat with a low BMI and some of the available indirect techniques are not helpful in the assessment of body composition. Therefore ethnic and/or population specific predictive equations have to be developed for the assessment of body composition, especially in a multicultural society using indirect methods such as BIA or anthropometry.

Validity of BMI as a measure of obesity in Australian white Caucasian and Australian Sri lankan children

Background: Body mass index ( BMI) is used to diagnose obesity. However, its ability to predict the percentage fat mass (% FM) reliably is doubtful. Therefore validity of BMI as a diagnostic tool of obesity is questioned. Aim: This study is focused on determining the ability of BMI- based cut- off values in diagnosing obesity among Australian children of white Caucasian and Sri Lankan origin. Subjects and methods: Height and weight was measured and BMI ( W/H-2) calculated. Total body water was determined by deuterium dilution technique and fat free mass and hence fat mass derived using age- and gender- specific constants. A % FM of 30% for girls and 20% for boys was considered as the criterion cut- off level for obesity. BMI- based obesity cut- offs described by the International Obesity Task Force ( IOTF), CDC/ NCHS centile charts and BMI- Z were validated against the criterion method. Results: There were 96 white Caucasian and 42 Sri Lankan children. Of the white Caucasians, 19 ( 36%) girls and 29 ( 66%) boys, and of the Sri Lankans 7 ( 46%) girls and 16 ( 63%) boys, were obese based on % FM. The FM and BMI were closely associated in both Caucasians ( r = 0.81, P < 0.001) and Sri Lankans ( r = 0.92, P< 0.001). Percentage FM and BMI also had a lower but significant association. Obesity cut- off values recommended by IOTF failed to detect a single case of obesity in either group. However, NCHS and BMI- Z cut- offs detected cases of obesity with low sensitivity. Conclusions: BMI is a poor indicator of percentage fat and the commonly used cut- off values were not sensitive enough to detect cases of childhood obesity in this study. In order to improve the diagnosis of obesity, either BMI cut- off values should be revised to increase the sensitivity or the possibility of using other indirect methods of estimating the % FM should be explored.

Ability of Bioelectrical Impedance to Predict Percentage Fat Mass in Children of Two Different Ethnic Origins

Detailed analysis of body composition in children has helped to understand changes that occur in growth and disease. Bioelectrical impedance analysis (BIA) has gained popularity as a simple, non-invasive and inexpensive tool of body composition assessment. Being an indirect technique, prediction equations have to be used in the assessment of body composition. There are many prediction equations available in the literature for the assessment of body composition from BIA. This study aims to cross-validate some of those prediction equations to determine the suitability of their use on Australian children of white Caucasian and Sri Lankan origins. Height, weight and BIA were measured. Total body water was measured using the isotope dilution method (D2O). Fat-mass (FM) and %FM were estimated from BIA using ten prediction equations described in the literature. Five to 14.99-year-old healthy, 96 white Caucasians and 42 Sri Lankan children were studied. The equation of Schaefer et al was the most suitable prediction equation for this group with the lowest mean bias for %FM assessment in both Caucasian (–1.0±9.6%) and Sri Lankan (1.6±5.2%) children and the fat content of the individuals did not influence the predictions by this equation. Impedance index (height2/impedance) explained for 80% of TBW in white Caucasians and 93% in Sri Lankans and figures were similar for the prediction of FFM. We conclude that BIA can be used effectively in the assessment of body composition in children. However, for the assessment of body composition using BIA, either prediction equations should be derived to suit the local populations or existing equations should be cross-validated to determine their suitability before their application.

Global standard for the composition of infant formula: Recommendations of an ESPGHAN coordinated international expert group

The Codex Alimentarius Commission of the Food and Agriculture Organization of the United Nations (FAO) and the World Health Organization (WHO) develops food standards, guidelines and related texts for protecting consumer health and ensuring fair trade practices globally. The major part of the world's population lives in more than 160 countries that are members of the Codex Alimentarius. The Codex Standard on Infant Formula was adopted in 1981 based on scientific knowledge available in the 1970s and is currently being revised. As part of this process, the Codex Committee on Nutrition and Foods for Special Dietary Uses asked the ESPGHAN Committee on Nutrition to initiate a consultation process with the international scientific community to provide a proposal on nutrient levels in infant formulae, based on scientific analysis and taking into account existing scientific reports on the subject. ESPGHAN accepted the request and, in collaboration with its sister societies in the Federation of International Societies on Pediatric Gastroenterology, Hepatology and Nutrition, invited highly qualified experts in the area of infant nutrition to form an International Expert Group (IEG) to review the issues raised. The group arrived at recommendations on the compositional requirements for a global infant formula standard which are reported here.