Association of accelerometry-based and self-reported physical activity with cardiovascular risk in South African children

The burden of non-communicable diseases is increasing, with risk factors emerging early in life. Physical activity reduces cardiovascular risk, but limited evidence exists for children from lower-income countries and mostly relies on self-reported methods that might be inaccurate and biased. We aimed to compare self-reported and accelerometer-measured physical activity in relation to cardiovascular risk markers in children from underserved communities in South Africa. We analysed cross-sectional data from 594 children aged 8 to 13. Physical activity was measured via accelerometry and the Physical Activity Questionnaire for Older Children (PAQ-C). Correlation analyses and linear regression models examined the relationship between accelerometer-measured and self-reported physical activity and their association with cardiovascular risk markers (body mass index, blood pressure, blood lipid profile and glycated haemoglobin). Results show a positive but weak correlation between PAQ-C scores and accelerometer-measured moderate-to-vigorous physical activity (MVPA). MVPA was inversely associated with body mass index, whilst sedentary behaviour correlated positively with lipid levels. PAQ-C scores were inversely associated with systolic blood pressure. The comparison of self-reported and accelerometer-measured physical activity in children from Gqeberha, South Africa, revealed inconsistencies in their correlation and association with cardiovascular risk markers. Accelerometry provided a more accurate cardiovascular risk estimation than PAQ-C, although associations were weak. Further, longitudinal studies should investigate the predictive power of both methodologies. These findings inform researchers and public health practitioners in the choice of method for physical activity appraisal beyond practical considerations, especially when combined with cardiovascular risk and in lower-income settings. Significance: We explore two widely used methods to assess physical activity levels in children. By comparing both methods, we expose inconsistencies in their correlation and association with cardiovascular risk markers. These data can guide researchers and public health practitioners in the use of one method beyond practical considerations. Whilst this work focuses on children from marginalised areas of South Africa, the issues explored are of relevance to other lower-income settings. Open data set: https://doi.org/10.5281/zenodo.721714

Etats des lieux et aspects évolutifs de la chirurgie pour hémorragie du post-partum en Basse-Normandie

CAEN-BU Médecine pharmacie (141182102) / SudocSudocFranceF

Création d’un groupe de patients simulés bénévoles : un atout pour la formation et l’évaluation à l’heure de la réforme du deuxième cycle des études médicales en France

Contexte : La simulation s’impose aujourd’hui comme l’un des outils pédagogiques essentiels dans les études de santé. La simulation avec patient simulé (PS) permet d’aborder des compétences différentes de la simulation procédurale ou de haute technicité, aussi bien en formation qu’en évaluation. Objectif : Présenter les modalités ayant conduit à la création d’un groupe de patients simulés bénévoles. Méthodes : Le recrutement des candidats est fait par des voies diverses. Une étape de sélection est réalisée pour tous les candidats par un binôme médecin-psychologue. La formation des futurs PS dure une journée et comprend une information sur les principes de la simulation, les mécanismes de défenses psychologiques et une formation aux jeux des émotions et de la douleur. Résultats : Cent-treize personnes ont répondu aux annonces de recrutement, 104 ont été retenues après sélection, 99 ont eu la formation de PS et, finalement, 87 ont participé aux sessions de formation ou d’évaluation des apprenants, dont 67 étudiants en médecine et neuf retraités. Conclusion : Pour le centre de simulation, le recrutement de PS bénévoles permet d’envisager le développement d’un nouveau champ d’activités de formation et d’évaluation. Pour les étudiants en médecine, la participation à ces activités constitue une initiation à la relation médecin-patient et une forme de préparation aux modalités des examens cliniques objectifs et structurés (ECOS)

Obtention de la vacuité utérine dans le cadre d'une perte de grossesse

Objective : To assess early and late benefits and harms of different management options for first trimester miscarriage and for induction of labor and obtaining of uterine vacuity in case of fetal death beyond of 14weeks of gestation.Methods : French and English publications were searched using PubMed and Cochrane Library.Results : Concerning missed miscarriage, expectant management is not recommended (LE1) because it increases the risk of failure, need of unplanned surgical procedure and blood transfusion (LE1). Surgical uterine evacuation remains more effective than medical treatment using misoprostol (LE1), but both techniques involve rare and comparable risks (EL1). When chosen, medical treatment should be a vaginal dose of 800μg of misoprostol, possibly repeated 24 to 48hours later (EL2). Administration of mifepristone prior to misoprostol is not recommended (EL2). In case of incomplete miscarriage, expectant management can be offered because it does not increase the risk of complications, neither haemorrhagic nor infectious (EL1). Medical treatment using misoprostol is not recommended (EL2) because it does not improve the evacuation rate when compared to our first option, and does not reduce the risk of complications (EL2). Surgical uterine evacuation leads to high evacuation rate (97–98%) and low risk of complications, haemorrhagic and infectious (<5%) (EL1). However, this option should not be the only one because of the good efficiency of the expectant management (more than 75% of evacuation) and comparably low risk of complications (EL1). Surgical aspiration should be favoured to curettage because it is quicker, less painful and leads to less bleeding (EL2). After a first trimester miscarriage future fertility is identical with each treatment (EL2). When a trophoblastic retention is suspected, a diagnostic hysteroscopy is recommended (EL2). In case of late intrauterine foetal death beyond 14weeks of gestation and without a past caesarean section, the most efficient protocol seems to be vaginal administration of misoprostol 200 to 400μg every 4 to 6hours (EL2). Twenty-four hours prior to misoprostol the administration of 200mg of mifepristone is recommended (EL3) because it improves the induction-expulsion time and diminishes the quantity of needed misoprostol (and so the complications linked to it) (EL3).Objectif : Évaluer les bénéfices et les risques précoces et tardifs des traitements des fausses couches (FC) précoces et des méthodes d’induction du travail et d’évacuation utérine en cas de mort fœtale in utero (MFIU) au-delà du premier trimestre de la grossesse.Méthode : Recherche bibliographique en langue française et anglaise effectuée par consultation des banques de données PubMed et Cochrane Library.Résultats : En cas de grossesse arrêtée, l’expectative n’est pas recommandée (grade A) car elle augmente les risques d’absence d’expulsion spontanée nécessitant un traitement chirurgical non programmé et de transfusion sanguine (NP1). Le traitement par aspiration d’une grossesse arrêtée est plus efficace que le traitement par misoprostol (NP1), mais les techniques médicale et chirurgicale comportent des risques de complications rares et comparables (NP1). Lorsqu’un traitement médical a été choisi, le misoprostol doit être administré par voie vaginale à la dose unique de 800μg, éventuellement renouvelée au bout de 24–48heures (grade B). L’administration préalable de mifépristone n’est pas recommandée (grade B). En cas de FC incomplète, l’expectative peut être proposée en première intention (grade A). Le traitement par misoprostol n’est pas recommandé (grade B) car il n’améliore pas le taux d’évacuation par rapport à une simple expectative et ne réduit pas les risques de complications (NP2). L’aspiration permet des taux d’évacuation complète élevés (97–98 %) pour des risques de complications hémorragiques et infectieuses faibles (<5 %) (NP1). Toutefois, il ne doit pas être imposé à la patiente en raison de la bonne efficacité (plus de 75 %) et des risques de complications rares de l’expectative (grade A). L’aspiration chirurgicale doit être préférée au curetage car elle est plus rapide, moins douloureuse et moins hémorragique (grade B). La fertilité ultérieure est identique quel que soit le traitement d’une FC précoce (NP2). En cas de suspicion de rétention trophoblastique prolongée, une hystéroscopie diagnostique est recommandée (grade B). En cas de MFIU, le protocole d’administration du misoprostol le plus efficace en l’absence d’utérus cicatriciel est la dose de 200 à 400μg par voie vaginale, renouvelée toutes les 4 à 6heures (grade B). L’administration préalable d’une dose de 200mg de mifépristone au moins 24heures avant celle de misoprostol est recommandée (grade C) car elle améliore les délais d’expulsion et diminue les besoins en misoprostol (NP3)

Low-Flow, Low-Gradient Severe Aortic Stenosis Despite Normal Ejection Fraction Is Associated With Severe Left Ventricular Dysfunction as Assessed by Speckle-Tracking Echocardiography: A Multicenter Study.

Background- Low-flow low-gradient (LFLG) is sometimes observed in severe aortic stenosis (AS) despite normal ejection fraction, but its frequency and mechanisms are still debated. We aimed to describe the characteristics of patients with LFLG AS and assess the presence of longitudinal left ventricular dysfunction in these patients. Methods and Results- In a multicenter prospective study, 340 consecutive patients with severe AS and normal ejection fraction were studied. Longitudinal left ventricular function was assessed by 2D-strain and global afterload by valvulo-arterial impedance. Patients were classified according to flow and gradient: low flow was defined as a stroke volume index ≤35 mL/m(2), low gradient as a mean gradient ≤40 mm Hg. Most patients (n=258, 75.9%) presented with high-gradient AS, and 82 patients (24.1%) with low-gradient AS. Among the latter, 52 (15.3%) presented with normal flow and low gradient and 30 (8.8%) with LFLG. As compared with normal flow and low gradient, patients with LFLG had more severe AS (aortic valve area=0.7±0.12 cm(2) versus 0.86±0.14 cm(2)), higher valvulo-arterial impedance (5.5±1.1 versus 4±0.8 mm Hg/mL/m(2)), and worse longitudinal left ventricular function (basal longitudinal strain=-11.6±3.4 versus -14.8±3%; P<0.001 for all). Conclusions- LFLG AS is observed in 9% of patients with severe AS and normal ejection fraction and is associated with high global afterload and reduced longitudinal systolic function. Patients with normal-flow low-gradient AS are more frequent and present with less severe AS, normal afterload, and less severe longitudinal dysfunction. Severe left ventricular longitudinal dysfunction is a new explanation to the concept of LFLG AS

Mixed intervention effects and long-term changes in physical activity and cardiovascular outcomes among children at risk of cardiovascular diseases

Objective: Risk factors for chronic diseases such as insufficient physical activity (PA), overweight or hypertension are getting more predominant among children. While school-based interventions are promising preventive strategies, evidence of their long-term effectiveness, especially among vulnerable populations is scarce. KaziKidz is a physical education intervention that promotes healthy and active lifestyles among children from low-income communities (https://www.kazibantu.org/kazikidz/). We aim at assessing the short- and long-term effects of KaziKidz on cardiovascular risk factors in high-risk children from disadvantaged communities. Methods: The intervention was tested in a cluster-randomized controlled trial between January and October 2019 in eight primary schools in South Africa. Children with adverse cardiovascular profiles were defined as presenting at least one risk factor for (1) overweight, (2) elevated blood pressure, (3) glycaemia, and/or (4) cholesterolemia. After their identification, high-risk children were re-assessed 2-years post-intervention. Study outcomes include accelerometry-measured PA (MVPA), body-mass-index (BMI), mean arterial pressure (MAP), glucose (HbA1c), and lipid levels (TC/HDL). We conducted mixed regression analyses to assess intervention effects by cardiovascular risk profile, and Wilcoxon signed-rank tests to evaluate longitudinal changes in the high-risk subpopulation. Results: A significant intervention effect on MVPA during school hours was found for physically inactive children (B: 1.71, 95% CI: 0.14 - 3.35, p-value: 0.008), and among active (B: 1.80, 95% CI: -0.22 - 3.82, p-value: 0.035) and inactive (B: 2.03, 95% CI: 0.58 - 3.42, p-value: < 0.001) girls. In contrast, the intervention lowered HbA1c (B: -0.26, 95% CI: -0.52 - -0.01, p-value: 0.037) and TC/HDL (B: -0.11, 95% CI: 0.18 - -0.05, p-value: 0.002) only in children with normal glucose or lipid values, respectively. The intervention effects were not maintained in at-risk children at follow-up. A decline was observed in MVPA from 53.29 to 41.90 min/day (z = -1.95, p = 0.05, r = 0.26), and an increase in BMI-for-age (z = -0.34, p = 0.737, r = 0.03), MAP (z = -5.18, p < 0.001, r = 0.42), HbA1c (z = -1.63, p = 0.104, r = 0.25) and TC/HDL (z = -1.61, p = 0.11, r = 0.21). Conclusion: We conclude that schools are key settings to promote PA and improve health; however, because the intervention effects were not maintained in children at risk of non-communicable diseases (NCDs), structural changes that ensure effective interventions reach disadvantaged populations are necessary to achieve sustainable impact. Funding: Swiss National Science Foundation (SNSF)

Relationship between Body Mass Index and Physical Activity among Children from Low-Income Communities in Gqeberha, South Africa: A Cross-Sectional Study

This study aimed to establish the prevalence of underweight, overweight and obesity, the level of moderate-to-vigorous physical activity (MVPA) and the association thereof among vulnerable children from low-income communities in South Africa. Cross-sectional data were collected from 916 children (467 boys and 449 girls) aged 8–13 years (x̄ = 10.4 ± 1.2 years) attending eight low-income schools in Gqeberha, South Africa. Measured outcomes included accelerometery-measured physical activity (PA), weight, height and body mass index (BMI). Analysis of variance was used to determine the mean difference of total MVPA stratified by sex and BMI classification. Overall, 13% of the cohort were underweight, 19% were overweight/obese and 64% engaged in 60 min of MVPA per day. Girls presented nearly twice the odds of being overweight or obese than boys (95% CI: 1.40–2.77). Underweight to normal-weight children (boys: OR = 3.89, 95% CI: 2.18–6.93; girls: OR = 1.78, 95% CI: 1.13–2.80) were more likely to engage in 60 min/day of MVPA than overweight to obese children. There is an inverse association between BMI categories and theduration of MVPA achieved per day. Special attention should be aimed at increasing awareness of healthy nutrition and promoting a variety of PA, especially among girls and children with excess weight

Practice Change Needed for the Identification of Pediatric Hypertension in Marginalized Populations: An Example From South Africa

Introduction: Hypertension in children has increased globally over the past 20 years; yet, little is known about this issue among disadvantaged communities from low- and middle-income countries. Age-, sex-, and height-adjusted normative tables are the "gold" standard for the diagnosis and estimation of pediatric hypertension worldwide, but it is unclear whether the use of international standards is appropriate for all contexts. The purpose of this study was to evaluate and compare different international references to identify hypertension among South African school-aged children from disadvantaged communities. Methods: Blood pressure, weight, and height were measured in a cohort of 897 children aged 8-16 years from eight peri-urban schools in the Eastern Cape of South Africa. Cross-sectional prevalence of hypertension was calculated according to American, German, and global normative tables, as well as pseudo-normative data from the own study population. Isolated systolic hypertension and body mass index (BMI) were considered markers for cardiovascular disease. Multinomial logistic regression was used to compare the likelihood of blood pressure categorization with increasing BMI levels. Results: Hypertension prevalence ranged from 11.4% with the pseudo-normative study tables to 28.8% based on the German reference. Global guidelines showed the highest agreement both among international standards (92.5% with American guidelines) and with the study reference (72.5%). While the global and the American references presented higher systolic over diastolic hypertension rates (23.6 vs. 10.6% and 24.2 vs. 14.7%, respectively), the American guidelines predicted the highest increased risk for hypertension stage 2 [odds ratio, 1.72 (95% confidence interval: 1.43-2.07)] with raising levels of BMI. Conclusion: Our results support the heterogeneity of blood pressure estimates found in the South African literature, and highlight the underrepresentation of African children in international guidelines. We call for caution in the use of international standards in different contexts and advocate for the development of normative tables that are representative of the South African pediatric population necessary to ensure an accurate identification of hypertension both from the clinical and epidemiological perspective

Clustered cardiovascular disease risk among children aged 8-13 years from lower socioeconomic schools in Gqeberha, South Africa

Objectives To determine the prevalence of individual cardiovascular disease (CVD) risk factors and clustered CVD risk among children attending schools in periurban areas of Gqeberha and to investigate the independent association between clustered CVD risk, moderate to vigorous physical activity (MVPA) and cardiorespiratory fitness (CRF). Methods Baseline data were collected in a cross-sectional analysis of 975 children aged 8-13 years. We measured the height, weight, waist circumference, blood pressure, fasting glucose, full lipid panel, 20 m shuttle run performance and accelerometry. The prevalence of individual risk factors was determined, and a clustered risk score (CRS) was constructed using principal component analysis. Children with an elevated CRS of 1 SD above the average CRS were considered 'at-risk'. Results We found 424 children (43.3%) having at least one elevated CVD risk factor: 27.7% elevated triglycerides, 20.7% depressed high-density lipoprotein cholesterol and 15.9% elevated total cholesterol. An elevated clustered risk was identified in 17% (n=104) of the sample; girls exhibited a significantly higher CRS >1 SD than boys (p=0.036). The estimated odds of an elevated clustered risk are doubled every 2 mL/kg/min decrease in VO 2 max (95% CI 1.66 to 3.12) or every 49 min reduction in MVPA (95% CI 27 to 224). Conclusion A relatively high prevalence of elevated individual and clustered CVD risk was identified. Our results have also confirmed the independent inverse association of the clustered CVD risk with physical activity and CRF. These indicate that increased levels of CRF or MVPA may aid in the prevention and reduction of elevated clustered CVD risk