Selecting short-statured children needing growth hormone testing: Derivation and validation of a clinical decision rule

<p>Abstract</p> <p>Background</p> <p>Numerous short-statured children are evaluated for growth hormone (GH) deficiency (GHD). In most patients, GH provocative tests are normal and are thus in retrospect unnecessary.</p> <p>Methods</p> <p>A retrospective cohort study was conducted to identify predictors of growth hormone (GH) deficiency (GHD) in children seen for short stature, and to construct a very sensitive and fairly specific predictive tool to avoid unnecessary GH provocative tests. GHD was defined by the presence of 2 GH concentration peaks < 10 ng/ml. Certain GHD was defined as GHD and viewing pituitary stalk interruption syndrome on magnetic resonance imaging. Independent predictors were identified with uni- and multi-variate analyses and then combined in a decision rule that was validated in another population.</p> <p>Results</p> <p>The initial study included 167 patients, 36 (22%) of whom had GHD, including 5 (3%) with certain GHD. Independent predictors of GHD were: growth rate < -1 DS (adjusted odds ratio: 3.2; 95% confidence interval [1.3–7.9]), IGF-I concentration < -2 DS (2.8 [1.1–7.3]) and BMI z-score ≥ 0 (2.8 [1.2–6.5]). A clinical decision rule suggesting that patients be tested only if they had a growth rate < -1 DS and a IGF-I concentration < -2 DS achieved 100% sensitivity [48–100] for certain GHD and 63% [47–79] for GHD, and a specificity of 68% [60–76]. Applying this rule to the validation population (n = 40, including 13 patients with certain GHD), the sensitivity for certain GHD was 92% [76–100] and the specificity 70% [53–88].</p> <p>Conclusion</p> <p>We have derived and performed an internal validation of a highly sensitive decision rule that could safely help to avoid more than 2/3 of the unnecessary GH tests. External validation of this rule is needed before any application.</p

Special Care and School Difficulties in 8-Year-Old Very Preterm Children: The Epipage Cohort Study

OBJECTIVES: To investigate school difficulties, special care and behavioral problems in 8 year-old very preterm (VPT) children. PATIENT AND METHODS: Longitudinal population-based cohort in nine regions of France of VPT children and a reference group born at 39-40 weeks of gestation (WG). The main outcome measures were information about school, special care and behavioral problems using Strengths and Difficulties Questionnaire from a questionnaire to parents. RESULTS: Among the 1439 VPT children, 5% (75/1439) were in a specialised school or class, 18% (259/1439) had repeated a grade in a mainstream class and 77% (1105/1439) were in the appropriate grade-level in mainstream class; these figures were 1% (3/327) , 5% (16/327) and 94% (308/327) , respectively, for the reference group. Also, 15% (221/1435) of VPT children in a mainstream class received support at school versus 5% (16/326) of reference group. More VPT children between the ages of five and eight years received special care (55% (794/1436)) than children born at term (38% (124/325)); more VPT children (21% (292/1387)) had behavioral difficulties than the reference group (11% (35/319)). School difficulties, support at school, special care and behavioral difficulties in VPT children without neuromotor or sensory deficits varied with gestational age, socioeconomic status, and cognitive score at the age of five. CONCLUSIONS: Most 8-year-old VPT children are in mainstream schools. However, they have a high risk of difficulty in school, with more than half requiring additional support at school and/or special care. Referral to special services has increased between the ages of 5 and 8 years, but remained insufficient for those with borderline cognitive scores

Prediction of High-Grade Vesicoureteral Reflux after Pediatric Urinary Tract Infection: External Validation Study of Procalcitonin-Based Decision Rule

BACKGROUND: Predicting vesico-ureteral reflux (VUR) 653 at the time of the first urinary tract infection (UTI) would make it possible to restrict cystography to high-risk children. We previously derived the following clinical decision rule for that purpose: cystography should be performed in cases with ureteral dilation and a serum procalcitonin level 650.17 ng/mL, or without ureteral dilatation when the serum procalcitonin level 650.63 ng/mL. The rule yielded a 86% sensitivity with a 46% specificity. We aimed to test its reproducibility. STUDY DESIGN: A secondary analysis of prospective series of children with a first UTI. The rule was applied, and predictive ability was calculated. RESULTS: The study included 413 patients (157 boys, VUR 653 in 11%) from eight centers in five countries. The rule offered a 46% specificity (95% CI, 41-52), not different from the one in the derivation study. However, the sensitivity significantly decreased to 64% (95%CI, 50-76), leading to a difference of 20% (95%CI, 17-36). In all, 16 (34%) patients among the 47 with VUR 653 were misdiagnosed by the rule. This lack of reproducibility might result primarily from a difference between derivation and validation populations regarding inflammatory parameters (CRP, PCT); the validation set samples may have been collected earlier than for the derivation one. CONCLUSIONS: The rule built to predict VUR 653 had a stable specificity (ie. 46%), but a decreased sensitivity (ie. 64%) because of the time variability of PCT measurement. Some refinement may be warranted

En France, vingt propositions pour une nouvelle politique périnatale

Bréart Gérard. En France, vingt propositions pour une nouvelle politique périnatale. In: Santé, Société et Solidarité, n°1, 2004. Naître en France et au Québec. pp. 69-72

Mobilisation en France : les États généraux de la naissance

Bréart Gérard. Mobilisation en France : les États généraux de la naissance. In: Santé, Société et Solidarité, n°1, 2004. Naître en France et au Québec. pp. 141-142

Editorial. Périnatalité en France et au Québec : des défis communs, des réponses différentes

Bréart Gérard, Fraser William. Editorial. Périnatalité en France et au Québec : des défis communs, des réponses différentes. In: Santé, Société et Solidarité, n°1, 2004. Naître en France et au Québec. pp. 5-6

Trends in gestational age and birth weight in Chile, 1991-2008. A descriptive epidemiological study.

International audienceUNLABELLED: ABSTRACT: BACKGROUND: Gestational age and birth weight are the principal determinants of newborn's health status. Chile, a middle income country traditionally has public policies that promote maternal and child health. The availability of an exhaustive database of live births has allows us to monitor over time indicators of newborns health. METHODS: This descriptive epidemiological study included all live births in Chile, both singleton and multiple, from 1991 through 2008. Trends in gestational age affected the rate of prevalence (%) of preterm births (<37 weeks, including the categories < 32 and 32-36 weeks), term births (37-41) and postterm births (42 weeks or more). Trends in birth weight affected the prevalence of births < 1500 g, 1500-2499 g, 2500-3999 g, and 4000 g or more. RESULTS: Data from an exhaustive register of live births showed that the number of term and postterm births decreased and the number of multiple births increased significantly. Birth weights exceeding 4000 g did not vary.Total preterm births rose from 5.0% to 6.6%, with increases of 28% for the singletons and 31% for multiple births (p for trend < 0.0001). Some categories increased even more: specifically preterm birth < 32 weeks increased 32.3% for singletons and 50.6% for multiple births (p for trend 0.0001).The overall rate of low birth weight infants (<2500 g) increased from 4.6% to 5.3%. This variation was not statistically significant for singletons (p for trend = 0.06), but specific analyses exhibited an important increase in the category weighing <1500 g (42%) similar to that observed in multiple births (43%). CONCLUSIONS: The gestational age and birth weight of live born child have significantly changed over the past two decades in Chile. Monitoring only overall rates of preterm births and low-birth-weight could provide restricted information of this important problem to public health. Monitoring them by specific categories provides a solid basis for planning interventions to reduce adverse perinatal outcomes.This epidemiological information also showed the need to assess several factors that could contribute to explain these trends, as the demographics changes, medical interventions and the increasing probability of survival of extremely and very preterm child

Sociodemographic characteristics of mother's population and risk of preterm birth in Chile.

International audienceBACKGROUND: Preterm birth is a global problem in Perinatal and infant Health. Currently is gaining a growing attention. Rates of preterm birth have increased in most countries, producing a dramatic impact on public health. Factors of diverse nature have been associated to these trends.In Chile, preterm birth has increased since 90. Simultaneously, the advanced demographic transition has modified the characteristics of woman population related to maternity.The principal objective of this study is to analyze some sociodemographic characteristics of the maternal population over time, and their possible association to rates of preterm birth. The second aim is to identify groups of mothers at high risk of having a preterm child. METHODS: This population-based study examined all liveborn singletons in Chile from 1991 to 2008; divided in three periods. Preterm birth rates were measured as % births 38 years of age; without a partner; primiparas and grandmultiparas. However, global increase in preterm birth was not explained by the modification of socio demographics characteristics of maternal population. CONCLUSIONS: Some socio demographic characteristics remained associated with preterm birth over time. These associations allowed identifying five groups of mothers at higher risk to have a preterm child in the population.Increase in overall preterm birth affected all women, even those considered at "low sociodemographic risk" and the contribution of more recent period (2001--2008) to this increase is greater.Then, studied factors couldn't explain the increase in preterm birth. Further research will have to consider other factors affecting maternal population that could explain the observed trend of preterm birth

Is prenatal identification of fetal macrosomia useful?

International audienceOBJECTIVES: To determine whether prenatal identification of macrosomia (≥4000g) reduces neonatal complications and maternal perineal lesions during delivery. STUDY DESIGN: This historical cohort study (n=14,684 from the National perinatal database of the Audipog Association, France) included women with cephalic singleton term pregnancies. Among the babies born with macrosomia, we compared those who had been identified as such in utero (n=1211) with those who were not (n=13,473). The principal outcome was a composite variable defined as resuscitation in the delivery room, death in the delivery room or the immediate postpartum period, or transfer to a neonatal intensive care unit (NICU). The secondary outcome measures were neonatal trauma, 5-min Apgar score (≤4 and <7), and maternal perineal lesions. Results are expressed as crude relative risks and adjusted odds ratios. RESULTS: The mean birthweight in the cohort was 4229g±219. The adjusted OR for the principal outcome defined above was 1.15 (95% CI: 0.89-1.50) in the group identified prenatally as macrosomic compared with the others (10.8% vs. 8.5%). The risk of neonatal trauma was higher in prenatally identified babies (adjusted OR: 1.80; 95% CI: 1.34-2.42). The 5-min Apgar score and the perineal lesion rate did not differ significantly between the groups. The a posteriori study power according to our results with α=0.05 was 84% (one-sided test). CONCLUSIONS: Among babies born with macrosomia, in utero identification did not improve neonatal or maternal outcomes