bluuebunny/crossref_metadata_2025 huggingface dataset:
Effects of Altered Excitation-Inhibition Balance on Decision Making in a Cortical Circuit Model
Authors: Lam Norman H. , Borduqui Thiago , Hallak Jaime , Roque Antonio , Anticevic Alan , Krystal John H. , Wang Xiao-Jing , Murray John D.
Published: December 2021

The synaptic balance between excitation and inhibition (E/I balance) is a fundamental principle of cortical circuits, and disruptions in E/I balance are commonly linked to cognitive deficits such as impaired decision-making. Explanatory gaps remain in a mechanistic understanding of how E/I balance contributes to cognitive computations, and how E/I disruptions at the synaptic level can propagate to induce behavioral deficits. Here, we studied how E/I perturbations may impair perceptual decision-making in a biophysically-based association cortical circuit model. We found that both elevating and lowering E/I ratio, via NMDA receptor (NMDAR) hypofunction at inhibitory interneurons and excitatory pyramidal neurons, respectively, can similarly impair psychometric performance, following an inverted-U dependence. Nonetheless, these E/I perturbations differentially alter the process of evidence accumulation across time. Under elevated E/I ratio, decision-making is impulsive, overweighting early evidence and underweighting late evidence. Under lowered E/I ratio, decision-making is indecisive, with both evidence integration and winner-take-all competition weakened. The distinct time courses of evidence accumulation at the circuit level can be measured at the behavioral level, using multiple psychophysical task paradigms which provide dissociable predictions. These results are well captured by a generalized drift-diffusion model (DDM) with self-coupling, implementing leaky or unstable integration, which thereby links biophysical circuit modeling to algorithmic process modeling and facilitates model fitting to behavioral choice data. In general, our findings characterize critical roles of cortical E/I balance in cognitive function, bridging from biophysical to behavioral levels of analysis.

SIGNIFICANCE STATEMENTCognitive deficits in multiple neuropsychiatric disorders, including schizophrenia, have been associated with alterations in the balance of synaptic excitation and inhibition (E/I) in cerebral cortical circuits. However, the circuit mechanisms by which E/I imbalance leads to cognitive deficits in decision-making have remained unclear. We used a computational model of decision-making in cortical circuits to study the neural and behavioral effects of E/I imbalance. We found that elevating and lowering E/I ratio produce distinct modes of dysfunction in decision-making processes, which can be dissociated in behavior through psychophysical task paradigms. The biophysical circuit model can be mapped onto a psychological model of decision-making which can facilitate experimental tests of model predictions.
INTEGRATED APPROACH OF FUZZY MULTI-ATTRIBUTE DECISION MAKING AND DATA MINING FOR CUSTOMER SEGMENTATION
Authors: Ray Manidatta , Ray Mamata , Muduli Kamalakanta , Banaitis Audrius , Kumar Anil
Published: December 2021

This research work focuses on integrating the multi attribute decision making with data mining in a fuzzy decision environment for customer relationship management. The main objective is to analyse the relation between multi attribute decision making and data mining considering a complex problem of ordering customers segments, which is based on four criteria of customer’s life time value, viz. length (L), recency (R), frequency (F) and monetary value (M). The proposed integrated approach involves fuzzy C-means (FCM) cluster analysis as data mining tool. The experiment conducted using MATLAB 12.0 for identifying eight clusters of customers. The two multi attribute decision making tools i.e., fuzzy AHP (Analytic Hierarchy Process) and fuzzy TOPSIS (Technique for Order Preference by Similarity to Ideal Solution) are used for ranking these identified clusters. The applicability of the integrated decision making technique is also demonstrated in this paper considering the case of Indian retail sector. This research collected responses from nine experts from Indian retail industry regarding their perception of relative importance of four criteria of customer life value and evaluated weights of each criterion using fuzzy AHP. Transaction data of 18 months of the case retail store was analysed to segment 1,600 customers into eight clusters using fuzzy c-means clustering analysis technique. Finally, these eight clusters were ranked using fuzzy TOPSIS (Technique for Order Preference by Similarity to Ideal Solution). The findings of this research could be helpful for firms in identifying the more valuable customers for them and allocate more resources to satisfy them. The findings will be also helpful in developing different loyalty program strategies for customers of different clusters.
Does exercise beneficially affect sex hormones when added to hypo-caloric diets in adults with overweight or obesity? A systematic review and meta-analysis of controlled clinical trials
Authors: Mohseni-Takalloo Sahar , Beigrezaei Sara , Yazdanpanah Zeinab , Rajaie Seyede Hamide , Soltani Sepideh , Zohrabi Tayebeh , Kaviani Mojtaba , Forbes Scott C , Baker Julien S , Salehi-Abargouei Amin
Published: December 2021

Objective

There is no consensus of opinion if exercise beneficially affects sex hormones if added to weight-loss diets. The purpose of this study was to perform a systematic review and meta-analysis of controlled clinical trials to evaluate the effect of adding exercise to a hypo-caloric diet during a weight-loss program, on serum testosterone, estradiol, and sex hormone-binding globulin (SHBG) in adults with overweight/obesity.

Design

Systematic review and meta-analysis of the literature.

Methods

Online databases including PubMed/MEDLINE, EMBASE, Scopus, ISI Web of Science, and Google Scholar were searched up to April 2021. A random-effects model was applied to compare mean changes in sex hormones and SHBG between participants undergoing a hypo-caloric diet with or without exercise.

Results

In total, 9 eligible clinical trials with 462 participants were included. Out of these, seven, three, and four studies illustrated changes in testosterone, estradiol, and SHBG, respectively. The meta-analysis revealed that exercise had no significant effect on circulating testosterone (WMD = −0.03 nmol/L, 95% CI: −0.11, 0.06, P = 0.51), estradiol (WMD = −0.46 pg/mL, 95% CI: −1.57, 0.65, P = 0.42), and SHBG (WMD = 0.54 nmol/L, 95% CI: −2.63, 3.71, P = 0.74) when added to low-calorie diets.

Conclusion

The addition of exercise to a hypo-caloric diet provided no additional improvement in sex hormone profiles. Further, well-designed randomized controlled trials with longer follow-up periods in both sexes are recommended to confirm and expand the current results.
General Provisions On Duties Of Company Officials In The Legislation Of Ukraine
Authors: Vasylieva V.V.
Published: December 2021

The purpose of the article is to study the provisions of the current legislative acts of Ukraine, which regulate the legal status and duties of the company’s officials, compare the completeness and detail of the regulation of duties of officials for joint stock companies, limited liability companies and additional liability companies. The main methods of research applied by the author are analysis and comparison. The norms of the Civil and Commercial Codes of Ukraine, laws of Ukraine on JSC, LLC and ALC were investigated. The article explores the provisions of the proposed draft law on joint stock companies; proposals for improving the legal regulation of this issue are analyzed. The author explored that new law contains such general provisions on duties of the joint stock company officials: the officials must act in the interests of the company, within the powers granted to them by the charter of the company and the legislation; act in good faith and reason; act in a manner that, in their good faith, will contribute to achieving the goal of the company. Also new regulation is supposed to include a list of duties of officials such as: 1) the duty to facilitate the company’s achievement of successful results in accordance with this Law; 2) the duty to make independent decisions in accordance with this Law; 3) duty to act with a reasonable degree of diligence, professionalism and diligence in accordance with this Law; 4) duty to avoid conflicts of interest; 5) duty to refrain from accepting benefits (benefits) from third parties; 6) duty of notification about the interest in the company’s agreement.

The author expressed positive comments on certain proposed changes, such as establishing a list of duties for officials of the joint stock company and determining the responsibility for these duties breaking, as well as negative comments on law drafting technique, vague concepts and providing the possibility of an exceptional approach towards responsibility for duties breach.
Institutional Management System Of National Nature Parks In Ukraine
Authors: Kosheliuk T.V.
Published: December 2021

The article presents an analysis of the understanding of the concept and management system in the field of nature reserves of Ukraine, in particular, national nature parks. As a result of the analysis of scientific literature, normative-legal acts the author’s approaches to systematization of types of management in this sphere are presented. The separation of three management systems is substantiated: 1) state; 2) intra-administrative 3) public. Based on this, a system of entities (institutions) that implement management functions at different levels. The study identified problems and shortcomings in the mechanism of public management of national nature parks and suggested ways to solve them.

The issues of peculiarities of management of national nature parks, legal status of subjects of administrative activity, competences of subjects of state management of nature reserve fund, as well as participation of public and scientific institutions in this process are insufficiently researched today. Therefore, there is a need to develop ways to improve the institutional framework of management in this area.

The author emphasizes the subordination of national nature parks various agencies, which creates a problematic situation, because when the national nature park belongs to a non-core agency, which does not have special units for the management of such facilities, there are numerous violations of current legislation on nature reserves.

After all, only a centralized management system of the relevant body will help maintain compliance with the legal regime in these areas and optimize the activities of national nature parks.
Formation And Development Of Constitutional And Legal Responsibility In Ukraine During The Cossack Republic And The Hetman State
Authors: Knysh V.V.
Published: December 2021

This scientific article is devoted to the problems of formation and development of the institute of constitutional and legal responsibility in the period of the Cossack republic and the Hetman state. A special role here belongs to the legal enshrinement of this institution in the provisions of the Constitution of Philip Orlyk.

In general, in legal science there are various scientific directions in the definition of constitutional liability. Such scientific approaches can be combined into four groups, in particular:

1)    scientific direction, which is based on the substantiation of a narrow understanding of constitutional and legal responsibility, which is based on the recognition of only retrospective (negative) constitutional and legal responsibility;

2)    scientific direction, which substantiates a broad understanding of constitutional and legal responsibility, which involves a combination of retrospective (negative) and long-term (positive) responsibility;

3)    scientific direction, which distinguishes between retrospective (negative) and long-term (positive) responsibility;

4) scientific direction, which substantiates both the combination of retrospective (negative) and perspective (positive) responsibility, and the existence of only retrospective (negative) responsibility.

At the same time, in the context of the latest trends in Ukrainian state-building and law-making, as well as taking into account the need for historical and legal (rather than purely theoretical, sectoral or institutional) study of the needs of transformation of legal responsibility in Ukraine and its individual types, constitutional and legal responsibility needs separate scientific research from a historical and legal point of view, including the formation and development during the Cossack republic and the Hetman state.

According to the author, the acts of the Cossack republic and the Hetman state, and especially the Constitution of Pylyp Orlyk of 1710 not only determined the foundations of the political and socio-economic system of Ukraine, the apparatus of state power on the basis of division of power into legislative, executive and judicial, but also provided constitutional legal responsibility as a means of ensuring interaction between branches of government and a means of their effective functioning.

This constitutional and legal responsibility existed both in the form of positive responsibility, which manifested itself in a clear definition of the powers of authorities and the establishment of ways and forms of interaction between them, and in the form of negative responsibility, which provided for sanctions against officials at all levels.
They See Me Rollin’, They Hatin’
Authors: Preston Jeff
Published: December 2021

Aubrey Graham, more commonly known as hip-hop performer Drake, presents himself as a man of contradiction—a lover and a fighter, sensitive but hard, successful but humble. Despite this subjective work, designed to present a complex embodiment of an artistic and financial success, the discourse of Graham online is often underpinned by suspicion and derision that seeks to redefine him as a pretender who is unworthy of the status he claims. Nowhere is this more evident than in the “Wheelchair Drake” memetic cluster, which uses an old Degrassi: The Next Generation promotional image of Graham sitting on a wheelchair, combined with humorous juxtaposition of rap lyrics, to critique Graham’s status as both a performer and a Black man. In various Wheelchair Drake memes, physical impairment becomes a living metaphor for a spoiled identity; the memes argue that, just like ableist imaginations of physically disabled people, Graham is doomed to a life of impotence and dependency. Built upon a sample of 583 user-generated images, coded into 9 thematic groups, this article excavates the latticed discourses of masculinity, disability and race that animate the Wheelchair Drake meme and consider the ways that this memetic cluster subjects Aubrey Graham to the strictures of ableist hegemonic masculinity.
Wettbewerbsprobleme bei Online-Handelsplattformen – Beurteilung nach klassischem Kartellrecht und neuen plattformbezogenen Regelungen
Authors: Schön Cordula
Published: December 2021

Die Bildung von Plattformmodellen mit dem Ziel einer verbesserten digitalen Vernetzung von Marktteilnehmern durch Kooperationen zwischen Industrieunternehmen bzw. zwischen Industrieunternehmen und ihren Abnehmern und Lieferanten ist in einer zunehmend digitalisierten Welt en vogue und wirft Fragen auf, insbesondere kartellrechtlicher Natur.

Seit mehr als 20 Jahren beschäftigen sich die Wettbewerbsbehörden mit den sich aus wettbewerbsrechtlicher Sicht aufdrängenden Fragen bezüglich elektronischen Online-Handelsplattformen. Durch die Corona-Pandemie hat die Digitalisierung einen weiteren deutlichen Schub erhalten, so dass mit einer Zunahme der digitalen Handelsplätze ebenso zu rechnen ist wie mit möglichen weiteren Vernetzungsformen zwischen Handeltreibenden.

Im Folgenden werden nach einer Beschreibung von Funktionsweise und Auftreten von Online-Handelsplattformen in dem hier interessierenden B2B-Bereich (dazu unten II.) die aus solchen Handelsplattformen herrührenden wettbewerblichen Problemlagen herausgearbeitet und systematisiert (dazu unten III.). Dabei werden die bisherige Behördenpraxis sowie der aktuelle Literatur-Stand berücksichtigt. Anschließend (dazu unten IV.) werden die aktuellen Entwicklungen in der einschlägigen Gesetzgebung inhaltlich kurz dargestellt und ihre Relevanz für die speziell mit Online-Handelsplattformen einhergehenden Wettbewerbsprobleme diskutiert. Hierzu zählt das im Januar dieses Jahres in Kraft getretene GWB-Digitalisierungsgesetz sowie das von der EU-Kommission am 15. Dezember 2020 vorgelegte Gesetzespaket in Form zweier Verordnungsvorschläge für eine Plattformregulierung, der sog. Digital Services Act (DSA) und den sog. Digital Markets Act (DMA). Danach wird ein Fazit gezogen (dazu unten V.).
Correlation between Serum Levels of Sympathetic Nerve Activity Markers and Sleep Quality and Cognitive Function in Patients with Chronic Insomnia Disorder
Authors: Gui-Hai Chen , Ting Hu , Xuan Song , Yi-Jun Ge , Ping Zhang , Xue-Yan Li , Xiao-Yi Kong
Published: December 2021

Objectives: To explore the changes of the serum levels of copeptin and α-amylase and the correlations with sleep quality and cognition function in the patients with chronic insomnia disorder (CID). Methods: Fifty-seven CID patients and thirty healthy controls were enrolled continuously. Pittsburgh Sleep Quality Index (PSQI), polysomnography (PSG) and Pre-Sleep Arousal Scale (PSAS) were used to assess the insomnia severity and cognitive and somatic manifestations of arousal experienced at bedtime. Montreal Cognitive Assessment scale (MoCA) and Nine-Box Maze were used to respectively assess general cognition and memories. The serum levels of copeptin and α-amylase were detected using Enzyme-Linked ImmunoSorbent Assay. Results: Compared to the controls, the CID patients had increased PSQI and PSAS scores (Z=‒7.678 and ‒7.350; Ps<0.001), decreased MoCA score (t=‒4.625, P<0.001), increased numbers of errors in the object working, spatial working and object recognition (Z=‒2.099, ‒3.935 and ‒2.266; Ps<0.05) memories, and elevated serum levels of copeptin and α-amylase (t=5.414 and 5.597, P <0.001). In the CID patients，the level of copeptin positively correlated with PSQI and PSAS scores (r=0.338 and 0.316; Ps<0.05), and PSG sleep latency, wake time and N1% (r=0.324, 0.325 and 0.278, Ps<0.05), and negatively correlated with PSG N 2% (r=‒0.279, Ps<0.05). Alpha-amylase was positively correlated with waking numbers in PSG (r=0.293, P< 0.05). Multiple linear regression analysis showed that copeptin level affected PSQI score and PSG sleep latency (P<0.05). Conclusions: The serum levels of copeptin and α-amylase elevated in the CID patients, and the serum levels of copeptin may be associated with the poor sleep quality, especially in the individuals of initial sleep difficulties.
Ion-selective Electrodes Based on PVC Membranes for Potentiometric Sensor Applications: A Review
Authors: Chandra Mohan , Vinod Kumar
Published: December 2021

Ion-selective electrodes (ISEs) are potentiometric sensors used to measure some of the most critical analytes in environmental laboratory. Recently ion sensors are taking place of various analytical techniques, as they provide a convenient and fast method of electroanalysis. Ion-selective electrodes are simple, relatively inexpensive, robust, durable, and ideal to be used for the detection of heavy metal ions. Important characterisctics of ISEs are selectivity, response time, detection limit, working range, effect of pH etc. Lot of research work is being done for the formation of ISEs by using polymeric membrane incorporated with ionophores or electroactive material. Various types of Schiff bases, macromolecules and metal complexes may be used as ionophores along with plasticizer, ion-excluder for the membrane preparation. Ion-selective electrodes will be optimized for pH range, selectivity, sensitivity, working concentration range and lifetime before their use as sensor electrode for determining the concentration of ions in solution. Various researchers are working in the field to develop Ion-selective electrodes which shows better selectivity and sensitivity than the previously reported electrodes and can be used as electrocatalysts. These ISEs can be used as electrochemical sensors for the analysis of food products, drinking water, beverages, fertilizers, and for the analysis of sample containing toxic substances.
Development and Evaluation of a Satisfaction Scale for Parents of Children With Special Health Care Needs
Authors: Ireys Henry T. , Perry Jamie J.
Published: December 2021

Objective.

This article describes the development and evaluation of the Multidimensional Assessment of Parental Satisfaction (MAPS) for Children With Special Needs, a tool for measuring satisfaction with providers at the individual level of care.

Methods.

Two studies were conducted. The first study created and pilot-tested the scale, using data from 158 parents of children with 4 selected chronic conditions to calculate estimates of reliability and validity. Initial psychometric characteristics were sufficiently strong to warrant further testing. The second study was a field trial of the 12-item MAPS, using data from 302 parents of children with diverse chronic conditions.

Results.

Reliability estimates were >.85. The scale's discriminative validity was supported by sharp distinctions between satisfaction ratings for different types of providers. Correlations in the .80s with general satisfaction items indicated strong concurrent validity. Factor analysis revealed a single factor.

Conclusions.

The MAPS has psychometric integrity. Assessing satisfaction for children with special health care needs is a complex, necessary part of a comprehensive assessment of quality of care.
Final Report of the FOPE II Pediatric Generalists of the Future Workgroup
Authors: Leslie Laurel , Rappo Peter , Abelson Herbert , Jenkins Renee R. , Sewall Sydney R. , Chesney Russell W. , Mulvey Holly J. , Simon Jimmy L. , Alden Errol R.
Published: December 2021

The Future of Pediatric Education II (FOPE II) Project was a 3-year, grant-funded initiative, which continued the work begun by the 1978 Task Force on the Future of Pediatric Education. Its primary goal was to proactively provide direction for pediatric education for the 21st century. To achieve this goal, 5 topic-specific workgroups were formed: 1) the Pediatric Generalists of the Future Workgroup, 2) the Pediatric Specialists of the Future Workgroup, 3) the Pediatric Workforce Workgroup, 4) the Financing of Pediatric Education Workgroup, and 5) the Education of the Pediatrician Workgroup. The FOPE II Final Report was recently published as a supplement toPediatrics (The Future of Pediatric Education II: organizing pediatric education to meet the needs of infants, children, adolescents, and young adults in the 21st century.Pediatrics. 2000;105(suppl):161–212). It is also available on the project web site at: www.aap.org/profed/fope1.htm This report reflects the deliberations and recommendations of the Pediatric Generalists of the Future Workgroup of the Task Force on FOPE II. The report looks at 5 factors that have led to changes in child health needs and pediatric practice over the last 2 decades. The report then presents a vision for the role and scope of the pediatrician of the future and the core attributes, skills, and competencies pediatricians caring for infants, children, adolescents, and young adults will need in the 21st century. Pediatrics 2000;106(suppl):1199–1223;pediatrics, medical education, children, adolescents, health care delivery.
Development of Wheezing Disorders and Asthma in Preschool Children
Authors: Martinez Fernando D.
Published: December 2021

Recent longitudinal studies have shed light on the pathogenesis and progression of asthma. The patterns of expression of childhood asthma that persist into adult life have been explored. Distinct asthma phenotypes (transient wheezing, nonatopic wheezing, and atopy-associated asthma) have been identified. Defining which children are at risk for persistent asthma could allow for better management and, potentially, for reduced morbidity and mortality.
Management of Child and Adolescent Obesity: Study Design and Practitioner Characteristics
Authors: Trowbridge Frederick L. , Sofka Denise , Holt Katrina , Barlow Sarah E.
Published: December 2021

Objective. A study was undertaken to examine the attitudes and practices of health care providers in the assessment and treatment of overweight and obese children and adolescents. This study describes the study design and the practice settings and person characteristics of the practitioners included in this study.

Methods. A needs assessment questionnaire was developed by a working group consisting of researchers, clinicians, educators, and representatives of the Maternal and Child Health Bureau, Health Resources and Services Administration (Department of Health and Human Services), National Center for Education in Maternal and Child Health, International Life Sciences Institute, and Harris Interactive, Inc. The questionnaire consisted of 35 questions divided into 3 topic areas and was disseminated to a sample of pediatricians (n = 1088), pediatric nurse practitioners (n = 879), and registered dietitians (n = 1652).

Results. Despite a low response rate (33% for pediatric nurse practitioners, 27% for registered dieticians, and 19% for pediatricians), descriptive data were obtained about a variety of practitioner characteristics. Some significant differences were observed across practitioner groups and between genders in regard to years in practice, body mass index, and dietary and physical activity behaviors. Significant relationships were also observed in some practitioner groups between body mass index and compliance with dietary and physical activity guidelines.

Conclusions. Our data show there is a wide variance in practitioner characteristics, particularly in regard to gender, years of practice, body mass index, and obesity-related behaviors. It is hoped the analyses presented in this and in the subsequent articles will provide useful information on current attitudes and practices and will contribute to improvements in the treatment of overweight children and adolescents.
Access to Health Care: Health Insurance Considerations for Young Adults With Special Health Care Needs/Disabilities
Authors: White Patience H.
Published: December 2021

Youth with special health care needs/disabilities want what all youth in America want: independence, health, friends, and jobs. Yet, between 19 and 23 years of age (depending on the state), youth with special health care needs/disabilities often find little availability of health insurance or health providers that were an essential part of why they survived and now are looking to participate in adult society. This article reviews the complex system of health insurance options that young adults with special health care needs/disabilities face as they move from pediatric to adult health insurance systems. Yet because of a maze of different eligibility criteria, many of these options are not available to young adults with special health care needs, and they are left with out health insurance. Similarly, the issues surrounding health provider reimbursement often leave the young adult with special health care needs without health care professionals who can manage their complex health conditions as they transition into adulthood. In conclusion, this article outlines what steps could be taken by associations and the health policy, advocacy, and governmental communities to improve the situation.
Pregnancy Intendedness and the Use of Periconceptional Folic Acid
Authors: Rosenberg Kenneth D. , Gelow Jill M. , Sandoval Alfredo P.
Published: December 2021

Objective. Periconceptional use of folic acid can prevent birth defects, including at least 50% of neural tube defects. This study used an ongoing surveillance system to explore the association between pregnancy intendedness and women taking periconceptional folic acid.

Methods. Oregon Pregnancy Risk Assessment Monitoring System (PRAMS) surveys a stratified random sample of women after a live birth. In 1998–1999, 1867 women completed the survey (64.0% response rate); responses were weighted for nonresponse. Women were asked whether they took folic acid most days in the month before becoming pregnant.

Results. Overall, 33.2% of women took folic acid most days in the month before becoming pregnant, and 39.9% said that their pregnancy was unintended. Adolescent mothers were less likely to take periconceptional folic acid (9.2%) and more likely to report unintended pregnancy (62.0%) than older women. Overall, women who said that their pregnancy was intended were more likely to report that they had taken periconceptional folic acid (odds ratio: 4.75; 95% confidence interval: 3.16–7.14); after controlling for maternal age and income the odds ratio was 3.70 (95% confidence interval: 2.38–5.56).

Conclusions. Women whose pregnancies were intended were more likely to have been taking periconceptional folic acid than women whose pregnancies were unintended. The importance of fertile women’s taking daily multivitamins that contain 400 μg (0.4 mg) of folic acid should be stressed among women who are not contemplating pregnancy, especially adolescents and low-income women.
Maternal Obesity and Risk for Birth Defects
Authors: Watkins Margaret L. , Rasmussen Sonja A. , Honein Margaret A. , Botto Lorenzo D. , Moore Cynthia A.
Published: December 2021

Objective. Several studies have shown an increased risk for neural tube defects associated with prepregnancy maternal obesity. Because few recent studies have examined the relation between maternal prepregnancy obesity and overweight and other birth defects, we explored the relation for several birth defects and compared our findings with those of previous studies.

Methods. We conducted a population-based case-control study of several selected major birth defects using data from the Atlanta Birth Defects Risk Factor Surveillance Study. Mothers who delivered an infant with and without selected birth defects in a 5-county metropolitan Atlanta area between January 1993 and August 1997 were interviewed. Maternal body mass index (BMI) was calculated from self-reported maternal prepregnancy weight and height. Women with known preexisting diabetes were excluded. The risks for obese women (BMI ≥30) and overweight women (BMI 25.0–29.9) were compared with those for average-weight women (BMI 18.5–24.9).

Results. Obese women were more likely than average-weight women to have an infant with spina bifida (unadjusted odds ratio [OR]: 3.5; 95% confidence interval [CI]: 1.2–10.3), omphalocele (OR: 3.3; 95% CI: 1.0–10.3), heart defects (OR: 2.0; 95% CI: 1.2–3.4), and multiple anomalies (OR: 2.0; 95% CI: 1.0–3.8). Overweight women were more likely than average-weight women to have infants with heart defects (OR: 2.0; 95% CI: 1.2–3.1) and multiple anomalies (OR: 1.9; 95% CI: 1.1–3.4).

Conclusions. Our study confirmed the previously established association between spina bifida and prepregnancy maternal obesity and found an association for omphalocele, heart defects, and multiple anomalies among infants of obese women. We also found an association between heart defects and multiple anomalies and being overweight before pregnancy. A higher risk for some birth defects is yet another adverse pregnancy outcome associated with maternal obesity. Obesity prevention efforts are needed to increase the number of women who are of healthy weight before pregnancy.
Associations of Intrauterine Growth Restriction Among Term Infants and Maternal Pregnancy Intendedness, Initial Happiness About Being Pregnant, and Sense of Control
Authors: Durousseau Sharon , Chavez Gilberto F.
Published: December 2021

Objective. Term infants (≥37 weeks’ gestation) who weigh <2500 g have intrauterine growth restriction (IUGR) and have a higher risk of mortality and morbidity. Little is known about how psychosocial factors affect the risk of IUGR. We examined the association between IUGR and maternal pregnancy intendedness, initial happiness about becoming pregnant, and maternal sense of control.

Methods. We analyzed data from a survey of California mothers aged ≥15 years with term live births in 1999 and 2000 (N = 5961). Mothers were asked about pregnancy intendedness before pregnancy, initial happiness about becoming pregnant, and maternal sense of control, assessed by a standardized scale. We examined the association of having an infant with IUGR and these factors in univariate and multivariate analyses.

Results. Mothers with low sense of control (3.0%) and average sense of control (2.7%) were more likely to have an infant with IUGR than mothers with high sense of control (1.8%; odds ratio: 1.8; 95% confidence interval: 1.2–2.9; and odds ratio: 1.6; 95% confidence interval: 1.0–2.5). After multivariate analysis, we found no significant association between sense of control and IUGR. We also found no significant association between IUGR and pregnancy intendedness and happiness about becoming pregnant.

Conclusions. We found no statistically significant association between IUGR and maternal pregnancy intendedness, initial happiness about becoming pregnant, and maternal sense of control. Although research should continue to explore associations between psychosocial factors and IUGR, prenatal care programs should focus on known risk factors for IUGR.
Symposium: Pediatric Food Allergy
Authors: Sicherer Scott H. , Muñoz-Furlong Anne , Murphy Ramon , Wood Robert A. , Sampson Hugh A.
Published: December 2021

Food allergy seems to be increasing in prevalence,1 significantly decreases the quality of life for patients and their families,2 and has become a common diagnostic and management issue for the pediatrician.3 Studies now a decade old showed that 6% to 8% of children younger than 3 years experience documented adverse reactions to foods. Several studies have defined the prevalence of allergy to specific foods in childhood. Population-based studies document a prevalence of cow milk allergy in 1.9% to 3.2% of infants and young children,4 egg allergy5–7 in 2.6% of children by age 2.5 years,8 and peanut allergy in 0.4% to 0.6% of those younger than 18 years.9,10 Overall, the typical allergens of infancy and early childhood are egg, milk, peanut, wheat, and soy, whereas allergens that are responsible for severe reactions in older children and adults are primarily caused by peanut, tree nuts, and seafood. Allergy to fruits and vegetables are prominent but usually not severe.11–13 For diagnostic purposes, it is instructive to consider the prevalence of food allergy as a cause of specific disorders. For example, food allergy accounts for 20% of acute urticaria,14,15 is present in 37% of children with moderate to severe atopic dermatitis16,17 and approximately 5% with atopic asthma,18 and is the most frequent cause of anaphylaxis outside the hospital setting.19–22
Mucosal Immunity
Authors: Mayer Lloyd
Published: December 2021

Food allergy is the manifestation of an abnormal immune response to antigen delivered by the oral route. Normal mucosal immune responses are generally associated with suppression of immunity. A normal mucosal immune response relies heavily on a number of factors: strong physical barriers, luminal digestion of potential antigens, selective antigen sampling sites, and unique T-cell subpopulations that effect suppression. In the newborn, several of these pathways are not matured, allowing for sensitization rather than suppression. With age, the mucosa associated lymphoid tissue matures, and in most individuals this allows for generation of the normal suppressed tone of the mucosa associated lymphoid tissue. As a consequence, food allergies are largely outgrown. This article deals with the normal facets of mucosal immune responses and postulates how the different processes may be defective in food-allergic patients.
Respiratory Manifestations of Food Allergy
Authors: James John M.
Published: December 2021

Food allergy may present with a variety of respiratory tract symptoms that generally involve immunoglobulin E antibody-mediated responses. Exposure is typically through ingestion, but in some cases, inhalation of airborne food particles may trigger these reactions. Upper and lower respiratory tract reactions are often a significant component of multisystem, anaphylactic reactions. However, chronic or isolated asthma or rhinitis induced by food is unusual. It is important to recognize that food allergy in early childhood is a marker indicating an increased risk to develop respiratory allergy. The role of food allergy in otitis media is controversial and probably is extremely rare. Likewise, asthmatic responses to food additives can occur but are uncommon. Studies using blinded oral food challenges have demonstrated that foods can elicit airway hyperreactivity and asthmatic responses. Therefore, an evaluation for food allergy should be considered in patients who are at risk, including those with recalcitrant or otherwise unexplained acute, severe asthma exacerbations, asthma triggered after ingestion of particular foods, and asthma that is accompanied by other manifestations of food allergy (eg, anaphylaxis, moderate to severe atopic dermatitis).
How Environmental Exposures Influence the Development and Exacerbation of Asthma
Authors: Etzel Ruth A.
Published: December 2021

Environmental exposures may increase a child’s risk of developing asthma and also may increase the risk of asthma exacerbations. This article reviews several environmental exposures and suggests whether they contribute to asthma prevalence, asthma exacerbations, or both. Outdoor air exposures and violence are not likely to cause the increase in asthma prevalence. Exposure to outdoor air pollutants primarily leads to increased exacerbations, sometimes manifested as asthma clusters. Clinicians should be alert for space-time clusters of asthma exacerbations in the community, because these clusters may suggest a modifiable point-source exposure. Indoor air exposures are more strongly linked to the increase in asthma prevalence. Exposure to dust mites and tobacco smoke are risk factors for the development of asthma and may also exacerbate existing asthma. Effective measures to prevent exposures to these pollutants are available. With proper management, the amount of environmental exposures can be decreased. Whether decreasing these exposures will result in decreases in asthma prevalence and exacerbations is not yet documented.
Herbal Remedies and Children: Do They Work? Are They Harmful?
Authors: Woolf Alan D.
Published: December 2021

More parents are considering the use of herbal remedies to maintain their children’s good health and to treat their illnesses. They look to pediatricians and other primary care clinicians for advice concerning the safety and efficacy of herbal products for children. This article reviews principles for the clinician to keep in mind while investigating the literature on herbal medicine and addressing the use of herbal medicines with parents.
Social, Economic, and Political Determinants of Child Health
Authors: Spencer Nick
Published: December 2021

The Issue. This article presents a brief overview of the effects of social, economic, and political factors on child health. It starts by highlighting child poverty in rich nations, in particular the United Kingdom and the United States, and identifies the economic and political factors underlying this phenomenon. The evidence linking socioeconomic status and child health is briefly reviewed with particular attention to birth weight and child mental health—2 of the most important public health challenges in the 21st century. The implications for pediatricians of high levels of child poverty and the effect that these have on children are discussed.
American Academy of Pediatrics Community Access to Child Health (CATCH) Program: A Model for Supporting Community Pediatricians
Authors: Burton O. Marion
Published: December 2021

The Issue. Advocacy on behalf of children who are medically underserved and the pediatricians who care for them has been a long-standing core commitment of the Royal College of Paediatrics and Child Health and the American Academy of Pediatrics. Although different in etiology, barriers to adequate health care exist in both nations. In the United States, almost 18 million children have either no health insurance or inadequate coverage, whereas in the United Kingdom, parents can, in most cases, readily enroll their youngsters in a universal health insurance program that is not dependent on employers or employment.1 However, despite universal access to health care in the United Kingdom, as in the United States, there are infants and children who do not regularly use or otherwise connect to available health care delivery systems. Many of these families are not participants in other social systems (eg, church, school, voting, employment, property ownership/rental) and therefore are not known to governments, agencies, authorities, or health care professionals. Both nations have citizens living in extreme poverty with its associated environmental and health hazards and tendencies to health risk behaviors. Both the Royal College of Paediatrics and Child Health and the American Academy of Pediatrics have strategies and programs to address these issues and to support pediatricians who work in their communities to improve the lives of children. The following describes the American Academy of Pediatrics Community Access to Child Health infrastructure that supports practicing community pediatricians in these efforts and opportunities to develop collaborative international endeavors to advance the practice of community pediatrics.
Research and Equity in Child Health
Authors: Logan Stuart
Published: December 2021

The Issue. In this article, I address 3 questions about research in the area of health inequities for children: why continue to do research, where should research efforts focus, and how best can we facilitate the development of research in the area of health equity? I was prompted to consider these issues by colleagues who think that doing research into child health inequalities is a waste of time. They say that not because they come from a right-wing perspective; on the contrary, they say, “Listen, we know about this stuff, why don’t you just get on and do something about it and stop worrying about the research?” Therefore, we must rethink the relevance of the why and the what before we consider the how.
The National Institute of Child Health and Human Development and Phenylketonuria
Authors: Alexander Duane
Published: December 2021

The National Institute of Child Health and Human Development (NICHD) was established shortly after the Guthrie test for screening newborn infants for phenylketonuria (PKU) was introduced. The NICHD supported the study demonstrating the long-term efficacy of screening and a low-phenylalanine diet in preventing mental retardation. With the identification of the adverse impact on fetal development of high intrauterine phenylalanine exposure from a mother with PKU, the NICHD organized and supported the study reported here, demonstrating the protective effect of phenylalanine restriction of the mother’s diet during pregnancy. The study provides clear guidance for the management of pregnancy in women with PKU.
Historical Background for the Maternal PKU Syndrome
Authors: Levy Harvey L.
Published: December 2021

Objective. To provide information on the history of maternal phenylketonuria.

Methods. A review of the literature and personal observations were conducted.

Results. Compilation of sequential information about the development of our understanding of maternal PKU was produced.

Conclusions. The history of maternal PKU reflects continuous additions to our understanding of this teratogenic syndrome.
Potential Role of Tetrahydrobiopterin in the Treatment of Maternal Phenylketonuria
Authors: Trefz Friedrich K. , Blau Nenad
Published: December 2021

Objective. To evaluate the clinical relevance of tetrahydrobiopterin (BH4) supplementation for pregnant women with phenylketonuria (PKU)/hyperphenylalaninemia (HPA) and the possibility of treating these patients with BH4 instead of a phenylalanine (Phe)-restricted diet.

Methods. Genotyping was performed on 41 patients with PKU/HPA identified by newborn screening. Evaluating the genotype according to their BH4 responsiveness is published. Follow-up of 3 patients with mild PKU treated with BH4 is evaluated. Discussion of the transfer of these experiences to the possibility of treating mothers at risk for maternal PKU is presented.

Results. In 41 patients with PKU/HPA, we found 17 (41%) bearing at least 1 allele with a mutation described as being responsive to BH4. In 8 of the patients, BH4 loading had been performed in the newborn period, in 6 of whom the test showed a clear decrease of blood Phe 4 and 8 hours after loading. One of the nonresponders was reinvestigated at 3 years of age, showing a clear response (genotype Y414C/R408W): BH4 supplementation resulted in a much higher Phe tolerance (500 instead of 250 mg/day) with blood Phe levels <200 μmol/L. Two children (genotype E390G/IVS10–11g>a and L48S/L48S, respectively) were treated with BH4 only (15–20 mg/kg body weight/day), one from birth, the other from 2 years of age. Blood Phe decreased from >800 μmol/L to a mean of 321.4 and 331.7 μmol/L, respectively (range: 141–718 μmol/L) under a normal diet (total observation time: 4 years). Development was normal with no adverse reactions.

Conclusions. BH4 supplementation seems to be a promising alternative treatment in some patients with mild PKU. Because blood Phe levels in maternal PKU should be maintained at 120 to 360 μmol/L, clinical relevance may be even greater than for treatment of children with PKU/HPA. BH4 supplementation may also be combined with a Phe-restricted diet, allowing higher Phe intake and protecting mothers from high Phe blood peaks. However, additional studies are necessary to prove the safety and economy of such an alternative treatment in patients with PKU/HPA, especially during pregnancy.
Measuring the Quality of Children’s Health Care: A Prerequisite to Action
Authors: Dougherty Denise , Simpson Lisa A.
Published: December 2021

Objective. To assess the availability and use of quality measures for children’s health care, highlight promising developments, and develop recommendations for future action steps by the child health quality measurement and improvement fields, pediatrics, and the national quality of care enterprise generally.

Study Design. Two-day invitational expert meeting, informed by 3 commissioned articles.

Results. Quality of care for children is far less than optimal. A number of measures are available for measuring children’s health care quality on a regular basis, although measures are scarce at least in many areas (eg, pediatric patient safety, end-of-life-care, mental health care, oral health care, neonatal care, care for school-aged children, and coordination of care). Many of the available measures are not being applied regularly to measure the quality of children’s health care; barriers to implementation include lack of an information infrastructure that is child- and quality-friendly and lack of public support for improving children’s health care quality. To improve the availability and use of quality measures for accountability and improvement, meeting participants recommended that at least 4 activities be national priorities: 1) build public support for quality measurement and improvement in children’s health care; 2) create the information technology infrastructure that can facilitate collection and use of data; 3) improve the reliability, validity, and feasibility of existing measures; and 4) create the evidence base for measures development and quality improvement.

Conclusions. Although substantial progress has been made in the development of quality measures and the implementation of quality-improvement strategies for children’s health care, interest in quality of care for children lags behind that for adult conditions and disorders. Making significant progress will require not only sustained attention by those concerned about improving children’s health and health care but also activities to build a broad base of support among the public and key health care decision-makers.