Indiana University-Purdue University Indianapolis (IUPUI) / Objective: Nutritional assessment and diagnosis of malnutrition in pediatric patients is dependent on anthropometric measurements. In macrocephalic children, current anthropometric measures may fail to correctly diagnose malnutrition. The purpose of this study is to determine if the measurement of mid-upper arm circumference (MUAC) in pediatric patients with macrocephaly better identifies children at nutritional risk as compared to weight-for-length (WFL) or body mass index (BMI). Methods: A cross-sectional pilot study of children aged 6-36 months with a head circumference 2 SD above the mean was performed. Visual assessment was used as the clinical “gold standard” for presence of malnutrition. MUAC was compared to the WFL or BMI for each child to determine which anthropometric measurement better identified presence of malnutrition. Statistics: Two-way contingency tables were used to summarize the relationships between each pair of assessments of whether a child is malnourished. Agreement between the methods was evaluated using kappa statistics and percent agreement. Analyses were performed using SAS version 9.4 ™ statistical software. Results: Twenty patients were included who met study criteria. The mean head circumference z-score was 2.6. The mean BMI/WFL z-score was 0.9, which would qualify the child as “nourished.” Of the 20 children included in the study, 20% (n=4) appeared visually malnourished on physical exam. BMI/WFL confirmed diagnosis of malnutrition in 75% (n=3) of children. MUAC confirmed diagnosis of malnutrition in 75% (n=3) of children. Diagnosis of malnutrition using BMI/WFL as compared to visual assessment had a non-significant p-value of 0.317. Diagnosis of malnutrition using MUAC as compared to visual assessment had a non-significant p-value of 0.317. With a p-value of >0.5, there is no statistically significant difference between BMI/WFL and MUAC in diagnosis of malnutrition. Conclusion: MUAC did not perform better than BMI/WFL at identifying malnutrition in pediatric macrocephalic patients.

Orientador: Wilson Nadruz Júnior / Tese (doutorado) - Universidade Estadual de Campinas, Faculdade de Ciências Médicas / Made available in DSpace on 2018-08-21T18:22:05Z (GMT). No. of bitstreams: 1 Magalhaes_JoseAlexandrePio_D.pdf: 2033621 bytes, checksum: 4f4a904e259bcb7c5ef05e924b40b3f2 (MD5) Previous issue date: 2012 / Resumo: A aferição da circunferência do braço é uma medida necessária para a seleção de manguitos apropriados e é recomendada para que se faça uma aferição correta da pressão arterial. O objetivo deste estudo foi identificar e quantificar as relações entre a circunferência do braço e medidas antropométricas usuais de distribuição de gordura corporal e a estrutura cardíaca em indivíduos hipertensos. Nós avaliamos 339 pacientes (202 mulheres e 137 homens) por história médica, exame físico, antropometria, parâmetros metabólicos e inflamatórios e ecocardiografia. Resultados de análise de correlação parcial ajustada por idade e índice de massa corpórea revelaram que variáveis antropométricas se associaram significativamente com parâmetros ecocardiográficos apenas em mulheres. Neste sentido, a circunferência do braço se correlacionou com a espessura do septo interventricular e da parede posterior do ventrículo esquerdo e com a espessura relativa do ventrículo esquerdo ?0,45, enquanto que a circunferência abdominal se correlacionou com o diâmetro do ventrículo esquerdo. Análise multivariada incluindo idade, índice de massa corpórea, pressão arterial sistólica, homeostasis model assessment index, e uso de medicações anti-hipertensivas demonstraram que a circunferência do braço foi um preditor independente de espessura da parede ventricular esquerda e de hipertrofia concêntrica em mulheres. Análise multivariada adicional revelou que a circunferência abdominal foi um preditor independente do diâmetro diastólico final do ventrículo esquerdo e do átrio esquerdo. Em geral, estes achados sugerem que a circunferência do braço possa servir não só como um procedimento para permitir uma medida adequada da pressão arterial, mas também como um preditor de remodelamento cardíaco desfavorável em mulheres hipertensas / Abstract: Upper arm circumference measurement is necessary for the proper sizing of cuffs and is recommended for accurate blood pressure assessment. The aim of this report is to identify and quantify the relationships between upper arm circumference and the usual anthropometric measurements of body fat distribution and cardiac structure in hypertensive subjects. We evaluated 339 patients (202 women and 137 men) by medical history, physical examination, anthropometry, metabolic and inflammatory parameters, and echocardiography. Partial correlation analyses adjusted for age and body mass index revealed that anthropometric variables were significantly associated with echocardiographic parameters exclusively in women. In this regard, upper arm circumference correlated with interventricular septum thickness, posterior wall thickness, and relative wall thickness >or=0.45, while waist circumference was related to left cardiac chamber diameter. Multivariate analyses including age, body mass index, systolic blood pressure, homeostasis model assessment index, and use of antihypertensive medications demonstrated that upper arm circumference was an independent predictor of left ventricular wall thickness and concentric hypertrophy in women. Further linear regression analyses revealed that waist circumference was an independent predictor of left ventricular end-diastolic and left atrial diameters in this gender. Overall, these findings suggest that upper arm circumference determination might serve not only as a routine approach preceding blood pressure evaluation but also as a simple and feasible predictor of adverse left ventricular remodeling in hypertensive women / Doutorado / Clinica Medica / Doutor em Clínica Médica

Death from hunger and starvation can be avoided with appropriate diagnosis and treatment if the necessary knowledge and resources are available. The current definitions of acute malnutrition are based either upon a weight-for-height Z-score (WHZ) below -2 standard deviations of the international reference population (World Health Organization 2006 Growth Standards) or a mid-upper arm circumference (MUAC) lower than 125 mm. These indicators are used independently to define the sum of moderate and severe acute malnutrition, commonly referred to as global acute malnutrition (GAM). Severe acute malnutrition (SAM) is defined as the children with WHZ < -3 SD or MUAC <115 mm. These cut-off points are used both to estimate the prevalence of malnutrition and also to identify those children who should be admitted for individual treatment of their acute malnutrition.However, the ramifications of the new WHO standards and the introduction of the absolute MUAC as an additional criterion have not been sufficiently explored. There appears to have been little detailed analysis of the variation of MUAC in children using these new standards. Thus, there is insufficient information available for predicting changes in patient load due to the addition of an absolute MUAC cut-off, the degree of overlap between the criteria and the factors that affect the selection of malnourished children using the two criteria, WHZ and MUACNevertheless, because of the ease of use of MUAC and strong advocacy based mainly the relative sensitivity and specificity of WHZ and MUAC in predicting long-term all-cause mortality in the community, many organizations and some governments are now moving from using MUAC to screen children in the community and elsewhere to MUAC-only programs with abandonment of using WHZ altogether.A better understanding of the relationship between these measures is important as differences can have significant implications on the decision to intervene in a nutritional crises, assessment of potential program size, resource requirements and outcome, selection of children admitted for treatment and the strategy which will have the greatest influence upon mortality and the other poor outcomes of being malnourished. To this end my thesis included the following studies which explored the variation of MUAC and WHZ in children for the assessment of malnutrition.In my first study, I examined the direction and degree of discrepancy between MUAC and WHZ of children aged 6-59 months in 1,832 anthropometric surveys from 47 countries, mainly in Africa. The results show that using MUAC or WHZ, 16.3% of children were identified with GAM and 3.5% with SAM. The proportion of overlap between the two indicators was 28.2% for GAM (15-38.5%) and 16.5 % for SAM (6.1-29.8%). Overlap for individual countries was especially low for SAM. The numbers of children diagnosed by either criterion varied dramatically by country: the difference between the relative case-load using WHZ and MUAC for GAM varied from minus 57% to plus 72%. For SAM, in four of the 38 countries, less than 25% of severely malnourished children would be identified and admitted for treatment if a MUAC-only admission policy were being used. For all countries examined, the discrepancies were not adequately explained by any single hypothesis. My second study was in three parts. Each part examined the veracity of the assertion that MUAC is a better indicator of mortality than WHZ. 1) I analysed individual data from 76,887 children admitted to a range of treatment programmes to determine the mortality rates associated with SAM. 2) I conducted an exhaustive search of the literature to identify reports of children diagnosed by WHZ or MUAC with their respective mortality rates.3) I analysed the effect of case load using the prevalence data published in the first study with Case Fatality Rates (CFRs) derived from the empirical data, the literature data and theoretical simulations. We found that mathematical coupling caused a reversal of significance generating Simpson’s paradox so that the interpretation of the relative mortality rates of WHZ and MUAC is unsafe when children with both criteria are included in each group being compared. The analysis suggests that children with SAM identified by WHZ <-3 and admitted for treatment are at as least as high a risk of death as children in treatment with MUAC<115cm and probably at higher risk. Review of 21 datasets that compared WHZ and MUAC mortality rates show problems with interpretation of the reported CFRs in each of the studies; inconsistencies greatly limit analysis, comparability and interpretation. Caseload is a more important determinant of the number of SAM related child deaths than the relative CFR to give the number of SAM attributable deaths. Where most of the children are identified as SAM using WHZ, rather than MUAC, it is estimated that fewer than half of all SAM related deaths will be identified using a MUAC-only programme.In my third study, I have conducted a Monte Carlo simulation of anthropometric surveys and imposed random errors of measurement on the data in order to examine the effect of measurement error. The results show that there is an increase in the standard deviation with each of the errors, that the spread becomes exponentially greater with the magnitude of the sort of error that occur in real life situations and that the effect of an increase in standard deviation (SD) that appears to be fairly trivial has a major effect upon the reported prevalence of the condition. I show that even within quite a narrow range of SDs (from 0.8 to 1.2) the proportion of children <-2 WHZ can increase from 6% to 15% - which would move the population from one of “acceptable” prevalence to an acute emergency situation. The corresponding SAM would increase from about 1% to nearly 5%. If one was to use such a survey to estimate the current case-load of SAM children the difference would be five-fold. However, this range of SDs is generally thought to represent a “good survey”. When larger and more complex surveys are considered, for example those included in the WHO database or the DHS surveys, the SD is frequently greater than 1.2 leading to give a higher reported prevalence of malnutrition than may be the actual prevalence. In my fourth study, I performed a secondary analysis of the surveys collected in my first study in order to examine the change in reliability of such surveys over time. I analysed the statistical distributions of the derived anthropometric parameters from 1,843 surveys conducted by 19 agencies between 1986 and 2015. The results show that with the introduction of standardised guidelines and software by 2003 and their more general application from 2007 the mean standard deviation, kurtosis and skewness of the parameters used to assess nutritional status have each moved to now approximate the distribution of the WHO standards when the exclusion of outliers from analysis is based upon the SMART flagging procedure. Where WHO flags, that only exclude data incompatible with life, are used the quality of anthropometric surveys has improved and the results now approach those seen with SMART flags and the WHO standards distribution. Agencies vary in their uptake and adherence to standard guidelines. Those agencies that fully implement the guidelines achieve the most consistently reliable results.In conclusion, well-defined and internationally accepted criteria to assess anthropometric survey quality should be universally applied and reported if the surveys are to be reliable, credible and form the basis for appropriate intervention. Using WHZ-only or MUAC-only estimates of prevalence will underestimate the burden of acute malnutrition. Such a program policy would result in between 300,000 and 600,000 SAM deaths occurring in children each year who have no possibility of being treated. WHZ and MUAC are complementary indicators, it is only by using both criteria to identify SAM and admit children for treatment that we will move towards reducing avoidable SAM- related mortality in most countries. This will only be realised when we can conveniently identify children with a low WHZ in community screening programs. / Doctorat en Sciences de la santé Publique / info:eu-repo/semantics/nonPublished

Introdução: O nascimento de recém-nascidos pré-termo tardios (RNPT-T), geralmente tratados como \"quase termo\", vem aumentando nas últimas décadas. Vários fatores são atríbuídos à sua etiologia e contribuem para aumentar as taxas de morbimortalidade perinatal e infantil. Atualmente se dispõe de poucos estudos sobre esses recém-nascidos, especialmente sobre o seu crescimento. Objetivos: Analisar o crescimento de RNPT-T nos seis primeiros meses de idade corrigida. Métodos: Estudo observacional, analítico de uma coorte de 64 RNPT-T, coletados nos quatro maiores hospitais de Cuiabá, entre janeiro e setembro de 2013 e acompanhados até 6 meses de idade corrigida. Os dados foram coletados ao nascer, às 40 semanas, 3 e 6 meses de idade corrigida. Foram realizadas análises de correlação entre os parâmetros antropométricos perímetro braquial (PB) e prega cutânea tricipital (PCT) em função dos índices antropométricos PB/PC (perímetro cefálico), peso/comprimento (P/C) e Índice de Massa Corpórea (IMC) e realizada regressão linear múltipla. Resultados: Ao nascimento, 81,3% foram classificados como adequados para a idade gestacional, com a média de peso de 2343,80g ± 430,50. Todos os recém-nascidos apresentaram crescimento contínuo nos seis meses de idade corrigida para os valores de peso, comprimento e perímetro cefálico (PC). Já os valores médios de PCT, de PB/PC e de IMC não mostraram diferença aos 6 meses de idade corrigida. Todos os coeficientes de correlação (r) dos parâmetros PCT e PB em relação aos índices antropométricos apresentaram significância estatística, sendo os valores mais altos para PB versus PB/PC e P/C e menores para PB versus IMC. No modelo final da regressão linear múltipla da PCT, o PB/PC contribuiu significantemente para predizer o depósito de gordura ao nascimento, às 40 semanas e aos 3 meses de idade corrigida (33,8%%, 46,07% e 18,08% respectivamente); aos 6 meses o melhor preditor foi a razão P/C (10,45%). O melhor preditor para o PB foi o PB/PC, que permaneceu no modelo com valores de 73,71%% em todos os tempos avaliados. Conclusão: Os parâmetros peso, comprimento, perímetro cefálico e perímetro braquial e a relação P/C aumentaram nos quatro tempos de aferição, enquanto o PCT e as relações PB/PC e IMC não se modificaram do primeiro para o segundo trimestre e o PB/PC foi o melhor preditor do depósito de gordura subcutânea tricipital (PCT) e de massa gorda e muscular (PB) / Introduction: The birth of newborns late preterm (RNPT -T), usually treated as \"near term\", has been increasing in recent decades. Several factors are attributed to its etiology and contribute to increased rates of perinatal and infant morbidity and mortality. Currently there are few studies of these newborns, especially about their growth. Objectives: To analyze the growth pattern of late preterm infants from birth to six months of corrected age. Methods: This cohort study included 64 RNPT-T, in four major hospitals in Cuiabá, between January and September 2013 and followed until 6 months corrected age. Data were collected at birth, at 40 weeks, 3 and 6 months corrected age. Correlation analyzes between anthropometric parameters mid- arm circumference (MAC) and triceps skinfold (TS) on the basis of anthropometric indices MAC / HC (head circumference), weight / length (W / L) and body mass index (BMI) were performed multiple linear regression. Results: At birth, 81.3 % were classified as appropriate for gestational age, with the average weight of 2343.80 ± 430.50 g. All newborns had a continuous growth in the six months corrected age for the values of weight, length and head circumference (HC). The average value of TS values of MAC / HC and BMI showed no difference at 6 months of corrected age. All correlation coefficients (r) of the TS and MAC parameters in relation to anthropometric indices showed statistically significant, with the highest values for MAC versus MAC / HC and W / L and lower for MAC versus BMI. At the end of the TS model of multiple linear regression, the MAC / HC contributed significantly to predict the deposition of fat at birth, at 40 weeks and at 3 months\' corrected age (33.8 %, 46.07 % and 18.08 % respectively); at 6 months was the best predictor of the ratio W/ L (10.45%). The best predictor for the MAC was the MAC / HC, which remained in the model with values of 73.71 % at all evaluated times. Conclusion: The parameters weight, length, head circumference and arm - circumference and the ratio W / L increased in the four times of measurement, while the TS and MUAC / HC relations and BMI did not change from the first to the second quarter and MAC / HC was the best predictor of subcutaneous fat deposit triceps (TS) and fat and muscle (MAC) mass

Introdução: O nascimento de recém-nascidos pré-termo tardios (RNPT-T), geralmente tratados como \"quase termo\", vem aumentando nas últimas décadas. Vários fatores são atríbuídos à sua etiologia e contribuem para aumentar as taxas de morbimortalidade perinatal e infantil. Atualmente se dispõe de poucos estudos sobre esses recém-nascidos, especialmente sobre o seu crescimento. Objetivos: Analisar o crescimento de RNPT-T nos seis primeiros meses de idade corrigida. Métodos: Estudo observacional, analítico de uma coorte de 64 RNPT-T, coletados nos quatro maiores hospitais de Cuiabá, entre janeiro e setembro de 2013 e acompanhados até 6 meses de idade corrigida. Os dados foram coletados ao nascer, às 40 semanas, 3 e 6 meses de idade corrigida. Foram realizadas análises de correlação entre os parâmetros antropométricos perímetro braquial (PB) e prega cutânea tricipital (PCT) em função dos índices antropométricos PB/PC (perímetro cefálico), peso/comprimento (P/C) e Índice de Massa Corpórea (IMC) e realizada regressão linear múltipla. Resultados: Ao nascimento, 81,3% foram classificados como adequados para a idade gestacional, com a média de peso de 2343,80g ± 430,50. Todos os recém-nascidos apresentaram crescimento contínuo nos seis meses de idade corrigida para os valores de peso, comprimento e perímetro cefálico (PC). Já os valores médios de PCT, de PB/PC e de IMC não mostraram diferença aos 6 meses de idade corrigida. Todos os coeficientes de correlação (r) dos parâmetros PCT e PB em relação aos índices antropométricos apresentaram significância estatística, sendo os valores mais altos para PB versus PB/PC e P/C e menores para PB versus IMC. No modelo final da regressão linear múltipla da PCT, o PB/PC contribuiu significantemente para predizer o depósito de gordura ao nascimento, às 40 semanas e aos 3 meses de idade corrigida (33,8%%, 46,07% e 18,08% respectivamente); aos 6 meses o melhor preditor foi a razão P/C (10,45%). O melhor preditor para o PB foi o PB/PC, que permaneceu no modelo com valores de 73,71%% em todos os tempos avaliados. Conclusão: Os parâmetros peso, comprimento, perímetro cefálico e perímetro braquial e a relação P/C aumentaram nos quatro tempos de aferição, enquanto o PCT e as relações PB/PC e IMC não se modificaram do primeiro para o segundo trimestre e o PB/PC foi o melhor preditor do depósito de gordura subcutânea tricipital (PCT) e de massa gorda e muscular (PB) / Introduction: The birth of newborns late preterm (RNPT -T), usually treated as \"near term\", has been increasing in recent decades. Several factors are attributed to its etiology and contribute to increased rates of perinatal and infant morbidity and mortality. Currently there are few studies of these newborns, especially about their growth. Objectives: To analyze the growth pattern of late preterm infants from birth to six months of corrected age. Methods: This cohort study included 64 RNPT-T, in four major hospitals in Cuiabá, between January and September 2013 and followed until 6 months corrected age. Data were collected at birth, at 40 weeks, 3 and 6 months corrected age. Correlation analyzes between anthropometric parameters mid- arm circumference (MAC) and triceps skinfold (TS) on the basis of anthropometric indices MAC / HC (head circumference), weight / length (W / L) and body mass index (BMI) were performed multiple linear regression. Results: At birth, 81.3 % were classified as appropriate for gestational age, with the average weight of 2343.80 ± 430.50 g. All newborns had a continuous growth in the six months corrected age for the values of weight, length and head circumference (HC). The average value of TS values of MAC / HC and BMI showed no difference at 6 months of corrected age. All correlation coefficients (r) of the TS and MAC parameters in relation to anthropometric indices showed statistically significant, with the highest values for MAC versus MAC / HC and W / L and lower for MAC versus BMI. At the end of the TS model of multiple linear regression, the MAC / HC contributed significantly to predict the deposition of fat at birth, at 40 weeks and at 3 months\' corrected age (33.8 %, 46.07 % and 18.08 % respectively); at 6 months was the best predictor of the ratio W/ L (10.45%). The best predictor for the MAC was the MAC / HC, which remained in the model with values of 73.71 % at all evaluated times. Conclusion: The parameters weight, length, head circumference and arm - circumference and the ratio W / L increased in the four times of measurement, while the TS and MUAC / HC relations and BMI did not change from the first to the second quarter and MAC / HC was the best predictor of subcutaneous fat deposit triceps (TS) and fat and muscle (MAC) mass