K. A. Cass

172 BRAIN NATRIURETIC PEPTIDE: A SENSITIVE MONITOR IN PATIENTS WITH HYPOPLASTIC LEFT HEART SYNDROME.

Introduction Amplified cardiac B-natriuretic peptide (BNP) expression results from ventricular volume or pressure overload. The literature reports limited experience with serial BNP levels in pediatric patients. We report a small series of patients with hypoplastic left heart syndrome (HLH) undergoing serial outpatient BNP monitoring. Objective To identify the clinical usefulness of rapid, serial BNP-level monitoring in patients with complex congenital heart disease. Methods Rapidly available fingerstick BNP levels were obtained in our in-office certified outpatient clinical laboratory. Results take less than 20 minutes. We analyzed 36 BNP values obtained in 12 patients with HLH. Results Age ranged from 2 months to 8 years. Patients were status post stage I, II, or III HLH Norwood palliation, and all were on combination medical therapy, including angiotensin-converting enzyme inhibitors, digoxin, diuretics, and aspirin or Coumadin. Serial BNP levels were normal (20 ± 6 pg/dL) in 8 patients > 4 weeks after cardiac surgery. BNP levels were elevated (range 103-839 pg/dL) during serial evaluation in four patients, two with systemic pressure overload (one with systemic hypertension and one with residual coarctation) and two with volume overload (atrioventricular valve regurgitation [AVR]). Elevated BNP values decreased with adjustments to medical therapy in the patients with hypertension and AVR and by interventional cardiac catheterization in the patient with residual coarctation. Conclusions BNP levels were normal in hemodynamically stable HLH patients. Abnormal BNP levels were a guide to clinical management. Prolonged pathologic loading conditions, especially in those patients with single right ventricles, may lead to ventricular dysfunction, congestive heart failure, and death. Predicting the potential for ventricular dysfunction is preferable to detecting its presence. Validation of the clinical usefulness of rapid, serial BNP level monitoring in patients with complex congenital heart disease warrants further study.

IMPROVEMENT IN EXERCISE CAPACITY IN OVERWEIGHT CHILDREN TREATED IN A LIFESTYLE MODIFICATION PROGRAM.: 299

Background Physical inactivity and decreased exercise capacity have been associated with long-term poor prognosis in terms of morbidity and mortality in overweight children. Objectives To assess changes in exercise capacity in overweight children attending a 12-week lifestyle modification program. Methods This study includes data from 121 children with body mass index (BMI) ≥ 95th percentile who complete a 12-week lifestyle modification program. The program consists of nutrition counseling and medically supervised exercise. BMIs were assessed using the 2000 CDC growth charts. Exercise capacity was estimated by the amount of exercise load (Rockport walking test) and the energy cost of exercise (metabolic equivalents [METs]). All measurements were taken at entry and at the end of the program. Each individual served as his or her own control. Results The group was composed of 50 girls and 73 boys, mean age 11.2 years (range 6-17 years) and ethnic distribution of Hispanic, 43%; Caucasian, 33%; African American, 7%; and other races, 13%. By the end of the program there was significant increase in the Rockport test (19.5 ± 11.9 vs 29.2 ± 9.3, p Conclusions This group of children was successful in achieving a significant improvement in their exercise capacity and BMI Z-score, after participation in a 12-week lifestyle modification program.

157 FAMILIAL HISTORY OF HYPERCHOLESTEROLEMIA AND ALTERED LIPID PANEL IN OVERWEIGHT CHILDREN AND ADOLESCENTS.

Background Serum lipid levels follow familial patterns. Obesity is associated with unfavorable lipid profile and increased cardiovascular risk. Our aim was to assess the relationship of familial history of hypercholesterolemia with the lipid profile in a group of overweight children and adolescents. Methods This study included 104 children and adolescents, with body mass index (BMI) ≥ 95th percentile, whose parents answered a questionnaire to address the familial history of hypercholesterolemia in first- and second-degree relatives. As part of the program, all participants received nutrition counseling and performed exercise under medical supervision over 12 weeks. Fasting blood samples were drawn at the first visit and at the end of the program. T-test was used for statistical analysis. Results There were 50 females and 54 males, mean age: 11.3 years (range 7-17 years), mean BMI Z-score: 2.36 ± 0.32, Hispanic: 52%, Caucasian: 30%, African American: 16%, and other races: 2%. At entry there were 44 patients who have one or more relatives with a positive familial history (Group A) and 60 with a negative history (Group B). Comparison in the lipid panel between groups is shown in the table. Conclusions At entry, the group with a positive familial history showed significantly higher serum levels in the lipid panel than those with a negative history. At the 12th week, initial differences in lipid panel still remained; this could mean that those individuals with a positive familial history require adding to nutrition counseling and medically supervised exercise, another type of intervention to lower their abnormal serum lipid levels.

462 USE OF QUANTITATIVE INSULIN SENSITIVITY CHECK INDEX (QUICKI) IN THE SCREENING OF HYPERINSULINEMIA IN OVERWEIGHT CHILDREN AND ADOLESCENTS.

Background Obesity in children and adolescents is a risk factor for development of type 2 diabetes later in life. Early detection of hyperinsulinemia with a simple but reliable clinical test is highly desirable. Objective To evaluate the Quantitative Insulin Sensitivity Check Index (QUICKI) as a screening tool for hyperinsulinemia in a group of non-diabetic overweight children and adolescents in a clinical setting. Methods This study included 598 children and adolescents with a body mass index (BMI) ≥ 95% percentile, referred to our risk factor reduction program for nutrition and healthy habits counseling. Fasting blood samples, for determination of glucose and insulin levels, were obtained early in the morning, during the first visit to the program. QUICKI was calculate as follows: 1/(log [insulin mIU/L] + log [glucose mg/dL]). The receiver operating characteristic (ROC) curve was constructed using the upper value of the normal range for clinical laboratory values of insulin (17 mIU/L). T test and binary nominal correlation was used for statistical analysis. Results There were 358 boys and 240 girls, mean age: 10.7 years (range: 2-18), mean BMI Z-score: 2.52 ± 0.58, ethnic distribution: Hispanic: 50%, Caucasian: 33%, African American: 11% and other races: 6%. Area under ROC curve was 99% (95% confident interval: 0.987-0.999). The best cutoff value of QUICKI for diagnosis of hyperinsulinemia was 0.317, sensitivity: 97.7%, specificity: 93.0%, positive likelihood ratio: 14.04. Those patients with a QUICKI ≤ 0.317 had statistically significant higher mean fasting insulin serum values than those with a QUICKI > 0.317 (31.8 ± 15.9 vs 10.8 ± 4.4 mIU/L, p < .001). Clinical diagnosis of hyperinsulinemia was highly correlated with hyperinsulinemia diagnosed by QUICKI (Phi coefficient correlation: 0.27, p < .0001). Conclusions In this group of overweight children and adolescents QUICKI showed a high correlation with the clinical diagnosis of hyperinsulinemia. At a cutoff value of ≤ 0.317 in this group of subjects the index had high predictive diagnostic values.

328 CHANGES IN SERUM LIPID VALUES IN OVERWEIGHT CHILDREN AND ADOLESCENTS TREATED FOR 12 WEEKS UNDER MEDICAL SUPERVISION.

Background Obesity has been related with abnormal serum lipid values and increased risk for cardiovascular disease. Objective To assess the changes in the serum lipid values in a group of overweight children and adolescents treated under medical supervision for 12 weeks. Methods This study included 270 children and adolescents with a body mass index (BMI) ≥ 95th percentile, treated in our risk factor reduction program over a period of 12 weeks. As part of the program all participants received nutrition and healthy style habits counseling and performed physical activity under medical supervision. Fasting blood samples were obtained at entry to the program and 12 weeks later. Paired t-test was used for statistical analysis. Results There were 127 girls and 143 boys, mean age: 11.3 years (range: 7-18), mean BMI Z-score: 2.34 ± 0.32, ethnic distribution: Hispanic: 50%, Caucasian: 30%, African American: 13%, other races: 7%. Comparisons of mean values of lipid panel are shown in the table below. Conclusion This group of overweight children and adolescents who participated in a 12-week intervention program designed to promote healthy nutritional and activity lifestyle achieved significant improvement in serum lipid values.

405 PLASMA LEVELS OF C-REACTIVE PROTEIN IN OVERWEIGHT CHILDREN AND ADOLESCENTS WITH CARDIAC-RELATED FAMILIAL RISK FACTORS.

Background Obesity has been associated with elevated C-reactive protein and increased cardiovascular risk. Genetic predisposition to atherosclerosis constitutes important risk for developing coronary artery disease (CAD). Objectives To assess the relationship of some cardiac-related familial risk factors (FRF) with the plasma level of highly sensitive C-reactive protein (hs-CRP) in a group of overweight children and adolescents. Methods This study included 101 children and adolescents with body mass index (BMI) ≥ 95th percentile, whose parents answered a questionnaire to address the familial history of diabetes, hypercholesterolemia, hypertension, heart attack, and congenital and/or acquired cardiac diseases. All children participated in a 12-week medically supervised risk factor reduction program. Fasting blood samples were drawn for determination of hs-CRP during the first visit. Results There were 54 males and 47 females, mean age: 11.3 years (range: 5-17), mean BMI Z-score: 2.37 ± 0.32, Hispanic: 50%, Caucasian: 30%, African American: 17%, other races: 3%. There were 36 patients with 1 or none FRF and 65 with 2 or more FRF. Conclusion In this group of overweight children and adolescents the presence of 2 or more familial cardiac-related risk factor was significantly associated with elevated plasma levels of hs-CRP. Elevation of hs-CRP in obese children and adolescents may help identify those individuals at high risk to develop CAD later in life.

398 QUANTITATIVE CHANGES IN DIAGNOSTIC CRITERIA OF METABOLIC SYNDROME IN OVERWEIGHT CHILDREN AND ADOLESCENTS ENROLLED IN A 12-WEEK MEDICALLY SUPERVISED RISK FACTOR REDUCTION PROGRAM.

Background Metabolic syndrome (MS) occurs in 29% of obese children. MS in adults is a risk factor for diabetes and cardiovascular disease. Although long-term consequences MS in childhood are unknown, early intervention with programs aimed to modify lifestyle patterns may have a positive effect on different parameters used to diagnose MS. Objective To assess the effect of a 12-week medically supervised program of nutritional counseling and exercise on each diagnostic criterion of MS in a group of overweight children. Methods Data from the 265 children with BMI ≥ 95th percentile enrolled in the program was analyzed. MS criteria were defined following NHANES III guidelines. The change in the mean value at 12 weeks for each positive criterion of MS found at entry was analyzed using paired t-test. Results There were 124 girls and 141 boys, mean age: 11.4 years (range: 6-18 years), mean BMI Z-score: 2.34 ± 0.34, Hispanic: 48%, Caucasian: 32%, African American: 13%, and other races: 7%. Changes in mean values of each MS criterion are shown in the table below. Conclusion A 12-week intervention program aimed to modify nutritional and exercise patterns in this group of overweight children and adolescents was associated with significant improvement in the mean values of triglycerides, HDL cholesterol levels, and systolic blood pressure percentile, when these values were initially abnormal according to the definition of MS.

329 EFFECTS OF A 12-WEEK RISK FACTOR REDUCTION PROGRAM IN OVERWEIGHT CHILDREN AND ADOLESCENTS WITH METABOLIC SYNDROME.

Background Metabolic syndrome (MS) is a recognized risk factor for diabetes and cardiovascular disease in adults and occurs in up to 29% of US obese children and adolescents. Although the long-term consequences of the MS in childhood are unknown, early intervention to promote healthy changes in lifestyle may have a beneficial effect in the factors used a diagnostic criteria of MS. Objectives To assess the effect of a 12-week medically supervised program of nutritional counseling and exercise on each diagnostic criterion of MS in a group of overweight children with this diagnosis. Methods This study included 31 children and adolescents, with body mass index (BMI) ≥ 95th percentile, who met the diagnostic criteria for MS as defined by NANHES III. The difference in the mean value of each diagnostic criterion was analyzed using paired t-test. Results There were 12 females and 19 males with a mean age of 11.4 years (range: 8-15 years), and a mean BMI Z-score of 2.33 ± 0.33. The ethnic composition was Hispanic: 74%, Caucasian: 16% and other races: 10%. Comparison of mean values is shown in the table below. Conclusion A 12-week intervention program to encourage healthy nutritional and exercise patterns in this group of overweight children and adolescents with MS was associated with significant improvement in the mean values of triglycerides and HDL cholesterol levels.

170 USE OF BRAIN NATRIURETIC PEPTIDE IN THE DIAGNOSIS OF PATENT DUCTUS ARTERIOSUS IN PRETERM INFANTS.

Background Brain natriuretic peptide (BNP) is a cardiac hormone released mainly by the cardiac ventricles in response to ventricular volume and/or pressure overload. BNP has been reported as a useful test in the diagnosis of patent ductus arteriosus (PDA) in premature newborns. Objectives To evaluate the usefulness of determination of BNP serum levels in the diagnosis of PDA in a group of premature newborns. Methods This study included 29 premature newborns (mean gestational age (GA): 31.6 ± 2.1 weeks) with PDA. The presence of a PDA was established by echocardiography (echo). Serum for BNP levels was collected at the time of echo. Patients were followed with serial echo until closure of the ductus was documented. Another blood sample for BNP was obtained with the last echo. Patients with heart disease other than PDA were not part of the study. BNP levels were also measured in 19 premature newborns without PDA (control group with a mean GA 32.0 ± 1.8 weeks and mean postnatal age of 2.7 ± 1.4 days). BNP levels were measured using a commercial kit (Triage® BNP Test Biosite Labs, San Diego CA). Results There were 13 males and 16 females. Patients with a PDA had significantly higher mean BNP levels (858.5 ± 945.6 vs 105.9 ± 135.4 pg/mL, p = .002) than the control group at age of PDA diagnosis (2.8 ± 1.5 days vs 2.7 ± 1.4 days). There was no correlation between BNP levels and PDA diameter, pressure gradient across the PDA, left atrium/aorta ratio. The area under the receiver operator characteristic (ROC) curve for detection of PDA was 84% (95% confidence interval: 72%-95%). BNP level cutoff for diagnosis of PDA at 2.8 ± 1.5 days was 155.5 pg/mL (sensitivity: 75.9%, specificity: 83.3%, positive likelihood ratio: 4.5). Conclusions The BNP test showed highly predictive diagnostic values. BNP levels were significantly higher in this group of premature infants with PDA.

372 ASSOCIATION OF TRIGLYCERIDE/HDL-CHOLESTEROL RATIO WITH INSULIN RESISTANCE INDICES IN OBESE CHILDREN

Background Previous studies in adults have shown that an elevated triglyceride/HDL-cholesterol ratio (Tg/HDL-c) may be related to coronary artery or cerebro-vascular events. It has shown that the Quicki and glucose/insulin ratio indices are bio-markers of insulin resistance (IR) in children. Objectives To assess the relationship between Tg/HDL-c ratio with Quicki and glucose/insulin ratio in non-diabetic obese children. Methods The study included 623 non-diabetic children with BMIs greater than the 95th percentile referred to our risk factor reduction program from February 2001 to April 2004. Fasting glucose, insulin levels and lipid profile were obtained. BMIs were assessed using 2000 CDC growth charts. Tg/HDL-c ratio and two indices of IR were calculated: glucose/insulin ratio and Quicki (1 / (log insulin + log glucose in mg/dl)). A glucose/insulin ration of ≤ 6 and a Quicki index ≤ 0.357 were considered as consistent with IR. Results There were 257 females and 366 males, with a mean age of 11.2 years (range: 4-18 years).Simple linear regression analysis showed a statistically significant relationship between Tg/HDL-c ratio with fasting glucose/insulin ratio (r = - 0.20 P value ≤ 0.005), and Quicki (r = - 0.22, P value ≤ 0.005). Furthermore, simple linear regression analysis showed a significant relationship between Tg/HDL-c ratio and fasting mean insulin (r = 0.17, P value ≤ 0.05). For patients classified as IR the mean Tg/HDL-c ratio (3.46 units, SD: 2.1) was significantly higher (2.44 units, SD: 2.9) than the mean Tg/HDL-c ratio of those classified as normal (P value ≤ 0.005). For patients with Tg/HDL-c ≥ 3.0 units mean fasting insulin level (164.6 pmol/L, SD: 109.5) was significantly higher than the mean fasting insulin level (130.9 pmol/L, SD: 97.1) of those with Tg/HDL-c ≤ 3.0 units (P value ≤ 0.01). Conclusions In a group of children whose BMI were greater than the 95th percentile; there was a significant relationship between an elevated Tg/HDL-c ratio and indices of insulin resistance. Tg/HDL-c ratio ≥ 3 units could identify children with BMIs greater than the 95th percentile who also have insulin resistance.