Updated and revised Diabetes Family Conflict Scale

OBJECTIVE

The purpose of this study was to update the Diabetes Family Conflict Scale (DFCS) in the era of intensive diabetes management and provide an indication of its psychometric properties.

RESEARCH DESIGN AND METHODS

The revised DFCS and measures of negative emotions around blood glucose monitoring (BGM), quality of life, and perceived parental burden from diabetes management were completed by 202 children and adolescents with type 1 diabetes and their primary caregivers. Insulin regimen, adherence, and glycemic control were also assessed.

RESULTS

The revised DFCS demonstrated strong psychometric properties. There was acceptable internal consistency for child and caregiver forms of the DFCS. Factor analysis revealed two factors related to direct and indirect management tasks. Both child (r = 0.27, P < 0.01) and caregiver (r = 0.26, P < 0.01) DFCS scores were correlated with A1C values. Multivariate analysis of factors usually associated with A1C values showed an additive, independent contribution of diabetes-specific family conflict to the prediction of glycemic control: F (12,189) = 6.17, P < 0.01, R2 = 0.28. Conflict around direct management tasks (e.g., BGM) was a more important predictor of higher A1C levels than conflict around indirect management tasks (e.g., telling friends about diabetes).

CONCLUSIONS

The revised and updated DFCS demonstrates strong psychometric properties and can be used as a tool for measuring the level of diabetes-specific conflict in families with children and adolescents with type 1 diabetes.

Can households earning minimum wage in Nova Scotia afford a nutritious diet?

OBJECTIVE

To assess the affordability of a nutritious diet for households earning minimum wage in Nova Scotia.

METHODS

Food costing data were collected in 43 randomly selected grocery stores throughout NS in 2002 using the National Nutritious Food Basket (NNFB). To estimate the affordability of a nutritious diet for households earning minimum wage, average monthly costs for essential expenses were subtracted from overall income to see if enough money remained for the cost of the NNFB. This was calculated for three types of household: 1) two parents and two children; 2) lone parent and two children; and 3) single male. Calculations were also made for the proposed 2006 minimum wage increase with expenses adjusted using the Consumer Price Index (CPI).

RESULTS

The monthly cost of the NNFB priced in 2002 for the three types of household was 572.90 dollars, 351.68 dollars, and 198.73 dollars, respectively. Put into the context of basic living, these data showed that Nova Scotians relying on minimum wage could not afford to purchase a nutritious diet and meet their basic needs, placing their health at risk. These basic expenses do not include other routine costs, such as personal hygiene products, household and laundry cleaners, and prescriptions and costs associated with physical activity, education or savings for unexpected expenses.

CONCLUSION

People working at minimum wage in Nova Scotia have not had adequate income to meet basic needs, including a nutritious diet. The 2006 increase in minimum wage to 7.15 dollars/hr is inadequate to ensure that Nova Scotians working at minimum wage are able to meet these basic needs. Wage increases and supplements, along with supports for expenses such as childcare and transportation, are indicated to address this public health problem.

Temporal trends in the treatment of pediatric type 1 diabetes and impact on acute outcomes

OBJECTIVE

To evaluate temporal trends in pediatric type 1 diabetes (T1DM) management and resultant effects on outcomes.

STUDY DESIGN

Two pediatric T1DM cohorts were followed prospectively for 2 years and compared; Cohort 1 (N = 299) was enrolled in 1997 and Cohort 2 (N = 152) was enrolled in 2002. In both cohorts, eligible participants were identified and sequentially approached at regularly scheduled clinic visits until the target number of participants was reached. Main outcome measures were hemoglobin A1c (A1c), body mass index Z score (Z-BMI), and incidence rate (IR; per 100 patient-years) of hypoglycemia, hospitalizations, and emergency room (ER) visits.

RESULTS

At baseline, Cohort 2 monitored blood glucose more frequently than Cohort 1 (> or = 4 times/day: 72% vs 39%, P < .001) and was prescribed more intensive therapy than Cohort 1 (> or = 3 injections/day or pump: 85% vs 65%, P < .001). A1c was lower in Cohort 2 than Cohort 1 at baseline (8.4% vs 8.7%, P = .03) and study's end (8.7% vs 9.0%, P = .04). The cohorts did not differ in Z-BMI (0.83 vs 0.79, P = .57) or IR of hospitalizations (11.2 vs 12.9, P = .38). Cohort 2 had lower IR of total severe hypoglycemic events (29.4 vs 55.4, P < .001) and ER visits (22.0 vs 29.3, P = .02).

CONCLUSIONS

T1DM management intensified during the 5 years between cohorts and was accompanied by improved A1c and stable Z-BMI. Along with improved control, IR of severe hypoglycemia and ER visits decreased by almost 50% and 25%, respectively.

Psychometric properties of questionnaires measuring associations between behavioral factors and diabetes care for youth with type 2 diabetes

BACKGROUND

Because of the recency of the large numbers of youth diagnosed with type 2 diabetes (T2D), measures of adherence behavior and family response to diabetes have not been developed or tested.

OBJECTIVE

The objective of this study is to identify whether questionnaires on personal and family behaviors regarding the care of diabetes previously used with youth with type 1 diabetes (T1D) are reliable and related to metabolic control among youth with T2D.

DESIGN/METHODS

During a regularly scheduled visit, youth with T2D and a parent/guardian were invited to participate in the study. Youth and a parent completed questionnaires and one 24-h dietary recall at the visit. During the following 2 wk, each youth completed two telephone dietary recalls and physical activity questionnaires.

RESULTS

Child-reported scales measuring parental reminding, positive family behavior, self-care behaviors, and self-efficacy and maternal report of child self-care behaviors and maternal self-efficacy were found to have adequate internal consistency. Only parental reminding was related to metabolic control. Those youth reporting higher parental reminding were in poorer metabolic control.

CONCLUSIONS

These scales appear to be reliable with youth with T2D in south Texas.

Re-assessment of risk factors for sporadic Salmonella serotype Enteritidis infections: a case-control study in five FoodNet Sites, 2002-2003

Active surveillance for laboratory-confirmed Salmonella serotype Enteritidis (SE) infection revealed a decline in incidence in the 1990s, followed by an increase starting in 2000. We sought to determine if the fluctuation in SE incidence could be explained by changes in foodborne sources of infection. We conducted a population-based case-control study of sporadic SE infection in five of the Foodborne Diseases Active Surveillance Network (FoodNet) sites during a 12-month period in 2002-2003. A total of 218 cases and 742 controls were enrolled. Sixty-seven (31%) of the 218 case-patients and six (1%) of the 742 controls reported travel outside the United States during the 5 days before the case's illness onset (OR 53, 95% CI 23-125). Eighty-one percent of cases with SE phage type 4 travelled internationally. Among persons who did not travel internationally, eating chicken prepared outside the home and undercooked eggs inside the home were associated with SE infections. Contact with birds and reptiles was also associated with SE infections. This study supports the findings of previous case-control studies and identifies risk factors associated with specific phage types and molecular subtypes.

The role of socioeconomic status, depression, quality of life, and glycemic control in type 1 diabetes mellitus

OBJECTIVE

To test the hypothesis that poor glycemic control in type 1 diabetes mellitus (T1DM) is associated with depression and poor quality of life (QOL), with a higher prevalence in persons of lower socioeconomic status (SES).

STUDY DESIGN

Subjects with T1DM age 8 to 17 years (n = 222) were evaluated using the Childrens Depression Inventory, the Hollingshead Four-Factor Index to determine SES, and PedsQL questionnaires to ascertain QOL. HbAlC > 8% was considered indicative of poor glycemic control.

RESULTS

A total of 110 well-controlled subjects and 112 poorly controlled subjects (HbA1C 7.1% +/- 0.7% vs 9.9% +/- 1.6%) were recruited. It was found that 9.5% of poorly controlled subjects were depressed, compared with 3% of well-controlled subjects. Logistic regression revealed a 27% increase in probability of depression per unit rise in HbA1C (P < .03). Higher SES was associated with better glycemic control (P < .0005) and QOL (P < .0005); longer duration of illness was not associated with poorer glycemic control. Diabetes QOL deteriorated with poorer glycemic control (P < .002).

CONCLUSIONS

Poor glycemic control in peridatric T1DM is associated with lower SES and depression. The probability of depression increases as glycemic control worsens. Screening for depression should be routinely carried out in patients with T1DM, targeting patients with deteriorating glycemic control.

Recent pharmacological advances in paediatric analgesics

Growth and development are two linked processes that distinguish children from adults. The use of size as the primary covariate during pharmacokinetic (PK) analyses allows exploration of the effects of age. Allometric scaling models have assisted understanding of the developmental clearance changes in common analgesic drugs such as paracetamol, morphine, tramadol and local anaesthetics agents. Single nucleotide polymorphisms (pharmacogenomics [PG]) and their impact on hepatic drug metabolism for opioids, tramadol, non-steroidal anti-inflammatory drugs (NSAIDs) and drug receptor responses are increasingly reported. Altered chemical structure or formulations of common analgesics alter pharmacodynamic (PD) effects enhancing safety and efficacy for NSAIDs by stereoselectivity and the addition of nitric oxide, for intravenous paracetamol by formulation and structural difference from propacetamol and for local anaesthetics through stereoselectivity. This article focuses upon recent data for analgesics used in paediatric pain management including paracetamol, NSAIDs, morphine, tramadol, amide local anaesthetics and ketamine. It centres on PK and clinical studies in neonates, infants and children. PG studies are acknowledged as potentially allowing individual drug therapy tailoring through a decrease in between-patient population variability, although the impact of PG in the very young is less certain. There are few data describing age-related PD changes in children despite recognition that the number, affinity and type of receptors or the availability of natural ligands changes with age.

Fibreoptic intubation skills among anaesthetists in New Zealand

The aim of this study was to investigate methods of practice, assess skill level, and evaluate attitudes towards fibreoptic intubation in the anaesthetic community of New Zealand. A postal survey questionnaire was sent to all vocationally registered anaesthetists in New Zealand and to all New Zealand anaesthetic trainees registered with the Australian and New Zealand College of Anaesthetists. There were 611 survey questionnaires posted and 386 (63%) respondents. Almost all respondents (98% of specialists, 100% of trainees) had access to fibreoptic equipment in public and 92% of respondents performed fibreoptic intubation. The median number of fibreoptic intubations performed per year was 3 for consultants and 4 for trainees. Respondents were either self taught or colleague taught (82%). Most learnt the technique on patients (92%). There were 14% who considered themselves experienced, 30% competent, 34% adequate and 20% novice. Skills were maintained by clinical patient mix in 73%. Fibreoptic intubation was considered a skill required by all anaesthetists in 87%, and 66% considered it the gold standard for expected difficult airways. Lack of clinical cases requiring the skill and lack of practice were identified as the primary barriers to skill development. Consultants had greater opportunity to learn fibreoptic intubation skills during daily practice than trainees. Only 18% of trainees had a formal airway management program available to them at their place of work. There appears to be a need to increase available opportunities to perform fibreoptic intubation to enable maintenance and improvement of fibreoptic skills in our community. A formalized program of teaching fibreoptic intubation may offer greater opportunity for learning and skill development.

Use of a Blood Glucose Monitoring Manual to Enhance Monitoring Adherence in Adults With Diabetes

BACKGROUND

Frequent blood glucose (BG) monitoring is a critical component of diabetes management, yet many barriers exist to consistent monitoring.

METHODS

In this randomized controlled trial, we sought to determine if an educational manual, the Blood Sugar Monitoring Owner's Manual (BGMOM), could increase adherence to BG monitoring by helping patients form realistic expectations and responses to BG monitoring results. The 199 participants were recruited from a multidisciplinary diabetes clinic and had high-risk diabetes (hemoglobin A(1C) >or=8.0%); 35% had type 1 diabetes mellitus. Participants were randomized to 1 of 3 groups: BGMOM intervention (BGM+), attention control (BG meter only [MT]), or standard care (SC). The BGM+ and MT groups received BG meters and meter education; the BGM+ group also received BGMOM booklets. The SC group received usual care. Data gathered during 6 months of follow-up included BG monitoring frequency and hemoglobin A(1C) measurement.

RESULTS

Monitoring frequency increased significantly in the BGM+ group (1.9 +/- 1.3 to 2.8 +/- 1.5 times daily, P<.001) but only slightly in the MT group (1.7 +/- 1.3 to 2.0 +/- 1.3 times daily). The BGM+ group experienced the greatest improvement in hemoglobin A(1C) level (BGM+: -0.13 +/- 1.28; MT: -0.04 +/- 1.31; SC: 0.04 +/- 1.10). Further, a higher percentage of those in the BGM+ group (61%) improved their glycemic control compared with the other groups (44%; P = .05). Finally, the BGM+ group displayed the most knowledge about the definition of hemoglobin A(1C) (P = .04) and reported the least amount of negative affect about out-of-range BG monitoring results (P = .03).

CONCLUSION

As an adjunct to standard diabetes education and support, a manual such as the BGMOM can help optimize BG monitoring and glycemic control.

Scattering for mixtures of hard spheres: comparison of total scattering intensities with model

The angular dependence of the intensity of x-rays scattered from binary and ternary hard sphere mixtures is investigated and compared to the predictions of two scattering models. Mixture ratio and total volume fraction dependent effects are investigated for size ratios equal to 0.51 and 0.22. Comparisons of model predictions with experimental results indicate the significant impact of the role of particle size distributions in interpreting the angular dependence of the scattering at wave vectors probing density fluctuations intermediate between the sizes of the particles in the mixture.

Prophylactic valacyclovir to prevent outbreaks of primary herpes gladiatorum at a 28-day wrestling camp

Herpes gladiatorum (HG) plagues the sport of wrestling, especially in high school wrestlers and summer camps they attend. This study evaluated the usage of valacyclovir to prevent acquisition of primary HG, due to herpes simplex virus type 1 (HSV-1), in high school wrestlers at a 28-day wrestling camp. At the beginning and end of camp, IgM and IgG anti-HSV-1 antibodies were collected. Out of 332 male wrestlers, aged 13-20, who entered camp, 94 elected to participate in blood sampling. Sixty-four were on antiviral medication. Among the 94 wrestlers, 28 (29.8%) had positive IgG anti-HSV-1 titers. Of this group, 66 of 94, were HSV-1 IgG seronegative. At the end of camp, 55 of these original seronegative individuals elected to participate in blood sampling and none had detectable IgM anti-HSV-1 and -2 antibodies. Compared to previous years without antiviral usage, introducing prophylactic valacyclovir reduced clinical HG outbreaks by 87% at this 28-day wrestling camp. Due to the high prevalence of this virus in high school wrestlers, serological testing should be done at the beginning of each season. HSV-1 seropositive individuals should consider being on antiviral medication throughout the season to minimize the risk of transmitting the virus to other wrestlers.

Impact of ibuprofen administration on renal drug clearance in the first weeks of life

The administration of ibuprofen or any other nonselective cyclooxygenase (COX) inhibitor drug in early neonatal life is associated with a reduction of glomerular filtration, which reduces the elimination of drugs dependent on renal function for clearance. However, the relationship between COX inhibitor drug indication (prophylactic or therapeutic) and the magnitude of this effect remains unclear. Observations collected in two population pharmacokinetic studies, in preterm neonates, investigating amikacin and vancomycin were used to estimate: i) the impact of ibuprofen administration on the clearance of these drugs; and ii) the difference between prophylactic and therapeutic administration of ibuprofen on this clearance. Prophylactic administration of ibuprofen to preterm neonates on the first day of life to enhance closure of an asymptomatic patent ductus arteriosus (PDA) reduced amikacin clearance by 21% while coadministration of ibuprofen to induce closure of a symptomatic PDA resulted in an 18% reduction in vancomycin clearance in the first month of postnatal life. A significant and clinically relevant reduction in drug clearance is observed when ibuprofen is coadministered independent of indication, postmenstrual or postnatal age. Population modeling with covariate analyses can provide us with the tools to further disentangle the impact of nonselective COX-inhibitors on renal drug clearance.

Review of Staphylococcus aureus infections requiring admission to a paediatric intensive care unit

AIMS

To review clinical features and outcome of children with severe Staphylococcus aureus sepsis (SAS) presenting to a paediatric intensive care unit (PICU) with particular focus on ethnicity, clinical presentation, cardiac involvement, and outcome.

METHODS

Retrospective chart review of patients coded for SAS over 10 years (October 1993 to April 2004).

RESULTS

There were 58 patients identified with SAS over the 10 year study period; 55 were community acquired. This accounted for 4% of hospital admissions for SAS over this time; children with staphylococcal illness comprised 1% of all admissions to the PICU. Maori and Pacific children with SAS were overly represented in the PICU (81%) from a paediatric population where they contribute 21.6%. Musculoskeletal symptoms (79%) dominated presentation rather than isolated pneumonia (10%). An aggressive search for foci and surgical drainage of infective foci was required in 50% of children. Most children had multifocal disease (67%) and normal cardiac valves (95%); the few children (12%) presenting with methicillin resistant S aureus (MRSA) had community acquired infection. The median length of stay in the PICU was 3 (mean 5.8, SD 7.6, range 1-44) days. The median length of stay in hospital was 15 (mean 21, SD 22.7, range 2-149) days. Mortality due to SAS was 8.6% (95% CI 1.4-15.8%) compared with the overall mortality for the PICU of 6% (95% CI 5.3-6.7%). Ten children had significant morbidity after discharge.

CONCLUSIONS

Community acquired SAS affects healthy children, is multifocal, and has high morbidity and mortality, in keeping with the high severity of illness scores on admission. It is imperative to look for sites of dissemination and to drain and debride foci. Routine echocardiography had low yield in the absence of pre-existing cardiac lesions, persisting fever, or persisting bacteraemia.

Pharmacokinetics of levobupivacaine after caudal epidural administration in infants less than 3 months of age

BACKGROUND

There are few data describing levobupivacaine pharmacokinetics in infants (<3 months) after caudal administration.

METHODS

An open-label study was undertaken to examine the pharmacokinetics of levobupivacaine 2.5 mg ml(-1), 2 mg kg(-1) in children aged less than 3 months after single-shot caudal epidural administration. Plasma concentrations were determined at intervals from 0.5 to 4 h after injection. A population pharmacokinetic analysis of levobupivacaine time-concentration profiles (84 observations) from 22 infants with mean postnatal age (PNA) 2.0 (range 0.6-2.9) months was undertaken using non-linear mixed effects models (NONMEM). Time-concentration profiles were analysed using a one-compartment model with first-order input and first-order elimination. Estimates were standardized to a 70 kg adult using allometric size models.

RESULTS

Population parameter estimates (between-subject variability) for total levobupivacaine were clearance (CLt) 12.8 [coefficient of variation (CV) 50.6%] litre h(-1) 70 kg(-1), volume of distribution (Vt) 202 (CV 31.6%) litre 70 kg(-1), absorption half-life (Tabs) 0.323 (CV 18.6%) h 70 kg(-1). Estimates for the unbound drug were clearance (CLfree) 104 (CV 43.5%) litre h(-1) 70 kg(-1), volume of distribution (Vfree) 1700 (CV 44.9%) litre 70 kg(-1), absorption half-life (Tabsfree) 0.175 (CV 83.7%) h 70 kg(-1). There was no effect attributable to PNA on CL or V. Time to peak plasma concentration (Tmax) was 0.82 (CV 18%) h. Peak plasma concentration (Cmax) was 0.69 (CV 25%) microg ml(-1) for total levobupivacaine and 0.09 (CV 37%) microg ml(-1) for unbound levobupivacaine.

CONCLUSIONS

Clearance in infants is approximately half that described in adults, suggesting immaturity of P450 CYP3A4 and CYP1A2 enzyme isoforms that metabolize levobupivacaine in infants. This lower clearance delays Tmax, which was noted to occur approximately 50 min after administration of caudal epidural levobupivacaine.

Valacyclovir to expedite the clearance of recurrent herpes gladiatorum

OBJECTIVE

To determine if valacyclovir usage expedites the clearance of recurrent herpes gladiatorum (HG) in wrestlers.

DESIGN

Double-blind, placebo-controlled, prospective study using valacyclovir from September 2001 through March 2003.

PARTICIPANTS

Twenty-nine wrestlers were recruited from the Minneapolis-St. Paul, Minnesota area. They ranged in ages from 18 to 36, of whom 7 were coaches and 22 active wrestlers. All participants had greater than 2-year history of recurrent HG.

MAIN OUTCOME MEASURES

Upon an outbreak, all participants would swab the area on a daily basis for 14 days. Swabs were analyzed for herpes simplex virus 1/2 via PCR. End point was determined as the last sample with measurable PCR detected. Individuals were randomly selected, yet equally distributed, to be in 1 of 3 groups: placebo x 7 days, valacyclovir 500 mg BID x 7 days, or valacyclovir 1,000 mg QD x 7 days.

RESULTS

Twenty participants (3 coaches and 17 active wrestlers) experienced outbreaks. All participants were compliant and started medication within 24 hours of developing symptoms. Valacyclovir usage showed significant reduction in mean time until PCR clearance, 8.14 days with placebo versus 6.43 days with valacyclovir 500 mg BID.

CONCLUSIONS

A 7-day regimen of valacyclovir 500 mg BID will reduce the length of time until clinical clearance of an outbreak of recurrent HG. Its usage reduced duration of viral presence by 21%.

Tramadol disposition in the very young: an attempt to assess in vivo cytochrome P-450 2D6 activity

BACKGROUND

Tramadol is potentially a very useful pain relief medication in neonates and infants. It is primarily metabolized into O-demethyl tramadol (M1) by CYP2D6. Data concerning tramadol disposition and CYP2D6 activity in young infants are not available.

METHODS

A population pharmacokinetic analysis of tramadol and M1 time-concentration profiles was undertaken using non-linear mixed-effects models (NONMEM), based on newly collected data on tramadol and M1 time-concentration profiles in neonates and young infants (n=20) and published studies on intravenous tramadol in children and adults. M1 formation served as a surrogate for CYP2D6 activity.

RESULTS

Tramadol clearance was described using a two-compartment linear model with zero-order input and first-order elimination. Clearance increased from 25 weeks post-conception age (PCA) (5.52 litre h(-1) [70 kg](-1)) to reach 84% of the mature value by 44 weeks PCA (standardized to a 70 kg adult using allometric '1/4 power' models). The central volume of distribution decreased from 25 weeks PCA (256 litre [70 kg](-1)) to reach 120% of its mature value by 87 weeks PCA. Formation clearance to M1 contributed 43% of tramadol clearance, but had no relationship with PCA. There was a weak non-linear relationship between PCA and M1 metabolite clearance.

CONCLUSIONS

Maturational clearance of tramadol is almost complete by 44 weeks PCA. A target concentration of 300 microg litre(-1) is achieved after a bolus of tramadol hydrochloride 1 mg kg(-1) and can be maintained by infusion of tramadol hydrochloride 0.09 mg kg(-1) h(-1) at 25 weeks PCA, 0.14 mg kg(-1) h(-1) at 30 weeks PCA, 0.17 mg kg(-1) h(-1) at 35 weeks PCA, 0.18 mg kg(-1) h(-1) at 40 weeks, 0.19 mg kg(-1) h(-1) at 50 weeks PCA to 1 yr, 0.18 mg kg(-1) h(-1) at 3 yr and 0.12 mg kg(-1) h(-1) in adulthood. CYP2D6 activity was observed as early as 25 weeks PCA, but the impact of CYP2D6 polymorphism on the variability in pharmacokinetics, metabolism and pharmacodynamics of tramadol remains to be established.

Transition through the continuum of care in a continuing care retirement community: can a functional rating scale be a decision-making tool?

This retrospective descriptive study was done to determine if the Geriatric Functional Rating Scale (GFRS) can be used as an objective measure of a resident's need for a higher level of care in a continuing care retirement community (CCRC). A total of 290 of the 300 available independent living residents in a CCRC underwent assessment with the GFRS. At the end of the study period (February 2000 through December 2003), 84% of those who initially had a score of > or =40 were still living independently (alone or with a spouse), of those scoring 20 to <40, 11% were living independently, 40% required some assistance, and 20% entered a Long-Term Care Facility (LTC). Of those scoring <20 initially, none were living independently at the end of the study period. GFRS scores of > or =40 seemed to correlate with continued independence and <40 with an increasing need for assistance. The GFRS provides a functional database on each resident and may be a good objective predictor of future level of care. The sensitivity and specificity of GFRS scores <40 were 42% and 96%, respectively, for either admission to a facility or death. The positive predictive value was 87% and the negative predictive value was 72%.

Identification and treatment of eating disorders in women with type 1 diabetes mellitus

A series of case reports in the early 1980s and prevalence studies in the 1990s highlighted the serious medical consequences of coexisting eating disorders and diabetes mellitus. Diabetes-specific treatment issues, such as the need to carefully monitor diet, exercise, and blood glucose, may contribute to the development of eating disorder symptoms among women with diabetes mellitus. The attention to food portions and bodyweight that is part of routine diabetes mellitus management parallels the rigid thinking about food and body image found in women with eating disorders who do not have diabetes mellitus. Additionally, intensive insulin management of diabetes mellitus, the current standard of care, has been shown to be associated with bodyweight gain. Following from this, it may be that the very goals of state-of-the-art diabetes mellitus care increase the risk for developing an eating disorder. Once an eating disorder and recurrent insulin omission becomes entrenched, a pattern develops which is hard to break - one of chronic hyperglycemia, depressed mood, fear of bodyweight gain, and frustration with diabetes management. Eating disorders predispose women with diabetes mellitus to many complex medical risks. For example, insulin omission and reduction, eating disorder symptoms unique to diabetes mellitus, are strongly associated with an increased risk of diabetic ketoacidosis and with microvascular complications of diabetes mellitus such as retinopathy. For this reason, it is critical that diabetes mellitus clinicians understand more about eating disorders so as to improve the likelihood of early detection, appropriate treatment, and prevention of acute and long-term medical complications within this high-risk group of women.

The Blood Glucose Monitoring Communication questionnaire: an instrument to measure affect specific to blood glucose monitoring

OBJECTIVE

The aim of this study was to present the psychometric properties of a new tool for evaluating affective response to blood glucose monitoring (BGM) in youths with type 1 diabetes and their parents.

RESEARCH DESIGN AND METHODS

Study participants included 153 youths with type 1 diabetes and their parents. Each youth and parent completed the Blood Glucose Monitoring Communication (BGMC) questionnaire, Diabetes Family Conflict Scale, and Pediatric Quality of Life Inventory. Statistical analyses evaluated the psychometric properties of the BGMC questionnaires and their association with glycemic outcomes.

RESULTS

Youth and parent BGMC questionnaires had acceptable internal consistency (youth, alpha = 0.77; parent, alpha = 0.82) and 1-year test-retest reliability (youth, r = 0.60; parent, r = 0.80). Higher BGMC questionnaire scores (indicating more negative affect) showed a strong association with higher levels of diabetes-specific family conflict (youth, r = 0.33; parent, r = 0.44) and poorer health-related psychosocial quality of life (youth, r = -0.50; parent, r = -0.42). Higher BGMC questionnaire scores were also associated with poorer glycemic control (youth, r = 0.28; parent, r = 0.20), even when the effects of diabetes-specific family conflict and psychosocial quality of life were controlled. Youths with BGMC questionnaire scores in the upper quartile had A1c values 1 percentage point higher (9.1%) than youths with scores in the lowest quartile (8.0%).

CONCLUSIONS

The BGMC questionnaires have strong psychometric properties and are convenient measures of affect specific to BGM. Further, BGM affect is associated with glycemic outcomes and may provide a unique contribution to factors associated with glycemic control in youths.

A developmental perspective on the challenges of diabetes education and care during the young adult period

There is increasing recognition that the patient education and care provided to young adults with chronic physical illnesses, including type 1 diabetes, is inattentive to the complex developmental issues facing the older adolescent transitioning into the young adult period [Pediatrics 110 (2002) 1307]. In this paper, we present a clinical perspective on the challenge of improving diabetes education and care during the young adult period focusing on the importance of the developmental changes-cognitive, social, emotional, educational, and familial-that occur during this transitional stage of life. This developmental perspective on young adulthood provides a conceptual framework to better understand the young adult's "readiness" for engagement in intensive medical therapy. We review factors such as the timing and context of diabetes care and education that may be important determinants of young adults' ultimate success in becoming independent managers of their health care during this difficult transition. Developmentally-based practice principles for the young adult period are presented which include: assessing the patient's expectation at transition, building the relationship, working with families, assessing barriers to care, and formulating treatment plans and goals.

Developmental pharmacokinetics of morphine and its metabolites in neonates, infants and young children

BACKGROUND

Descriptions of the pharmacokinetics and metabolism of morphine and its metabolites in young children are scant. Previous studies have not differentiated the effects of size from those related to age during infancy.

METHODS

Postoperative children 0-3 yr old were given an intravenous loading dose of morphine hydrochloride (100 micro g kg(-1) in 2 min) followed by either an intravenous morphine infusion of 10 micro g h(-1) kg(-1) (n=92) or 3-hourly intravenous morphine boluses of 30 micro g kg(-1) (n=92). Additional morphine (5 micro g kg(-1)) every 10 min was given if the visual analogue (VAS, 0-10) pain score was >/=4. Arterial blood (1.4 ml) was sampled within 5 min of the loading dose and at 6, 12 and 24 h for morphine, morphine-3-glucuronide (M3G) and morphine-6-glucuronide (M6G). The disposition of morphine and formation clearances of morphine base to its glucuronide metabolites and their elimination clearances were estimated using non-linear mixed effects models.

RESULTS

The analysis used 1856 concentration observations from 184 subjects. Population parameter estimates and their variability (%) for a one-compartment, first-order elimination model were as follows: volume of distribution 136 (59.3) litres, formation clearance to M3G 64.3 (58.8) litres h(-1), formation clearance to M6G 3.63 (82.2) litres h(-1), morphine clearance by other routes 3.12 litres h(-1) per 70 kg, elimination clearance of M3G 17.4 (43.0) litres h(-1), elimination clearance of M6G 5.8 (73.8) litres h(-1). All parameters are standardized to a 70 kg person using allometric 3/4 power models and reflect fully mature adult values. The volume of distribution increased exponentially with a maturation half-life of 26 days from 83 litres per 70 kg at birth; formation clearance to M3G and M6G increased with a maturation half-life of 88.3 days from 10.8 and 0.61 litres h(-1) per 70 kg respectively at birth. Metabolite formation decreased with increased serum bilirubin concentration. Metabolite clearance increased with age (maturation half-life 129 days), and appeared to be similar to that described for glomerular filtration rate maturation in infants.

CONCLUSION

M3G is the predominant metabolite of morphine in young children and total body morphine clearance is 80% that of adult values by 6 months. A mean steady-state serum concentration of 10 ng ml(-1) can be achieved in children after non-cardiac surgery in an intensive care unit with a morphine hydrochloride infusion of 5 micro g h(-1) kg(-1) at birth (term neonates), 8.5 micro g h(-1) kg(-1) at 1 month, 13.5 micro g h(-1) kg(-1) at 3 months and 18 micro g h(-1) kg(-1) at 1 year and 16 micro g h(-1) kg(-1) for 1- to 3-yr-old children.

Chronic corticosterone affects brain weight, and mitochondrial, but not glial volume fraction in hippocampal area CA3

Corticosterone (CORT), the predominant glucocorticoid in rodents, is known to damage hippocampal area CA3. Here we investigate how that damage is represented at the cellular and ultrastructural level of analyses. Rats were injected with CORT (26.8 mg/kg, s.c.) or vehicle for 56 days. Cell counts were estimated with the physical disector method. Glial and mitochondrial volume fractions were obtained from electron micrographs. The effectiveness of the CORT dose used was demonstrated in two ways. First, CORT significantly inhibited body weight gain relative to vehicles. Second, CORT significantly reduced adrenal gland, heart and gastrocnemius muscle weight. Both the adrenal and gastrocnemius muscle weight to body weight ratios were also significantly reduced. Although absolute brain weight was reduced, the brain to body weight ratio was higher in the CORT group relative to vehicles, suggesting that the brain is more resistant to the effects of CORT than many peripheral organs and muscles. Consistent with that interpretation, CORT did not alter CA3 cell density, cell layer volume, or apical dendritic neuropil volume. Likewise, CORT did not significantly alter glial volume fraction, but did reduce mitochondrial volume fraction. These findings highlight the need for ultrastructural analyses in addition to cellular level analyses before conclusions can be drawn about the damaging effects of prolonged CORT elevations. The relative reduction in mitochondria may indicate a reduction in bioenergetic capacity that, in turn, could render CA3 vulnerable to metabolic challenges.

General quality of life in youth with type 1 diabetes: relationship to patient management and diabetes-specific family conflict

OBJECTIVE

To evaluate self-report and parent proxy report of child/teen general quality of life in youth with type 1 diabetes, compare their responses with those of a general pediatric population, and identify relationships between diabetes management, diabetes-related family behavior, and diabetes-specific family conflict with quality of life in youth with type 1 diabetes.

RESEARCH DESIGN AND METHODS

Study participants included 100 children, 8-17 years of age (12.1 +/- 2.3), with type 1 diabetes for 0.5-6 years (2.7 +/- 1.6). Each child and a parent completed the Pediatric Quality of Life Inventory (PedsQL), completed the Diabetes Family Conflict Scale, and provided data on parent involvement in diabetes management. An independent measure of adherence to treatment assessed by the patient's clinician and a measure of glycemic control (HbA(1c)) were also collected.

RESULTS

PedsQL responses from youth with type 1 diabetes were stable over 1 year and similar to norms from a healthy standardization sample for all three scales of the PedsQL: total, physical, and psychosocial quality of life. After controlling for age, duration of diabetes, sex, HbA(1c), and family involvement, child report of diabetes-specific family conflict (P < 0.01) was the only significant predictor of child report of quality of life (model R(2) = 0.21, P < 0.02).

CONCLUSIONS

Youth with type 1 diabetes report remarkably similar quality of life to a nondiabetic youth population. Greater endorsement of diabetes-specific family conflict predicted diminished quality of life for the child. As treatment programs focus on intensifying glycemic control in youth with type 1 diabetes, interventions should include efforts to reduce diabetes-specific family conflict in order to preserve the child's overall quality of life.

Reducing acute adverse outcomes in youths with type 1 diabetes: a randomized, controlled trial

OBJECTIVE

Both acute and chronic complications of diabetes account for a disproportionate percentage of US health care expenditures. Despite improvements in diabetes care, the incidence of adverse events in children with type 1 diabetes remains high, particularly for youths with poor glycemic control. Cost-effective intervention programs designed to reduce complications are needed. This study evaluated a low-intensity, nonmedical intervention using a case manager (called a "Care Ambassador"), with and without the supplementation of psychoeducational modules, designed to monitor and encourage routine diabetes care visits to reduce short-term adverse outcomes and improve glycemic control in youths with type 1 diabetes.

METHODS

We performed a 2-year prospective, randomized clinical trial in 299 youths with type 1 diabetes, aged 7 to 16 years, comparing 3 treatment programs (Care Ambassador [CA], Care Ambassador plus psychoeducational modules [CA+], and standard multidisciplinary diabetes care [SC]). The study was conducted in a large metropolitan US city from April 1997 through April 2000. Number of medical visits, frequency of hypoglycemic events, hospital/emergency department (ED) utilization, and glycosylated hemoglobin A1c were assessed during follow-up.

RESULTS

During the 2-year study period, both the CA and CA+ groups had significantly more routine visits (mean [standard deviation]: 7.3 [2.06] and 7.5 [2.02], respectively) compared with the SC group (5.4 [2.62]). The CA+ intervention group had significantly reduced rates of short-term adverse outcomes compared with the other 2 groups; 25% fewer total hypoglycemic events, 60% fewer severe hypoglycemic events, and 40% fewer hospitalizations and ED visits. "High-risk" youths in the CA+ group (baseline glycosylated hemoglobin A1c > or =8.7%) were 3.4-fold (1.57-7.41) more likely to improve their glycemic control compared with those at high risk in the other 2 groups.

CONCLUSIONS

For youths with type 1 diabetes, the CA and CA+ interventions increased visit frequency. Youths in the CA+ intervention had reduced rates of hypoglycemia and hospital/ED utilization with estimated annual cost savings of 80 000 dollars to 90 000 dollars. The CA+ intervention compared with the other 2 groups improved glycemic control in "high-risk" youths. Nonmedical case management incorporating psychoeducational modules seems to be a cost-effective approach to improving outcomes in youths with diabetes.

Acetaminophen in cerebrospinal fluid in children

BACKGROUND

There are few studies describing acetaminophen (APAP) cerebrospinal fluid (CSF) concentrations in children. This current study was undertaken in children--from neonates to adolescents--in order to investigate age-related changes in the plasma to CSF equilibration half-time (Teq) of APAP.

METHODS

Children (n=41) 1 week to 18 years of age undergoing (semi) elective surgery for placement or revision of a ventriculo-peritoneal shunt or insertion of a temporary external ventricular drain received a loading dose of 30-40 mg/kg APAP 1 h before scheduled surgery. Blood and CSF samples for APAP concentration analysis were collected during surgery. In those children with a temporary external drain, blood and CSF sampling were extended into the postoperative period. APAP and CSF pharmacokinetics were estimated using non-linear mixed-effects models. Size was standardized to a 70-kg person using allometric "1/4 power models".

RESULTS

Median (25-75th percentile) age and weight of the patients included in this study were 12 months (3-62 months) and 10.0 kg (5.8-20.0 kg). Median (25-75th percentile) time between APAP loading dose administration and collection of blood samples and median time (25-75th percentile) between APAP loading dose and collection of CSF were, respectively, 125 min (95-210 min) and 133 min (33-202 min). The population mean Teq, standardized to a 70-kg person, was 1.93 h (CV 43%), an estimate similar to that described in adults (2.1 h). There was no relationship between age and Teq other than that predicted by size. APAP plasma concentrations ranged from 0.0 mg/l to 33.0 mg/l, APAP CSF concentrations ranged from 0.0 mg/l to 21.0 mg/l.

CONCLUSION

Size rather than blood-brain-barrier maturation determines Teq changes with age in children. We predict a neonate (3.5 kg), 1-year-old child (10 kg), 5-year-old child (20 kg), 10-year-old child (30 kg) and adult (70 kg) to have Teq values of 0.9, 1, 1.4, 1.6, and 1.93 h, respectively.

Chronic administration of corticosterone impairs spatial reference memory before spatial working memory in rats

Corticosterone (CORT), the predominant glucocorticoid in rodents, elevated for 21 days damages hippocampal subregion CA3. We tested the hypothesis that CORT would impair spatial memory, a hippocampal function. In each of the three experiments, rats received daily, subcutaneous injections of either CORT (26.8 mg/kg body weight in sesame oil) or sesame oil vehicle alone (VEH). CORT given for 21 or 56 days effectively attenuated body weight gain and reduced selective organ and muscle weights. All behavioral testing was done on tasks that are minimally stressful and avoid deprivation. For each experiment, testing commenced 24h after the last injection. CORT given for 21 days did not impair spatial working memory in the Y-maze (Experiments 1 and 2). After 56-day administration of CORT, spatial working memory was impaired in the Y-maze (Experiment 2). CORT given for 21 days also failed to impair spatial working memory in the Barnes maze (Experiment 3). However, in trials that depended solely on reference memory, the VEH group improved in performance, whereas the CORT group did not. In conclusion, CORT elevated over a period of 21 days did not impair spatial working memory, but impaired the formation of a longer-term form of memory, most likely reference memory. Impairments in spatial working memory are seen only after longer durations of CORT administration.

Diabetes self-care: lessons from research on the family and broader contexts

The foundation of diabetes management is the self-care behavior of the patient. All of the systems within which the person with diabetes interacts, as well as the media and broader social and cultural values, affect this self-care behavior. In this article I focus on recent research that has examined the link between relationships in the patient's intimate network (i.e., family and close friends) and in the patient's exchange network (i.e., patient-provider relationship, Internet support). The goal of this review is to identify relational targets associated with self-care behaviors that are potentially modifiable within the diabetes medical care setting. Evidence-based suggestions are made for points of intervention entry, and areas for future research are explored.

Impact of ambulatory, family-focused teamwork intervention on glycemic control in youth with type 1 diabetes

OBJECTIVE

To evaluate an ambulatory, family-focused intervention aimed at optimizing

STUDY DESIGN

Study design We randomly assigned 105 children and adolescents, 8 to 17 years of age, with T1DM for < or =6 years, to a family-focused teamwork (TW) intervention or to standard multidisciplinary diabetes care (SC). Patients in both study groups were seen at 3- to 4-month intervals and were followed prospectively for 1 year. Measures of family involvement in diabetes tasks, DFC, and quality of life were performed at baseline and after 1 year. Hemoglobin A1c was measured at each visit.

RESULTS

Patients (n = 100) completed follow-up, (50 in TW and 50 in SC). At entry, A1c was 8.4% +/- 1.3% in TW and 8.3% +/- 1.0% in SC. After 1 year, A1c was 8.2% +/- 1.1% in TW compared with 8.7% +/- 1.5% in SC (P <.05). Both groups had similar frequencies of blood glucose monitoring (BGM) and insulin dosing. Families exposed to the TW intervention maintained or increased family involvement significantly more than families exposed to SC (P =.05). In multivariate analysis, the TW intervention and the daily frequency of BGM significantly predicted A1c (R (2) = 0.17, P =.05). Despite increased family involvement, the TW group reported no increase in DFC or decrease in quality of life.

CONCLUSIONS

The ambulatory TW intervention prevented the expected deterioration in glycemic control seen with SC in youths with T1DM of < or =6 years' duration. Successful family involvement may assist in the preservation of health and the prevention of long-term diabetes complications for youth with diabetes.

Family conflict, adherence, and glycaemic control in youth with short duration Type 1 diabetes

AIMS

Behavioural support around diabetes management tasks is linked to glycaemic outcomes. In this study we investigated the relationship between diabetes-related parental behaviours (conflict around and involvement in treatment tasks), adherence to blood glucose monitoring (BGM), and glycaemic control in youth with short duration Type 1 diabetes mellitus (DM).

METHODS

In a cross-sectional study, 104 youth (aged 8-17 years, duration of Type 1 DM 0.5-6 years) along with a parent, completed the Diabetes Conflict Scale. Parental involvement in management tasks was assessed with structured interviews and the Diabetes Family Responsibility Questionnaire. Adherence to BGM was evaluated by family report and by independent clinician rating. Glycaemic control was assessed with glycosylated haemoglobin (HbA1c) (ref. range, 4-6%).

RESULTS

Children (8-12 years; n = 69) and adolescents (13-17 years; n = 35), respectively, had similar durations of diabetes (x +/- sd; 2.7 +/- 1.69, 2.4 +/- 1.32 years) and similar glycaemic control (8.3 +/- 1.1%, 8.4 +/- 1.1%). In both age groups, parental involvement was a significant predictor of adherence to BGM (P = 0.01). Multivariate analyses, controlling for age, sex, disease duration, and BGM adherence, revealed that higher diabetes conflict significantly related to poorer glycaemic control (HbA1c) (R2 = 0.17; P < 0.01).

CONCLUSIONS

These findings indicate that in this cohort, early in the course of diabetes, diabetes-specific conflict and adherence to BGM became strongly linked to the child's glycaemic control. This suggests that to insure optimal control, it may be beneficial to introduce targeted interventions to build positive family involvement and interaction around diabetes tasks early in the disease course, before negative behaviours become established.

A new method for the investigation of capillary structure

Numerous physiological conditions as well as behavioral conditions have been shown to influence central nervous system vascular structure. Many of the methods used to investigate these structural alterations take advantage of the visibility of viscous substances (e.g. India ink in gelatin) perfused into the vasculature. The high viscosity of the solution, however, can cause incomplete vessel perfusion. The aim of the present study was to test whether or not capillaries seen in tissue perfused with fixative, embedded in celloidin and stained with Methylene Blue-Azure II (n=6) could be a useful alternative for the investigation of brain vascular structure. The method was compared to tissue from six rats perfused with India ink in gelatin and stained with cresyl violet. Qualitatively, vessels in the standard perfused tissue embedded in celloidin yielded clear vessels with stained pericytes. The two methods did not differ in branch point to cell ratio, length of individual capillaries, vessel length per mm(3), and capillary tortuosity. The capillary diameter was greater in the celloidin embedded tissue than in the India ink perfused tissue. Measuring the diameter between vessel walls appears to provide a more accurate measure than the widest distance between India ink pigments. Quantitative comparisons suggest that perfusion with standard fixative followed by embedding in celloidin provides vascular quantification comparable to that from India ink perfused tissue. The present method has several advantages, which include visualization of pericytes, increased probability of complete perfusion, clear view of cells that might otherwise be obscured by opaque vessels, and the possibility of using the alternate cerebral hemisphere for investigation of vascular ultrastructure.

Acetaminophen analgesia in children: placebo effect and pain resolution after tonsillectomy

BACKGROUND

Pharmacodynamic models of acetaminophen analgesia in children have not explored the efficacy of single oral doses greater than 40 mg/kg.

METHODS

Children aged 9.0 +/- 3.0 years (+/- SD) and weight 37.9+/- 16.6 kg undergoing outpatient tonsillectomy were randomised to receive acetaminophen elixir 40 mg/kg (n = 12). high dose acetaminophen elixir 100 mg/kg (n =20) or placebo (n=30) 0.5 -1 h preoperatively. No other analgesics were given. Individual acetaminophen serum concentrations and pain scores [visual analogue scale (VAS) 0-10] were measured over a 4-8 h postoperative period. These data were pooled with data from a previous study investigating acetaminophen pharmacodynamics (n = 120) and analysed using a non-linear mixed effect model. Placebo effects and drug effects were modelled using effect-site concentration models.

RESULTS

A one-compartment model with first-order input, lag time and first-order elimination was used to describe the population pharmacokinetics of acetaminophen. Pharmacokinetic parameter estimates were similar to those previously described. Pharmacodynamic population parameter estimates [population variability coefficient of variation (CV)] for a maximum analgesic effect (Emax) model, in which the greatest possible pain relief (VAS 0-10) equates to an Emax of 10, were Emax 5.17 (64%) and 50% effective concentration 9.98 mg/l (107%). The equilibration half-life (t(eq)) of the analgesic effect compartment was 53 min (217%). A placebo drug model for the effects of placebo response had a t(eq) of 1.96 h (40%), an elimination half-life of 2.06 h (50%) and a potency of 1.54 pain relief units (24%).

CONCLUSIONS

High dose acetaminophen (100 mg/kg) was no more effective than 40 mg/kg and was associated with increased nausea and vomiting. A target effect compartment concentration of 10 mg/l is expected to produce a pain reduction of 2.6 units. The placebo model accounted for a maximum pain reduction of 5.6 units at 3 h. The combination of placebo effect and preoperative acetaminophen 40 mg/kg results in pain scores below 4 units for 5 h postoperatively.

Predictors of glycemic control and short-term adverse outcomes in youth with type 1 diabetes

OBJECTIVES

To examine predictors of glycemic control and to assess how glycemic control affects the incidence of short-term adverse outcomes in a pediatric population with type 1 diabetes.

STUDY DESIGN

Three hundred youth, aged 7 to 16 years, with type 1 diabetes who were receiving diabetes specialty care were followed up prospectively for 1 year. Treatment plans and frequency of adverse outcomes were ascertained by questionnaires and medical record review. Incidence rates of adverse outcomes were compared among 3 strata of the population, representing tertiles of baseline glycosylated hemoglobin (HbA1c).

RESULTS

Blood glucose monitoring frequency was the sole modifiable predictor of HbA1c (P <.0001). Overall incidence rate of hospitalization was 13 per 100 person-years, more than 3 times the rate in the general pediatric population and significantly higher in the upper HbA1c tertile compared with the other strata (P =.001). Rate of emergency department use was 29 per 100 person-years and did not differ significantly among tertiles. Incidence of severe hypoglycemia was 62 per 100 person-years and notably high even in those with poorest glycemic control.

CONCLUSION

Despite improvements in diabetes care, the incidence of short-term adverse events in children with type 1 diabetes remains high, particularly in those with poorest glycemic control.

Valvular heart operation in patients with previous mediastinal radiation therapy

BACKGROUND

The outcome of valvular heart operations in patients with previous mediastinal radiation therapy was studied.

METHODS

This is a single center retrospective study of 60 patients (37 females, 23 males) with a mean age of 62 +/- 15 years (28 to 88 years old) operated on from January 1976 to December 1998. Valvular heart operations performed included aortic valve replacements (n = 26), mitral valve procedures (n = 16), tricuspid valve procedures (n = 6), and multiple valve procedures (n = 12). A total of 264 clinical, hemodynamic, electrocardiographic and echocardiographic variables were analyzed.

RESULTS

Total follow-up was 199 patient-years with a mean of 3.3 +/- 3.1 years and a range of 0 to 12.4 years old. Early mortality was 7 patients (12%). Early mortality in patients with constrictive pericarditis was 40% (4 of 10) compared with 6% (3 of 50) in patients without constrictive pericarditis. By univariate analysis, early mortality was associated with constrictive pericarditis (p = 0.011), reduced preoperative ejection fraction (p = 0.015), and longer cardiopulmonary bypass times (p = 0.037). A total of 14 patients (23%) required permanent pacemaker placement before (n = 7), during (n = 1), or early (n = 6) after valvular heart operations. There were 19 late deaths (malignancies, 7; heart failures, 5; other cardiac, 4; and other noncardiac, 3). Overall survival and freedom from late cardiac death and cardiac reoperation at 5 years for hospital survivors were 66% +/- 8%, 82% +/- 7%, and 93% +/- 4%, respectively. By univariate analysis, late cardiac death was associated with low ejection fraction (p = 0.002), New York Heart Association (NYHA) functional class IV (p = 0.004), preoperative congestive heart failure (p = 0.02), and preoperative atrial fibrillation (p = 0.038). Eighty-five percent of the discharged patients were in NYHA functional class I or II at follow-up.

CONCLUSIONS

Early results of valve replacement after mediastinal radiation therapy were good except in the presence of constrictive pericarditis. Long-term outcome was limited by malignancy and heart failure. Early surgical intervention is recommended before the development of risk factors for late death, namely, severe symptoms, left ventricular dysfunction, and atrial fibrillation.