Beyond pain: predictors of postoperative maladaptive behavior change in children

Objectives & Aim: Using well‐validated measures and controlling for potential confounding variables such as pain and surgical and anesthetic technique, the goal of this project was to identify the incidence of and risk factors for the development of behavior change in children after surgery. Background: Although researchers have described maladaptive behavior change following surgery, many previous studies are limited by potential confounding variables, including postoperative pain, type of surgery, and surgical and anesthetic procedure. Methods: Participants included 260 children undergoing tonsillectomy and adenoidectomy. Baseline and demographic data were collected prior to surgery and pain and behavioral recovery were recorded for 2 weeks following surgery. A standardized approach to anesthesia and surgical procedure was implemented and well‐validated assessment measures were used. Results: On the first day at home following surgery, 80.4% of children exhibited negative behavior change. Nearly one‐third of children continued to exhibit behavior changes 2 weeks after surgery. Logistic regression analyses that controlled for pain severity identified several predictors of behavior change: preexisting somatic and anxious/depressed problems predicted new onset postoperative general anxiety, χ² (8) = 20.10, P = 0.010; younger age predicted separation anxiety, χ² (4) = 20.41, P < 0.01; and inhibited temperament predicted postoperative sleep disturbance, χ² (2) = 9.19, P = 0.010. Conclusions: Individual child factors above and beyond pain predict maladaptive postoperative behavior change; identification of these predictors may be helpful in both preventing and ameliorating difficulties with behavioral recovery following surgery.     

Reliability and Validity of the Child and Adolescent Trial for Cardiovascular Health (CATCH) Food Checklist: A Self-report Instrument to Measure Fat and Sodium Intake by Middle School Students

OBJECTIVE: To develop a scoring algorithm and evaluate the reliability and validity of scores from the Child and Adolescent Trial for Cardiovascular Health (CATCH) Food Checklist (CFC) as measures of total fat, saturated fat, and sodium intake in middle school students. DESIGN: Randomized, controlled trial in which participants were assigned to 1 of 3 study protocols that varied the order of CFC and 24-hour dietary recall administration. Criterion outcomes were percent energy from total fat, percent energy from saturated fat, and sodium intake in milligrams. SUBJECTS/SETTING: A multiethnic sample (33% ethnic and racial minorities) of 365 seventh-grade students from 8 schools in 4 states. STATISTICAL ANALYSES: Multivariable regression models were used to calibrate the effects of individual food checklist items; bootstrap estimates were used for cross-validation; and kappa statistics, Pearson correlations, t tests, and effect sizes were employed to assess reliability and validity. RESULTS: The median same-day test-retest reliability kappa for the 40 individual CFC food items was 0.85. With respect to item validity, the median kappa statistic comparing student choices to those identified by staff dietitians was 0.54. Test-retest reliability coefficients ranged from 0.84 to 0.89 for CFC total nutrient scores. Correlations between CFC scores and 24-hour recall values were 0.36 for total fat, 0.36 for saturated fat, and 0.34 for sodium; CFC scores were consistent with hypothesized gender differences in nutrient intake. APPLICATIONS/CONCLUSIONS: The CFC is a reliable and valid tool for measuring fat, saturated fat, and sodium intake in middle school students. Its brevity and ease of administration make the CFC a cost-effective way to measure middle school students' previous day's intake of selected nutrients in school surveys and intervention studies.     

Comparison of Titanium-Mesh and Porous Disc Electrodes for Epicardial Defibrillation

The object of this study was to compare the effectiveness of chronically implanted porous electrodes with that of smooth mesh titanium electrodes of the same diameter but smaller effective surface area. The criteria used in evaluating the electrodes were (1) acute, subacute, and chronic resistance and (2) acute, subacute, and chronic defibrillation thresholds. Electrode pairs 2.5 cm in diameter were implanted in each of 17 dogs (ten mesh and seven porous). One electrode of each pair was sutured to the right ventricle and one to the left ventricle near the cardiac apex. Defibrillalion threshold energy and total resistance were measured at the time of implantation and again 6 and 12 weeks after implantation. The mean initial resistance of the titanium electrodes was 131.7 Ω; the mean defibrillation values /or the porous electrode implant were 96.9 Ω and 7,5 joules, respectively. Three to 6 weeks after implantation, the values for the titanium mesh electrode were 88.9 Ω and 12.0 joules, while those for the porous electrode were 59.9 Ω and 8.0 joules. In the chronic state, the figures for the titanium mesh electrode were 78.1 Ω and 13.0 joules, while those for the porous electrode were 64.3 Ω and 8.3 joules. We conclude that defibrillation can be achieved successfully with small epicardial electrodes. The findings suggest that a porous electrode, with its larger effective surface area, has lower electrode/tissue interface resistance in the acute and chronic phases, and, therefore, provides lower defibrillation threshold energy.     

The status of geriatric education in dental hygiene curricula

To assess the status of geriatric education in dental hygiene curricula, a pretested survey was sent to a 55% random sample of the 198 US dental hygiene programs. Of the 109 surveys mailed, a 90% response rate showed that geriatric didactic material is most frequently presented via occasional lectures, rather than in a formal course or an organized series of presentations. Seventy-five percent of the programs have a geriatric clinical component. Baccalaureate programs and programs longer than 2 years are more likely than associate programs and programs shorter than 2 years, respectively, to teach geriatrics in a more formalized setting. There is no significant difference in the way geriatric material is presented between hygiene programs that are and are not within dental schools.     

Determinants of Dietary Intake in a Sample of White and Mexican-American Children

Objective To assess the influence of several potential psychosocial determinants on children's eating behavior.Participants Three hundred fifty-one Mexican-American and non-Hispanic white children (mean age=4.4 years old at baseline) participated in the San Diego Study of Children's Activity and Nutrition for up to 2.5 years.Methods Child's eating behavior was described by 3 dependent variables: total energy, percentage energy from fat, and sodium intake per 1,000 kcal. Dietary information was collected 4 days a year using a 24-hour food intake record, which was a combination of direct observation and interviews with food preparers. The 35 predictor variables from child, parental, demographic, and environmental domains were collected by behavioral observation, interviewer-administered questionnaires, and physical measurements.Statistical analyses Bivariate and regression analyses via mixed linear models were performed.Results Variables from the children's domain (such as skinfold thickness and weight) had the strongest associations with energy intake; parental variables (such as fat avoidance behavior and prompts to increase children's food intake) were associated with child's percentage energy from fat and sodium intake. In regression analyses, parsimonious subsets of variables accounted for 46% of variance in energy intake (3 variables), 40% of the variance in percentage of energy from fat (4 variables), and 44% of variance in sodium intake per 1,000 kcal energy (1 variable) in between-subject variance components.Conclusions Fat and sodium intake of children may be improved by improving parents’ nutrition habits and by having parents encourage children to eat a healthful diet. Few modifiable correlates of children's energy intake were identified. J Am Diet Assoc. 1998;98:1282–1289.     

Late onset Pneumocystis pneumonia in patients receiving rituximab for humoral renal transplant rejection

Rituximab has been used increasingly in the treatment of antibody-mediated rejection (AbMR) in solid organ transplantation despite the absence of clinical trials demonstrating efficacy. A contributor to the growing use of rituximab is an apparent lack of morbidity; and there are no reports of specific opportunistic infections associated with its use in renal transplant recipients. Two cases of Pneumocystis pneumonia (PCP) occurring nearly 3 years after administration of rituximab for refractory AbMR are reported herein. These cases emphasize the need for ongoing vigilant observation in patients who have received rituximab, and highlight the importance of clinical trials to establish the role of rituximab in prevention and treatment of AbMR.     

How do pediatric anesthesiologists define intraoperative hypotension?

Introduction: Although blood pressure (BP) monitoring is a recommended standard of care by the ASA, and pediatric anesthesiologists routinely monitor the BP of their patients and when appropriate treat deviations from ‘normal’, there is no robust definition of hypotension in any of the pediatric anesthesia texts or journals. Consequently, what constitutes hypotension in pediatric anesthesia is currently unknown. We designed a questionnaire‐based survey of pediatric anesthesiologists to determine the BP ranges and thresholds used to define intraoperative hypotension (IOH). Methods: Members of the Society of Pediatric Anesthesia (SPA) and the Association of Paediatric Anaesthetists (APA) of Great Britain and Ireland were contacted through e‐mail to participate in this survey. We asked a few demographic questions and five questions about specific definitions of hypotension for different age groups of patients undergoing inguinal herniorraphy, a common pediatric surgical procedure. Results: The overall response rate was 56% (483/860), of which 76% were SPA members. Majority of the respondents (72%) work in academic institutions, while 8.9% work in institutions with fewer than 1000 annual pediatric surgical caseload. About 76% of respondents indicated that a 20–30% reduction in baseline systolic blood pressure (SBP) indicates significant hypotension in children under anesthesia. Most responders (86.7%) indicated that they use mean arterial pressure or SBP (72%) to define IOH. The mean SBP values for hypotension quoted by SPA members was about 5–7% lower across all pediatric age groups compared to values quoted by APA members (P = 0.001 for all age groups). Conclusions: There is great variability in the BP parameters used and the threshold used for defining and treating IOH among pediatric anesthesiologists. The majority of respondents considered a 20–30% reduction from baseline in SBP as indicative of significant hypotension. Lack of a consensus definition for a common clinical condition like IOH could have implications for patient care as well as future clinical research.