Delay discounting and parental monitoring in adolescents with poorly controlled type 1 diabetes

In a sample of adolescents with poorly controlled type 1 diabetes, this study examined if delay discounting, the extent to which individuals prefer immediate over delayed rewards, was associated with severity of non-adherence and poor glycemic control, and if parental monitoring of diabetes management moderated those associations. Sixty-one adolescents (M _age = 15.08 years, SD 1.43) with poorly controlled type 1 diabetes completed a delayed discounting task and an HbA1c blood test. Adherence was assessed via self-monitoring of blood glucose (SMBG) data from adolescents’ glucometers. Parents completed a parental monitoring questionnaire. Greater delay discounting was associated with higher HbA1c, but not SMBG. Direct parent observation of diabetes tasks, but not indirect parental monitoring, moderated the link between greater delay discounting and higher HbA1c, with higher direct parent observation buffering the link between greater discounting and poorer glycemic control. Delay discounting may be a target for future interventions to improve HbA1c in youth with type 1 diabetes.     

Management of chronic osteomyelitis of the tibia with life‐threatening complications under negative pressure wound therapy and isolation of Helcococcus kunzii

We report the case of an 86‐year‐old man with severe wound infection originating from a chronic crural ulcer of the lower limb, which under negative pressure wound therapy led to excessive tissue necrosis and perforation of the anterior tibial artery. A swab taken 10 and 7 days preoperatively was positive for Helcococcus kunzii. H. kunzii has been described as a potentially pathogenic organism. The questions whether the negative pressure wound therapy itself caused the bleeding or the negative pressure wound therapy, which generates an anaerobic atmosphere, has triggered the growth and invasion of the facultative anaerobic bacterium H. kunzii and owing to the infection the artery perforated or whether the bacteria has no influence at all remain currently unanswered. After surgical debridement the signs of infection were completely eliminated, and a free musculocutaneous flap led to rapid healing of the wound. Following which H. kunzii was no longer detectable.     

Severe non-valve-related hemolytic anemia following aortic root replacement

Aortic interposition grafting combined with aortic root replacement (conduit) is widely performed to manage thoracic aortic aneurysms. Intravascular hemolysis without clinical significance is occasionally observed as a complication after prosthetic valve replacement. Symptomatic lysis of red blood cells (RBCs) is rare and primarily attributed to mechanical damage as result of high shear stress, turbulent flow, and physical interaction. We report a case of severe hemolytic anemia shortly after mechanical conduit implantation. The RBC damage was not related to the valve prosthesis and resolved completely after replacement of a section of the kinked Dacron tube graft to correct a fold.     

Disseminated intravascular coagulation after craniotomy

Disseminated intravascular coagulation (DIC) is reported in neurosurgical patients; however, the incidence of DIC after craniotomy procedures is unknown. Using a surgical database, we identified 3164 patients who underwent primary craniotomy at Mayo Clinic Rochester between January 1, 2000 and December 31, 2004. Potential cases of DIC in this population were identified using 3 search triggers, patients: (1) in whom the diagnosis of DIC was noted on their hospital discharge summary, (2) who received red blood cell-free blood products, or (3) in whom a blood fibrinogen or d-dimer concentration was assessed. Using criteria based on laboratory values, we estimated the incidence of DIC developing within 72 hours of primary craniotomy to be between 13 and 44 per 10,000 patients. Despite a low incidence of DIC, the associated mortality rate was 43% to 75%. Traumatic head injury was a significant risk factor for the development of DIC [odds ratio of trauma was in the range of 16 (95% confidence interval (CI)=5.3-49) to 29 (CI=4.0-204)]. Autologous salvaged blood was administered intraoperatively to 44 patients, and 1 of these developed DIC. Although this small sample of patients receiving salvaged blood requires caution in interpreting the results, the risk of DIC seemed to be greater with salvaged blood than without [odds ratio 24 (CI=2.5-237)]. In children, 2 of 3 patients who developed DIC had congenital malformations of the brain. Findings from this study suggest that DIC is rare after craniotomy, but is often associated with mortality.     

Tumor-derived granulocyte-macrophage colony-stimulating factor regulates myeloid inflammation and T cell immunity in pancreatic cancer

Cancer-associated inflammation is thought to be a barrier to immune surveillance, particularly in pancreatic ductal adenocarcinoma (PDA). Gr-1(+) CD11b(+) cells are a key feature of cancer inflammation in PDA, but remain poorly understood. Using a genetically engineered mouse model of PDA, we show that tumor-derived granulocyte-macrophage colony-stimulating factor (GM-CSF) is necessary and sufficient to drive the development of Gr-1(+) CD11b(+) cells that suppressed antigen-specific T cells. In vivo, abrogation of tumor-derived GM-CSF inhibited the recruitment of Gr-1(+) CD11b(+) cells to the tumor microenvironment and blocked tumor development-a finding that was dependent on CD8(+) T cells. In humans, PDA tumor cells prominently expressed GM-CSF in vivo. Thus, tumor-derived GM-CSF is an important regulator of inflammation and immune suppression within the tumor microenvironment.     

Interactions between child and parent temperament and child behavior problems

OBJECTIVE: Few studies of temperament have tested goodness-of-fit theories of child behavior problems. In this study, we test the hypothesis that interactions between child and parent temperament dimensions predict levels of child psychopathology after controlling for the effects of these dimensions individually. METHODS: Temperament and psychopathology were assessed in a total of 175 children (97 boys, 78 girls; mean age, 10.99 years; SD, 3.66 years) using composite scores from multiple informants of the Junior Temperament and Character Inventory and the Achenbach System of Empirically Based Assessment. Parent temperament was assessed using the adult version of the Temperament and Character Inventory. Statistical analyses included multiple regression procedures to assess the contribution of child-parent temperament interactions after controlling for demographic variables, other types of child psychopathology, and the individual Temperament and Character Inventory and Junior Temperament and Character Inventory dimensions. RESULTS: Interactions between child and parent temperament dimensions predicted higher levels of externalizing, internalizing, and attention problems over and above the effects of these dimensions alone. Among others, the combination of high child novelty seeking with high maternal novelty was associated with child attention problems, whereas the combination of high child harm avoidance and high father harm avoidance was associated with increased child internalizing problems. Many child temperament dimensions also exerted significant effects independently. CONCLUSIONS: The association between a child temperament trait and psychopathology can be dependent upon the temperament of parents. These data lend support to previous theories of the importance of goodness-of-fit.     

Growth hormone supplementation improves implantation and pregnancy productivity rates for poor-prognosis patients undertaking IVF

In a sequential crossover study of IVF conducted from 2002 to 2006, growth hormone (GH) supplementation was assessed in poor-prognosis patients, categorized on the basis of past failure to conceive (mean 3.05 cycles) due to low response to high-dose stimulation (<3 metaphase II oocytes) or poor-quality embryos. Pregnancy rates in both fresh and frozen transfer cycles and the total productivity rates (fresh and frozen pregnancies per egg collection) were compared. In all, 159 patients had 488 treatment cycles: 221 with GH and 241 without GH. These cycles were also compared with 1572 uncategorized cycles from the same period. GH co-treatment significantly improved the clinical pregnancy rate per fresh transfer (P < 0.001) as well as per frozen–thawed embryo derived from GH cycles (P < 0.05) creating a highly significant productivity rate (P < 0.001). The effect was significant across all age groups, especially in younger patients, and was independent of stimulation modality or number of transfers. GH cycles resulted in significantly more babies delivered per transfer than non-GH cycles (20% versus 7%; P < 0.001) although less than the uncategorized cycles (53%). The data uniquely show that the effect of GH is directed at oocyte and subsequent embryo quality.     

Diagnostic accuracy of pediatric echocardiograms performed in adult laboratories

Although cardiologists who treat adults have been evaluating pediatric patients using echocardiography since the early 1980s, the diagnostic accuracy of such studies has never been tested. To prospectively assess diagnostic accuracy of pediatric echocardiograms performed in adult laboratories (adult-lab echos) compared with evaluations of the same patients in pediatric laboratories (pediatric-lab echos), we gathered data from 66 patients, ages 1 day to 18 years (median 19 months), who underwent adult-lab echos in community hospitals or private offices before evaluation by a pediatric cardiologist; subsequently, 65 underwent pediatric-lab echos in a university hospital laboratory. Echocardiographic diagnoses were compared with (1) diagnoses proved by catheterization or surgery (25 patients), and (2) echocardiographic diagnoses verified by blinded duplicate-observer review (41 patients). Eighteen patients had no cardiac disease; 42 had simple lesions, 5 had intermediate lesions, and 1 had a complex lesion. In 25 patients with 46 procedure-proven diagnoses, the most important error per adult-lab echo was major in 11 (44%), moderate in 7 (28%), and minor in 3 (12%); in pediatric-lab echos it was major in 0 (0%), moderate in 1 (4%), and minor in 1 (4%). In 41 patients with 62 duplicate-observer-verified diagnoses, the most important error per adult-lab echo was major in 5 (12%), moderate in 12 (29%), and minor in 5 (12%); pediatric-lab echos had no errors. In 35 of 66 adult-lab echos (53%), the most important error was major or moderate. Of these, 71% were interpretive, 17% technical, and 11% both. Error incidences were not related to patient age, study year, use of color Doppler, or complexity of diagnoses. In 29 of these 35 patients, pediatric-lab echos resulted in altered clinical management, including 12 surgeries and 2 averted surgeries. In 3 of the 29, delayed diagnoses were associated with fixed pulmonary vascular disease, hypoxemic spells, and vascular collapse with severe metabolic acidosis. This study reveals a high incidence of diagnostic errors in pediatric echocardiograms performed in community-based adult laboratories, despite a preponderance of patients with simple diagnoses or no heart disease.     

A randomized trial of laparoscopy and transvaginal ultrasound-directed oocyte pickup for in vitro fertilization

Ninety-four (94) couples undergoing IVF for the usual spectrum of clinical reasons and who were suitable for either laparoscopic or vaginal ovum pickup (OPU) were randomly assigned at the commencement of 166 treatment cycles to one of two OPU procedures. Both patient and clinician were informed of the allocation. If either wished to change this, then that cycle was eliminated from the trial. After a period of 15 months, 103 cycles were appropriate for analysis, of which 64 had been subject to ultrasound and 39 to laparoscopic OPU. Patients in the two groups did not differ significantly in terms of are or diagnosis, and the treatment cycles did not differ significantly in terms of stimulation used, commencing or maximum estradiol (E₂) concentrations, E₂ per follicle aspirated, or characteristics of the semen used for IVF. The rate of oocyte recovery (number of oocytes obtained per follicle aspirated), the average number of embryos available for transfer, and the pregnancy rate per oocyte recovery procedure did not differ significantly in the two groups. Ovum recovery for IVF using vaginal aspirations and ultrasound guidance is as efficacious as that which uses laparoscopy.