Exploring causal pathways of child behavior and maternal mental health in families with a child with congenital heart disease: a longitudinal study.

BACKGROUND: A congenital heart defect (CHD) can increase the risk of mental health problems in affected children and their parents. The extent to which risk factors for these problems are shared in families or are specific to the individual family member is unclear. METHOD: Prospective data from the Norwegian Mother and Child Cohort Study (MoBa; n = 93,009) were linked with a nationwide CHD registry, and 408 children with CHD were identified. Mothers' reports on child internalizing problems and their own distress were assessed by questionnaires at child ages 6, 18 and 36 months. A structural model was applied to distinguish between familial (shared) factors and individual-specific factors for mental health problems. RESULTS: CHD was a substantial risk factor for problems in children and their mothers at all time points. CHD contributed on average 31% and 39% to the variance in children's and mothers' problems respectively. Both shared familial and individual-specific factors unique to CHD families contributed to risk for mental health problems. Whereas individual-specific risk factors contributed to the stability of problems in mothers, the effect of these factors lasted only a short time in children. Mutual influences over time were found between the mother's and the child's mental health at 18 and 36 months. CONCLUSIONS: The burden of CHD in a child is shared between family members but is also specific to the individual. This study points to a need for both an individual and a family-based approach to provide psychological support to children with CHD and their parents.

Symptoms of communication and social impairment in toddlers with congenital heart defects.

BACKGROUND: With the advances in congenital cardiac surgery and medical management, mortality rates for congenital heart defects (CHD) have declined remarkably. As the number of CHD survivors have increased there is a growing focus on developmental morbidity. The objective of the current study is to compare symptoms of communication and social impairment in 18-month-old children with different severity of CHD with those of controls. METHOD: We linked prospective data from the Norwegian Mother and Child Cohort Study, conducted by the Norwegian Institute of Public Health, with a nationwide medical CHD registry and identified 198 18-month-olds with CHD in a cohort of 47,692. Three groups of CHD were distinguished: mild/moderate (n= 122), severe (n= 54) and CHD with comorbidity (n= 22). Mothers reported on the child's communication and social skills by completing items from the Ages and Stages Questionnaire as part of the Norwegian Mother and Child Cohort Study. RESULTS: Children aged 18 months old with CHD differed significantly from controls in levels of symptoms of communication impairment (P≤ 0.0001) and social impairment (P≤ 0.0001). The largest differences were found in children with CHD and comorbidity. Children with severe CHD also showed higher levels of both symptoms of communication and social impairment. Children with mild/moderate CHD showed a small difference only in symptoms of communication impairment. CONCLUSION: Children with severe CHD and CHD with comorbidity show more symptoms of communication and social impairment compared with a large cohort at the age of 18 months. It is important to broaden the scope of inquiry to involve communication and social developmental domains.

Emotional reactivity in infants with congenital heart defects: findings from a large case-cohort study in Norway.

AIM: Advances in medical treatment in recent years have led to dramatically improved survival rates of children with severe congenital heart defects (CHD). However, very little is known about the psychological consequences for these children, particularly during and after the early period of invasive treatment. In this study, we investigated the extent to which the severity of the CHD affects the child's emotional reactivity at 6 months of age. METHOD: We linked prospective data from the Norwegian Mother and Child Cohort Study, conducted by the Norwegian Institute of Public Health with a nationwide medical CHD registry and identified 212 infants with CHD in a cohort of 61 299 infants. Mothers reported on their child's emotional reactivity at age 6 months by means of a standardized questionnaire. RESULTS: Infants with severe to moderate CHD had 60% higher odds for severe emotional reactivity (cut-off at the 85 percentile) compared with healthy infants, after controlling for important maternal and child confounders. CONCLUSION: Our study is the first to show elevated emotional reactivity in children with moderate to severe CHD, suggesting a need for special parental attention to soothe their distress. Follow-up studies will show whether this emotional reactivity is transient or an early marker of continuing emotional or behavioural problems.

Feeding infants with CHD with breast milk: Norwegian Mother and Child Cohort Study.

OBJECTIVE: To explore the prevalence of breast milk feeding (BMF) of infants with congenital heart defects (CHD) during first 6 months of life, as compared with general population. DESIGN: The study is based on a subsample of the Norwegian Mother and Child Cohort Study conducted by Norwegian Institute of Public Health. A total of 60,600 mothers completed a questionnaire about infant feeding at 6 months postpartum. Infants with moderate/severe CHD (n = 131) were identified using nationwide CHD registry. A group of infants with CHD with comorbidity was also defined (n = 65). BMF was classified as predominant, continued, or no BMF. Month to month feeding status was analysed by means of Cox regression analyses. RESULTS: Between child age 2-6 months, mothers of infants with CHD had a hazard ratio (HR) of 1.69 of weaning their child compared with mothers of controls. Mothers of infants with CHD with comorbidity weaned at an even faster rate (HR 3.54). At age 6 months, 9.9% of infants with CHD were fed with breast milk predominately, 64.1% continued to receive breast milk, and only 26% were fed no breast milk. For infants with CHD with comorbidity, corresponding percentages were 7.7%, 43.1% and 49.2%, respectively. CONCLUSIONS: Although CHD alone and particularly CHD with comorbidity increased risk that mothers wean earlier, a relatively high rate of continued breastfeeding was maintained. Future studies should investigate factors that support continued BMF even in the most severely affected children with CHD.

Children with acute lymphoblastic leukaemia have high plasma levels of total homocysteine at time of diagnosis.

OBJECTIVE: Cancer can induce venous thromboembolic complications for various reasons. As part of a greater study, acquired and congenital prothrombotic risk factors were investigated in children with leukaemia or non-Hodgkin's lymphoma and compared with similar investigations in children with congenital heart defects. MATERIAL AND METHODS: Blood samples were taken from 60 children with newly diagnosed leukaemia or lymphoma and 133 children with congenital heart defects in the course of a scheduled cardiac catheterization. When children with cancer were in remission, analyses of acquired prothrombotic risk factors were repeated. Children with cancer were observed for symptoms of thromboembolism throughout their treatment period. RESULTS: Total homocysteine levels were significantly raised in children with cancer (median value 10.0 micromol/L) as compared with the levels in children with congenital heart diseases (5.0 micromol/L) (p<0.001), while children with acute lymphoblastic leukaemia had the highest values. The median level of lipoprotein(a) was slightly increased in children with newly diagnosed leukaemia or lymphoma (105 mg/L versus 100 mg/L, p<0.001), and levels of coagulation inhibitors were higher (p<0.001). Total homocysteine levels normalized when children attained remission of cancer disease. Two children had symptoms of acute thrombosis. CONCLUSIONS: Raised concentrations of total homocysteine were frequent in children with newly diagnosed cancer, but this normalized when the children were in remission. The clinical significance of our observations and the impact on venous thromboembolism have yet to be defined.

Successful thrombolysis by prolonged low-dose alteplase in catheter-directed infusion.

UNLABELLED: Catheter-directed thrombolysis is a sophisticated method in the treatment of thromboembolism with maximum effect on the thrombus and minimal systemic effect. The consequences are enhanced local thrombolysis and a reduction in general bleeding tendency, compared with systemic thrombolysis. At our institution, two children had successful thrombolysis by prolonged continuous catheter-directed low-dose alteplase. The first patient, a boy with Fontan physiology, was successfully treated for a massive pulmonary thromboembolism by catheter-directed very low-dose alteplase for five days. The second patient, who suffered from relapsing nephrotic syndrome, achieved satisfactory thrombolysis of an arterial leg thrombosis after four days of continuous catheter-directed low-dose alteplase. CONCLUSION: Although catheter-directed thrombolysis seems to be a valuable method in thrombolytic therapy, there is a lack of evidence-based recommendations concerning dosage, effect of bolus, simultaneous anticoagulation and duration of treatment for children.

Breast cancer patients' experiences of lymphoedema.

The aim of this study was to explore employed women's experiences of light or moderate arm lymphoedema following breast cancer treatment in order to gain a deeper understanding of this phenomenon. Twelve women took part in a semistructured interview. A qualitative method with a phenomenological approach was applied to analyse data. In order to integrate the experiences in the everyday life of the women, a critical incident method was used. The findings indicate that there are many different practical and psychosocial problems related to arm lymphoedema. Three main themes were common to all the women. These themes were: (i) Attitudes from people in their surroundings, including reactions to the problem from other people and reactions from the women on the attitudes of other people. (ii) Discovery and understanding of oedema as a chronic disease and its treatment. (iii) Coping, including both problem-focused and emotion-focused strategies. The problems integrated in daily life were of low frequency but of considerable importance to the women. In conclusion, it is of great importance that health care professionals should be aware of and have knowledge about these problems. The women's needs for expressing their experiences of arm lymphoedema may be encouraged at the time of discovery and then regularly as long as the women seek care. Efforts may be made to strengthen the women's coping skills, eventually in a multidisciplinary approach. The interaction skills of health care professionals are probably of great importance in strengthening the resources of the women leading to a positive outcome.

The lateral thoracodorsal flap in breast reconstruction: a long-term follow up study.

Fifty-four patients were studied a mean of five years after their breasts had been reconstructed between 1984 and 1990 using the lateral thoracodorsal (LTD) flap in combination with either a thin shell, non-low-bleed (n = 35) or a thick shell, low bleed (n = 19) silicone gel implant. The rate of capsular contracture (Baker III-IV) was 11% in the first group and 10% in the second according to a modified Baker classification. Open capsulotomy was common in both groups of patients (15/35 in the first group and 13/19 in the second). Investigation by applanation tonometry of the capsular contracture agreed with the modified Baker classification. The cosmetic results were evaluated clinically and from photographs. Best scores were recorded for scars and ptosis in both evaluations. There were no significant differences between the general cosmetic results in the two groups. The patients graded their estimations of the final outcome of their breast reconstruction on a 10-point visual analogue scale (VAS); the mean for the first group was 8.7 and for the second 9.2. None of the patients regretted her operation and they would all recommend the procedure to another patient.

Geochemical investigations of sulfide-bearing tailings at Kristineberg, northern Sweden, a few years after remediation.

In the Kristineberg mining area in northern Sweden, massive, pyrite-rich Zn Cu ores are intercalated in ca. 1.9 Ga volcano-sedimentary rocks. Investigations of a tailings impoundment remediated by means of both till coverage and raising the groundwater table have been undertaken. The aim of the study was to characterise the tailings with respect to mineralogy, the chemical composition of both the tailings and the pore water, and to try to identify the significant reactions that may have occurred before and after remediation. It was found that the oxidation front had reached down to depths of between approximately 0.1 and 1.15 m before remediation. The oxidation of sulfides has produced high concentrations of some metals in the pore water; up to 26, 16, 4.1, 2.7 and 82 mg/l have been measured for Al, Mn, Fe and Zn, respectively. Concentrations of metals such as Cd, Co, Cu, Ni and Pb are lower, with average concentrations of 18.4, 83.8, 45, 79.6 and 451 microg/l, respectively. Higher concentrations of major elements such as Ca, Fe, Mn, Mg and S have been measured at depth in pore water than at shallower levels. This is probably caused by flush out of elements after remediation and vertical transport from the upper parts before remediation. The pH is relatively high, approximately 5.5 at most depths in the tailings, except in and around the former oxidation zone where it is lower, and where the highest dissolved concentrations of elements such as As, Cd, Co, Cu, Pb and Zn occur. This is probably due to the release of metals secondarily retained below the oxidation front prior to the remediation. Since the groundwater table is raised, the groundwater reaches the retained metals, which leads to desorption of metals and dissolution of secondary minerals.

Plasma levels of natriuretic peptides and hemodynamic assessment of patent ductus arteriosus in preterm infants.

UNLABELLED: The main purpose of this study was to investigate whether circulating natriuretic peptides in premature infants reflect the hemodynamic significance of a patent ductus arteriosus (PDA). The study comprises 120 examinations in 55 premature infants with a mean gestational age of 27.2 wk and a mean birthweight of 933 g. Based on clinical and echocardiographic findings, the hemodynamic influence of ductal shunting was classified as small, moderate or large. Blood samples for N-terminal proatrial natriuretic peptide (Nt-proANP) and brain natriuretic peptide (BNP) were analysed after completion of the clinical part of the study. Linear regression indicated a very strong association between Nt-proANP and BNP (adjusted R = 0.89). The mean levels of Nt-proANP and BNP increased with the size of the shunt through a PDA, and peptide values followed hemodynamic alterations. The size of PDA accounted for 50% and 47% of the total variation in the plasma values of Nt-proANP and BNP, respectively. In detecting an echocardiographically significant PDA, the area under a ROC curve was 0.94 for Nt-proANP and 0.90 for BNP. CONCLUSION: The magnitude of shunting through a PDA is the main determinant of plasma levels of natriuretic peptides in premature infants. Nt-proANP and BNP seem to have the same pattern of secretion. Our findings indicate that measurements of natriuretic peptides may provide clinically relevant information in the hemodynamic assessment of premature infants.

Skin island urethroplasty in deep urethral lesions--a long-term follow-up of 25 consecutive patients.

Strictures and ruptures of the bulbomembranous urethra have traditionally been treated by a two-stage scrotal skin inlay technique (Johanson B. Reconstruction of the male urethra in strictures. Acta Chir Scand 1953; Suppl 176). For the last 10 years we have treated the patients instead with a skin-dartos island flap pedicled on intertesticular septal vessels. The skin island has been taken from the scrotum, the penile base, or the penile shaft. Twenty-five consecutive patients were treated until 1993 and followed up for at least 5 years. Five of the patients had had open urethroplasty before. Fifteen of the patients had urethral strictures and 10 had complete ruptures. Of the 25 patients 6 had to have a further operation; in 4 patients this was because of restricture, in 1 patient a urethral pouch had to be reduced, and in the final patient the operation was both for restricture and pouch formation. At final follow-up impaired micturition occurred in three patients: two of them had had a ruptured urethra treated previously, and one had a chronic infectious stricture. Problems related to hirsutism were low. No obvious advantage was detected from using distal penile skin, so a skin-dartos island from the penile base is advocated. In conclusion, a one-stage skin-dartos island flap pedicled on the intertesticular septal vessels may be recommended in the treatment of both strictures and complete ruptures in the bulbomembranous urethra.

Plasma levels of N-terminal proatrial natriuretic peptide in children are dependent on renal function and age.

Plasma levels of natriuretic peptides are used as diagnostic markers of heart failure. The aim of this study was to analyse the relation between plasma levels of N-terminal proatrial natriuretic peptide (Nt-proANP) and renal function, and to develop reference values in children. Nt-proANP was measured in the plasma of 86 patients whose glomerular filtration rate (GFR) was determined by use of the X-ray contrast medium iohexol and a fluorescence technique. Blood samples for Nt-proANP were also collected in 399 reference children, aged 0 - 15 years. The relationship between Nt-proANP and GFR was examined using a multiple regression analysis. The mean value of Nt-proANP was markedly higher in children with heart failure than in children with malignant or urologic diseases (p<0.001). The variability in plasma levels of Nt-proANP was mainly (adjusted R2=0.81) explained by the following four variables: presence of heart failure, GFR, age and previous treatment with anthracyclins. Plasma levels of the peptide are raised at birth, but fall rapidly to adult levels. We conclude that the plasma levels of Nt-proANP are age-dependent. Moderately elevated values were registered in children with severe renal impairment. Heart failure is regularly associated with excessive elevation of Nt-proANP in plasma. Our findings suggest that the influence of heart failure on levels of this peptide in children greatly exceeds the influence of renal dysfunction.

[Thromboembolic diseases in children]. / Tromboemboliske sykdommer hos barn.

The incidence of thromboembolic diseases in children is increasing, probably as a consequence of medical progress and modern intensive care. Due to lack of scientific evidence, clinical recommendations for treatment of children are mainly based on opinions and extrapolations from adult medicine. This article presents current concepts of thromboembolic diseases in children, based on a review of the literature. Characteristic features are presented and differences between the disease in adults and children are outlined. Guidelines for antithrombotic treatment are provided. We suggest that screening for thrombophilic disorders should be performed on wide indications, and that modern principles of treatment in adult medicine should also be applied for children with thromboembolic diseases.

The character of the suspended and dissolved phases in the water cover of the flooded mine tailings at Stekenjokk, northern Sweden.

Studies of the suspended and dissolved phases of the pond water, material collected from sediment traps, and surficial sediments/tailings from the flooded tailings pond at Stekenjokk have been performed. The aim was to characterise the material, to study the seasonal variations and to quantify possible resuspension of the tailings in the pond. The element concentrations in the pond at Stekenjokk seem to be largely controlled by processes controlling the precipitation and dissolution of Mn- and Fe-oxyhydroxides in both the water column and in the surficial tailings. Physiochemical processes such as weathering of silicates on the surrounding mountain slopes or dykes contributes both dissolved elements and detrital particles. The suspended phase consists of detrital silicate material as well as Fe- and Mn-oxyhydroxides. The average heavy metal concentrations are high, e.g. 0.42% Cu, 0.15% Pb and 3.1% Zn, which is probably due to sorption onto Fe- and Mn-oxyhydroxides. The suspended phase is richer in Fe, and particularly Mn, during the winter. The suspended phase resembles the material collected in sediment traps and the material in the surficial sediments. The pond water is well mixed during the ice-free season. The dissolved heavy metal concentrations are generally rather low with, e.g. maximum concentrations of 2.03 micrograms/l Cu, 0.23 microgram/l Pb and 268 micrograms/l Zn during the winter. Higher dissolved concentrations are found below the ice-cover above the sediment surface during the winter, caused by diffusion of elements from the sediment-water interface up into the pond water. Most of the metals occurring in the pond are dissolved and resuspension of tailings is negligible.

The lateral thoracodorsal flap in breast reconstruction: a comparison between two plastic surgical centres.

In a retrospective study the results of breast reconstruction with 146 lateral thoracodorsal flaps operated on during the period 1991-94 at the Departments of Plastic Surgery at the Sahlgrenska University Hospital in Göteborg and the Stockholm Söder Hospital were evaluated. The median age of the 135 patients was 51 years (range 37-74). About two thirds of the patients were also operated on on the opposite side at the same time; and this was done more often in Stockholm, which partly explains the longer operating time in Stockholm. Perioperative bleeding (median 100 ml, range 25-400) was similar in both groups. Median postoperative bleeding, which was measured only in Stockholm, was 300 ml (range 30-1000). Seromas were seen only in Göteborg where postoperative drains were rarely used. The rate of early complications (infection and partial necrosis) were higher in Stockholm where more flaps were raised in irradiated tissue. We conclude that the results were similar in the two centres, and the thoracodorsal flap gives good results. The incidence of early morbidity could be reduced by excluding patients who had been irradiated, by inserting drains, and by giving antibiotic prophylaxis.

Clinical follow up of the lateral thoracodorsal flap in breast reconstruction: comparative evaluation from two plastic surgical centres.

A follow up study that compared the results from two plastic surgical centres comprised 95 patients after breast reconstruction with the lateral thoracodorsal (LTD) flap combined with either a smooth or textured saline-filled implant. It was conducted a median of 39 months (range 15-67) after the reconstruction. We investigated the size of the reconstructed breast and LTD flap, symmetry of the breasts, orientation of the mastectomy scar, and the rate of capsular contracture, which were similar in the two centres. However, according to the modified Baker classification and applanation tonometry reconstructions with smooth-surfaced implants and drainage of the implant pocket resulted in softer breasts (p = 0.03). The LTD flap technique in breast reconstruction was a good choice, particularly for women who required a minor breast reconstruction, and the technique can be recommended for suitable patients.

[Thromboembolic diseases in children]. / Tromboemboliske sykdommer hos barn.

The incidence of thromboembolic diseases in children is increasing, probably as a consequence of medical progress and modern intensive care. Due to lack of scientific evidence, clinical recommendations for treatment of children are mainly based on opinions and extrapolations from adult medicine. This article presents current concepts of thromboembolic diseases in children, based on a review of the literature. Characteristic features are presented and differences between the disease in adults and children are outlined. Guidelines for antithrombotic treatment are provided. We suggest that screening for thrombophilic disorders should be performed on wide indications, and that modern principles of treatment in adult medicine should also be applied for children with thromboembolic diseases.

[Measurements of N-terminal proatrial natriuretic factor in children]. / Måling av N-terminal proatrial natriuretisk faktor hos barn.

Measurement of plasma levels of natriuretic peptides are now in clinical use in adult patients with heart failure. Experiences in adult medicine cannot be extended to paediatric cardiology due to important physiological differences between adults and children. The haemodynamic background of heart failure in children with congenital heart disease is diverse, and there is no relevant functional or echocardiographic grading system. The authors present results from published studies and summarizes the results of a research project concerning the clinical potential of N-terminal proatrial natriuretic peptide (Nt-proANP) in paediatric cardiology. Peptide levels in newborn children with or without disease are not fully clarified. In children above three months of age, an elevated Nt-proANP value strongly indicates haemodynamic imbalance. This may be important in the follow-up of children with congenital heart disease. A normal value does not exclude the presence of heart disease. A case report illustrates the clinical use of Nt-proANP, and peptide levels in different haemodynamic situations are discussed.

Elevation of atrial natriuretic peptide prohormone. Hemodynamic background of the elevation of N-terminal natriuretic peptide prohormone in children with congenital heart disease.

We postulated previously that variables related to pulmonary flow are independent predictors of levels of atrial natriuretic peptide in children with congenital heart disease. The aim of this study was to test this hypothesis in relation to other hemodynamic and clinical variables. During catheterization we measured the levels of plasma N-terminal atrial natriuretic peptide prohormone in the plasma of 68 children with congenital heart disease. All had undergone complete clinical, echocardiographic and invasive hemodynamic investigations. The influence on the prohormone was analyzed for 10 different variables in a multiple linear regression model. The variability could be explained in large parts (adjusted R2 =77.2%) by variations in atrial pressures or sizes, together with the degree of excessive pulmonary blood flow and signs of heart failure. A value for atrial natriuretic peptide prohormone above 800 pmol/l predicted hemodynamic imbalance (defined as elevated pressures in left or right atrium or the pulmonary arteries, and/or Qp/Qs > 1.5) with a specificity of 94%, a sensitivity of 73%, a positive likelihood ratio of 12.2, and a negative likelihood ratio of 0.29. In conclusion, variables related to pulmonary blood flow are influential determinants of the levels of atrial natriureic peptide in children with congenital heart disease. Atrial pressures, and symptoms of heart failure are also of major importance.