Neurodevelopmental outcomes after infant cardiac surgery with circulatory arrest and intermittent perfusion.

BACKGROUND: Optimal perfusion strategies for neuroprotection during infant cardiac surgery remain undefined. Despite encouraging experimental data, neurodevelopmental (ND) outcomes after cardiac surgery in neonates and infants using deep hypothermic circulatory arrest (DHCA) with a period of intermittent perfusion have not been reported, and it is not known whether DHCA can be extended while preserving ND outcomes. METHODS: Cross-sectional ND evaluation with the Bayley Scales of Infant and Toddler Development, Third Edition was conducted at 24 months of age. Retrospective clinical data were extracted from the electronic medical record. RESULTS: Forty patients underwent cardiac surgery during the first year of life using a period of uninterrupted DHCA (24 patients) or DHCA interrupted by a period of intermittent perfusion (16 patients). Total duration of DHCA ranged from 5 to 74 minutes and did not predict ND scores. Despite a longer exposure to DHCA in the intermittent perfusion group (55 minutes [1,3 interquartile [IQ] 45.3 to 65.5] versus 38 minutes [1,3 IQ 32 to 40.8]), no differences in ND scores were detected. Significant comorbidities, duration of intensive care unit and hospital stay, as well as multiple procedures with DHCA were independent predictors of ND outcomes at 24 months of age. CONCLUSIONS: Despite extended duration of total DHCA, the use of a period of intermittent perfusion to limit uninterrupted DHCA periods to less than 45 minutes could lead to ND outcomes similar to those of patients exposed to brief periods of DHCA. Deep hypothermic circulatory arrest with intermittent perfusion may facilitate implementation of prospective studies to identify the optimal cerebral perfusion strategy.

Predictive value of perioperative near-infrared spectroscopy for neurodevelopmental outcomes after cardiac surgery in infancy.

OBJECTIVE: The study objective was to expand on prior research examining intraoperative regional cerebral oxygen saturation (rSO(2)) measured by near-infrared spectroscopy (NIRS) by evaluating the predictive value of perioperative NIRS monitoring for neurodevelopmental outcomes after infant cardiac surgery. METHODS: Cross-sectional neurodevelopmental evaluation at 24 months of age with the Bayley Scales of Infant and Toddler Development, Third Edition was performed for patients who underwent cardiac surgery with perioperative NIRS monitoring between 2007 and 2010. Retrospective clinical data were extracted from the electronic medical record. Evaluation of selected NIRS measures, including preoperative rSO(2) (baseline) as well as rSO(2) nadir and percent decrease from baseline during the intraoperative and early postoperative periods, was undertaken. RESULTS: Perioperative NIRS and neurodevelopmental data were available for 31 patients without chromosomal anomalies who underwent cardiac surgery during infancy at a median age of 0.43 months. Optimal thresholds on NIRS measures identified through receiver operating characteristic analyses were intraoperative percent decrease of 52% for receptive communication delay and postoperative rSO(2) nadir of 56% for cognitive delay and 49% for gross motor delay. When considered in conjunction with other clinical characteristics in stepwise linear regression analyses, intraoperative percent decrease of more than 52% entered into the final model for receptive communication outcome and postoperative rSO(2) nadir of less than 56% entered into the final model for cognitive outcome. CONCLUSIONS: Perioperative NIRS monitoring seems to enhance the ability to predict neurodevelopmental outcome. Specific NIRS measures associated with neurodevelopmental outcome, as well as optimal thresholds, seem to differ across the continuum of the perioperative period.

Mother-father informant discrepancies regarding diabetes management: associations with diabetes-specific family conflict and glycemic control.

OBJECTIVE: To examine the relationship of mother-father informant discrepancies regarding diabetes management to diabetes-specific family conflict and glycemic control. METHODS: One hundred thirty-six mothers and fathers of youth with Type 1 diabetes reported on the youth's diabetes management, diabetes-specific family conflict, and amount of paternal involvement in diabetes care. Glycosylated hemoglobin A1c (HbA1c) was used to measure glycemic control. RESULTS: As hypothesized, mother-father discrepancies regarding diabetes management were positively associated with frequency of diabetes-specific family conflict. Contrary to hypotheses, mother-father discrepancies regarding diabetes management predicted poorer glycemic control for youth with less involved fathers only. CONCLUSIONS: Results highlight the importance of caregivers being consistent about pediatric illness management and support the idea that informant discrepancies represent an important window into the functioning of the family system.

Predictive value of near-infrared spectroscopy on neurodevelopmental outcome after surgery for congenital heart disease in infancy.

OBJECTIVE: To explore the relationship between intraoperative regional cerebral oxygen saturation (rSO(2)) measured by near-infrared spectroscopy (NIRS) and neurodevelopmental outcome in children after cardiac surgery. METHODS: Cross-sectional neurodevelopmental evaluation at 2 years of age was performed in a cohort of young infants who had surgery for congenital heart disease in 2007. The third edition of Bayley Scales of Infant and Toddler Development (Bayley-III) was used to assess cognitive, language, and motor functioning. Clinical and perioperative data were collected, including intraoperative rSO(2) nadir, rSO(2) percent decrease from baseline, and cumulative minutes of at least 20%, 30%, and 40% decrease from baseline. RESULTS: Twenty-seven patients without chromosomal abnormality were included in analyses. Mean Bayley-III scores fell within 1 standard deviation of the normative mean. Stepwise regression analyses of patient- and procedure-related variables, including rSO(2), demonstrated that cognitive ability was predicted by length of hospital stay and premature birth (58.1% of variance), receptive communication was predicted by length of hospital stay and rSO(2) nadir (40.2% of variance), expressive communication was predicted by birth weight (26.2% of variance), fine motor functioning was predicted by duration of cardiac intensive care unit stay (41.4% of variance), and gross motor functioning was predicted by the presence of a significant comorbidity (43.5% of variance). CONCLUSIONS: In a contemporary cohort of infants undergoing surgery for congenital heart disease, neurodevelopmental outcomes at 2 years of age are largely influenced by patient-related characteristics. Although receptive communication appears to be influenced by rSO(2) nadir, the predictive value of NIRS remains unclear.

Anxiety, mood, and substance use disorders in parents of children with anxiety disorders.

Examined the prevalence of anxiety, mood, and substance use disorders in the parents of anxiety disordered (AD) children relative to children with no psychological disorder (NPD). The specificity of relationships between child and parent anxiety disorders was also investigated. Results revealed higher prevalence rates of anxiety disorders in parents of AD children relative to NPD children. Specific child-mother relationships were found between child separation anxiety and panic disorder and maternal panic disorder, as were child and maternal social phobia, obsessive compulsive disorder, and specific phobias. Findings are discussed with reference to theory, clinical implications, and future research needs.

Diagnosis and treatment of pathologic gambling.

Pathologic gambling (PG) is an impulse control disorder characterized by recurrent and maladaptive gambling behaviors that significantly disrupt the patient's functioning in the personal, familial, or vocational spheres. Pathologic gambling is estimated to currently affect 1% to 3.4% of the adult US population and is frequently comorbid with substance abuse or dependence, attention-deficit/hyperactivity disorder (ADHD), and affective disorders. Studies show evidence for the involvement of the serotonergic, noradrenergic, and dopaminergic systems in the etiology of PG. Medication treatment studies performed in PG patients demonstrated the short-term efficacy of various serotonin reuptake inhibitors, opioid antagonists, and mood stabilizers in a subsample of adult pathologic gamblers who seek treatment. This review focuses on recent research examining the neurobiology and treatment of PG.