Growth and maturation of children with insulin-dependent diabetes mellitus.

The purpose of this paper is to define criteria used for classifying patients into varying degrees of diabetic control and to verify that children with diabetes maintained in higher degrees of metabolic control do not have delayed growth and maturation. Growth records of 252 children with insulin-dependent diabetes who have been under continuous observation in our clinic at three- to five-month intervals for at least three years and up to 16 years have been individually reviewed and analyzed. All children received two daily injections of a mixture of two parts of an intermediate to one part of regular insulin and were instructed to eat structured meals of high-quality selected foods. An over-all rating for diabetic control based primarily on the frequency and degree of glycosuria was made for the time period between clinic visits. The over-all diabetic control rating and the size of the subgroups were "good"--20 per cent, "fair to good"--64 per cent, and "fair"--16 per cent. All children maintained in "good" and "fair to good" control (84 per cent), grew and matured at a normal rate regardless of the age at onset or duration of diabetes. All children in lower degrees of control coming under care for greater than 24 months after diagnosis had accelerated growth during the early months after attaining a higher degree of control.

Hemoglobin A1c levels in children and adolescents with diabetes mellitus.

Hemoglobin A1c (HbA1c) was measured as an indicator of glucose control in 180 children and adolescents with diabetes mellitus who received two daily injections of insulin as part of a highly structured treatment program. A total of 426 HbA1c determinations was made in the group of 180 patients. HbA1c values were elevated in most patients despite the aggressive treatment. The HbA1c level was very elevated at diagnosis, fell to near normal after 60-90 days of insulin therapy, increased gradually, and reached a plateau after approximately 4 yr duration (at about twice the level in normal subjects) (mean +/- SEM, 10.0 +/- 0.2% and 5.34 +/- 0.07%, respectively). Mean insulin dose (U/kg/24 h) paralleled both HbA1c and duration of diabetes. The relationship between endogenous insulin secretion and glucose control was examined in those patients with diabetes for longer than 5 yr. Patients were separated into three groups based on HbA1c levels: those with HbA1c less than 9% (N = 22), between 9 and 11% (N = 26), and greater than 11% (N = 28). Serum C-peptide and glucose concentrations were measured 2 h after a standard breakfast in those patients in the "low" and "high" HbA1c groups (mean HbA1c values 8.2% and 12.7%, respectively). C-peptide was detectable in all patients and the mean C-peptide levels did not differ significantly in the two groups, although postprandial glucose concentrations were significantly lower in the "low" HbA1c group (means +/- SEM, 96 +/- 11 and 211 +/- 21 mg/dl, respectively; P less than 0.001).

Vitamin A status of preterm infants: correlation between plasma retinol concentration and retinol dose response.

Retinol dose response tests were performed on 83 preterm infants shortly before discharge by giving orally 5000 IU of an aqueous dispersion of retinol. Predose plasma retinol concentrations were 2.5-20.5 micrograms/dL (0.087-0.72 mumol/L) and the retinol dose responses were 0-59.8%. The regression of retinol dose response on predose retinol was -0.58. There was a parallel increase in both retinol and retinol-binding protein and an increase in the molar ratio of retinol-binding protein to prealbumin. Prealbumin did not increase. These findings suggest that preterm infants have reduced liver stores of vitamin A.

Vitamin A status of preterm infants: the influence of feeding and vitamin supplements.

Consecutive weekly determinations of plasma retinol, alpha-tocopherol, retinol-binding protein, prealbumin, and zinc were performed on a group of 58 infants weighing less than 2000 g at birth in an intensive-care nursery. Data were classified by the feeding regimen of the preceding week: parenteral, premature formula, or own mother's milk. Mean plasma-retinol values were less than 20 mcg/dl, the lower limit of normal for adults, with the highest values in the formula-fed group. Retinol-binding protein and prealbumin values were lowest in the parenterally-fed group. Alpha-tocopherol concentrations were consistently maintained at levels higher than 500 mcg/dl only in infants fed their own mother's milk. Mean zinc concentrations above 70 mcg/dl, the lower limit of normal for adults, occurred only in parenterally fed infants. Doubling the recommended vitamin supplement in formula-fed infants did not produce a significant increase in plasma retinol or tocopherol.

Clinical and clinicopathologic effects of samarium-153-EDTMP administered intravenously to normal beagle dogs.

A study was undertaken to determine the degree of acute bone marrow and vital organs injury sustained when dogs were administered doses of 153Sm-EDTMP calculated to irradiate an acute bone lesion arising from cancer metastasis to a dose considered palliative or even therapeutic (20-160 Gy). The study revealed significant (p less than 0.05) temporary depression of the bone marrow in all doses in the therapeutic (greater than 40 Gy) range. Palliative (20 Gy) doses caused significant leukocyte depression but insignificant (p greater than 0.05) depression of platelet and packed cell volumes when compared to control animals. A mild transient rise in the levels of serum alkaline phosphatase occurred immediately following radioisotope administration. All hematologic parameters had returned to normal by six weeks after the last injection of radioisotope. The study indicates potential for this compound as a safe, therapeutic radiopharmaceutical for treatment of cancer bone metastasis.

Physical fitness and work capacity in women with rheumatoid arthritis.

OBJECTIVE: To investigate physical fitness and work capacity in women with rheumatoid arthritis (RA). METHODS: The 42 subjects were a subset of a prospective trial of conditioning exercise in rheumatic disease. Assignment to an exercise or nonexercise group was determined by proximity to the intervention, a 3-month supervised group exercise program. Physical fitness and work capacity were assessed at baseline, 3 months, and 12 months. RESULTS: At baseline, subjects were deconditioned and limited in hand function, lifting ability, and lower extremity mobility. Only the exercise group improved their aerobic capacity and exercise tolerance. There were no significant changes in measured work capacity in either group. Moderate to strong correlations were found between aerobic capacity, mobility, hand function, and work capacity. Grip strength was a strong and consistent correlate of work capacity. CONCLUSION: Our findings suggest that physical capacity, particularly hand function, may be important in the complex phenomenon of work disability in RA.

Multivariate outcome research in arthritis. Implications for sample sizes.

Planning appropriate sample sizes prior to data collection is critical to the overall success of a research project. However, the investigator often encounters practical limitations regarding the number of subjects available. While the literature discusses the various options of analysis of clinical trial data, there is little discussion as to the sample size implications of the statistical method chosen. Since the analysis technique employed affects the required sample size, the investigator should select the analysis that is most appropriate for the data and has the most efficient sample size requirement. This paper addresses the sample size implications of three commonly used methods for comparing two populations when there are two or more outcome measures (multivariate outcome). The concepts and methods are illustrated using a Pain Management Study that was conducted using people with rheumatoid arthritis as subjects.

Protocol for verifying expertise in locating fibromyalgia tender points.

OBJECTIVE: To develop a protocol for determining when an individual is adequately trained to locate the tender points relative to fibromyalgia in an exam. METHODS: The error distance for each tender point was established by polling individuals with experience in conducting tender point exams. Bayesian statistical methods were employed to form a protocol for determining an individual's proficiency in locating the tender points. A predictive distribution was utilized to find the probability of remaining trained at locating tender points. Also, the probability of classifying at least 11 tender points as tender (mild) under different "locating" criteria and different number of points that are truly tender was computed. RESULTS: Critical values indicating the number of tender points needed in the qualification process for various standards of reliability--80%, 85%, and 90%--are presented. To be certified after 3 subjects have been examined in the 80%, 85%, and 90% criteria, one has to correctly identify 48, 50, and 52, respectively, out of the 54 possible tender points. CONCLUSION: We believe that at least 3 subjects should be examined before certification is granted using any of the 3 criteria--80%, 85%, and 90%. In our example, when using the 85% criterion, the qualification process required 7 subjects to certify an individual.

Self-efficacy, pain, and physical activity among fibromyalgia subjects.

PURPOSE: The purpose of this study was to examine the effects of self-efficacy on self-report pain and physical activities among subjects with fibromyalgia (FM). In addition, descriptive statistics of the Arthritis Impact Measurement Scale (AIMS), a measure developed for use with arthritis patients, were reported. METHODS: Seventy-nine subjects with FM, as classified by the American College of Rheumatology (ACR) criteria, completed the Visual Analogue Scale for Pain, the AIMS, and the Arthritis Self-Efficacy Scale. A myalgic score was obtained during a tender point evaluation. Hierarchical multiple regression analyses were used to assess the effect of self-efficacy on self-report pain and physical activities measures after controlling for demographic variables (age, education, and symptom duration), disease severity (myalgic scores), and psychological distress (negative affect from the AIMS). RESULTS: Higher self-efficacy was associated with less pain and less impairment on the physical activities measure after controlling for demographic and disease severity measures. CONCLUSIONS: This study underscores the unique importance of self-efficacy in understanding pain and physical activities impairment.

Biopsychosocial parameters of disease activity in rheumatoid arthritis.

The purpose of this study was to examine the applicability of a biopsychosocial model for estimating disease activity in rheumatoid arthritis (RA). Sixty-three patients with RA were evaluated at baseline, 3 months, and 6 months. Joint counts were collected as the measure of disease activity. Peripheral blood immunophenotypic subsets, demographic characteristics, and psychological measures were obtained and entered into hierarchical regression analyses, with the joint count as the dependent variable. Immunophenotypic subsets (that is, CD57+/CD16-, HLA-DR+) were predictive of disease activity at all three time intervals. At baseline and 3 months, psychological variables (that is, helplessness and depression) were significantly related to joint counts, and the full model was highly significant. The conclusion was that the biopsychosocial perspective is useful for estimating RA disease activity.

Implications of depression in rheumatoid arthritis: do subtypes really matter?

OBJECTIVE: To examine depressive disorders and health status in patients with rheumatoid arthritis (RA), controlling for potential confounds. METHOD: Subjects (n = 426) completed measures of depressive symptoms (Center for Epidemiological Studies Depression Scale [CES-D]) and health status (Arthritis Impact Measurement Scales 2 [AIMS2]), via cross-sectional survey. Subjects (n = 299) with few depressive symptoms (CES-D < or = 10) were not evaluated further. Subjects with CES-D > or = 11 were interviewed using the Primary Care Evaluation of Mental Disorders to diagnose major depressive disorder (MDD; n = 46), dysthymic disorder (DD; n = 21), or minor depressive disorder (MND; n = 18). RESULTS: Regression analyses examined differences between the depressive disorders on AIMS2 subscales. Health status scores were similar between the depressive disorder subcategories; significant differences were found between MDD and MND on AIMS2 Physical scores and MDD and DD on AIMS2 Symptom scores. CONCLUSION: Regarding health status, presence of depression itself seems to overshadow differences between depression subtypes; antidepressant treatments/referrals for persons with concomitant RA and any depressive disorder subtype appear warranted.

Risk factors for depression in rheumatoid arthritis.

OBJECTIVE: To identify risk factors for the development of depression in persons with rheumatoid arthritis (RA). METHODS: Subjects were divided into depressed versus nondepressed groups on the basis of the Center for Epidemiologic Studies-Depression Scale; a range of psychological, pain-related, disease-related, and demographic variables were analyzed to predict depression. Both cross-sectional and longitudinal predictive models were examined. RESULTS: A series of analyses, including multiple logistic regression, found that the optimal predictors of depression in RA were average daily stressors, confidence in one's ability to cope, and degree of physical disability. The model was successfully cross-validated on separate data sets (i.e., same subjects at different time points). CONCLUSION: All of the identified risk factors for depression in RA are preventable to some extent and, therefore, should be addressed in comprehensive, rheumatology team care.

A biopsychosocial model of disability in rheumatoid arthritis.

OBJECTIVE: To test and cross-validate a model using disease activity, pain, and helplessness to predict future psychological and physical disability in persons with rheumatoid arthritis (RA) across time. METHODS: Measures of disease activity, pain, helplessness, psychological function, and physical function were collected from 63 males with RA at baseline, 3 months, and 6 months. Path analytic methods were used to examine longitudinal relationships among these variables. RESULTS: Path analysis revealed that pain and helplessness were significant mediators of the relationship between disease activity and future disability in RA; the predictive model withstood two cross-validations. CONCLUSION: The findings suggest that pain and helplessness are key biopsychosocial variables that affect the development of disability in RA.

Self-efficacy predicting outcome among fibromyalgia subjects.

OBJECTIVES: This study examined whether pretreatment self-efficacy and pre- to post-treatment changes in self-efficacy predict post-treatment tender point index, disease severity, pain, and physical activity. METHODS: One hundred nine subjects with fibromyalgia were assessed before and after a 6-week training intervention. Measures included tender point index, physician ratings of disease severity, the visual analog scale for pain, the Physical Activities subscale of the Arthritis Impact Measurement Scales, and the Arthritis Self-Efficacy Scale. RESULTS: Pretreatment self-efficacy significantly predicted post-treatment physical activity, with higher self-efficacy associated with better physical activity outcome. Changes in self-efficacy significantly predicted post-treatment tender point index, disease severity, and pain; improvements in self-efficacy were associated with better outcomes on each measure. CONCLUSIONS: Higher levels of self-efficacy are associated with better outcome, and may mediate the effectiveness of rehabilitation-based treatment programs for fibromyalgia.

Stress management in rheumatoid arthritis: what is the underlying mechanism?

OBJECTIVE: To test whether change in cognitive-behavioral variables (such as self-efficacy, coping strategies, and helplessness) is a mediator in the relation between cognitive behavior therapy and reduced pain and depression in persons with rheumatoid arthritis (RA). METHODS: A sample of patients with RA who completed a stress management training program (n = 47) was compared to a standard care control group (n = 45). A path analysis testing a model including direct effects of comprehensive stress management training on pain and depression and indirect effects via change in cognitive-behavioral variables was conducted. RESULTS: The path coefficients for the indirect effects of stress management training on pain and depression via change in cognitive-behavioral variables were statistically significant, whereas the path coefficients for the direct effects were found not to be statistically significant. CONCLUSION: Decreases in pain and depression following stress management training are due to beneficial changes in the arenas of self-efficacy (the belief that one can perform a specific behavior or task in the future), coping strategies (an individual's confidence in his or her ability to manage pain), and helplessness (perceptions of control regarding arthritis). There is little evidence of additional direct effects of stress management training on pain and depression.

The importance of enhancing self-efficacy in rheumatoid arthritis.

OBJECTIVE: To examine relationships among changes in self-efficacy and changes in other clinically relevant outcome measures. METHOD: Subjects (n = 44) were participants in a prospective, randomized stress-management study followed over 15 months. Outcome measures included self-efficacy, depression, pain, health status, and disease activity. RESULTS: Correlational analyses revealed significant associations between changes in self-efficacy (particularly total self-efficacy) and changes in selected measures of depression, pain, health status, and disease activity. The observed associations were not due to changes in medication regimen or to nonadherence to the stress-management program. CONCLUSIONS: Evidence is provided that induced changes in self-efficacy following a stress-management program were significantly related to other clinically important outcome measures.

Disease and family contributors to adaptation in juvenile rheumatoid arthritis and juvenile diabetes.

OBJECTIVE: Research in the areas of pediatric rheumatology and pediatric chronic illness has emphasized comprehensive models of adaptation involving risk and resistance factors. This study examined adaptation, within this framework, among a large sample of children with chronic illness and children without chronic illness. METHODS: A comprehensive battery of adaptation measures was administered to a sample of 107 children with juvenile rheumatoid arthritis, 114 children with insulin-dependent diabetes mellitus, and 88 healthy controls. RESULTS: Medical diagnosis was associated with mothers' depression and a composite measure of parental (mother and father) distress and passive coping. Children's emotional and behavioral functioning was not related to medical diagnosis, but mothers' depression and parental distress were associated with child behavior problems. CONCLUSION: Because parental distress was associated with child functioning, interventions to ameliorate parental distress may have beneficial effects on the children's behavior and on parents' reactions to their children.

Biofeedback/relaxation training and exercise interventions for fibromyalgia: a prospective trial.

OBJECTIVE: To compare the effectiveness of biofeedback/relaxation, exercise, and a combined program for the treatment of fibromyalgia. METHODS: Subjects (n = 119) were randomly assigned to one of 4 groups: 1) biofeedback/relaxation training, 2) exercise training, 3) a combination treatment, or 4) an educational/attention control program. RESULTS: All 3 treatment groups produced improvements in self-efficacy for function relative to the control condition. In addition, all treatment groups were significantly different from the control group on tender point index scores, reflecting a modest deterioration by the attention control group rather than improvements by the treatment groups. The exercise and combination groups also resulted in modest improvements on a physical activity measure. The combination group best maintained benefits across the 2-year period. CONCLUSION: This study demonstrates that these 3 treatment interventions result in improved self-efficacy for physical function which was best maintained by the combination group.

Trajectories of adaptation in pediatric chronic illness: the importance of the individual.

This study used individual growth modeling to examine individual difference and group difference models of adaptation. The adaptation of 27 children with juvenile rheumatoid arthritis (JRA) and 40 children with insulin-dependent diabetes mellitus (IDDM) was tracked for 18 months from diagnosis. A control group of 62 healthy children was followed over the same time period. Clustering procedures indicated that child and family adaptation could be described by a number of distinct adaptation trajectories, independent of diagnostic group membership. In contrast, parental adaptation trajectory was associated with diagnostic group membership and control over disease activity for the JRA group and with diagnostic group membership for healthy controls. The observation of common patterns across trajectory sets, as well as the finding that trajectories were differentially related to a number of variables of interest, support the use of trajectories to represent adaptation to chronic disease.

Occurrence and implications of seizures in subarachnoid hemorrhage due to ruptured intracranial aneurysms.

The records of 100 consecutive cases of subarachnoid hemorrhage due to ruptured aneurysm were reviewed to determine the incidence and the prognostic implications of seizures during the acute phase. Seizures occurred in 26% of the patients. Sixty-three per cent of the seizures occurred near the onset of the initial hemorrhage. The occurrence of these early seizures did not correlate with the location of the aneurysm or the prognosis. Most of the remaining seizures occurred immediately after rebleeding, with no greater morbidity or mortality compared to all patients who rebled. Pathogenic mechanisms of seizures associated with subarachnoid hemorrhage are proposed and discussed.