The Role Of Family Psychosocial Variables In Glucose Control Of Children And Adolescents With Insulin-dependent Diabetes Mellitus: A Six Month Study

The relationship of psychosocial factors to glucose control in persons with Insulin Dependent Diabetes Mellitus (IDDM) is not clearly understood. The present study examined the effects of sources of stress and its mediators and moderators on glucose control in children with IDDM. Forty children with IDDM and their caretakers were followed for a period of six months with data collected at two 3 month intervals (phase 1 and phase 2). The primary caretaker and child provided ratings of sources of general and diabetes related stress. General and diabetes related social support, coping and behavior measures were collected as well as health history and demographic information. Glucose control was measured through an aggregated daily measure, glycosylated hemoglobin levels (GHB) and the number of hypoglycemic reactions.;The results indicated that the children in this study had more internal and external behavior problems than their nonchronically ill peers. It was not clear, however, if the caretakers rated their chronically ill children\u27s behavior in a more negative light, or if the children did have elevated behavior problems relative to the normative sample.;The measures of glucose control were demonstrated to be complementary, rather than redundant indices, and were differentially sensitive to certain psychosocial factors within and across phases of the study. Sources of stress and supportive diabetes related behaviors reported by primary caretaker and child were associated with variability in daily glucose control within phases of the study. Across phases, primary caretaker stress predicted GHB levels; while the daily measure of glucose control predicted primary caretaker stress and nonsupportive diabetes related behaviors.;The age of the child proved to be an important factor in daily glucose control. The younger the child, the more variable the daily glucose control. In addition, there was a moderating effect of the age of the child on primary caretaker sources of stress in the prediction of later daily glucose control.;The across phase analyses revealed preliminary evidence to support the existence of a unidirectional causal relation, with daily glucose control predicting later sources of stress in the primary caretaker and nonsupportive diabetes related behavior. In addition, primary caretaker sources of stress predicted GHB levels. Further examination of the existence of a circular relationship between sources of stress and measures of glucose control (i.e., GHB and daily measure) is warranted.;Although the findings are preliminary, they underscore the importance of using more than one outcome measure when looking at the effects of psychosocial factors on glucose control. The differential sensitivity of the daily glucose measure to certain psychosocial factors was explained by the proposal that the effect of psychosocial factors does not cause a tonic change in glucose control, but rather produces fluctuations that were only reflected in the daily measures of glucose control. Clinical and research implications of the findings were discussed. The limitations of the present study were outlined and future research was proposed

Health-status outcomes with invasive or conservative care in coronary disease

BACKGROUND In the ISCHEMIA trial, an invasive strategy with angiographic assessment and revascularization did not reduce clinical events among patients with stable ischemic heart disease and moderate or severe ischemia. A secondary objective of the trial was to assess angina-related health status among these patients. METHODS We assessed angina-related symptoms, function, and quality of life with the Seattle Angina Questionnaire (SAQ) at randomization, at months 1.5, 3, and 6, and every 6 months thereafter in participants who had been randomly assigned to an invasive treatment strategy (2295 participants) or a conservative strategy (2322). Mixed-effects cumulative probability models within a Bayesian framework were used to estimate differences between the treatment groups. The primary outcome of this health-status analysis was the SAQ summary score (scores range from 0 to 100, with higher scores indicating better health status). All analyses were performed in the overall population and according to baseline angina frequency. RESULTS At baseline, 35% of patients reported having no angina in the previous month. SAQ summary scores increased in both treatment groups, with increases at 3, 12, and 36 months that were 4.1 points (95% credible interval, 3.2 to 5.0), 4.2 points (95% credible interval, 3.3 to 5.1), and 2.9 points (95% credible interval, 2.2 to 3.7) higher with the invasive strategy than with the conservative strategy. Differences were larger among participants who had more frequent angina at baseline (8.5 vs. 0.1 points at 3 months and 5.3 vs. 1.2 points at 36 months among participants with daily or weekly angina as compared with no angina). CONCLUSIONS In the overall trial population with moderate or severe ischemia, which included 35% of participants without angina at baseline, patients randomly assigned to the invasive strategy had greater improvement in angina-related health status than those assigned to the conservative strategy. The modest mean differences favoring the invasive strategy in the overall group reflected minimal differences among asymptomatic patients and larger differences among patients who had had angina at baseline

Initial invasive or conservative strategy for stable coronary disease

BACKGROUND Among patients with stable coronary disease and moderate or severe ischemia, whether clinical outcomes are better in those who receive an invasive intervention plus medical therapy than in those who receive medical therapy alone is uncertain. METHODS We randomly assigned 5179 patients with moderate or severe ischemia to an initial invasive strategy (angiography and revascularization when feasible) and medical therapy or to an initial conservative strategy of medical therapy alone and angiography if medical therapy failed. The primary outcome was a composite of death from cardiovascular causes, myocardial infarction, or hospitalization for unstable angina, heart failure, or resuscitated cardiac arrest. A key secondary outcome was death from cardiovascular causes or myocardial infarction. RESULTS Over a median of 3.2 years, 318 primary outcome events occurred in the invasive-strategy group and 352 occurred in the conservative-strategy group. At 6 months, the cumulative event rate was 5.3% in the invasive-strategy group and 3.4% in the conservative-strategy group (difference, 1.9 percentage points; 95% confidence interval [CI], 0.8 to 3.0); at 5 years, the cumulative event rate was 16.4% and 18.2%, respectively (difference, 121.8 percentage points; 95% CI, 124.7 to 1.0). Results were similar with respect to the key secondary outcome. The incidence of the primary outcome was sensitive to the definition of myocardial infarction; a secondary analysis yielded more procedural myocardial infarctions of uncertain clinical importance. There were 145 deaths in the invasive-strategy group and 144 deaths in the conservative-strategy group (hazard ratio, 1.05; 95% CI, 0.83 to 1.32). CONCLUSIONS Among patients with stable coronary disease and moderate or severe ischemia, we did not find evidence that an initial invasive strategy, as compared with an initial conservative strategy, reduced the risk of ischemic cardiovascular events or death from any cause over a median of 3.2 years. The trial findings were sensitive to the definition of myocardial infarction that was used