BACKGROUND & AIMS: BACKGROUND:Central venous oxygen saturation (ScvO2) remains the gold standard surrogate for tissue oxygen extraction in paediatric cardiac surgery. Near-infrared spectroscopy (NIRS) has been developed as a non-invasive diagnostic tool for regional oxygen saturation. The aim was to compare regional oxygen saturation measured by NIRS with ScvO2 in postoperative paediatric cardiac patients. METHODS:In this prospective study, we included newborns and infants younger than 45 days undergoing heart surgery. We recorded continuous ScvO2 and NIRS regional saturation placed on the forehead (B) and right flank (S) for 48 h postoperatively. A Bland-Altman's analysis was used to assess the agreement between these measurements. RESULTS:A total of 23 patients were included with a median age of 12 days (2-46) and median weight of 3.1 kg (2.3-4.47). The mean difference (MD) ScvO2- B NIRS was 10.45% with limits of agreement (LOA) -17.23 to 38.13% and ScvO2- S NIRS MD 7.16% with LOA: -25.51 to 39.84%. The single ventricle ScvO2- S NIRS subgroup had MD within ± 5%; however, wide LOA was observed. The remaining subgroups showed MD nearly above ± 5%, with wide LOA. CONCLUSIONS:The regional oxygen saturation of brain and kidney did not match ScvO2 as estimation of global tissue perfusion. Nevertheless, NIRS may still provide information regarding regional circulation that may help in the management of neonatal cardiac surgery patients.

背景与目标：

BACKGROUND & AIMS: OBJECTIVE:To identify early clinical factors that are correlated with death or severe disability in paediatric patients who have sustained an injury by hanging or strangulation. METHODS:A retrospective review of all patient records from January 1, 1997, to September 30, 2007, was conducted. Patient records were identified by International Classification of Diseases and Related Health Problems, Tenth Revision, Canada diagnostic codes for asphyxia, strangulation, hypoxic-ischemic encephalopathy, hanging, hypoxemia, hypoxia or anoxia. RESULTS:A total of 109 records were identified. Of these, 41 met the inclusion criteria for the study. Of 19 (46%) children who were pulse-less and received cardiopulmonary resuscitation, 16 died and the survivors were severely disabled. Of the 22 (54%) children who were found with a pulse, 18 made a full recovery. CONCLUSIONS:Children who are pulseless at discovery for hanging injuries are at high risk of death or severe disability. Early clinical and neurophysiological indicators should be applied systematically to best guide clinicians and parents in their decision making.

背景与目标：

BACKGROUND & AIMS: Two distinct trends can be identified in the context within which nursing care is planned and delivered. One is the continuous pressure to find ways of increasing efficiency and cost-effectiveness. The second is the widespread expectation that public services in general, and health services in particular, should be monitored and evaluated. In these circumstances, nurses and their managers need a range of evaluative tools so that changes in the organization of nursing care can be evaluated. Hackman and Oldham's 'Job Diagnostic Survey' (JDS) approach was tested in a Paediatric Unit in which aspects of primary nursing were being introduced. The paper outlines the JDS approach in the Unit in question and offers an assessment of the value of the JDS as an evaluative tool.

背景与目标： 在计划和提供护理的背景下，可以确定两个不同的趋势。一是不断寻求提高效率和成本效益的方法的压力。第二是普遍期望对一般公共服务，特别是卫生服务进行监测和评估。在这种情况下，护士及其管理人员需要一系列评估工具，以便可以评估护理组织的变化。Hackman和Oldham的 “工作诊断调查” (JDS) 方法在儿科病房中进行了测试，其中介绍了初级护理的各个方面。本文概述了有关单位中的JDS方法，并提供了对JDS作为评估工具的价值的评估。

BACKGROUND & AIMS: BACKGROUND:The relative importance of previous diagnosis and hereditary prothrombotic risk factors for cerebral venous thrombosis (CVT) in children in determining risk of a second cerebral or systemic venous thrombosis (VT), compared with other clinical, neuroimaging, and treatment variables, is unknown. METHODS:We followed up the survivors of 396 consecutively enrolled patients with CVT, aged newborn to 18 years (median 5.2 years) for a median of 36 months (maximum 85 months). In accordance with international treatment guidelines, 250 children (65%) received acute anticoagulation with unfractionated heparin or low-molecular weight heparin, followed by secondary anticoagulation prophylaxis with low-molecular weight heparin or warfarin in 165 (43%). RESULTS:Of 396 children enrolled, 12 died immediately and 22 (6%) had recurrent VT (13 cerebral; 3%) at a median of 6 months (range 0.1-85). Repeat venous imaging was available in 266 children. Recurrent VT only occurred in children whose first CVT was diagnosed after age 2 years; the underlying medical condition had no effect. In Cox regression analyses, non-administration of anticoagulant before relapse (hazard ratio [HR] 11.2 95% CI 3.4-37.0; p<0.0001), persistent occlusion on repeat venous imaging (4.1, 1.1-14.8; p=0.032), and heterozygosity for the G20210A mutation in factor II (4.3, 1.1-16.2; p=0.034) were independently associated with recurrent VT. Among patients who had recurrent VT, 70% (15) occurred within the 6 months after onset. CONCLUSION:Age at CVT onset, non-administration of anticoagulation, persistent venous occlusion, and presence of G20210A mutation in factor II predict recurrent VT in children. Secondary prophylactic anticoagulation should be given on a patient-to-patient basis in children with newly identified CVT and at high risk of recurrent VT. Factors that affect recanalisation need further research.

背景与目标：

BACKGROUND & AIMS: :Forty-three children for day case inguinal herniotomy under general anaesthesia were assigned randomly to receive either 1 ml/kg caudal bupivacaine 0.25% or rectal diclofenac 0.25 mg/kg intra-operatively to provide postoperative analgesia. Pain and demeanour were assessed by an observer in the early postoperative period after operation and by questionnaire for the parents over the first 24 hours. Caudal bupivacaine provided more pain-free patients at first but later the incidence of pain was similar in the two treatment groups. Rectal diclofenac is a useful alternative to caudal blockade in this group of patients.

背景与目标： : 43名在全身麻醉下进行日间手术的腹股沟疝切开术的儿童被随机分配接受1毫升/kg的尾侧布比卡因0.25% 或直肠双氯芬酸0.25 mg/kg的术中，以提供术后镇痛。在术后早期，由观察者评估疼痛和举止，并在最初的24小时内对父母进行问卷调查。尾侧布比卡因起初提供了更多无疼痛的患者，但后来两个治疗组的疼痛发生率相似。在这组患者中，直肠双氯芬酸是尾管阻滞的有用替代品。

BACKGROUND & AIMS: BACKGROUND:Oral health literacy is a newly emerging field with considerable research potential. AIM:To validate an original instrument, the Hong Kong Oral Health Literacy Assessment Task (HKOHLAT-P) for paediatric dentistry. DESIGN:A convenient sample of 200 child/parent dyads attending a dental hospital in Hong Kong was selected. Convergent validity was tested by examining the association of HKOHLAT-P scores with those derived from the Test of Functional Health Literacy in Dentistry (TOFHLiD) and Hong Kong Rapid Estimate of Adult Literacy in Dentistry (HKREALD-30). The predictive validity of HKOHLAT-P was determined by testing the association between HKOHLAT-P and children's caries experience (dmft) and the Chinese Early Childhood Oral Health Impact Scale (ECOHIS). The test-retest reliability and internal consistency of HKOHLAT-P were also evaluated. RESULTS:HKOHLAT-P was positively correlated with TOFHLiD and HKREALD-30 (P < 0.01), and was negatively correlated with children's dmft and ECOHIS. In the regression model, HKOHLAT-P was associated with TOFHLiD, HKEALD-30, children's dmft, and ECOHIS (P < 0.05) after controlling for participants' demographic characteristics. The intra-class correlation coefficient of HKOHLAT-P was 0.63 and the Cronbach's α was 0.71. CONCLUSION:Initial testing of HKOHLAT-P suggested that it is a valid and reliable instrument.

背景与目标：

BACKGROUND & AIMS: :The success of paediatric liver transplantation is attributed to improved surgical techniques and the advent of calcineurin inhibitor-based immunosuppression. Acute rejection (AR) rarely results in graft loss with calcineurin inhibitor immunosuppressive regimens, and the advent of newer agents like interleukin (IL)-2 receptor antibodies. The latter have the benefit of reducing the incidence of AR further and may be of use in patients who are susceptible to recurrent AR, were retransplanted for graft rejection or are in a steroid-sparing regimen. A total of 60 % of all paediatric liver transplants result in AR; however, there is a 75 % response rate to initial steroid therapy. Steroid therapy remains the mainstay of initial AR management, coupled with an increase in baseline immunosuppression. Steroid-resistant rejection (SRR), previously an immediate indication for potent anti-lymphocyte preparations, is now effectively treated with chimeric or humanised IL-2 receptor monoclonal antibodies. Recurrent AR can be treated by adding adjuvant immunosuppressive agents such as mycophenolate mofetil (MMF) or sirolimus. Studies have also demonstrated the efficacy of MMF as rescue therapy for SRR. Anti-lymphocyte preparations such as anti-thymocyte globulin (ATG) and OKT3 are rarely used in SRR but may be of use as rescue therapy for severe SRR. The challenges of the management of AR remain in the management of recurrent AR and SRR. We discuss the pathogenesis, diagnosis and management of AR, including prevention, and specific management of AR and SRR based on current evidence and our own experience at the King's College Paediatric Liver, Gastroenterology and Nutrition Centre in London.

背景与目标： : 小儿肝移植的成功归因于手术技术的改进和基于钙调神经磷酸酶抑制剂的免疫抑制的出现。急性排斥反应 (AR) 很少会导致钙调神经磷酸酶抑制剂免疫抑制方案的移植物丢失，以及诸如白介素 (IL)-2受体抗体等新型药物的出现。后者具有进一步降低AR发生率的好处，可用于易复发AR，因移植排斥反应而移植或采用类固醇保留方案的患者。所有儿科肝移植中总共有60% 个会导致AR; 但是，对最初的类固醇治疗的反应率75%。类固醇治疗仍然是初始AR管理的主要手段，同时增加了基线免疫抑制。类固醇抗性排斥 (SRR) 以前是有效的抗淋巴细胞制剂的直接适应症，现在可以用嵌合或人源化的IL-2受体单克隆抗体有效治疗。复发性AR可以通过添加佐剂免疫抑制剂如霉酚酸酯 (MMF) 或西罗莫司来治疗。研究还证明了MMF作为SRR抢救疗法的功效。抗淋巴细胞制剂 (例如抗胸腺细胞球蛋白 (ATG) 和OKT3) 很少用于SRR，但可能用作严重SRR的抢救疗法。AR管理的挑战仍然在于经常性AR和SRR的管理。我们根据目前的证据和我们在伦敦国王学院儿科肝脏，胃肠病学和营养中心的经验，讨论了AR的发病机理，诊断和管理，包括AR和SRR的预防以及具体管理。

BACKGROUND & AIMS: AIM:This study investigates the prevalence of disturbed eating behaviours in children and adolescents initiating obesity treatment, and how the prevalence varies with age, sex and body mass index (BMI) standard deviation score (SDS). Secondly, it examines whether the presence of disturbed eating behaviours at enrolment is associated with the degree of weight loss after 12 months of treatment. METHODS:A total of 3621 patients aged 3-18 years enrolled in a multidisciplinary obesity treatment programme were studied. Follow-up data after a median of 12.4 months were available for 2055 patients. Upon entry, patients were assessed for the following disturbed eating behaviours: meal skipping, emotional eating, overeating and rapid eating. Height and weight were measured at baseline and follow-up. RESULTS:At enrolment, median age was 11.4 years, median BMI SDS was 2.87, and 82.2% of patients exhibited one or more disturbed eating behaviours. The prevalence of meal skipping, emotional eating and rapid eating increased with age (P < 0.01). Patients who reported overeating or rapid eating exhibited a 0.06-0.11 higher BMI SDS at enrolment than patients without these disturbed eating behaviours (P < 0.02). After 1 year of treatment, BMI SDS was reduced in 75.7% of patients, and the median reduction was 0.24 (95% confidence interval: 0.22-0.27). Overeating was associated with a higher degree of weight loss, while meal skipping, emotional eating and rapid eating did not associate with the degree of weight loss at follow-up. CONCLUSIONS:Disturbed eating behaviours were highly prevalent in children and adolescents with overweight or obesity, and varied with age and sex. After 1 year of treatment, the degree of obesity improved, regardless of the presence of disturbed eating behaviours at treatment initiation.

背景与目标：

BACKGROUND & AIMS: OBJECTS:Optic nerve sheath diameter has been linked with intracranial pressure in previous studies. Measurement of sheath diameter using transorbital ultrasound is proposed as a clinical assessment indicator of developing hydrocephalus in the paediatric population. METHODS:A retrospective review of optic nerve sheath ultrasound examinations performed in a clinical setting between 2000 and 2006 for assessment of hydrocephalus in a single institution. RESULTS:A total of 331 examinations were performed in 160 patients over the study period. A satisfactory image was possible in all cases. Sheath diameters were correlated with clinical case data from concurrent case records. CONCLUSION:Transorbital ultrasound is a reproducible, non-invasive technique for the assessment of optic nerve sheath diameter and is well tolerated in children. Our series revealed asymptomatic baseline value higher than in previous reports. Variation from individual case asymptomatic baseline was the most sensitive variable in the series in determining development of hydrocephalus. This technique is felt to be a useful adjunct in the assessment of hydrocephalus in the paediatric neurosurgical population.

背景与目标：

BACKGROUND & AIMS: :The aim was to clarify the developmental nature of associations between psychiatric illness and risk for cardiovascular disease by investigating differences in cardiac functioning between youth with anxiety disorders and healthy controls. Twenty-two children meeting DSM-IV criteria for either separation anxiety disorder, overanxious disorder, panic disorder/panic attacks, or social phobia and 12 healthy controls underwent continuous electrocardiogram and respiration rate monitoring during a 15 min baseline period and 15 min of exposure to 5% CO(2). Heart rate (HR) and high frequency heart rate variability (HRV), a non-invasive measure of cardiac parasympathetic control, were calculated. Youth with anxiety disorders had higher and less fluctuating HR during baseline. Data also suggested that probands showed diminished overall changes in HRV during baseline and CO(2) inhalation relative to controls. However, as respiration rate affects HRV, these findings were confounded by changes in respiration elicited by CO(2) inhalation. The data suggest that youth with anxiety disorders experience an elevated and less fluctuating HR in the face of a novel situation, possibly due to a failure to appropriately modulate HRV. In adults, sustained elevations in HR in conjunction with deficient vagal modulation predicts risk for future cardiovascular disease. As such, the current data suggest that the presence of an anxiety disorder may identify youth who exhibit autonomic profiles that place them at risk for cardiac disease.

背景与目标： : 目的是通过调查焦虑症青年与健康对照者之间心脏功能的差异，阐明精神疾病与心血管疾病风险之间关联的发展性质。22名符合dsm-iv标准的分离焦虑症，过度焦虑症，恐慌症/惊恐发作或社交恐惧症的儿童和12名健康对照者在15分钟的基线期和15分钟的暴露期间接受了连续心电图和呼吸频率监测5% CO(2)。计算了心率 (HR) 和高频心率变异性 (HRV)，这是一种非侵入性的心脏副交感神经控制措施。焦虑症的青年在基线期间的HR波动较高，且波动较小。数据还表明，先证者显示，相对于对照组，基线和CO(2) 吸入期间HRV的总体变化减少。然而，由于呼吸速率会影响HRV，因此这些发现被CO(2) 吸入引起的呼吸变化所混淆。数据表明，面对新情况，患有焦虑症的年轻人的HR升高且波动较小，这可能是由于未能适当调节HRV所致。在成人中，HR的持续升高与迷走神经调节不足相结合可预测未来心血管疾病的风险。因此，当前的数据表明焦虑症的存在可能会识别出表现出自主神经特征的年轻人，这使他们有患心脏病的风险。

BACKGROUND & AIMS: :The study tested the prevalence of graft vessel disease (GVD) in 54 paediatric heart transplant (HTx) patients (32 male, age 0-17 years) who underwent coronary angiographic investigations (N=117). These were evaluated according to the Stanford classification and additional criteria (peripheral obliterations, diameter fluctuations, pathologic tapering) were applied for risk assessment (no GVD/minimal lesions, GVD without Stanford lesions, accelerated GVD). In H&E stainings from right ventricular endomyocardial biopsies (EMB=169) diagnosis of acute cellular rejection (ACR, ISHLT) and microvasculopathy were performed. Mild rejection was found in 43% (N=44) and severe rejection in 7% (N=7) of EMB early (1st year) and mild rejection in 31% (N=32) and severe in 8% (N=9) late (>3 years) after HTx. Microvasculopathy was present in 22% of EMB. Risk assessment of coronary angiographies showed no GVD/minimal disease in 25% (N=29), GVD without Stanford lesions in 12% (N=14) and different grades of accelerated GVD in 74% (N=74) of studies. All patients dying due to cardiac related causes of death (N=6, 3-12 years after HTx) had evidence of GVD. The data show GVD to be an important cause of late cardiac related deaths in this population.

背景与目标： : 该研究测试了54例接受冠状动脉造影检查 (N = 117) 的小儿心脏移植 (HTx) 患者 (32名男性，年龄0-17岁) 的移植物血管疾病 (GVD) 的患病率。根据Stanford分类对这些进行评估，并将其他标准 (外周闭塞，直径波动，病理渐缩) 用于风险评估 (无GVD/最小病变，无Stanford病变的GVD，加速GVD)。在右心室心内膜活检 (EMB = 169) 的H & E染色中，进行了急性细胞排斥 (ACR，ISHLT) 和微血管病变的诊断。在EMB早期 (1年) 的43% (N = 44) 中发现轻度排斥反应，在7% (N = 7) 中发现严重排斥反应，在31% (N = 32) 中发现轻度排斥反应，在HTx后晚期 (>3年) 中发现严重排斥反应。EMB 22% 存在微血管病变。冠状动脉造影的风险评估显示，在25% (N = 29) 中没有GVD/最小疾病，在12% (N = 14) 中没有斯坦福病变的GVD，在74% (N = 74) 的研究中没有不同程度的加速GVD。所有因心脏相关死亡原因死亡的患者 (HTx后6年，3-12年) 都有GVD的证据。数据显示GVD是该人群晚期心脏相关死亡的重要原因。

BACKGROUND & AIMS: BACKGROUND:Undifferentiated embryonal sarcomas of the liver (UESL) are extremely rare and continue to pose a diagnostic and therapeutic challenge. The aim of the study was to present a multicenter experience of the German CWS and Polish PPSTG groups in the treatment of UESL in children. PROCEDURE:Twenty-five patients were treated according to the CWS-96, CWS-2002, and CYVADIC protocols. Distant metastases were observed in four cases (16%). In four cases, an initial disease presentation mimicked other entities. A pure cystic appearance of liver mass led to misdiagnosis of hydatid cyst in three cases. In one case, laparotomy was performed due to the signs of appendicitis, and bleeding from ruptured liver tumor was found. All these patients were finally diagnosed as UESL. RESULTS:Thirteen patients received preoperative chemotherapy. Partial response was observed in 10 cases. Tumor resection was performed in 20 patients (primary resections, 12; delayed resections-, 8). In five patients, the primary tumor never became operable. The macroscopically complete resection rate was 95% (19/20). Postoperative chemotherapy was given to 20 children. Local radiotherapy was used in three children. After a median follow-up time of 136 months, 17 patients (68%) were alive with no evidence of disease. All children with unresectable tumor and three out of four patients with distant metastases died. The five-year overall survival (OS) rate was 72%. CONCLUSIONS:In summary, a complete tumor excision plays the central role in the treatment of UESL. A cystic presentation of the liver lesion on imaging does not exclude the diagnosis of malignant tumor.

背景与目标：

BACKGROUND & AIMS: :The anaesthetic management of children with craniofacial abnormalities often presents unique challenges because soft tissue and bony abnormalities can affect the airway and influence airway management. We report four paediatric patients with predicted difficult airways due to craniofacial abnormalities. They all had a laryngeal view of Cormack-Lehane grade IV and were impossible to intubate using direct laryngoscopy. Fibreoptic intubation was also repeatedly attempted but was not successful. All the tracheal intubations were completed using a lightwand on the first attempt in less than 30 s. We consider that lightwand guided intubation technique may be a useful alternative approach to fibreoptic intubation technique in managing the difficult paediatric airway.

背景与目标： : 颅面异常儿童的麻醉管理通常会带来独特的挑战，因为软组织和骨异常会影响气道并影响气道管理。我们报告了四名因颅面异常而预计气道困难的儿科患者。他们都具有Cormack-Lehane IV级的喉部视图，并且无法使用直接喉镜检查进行插管。也反复尝试过光纤插管，但未成功。在不到30 s的第一次尝试中，所有气管插管均使用lightwand完成。我们认为，在管理困难的儿科气道方面，lightwand引导的插管技术可能是光纤插管技术的有用替代方法。

BACKGROUND & AIMS: :The combination of pediatric cardiology being both a perceptual and a cognitive subspecialty demands a complex decision-making model which makes artificial intelligence a particularly attractive technology with great potential. The prototypical artificial intelligence system would autonomously impute patient data into a collaborative database that stores, syncs, interprets and ultimately classifies the patient's profile to specific disease phenotypes to compare against a large aggregate of shared peer health data and outcomes, the current medical body of literature and ongoing trials to offer morbidity and mortality prediction, drug therapy options targeted to each patient's genetic profile, tailored surgical plans and recommendations for timing of sequential imaging. The focus of this review paper is to offer a primer on artificial intelligence and paediatric cardiology by briefly discussing the history of artificial intelligence in medicine, modern and future applications in adult and paediatric cardiology across selected concentrations, and current barriers to implementation of these technologies.

背景与目标： : 儿科心脏病学既是感知专业又是认知专业的结合，需要一个复杂的决策模型，这使人工智能成为具有巨大潜力的特别有吸引力的技术。原型人工智能系统将自动将患者数据输入到协作数据库中，该数据库存储，同步，解释并最终将患者的概况分类为特定的疾病表型，以与大量共享的同伴健康数据和结果进行比较，当前的医学文献和正在进行的试验提供发病率和死亡率预测，针对每个患者的遗传特征的药物治疗选择，量身定制的手术计划以及顺序成像时机的建议。本文的重点是通过简要讨论人工智能在医学中的历史，成人和儿科心脏病学在选定浓度范围内的现代和未来应用以及当前实施这些技术的障碍，来提供有关人工智能和儿科心脏病学的入门知识。

BACKGROUND & AIMS: BACKGROUND:The magnitude of cardiovascular morbidity in paediatric, adolescent, and young adult survivors of Hodgkin's lymphoma is not known. Using medically ascertained data, we applied the cumulative burden metric to compare chronic cardiovascular health conditions in survivors of Hodgkin's lymphoma and general population controls. METHODS:For this study, participant data were obtained from two ongoing cohort studies at St Jude Children's Research Hospital: the St Jude Lifetime Cohort Study (SJLIFE) and the St Jude Long-term Follow-up Study (SJLTFU). SJLIFE is a cohort study initiated on April 27, 2007, to enable longitudinal clinical evaluation of health outcomes of survivors of childhood cancer treated or followed at St Jude Children's Research Hospital, and SJLTFU is an administrative system-based study initiated in 2000 to collect outcome and late toxicity data for all patients treated at the hospital for childhood cancer. The patient cohort for our study was defined as patients treated at St Jude Children's Research Hospital who reached 18 years of age and were at least 10 years post-diagnosis of pathologically confirmed primary Hodgkin's lymphoma. Outcomes in the Hodgkin's lymphoma survivors were compared with a sample of SJLIFE community control participants, aged 18 years or older at the time of assessment, frequency-matched based on strata defined by 5-year age blocks within each sex, who were selected irrespective of previous medical history. All SJLIFE participants underwent assessment for 22 chronic cardiovascular health conditions. Direct assessments, combined with retrospective clinical reviews, were used to assign severity to conditions using a modified Common Terminology Criteria of Adverse Events (CTCAE) version 4.03 grading schema. Occurrences and CTCAE grades of the conditions for eligible non-SJLIFE participants were accounted for by multiple imputation. The mean cumulative count (treating death as a competing risk) was used to estimate cumulative burden. FINDINGS:Of 670 survivors treated at St Jude Children's Research Hospital, who survived 10 years or longer and reached age 18 years, 348 were clinically assessed in the St Jude Lifetime Cohort Study (SJLIFE); 322 eligible participants did not participate in SJLIFE. Age and sex frequency-matched SJLIFE community controls (n=272) were used for comparison. At age 50 years, the cumulative incidence of survivors experiencing at least one grade 3-5 cardiovascular condition was 45·5% (95% CI 36·6-54·3), compared with 15·7% (7·0-24·4) in community controls. The survivor cohort at age 50 experienced a cumulative burden of 430·6 (95% CI 380·7-480·6) grade 1-5 and 100·8 (77·3-124·3) grade 3-5 cardiovascular conditions per 100 survivors; these numbers were appreciably higher than those in the control cohort (227·4 [192·7-267·5] grade 1-5 conditions and 17·0 [8·4-27·5] grade 3-5 conditions per 100 individuals). Myocardial infarction and structural heart defects were the major contributors to the excess grade 3-5 cumulative burden in survivors. High cardiac radiation dose (≥35 Gy) was associated with an increased proportion of grade 3-5 cardiovascular burden, whereas increased anthracyline dose was not. INTERPRETATION:The true effect of cardiovascular morbidity in paediatric, adolescent, and young adult survivors of Hodgkin's lymphoma is reflected in the cumulative burden. Survivors aged 50 years will experience more than two times the number of chronic cardiovascular health conditions and nearly five times the number of more severe (grade 3-5) cardiovascular conditions compared with community controls and, on average, have one severe, life-threatening, or fatal cardiovascular condition. The cumulative burden metric provides a more comprehensive approach for assessing overall morbidity compared with currently used cumulative incidence based analytic methodologies, and will assist clinical researchers when designing future trials and refining general practice screening guidelines. FUNDING:US National Cancer Institute, St Baldrick's Foundation, and American Lebanese Syrian Associated Charities.

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