Πέμπτη, 31 Οκτωβρίου 2019

Mitteilungen der DGG

Künstliche Intelligenz und Robotik – Gedanken eines Baby‑Boomers

Beinvenenthrombosen und Lungenembolien

Endovaskuläres Komplikationsmanagement einer iatrogenen Aortenverletzung während transthorakaler Spondylodese

Zusammenfassung

Der Fallbericht beschreibt die erfolgreiche endovaskuläre Therapie einer intraoperativen Verletzung der Ao. thoracica descendens im Rahmen einer Re-Spondylodese in einem malignombedingt schwierigen Operationssitus. Die Intervention erfolgte im Sinne der aortalen Blutungskontrolle und verdeutlicht die Notwendigkeit und Möglichkeiten eines interdisziplinären operativen Netzwerks.

Künstliche Intelligenz in der Gefäßchirurgie

Methoden der künstlichen Intelligenz in der vaskulären Medizin

Zusammenfassung

Hintergrund

Methoden der künstlichen Intelligenz (KI) erlangen in immer mehr Lebensbereichen Bedeutung und finden auch in der Medizin zunehmend Anwendung.

Fragestellung

Wo und wie werden KI-Methoden heute schon in der vaskulären Medizin eingesetzt? Wo besteht Potenzial für klinische Anwendungen? Wo liegen Herausforderungen?

Material und Methoden

Auf Basis einer Literaturrecherche wird der Einsatz von KI-Methoden im medizinischen Umfeld analysiert, bestehende Ansätze vorgestellt und Möglichkeiten für eine Anwendung in der Gefäßchirurgie aufgezeigt. Anhand eines aktuellen Forschungsthemas, der Rupturrisikoabschätzung bei abdominalen Aortenaneurysmen (AAA), wird der Einsatz und das Zusammenspiel mehrerer KI-Methoden veranschaulicht.

Ergebnisse

KI-Methoden sind in der Gefäßchirurgie noch unterrepräsentiert. Wie die gezeigten Beispiele verdeutlichen, besteht allerdings ein hohes Anwendungspotenzial.

Diskussion

Eine Herausforderung für die Anwendung von KI-Methoden besteht in der Interpretierbarkeit der KI-basierten Modelle, da diese keine kausalen Beziehungen preisgeben können. Des Weiteren werden zur Erstellung aussagekräftiger KI-Modelle große medizinische Datensätze benötigt, was aufgrund heterogener Datenquellen und Datenschutzbedenken insbesondere in Deutschland eine Hürde darstellt.

Robotik: automatisierte Verfahren in der Gefäßmedizin

Zusammenfassung

Die medizinische Robotik hat eine Vielzahl von technischen und mathematischen Problemen gelöst, um den Robotereinsatz im klinischen Alltag zu ermöglichen. Im Vergleich zur Industrierobotik sind die technischen und regulatorischen Herausforderungen anspruchsvoller und nehmen durch die Novellierungen des Medizinproduktegesetzes weiter zu. Zu den medizintechnischen Herausforderungen zählen höhere Genauigkeitsanforderungen, die Notwendigkeit zur automatischen Bildverarbeitung sowie zunehmend der Einsatz von maschinellen Lernverfahren und künstlicher Intelligenz. In der Gefäßmedizin wurden bereits robotische Systeme in der laparoskopischen und der endovaskulären Gefäßchirurgie erprobt. In Fallserien wurde die technische Machbarkeit nachgewiesen und einzelne Parameter deuten auf Vorteile dieser medizintechnischen Entwicklungen hin. Deren Nutzen wird sich weiter steigern, wenn in den kommenden Jahren weitere medizintechnische Entwicklungen auf dem Gebiet der Robotik, wie z. B. die Kombination mit bildgebenden Verfahren (augmentierte Realität) oder maschinelles Lernen, eingeführt werden. Für eine generelle klinische Hinwendung zum Thema Robotik fehlen derzeit jedoch valide Studien. Möglicherweise bietet die automatisierte Ultraschalldiagnostik einen guten Weg, robotische Entwicklungen in der klinischen Breite auszuüben, da unter zeitökonomischen Aspekten Vorteile im klinischen Alltag in Abhängigkeit der Patientenakzeptanz zu erwarten sind. Neuere endovaskuläre robotisch-assistierte Verfahren versprechen eine Unterstützung bei hoch spezialisierten Prozeduren mit verringerter Strahlenbelastung von Patienten und Operateuren. Ihr Einsatz sollte in kontrollierten multizentrischen Studien unter Beachtung des Patientennutzens erfasst werden.

Die künstliche Intelligenz in der Einzelzellgenomik

Zusammenfassung

Die individuelle Zelle stellt die fundamentale Einheit des Lebens dar. Ihre Funktionsweise ist seit Jahrhunderten Gegenstand der biomedizinischen Forschung. Seit Kurzem erlaubt die sogenannte Einzelzellsequenzierung revolutionäre neue Einblicke in die Komposition von Geweben, die Interaktion zwischen Zellen und den Ablauf dynamischer Prozesse. Die damit verbundenen Daten, z. B. aus der Transkriptomik, stellen Analysten jedoch vor neue Herausforderungen. Die Daten sind typischerweise sehr groß, verrauscht und stark mit anderen Informationen vernetzt, sodass herkömmliche Verfahren ausscheiden. Neue, speziell adaptierte Algorithmen aus dem Feld der künstlichen Intelligenz können hier Abhilfe schaffen.
In Verbindung stellen Einzelzellsequenzierung und künstliche Intelligenz mächtige neue Werkzeuge für die biomedizinische Forschung dar und erlauben Einblicke in höchster Auflösung. Wir geben einen kurzen Überblick über beide Technologien und liefern Beispiele für ihre Anwendung im medizinischen Bereich. Wir demonstrieren anschließend beispielhaft, wie Methoden der künstlichen Intelligenz erfolgreich für die Analyse von Einzelzelltranskriptomdaten eingesetzt werden können. Da der korrekte und gewinnbringende Einsatz dieser Methoden weiterhin detailliertes Hintergrundwissen verlangt, ist ein intensivierter Austausch zwischen den Disziplinen unumgänglich. Wir gehen deshalb abschließend auf den Einsatz neuer Plattformen zur Kollaboration und zum Wissensaustausch ein.

Zukunftsperspektiven digitaler Visualisierungstechnologien in der Gefäßchirurgie

Zusammenfassung

Die Digitalisierung der Chirurgie ist eine der richtungsweisenden Herausforderungen der aktuellen und kommenden Chirurgengenerationen. Für das Gebiet der Gefäßmedizin stehen mit der „augmented reality“ (AR) und „virtual reality“ (VR) sowie dem 3‑D-Druck digitale Technologien zur Verfügung, deren Implementierung einerseits notwendig und sinnvoll ist, aber auch kritisch evaluiert und begleitet werden muss. Im Zentrum dieser drei Technologien zur Visualisierung steht das elektronische Modell der jeweiligen Anatomie, das dann auf unterschiedliche Weise dargestellt werden kann. Die aktuellen Einsatzgebiete für AR/VR liegen vor allem im Bereich von Simulation und Training mit den potenziellen Vorteilen Zeitersparnis und Fehlerreduktion. Während die AR-Technologie bereits probeweise im OP eingesetzt wurde (jedoch noch nicht praxisreif ist), muss für die VR die Frage der prinzipiellen Einsatzmöglichkeit im OP noch geklärt werden. Die 3‑D-Drucktechnologie erlaubt neben dem Einsatz zu Aufklärungs‑, Trainings- und Simulationszwecken auch die Herstellung von patientenindividuellen Operationsschablonen.

Transparenz und Antikorruption

Zusammenfassung

Transparenz für das Gesundheitswesen wird seit Jahren gefordert und gefördert. Ziel einer solchen Transparenz soll es sein, dass geschäftliche Verbindungen offengelegt werden und sich jeder Patient ein eigenes Bild darüber verschaffen kann, in welchen wirtschaftlichen Beziehungen der ihn behandelnde Arzt steht. Ferner sollen insbesondere unlautere Zahlungen durch Transparenzmaßnahmen unterbunden werden. Insgesamt soll dadurch das Gesundheitswesen freigehalten werden von sachfremden Erwägungen, die dem Patientenwohl entgegenstehen könnten. Teil dieser Strategie ist das am 13. April 2016 verabschiedete Gesetz zur Bekämpfung der Korruption im Gesundheitswesen, das sog. Antikorruptionsgesetz.

Systematic Surveys in Informal Settlements: Challenges in Moving Toward Health Equity

Perceived Discrimination Based on Criminal Record in Healthcare Settings and Self-Reported Health Status among Formerly Incarcerated Individuals

Abstract

Perceived discrimination based on criminal record is associated with social determinants of health such as housing and employment. However, there is limited data on discrimination based on criminal record within health care settings. We examined how perceived discrimination based on criminal record within health care settings, among individuals with a history of incarceration, was associated with self-reported general health status. We used data from individuals recruited from 11 sites within the Transitions Clinic Network (TCN) who were released from prison within the prior 6 months, had a chronic health condition and/or were age 50 or older, and had complete information on demographics, medical history, self-reported general health status, and self-reported perceived discrimination (n = 743).
Study participants were mostly of minority racial and ethnic background (76%), and had a high prevalence of self-reported chronic health conditions with half reporting mental health conditions and substance use disorders (52% and 50%, respectively), and 85% reporting one or more chronic medical conditions. Over a quarter (27%, n = 203) reported perceived discrimination by health care providers due to criminal record with a higher proportion of individuals with fair or poor health reporting discrimination compared to those in good or excellent health (33% vs. 23%; p = .002). After adjusting for age and reported chronic conditions, participants reporting discrimination due to criminal record had 43% increased odds of reporting fair/poor health (AOR 1.43, 95% CI 1.01–2.03). Race and ethnicity did not modify this relationship.
Participants reporting discrimination due to criminal record had increased odds of reporting fair/poor health. The association between perceived discrimination by health care providers due to criminal record and health should be explored in future longitudinal studies among individuals at high risk of incarceration.
Clinical Trial Registration: NCT01863290

Correction to: Extending Data for Urban Health Decision-Making: a Menu of New and Potential Neighborhood-Level Health Determinants Datasets in LMICs
Readers should note an additional Acknowledgment for this article: Dana Thomson is funded by the Economic and Social Research Council grant number ES/5500161/1.

The Last Link: from Gun Acquisition to Criminal Use

Abstract

Guns that are used in crime and recovered by the police typically have changed hands often since first retail sale and are quite old. While there is an extensive literature on “time to crime” for guns, defined as the elapsed time from first retail sale to known use in a crime, there is little information available on the duration of the “last link”—the elapsed time from the transaction that actually provided the offender with the gun in question. In this article, we use data from the new Chicago Inmate Survey (CIS) to estimate the duration of the last link. The median is just 2 months. Many of the gun-involved respondents to the CIS (42%) did not have any gun 6 months prior to their arrest for the current crime. The CIS respondents were almost all barred from purchasing a gun from a gun store because of their prior criminal record—as a result, their guns were obtained by illegal transactions with friends, relatives, and the underground market. We conclude that more effective enforcement of the laws governing gun transactions may have a quick and pervasive effect on gun use in crime.

Homelessness, Personal Hygiene, and MRSA Nasal Colonization among Persons Who Inject Drugs

Abstract

Methicillin-resistant Staphylococcus aureus (MRSA) infection is a leading cause of hospitalization and medical visits among individuals experiencing homelessness and also among persons who inject drugs (PWID), populations with significant overlap in urban centers in the USA. While injection drug use is a risk factor for MRSA skin infections, MRSA is also known to transmit easily in crowded, public locations in which individuals have reduced personal hygiene. Individuals in urban centers who experience homelessness or drug addiction may spend significant amounts of time in environments where MRSA can be easily transmitted, and may also experience reduced access to facilities to maintain personal hygiene. We assessed the relationship between homelessness, personal hygiene, and MRSA nasal colonization, a proxy for MRSA infection risk, in a study of PWID in Boston, MA (n = 78). Sleeping in a homeless shelter for at least one night in the last 3 months was significantly associated with MRSA nasal colonization (OR 3.0; p = 0.02; 95% CI 1.2, 7.6). Sleeping at more than one place during the last week (considered a metric of elevated housing instability) was also associated with a threefold increase in odds of MRSA nasal colonization (OR 3.1; p = 0.01; 95% CI 1.3, 7.6). MRSA nasal colonization was strongly associated with use of public showers (OR 13.7; p = 0.02; 95% CI 1.4, 132.8), although few people in this study (4 of 78) reported using these public facilities. Sharing bedding with other people was also associated with increased risk of MRSA colonization (OR 2.2; p = 0.05; 95% CI 1.0–4.7). No associations between hand hygiene, frequency of bathing or clothes laundering, or street sleeping were observed. Use of public facilities supporting persons experiencing homelessness and housing instability, including shelters and public showers, is associated with an increased risk of MRSA nasal colonization in this study. Personal hygiene behaviors appear less associated with MRSA nasal colonization. Environmental assessments of MRSA contamination in homeless shelters and public sanitation facilities are warranted so as to inform appropriate intervention activities.

Individual-Level Predictors for Becoming Homeless and Exiting Homelessness: a Systematic Review and Meta-analysis

Abstract

Homelessness remains a societal problem. Compiled evidence of predictors for becoming homeless and exiting homelessness might be used to inform policy-makers and practitioners in their work to reduce homeless-related problems. We examined individual-level predictors for becoming homeless and exiting homelessness by searching PubMed, EMBASE, PsycINFO, and Web of Science up to January 2018. Becoming homeless and exiting homelessness were the outcomes. Observational studies with comparison groups from high-income countries were included. The Newcastle Ottawa Quality Assessment Scale was used for bias assessment. Random effects models were used to calculate pooled odds ratios (ORs) with 95% confidence intervals (CIs). We included 116 independent studies of risk factors for becoming homeless and 18 for exiting homelessness. We found evidence of adverse life events as risk factors for homelessness, e.g., physical abuse (OR 2.9, 95% CI 1.8–4.4) and foster care experiences (3.7, 1.9–7.3). History of incarceration (3.6, 1.3–10.4), suicide attempt (3.6, 2.1–6.3), and psychiatric problems, especially drug use problems (2.9, 1.5–5.1), were associated with increased risk of homelessness. The heterogeneity was substantial in most analyses (I2 > 90%). Female sex (1.5, 1.1–1.9; I2 = 69%) and having a partner (1.7, 1.3–2.1; I2 = 40%) predicted higher chances whereas relationship problems (0.6, 0.5–0.8), psychotic disorders (0.4, 0.2–0.8; I2 = 0%), and drug use problems (0.7, 0.6–0.9; I2 = 0%) reduced the chances for exiting homelessness. In conclusion, sociodemographic factors, adverse life events, criminal behaviour, and psychiatric problems were individual-level predictors for becoming homeless and/or exiting homelessness. Focus on individual-level vulnerabilities and early intervention is needed. PROSPERO registration number: CRD42014013119.

“Housing Insecurity Seems to Almost Go Hand in Hand with Being Trans”: Housing Stress among Transgender and Gender Non-conforming Individuals in New Orleans

Abstract

Housing is an important social determinant of physical and mental health. Transgender and gender non-conforming individuals (T/GNCI) face a unique constellation of discrimination and compromised social services, putting them at risk for housing insecurity, homelessness, and its associated public health concerns. This study explores housing insecurity among T/GNCI in New Orleans, LA, where the infrastructural landscape is marked by an underinvestment in housing stock and disaster capitalism. In-depth interviews were conducted with T/GNCI (n = 17) living in New Orleans, identified through purposive sampling. Semi-structured guides were used to elicit personal stories and peer accounts of insecure housing experiences and coping strategies. Interviews were audio recorded and transcribed. Data was coded, sorted, and analyzed for key themes using NVIVO 11. Respondents discussed an array of circumstances that contribute to housing insecurity, including intersectional stigma and discrimination coupled with gentrification and a changing housing landscape in the city. Housing was intricately intertwined with employment and other structural issues; vulnerability in one realm was closely tied to insecurity in the others. Social support and queer family structures emerged as a key source of resilience, coping, and survival. The study supports an increase of resources for T/GNC housing access and interventions that address the cyclical discrimination, housing, and employment issues this population faces with a consideration of the historical and current structural barriers impeding their access to safe, stable, long-term housing.

Urban Green Space Is Spatially Associated with Cardiovascular Disease Occurrence in Women of Mashhad: a Spatial Analysis of Influential Factors on their Presence in Urban Green Spaces

Abstract

Chronic diseases have spread around the world. Cardiovascular diseases (CVD), the most important of the chronic diseases and the leading cause of death in women of Mashhad, are impacted by environmental factors. Urban green spaces (UGSs) are important environmental factors playing a critical role in the prevention and control of CVD. Spatial analysis is useful in understanding the application of UGSs in CVD prevention. To identify the spatial distribution of CVD in Mashhad, Moran’s index was used and 7539 home addresses of female patients with CVD were imported into ArcMap. Moran’s coefficient was estimated to be 0.34, revealing a clustered distribution of CVD. The spatial autocorrelation between CVD and UGSs was analyzed using Moran’s I. Moran’s I index value was calculated to be − 0.15, and four types of clusters were identified in eight sub-districts of Mashhad municipality. To find the factors influencing the presence in UGSs among women affected by CVD, 607 female patients living in the selected sub-districts were asked to take part in a telephone survey. Data were analyzed using ordinary least squares (OLS) and geographically weighted regression (GWR) at block level (343 statistical blocks in total). Accordingly, the spatial diversity and effects of three variables of income, level of education, and access to UGSs among female patients with CVD were measured. According to OLS results and the standard residual, two clusters were removed. Finally, vulnerable blocks were identified that could be helpful in the development of prevention policies and place-based interventions.

“You Do Not Think of Me as a Human Being”: Race and Gender Inequities Intersect to Discourage Police Reporting of Violence against Women

Abstract

Intimate partner violence (IPV) and sexual violence (SV) are drivers of women’s morbidity and mortality in urban environments yet remain among the most underreported crimes in the USA. We conducted 26 in-depth interviews with women who experienced past-year IPV or SV, to explore structural and community influences on police contact in Baltimore, MD. Results indicate that gender-based and race-based inequities intersected at the structural and community levels to discourage women from police contact following IPV/SV. Structural influences on police reporting included police discriminatory police misconduct, perceived lack of concern for citizens, power disparities, fear of harm from police, and IPV/SV-related minimization and victim-blaming. Community social norms of police avoidance discouraged police contact, enforced by stringent sanctions. The intersectional lens contextualizes a unique paradox for Black women: the fear of unjust harm to their partners through an overzealous and racially motivated police response and the simultaneous sense of futility in a justice system that may not sufficiently prioritize IPV/SV. This study draws attention to structural race and gender inequities in the urban public safety environment that shape IPV/SV outcomes. Race-based inequity undermines women’s safety and access to justice and pits women’s safety against community priorities of averting police contact and disproportionate incarceration. A social determinants framework is valuable for understanding access to justice for IPV/SV. Enhancing access to justice for IPV/SV requires overcoming deeply entrenched racial discrimination in the justice sector, and historical minimization of violence against women.

Structural Characteristics of Tree Cover and the Association with Cardiovascular and Respiratory Health in Tampa, FL

Abstract

Urban tree cover can provide several ecological and public health benefits. Secondary datasets for Tampa, FL, including sociodemographic variables (e.g., race/ethnicity), health data, and interpolated values for features of tree cover (e.g., percent canopy and leaf area index) were analyzed using correlation and regression. Percent canopy cover and leaf area index were inversely correlated to respiratory and cardiovascular outcomes, yet only leaf area index displayed a significant association with respiratory conditions in the logistic regression model. Percent racial/ethnic minority residents at the block group level was significantly negatively correlated with median income and tree density. Leaf area index was also significantly lower in block groups with more African-American residents. The percentage of African Americans (p = 0.101) and Hispanics (p < 0.001) were positively associated with respiratory outcomes while population density (p < 0.001), percent canopy (p < 0.01), and leaf area index (p < 0.01) were negatively associated. In multivariate models, higher tree density, leaf area index, and median income were significantly negatively associated with respiratory cases. Block groups with a higher proportion of African Americans had a higher odds of displaying respiratory admissions above the median rate. Tree density and median income were also negatively associated with cardiovascular cases. Home ownership and tree condition were significantly positively associated with cardiovascular cases.

Desmoid-type fibromatosis arising in a bifid rib chest wall

Abstract

Desmoid-type fibromatosis is a rare soft tissue tumor and the chest wall is one of the common sites of its extra-abdominal occurrence. A bifid rib is one of the congenital rib abnormalities. We report a case of desmoid-type fibromatosis arising in a chest wall’s bifid rib. A 42-year-old female complained of right chest pain without remarkable medical, traumatic, or familial history. Chest-computed tomography revealed a chest wall tumor located adjacent to a bifid costal cartilage of third rib. We performed chest wall resection of second and third ribs. Pathologically, the tumor was diagnosed a desmoid-type fibromatosis of the chest wall. We surmise mechanical stimulation due to the bifid rib may be related to the occurrence of the tumor. In case of desmoid-type fibromatosis without somatic gene mutation, traumatic history, wound, implants, or use of female hormonal agents, we should search also local congenital abnormality.

Two cases of air leak syndrome after bone marrow transplantation successfully treated by the pleural covering technique

Abstract

Air leak syndrome (ALS) is a rare complication after bone marrow transplantation (BMT) and usually has a fatal outcome because of the high recurrence rate and treatment-refractory nature. A 32-year-old man with a history of BMT for acute lymphoblastic leukemia suffered from metachronous bilateral ALS. Bullectomy and the pleural covering procedure (PLC) were successfully performed for each side of the thorax. After surgery, no relapse of pneumothorax was seen for 2 years on the right side and for 1 year on the left side. A 38-year-old man with a history of BMT for acute myelogenous leukemia (AML) suffered from ALS at the thorax on the left side. Bullectomy and the PLC were successfully performed. After that no recurrence of left pneumothorax for 7 years. We experienced two cases of ALS after BMT successfully treated by the PLC. This technique may be a viable treatment option for future lung transplantation.

Application of decellularized allograft for primary repair of congenital heart disease in Japan

Abstract

A 6-month-old infant with a double outlet right ventricle, doubly committed ventricular septal defect, and right ventricle outflow tract (RVOT) stenosis underwent intracardiac repair with RVOT reconstruction using a fresh decellularized allograft derived from a 1-year-old heart transplant recipient in Japan. Early postoperative evaluation via echocardiography and cardiac magnetic resonance imaging revealed that the pulmonary allograft and cardiac function were stable. This is the first case report on using a decellularized heart valve, which was resected from a heart transplant recipient, for primary repair of congenital heart disease in Japan.

Folding procedure to diminish type 3 endoleakage after open stent graft surgery with TEVAR extension

Abstract

We herein report a new procedure to prevent type 3 endoleakage (EL3) after open stent graft (OSG) surgery with thoracic endovascular aortic repair (TEVAR) extension. The OSG Dacron graft portion is reversed and folded inside the OSG stent graft portion intraoperatively, filling the crack between the OSG and TEVAR device. We applied this procedure in two patients with no postoperative complications. Our folding procedure may prevent EL3 after OSG surgery if TEVAR extension is needed in the future.

Spontaneous ascending aortic rupture in a pregnant woman with neurofibromatosis type 1

Abstract

Neurofibromatosis type 1 (NF-1) is an autosomal dominant disorder that affects 1 in 3000 individuals. Vascular involvement in NF-1 is a well-recognized, but rare, feature of this disease. In pregnant women, the risk of aortic dissection or rupture is elevated during pregnancy and the postpartum period. We report a pregnant woman who had a history of NF-1 with a spontaneous ascending aortic rupture. This rupture was successfully treated by emergent surgery. The mother and the 28-week-gestation newborn recovered uneventfully. During 7 years of follow-up, aorta of the patient shows no significant change. A review of the literature regarding the pathogenesis of this condition is also presented.

“ Mantle-style ” modification of Cabrol shunt for hemostasis after extended aortic reconstruction in acute type A aortic dissection

Abstract

Cabrol shunt and several of its modifications have been used as adjunctive procedures to control inaccessible bleeding occurring after aortic root surgeries. Nevertheless, the hemostatic effect of the shunt is suboptimal when the reconstructive procedure extends to the aortic arch and coronary arteries. We propose a “Mantle-style” modified Cabrol shunt to facilitate hemostasis of the exsanguination from the neo-root after aortic root replacement with concomitant arch and coronary reconstruction.

Behavior of primary tracheal glomus tumor, uncertain malignant potential subtype

Abstract

The behavior of the pathological subtypes of tracheal glomus tumor (benign, uncertain malignant potential UMP, malignant) is vague. In a 51-year-old gentleman, suffering from cough for 4 months, computed tomography scan showed a mass at lower third of the trachea and the bronchoscope revealed exophytic mass at the tracheal lumen. Segmental tracheal resection was done using special modified endotracheal tube for the distal lung ventilation. The tracheal glomus tumor was also diagnosed based on the immunohistochemical staining. The tumor was 2 cm in diameter, deeply located, mitotic phase was difficult to identify, and a diagnosis of UMP subtype was made. There was no recurrence after 2 years follow-up. This is the first reported case of UMP subtype in lower trachea and we studied the treatment options with the clinic-pathological behavior of this tumor and its sequel by regular follow-up.

Significance of preoperative right ventricular function on mid-term outcomes after surgical ventricular restoration for ischemic cardiomyopathy

Abstract

Objectives

To analyze our surgical experiences with surgical ventricular restoration (SVR) for dilated ischemic cardiomyopathy (ICM) and to determine the significance of preoperative right ventricular (RV) function on outcomes.

Methods and results

This study retrospectively analyzed 19 patients who underwent SVR between April 2010 and May 2016. Their mean age and New York Heart Association functional class were 62 ± 11 years and 2.9 ± 0.8, respectively. The preoperative mean left ventricular (LV) end-systolic volume index and LV ejection fraction (LVEF) were 134 ± 56 mL/m2 and 24 ± 7%, respectively. The preoperative mean RV fractional area change (RVFAC) to quantify RV systolic function was 33 ± 13%, as assessed by transthoracic echocardiography. The mean follow-up period was 47 ± 20 months. Three patients died of cardiac causes during the follow-up, with the 3-year and 5-year freedoms from cardiac-related death of 89% and 79%, respectively. Major adverse cardiac events (MACEs) occurred in ten patients, with the 3-year and 5-year MACE-free survival rates of 58% and 41%, respectively. RVFAC (risk ratio [RR] = 0.92, 95% confidence interval [CI] 0.86–0.98, p = 0.01) and LVEF (RR = 0.83, 95% CI 0.68–0.97, p = 0.02) were significant predictors of MACEs in the multivariate analysis. Patients with RVFAC of < 35% had significantly poorer MACE-free survival rates (33% at 3 years) than those with RVFAC of ≥ 35% (80% at 3 years).

Conclusion

SVR for ICM provided acceptable freedom from cardiac-related death; however, MACEs commonly occurred and was associated with RV dysfunction.

If post-thoracotomy pain is the target, Integrated Thoracotomy is the choice

Abstract

Objectives

Despite the overgrowth of procedures done by VATS, there are still needs for thoracotomy. Post-thoracotomy pain plays an important role in many post-operative morbidities. Surgeons should make efforts to evolve new techniques to reduce post-thoracotomy pain with its associated morbidities. This trial aimed to study the impact of combining lack of rib retraction with protection of both intercostal nerves on post-operative pain.

Methods

This was a prospective study of 57 patients who had Integrated thoracotomy (I group) which consists of modified French window with Double-Edge closure. The results of I group were compared to our previous study that contained two groups 60 patients each, double edge (DE group) in which standard thoracotomy was closed using double-edge technique and (PC group) in which pericostal sutures was used for closure of thoracotomy. Outcomes assessed were operative time, time to ambulation, doses of analgesics injected in the epidural catheter, post-operative complications, chest tube drainage, hospital stay, and pain score and use of analgesics during the first post-operative year.

Results

All groups had similar demographics, operative time, and incisions length, but in I group, there were significantly a smaller number of lobectomies and pneumonectomies. Patients in I group had significantly lower time to ambulation, epidural doses and post-operative pain score throughout the first week. Patients in the (I group) had a significantly lower pain score throughout the first 9 months post-operatively. Up to 6 months post-operatively, there was significantly less use of analgesics among the I group.

Conclusion

The combination of retractor-free exposures and neurovascular exclusion sutures for thoracotomy is safe and effective in decreasing post-thoracotomy pain and use of analgesics.

Preoperative frailty is associated with progression of postoperative cardiac rehabilitation in patients undergoing cardiovascular surgery

Abstract

Objective

Preoperative frailty affects the progression of cardiac rehabilitation (CR) after cardiovascular surgery. Different frailty assessment measures are available. However, it remains unclear which tool most likely predicts the progress of CR. Our aim was to evaluate preoperative frailty using different methods and to identify the predictors in the progress of postoperative CR.

Methods

Eighty-nine patients underwent elective cardiovascular surgery at our institution between May 2016 and April 2018. Mortality cases and patients without evaluation of preoperative frailty were excluded. This study included the remaining 78 patients. We divided the patients into two groups: 47 patients who achieved 100 m walking within 7 days after surgery (successful CR group) and 31 patients who achieved 100 m walking later than 8 days after surgery (delayed CR group). Preoperative frailty was assessed using the Kaigo-Yobo Check-List, Cardiovascular Health Study, Short Physical Performance Battery, and Clinical Frailty Scale.

Results

The prevalence of frailty defined by these four measures was higher in the delayed CR group. The delayed CR group had lower nutritional status, serum hemoglobin level, serum albumin level, and psoas muscle index. Multivariable analysis demonstrated the Kaigo-Yobo Check-List score as an independent predictor for delayed CR (odds ratio 1.53, 95% confidence interval 1.18–1.98, p = 0.001) and Clinical Frailty Scale as an independent predictor for discharge to a health care facility (odds ratio 3.70, 95% confidence interval 1.30–10.51, p = 0.014).

Conclusions

Among the various tools for assessing frailty, the Kaigo-Yobo Check-List was most likely to predict the progress of postoperative CR after elective cardiovascular surgery.

When is Parental Monitoring Effective? A Person-centered Analysis of the Role of Autonomy-supportive and Psychologically Controlling Parenting in Referred and Non-referred Adolescents

Abstract

Over the last few years, the protective role of parental monitoring on adolescent adjustment (i.e., active parental efforts aimed at setting limits and tracking adolescents’ activities and whereabouts) has been challenged. Recent research has shifted attention to the conditions under which monitoring may be more or less effective. Grounded in Self-Determination Theory, this study investigated the role of parents’ autonomy-supportive and psychologically controlling parenting in effects of parental monitoring on adolescents’ adjustment. It also considered the role of adolescents’ clinical status (i.e., clinically referred vs non-referred). Adopting a person-centered approach, we aimed to identify naturally occurring profiles of monitoring, autonomy-support, and psychological control and to examine differences between these profiles in terms of life satisfaction, positive affect, and internalizing and externalizing problems. Participants included 218 referred (Mage = 14.44, 56% girls) and 218 matched adolescents from a larger sample of 1056 community (Mage = 14.83, 52.9% girls). Multigroup Latent Profile Analyses revealed five parenting profiles which were structurally equivalent in both samples: high monitoring with either high autonomy support or high psychological control, low monitoring with either high autonomy-support or high psychological control, and an average profile. Referred youth were significantly more present in the average profile and in the profiles characterized by high levels of psychological control. As hypothesized, profiles showed a differential association with adolescents’ self-reported adjustment, with the high monitoring—high autonomy support profile yielding the most optimal and the low monitoring—high psychological control profile yielding the worst outcomes. Associations between profiles and outcomes were similar for referred and non-referred adolescents. These findings highlight the importance of considering the parenting climate (i.e., autonomy-supportive versus psychologically controlling) to understand effects of parental monitoring during adolescence.

Adolescents’ Future Aspirations and Expectations in the Context of a Shifting Rural Economy

Abstract

Adolescents’ future aspirations and expectations influence the decisions they make as they transition into adulthood. However, less is known about how specific sociocultural factors interact with the formation of future aspirations and expectations and their association with goal attainment in emerging adulthood. The present study begins to fill this gap by using person-centered analysis with high school students (N = 517; 53% female; 92% white) from a rural county undergoing significant economic transition. Its aim was to identify future orientation profiles based on adolescent-reported future aspirations and expectations for success in both education and career. Four latent profiles were identified and labeled: universally high aspirations and expectations; low college aspirations and expectations; lower aspirations than expectations; and universally low aspirations and expectations. Significant gender differences were found. High school males were less likely to be in the universally high profile and more likely to be in the universally low and low college aspirations and expectations profiles. Future orientation profile placement was associated with differences in adolescent experiences in family, school, and community contexts as well as their work and education status and future residential aspirations in emerging adulthood. The findings inform future research and applied efforts focused on rural youth’s preparation for adult roles, and on retaining rural youth, a necessity for the vitality of rural communities.

Trajectories of Discrimination across the College Years: Associations with Academic, Psychological, and Physical Adjustment Outcomes

Abstract

Despite growing evidence that racial-ethnic discrimination has a critical impact on college students of color, there is a shortage of longitudinal studies investigating such discrimination across the course of students’ college careers. The present study examined trajectories of professor- and peer-perpetrated ethnic-racial discrimination across the first three years in college and the correlations between these trajectories and academic, psychological, and physical adjustment outcomes during students’ fourth year in a sample of 770 Black, 835 Asian American, and 742 Latino college students (total n = 2347; 60.1% female) at elite colleges and universities in the United States. Latent growth modeling revealed stability in reported peer discrimination over the first three years of college and an increase in reported discrimination from professors. Discrimination from peers and professors equally predicted unfavorable grades, a lower likelihood of on-time graduation, and less school satisfaction. Perceived discrimination from peers (but not from professors) during students’ first year predicted higher rates of depressive symptoms and more health problems in their fourth year. Although initial levels and trajectories of discrimination varied as a function of students’ ethnicity-race, the correlates between discrimination and adjustment outcomes did not vary between ethnic-racial groups. The present findings suggest that ethnic-racial discrimination is a complex, ecologically-based stressor that presents a constellation of challenges for students of color attending elite colleges and universities.

Parenting, Effortful Control, and Adolescents’ Externalizing Problem Behavior: Moderation by Dopaminergic Genes

Abstract

Research shows that genetics and effortful control play an important role in the link between parenting and problem behavior. However, little is known about how these factors act simultaneously. This article used a moderated mediation model to examine whether effortful control mediated the link between parenting and externalizing problem behavior, and whether dopaminergic genes (i.e., polygenic index score including DAT1, DRD2, DRD4, COMT) moderated this link. Two three-wave studies were conducted on community samples (adolescents: Study 1: N = 457; Mage = 15.74; Study 2: N = 221; Mage = 12.84). There was no mediation by effortful control, but a moderation by dopaminergic reactivity was observed. Despite inconsistent evidence, this article indicates that the development of externalizing problem behavior is subject to genetic characteristics and parenting.

The Combination of Living in High Crime Neighborhoods and High Rumination Predicts Depressive Symptoms among Adolescents

Abstract

Living in high crime areas and rumination each have been identified as risk factors for depression among youth, yet it is unclear how crime and rumination may synergistically increase the risk of adolescent depression. Adolescents (N = 309; 51% female, Mage= 12.9, SD = 0.61) completed self-report measures of rumination, depressive symptoms, and provided local addresses, which were used to match police district crime statistics. Approximately one year later, participants again reported depressive symptoms. Moderation analyses indicated that the tendency to ruminate exacerbated the relationship between violent crime rates, but not non-violent crime, and higher prospective levels of depressive symptoms among adolescents. These findings suggest that individual-level interventions that promote more adaptive emotion response styles may lower the risk of depression among adolescents residing in high crime areas.

Dispositional Mindfulness Profiles in Adolescents and their Associations with Psychological Functioning and Hypothalamic–Pituitary–Adrenal Axis Hormones

Abstract

Adolescence is often accompanied by an increase in stress and depression. Although there is considerable consensus about the benefits of mindfulness-based interventions to reduce these problems, the results for the role of dispositional mindfulness facets have been mixed. Recent studies have contributed to clarifying this role by identifying subtypes of individuals according to their profiles in mindfulness facets and examining the functioning of these profiles in relation to several self-reported indicators of wellbeing and health. The current study extends previous research by exploring mindfulness profiles in adolescents and by providing several sources of indicators (self-reports, parent-reports, and hypothalamic–pituitary–adrenal axis hormones) to examine the adaptive role of these profiles. A sample of 571 adolescents (50.61% girls; 12–17 years old) completed measures of mindfulness, depression, maladaptive schemas, and temperament (neuroticism, extraversion, and effortful control), and provided salivary samples for cortisol and dehydroepiandrosterone sulfate. In addition, 331 adolescents’ parents completed measures of their children’ temperaments. The results of latent profile analyses supported a three-profile solution: (1) moderate mindfulness (65.5%), (2) judgmental observing (24.2%), and (3) nonjudgmentally aware (10.3%). The judgmental observing profile was associated with a worse adjustment, indicated by higher depressive symptoms, maladaptive schemas, perceived stress, stress-associated hormones, and neuroticism, as well as lower scores on extroversion and effortful control. This profile was more frequent among the oldest adolescents. In contrast, the nonjudgmentally aware group presented a better adjustment and was more frequent among the youngest adolescents. These findings have implications for preventive interventions. Analyzing the specific profile of each adolescent can help improve individual intervention, taking into account the strengths and weaknesses of each adolescent.

Cross-Ethnic Friendships, Intergroup Attitudes, Intragroup Social Costs, and Depressive Symptoms among Asian-American and Latino-American Youth

Abstract

As American school districts become increasingly diverse, understanding the processes that promote positive intergroup relations is a critical task. The role of cross-ethnic friendships is one important factor, given the significance of these reciprocated peer relationships for social development. The current study examines the short-term longitudinal impact of cross-ethnic friendships on peer group attitudes and emotional adjustment. 524 student participants (54.8% female; Mage = 15.06 years, SD = 0.75; 47% Latino, 53% Asian-American) were followed for one year with two spring data collections. Students completed a self-report inventory assessing depressive symptoms and a peer nomination inventory assessed friendship, liking, disliking, popularity, and unpopularity. Cross-ethnic friendships were predictive of positive attitudes toward peers from other ethnic/racial groups and were also linked to declines in depressive symptoms for boys. Moreover, these positive effects did not come at a social cost, as cross-ethnic friendships were not associated with rejection by same-ethnic peers. Cross-ethnic friendships provide a unique environment that contributes to positive intergroup attitudes and beneficial socioemotional development for some youth.

Depressive Symptoms Amplify Emotional Reactivity to Daily Perceptions of Peer Rejection in Adolescence

Abstract

During adolescence, interpersonal stressors such as peer rejection pose challenges to emotion regulation. Yet, very little is known about how these transactional processes unfold in adolescents’ daily lives. This study investigated adolescents’ (a) emotional reactivity to daily perceptions of peer rejection, which concerns concurrent changes in negative and positive emotions, and (b) emotional recovery from daily perceptions of peer rejection, which concerns subsequent changes in negative and positive emotions. Because depressive symptoms can compromise effectiveness of emotion regulation, it was investigated as a moderator for emotional reactivity and recovery to daily perceptions of peer rejection. The sample consisted of 303 adolescents (59% girls; Mage = 14.20, SD = 0.54; range 13–16 years) who reported depressive symptoms at baseline and completed ecological momentary assessments of emotions and perceived peer rejection at nine random time-points per day for six consecutive days. Results from multi-level modeling analyses showed that perceived peer rejection was related to emotional reactivity (i.e., higher levels of negative emotions and lower levels of positive emotions). This effect was stronger for those with higher depressive symptoms. For emotional recovery, perceived peer rejection had lasting effects on adolescents’ negative emotions, but was not related to positive emotions. Depressive symptoms did not moderate effects of perceived peer rejection on emotional recovery. This study provides a more nuanced understanding of how depressive symptoms amplify the emotional impact of perceived peer rejection in adolescents’ day-to-day lives.

Youth Parasympathetic Functioning Moderates Relations between Cumulative Family Risk and Internalizing Behaviors

Abstract

Problematic family functioning places young adolescents at risk for internalizing behaviors. However, not all adolescents who experience family risk develop internalizing behaviors during early adolescence. Informed by a cumulative risk perspective, the current study examined whether associations between cumulative family risk, as well as particular family risk domains, and youth internalizing behaviors are moderated by youth parasympathetic reactivity. Participants include 68 young adolescents in 6th grade. Youth were 56% female, 41% African American, and 54% European American. For young adolescents who experienced higher change in respiratory sinus arrhythmia during a challenge/stressor task, greater cumulative family risk, exposure to more family risk domains, and several particular risk factors (maternal psychological well-being, marital/family system risk), were associated with higher levels of internalizing behaviors. The findings from this study demonstrate that the extent to which both particular family risk factors and cumulative family risk place youth at increased risk for internalizing behaviors depends on youth’s parasympathetic functioning.

LGBTQ Youth-Serving Community-Based Organizations: Who Participates and What Difference Does it Make?

Abstract

LGBTQ youth are at greater risk for compromised health, yet large-scale health promotion programs for LGBTQ young people have been slow to develop. LGBTQ community-based organizations—which provide LGBTQ-focused support and services—have existed for decades, but have not been a focus of the LGBTQ youth health literature. The current study used a contemporary sample of LGBTQ youth (age 15–21; M = 18.81; n = 1045) to examine who participates in LGBTQ community-based organizations, and the association between participation and self-reported mental health and substance use. Youth who participated in LGBTQ community-based organizations were more likely to be assigned male at birth, transgender, youth of color, and accessing free-or-reduced lunch. Participation was associated with concurrent and longitudinal reports of mental health and substance use. LGBTQ community-based organizations may be an underutilized resource for promoting LGBTQ youth health.


Cover ImagePediatric Dermatology,
Early View,

Online Version of Record before inclusion in an issue,

BRIEF REPORTS
Novel dermoscopic features of pityriasis versicolor–like macules in epidermodysplasia verruciformis
T. P. Afra MD, Keshavamurthy Vinay MD, Muhammed Razmi T MD, Aysha Khader MD, N. A. Bishurul Hafi MD
Version of Record online: 23 October 2019
    ORIGINAL ARTICLES
    Occlusive versus neurotoxic agents for topical treatment of head lice infestation: A systematic review and meta‐analysis
    Rowena Natividad S. Flores‐Genuino MD, MSc, Charissa Mia S. Gnilo MD, Belen L. Dofitas MD, MSc
    Version of Record online: 22 October 2019
      CASE REPORTS
      PLAID syndrome: Characteristic presentation and a novel therapeutic option
      James Shea MD, Thy Huynh MD, Joshua Milner MD, Sarah Chamlin MD
      Version of Record online: 21 October 2019
        CASE REPORTS
        STAT1 gain‐of‐function and chronic demodicosis
        Vered Molho‐Pessach MD, Arnon Meltser BSc, Adaia Kamshov MD, Yuval Ramot MD, MSc, Abraham Zlotogorski MD
        Version of Record online: 21 October 2019
          ORIGINAL ARTICLES
          Prevalence of FLG loss‐of‐function mutations R501X, 2282del4, and R2447X in Spanish children with atopic dermatitis
          Ricardo González‐Tarancón MD, Rosalia Sanmartín MD, Fabiola Lorente, Elvira Salvador‐Rupérez MD, Angela Hernández‐Martín MD, Luis Rello MD, Jose Puzo MD, Yolanda Gilaberte MD
          Version of Record online: 21 October 2019
            REVIEW ARTICLES
            Mycosis fungoides in pediatric patients: Clinical features, diagnostic challenges, and advances in therapeutic management
            Julie H. Wu MD, Bernard A. Cohen MD, Ronald J. Sweren MD
            Version of Record online: 20 October 2019
              CASE REPORTS
              Onychodystrophy as the only sign of congenital candidiasis
              Susy M. Joy Way Bueno MD, Andrea Santos Muñoz MD, Ivana Maldonado MD, Margarita Larralde MD, PhD
              Version of Record online: 20 October 2019
                PEDIATRIC PROCEDURAL DERMATOLOGY
                Hangnails: Paste them back
                Ishmeet Kaur MD, Deepak Jakhar MD, Rachita Misri MD
                Version of Record online: 20 October 2019
                  CASE REPORTS
                  Bathing suit ichthyosis: Two Burmese siblings and a review of the literature
                  Wendy Li BS, Kate E. Oberlin MD, Theodore E. Wilson MD, Anita N. Haggstrom MD
                  Version of Record online: 20 October 2019
                    ORIGINAL ARTICLES
                    Acquired port‐wine stains in six pediatric patients
                    Michael R. Stephens BA, Elana Putterman BS, Albert C. Yan MD, Leslie Castelo‐Soccio MD, PhD, Marissa J. Perman MD
                    Version of Record online: 20 October 2019
                      ORIGINAL ARTICLES
                      Hamartomas and midline anomalies in association with infantile hemangiomas, PHACE, and LUMBAR syndromes
                      Nicole S. Stefanko MD, Olivia M.T. Davies BS, Maria Jose Beato MD, Francine Blei MD, Beth A. Drolet MD, Janet Fairley MD, Ilona J. Frieden MD, Eloise R. Galligan MD, Deborah Goddard MD, Renee Howard MD, Sameera Husain MD, Christine T. Lauren MD, Juan Carlos Lopez‐Gutierrez MD, Carol MacArthur MD, Denise W. Metry MD, Kimberly D. Morel MD, George W. Niedt MD, Maria C. Garzon MD, Olayemi Sokumbi MD, Dawn H. Siegel MD
                      Version of Record online: 20 October 2019