The use of mobile thermal imaging and machine learning technology for the detection of early surgical site infections

BACKGROUND

Surgical Site Infections (SSI) yield subtle, early signs that are not readily identifiable. This study sought to develop a machine learning algorithm that could identify early SSIs based on thermal images.

METHODS

Images were taken of surgical incisions on 193 patients who underwent a variety of surgical procedures. Two neural network models were generated to detect SSIs, one using RGB images, and one incorporating thermal images. Accuracy and Jaccard Index were the primary metrics by which models were evaluated.

RESULTS

Only 5 patients in our cohort developed SSIs (2.8%). Models were instead generated to demarcate the wound site. The models had 89-92% accuracy in predicting pixel class. The Jaccard indices for the RGB and RGB ​+ ​Thermal models were 66% and 64%, respectively.

CONCLUSIONS

Although the low infection rate precluded the ability of our models to identify surgical site infections, we were able to generate two models to successfully segment wounds. This proof-of-concept study demonstrates that computer vision has the potential to support future surgical applications.

Quantifying the benefit of whole blood on mortality in trauma patients requiring emergent laparotomy

BACKGROUND

Whole blood (WB) transfusions in trauma represent an increasingly utilized resuscitation strategy in trauma patients. Previous reports suggest a probable mortality benefit with incorporating WB into massive transfusion protocols. However, questions surrounding optimal WB practices persist. We sought to assess the association between the proportion of WB transfused during the initial resuscitative period and its impact on early mortality outcomes for traumatically injured patients.

METHODS

We performed a retrospective analysis of severely injured patients requiring emergent laparotomy and ≥ 3 units of red blood cell containing products (WB or packed red blood cells) within the first hour from an ACS Level 1 Trauma Center (2019-2022). Patients were evaluated based on the proportion of WB they received compared to packed red blood cells during their initial resuscitation (high ratio cohort ≥50% WB vs low ratio cohort <50% WB). Multilevel Bayesian regression analyses were performed to calculate the posterior probabilities and risk ratios (RR) associated with a WB predominant resuscitation for early mortality outcomes.

RESULTS

266 patients were analyzed (81% male, mean age of 36 years old, 61% penetrating injury, mean ISS of 30). The mortality was 11% at 4-hours and 14% at 24-hours. The high ratio cohort demonstrated a 99% (RR 0.12; 95% CrI 0.02-0.53) and 99% (RR 0.22; 95% CrI 0.08-0.65) probability of decreased mortality at 4-hours and 24-hours, respectively, compared the low ratio cohort. There was a 94% and 88% probability of at least a 50% mortality relative risk reduction associated with the WB predominate strategy at 4 hours and 24 hours, respectively.

CONCLUSION

Preferential transfusion of WB during the initial resuscitation demonstrated a 99% probability of being superior to component predominant resuscitations with regards to 4 and 24-hour mortality suggesting that WB predominant resuscitations may be superior for improving early mortality. Prospective, randomized trials should be sought.

LEVEL OF EVIDENCE

Therapeutic, Level III.

Effects of Gynecomastia Surgery on Readiness and Return to Duty in an Active Duty Military Population

INTRODUCTION

Simple mastectomies are routinely performed in the military health care system as gynecomastia can cause significant pain and discomfort when wearing body armor. Postoperative recovery negatively impacts personnel readiness. In this study, we sought to study time to return to duty in active duty service members who undergo surgery for gynecomastia.

METHODS AND MATERIALS

We conducted a single-center retrospective review of active duty patients undergoing a surgical operation for gynecomastia from July 2020-June 2022. A total of 96 patients were included. Our primary outcome of interest was time from surgery to return to duty. A multivariate analysis was performed to assess for factors independently associated with surgical complications including patient demographics and operative techniques.

RESULTS

The median number of days to return to duty after surgery was 28 days (IQR 13-37). The median loss of duty days because of gynecomastia without surgery was 19 days (IQR 10-21), which was different on the Mann-Whitney U test. Surgical complications were observed in 19 patients (19.7%) with the most common complications being seroma (11), hematoma (4), nipple-areolar complex necrosis (2), and infection (2). Patients with a complication have significantly more time to return to duty (28 vs. 49 days, P < .001). Risk factors associated with an increased risk of complication include ranks E1-E4, behavioral health diagnosis, "open" vs. "combined" technique with liposuction, length of operation greater than 58 minutes, and excised breast mass greater than 17.9 g.

CONCLUSIONS

Gynecomastia surgery is associated with a detriment to personnel readiness. Surgery should be reserved for patients with severe symptoms that prevent the performance of daily duties. Furthermore, factors associated with an increased risk for complications include ranks E1-E5, behavioral health diagnosis, length of operation >58 minutes, and excised breast mass >17.9 g. The operating surgeon should be mindful of these factors.

Modern Statistical Methods for the Surgeon Scientist: The Clash of Frequentist versus Bayesian Paradigms

The practice of evidence-based medicine is the result of a multitude of research and trials aimed toward improving health-care outcomes. An understanding of the associated data remains paramount toward optimizing patient outcomes. Medical statistics commonly revolve around frequentist concepts that are convoluted and nonintuitive for nonstatisticians. Within this article, we will discuss frequentist statistics, their limitations, as well as introduce Bayesian statistics as an alternative approach for data interpretation. By doing so, we intend to highlight the importance of correct statistical interpretations through clinically relevant examples while providing a deeper understanding of the underlying philosophies of frequentist and Bayesian statistics.

Early Use of Extracorporeal Membrane Oxygenation for Traumatically Injured Patients: A National Trauma Database Analysis

INTRODUCTION

Extracorporeal membrane oxygenation (ECMO) in acute trauma patients is a poorly characterized event. While ECMO most commonly has been deployed for advanced cardiopulmonary or respiratory failure following initial resuscitation, growing levels of evidence for out of hospital cardiac arrest support early ECMO cannulation as part of resuscitative efforts. We sought to perform a descriptive analysis evaluating traumatically injured patients, who were placed on ECMO, during their initial resuscitation period.

METHODS

We performed a retrospective analysis of the Trauma Quality Improvement Program Database from 2017 to 2019. All traumatically injured patients who received ECMO within the first 24 hours of their hospitalization were assessed. Descriptive statistics were used to define patient characteristics and injury patterns associated with the need for ECMO, while mortality represented the primary outcome evaluated.

RESULTS

A total of 696 trauma patients received ECMO during their hospitalization, of which 221 were placed on ECMO within the first 24 hours. Early ECMO patients were on average 32.5 years old, 86% male, and sustained a penetrating injury 9% of the time. The average ISS was 30.7, and the overall mortality rate was 41.2%. Prehospital cardiac arrest was noted in 18.2% of the patient population resulting in a 46.8% mortality. Of those who underwent resuscitative thoracotomy, a 53.3% mortality rate was present.

CONCLUSION

Early cannulation for ECMO in severely injured patients may provide an opportunity for rescue therapy following severe injury patterns. Further evaluation regarding the safety profile, cannulation strategies, and optimal injury patterns for these techniques should be evaluated.

Rapid cold sterilization of 3D printed surgical instruments for the austere environment

INTRODUCTION

Medical operations are vulnerable to global supply chain fluctuations. The ability to locally produce and reliably sterilize medical equipment may mitigate this risk. This project developed a reliable high-level disinfection process for 3D printed surgical tools.

METHODS

Surgical instruments and consumables were designed and printed from various materials. Devices contaminated with known and unknown bacteria underwent one of three cleaning methods followed by high-level disinfection using submersion in a Cidex OPA Solution. Devices were then cultured on blood agar plates and incubated for 48 h. Positive and negative controls were performed.

RESULTS

The results of control experiments showed no growth on negative controls and significant growth on all positive control plates. Of the three cleaning methods tested, one showed no growth: cleaning with isopropyl alcohol and chlorhexidine followed by Cidex bath.

DISCUSSION

This project successfully developed a rapid high-level disinfection process for 3D printed surgical instruments made from two different types of 3D printing material.

Impact of COVID on surgical case volume at military treatment facilities with surgical residencies

INTRODUCTION

The Military Health System (MHS) is tasked with the dual mission of providing medical care to beneficiaries while ensuring medical readiness. MHS provides care through a combination of military treatment facilities (MTF) ("direct care"; DC) & off-base civilian facilities ("purchased care"; PC). Given recent concerns regarding low surgical volume at MTFs, we sought to evaluate COVID's impact on elective and non-elective case volume at MTFs with surgical residencies.

METHODS

Retrospective review of 2017-2021 M2 database was performed on Tricare beneficiaries who underwent bariatric surgery or major colorectal surgery in the DC or PC market at, or, surrounding MTFs with surgical residencies. Procedures were identified using ICD-10 procedure codes and Medicare severity-diagnosis related groups. A detailed analysis was then performed on changes in case volume in the DC and PC markets.

RESULTS

5,698 bariatric and 5,517 major colorectal procedures were performed during the study period. There was an 84% vs 20% quarterly decrease in elective bariatric surgeries completed in the DC and PC markets from Q1 to Q2 2020. Pre to post-COVID (Q1 2017 - Q1 2020 vs Q3 2020 - Q4 2021) there was a decrease in the percentage of bariatric surgeries completed in the DC market (74.1% vs 55.0%, p = 0.001). Meanwhile, major colorectal surgery quarterly case volume remained unchanged in the DC (137 vs 125, p = 0.18) and PC (146 v 137, p = 0.13) markets, pre- and post-COVID.

DISCUSSION

Bariatric surgical case volume at MTFs disproportionately decreased during COVID when compared to the PC market and major colorectal cases. Bariatric case volume has rebounded in PC markets surpassing pre-COVID levels while DC case volume remains depressed. Further attention is warranted regarding decreased elective surgical case volume at MTFs.

See one, do one, but never teach one? An analysis of resident teaching assist cases under various levels of attending supervision

BACKGROUND

Surgical training has traditionally relied on increasing levels of resident autonomy. We sought to analyze the outcomes of senior resident teaching assist (TA) cases performed with a structured policy including varying levels of staff supervision.

METHODS

Retrospective review at a military medical center of TA cases from 2009 to 2014. The level of staff supervision included staff scrubbed (SS), staff present and not scrubbed (SP), or staff not present but available (NP). Operative variables were analyzed. An anonymous survey of residents and attendings at 6 military programs regarding experience and opinions on TA cases was distributed.

RESULTS

389 TA cases were identified. The majority (52%) were performed as NP. Operative times were shorter for NP cases (p < 0.05). Overall complication rate and length of stay were not different between groups (p > 0.05). Survey results demonstrated agreement amongst staff and residents that allowing selective NP was critical for achieving resident competence.

CONCLUSION

There were no identified adverse effects on intraoperative or postoperative complications. This practice is a critical component of training senior residents to transition to independent practice.

Plasma coadministration improves resuscitation with tranexamic acid or prothrombin complex in a porcine hemorrhagic shock model

BACKGROUND

Traumatic coagulopathy has now been well characterized and carries high rates of mortality owing to bleeding. A 'factor-based' resuscitation strategy using procoagulant drugs and factor concentrates in lieu of plasma is being used by some, but with little evidentiary support. We sought to evaluate and compare resuscitation strategies using combinations of tranexamic acid (TXA), prothrombin complex concentrate (PCC), and fresh frozen plasma (FFP).

METHODS

Sixty adult swine underwent 35% blood volume hemorrhage combined with a truncal ischemia-reperfusion injury to produce uniform shock and coagulopathy. Animals were randomized to control (n = 12), a single-agent group (TXA, n = 10; PCC, n = 8; or FFP, n = 6) or combination groups (TXA-FFP, n = 10; PCC-FFP, n = 8; TXA-PCC, n = 6). Resuscitation was continued to 6 hours. Key outcomes included hemodynamics, laboratory values, and rotational thromboelastometry. Results were compared between all groups, with additional comparisons between FFP and non-FFP groups.

RESULTS

All 60 animals survived to 6 hours. Shock was seen in all animals, with hypotension (mean arterial pressure, 44 mm Hg), tachycardia (heart rate, 145), acidosis (pH 7.18; lactate, 11), anemia (hematocrit, 17), and coagulopathy (fibrinogen, 107). There were clear differences between groups for mean pH (p = 0.02), international normalized ratio (p < 0.01), clotting time (CT; p < 0.01), lactate (p = 0.01), creatinine (p < 0.01), and fibrinogen (p = 0.02). Fresh frozen plasma groups had significantly improved resuscitation and clotting parameters (Figures), with lower lactate at 6.5 versus 8.4 (p = 0.04), and increased fibrinogen at 126 versus 95 (p < 0.01). Rotational thromboelastometry also demonstrated shortened CT at 60 seconds in the FFP group vs 65 seconds in the non-FFP group (p = 0.04).

CONCLUSION

When used to correct traumatic coagulopathy, combinations of FFP with TXA or PCC were superior in improving acidosis, coagulopathy, and CT than when these agents are given alone or in combination without plasma. Further validation of pure factor-based strategies is needed.

Muscle activity during running in water and on dry land: matched physiology

We investigated muscle activity during deep water running (DWR) and treadmill running on dry land (TMR) at similar physiological responses. 9 subjects (30.7±10.4 years) participated in this study. The baseline conditions consisted of TMR at 3 ratings of perceived exertion (RPE) level (RPE 11, 13, and 15) with heart rate (HR) recorded during each condition. The target HR for each level of DWR condition was determined by the HR recorded during the TMR. Muscle activity from the rectus femoris (RF), biceps femoris (BF), tibialis anterior (TA), and gastrocnemius (GA) were measured. As originally planned, HR was not different between modes (P>0.05) and was different between exercise intensities (P<0.001). Only TA muscle activity was influenced by the interaction of mode and intensity (P<0.05). Muscle activity from the GA during DWR was significantly lower than that of TMR (a 34-48% decrease; P<0.05), although muscle activity from the remaining tested muscles were not influenced by modes of exercise (P>0.05). These observations suggest that matching HR can be recommended to produce similar magnitude of lower extremity muscle activity during DWR to that of TMR, with the exception of the GA.

Summary of the practice parameter for the use of stimulant medications in the treatment of children, adolescents, and adults

This practice parameter describes treatment with stimulant medication. It uses an evidence-based medicine approach derived from a detailed literature review and expert consultation. Stimulant medications in clinical use include methylphenidate, dextroamphetamine, mixed salts of amphetamine, and pemoline. They carry U.S. Food and Drug Administration indications for the treatment of attention-deficit hyperactivity disorder.

Summary of the practice parameter for the prevention and management of aggressive behavior in child and adolescent psychiatric institutions with special reference to seclusion and restraint

This parameter reviews the current state of the prevention and management of child and adolescent aggressive behavior in psychiatric institutions, with particular reference to the indications and use of seclusion and restraint. It also presents guidelines that have been developed in response to professional, regulatory, and public concern about the use of restrictive interventions with aggressive patients with regard to personal safety and patient rights. The literature on the use of seclusion, physical restraint, mechanical restraint, and chemical restraint is reviewed, and procedures for carrying out each of these interventions are described. Clinical and regulatory agency perspectives on these interventions are presented. Effectiveness, indications, contraindications, complications, and adverse effects of seclusion and restraint procedures are addressed. Interventions are presented to provide more opportunities to promote patient independence and satisfaction with treatment while diminishing the necessity of using restrictive procedures.

Stimulation of adenosine A3 receptors in cerebral ischemia. Neuronal death, recovery, or both?

The role of the adenosine A3 receptor continues to baffle, and, despite an increasing number of studies, the currently available data add to, rather than alleviate, the existing confusion. The reported effects of adenosine A3 receptor stimulation appear to depend on the pattern of drug administration (acute vs. chronic), dose, and type of the target tissue. Thus, while acute exposure to A3 receptor agonists protects against myocardial ischemia, it is severely damaging when these agents are given shortly prior to cerebral ischemia. Mast cells degranulate when their A3 receptors are stimulated. Degranulation of neutrophils is, on the other hand, impaired. While reduced production of reactive nitrogen species has been reported following activation of A3 receptors in collagen-induced arthritis, the process appears to be enhanced in cerebral ischemia. Indeed, immunocytochemical studies indicate that both pre- and postischemic treatment with A3 receptor antagonist dramatically reduces nitric oxide synthase in the affected hippocampus. Even more surprisingly, low doses of A3 receptor agonists seem to enhance astrocyte proliferation, while high doses induce their apoptosis. This review concentrates on the studies of cerebral A3 receptors and, based on the available evidence, discusses the possibility of adenosine A3 receptor serving as an integral element of the endogenous cerebral neuroprotective complex consisting of adenosine and its receptors.

Early onset psychotic disorders: diagnostic stability and clinical characteristics

OBJECTIVES

To examine the clinical features and diagnostic stability of early-onset psychotic disorders.

METHODS

These data are from a two-year longitudinal prospective study of youth with psychotic disorders. Standardized diagnostic assessments are administered at baseline and at one and two-year's follow-up.

RESULTS

Fifty-one subjects have been recruited to date; 18 with schizophrenia, 14 with bipolar disorder, 7 with schizoaffective disorder, 1 with an organic psychosis, and 11 subjects whose symptoms where either questionable and/or did not meet diagnostic criteria for another disorder (classified as psychosis nos). Thirty-nine subjects were reassessed at year one, twenty-four at year two. Three subjects have been lost to follow-up. The study diagnosis was the same as the first onset diagnosis (prior to entering the study) in 50% of subjects. Over the two-year period of the study, the diagnosis remained unchanged in over 90% of subjects. Subjects with schizophrenia had higher ratings of premorbid impairment, including social withdrawal and dysfunctional peer relationships, than those with bipolar disorder. At the one-year follow-up, subjects with schizophrenia and schizoaffective disorder had significantly higher rates of delusions, bizarre behavior, and negative symptoms than those with bipolar disorder. Subjects with bipolar disorder tended to have cyclical courses, whereas those with schizophrenia and schizoaffective disorder were often chronically impaired. Subjects with psychosis nos had higher rates of dissociative symptoms and histories of child maltreatment.

CONCLUSIONS

Early-onset psychotic disorders can be reliably diagnosed using standardized assessments and are stable over a two-year period. Compared to bipolar disorder, schizophrenia is associated with a poorer premorbid history, and persistent positive and negative symptoms.

Early-onset psychotic disorders: course and outcome over a 2-year period

OBJECTIVE

To examine the course and outcome of early-onset psychotic disorders.

METHOD

These are data from a longitudinal, prospective study of youths with psychotic disorders. Standardized diagnostic and symptom rating measures were used.

RESULTS

Fifty-five subjects with the following disorders have been recruited: schizophrenia (n = 18), bipolar disorder (n = 15), psychosis not otherwise specified (n = 15), schizoaffective disorder (n = 6), and organic psychosis (n = 1). Follow-up assessments were obtained on 42 subjects at year 1 and 31 subjects at year 2. Youths with schizophrenia had more chronic global dysfunction, whereas subjects with bipolar disorder overall had better functioning, with a cyclical course of illness. However, according to results of a regression model, premorbid functioning and ratings of negative symptoms, but not diagnosis, significantly predicted the highest level of functioning over years 1 and 2.

CONCLUSIONS

Course and level of functioning differentiated bipolar disorder from schizophrenia. However, premorbid functioning and ratings of negative symptoms were the best predictors of functioning over the follow-up period. These findings are consistent with the adult literature, and they further support that psychotic illnesses in young people are continuous with the adult-onset forms.

Brown-Sequard syndrome after management of vertebral hemangioma with intralesional alcohol. A case report

STUDY DESIGN

This report describes Brown-Sequard syndrome after intralesional injection of absolute alcohol into vertebral hemangioma.

OBJECTIVE

To discuss whether the described technique is safe in the management of vertebral hemangiomas.

SUMMARY OF BACKGROUND DATA

The management of vertebral hemangiomas remains controversial. There have been reports of successful management using intralesional absolute alcohol.

METHODS

The clinical and radiologic features of the reported complication are detailed.

RESULTS

Intralesional injection of absolute alcohol caused Brown-Sequard syndrome.

CONCLUSION

This case shows that intralesional alcohol injection cannot be considered a safe technique for management of vertebral hemangiomas with spinal cord compression.

Preschool boys with oppositional defiant disorder: clinical presentation and diagnostic change

OBJECTIVE

Little is known about the clinical presentation and course of oppositional defiant disorder (ODD) when first diagnosed in the preschool years. Patterns of ODD symptomatology, comorbidity, persistence of disorder, and predictors of diagnostic outcome were examined in clinic-referred preschool boys.

METHOD

Boys (aged 4-5.5 years) with a DSM-III-R diagnosis of ODD were prospectively followed over a 2-year period. Multiple assessment procedures were used, including a modified version of the Diagnostic Interview Schedule for Children and parent and teacher ratings.

RESULTS

Ninety-two boys (mean age 56.9 months) with ODD were followed; 42 had comorbid attention-deficit hyperactivity disorder (ADHD). Among 79 boys assessed 2 years later, 76% had ODD, ADHD, or both. Of those, 25% had other diagnoses as well, primarily anxiety and/or mood disorders. Conduct disorder was rare. Subjects with comorbid ODD/ADHD at intake were significantly more likely to have a psychiatric disorder at follow-up, especially ADHD alone.

CONCLUSIONS

The findings suggest that ODD in the preschool period is a clear indicator of high risk, especially when co-occurring with ADHD. Further investigation of individual patterns of ODD symptom expression is recommended.

Sexual behavior associated with low Verbal IQ in youth who have severe mental illness

A retrospective chart review was used to examine sexual behavior (hypersexual, exposing, and victimizing) and cognitive impairment in 200 youth who had serious mental illness. Lower IQ was associated with increased sexual acting-out. For more serious victimizing sexual behaviors, only Verbal IQ differences reached statistical significance. Overall, sexual behavior was strongly associated with a history of sexual abuse. Sexual abuse history was significantly associated only with lower Performance IQ. Therefore, the association between low Verbal IQ and sexual victimizing behavior is distinct from the effects of sexual abuse. Results underscore the importance of verbal cognitive abilities, regardless of overall cognitive level, in the etiology and treatment of sexual behaviors, especially among individuals without a history of sexual abuse.

Practice parameters for the assessment and treatment of children and adolescents with bipolar disorder. American Academy of Child and Adolescent Psychiatry

These practice parameters describe the assessment and treatment of early-onset bipolar disorder based on scientific evidence regarding diagnosis and effective treatment and on the current state of clinical practice. Given the paucity of research on bipolar disorder in children and adolescents, many of the treatment recommendations are drawn from the adult literature. Although the same diagnostic criteria are used as for adults, youth may differ with regard to the developmental presentation of symptoms and comorbid psychiatric disorders. Treatment involves the combination of pharmacotherapy and adjunctive psychosocial interventions. Antimanic agents (primarily lithium or valproic acid) are the mainstays of pharmacotherapy. The treatment focuses on (1) amelioration of acute symptoms; (2) the prevention of relapse; (3) the reduction of long-term morbidity; and (4) the promotion of long-term growth and development. These parameters were approved by Council of the American Academy of Child and Adolescent Psychiatry on June 5, 1996, and were previously published in J. Am. Acad. Chil Adolesc. Psychiatry, 1997, 36:138-157.

Practice parameters for the assessment and treatment of children and adolescents with schizophrenia. American Academy of Child and Adolescent Psychiatry

These practice parameters review the literature on children and adolescents with schizophrenia. Because this literature is sparse, information is also drawn from research with adults. Clinical features in youth with schizophrenia include predominance in males, high rate of premorbid abnormalities, increased family history of schizophrenia, and often poor outcome. Diagnostic issues include the overlap, and therefore potential for misdiagnosis, between the first presenting symptoms of schizophrenia and those of psychotic mood disorders, developmental disorders, organic conditions, and other nonpsychotic emotional/behavioral disorders. Treatment should include using antipsychotic medications in conjunction with psychoeducational, psychotherapeutic, and social and educational support programs. These parameters were previously published in J. Am. Acad. Child Adolesc. Psychiatry, 1994, 33:616-635.

Relationship between sexual abuse, gender, and sexually inappropriate behaviors in seriously mentally ill youths

OBJECTIVE

To examine gender differences in sexual abuse histories and in the development of inappropriate sexual behaviors in a sample of seriously mentally Ill youths.

METHOD

A retrospective chart review was completed for all patients from 1987 through 1992 at a tertiary care public sector psychiatric hospital for youths (N = 499). Subjects were categorized by gender, sexual abuse status, and whether they had sexually reactive or victimizing behaviors.

RESULTS

Girls were more likely to have been sexually abused, and their abuse histories were more severe. Sexual behavior problems in girls were almost exclusively associated with sexual abuse, whereas 29% of boys with victimizing behaviors had no sexual abuse history. Among sexually abused youths, boys were more likely to display victimizing behaviors, whereas both genders displayed similar rates of sexually reactive behaviors. Of the 19 girls who displayed victimizing behaviors, 95% were chronically sexually abused and one third had also received a major injury due to physical abuse.

CONCLUSIONS

Boys appear to have a lower threshold of abuse exposure required to develop sexually inappropriate behaviors and are significantly more likely to display victimizing behaviors. Conversely, victimizing behaviors in girls may require a catastrophic maltreatment history. These gender differences should be incorporated into treatment interventions directed at sexual abuse victims.

Case study: two additional sudden deaths with tricyclic antidepressants

Since 1990, there have been five reported cases of sudden death in children treated with desipramine. This case study describes the sudden deaths of two additional children treated with tricyclic antidepressants, one with desipramine, 3.3 mg/kg per day, the other with imipramine, 6 mg/kg per day and thioridazine, 1 mg/kg per day. The reports add to concerns about the use of tricyclics in children.

Age of onset of sexual abuse: relationship to sexually inappropriate behaviors

OBJECTIVE

To examine how the age of onset of sexual abuse predicted inappropriate sexual behaviors in a sample of seriously mentally ill youths.

METHOD

A retrospective chart review was completed for all youths treated from 1987 through 1992 at a tertiary care public sector psychiatric hospital (n = 499). Subjects were grouped according to the age at which they were first sexually abused: no sexual abuse (n = 225), 0 through 3 years (n = 78), 4 through 6 years (n = 105), 7 through 12 years (n = 71), and 13 through 17 years (n = 19).

RESULTS

The rates of sexually inappropriate behaviors in subjects with sexual abuse histories were quite substantial, ranging from 79.5% of the 0- through 3-year group to 42.1% of the 13- through 17-year group. Subjects first abused during early childhood, especially during the ages 0 through 3 years, had significantly elevated rates of hypersexual, exposing, and victimizing sexual behaviors. They also were significantly younger at the time of admission, came from more disrupted family settings, and had significantly higher rates of physical abuse, neglect, chronic sexual abuse, sexual abuse by either parent/stepparent and a higher total number of victimizers. When logistic regression analyses were done to examine the predictive power of potential risk factors, early age of onset of sexual abuse was the most significant predictor of all three types of inappropriate sexual behaviors.

CONCLUSIONS

Onset of sexual abuse prior to 7 years of age was significantly associated with hypersexual, exposing, and victimizing sexual behaviors. Early sexual abuse is also associated with a number of other poor prognostic factors, and further research is needed to define how these variables interact.

Clinical characteristics related to severity of sexual abuse: a study of seriously mentally ill youth

OBJECTIVE

In this study we examined demographic, social, and clinical variables related to sexual abuse histories in a sample of severely mentally ill youth.

METHOD

Data were collected via a retrospective chart review of all patients treated over a 5-year period (1987-1992) at a tertiary care public sector psychiatric hospital. The sample was divided into four groups: no history of sexual abuse (n = 226); isolated events (n = 62); intermittent abuse (n = 61); and chronic (n = 150).

RESULTS

Youth with sexual abuse histories were more often female, had higher rates of social chaos and associated physical abuse and neglect, and had higher rates of post-traumatic stress disorder (PTSD) and substance abuse disorders. Chronically abused subjects came from the most chaotic and abusive backgrounds; were younger when first abused; had the highest number of abusers; were more likely to have been molested; and were more often abused by their father/stepfather and/or their mother/stepmother. Using logistic regression analyses, sexual abuse histories were predicted by sexually inappropriate behaviors, symptoms of PTSD and borderline personality disorders, dissociative symptoms, substance abuse and animal cruelty.

CONCLUSION

Sexual abuse histories were quite common in this sample. Sexually abused subjects had increased rates of inappropriate sexual behaviors, substance abuse, and post-traumatic reactions; and were frequently exposed to other confounding environmental risk factors, including physical abuse, family problems and social chaos.

Sexually inappropriate behaviors in seriously mentally ill children and adolescents

This study examined the prevalence and clinical correlates of sexually inappropriate behaviors in all youth treated at a tertiary care public sector psychiatric hospital over a 5-year period. A retrospective chart review was completed on 499 subjects. Subjects were grouped in four mutually exclusive categories: no inappropriate sexual behaviors (n = 296), hypersexual (n = 82), exposing (n = 39) and victimizing (n = 82) behaviors. Those with histories of sexually inappropriate behaviors had much higher rates of being sexually abused (82 vs. 36%), and also had higher rates of physical abuse and neglect, behavior disorders, developmental problems, and family histories of antisocial behavior. They were less likely to have affective disorders. The hypersexual group had a higher proportion of females, and was associated in part with variables relating to sexual abuse and posttraumatic stress disorder. The more severe offending groups (exposing and victimizing) were associated with variables related to sexual abuse, developmental delays, lower IQ's, peer problems, and other acting-out behavior problems. These findings underscore the importance of evaluating for sexually inappropriate behaviors in seriously mentally ill youth, especially in those with histories of sexual abuse.

Regulation of scatter factor production via a soluble inducing factor

Scatter factor (SF) (also known as hepatocyte growth factor [HGF]) is a fibroblast-derived cytokine that stimulates motility, proliferation, and morphogenesis of epithelia. SF may play major roles in development, repair, and carcinogenesis. However, the physiologic signals that regulate its production are not well delineated. We found that various human tumor cell lines that do not produce SF secrete factors that stimulate SF production by fibroblasts, suggesting a paracrine mechanism for regulation of SF production. Conditioned medium from these cell lines contained two distinct scatter factor-inducing factor SF-IF activities: a high molecular weight (> 30 kD), heat sensitive activity and a low molecular weight (< 30 kD) heat stable activity. Further studies revealed that SF-producing fibroblasts also secrete factors that stimulate their own SF production. We characterized the < 30-kD SF-IF activity from ras-3T3 (clone D4), a mouse cell line that overproduces both SF and SF-IF. The < 30-kD filtrate from ras-3T3 conditioned medium induced four- to sixfold increases in expression of SF biologic activity, immunoreactive protein, and mRNA by multiple SF-producing fibroblast lines. Ras-3T3 SF-IF activity was stable to boiling, extremes of pH, and reductive alkylation, but was destroyed by proteases. We purified ras-3T3 SF-IF about 10,000-fold from serum-free conditioned medium by a combination of ultrafiltration, cation exchange chromatography, and reverse phase chromatography. The purified protein exhibited electrophoretic mobility of about 12 kD (reduced) and 14 kD (nonreduced) by SDS-PAGE. The identity of the protein was verified by elution of biologic activity from gel slices. Purified SF-IF stimulated SF production in a physiologic concentration range (about 20-400 pM). Its properties and activities were distinct from those of IL-1 and TNF, two known inducers of SF production. We suggest that SF-IF is a physiologic regulator of SF production.

Practice parameters for the assessment and treatment of children and adolescents with schizophrenia. American Academy of Child and Adolescent Psychiatry

These practice parameters review the literature on children and adolescents with schizophrenia. Because this literature is sparse, information is also drawn from research with adults. Clinical features in youth with schizophrenia include predominance in males, high rate of premorbid abnormalities, increased family history of schizophrenia, and often poor outcome. Diagnostic issues include the overlap, and therefore potential for misdiagnosis, between the first presenting symptoms of schizophrenia and those of psychotic mood disorders, developmental disorders, organic conditions, and other nonpsychotic emotional/behavioral disorders. Treatment should include using antipsychotic medications in conjunction with psychoeducational, psychotherapeutic, and social and educational support programs.

Children on child protective service caseloads: prevalence and nature of serious emotional disturbance

A multivariate, criterion-referenced approach was used to assess prevalence of serious emotional disturbance among children on protective service case loads. Of 140 recipients of protective services, 72% were statistically indistinguishable from children in Washington State's most intensive mental health treatment programs. School problems, substance abuse, and antisocial behaviors were common in the sample, as were family histories of mental illness or substance abuse. Greatest service needs included family support groups, outpatient treatment, school-based treatment, and diagnostic services. These results underline the importance of structural changes to facilitate cross-system collaboration between mental health and protective services.

Familial pancreatic cancer (Part II): Surveillance, diagnostic tests, and surgical strategies

We have provided a description of the current state of knowledge relevant to familial/hereditary pancreatic cancer. Since the most important clinical ramifications of this disease, whose incidence and mortality are essentially the same, rests upon its earlier detection, we have also characterized available diagnostic tests, surgical strategies, and current knowledge about its pathology. We believe that advances in control of pancreatic cancer will be heavily impacted by progress in the search for new and better diagnostic tests. These could include monoclonal antibodies targeted to pancreatic tumor tissue, and possibly pancreatic site-specific P450's, as well as biomolecular/genetic techniques, particularly when focused on individuals at high risk. Thus, family studies are important in this disease because if an autosomal dominantly inherited form of pancreatic cancer is delineated, one could identify individuals at high risk early in life. Comparison could then be made with individuals in branches of the family where the disease is not segregating. Thus, there would be a greater potential for discovery of methods for early detection with evaluation of sensitivity and specificity in families wherein the predictability for pancreatic cancer occurrence is high.

Familial pancreatic cancer: clinicopathologic study of 18 nuclear families

Host factors have been given scant attention in the search for etiology in pancreatic cancer. Several anecdotal reports have identified its familial clustering, whereas a recent population-based case/control study has shown that 6.7% of cases and 0.7% of controls had positive family histories of this disease (p less than 0.001). Forty-seven individuals with pancreatic cancer from 18 families were identified from a review of the medical records of all kindreds on file at our Hereditary Cancer Institute. The observed sex ratio, age of onset, histologic type, and survival were comparable to published data on unselected patients. We did not identify any pattern of extra-pancreatic cancer association. A serious limitation of our study is its lack of a population-based case/control design. Whereas our data are primarily descriptive, they do indicate the need to learn more about the role of familial factors in the etiology of pancreatic cancer. Pancreatic cancer is increasing in incidence, and its prognosis is almost uniformly dismal; identification of persons at high risk may improve cancer control.

Prevention of psychiatric disorders in children

Mental health professionals have the capability to identify children who are at risk of developing psychiatric disorders. Early intervention with these children can help prevent significant maladjustment and reduce their future need for mental health services. The authors review studies of environmental and temperamental factors associated with children's vulnerability and resilience to psychiatric disorders. The goals and effects of selected prevention approaches designed for preschool children, elementary-school-age children, and parents are discussed. Families in need of prevention services may be more likely to use these interventions if they are integrated into existing school programs and social welfare systems.

Response to lactate infusion in generalized anxiety disorder

Intravenous sodium lactate infusion provokes symptoms of panic in patients with panic disorder at a significantly higher rate than in normal controls. Lactate sensitivity has been postulated to be specific for patients with panic attacks regardless of frequency of attacks or coexisting diagnoses. The authors present results of a pilot study of lactate infusions in patients with generalized anxiety disorder (GAD) without any history of panic attacks. Patients with GAD reacted more like panic disorder patients than like normal controls in anxiety and symptom scores during lactate infusion and in the rate of positive responses to lactate. Although preliminary, these findings raise questions regarding the specificity of lactate sensitivity and the relationship of GAD to panic disorder.

Initial alkylating agent chemotherapy in a leukemic hairy cell patient

A patient with moderate splenomegaly and the leukemic phase of hairy cell leukemia presented with a white blood cell count (WBC) of 85,600/mm3 with 87% hairy cells and platelets of 125,000/mm3. Initial therapy consisted of chlorambucil alone at 4 mg each day. Within 6 months, the WBC decreased to 27,000/mm3 with 82% hairy cells, and the spleen was not palpable; platelets remained at 142,000/mm3. The patient has continued to do well for 2 years since the start of therapy, requiring no transfusions and having no problems secondary to organ infiltration. Selected hairy cell patients, those with a significant leukemic phase and with only mild thrombocytopenia, may benefit from initial chlorambucil therapy rather than immediate splenectomy.

Two-dimensional echocardiographic assessment of vegetative endocarditis

Real-time, two-dimensional echocardiography was used to document the presence and assess the size and location of vegetative lesions of the cardiac valves and chambers in seven patients with bacterial endocarditis. Anatomic correlation (surgical or autopsy) was accurate in all patients. Two-dimensional echocardiography was shown to be of particular value in determining morphologic characteristics of the lesions since this technique provides spatial information concerning moving cardiac structures. The results of two-dimensional echocardiography were most helpful in determining selected aspects of the clinical care provided for each patient. These data demonstrate that real-time, two-dimensional echocardiography, in combination with M-mode imaging techniques, may be of great potential value in the detection of vegetative endocarditis. Furthermore, reliable assessment of lesion size and location may, in time, become a valuable method for following the morphologic changes that occur in vegetative lesions, and thus determine the efficacy of antibiotic therapy. This information may also provide a means for evaluating certain patients for surgical intervention.