Prevalence of suicidal ideation in German psychotherapy outpatients: A large multicenter assessment

BACKGROUND

Suicidal ideation is a major concern in clinical practice. Yet, little is known about prevalence rates of suicidal ideation in patients undergoing outpatient psychotherapeutic treatment. Therefore, the aim of the current study is to assess the prevalence of suicidal ideation in a large sample of psychotherapy outpatients in Germany. The data analyzed in this study is taken from the KODAP-project on the coordination of data collection and analysis at German university-based research and training outpatient clinics for psychotherapy.

METHODS

A total of N = 10,357 adult outpatients (64.4 % female; age: M(SD) = 35.94 (13.54), range: 18-92 years of age) starting cognitive-behavioral therapy at one of 27 outpatient clinics in Germany were included in the current study. Prevalence of suicidal ideation was assessed with the Suicide Item (Item 9) of the Beck-Depression Inventory II.

RESULTS

Suicidal ideation was reported by 36.7 % (n = 3795) of the participants. Borderline Personality Disorder, Posttraumatic Stress Disorder, and recurrent Major Depression were the diagnoses most strongly associated with the presence and severity of suicidal ideation.

LIMITATION

Suicide ideation was assessed only with the respective item of the Beck Depression Inventory II.

CONCLUSION

Suicidal ideation is very common among adult patients who start psychotherapy in Germany. A well-founded knowledge of risk assessment in suicidal patients and suicide-specific treatment options is therefore highly relevant.

Carotid Artery Patency and Neurodevelopmental Outcomes After Decannulation in Pediatric Extracorporeal Life Support

INTRODUCTION

Decannulation from veno-arterial extracorporeal life support may involve ligation or repair of the carotid artery; however, differences in outcomes are not clear. This study aimed to describe short- and long-term artery patency and neurodevelopmental outcomes in neonatal and pediatric patients who underwent carotid artery repair (CAR) versus ligation at decannulation.

METHODS

Patients supported on veno-arterial extracorporeal life support during the first 15 mo of life from 2010 to 2020 at a large, tertiary care children's hospital were included. Decannulation strategy, postdecannulation imaging, and follow-up visits were reviewed.

RESULTS

74 patients were identified with median age at cannulation 2 d (interquartile range [IQR] = 1-21 d) and median weight 3.7 kg (interquartile range= 3.2-4.4 kg). Indications included congenital cardiac conditions (27%), congenital diaphragmatic hernia (19%), pulmonary hypertension (19%), meconium aspiration (16%), and pneumonia/sepsis (14%). Forty-two patients (57%) underwent CAR. Patients on extracorporeal life support >5 d were 95% less likely to undergo CAR (P < 0.001). Of CAR patients, 18 (43%) had doppler ultrasound performed within the 2-y follow-up period. Ten of 18 patients (55.6%) had >50% stenosis (3) or complete occlusion (7). Only 36% (27/74) had formal neurodevelopmental follow-up within 6 mo and 41% (30/74) within 2 y; however, no significant differences in function were seen between groups.

CONCLUSIONS

Neonates and young toddler patients undergoing CAR following extracorporeal life support decannulation are at risk for partial or complete artery occlusion. In our study population, repair and ligation at decannulation appear to have similar neurodevelopmental outcomes; however, follow-up to assess function is not standardized. Longer term follow-up and risk stratification are needed to guide decannulation strategy.

Critical elements of pediatrics sacrococcygeal germ cell tumor surgery

Sacrococcygeal teratoma is the most common extragonadal germ cell tumor in the pediatric population, and accounts for approximately 70% of all teratomas in childhood.1,2 They present in two distinct phases, with most cases seen in neonates with large predominately exophytic tumors, often detected in utero on prenatal sonography or at birth. A smaller cohort presents in older infants and children with primarily hidden tumors in the pelvis which have a much higher rate of malignancy. The primary surgical objective is complete tumor resection without compromise to critical structures or function. Herein we outline the critical elements of tumor resection and management of sacrococcygeal germ cell tumors with a focus on the technical aspects of this tumor across a range of presentations.

Congenital pleuropulmonary blastoma in a newborn with a variant of uncertain significance in DICER1 evaluated by RNA-sequencing

BACKGROUND

Pleuropulmonary blastoma (PPB) is a rare mesenchymal malignancy of the lung and is the most common pulmonary malignancy in infants and children. Cystic PPB, the earliest form of PPB occurring from birth to approximately two years of age, is often mistaken for a congenital pulmonary airway malformation, as the two entities can be difficult to distinguish on imaging and pathology. Diagnosis of PPB should prompt workup for DICER1 syndrome, an autosomal dominant tumor predisposition syndrome. We report a newborn with a congenital PPB presenting with tachypnea and hypoxia, who was found to have variant of uncertain clinical significance (VUS) in DICER1.

CASE PRESENTATION

A term female infant developed respiratory distress shortly after birth. Initial imaging was concerning for a congenital pulmonary airway malformation versus congenital diaphragmatic hernia, and she was transferred to a quaternary neonatal intensive care unit for management and workup. Chest CT angiography demonstrated a macrocytic multicystic lesion within the right lower lobe without systemic arterial supply. The pediatric surgery team was consulted, and the neonate underwent right lower lobectomy. Pathology revealed a type I PPB. Oncology and genetics consultants recommended observation without chemotherapy and single gene sequencing of DICER1, which identified a germline VUS in DICER1 predicted to alter splicing. RNA-sequencing from blood demonstrated that the variant resulted in an in-frame deletion of 29 amino acids in a majority of transcripts from the affected allele. Due to the patient's young age at presentation and high clinical suspicion for DICER1 syndrome, tumor surveillance was initiated. Renal and pelvic ultrasonography were unremarkable.

CONCLUSION

We present the case of a term neonate with respiratory distress and cystic lung mass, found to have a type I PPB with a germline VUS in DICER1 that likely increased her risk of DICER1-related tumors. Nearly 70% of patients with PPB demonstrate germline mutations in DICER1. Review of RNA sequencing data demonstrates the difficulty in classifying splice variants such as this. Penetrance is low, and many patients with pathogenic DICER1 variants do not develop a malignancy. Best practice surgical and oncologic recommendations include an individualized approach and tumor board discussion. This case highlights the importance of a multidisciplinary team approach and the utility of international registries for patients with rare diagnoses.

Similar frequency of atrial perforation between atrial and bicaval dual lumen veno-venous ECMO cannulas in a pediatric population

PURPOSE

Complications associated with use of dual-lumen venovenous extracorporeal membrane oxygenation (VV-ECMO) cannulas are of concern in pediatric patients. While the risk of atrial perforation is believed to be higher with bicaval cannulas, direct comparison of complication rate between atrial and bicaval cannulas has not been conducted in this population.

METHODS

A retrospective review was conducted at a free-standing children's hospital of all patients 0-18 years old, placed on VV-ECMO with a dual-lumen cannula from January 2009 to December 2018. Patients were grouped based on cannula type. Complications were assessed over the entire duration of the ECMO run. Logistic regression analyses were used to evaluate for an association between cannula type and risk of pericardial effusion or cannula-related complication requiring median sternotomy or pericardial drain placement.

RESULTS

During the study period 119 patients were placed on VVECMO using a dual-lumen cannula. Eighty-two patients (69%) were <2 years old, 19 (16%) were 2-10 years old, and 18 (15%) were 11-18 years old. Seventy-three were cannulated with an atrial cannula and 46 patients received a bicaval cannula. Pericardial effusions were seen in 30% and 24% of these patients respectively while severe complications were seen in 9.6% and 8.7% of patients respectively. Compared to patients treated with a bicaval cannula, those who received an atrial cannula had similar odds of effusions (OR: 1.41, 95% CI: 0.62-3.36) and severe complications (OR 0.89, 95% CI: 0.27-3.18). After adjusting for age, weight, cannula and circuit manipulations, and use of echocardiography, the OR of effusion was 1.91 (95% CI: 0.65-6.42), and the adjusted OR of severe complication was 0.69 (95% CI: 0.16-3.33).

CONCLUSIONS

There were no significant differences in frequency of pericardial effusions or severe cannula-related complications between the treatment groups across all pediatric patients and within the subgroup of patients under 2 years of age.

Appendectomy Versus Observation for Appendicitis in Neutropenic Children With Cancer

BACKGROUND

Optimal management of neutropenic appendicitis (NA) in children undergoing cancer therapy remains undefined. Management strategies include upfront appendectomy or initial nonoperative management. We aimed to characterize the effect of management strategy on complications and length of stay (LOS) and describe implications for chemotherapy delay or alteration.

METHODS

Sites from the Pediatric Surgery Oncology Research Collaborative performed a retrospective review of children with NA over a 6-year period.

RESULTS

Sixty-six children, with a median age of 11 years (range 1-17), were identified with NA while undergoing cancer treatment. The most common cancer diagnoses were leukemia (62%) and brain tumor (12%). Upfront appendectomy was performed in 41% of patients; the remainder had initial nonoperative management. Rates of abscess or perforation at diagnosis were equivalent in the groups (30% vs 24%; P = .23). Of patients who had initial nonoperative management, 46% (17 of 37) underwent delayed appendectomy during the same hospitalization. Delayed appendectomy was due to failure of initial nonoperative management in 65% (n = 11) and count recovery in 35% (n = 6). Cancer therapy was delayed in 35% (n = 23). Initial nonoperative management was associated with a delay in cancer treatment (46% vs. 22%, P = .05) and longer LOS (29 vs 12 days; P = .01). Patients who had initial nonoperative management and delayed appendectomy had a higher rate of postoperative complications (P < .01).

CONCLUSIONS

In pediatric patients with NA from oncologic treatment, upfront appendectomy resulted in lower complication rates, reduced LOS, and fewer alterations in chemotherapy regimens compared to initial nonoperative management.

Assessment of excess medical costs for persons with type 2 diabetes according to age groups: an analysis of German health insurance claims data

AIM

This cross-sectional study used a large nationwide claims data set to assess the excess medical costs of people with type 2 diabetes according to age group in 2015.

METHODS

Data from 291 709 people with diabetes and 291 709 age- and sex-matched controls were analysed. Total costs (expressed as 2015 euros) of outpatient and inpatient services, medication, rehabilitation, and the provision of aids and appliances were examined. Overall and age-stratified excess costs of people with diabetes were estimated using gamma regression with a log-link.

RESULTS

Overall, the estimated total direct costs of a person with type 2 diabetes are approximately double those of a person without diabetes: €4727 vs. €2196, respectively. Absolute excess costs were approximately the same in all age groups (around €2500), however, relative excess costs of persons with diabetes were much higher in younger (~ 334% for < 50 years) than in older age groups (~ 156% for ≥ 80 years). Regional costs, both absolute and excess, partly differed from the national level.

CONCLUSIONS

This study complements and updates previous studies on the excess medical costs of people with diabetes in Germany. The results indicate the importance of preventing the development of type 2 diabetes, especially in younger age groups. Longitudinal and regional studies examining changes in prevalence and the development of excess costs in groups with different types of diabetes, and according to age, would be of interest to validate our findings and better understand the avoidable burden of having diabetes.

Food cue-elicited brain potentials change throughout menstrual cycle: Modulation by eating styles, negative affect, and premenstrual complaints

BACKGROUND

While there is evidence for increased food intake and craving during the luteal phase, underlying mechanisms are incompletely understood. The present study investigated electrophysiological responses to food pictures as a function of menstrual cycle phase. In addition, the moderating effects of progesterone, eating behaviors (restraint, emotional, orthorexic), negative affect, and premenstrual complaints were explored.

METHODS

Using a within-subject design, 35 free-cycling women watched and rated pictures of food (high and low caloric) and control items during the follicular, the ovulatory, and the luteal phase (counterbalanced), while EEG was recorded to examine the late positive potentials (LPP). Salivary gonadal hormones and affect were examined at each occasion. Eating behaviors and premenstrual complaints were assessed once.

RESULTS

For parietal regions, average LPPs were comparable between cycle phases but slightly larger LPP amplitudes were elicited by high caloric food pictures as compared to the neutral category. Descriptively, both food categories elicited larger parietal LPPs than neutral pictures during the luteal phase. Analyses of LPPs for central-parietal regions showed no effect of picture category or cycle phase, except higher amplitudes in the right area during the luteal phase. During the luteal phase, progesterone and functional interference from premenstrual symptoms (but not age, BMI, picture ratings, affect, estradiol, or eating behaviors) significantly predicted larger parietal LPPs towards high caloric (but not low caloric) pictures.

CONCLUSION

Our findings suggest a heightened food cue reactivity during the luteal phase, which may relate to higher ovarian hormone secretion and more functional impact of premenstrual symptoms. This research contributes to a better understanding of menstrual health and the identification of preventive strategies for premenopausal women.

Surgical management of pediatric rectal prolapse: A survey of the American Pediatric Surgical Association (APSA)

INTRODUCTION

Many management options exist for the treatment of refractory rectal prolapse (RP) in children. Our goal was to characterize current practice patterns among active members of APSA.

METHODS

A 23-item questionnaire assessed the management of full-thickness RP for healthy children who have failed medical management. The survey was approved by our IRB and by the APSA Outcomes committee.

RESULTS

236 surgeons participated. The respondents were geographically dispersed (44 states, 5 provinces). 32% of respondents had twenty or more years of clinical experience. 71% evaluated 1-5 RP patients in the last 2 years, while 5% evaluated >10. 71% performed 0-1 procedure (operation or local therapy [LT]) for RP over 2 years. 59% would treat a 2-year-old patient differently than a 6-year-old with the same presentation, and were more likely to offer up-front surgery to a 6-year-old (26% vs 15%, p = 0.04), less likely to continue medical management indefinitely (2% vs 7%, p=0.01), and more likely to perform resection with rectopexy (30% vs. 15%, p=0.01). 71% perform LT as an initial intervention: injection sclerotherapy (59%), anal encirclement (8%), and sclerotherapy + anal encirclement (5%). 70% consider LT a failure after 1-3 attempts. If LT fails, surgical management consists of transabdominal rectopexy (46%), perineal proctectomy or proctosigmoidectomy (22%), transabdominal sigmoidectomy + rectopexy (22%), and posterior sagittal rectopexy (9%).

CONCLUSIONS

There is wide variability in the surgical management of pediatric rectal prolapse. This suggests a need for development of processes to identify best practices and optimize outcomes for this condition.

Attentional bias toward and distractibility by sexual cues: A meta-analytic integration

From an evolutionary perspective, sexual stimuli are highly salient and are assumed to be processed with high priority. Hence, attentional processing of sexual cues is expected to not only bias attention but to also distract from other cognitive (foreground) tasks. It is, however, unclear to what extent these stimuli capture attention and whether there are differences between men and women. This meta-analysis combined the results of 32 studies employing experiments of attentional bias toward and distraction by sexual stimuli. From these, 13 studies provided data to examine gender differences. Overall, attentional bias and distractibility was lower than anticipated (g_z = 0.43, p < .001) and there was support for the assumption of higher attention bias/interference in men (g_s = 0.29, p = .031). Importantly, there was evidence for the presence of publication bias. With this in mind, findings are discussed in the context of stimulus features, the impact of provoked sexual arousal and motivational state, and gender-specific and -nonspecific neural processing of sexual stimuli which influence attention toward them.

[Physical activity as therapeutic intervention for depression]

AIM

This article gives a conspectus of the present state of research on the efficiency of exercise as a treatment for patients suffering from depression.

METHODS

A systematic review of articles published between December 1980 and March 2016 was carried out. The review focused on studies that examined the effects of exercise compared to control conditions in the treatment of depression. Extracted and analyzed information from the articles included details about participants, characteristics of exercise and control conditions, assessments, study design and outcomes.

RESULTS

A total of 34 of the 48 studies included in the literature search reported a significant reduction of depressive symptoms due to exercise interventions. There was a trend to reduced depressive symptoms following the exercise interventions in five studies. In nine studies no positive impact of exercise on depression and affective well-being could be detected.

DISCUSSION

This review article shows that physical activity decreases depressive symptoms and increases affective well-being in patients with depressive diseases; therefore, exercise should be recommended as a component of depression treatment within the framework of a multi-dimensional approach.

Trigger-happy resident memory CD4+ T cells inhabit the human lungs

Resident memory T cells (T_RM) reside in the lung epithelium and mediate protective immunity against respiratory pathogens. Although lung CD8⁺ T_RM have been extensively characterized, the properties of CD4⁺ T_RM remain unclear. Here we determined the transcriptional signature of CD4⁺ T_RM, identified by the expression of CD103, retrieved from human lung resection material. Various tissue homing molecules were specifically upregulated on CD4⁺ T_RM, whereas expression of tissue egress and lymph node homing molecules were low. CD103⁺ T_RM expressed low levels of T-bet, only a small portion expressed Eomesodermin (Eomes), and although the mRNA levels for Hobit were increased, protein expression was absent. On the other hand, the CD103⁺ T_RM showed a Notch signature. CD4⁺CD103⁺ T_RM constitutively expressed high transcript levels of numerous cytotoxic mediators that was functionally reflected by a fast recall response, magnitude of cytokine production, and a high degree of polyfunctionality. Interestingly, the superior cytokine production appears to be because of an accessible interferon-γ (IFNγ) locus and was partially because of rapid translation of preformed mRNA. Our studies provide a molecular understanding of the maintenance and potential function of CD4⁺ T_RM in the human lung. Understanding the specific properties of CD4⁺ T_RM is required to rationally improve vaccine design.

Acyl ghrelin improves cognition, synaptic plasticity deficits and neuroinflammation following amyloid β (Aβ1-40) administration in mice

Ghrelin is a metabolic hormone that has neuroprotective actions in a number of neurological conditions, including Parkinson's disease (PD), stroke and traumatic brain injury. Acyl ghrelin treatment in vivo and in vitro also shows protective capacity in Alzheimer's disease (AD). In the present study, we used ghrelin knockout (KO) and their wild-type littermates to test whether or not endogenous ghrelin is protective in a mouse model of AD, in which human amyloid β peptide 1-40 (Aβ_1-40 ) was injected into the lateral ventricles i.c.v. Recognition memory, using the novel object recognition task, was significantly impaired in ghrelin KO mice and after i.c.v. Aβ_1-40 treatment. These deficits could be prevented by acyl ghrelin injections for 7 days. Spatial orientation, as assessed by the Y-maze task, was also significantly impaired in ghrelin KO mice and after i.c.v. Aβ_1-40 treatment. These deficits could be prevented by acyl ghrelin injections for 7 days. Ghrelin KO mice had deficits in olfactory discrimination; however, neither i.c.v. Aβ_1-40 treatment, nor acyl ghrelin injections affected olfactory discrimination. We used stereology to show that ghrelin KO and Aβ_1-40 increased the total number of glial fibrillary acidic protein expressing astrocytes and ionised calcium-binding adapter expressing microglial in the rostral hippocampus. Finally, Aβ_1-40 blocked long-term potentiation induced by high-frequency stimulation and this effect could be acutely blocked with co-administration of acyl ghrelin. Collectively, our studies demonstrate that ghrelin deletion affects memory performance and also that acyl ghrelin treatment may delay the onset of early events of AD. This supports the idea that acyl ghrelin treatment may be therapeutically beneficial with respect to restricting disease progression in AD.

Renewal of conditioned fear in a novel context is associated with hippocampal activation and connectivity

Return of fear is a serious problem in exposure-based treatments of anxiety disorders. Renewal of the fear response may occur when re-encountering the conditioned stimulus within a novel context. Findings in rodents underpin the hippocampus' role in conditioned fear renewal in novel contexts, but it has yet to be investigated in humans. Forty-six healthy men took part in a 2-day, context-dependent, cued fear conditioning paradigm with fear acquisition, extinction learning (day 1) and extinction recall in the acquisition, extinction and a novel context one day later. Conditioned evaluative, skin conductance responses (SCRs) and blood-oxygen-level-dependent responses served as dependent variables. Context-dependent fear renewal was reflected in stronger conditioned SCRs. In the acquisition context, individuals with a higher renewal of conditioned SCRs showed stronger activation of the fear circuit. Hippocampal activation distinguished conditioned responding in the novel compared with the extinction context. Individuals with a stronger renewal of conditioned SCRs in the novel context showed increased effective connectivity of hippocampal activation foci with structures in the fear and extinction network. These results outline the pivotal role of the hippocampus and its connectivity in conditioned fear renewal in a novel context in humans and might have important implications for exposure therapy in anxiety disorders.

Integration of copy number and transcriptomics provides risk stratification in prostate cancer: A discovery and validation cohort study

BACKGROUND

Understanding the heterogeneous genotypes and phenotypes of prostate cancer is fundamental to improving the way we treat this disease. As yet, there are no validated descriptions of prostate cancer subgroups derived from integrated genomics linked with clinical outcome.

METHODS

In a study of 482 tumour, benign and germline samples from 259 men with primary prostate cancer, we used integrative analysis of copy number alterations (CNA) and array transcriptomics to identify genomic loci that affect expression levels of mRNA in an expression quantitative trait loci (eQTL) approach, to stratify patients into subgroups that we then associated with future clinical behaviour, and compared with either CNA or transcriptomics alone.

FINDINGS

We identified five separate patient subgroups with distinct genomic alterations and expression profiles based on 100 discriminating genes in our separate discovery and validation sets of 125 and 103 men. These subgroups were able to consistently predict biochemical relapse (p = 0.0017 and p = 0.016 respectively) and were further validated in a third cohort with long-term follow-up (p = 0.027). We show the relative contributions of gene expression and copy number data on phenotype, and demonstrate the improved power gained from integrative analyses. We confirm alterations in six genes previously associated with prostate cancer (MAP3K7, MELK, RCBTB2, ELAC2, TPD52, ZBTB4), and also identify 94 genes not previously linked to prostate cancer progression that would not have been detected using either transcript or copy number data alone. We confirm a number of previously published molecular changes associated with high risk disease, including MYC amplification, and NKX3-1, RB1 and PTEN deletions, as well as over-expression of PCA3 and AMACR, and loss of MSMB in tumour tissue. A subset of the 100 genes outperforms established clinical predictors of poor prognosis (PSA, Gleason score), as well as previously published gene signatures (p = 0.0001). We further show how our molecular profiles can be used for the early detection of aggressive cases in a clinical setting, and inform treatment decisions.

INTERPRETATION

For the first time in prostate cancer this study demonstrates the importance of integrated genomic analyses incorporating both benign and tumour tissue data in identifying molecular alterations leading to the generation of robust gene sets that are predictive of clinical outcome in independent patient cohorts.

The influence of herbs and spices on overall liking of reduced fat food

Most adults consume more fat than is recommended in the Dietary Guidelines for Americans. We examined whether adding herbs and spices to reduced-fat foods would improve their consumer liking. We recruited adults 18-65 years old to taste three lunch conditions: full fat (FF), reduced fat with no added spice (RF), and reduced fat plus spice (RFS). Subjects rated their liking of a meatloaf entrée, vegetable side dish, pasta side dish, and overall meal on a 9-point hedonic Likert scale. Subjects came weekly for 3 weeks to consume meals and were randomized to the condition order. We enrolled 148 subjects who were predominantly female (n = 101, 68%), had a mean age of 35.9 years, and body mass index of 24.4 kg/m2. Subjects reported habitual diets as 36% of total calories from fat (2005 Block Food Frequency Questionnaire). Reducing fat content alone significantly dropped overall liking of the meal compared with FF and RFS conditions (6.29 RF vs. 7.05 FF, P < 0.0001; 6.29 RF vs. 6.98 RFS, P ≤ 0.0001). The RFS overall meal was liked as well as the FF condition. FF and RFS conditions were liked significantly more than RF conditions for each meal item. Liking of FF and RFS meatloaf and vegetables were not significantly different from one another. Pasta FF and RFS conditions were rated significantly differently from each other (7.33 FF vs. 6.61 RFS, P < 0.0001). Adding herbs and spices to reduced fat foods restored liking of the overall meal, meatloaf, and vegetables to that of FF conditions, and significantly improved the liking of RF pasta. Herbs and spices can be a useful tool to improve liking of foods consistent with national guidelines.

Medication costs by glucose tolerance stage in younger and older women and men: results from the population-based KORA survey in Germany

To estimate medication costs in individuals with diagnosed diabetes, undetected diabetes, impaired glucose regulation and normal blood glucose values in a population-based sample by age and sex.Using the KORA F4 follow-up survey, conducted in 2006-2008 (n=2611, age 40-82 years), we identified individuals' glucose tolerance status by means of an oral glucose tolerance test. We assessed all medications taken regularly, calculated age-sex specific medication costs and estimated cost ratios for total, total without antihyperglycemic drugs, and cardiovascular medication, using multiple 2-part regression models.Compared to individuals with normal glucose values, costs were increased in known diabetes, undetected diabetes and impaired glucose regulation, which was more pronounced in participants aged 40-59 years than in those aged 60-82 years (cost ratios for all medications: 40-59 years: 2.85; 95%-confidence interval: 1.78-4.54, 2.00; 1.22-3.29 and 1.53; 1.12-2.09; 60-82 years: 2.04; 1.71-2.43, 1.17; 0.90-1.51 and 1.09; 0.94-1.28). Compared to individuals with diagnosed diabetes, costs were significantly lower among individuals with impaired glucose regulation across all age and sex strata, also when antihyperglycemic medication was excluded (40-59 years: 0.60; 0.36-0.98, 60-82 years: 0.74; 0.60-0.90; men: 0.72; 0.56-0.93; women: 0.72; 0.54-0.96).We could quantify age- and sex-specific medication costs and cost ratios in individuals with diagnosed diabetes, undetected diabetes and impaired glucose regulation compared to those with normal glucose values, using data of a population-based sample, with oral glucose tolerance test-based identification of diabetes states. These results may help to validly estimate cost-effectiveness of screening and early treatment or prevention of diabetes.

Regeneration of enteric ganglia in mechanically lengthened jejunum after restoration into intestinal continuity

PURPOSE

We previously demonstrated that it is feasible to lengthen intestinal segments with mechanical force and to restore them back into intestinal continuity. The changes in the enteric ganglia in the lengthened intestinal segments have not been described.

METHODS

A 1-cm segment of rodent jejunum was isolated from intestinal continuity and was lengthened using a spring. After lengthening, jejunal segments were either retrieved (n=4) or restored into intestinal continuity (n=4). Rats with restored segments were euthanized 2 to 3 weeks later. Ganglia were identified and quantified by immunostaining of histological sections.

RESULTS

The normal jejunum had 51 ± 5 myenteric and 31 ± 2 submucosal ganglia per circumferential tissue section. Lengthened segments had 21 ± 7 myenteric and 2 ± 2 submucosal ganglia. Restored segments had 46 ± 14 myenteric and 10 ± 10 submucosal ganglia. Circumferential density of ganglia followed a similar pattern.

CONCLUSION

Mechanical lengthening led to a paucity of submucosal and myenteric ganglia. After restoration into continuity, the number increased toward normal, indicating regeneration of the enteric ganglia. The function of regenerated ganglia needs to be assessed in the future.

MR∕PET quantification tools: registration, segmentation, classification, and MR-based attenuation correction

PURPOSE

Combined MR∕PET is a relatively new, hybrid imaging modality. A human MR∕PET prototype system consisting of a Siemens 3T Trio MR and brain PET insert was installed and tested at our institution. Its present design does not offer measured attenuation correction (AC) using traditional transmission imaging. This study is the development of quantification tools including MR-based AC for quantification in combined MR∕PET for brain imaging.

METHODS

The developed quantification tools include image registration, segmentation, classification, and MR-based AC. These components were integrated into a single scheme for processing MR∕PET data. The segmentation method is multiscale and based on the Radon transform of brain MR images. It was developed to segment the skull on T1-weighted MR images. A modified fuzzy C-means classification scheme was developed to classify brain tissue into gray matter, white matter, and cerebrospinal fluid. Classified tissue is assigned an attenuation coefficient so that AC factors can be generated. PET emission data are then reconstructed using a three-dimensional ordered sets expectation maximization method with the MR-based AC map. Ten subjects had separate MR and PET scans. The PET with [(11)C]PIB was acquired using a high-resolution research tomography (HRRT) PET. MR-based AC was compared with transmission (TX)-based AC on the HRRT. Seventeen volumes of interest were drawn manually on each subject image to compare the PET activities between the MR-based and TX-based AC methods.

RESULTS

For skull segmentation, the overlap ratio between our segmented results and the ground truth is 85.2 ± 2.6%. Attenuation correction results from the ten subjects show that the difference between the MR and TX-based methods was <6.5%.

CONCLUSIONS

MR-based AC compared favorably with conventional transmission-based AC. Quantitative tools including registration, segmentation, classification, and MR-based AC have been developed for use in combined MR∕PET.

Are there differences in access to care, treatment, and outcomes for children with appendicitis treated at county versus private hospitals?

INTRODUCTION

We conducted a study to determine whether hospital type (county [ie, safety-net] vs private) affects health care access (appendiceal perforation [AP] rates), treatment (laparoscopic appendectomy [LA] rates), and outcomes in children with appendicitis.

METHODS

A review of cases involving children who had appendicitis between 1998 and 2007 was performed. Data from county and private hospitals were compared. Outcomes were AP rates, LA rates, need for postoperative abscess drainage, length of hospitalization (LOH), and cost.

RESULTS

Multivariate analysis confirmed that among 7902 patients, (county = 682; private = 7220), county-hospital patients had lower incomes, higher AP rates, higher LA rates, lower postoperative abscess drainage rates, and longer LOH than did private-hospital patients. The longer LOH at the county institution led to higher costs. Within the county hospital, outcomes were similar across all ethnic groups and income levels.

CONCLUSIONS

Children with appendicitis treated at a county hospital were of lower socioeconomic background and had higher AP rates, longer LOH, and higher costs than their counterparts at private hospitals, but were more likely to undergo LA and require less abscess drainage. Within the county hospital, ethnic and socioeconomic disparities were not apparent; thus, these differences between institutions might have been caused by underlying disparities in ethnicity, income, and health care access.

Obesity Does Not Impact Outcomes for Appendicitis

Obesity has long been considered a risk factor for surgery. The purpose of this study was to evaluate the impact of obesity on outcomes after appendectomy. A retrospective study was performed using discharge abstract data obtained from patients with documented body mass index (BMI) undergoing appendectomy for appendicitis (n = 2919). Complications and length of stay for different BMI categories were compared. Obese patients (BMI > 30 kg/m2) had similar rates of perforation (20%) and were as likely to undergo a laparoscopic approach (85%) as nonobese patients. On multivariable and univariate analysis, no significant differences were observed when comparing obese and nonobese patients for the outcomes of length of stay, infectious complications, and need for readmission. On multivariate analysis, laparoscopy predicted lower complication rates and decreased length of stay. In this study, obesity did not significantly impact rates of perforation, operative approach, length of stay, infectious complications, or readmission.

Obesity does not impact outcomes for appendicitis

Obesity has long been considered a risk factor for surgery. The purpose of this study was to evaluate the impact of obesity on outcomes after appendectomy. A retrospective study was performed using discharge abstract data obtained from patients with documented body mass index (BMI) undergoing appendectomy for appendicitis (n = 2919). Complications and length of stay for different BMI categories were compared. Obese patients (BMI > 30 kg/m(2)) had similar rates of perforation (20%) and were as likely to undergo a laparoscopic approach (85%) as nonobese patients. On multivariable and univariate analysis, no significant differences were observed when comparing obese and nonobese patients for the outcomes of length of stay, infectious complications, and need for readmission. On multivariate analysis, laparoscopy predicted lower complication rates and decreased length of stay. In this study, obesity did not significantly impact rates of perforation, operative approach, length of stay, infectious complications, or readmission.

Less advanced stages of colon cancer in patients with type 2 diabetes mellitus: an unexpected finding?

INTRODUCTION

Epidemiological studies have found an increased risk for colon cancer and faster disease progression in patients with type 2 diabetes mellitus (T2DM). We aimed to determine whether patients with T2DM are diagnosed with more advanced stages of colorectal cancer, i. e., metastasized disease (UICC III and IV), at the time of diagnosis, since such a finding may have an impact on future guidelines for patients with T2DM.

MATERIALS AND METHODS

A cross-sectional analysis of colorectal cancer patients was performed. Stages at diagnosis in patients with (18.0%) or without (82%) T2DM were compared using logistic regression analysis to correct for confounders.

RESULTS

Patients with T2DM were older, more obese, and more often male (each p<0.05). Unexpectedly, patients with T2DM had a lower risk for metastasized disease at diagnosis (p=0.023). Correction for age, gender, BMI, smoking and aspirin intake in a multiple logistic regression analysis did not change the result (OR=0.57, p=0.037). When looking at individual cancer stages rather than collapsed categories, there was a trend for less advanced stages in patients with T2DM (p=0.093). Excluding stage I because of potential screening bias due to the introduction of (insurance-covered) colonoscopy screening improved model fit, and confirmed less advanced cancer stages (p=0.0246).

CONCLUSIONS

Possibly because of earlier detection, patients with T2DM may be at lower risk for advanced stages of colon cancer at diagnosis. Further studies are warranted to confirm our results and to investigate the impact of closer medical surveillance in patients with type 2 diabetes mellitus.

Development of an endoluminal intestinal lengthening capsule

PURPOSE

Prior studies demonstrated the ability of a spring to lengthen intestinal segments. We made two innovations to this device. First, we employed a degradable capsule to control the deployment of the spring. Second, we decreased the spring force to allow slower expansion of the intestinal segment.

METHODS

Nitinol springs with varying forces were compressed and placed in gelatin capsules. These capsules were coated with a degradable polymer and were placed in isolated segments of rat jejunum. Serial x-rays were used to determine the rate of spring expansion. Retrieved jejunal segments were analyzed histologically.

RESULTS

Using the polymer-coated capsule, the spring was reliably deployed between 24 and 48 hours. Intestinal segments were lengthened from 1.0 cm to 3.6 cm after 14 days. The optimal spring for the gradual expansion of jejunal segments had a spring constant of 0.0010 N/mm. Villus height was preserved, but crypt depth was significantly greater in the lengthened intestine.

CONCLUSION

Use of a low-force spring resulted in a nearly four-fold lengthening of jejunal segments. The use of a polymer-coated capsule provided a reliable way to control the timing of spring deployment. This capsule may be useful for the endoscopic placement of the spring in patients with short bowel syndrome.

Does age affect the outcomes and management of pediatric appendicitis?

PURPOSE

Although it is recognized that younger children have higher appendiceal perforation rates, little is known about the effect of age on postoperative morbidity. The purpose of this study was to determine whether age affects the outcome and management of pediatric appendicitis.

METHODS

A retrospective review of all patients 14 years and younger who were treated for appendicitis over a 10-year period was performed. Study outcomes included 30-day postoperative morbidity, use of laparoscopy, and length of hospitalization (LOH). Postoperative morbidity included rates of wound infection, postoperative abscess drainage, and readmission. Patients were categorized into 3 age groups: young (≤5 years), middle (6-9 years), and older (≥10 years). Data for univariate associations were analyzed using χ(2) and Wilcoxon rank sum tests and reported as medians with interquartile ranges (IQR). Study outcomes were also analyzed using multivariable regression.

RESULTS

Overall, 5894 patients were identified. Median age was 10.3 years (IQR 7.3-12.5), and 61% were boys. The perforation rate was highest for patients 5 years and younger (≤5 years, 51%; 6-9 years, 32%; ≥10 years, 27%; P < .0001). Multivariable analysis demonstrated that although the need for postoperative abscess drainage was greatest in older children (10-14 years), the readmission rate and LOH was highest in the youngest children (≤5 years). Wound infection rates were similar across all age groups.

CONCLUSIONS

Although older children had a higher risk of abscess drainage, younger children were more likely to have perforated appendicitis, be readmitted, and have longer LOH. Management of appendicitis differed according to age. Laparoscopic appendectomy was more frequently performed in older children, whereas the youngest children were more likely to be treated nonoperatively.

Can patient factors predict early discharge after pyloromyotomy?

BACKGROUND

Because of increased pressure to shorten hospital stays, some advocate discharging patients with pyloric stenosis within four hours of pyloromyotomy. Because some patients have persistent emesis after pyloromyotomy and thus require prolonged hospitalization to prevent dehydration, it would be helpful to be able to predict in which patients this will occur.

METHODS

We conducted a retrospective review of pyloromyotomies performed within a six-year period to determine whether patient factors could predict length of hospitalization in patients with pyloric stenosis. The study outcome was time to discharge after pyloromyotomy, and the independent variables were patient's age, patient's weight, symptom duration, duration of preoperative hydration, and pyloric length and thickness. Patients were grouped on the basis of time of discharge after pyloromyotomy: <24, 24 to 48, and >48 hours.

RESULTS

Of 230 patients, 58% were discharged within 24 hours, 31% between 24 and 48 hours, and 11% after 48 hours. Patients' weight was inversely proportional to the postoperative length of hospitalization. Conversely, length of time required for preoperative hydration was directly proportional to the duration of postoperative hospitalization.

CONCLUSIONS

Patients with lower weight and a longer preoperative hydration period had an increased risk of prolonged hospitalization after pyloromyotomy.

Common denominators in death from pediatric back-over trauma

Low-speed "back-over" injuries comprise a small number of pediatric automobile versus pedestrian (AVP) trauma, however these injuries tend to be more severe and have a higher rate of mortality. The objective of this study was to determine environmental, mechanistic, and demographic factors common in pediatric back-over injuries resulting in death. Patients were identified from the trauma registry of an urban Level I trauma center over a 15-year period. Charts for all pediatric AVP injuries in ages 4 years and younger were reviewed. Mortalities due to back-over injuries were identified. For the study period reviewed (1995-2010) we identified 535 cases of auto versus pedestrian injury in children less than 4-years-old. Of these, 31 (5.79%) were mortalities. Among those 31 mortalities, six (19.3%) were identified as resulting from back-over trauma. Mean age was significantly lower in back-over injuries as compared with non back-over AVP trauma (1.33 ± 0.23 years, vs 3.5 ± 1.0 years, P = 0.001). We noted a trend toward female gender (67%) and Hispanic ethnicity (67%). All sustained massive blunt head trauma as the cause of death. There were no significant differences in Injury Severity Score or Revised Trauma Score in the back-over group. Environmental analysis revealed that cars were the perpetrating vehicle 50 per cent of the time, and sport utility vehicles, vans, or trucks 50 per cent of the time. In all cases, the accidents occurred in the patient's own driveway and by either a family member (67%) or acquaintance (33%). These data suggest that key characteristics of back-over trauma resulting in mortality include very young age, massive head trauma, injury occurring in the patient's own driveway, and with a family member or acquaintance behind the wheel. This may help identify points of injury prevention to decrease the number of victims of back-over trauma in the pediatric population.

Common Denominators in Death from Pediatric Back-Over Trauma

Low-speed “back-over” injuries comprise a small number of pediatric automobile versus pedestrian (AVP) trauma, however these injuries tend to be more severe and have a higher rate of mortality. The objective of this study was to determine environmental, mechanistic, and demographic factors common in pediatric back-over injuries resulting in death. Patients were identified from the trauma registry of an urban Level I trauma center over a 15-year period. Charts for all pediatric AVP injuries in ages 4 years and younger were reviewed. Mortalities due to back-over injuries were identified. For the study period reviewed (1995–2010) we identified 535 cases of auto versus pedestrian injury in children less than 4-years-old. Of these, 31 (5.79%) were mortalities. Among those 31 mortalities, six (19.3%) were identified as resulting from back-over trauma. Mean age was significantly lower in back-over injuries as compared with non back-over AVP trauma (1.33 ± 0.23 years, vs 3.5 ± 1.0 years, P = 0.001). We noted a trend toward female gender (67%) and Hispanic ethnicity (67%). All sustained massive blunt head trauma as the cause of death. There were no significant differences in Injury Severity Score or Revised Trauma Score in the back-over group. Environmental analysis revealed that cars were the perpetrating vehicle 50 per cent of the time, and sport utility vehicles, vans, or trucks 50 per cent of the time. In all cases, the accidents occurred in the patient's own driveway and by either a family member (67%) or acquaintance (33%). These data suggest that key characteristics of back-over trauma resulting in mortality include very young age, massive head trauma, injury occurring in the patient's own driveway, and with a family member or acquaintance behind the wheel. This may help identify points of injury prevention to decrease the number of victims of back-over trauma in the pediatric population.

Modification of a commercial atomic force microscopy for low-noise, high-resolution frequency-modulation imaging in liquid environment

A key issue for high-resolution frequency-modulation atomic force microscopy imaging in liquids is minimizing the frequency noise, which requires a detailed analysis of the corresponding noise contributions. In this paper, we present a detailed description for modifying a commercial atomic force microscope (Bruker MultiMode V with Nanoscope V controller), aiming at atomic-resolution frequency-modulation imaging in ambient and in liquid environment. Care was taken to maintain the AFMs original stability and ease of operation. The new system builds upon an optimized light source, a new photodiode and an entirely new amplifier. Moreover, we introduce a home-built liquid cell and sample holder as well as a temperature-stabilized isolation chamber dedicated to low-noise imaging in liquids. The success of these modifications is measured by the reduction in the deflection sensor noise density from initially 100 fm/√Hz to around 10 fm/√Hz after modification. The performance of our instrument is demonstrated by atomically resolved images of calcite taken under liquid conditions.