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Objective: Given the call to reduce rates of non-medically indicated cesarean deliveries (CDs) by encouraging trials of labor after cesarean (TOLAC), this study looks at social characteristics of patients choosing a TOLAC versus a scheduled repeat cesarean delivery (SRCD) to determine disparities regarding delivery method choice., Methods: This was a retrospective cohort study of patients with a history of one CD between April 29, 2015-April 29, 2020. Patients were divided based on type of delivery chosen at admission. Chi-squared tests examined proportional differences between groups and logistic regression models examined odd ratios of choosing TOLAC versus SRCD according to socially dependent categories including race/ethnicity, health insurance, pre-pregnancy body mass index, and Social Vulnerability Index (SVI)., Results: 1,983 patients were included. Multivariable logistic regression models revealed that patients with a high SVI (reference: low/medium SVI) (AOR 2.0, CI: 1.5, 2.5), self-identified as Black/ African American (AOR: 2.4, CI: 1.6, 3.6) or Hispanic/Latina (AOR: 2.0, CI: 1.4, 2.8) (reference: White), had public insurance (reference: private insurance) (AOR: 3.7, CI: 2.8, 5.0), and who had an obese BMI (reference: non-obese BMI) were more likely to opt for a TOLAC rather than SRCD., Conclusion: These findings demonstrate differences in delivery method preferences. Specifically, more disadvantaged patients are more likely to choose TOLAC, suggesting that social and economic factors may play a role in delivery preferences. These findings have implications for improving individualized counselling and engaging in shared decision-making around mode of delivery., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 Elsevier B.V. All rights reserved.)

Objective: To examine whether patients with both breast cancer (BC) and endometrial cancer (EC) have different features of disease, and whether the sequence of appearance of these tumors is correlated with a more aggressive course., Methods: A retrospective, multi-center observational cohort study of patients treated in two tertiary medical centers between 2014 and 2020. Files of patients who had a co-diagnosis of BC and EC were reviewed and clinical, epidemiological, pathological and genetic characteristics were collected., Results: 67 patients with a co-diagnosis of both malignances were divided into two groups according to primary tumor diagnosis: BC first group (43/67, 64%) and EC first group (24/67, 36%). The time interval between diagnosis of malignancies was significantly longer in the BC first group (mean 144.5 months vs. 67 months, p < 0.05). BRCA mutations were found in higher numbers in the BC first group (27.5% vs. 9.5%, p = 0.18). A significantly higher number of patients in the BC first group had uterine serous carcinoma (USC) histology (44% vs. 12.5%, p < 0.05). This was independent of tamoxifen usage among patients (OR 0.65, 95% CI 0.17-2.49)., Conclusions: In patients suffering from both BC and EC, the sequence of occurrence of malignancies has relevance: When EC presents as a second primary tumor, it tends to present in a more aggressive form, independent of previous tamoxifen use. The time interval between the diagnosis of malignancies was significantly longer in this group, offering an opportunity to improve preventive measures to decrease the likelihood of a subsequent lethal second cancer., Competing Interests: The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (© 2021 Published by Elsevier Inc.)

Background: Approximately 1 in every 50 to 100 people is affected with bipolar disorder (BD), making this disease a major economic burden. The introduction of induced pluripotent stem cell methodology enabled better modeling of this disorder., Methods: Having previously studied the phenotype of dentate gyrus granule neurons, we turned our attention to studying the phenotype of CA3 hippocampal pyramidal neurons of 6 patients with BD compared with 4 control individuals. We used patch clamp and quantitative polymerase chain reaction to measure electrophysiological features and RNA expression by specific channel genes., Results: We found that BD CA3 neurons were hyperexcitable only when they were derived from patients who responded to lithium; they featured sustained activity with large current injections and a large, fast after-hyperpolarization, similar to what we previously reported in dentate gyrus neurons. The higher amplitudes and faster kinetics of fast potassium currents correlated with this hyperexcitability. Further supporting the involvement of potassium currents, we observed an overexpression of KCNC1 and KCNC2 in hippocampal neurons derived from lithium responders. Applying specific potassium channel blockers diminished the hyperexcitability. Long-term lithium treatment decreased the hyperexcitability observed in the CA3 neurons derived from lithium responders while increasing sodium currents and reducing fast potassium currents. When differentiating this cohort into spinal motor neurons, we did not observe any changes in the excitability of BD motor neurons compared with control motor neurons., Conclusions: The hyperexcitability of BD neurons is neuronal type specific with the involvement of altered potassium currents that allow for a sustained, continued firing activity., (Copyright © 2019 Society of Biological Psychiatry. Published by Elsevier Inc. All rights reserved.)

Background: We recently reported a hyperexcitability phenotype displayed in dentate gyrus granule neurons derived from patients with bipolar disorder (BD) as well as a hyperexcitability that appeared only in CA3 pyramidal hippocampal neurons that were derived from patients with BD who responded to lithium treatment (lithium responders) and not in CA3 pyramidal hippocampal neurons that were derived from patients with BD who did not respond to lithium (nonresponders)., Methods: Here we used our measurements of currents in neurons derived from 4 control subjects, 3 patients with BD who were lithium responders, and 3 patients with BD who were nonresponders. We changed the conductances of simulated dentate gyrus and CA3 hippocampal neurons according to our measurements to derive a numerical simulation for BD neurons., Results: The computationally simulated BD dentate gyrus neurons had a hyperexcitability phenotype similar to the experimental results. Only the simulated BD CA3 neurons derived from lithium responder patients were hyperexcitable. Interestingly, our computational model captured a physiological instability intrinsic to hippocampal neurons that were derived from nonresponder patients that we also observed when re-examining our experimental results. This instability was caused by a drastic reduction in the sodium current, accompanied by an increase in the amplitude of several potassium currents. These baseline alterations caused nonresponder BD hippocampal neurons to drastically shift their excitability with small changes to their sodium currents, alternating between hyperexcitable and hypoexcitable states., Conclusions: Our computational model of BD hippocampal neurons that was based on our measurements reproduced the experimental phenotypes of hyperexcitability and physiological instability. We hypothesize that the physiological instability phenotype strongly contributes to affective lability in patients with BD., (Copyright © 2020 Society of Biological Psychiatry. Published by Elsevier Inc. All rights reserved.)

Convergent extension driven by mediolateral intercalation of chondrocytes is a key process that contributes to skeletal growth and morphogenesis. While progress has been made in deciphering the molecular mechanism that underlies this process, the involvement of mechanical load exerted by muscle contraction in its regulation has not been studied. Using the zebrafish as a model system, we found abnormal pharyngeal cartilage morphology in both chemically and genetically paralyzed embryos, demonstrating the importance of muscle contraction for zebrafish skeletal development. The shortening of skeletal elements was accompanied by prominent changes in cell morphology and organization. While in control the cells were elongated, chondrocytes in paralyzed zebrafish were smaller and exhibited a more rounded shape, confirmed by a reduction in their length-to-width ratio. The typical columnar organization of cells was affected too, as chondrocytes in various skeletal elements exhibited abnormal stacking patterns, indicating aberrant intercalation. Finally, we demonstrate impaired chondrocyte intercalation in growth plates of muscle-less Sp(d) mouse embryos, implying the evolutionary conservation of muscle force regulation of this essential morphogenetic process.Our findings provide a new perspective on the regulatory interaction between muscle contraction and skeletal morphogenesis by uncovering the role of muscle-induced mechanical loads in regulating chondrocyte intercalation in two different vertebrate models., (Copyright © 2012 Elsevier Inc. All rights reserved.)

Embryo development is a dynamic process, determined by both the genetic background of the organism and the environment in which it develops. Environmental alterations during an organism's embryogenesis may induce changes in the development of some physiological regulatory systems, thereby causing permanent phenotypic changes in the embryo. The present study aimed to assess the effect of 17% O(2) concentration during chorioallantoic membrane (CAM) development on a) CAM development, b) cardiovascular parameters, and c) embryo development postexposure and up to hatch. Two replicated trials, each with 840 fertile Cobb eggs, were conducted. At embryonic d 5 (E5) eggs were divided into 2 treatments: 1) control, and 2) 17% O(2) concentration for 12 h/d from E5 through E12 (12H). The 12H embryos exhibited a clear and significant increase in the vascular area of the CAM, which grew to 6.8% larger than that of the control. Hematocrit and hemoglobin levels, as measured on E13 and E14, increased in response to the hypoxic treatments, but these differences were not maintained subsequently. Heart rate and relative heart weight were not affected by hypoxic exposure, but eggshell temperature in the 12H treatment was higher than that of the control, indicating higher heat production, which is consistent with the elevated plasma concentrations of triiodothyronine and thyroxin and with the enhanced oxygen consumption and residual yolk intake rate that followed exposure to hypoxic conditions. These findings indicate that embryos adapted to hypoxic condition enhance angiogenesis processes, which subsequently increase their blood oxygen-carrying capacity, enabling the increase of oxygen consumption, which positively affects their growth development and maturation compared with the control embryos. Such alterations may affect posthatch performance and the ability of broilers cardiovascular system to meet elevated oxygen demand.

Objectives: Cell therapy is a novel experimental treatment modality for patients with critical limb ischemia (CLI) of the lower extremities and no other established treatment options. This study was conducted to assess the safety and clinical efficacy of intramuscular injection of autologous tissue repair cells (TRCs)., Methods: A prospective, randomized double-blinded, placebo controlled, multicenter study (RESTORE-CLI) was conducted at 18 centers in the United States in patients with CLI and no option for revascularization. Enrollment of 86 patients began in April 2007 and ended in February 2010. For the prospectively planned interim analysis, conducted in February 2010, 33 patients had the opportunity to complete the trial (12 months of follow-up), and 46 patients had completed at least 6 months of follow-up. The interim analysis included analysis of both patient populations. An independent physician performed the bone marrow or sham control aspiration. The aspirate was processed in a closed, automated cell manufacturing system for approximately 12 days to generate the TRC population of stem and progenitor cells. An average of 136 ± 41 × 10(6) total viable cells or electrolyte (control) solution were injected into 20 sites in the ischemic lower extremity. The primary end point was safety as evaluated by adverse events, and serious adverse events as assessed at multiple follow-up time points. Clinical efficacy end points included major amputation-free survival and time to first occurrence of treatment failure (defined as any of the following: major amputation, death, de novo gangrene, or doubling of wound size), as well as major amputation rate and measures of wound healing., Results: There was no difference in adverse or serious adverse events between the two groups. Statistical analysis revealed a significant increase in time to treatment failure (log-rank test, P = .0053) and amputation-free survival in patients receiving TRC treatment, (log-rank test, P = .038). Major amputation occurred in 19% of TRC-treated patients compared to 43% of controls (P = .14, Fisher exact test). There was evidence of improved wound healing in the TRC-treated patients when compared with controls at 12 months., Conclusions: Intramuscular injection of autologous bone marrow-derived TRCs is safe and decreases the occurrence of clinical events associated with disease progression when compared to placebo in patients with lower extremity CLI and no revascularization options., (Copyright © 2011 Society for Vascular Surgery. Published by Mosby, Inc. All rights reserved.)

Background: Solid organ transplantation in elderly patients has become more common in recent years. An increasing number of patients present with renal failure requiring transplantation and comorbid occlusive or aneurysmal aortic pathology. The optimal strategy for the timing and management of the aortic disease and renal transplantation in these patients is unknown. Before the availability of endovascular therapies, our policy was to provide open repair of aortic disease before cadaveric transplantation, or by simultaneous aortic reconstruction with renal allotransplantation if a living donor was available. Since the wide acceptance of endovascular modalities, our strategy has changed to take advantage of endovascular treatment pre-transplant. This study examines the outcome of both approaches., Methods: We performed a retrospective review of 12 patients between 1996 and 2009 who underwent both renal transplantation and a major abdominal aortic procedure either simultaneously (n = 6), metachronous, with the procedures occurring within the same month (n = 2), or distant, with the aortic procedures occurring between 5 and 24 months before or after transplantation (n = 4). All patients with occlusive disease underwent an aortobifemoral bypass, one before transplant, one subsequent to transplantation, and four simultaneous with a renal allograft. To assess renal transplant status, patients' serum creatinine levels were followed up every 3 months. Of the 12 patients, eight underwent open aortic procedures, whereas four underwent endovascular aortic aneurysm repair. Patients who underwent endovascular aortic aneurysm repair were followed up with ultrasound examinations at 6-month intervals, and with contrast computed tomography scans every other year., Results: Aortic reconstruction was performed successfully in all the 12 patients irrespective of timing strategy. All the patients who underwent endovascular repair had functional renal allografts for the duration of follow-up. Two patients had simultaneous aortobifemoral bypass and pancreas-kidney transplantation without complication. Among the patients with open aortic repairs, there was one 5-year mortality and one patient had failure of two renal allografts. None of the patients had limb loss, and aortic grafts (one limb required a secondary procedure) remained patent. The 5-year patient survival of 90% and kidney survival of 75% appeared similar to results in the general transplant population without aortic disease. Two significant complications related to the open procedures were observed: two renal transplants developed postoperative hematomas requiring evacuation and one aortobifemoral bypass (ABF) developed a femoral wound infection requiring evacuation and sartorius flap closure. The 30-day mortality rate in all patients was zero. The length of stay for patients receiving simultaneous procedures ranged from 5 to 14 days (median, 10.5) and was significantly lower than the 10-52-day (median, 18) combined length of stay in the metachronous and/or distant groups (p = 0.016)., Conclusion: The coexistence of aortic disease and renal transplantation is an increasingly common clinical scenario. Exclusion from transplantation of patients with major aortoiliac disease is commonplace in many transplant centers as early registry data suggested a poor outcome. Appropriate planning with a vascular surgical team can lead to outcomes, which are comparable with the general transplant population without significant aortic disease., (Copyright © 2011 Annals of Vascular Surgery Inc. Published by Elsevier Inc. All rights reserved.)

Objective: Renal artery aneurysms are being discovered more frequently due to increased use of non-invasive imaging. Complex renal artery aneurysms involving multiple secondary or tertiary branches are not amenable to in vivo or endovascular treatment and often require ex vivo repair with autotransplantation. In order to minimize incisional morbidity and hasten recovery, we developed a technique of laparoscopic nephrectomy combined with backbench ex vivo repair, followed by autotransplantation through a small laparoscopic extraction incision. This study describes our initial experience with this combined technique in patients that were not candidates for endovascular techniques or in vivo arterial reconstruction., Methods: Seven patients with complex renal artery aneurysms underwent laparoscopic nephrectomy and ex vivo repair with multiple saphenous vein grafts and autotransplantation through the small laparoscopic extraction incision. The aneurysms ranged from 2.5 to 5.0 cm. In all cases, the aneurysm was resected ex vivo, leaving multiple branch arteries that were extended with saphenous vein grafts. Arterial inflow was then re-established with sequential saphenous vein anastomoses to the external iliac artery. Ureteral reconstruction was performed via standard Lich ureteroneocystostomy. Patients were followed postoperatively for two to eight years., Results: Laparoscopic nephrectomy with ex vivo repair of complex aneurysms was successfully employed in seven patients with renal aneurysms that were not amenable to endovascular or in vivo repair. There were no incisional morbidities and all patients had significant improvements in symptoms post-operatively. Renal function remained unchanged and there were no ureteral complications following surgery. All patients had postoperative ultrasound imaging done at two years which demonstrated patency of the anastomoses. The mean hospital stay was four days (range, two to seven days)., Conclusion: Repair of complex renal artery aneurysms involving distal branch arteries remains a challenge. This new technique combines the advantages of minimally invasive surgery with the effectiveness of ex vivo aneurysm repair.

Objective: This study tested a multilevel biobehavioral family model proposing that negative family emotional climate contributes to child depressive symptoms, which in turn contribute to asthma disease severity. Parent-child relational insecurity is proposed as a mediator., Method: Children with asthma (N = 112; ages 7-18; 55% male) reported relational security, anxiety, and depressive symptoms. Parent(s) reported demographics, asthma history and symptoms, and family emotional expression. Asthma diagnosis was confirmed by medical history provided by parent and child together, clinical evaluation, pulmonary function tests, and methacholine challenge, with disease severity categorized by National Heart, Lung, and Blood Institute guidelines. Medication adherence was measured prospectively., Results: Path analysis indicated a good fit of data to the hypothesized model (chi2 = 0.072, p =.97, normal fit index = 0.998, root mean square error of approximation = 0.000). Negative family emotional climate predicted child depressive symptoms (beta =.21, p < .04), which predicted asthma disease severity (beta =.35, p < .001), with relational insecurity a partial mediator (beta = -.23, p < .05, beta =.46, p < .001, respectively). Depression was associated with disease severity even after controlling for adherence (r p = 0.38, p < .05)., Conclusion: Findings are consistent with the proposed family model, suggesting the clinical importance of assessing and intervening in these specific family relational processes when treating children with depression and asthma.

Objective: This study was designed to assess the prevalence of depressive symptoms in children with asthma and the association between depression and asthma activity., Method: Children ages 7 to 17 (n = 129) were recruited from a hospital emergency department after presenting for asthma symptoms. The majority of subjects were from disadvantaged, inner city families. Subjects' asthma disease activity was assessed using the revised National Heart, Lung, and Blood Institute guidelines, and subjects' emotional status was assessed by a combination of self-, parent-, and clinician-reported measures. Parental emotional status was assessed by self-report., Results: Depressive symptoms within the clinical range were reported in 26% of subjects and 43% of mothers, although symptom severity varied across scales. Self-reported depressive symptoms were more strongly correlated with asthma activity (r = 0.25) than clinician-reported (r = 0.14) or parent-reported symptoms (r = 0.12/0.18). Depressive symptoms in parents were correlated with child's depression scores but not with their asthma activity., Conclusions: Depressive symptoms were common and associated with asthma activity in this inner city population of asthmatic children. Self-reported depressive symptoms were more strongly associated with child's asthma activity than either parental depression or parental/clinician ratings of the child's depression.

This practice guideline seeks to provide guidance to psychiatrists who regularly evaluate and manage patients with medical illnesses. The guideline is intended to delineate the knowledge base, professional expertise, and integrated clinical approach necessary to effectively manage this complex and diverse patient population. This guideline was drafted by a work group consisting of psychiatrists with clinical and research expertise in the field, who undertook a comprehensive review of the literature. The guideline was reviewed by the executive council of the Academy of Psychosomatic Medicine and revised prior to final approval. Some of the topics discussed include qualifications of C-L consultants, patient assessment, psychiatric interventions (e.g., psychotherapy, pharmacotherapy), medicolegal issues, and child and adolescent consultations.

Psychiatric consultation for assessment of competency is common but infrequently studied. Past studies have used chart reviews. The authors prospectively studied 88 consecutive psychiatric consultations at 3 centers. Competency evaluation was performed to determine whether the patient could 1) sign out of the hospital against medical advice (AMA) (N = 16); 2) give informed consent (N = 16); 3) take care of him-/herself (N = 33); 4) refuse medical care (N = 24); or 5) deal with other matters (N = 12). Patients with a favorable risk-benefit ratio were more likely to be seen in consultation compared with those with an unfavorable ratio. Patients in whom there was concordance in the assessment of the psychiatric consultant and the referring physician (N = 61) were more likely to be male, single, to have psychotropics recommended, to sign out AMA, and to be discharged from the hospital. Patients in whom there was disagreement between the consultee and the consultant merits further study.

Torsades de Pointes (TDP) is a potentially malignant ventricular arrhythmia that often has a drug-induced origin. Oral, but not intravenous, haloperidol has been generally associated with this arrhythmia. The authors detail three patient cases of TDP that occurred while the patients were receiving intravenous haloperidol. The authors discuss the known risk factors for the development of TDP and review the literature on ventricular arrhythmias associated with haloperidol use.

The authors critically review the literature describing the varied neuropsychiatric syndromes associated with systemic lupus erythematosus (SLE). Factors that have complicated the identification and treatment of affective, behavioral, and cognitive disturbances in these patents are identified, and the utility of various diagnostic interventions is examined. Finally, the authors outline the role of the consultation-liaison psychiatrist in the clinical management of the SLE patient with neuropsychiatric disturbances.

The authors describe the autognosis countertransference rounds for medical house staff at the Massachusetts General Hospital. At these rounds, which have been held weekly for more than a decade in the intensive care unit, countertransference phenomena and their relationship to medical practice are discussed. Methods that have facilitated the autognostic process are provided and highlighted by brief case examples. Participants at these rounds report that their self-awareness increases and the clinical care they provide often improves.

A patient underwent myocardial revascularization for acute ischemia following early postoperative graft closure and ventricular fibrillation. Extensive myocardial infarction was prevented by electrocardiographic and enzyme criteria. The time lapse between onset of the ischemic episode and revascularization is critical. Our knowledge of the patient's coronary anatomy obviated the need for angiography; the graft occlusion was diagnosed by electrocardiogram.