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Objective: To perform a statewide characteristics and outcomes analysis of the Trisomy 18 (T18) population and explore the potential impact of associated congenital heart disease (CHD) and congenital heart surgery. Study Design: Retrospective review of the Texas Hospital Inpatient Discharge Public Use Data File between 2009 and 2019, analysing discharges of patients with T18 identified using ICD-9/10 codes. Discharges were linked to analyse patients. Demographic characteristics and available outcomes were evaluated. The population was divided into groups for comparison: patients with no documentation of CHD (T18NoCHD), patients with CHD without congenital heart surgery (T18CHD), and patients who underwent congenital heart surgery (T18CHS). Results: One thousand one hundred fifty-six eligible patients were identified: 443 (38%) T18NoCHD, 669 (58%) T18CHD, and 44 (4%) T18CHS. T18CHS had a lower proportion of Hispanic patients (n = 9 (20.45%)) compared to T18CHD (n = 315 (47.09%)), and T18NoCHD (n = 219 (49.44%)) (p < 0.001 for both). Patients with Medicare/Medicaid insurance had a 0.42 odds ratio (95%CI: 0.20–0.86, p = 0.020) of undergoing congenital heart surgery compared to private insurance. T18CHS had a higher median total days in-hospital (47.5 [IQR: 12.25–113.25] vs. 9 [IQR: 3–24] and 2 [IQR: 1–5], p < 0.001); and a higher median number of admissions (n = 2 [IQR: 1–4]) vs. 1 [IQR: 1–2] and 1 [IQR: 1–1], (p < 0.001 for both). However, the post-operative median number of admissions for T18CHS was 0 [IQR: 0–2]. After the first month of life, T18CHS had freedom from in-hospital mortality similar to T18NoCHD and superior to T18CHD. Conclusions: Short-term outcomes for T18CHS patients are encouraging, suggesting a freedom from in-hospital mortality that resembles the T18NoCHD. The highlighted socio-economic differences between the groups warrant further investigation. Development of a prospective registry for T18 patients should be a priority for better understanding of longer-term outcomes.

Introduction: With advances in care, an increasing number of individuals with single-ventricle congenital heart disease (SVCHD) are surviving into adulthood. Partners of individuals with chronic illness have unique experiences and challenges. This pilot qualitative research study explores the lived experiences of partners of individuals with SVCHD. Methods: Partners of SVCHD patients ≥18 years were recruited and participated in Experience Group (EG) sessions and 1:1 interviews. EG sessions are lightly moderated groups that bring together individuals with similar experiences and place them as the experts to discuss lived experiences. Formal qualitative coding was performed to identify salient themes. Results: A total of 6 partners, 4 male, 4 married and all partners of someone of the opposite sex, participated. Themes identified included uncertainty of their partners future health and mortality, becoming a lay SVCHD specialist, balancing multiple roles, and providing positivity and optimism.(Table) Participants expressed a steep learning curve initially, which transforms into a strong understanding of the condition. Over time they took on the advocacy role as a repository of medical history and navigating the health system, which is often a role of parents of younger SVCHD patients. They struggled with taking on the role of primary medical caregiver of their partner while managing greater responsibility at home, and changes to their role as a spouse and a parent. Despite the uncertainties, participants described many facets of championing positivity and optimism for the future for their partner. Conclusions: In this first of its kind pilot study, partners of individuals with SVCHD expressed unique challenges and experiences in their lives. There is a tacit need to design strategies to help partners of SVCHD patients cope with those challenges. Further larger-scale research is required to better understand the experiences of this unique population.

Adolescents with depression are at risk for negative long-term consequences and recurrence of depression. Many do not receive nor access treatment, especially Latino youth. New treatment approaches are needed. This study examined the feasibility and acceptability of a stepped collaborative care treatment model (SCIPT-A) for adolescents with depression utilizing interpersonal psychotherapy for adolescents (IPT-A) and antidepressant medication (if needed) compared to Enhanced Treatment as Usual (E-TAU) in urban pediatric primary care clinics serving primarily Latino youth. Results suggest the SCIPT-A model is feasible, acceptable and potentially beneficial for urban Latino adolescents. Clinicians delivered the SCIPT-A model with fidelity using supervision successfully implemented in a community setting.

Background and Purpose— Microembolic signals (MES) found on transcranial Doppler range from harmless air bubbles to large, solid, particulate emboli from the heart and large vessels. The presence of MES is not always associated with poor clinical outcome. The purpose of our study was to determine whether the relative energy index of MES measured by power M-mode Doppler can distinguish malignant from benign MES and to identify patients with worse prognosis. Methods— We prospectively collected transcranial Doppler emboli monitoring data from patients with symptomatic carotid stenosis presenting with TIA or ischemic stroke. For each patient, we calculated the relative energy index of MES and categorized those >1.0 as malignant MES. We compared the clinical characteristics, number, and volume of diffusion-weighted imaging lesions, and degree of stenosis and plaque characteristics on CT angiogram of patients with malignant and benign MES. Results— We enrolled 92 patients, 29 with TIA and 63 with stroke, within 48 hours of symptom onset. Twenty-six patients had a total of 319 MES; of these, 82.4% were benign and were 17.6% malignant. Malignant MES traveled further within intracranial vessels than benign MES. The 9 patients with >1 malignant MES had significantly larger baseline diffusion-weighted imaging lesion volume, had a higher prevalence of intraluminal thrombus on CT angiogram of the neck and plaque ulceration, and were more likely to have a poor clinical outcome (modified Rankin Score ≥2) than those with benign MES (OR, 6.5; 95% CI, 1.47–28.68). The presence of malignant MES led to the institution of more aggressive secondary prevention measures. Conclusions— Power M-mode transcranial Doppler identifies a subgroup of patients with malignant MES. These signals are more frequent in longer arterial trajectory. Patients with malignant MES have larger baseline infarcts, a higher prevalence of intraluminal thrombus or ulcerated plaque in the carotid artery, and worse clinical outcome.

BACKGROUND AND PURPOSE Single gate transcranial Doppler spectrogram (sgTCD) has a high variability in the detection of microembolic signals (MES), Adding Power M-mode Doppler (PMD) information may improve MES detection. Our study's aim is to derive combined PMD/sgTCD microemboli criteria to overcome this limitation. METHODS Patients with symptomatic carotid disease were prospectively enrolled within 24 h of symptom onset underwent 1 hour TCD emboli monitoring. We reviewed disparity between PMD MES criteria and sgTCD MES criteria. We compared combined PMD/sgTCD criteria to sgTCD alone criteria by measuring the intraclass correlation coefficient (ICC). RESULTS Of 92 patients, 28 patients had evidence of MES on sgTCD or PMD. Total MES count was 269 based on sgTCD criteria, and 326 based on combined PMD/sgTCD criteria (P= 0.005). Combined PMD/sgTCD criteria revealed 17 MESs (4.8%) based on sgTCD criteria to represent artifacts and 57 MESs (17.5%) not to be detected by sgTCD criteria. Overall ICC based on sgTCD criteria was 0.67 [95% confidence interval (CI): 0.58–0.74]; however, introducing combined PMD/sgTCD criteria resulted in a significant increase in the ICC, 0.91 (95% CI: 0.88–0.93). CONCLUSION Our combined PMD/sgTCD criteria for MES appeared to improve the yield of MES detection. Reliability in MES detection interpretation was improved when combined PMD/sgTCD criteria was applied.

Background:In the emergency department, portable point-of-care testing (POCT) coagulation devices may facilitate stroke patient care by providing rapid International Normalized Ratio (INR) measurement. The objective of this study was to evaluate the reliability, validity, and impact on clinical decision-making of a POCT device for INR testing in the setting of acute ischemic stroke (AIS).Methods:A total of 150 patients (50 healthy volunteers, 51 anticoagulated patients, 49 AIS patients) were assessed in a tertiary care facility. The INR’s were measured using the Roche Coaguchek S and the standard laboratory technique.Results:The interclass correlation coefficient and 95% confidence interval between overall POCT device and standard laboratory value INRs was high (0.932 (0.69 - 0.78). In the AIS group alone, the correlation coefficient and 95% CI was also high 0.937 (0.59 - 0.74) and diagnostic accuracy of the POCT device was 94%.Conclusions:When used by a trained health professional in the emergency department to assess INR in acute ischemic stroke patients, the CoaguChek S is reliable and provides rapid results. However, as concordance with laboratory INR values decreases with higher INR values, it is recommended that with CoaguChek S INRs in the > 1.5 range, a standard laboratory measurement be used to confirm the results.

Structural birth defects in the kidney and urinary tract are observed in 0.5% of live births and are a major cause of end-stage renal disease, but their genetic aetiology is not well understood. Here we analyse 135 lines of mice identified in large-scale mouse mutagenesis screen and show that 29% of mutations causing congenital heart disease (CHD) also cause renal anomalies. The renal anomalies included duplex and multiplex kidneys, renal agenesis, hydronephrosis and cystic kidney disease. To assess the clinical relevance of these findings, we examined patients with CHD and observed a 30% co-occurrence of renal anomalies of a similar spectrum. Together, these findings demonstrate a common shared genetic aetiology for CHD and renal anomalies, indicating that CHD patients are at increased risk for complications from renal anomalies. This collection of mutant mouse models provides a resource for further studies to elucidate the developmental link between renal anomalies and CHD., Using forward genetic screen in fetal mice, Gregory Pazour and colleagues describe mutants affecting kidney/urinary tract development. The authors also show that mutants that cause kidney defects overlaps with those leading to congenital heart defects, thus linking renal anomalies and congenital heart disease.

Objective Heterotaxy (HTX) congenital heart disease (CHD) patients with ciliary dysfunction (CD) have been shown to have increased postoperative respiratory morbidity. We hypothesized that non-HTX CHD infants with CD also will have increased postoperative morbidity, particularly respiratory complications. Methods Sixty-three infants with non-HTX CHD undergoing cardiac surgery were enrolled. Tests commonly used to assess for CD, nasal nitric oxide (nNO) measurements and nasal epithelial ciliary motion (CM) assessment, were obtained. Baseline characteristics and postoperative outcomes were collected and analyzed. Results Non-HTX CHD infants exhibited a high prevalence of abnormal CM (32%) and low nNO (39%). This finding was not correlated with demographics or surgical complexity. Infants with abnormal CM had increased odds of requiring noninvasive positive pressure ventilation (odds ratio [OR], 6.5; 95% confidence interval [CI], 1.5-29.4; P = .016) and respiratory medication use (OR, 4.4; 95% CI, 1.5-13.3; P = .01). In contrast, infants with low nNO showed evidence of abnormal pre- and postoperative systolic function (40% vs 4%; P = .004, and 34% vs 13%; P = .056, respectively) and had greater odds of acquiring infections (OR, 4.9; 95% CI, 1.4-17; P = .014). Conclusions Non-HTX CHD infants with abnormal CM showed increased postoperative morbidity associated with poor respiratory outcomes. In contrast, low nNO correlated with reduced hemodynamic function. These findings suggest screening for abnormal CM may allow perioperative interventions to reduce pulmonary morbidities. Whether low nNO may prognosticate poor hemodynamic function warrants further investigation.

Introduction: Congenital heart disease (CHD) patients with heterotaxy (HTX) have high prevalence of airway ciliary dysfunction (CD). This is associated with higher postoperative morbidity and more respiratory complications. As a high prevalence of airway CD is also observed in CHD patients without HTX, we hypothesize patients with broad spectrum of CHD may have increased postoperative morbidity associated with airway CD. Methods: CHD patients Results: We recruited 55 CHD patients with 76 surgical events; 38% had airway CD (low nNO/ abnormal CM). Demographics and surgical complexity scores were similar between patients with or without CD. In CHD patients with CD, there was significant increase in continuous positive airway pressure ventilation (CPAP) (p = 0.008) and trend for more reintubation (11% non-CD vs. 27% CD patients) (Table 1). There was significant increase in beta-agonist use in CD patients (p = 0.006) and five-fold increase in respiratory medication use (Table 1). No difference was observed in length of stay, ventilator days, overall supportive ventilation (CPAP, high flow nasal cannula, nasal cannula), use of pulmonary vasodilators, chest tube days, effusion, or need for extracorporeal membrane oxygenation (ECMO). Conclusions: CHD patients with airway CD have increased postoperative morbidity, including increased need for CPAP, more use of albuterol and respiratory medications, and more reintubations. These results suggest CHD patients may benefit from presurgical screening for airway CD, with those identified with CD given perioperative respiratory therapy to reduce postoperative morbidity.

BACKGOUND: We evaluated the safety of the steps during carotid stenting. METHODS: This was a prospective single-arm study. Cases were monitored by TCD during the stenting procedure. The time of each of 11 steps was recorded and noted during TCD interpretation. Post stenting MRI was done in all patients. Emboli on TCD were classified based on the relative energy index of microemboli (REIM) method into microemboli (REIM ≤ 1) or malignant (REIM >1). Medians were compared using Mann-Whitney test. A negative binomial model was used to investigate the predictive value of TCD findings on new DWI hits. RESULTS: We enrolled 30 subjects. The median age was 70.5 years and 23.3% were asymptomatic. The median count of embolic signals was 212.5 (108 microemboli, 80 malignant). Stent deployment had the highest median count 58 (31 microemboli, 20 malignant) followed by protection device deployment 30 (21 microemboli, 10 malignant, (p value 0.0006)) “Figure”. On post stenting MRI, 80% had new DWI hits. The median DWI count was 4 (range 0-33). The median volume of DWI hits was 0.4 ml (range 0 - 6.1 ml). 63% of patients had a total volume under 1 ml. Only 2 patients (6.7%) had new deficits post stenting. The median DWI volume in those patients was 3.0 ml compared to 0.6 ml in asymptomatic cases (p 0.037). Median emboli count in those with vs. without new deficits was not different (p 0.87) Total TCD emboli count did not predict DWI hits, adjusting for age and symptoms’ status (p 0.25). Malignant emboli predicted new DWI hits (p 0.044). For every malignant embolus, the expected count of DWI hits increases by 1% (CI95 0-2%). There was no relation between total or malignant emboli with the DWI volume. CONCLUSIONS: In this prospective study, we observed a high incidence of emboli on TCD during stenting, especially when stent and protection device were deployed. Most patients developed new DWI hits but only 6.7% had new deficits. The combined DWI volume was less than 1.0 ml in most cases. Only malignant emboli predicted new DWI hits.

Can J Psychiatry. 2011;56(5):256-257. Resilience, or the ability to maintain or regain mental health despite exposure to significant adversity, has captured the attention of researchers, clinicians, and policymakers in the last decade. Although systematic research on resilience began in the 1970s,1 its conceptualization has evolved from attention solely to personal psychological attributes, to an understanding that environment, in its broadest sense, interacts with genetic endowment and psychological factors to contribute to resilience.2 Consequently, the roles of family, schools, communities, social and health systems, and policies have assumed greater importance in resilience research and interventions. Resilience has evolved so rapidly that Norwegian researchers3 commented in 2007 that 85% of publications on this topic had appeared in the last decade. They attributed the growing interest in resilience to be largely motivated by the potential of identifying protective factors and mechanisms essential to prevent the development of psychiatric disorders despite exposure to significant life Stressors. The term resilience was made a Medical Subject Heading term in 2009, greatly facilitating literature searches so that a search of PsycINFO in August 2010 using the search term psychological resilience yielded 3931 papers. The first review article, "What Is Resilience?" by Professor Helen Herman (from Australia) and colleagues,4 discusses the evolution of definitions of resilience, the various psychological, biological, and environmental factors that contribute to it and recent attempts to measure resilience. The authors delineate some of the gaps in the resilience field that need to be addressed, including a lack of a standardized definition, a generally accepted theory, and some methodological issues. They outline exciting new biological research, including epigenetic (Gene ? Environment) investigations that are beginning to partly explain some of the mechanisms involved when some people exposed to adversity do not develop psychiatric disorders and how a few very fortunate people may even thrive following extreme hardship. They note the emerging view of resilience as resulting from multiple interacting personal and social circumstances and experiences. Finally, they consider the clinical and public health implications. As the factors determining mental health and resilience operate at 2 broad levels: each person's life and development and the socioculturel context; therefore, 2 different types of actions are needed to influence change in both of these. Resilience and mental health are promoted, as in all fields of health, through population-based public health measures alongside improved access to evidence-based treatment and prevention in primary and mental health care systems. The second review paper, "Resilience Following Child Maltreatment: A Review of Protective Factors" by Dr Tracie O Afifi and Professor Harriet L MacMillan,5 is a welcome contribution to the resilience field. The authors selected the 27 highest quality studies published on protective factors following child maltreatment and found that a stable family environment and supportive relationships were consistently linked to resilience. Individual personality traits were also found to be associated with resilience, but not so frequently as family environment and supportive relationships, thereby underscoring the importance of looking not only at individual psychological factors but also the contextual environment in which they are embedded. The authors comment that the subtypes of child maltreatment (physical, sexual, emotional, neglect, and exposure to intimate partner violence) need to be specified more clearly in future research on protective factors. Unlike many reviews on this topic that combine studies, Dr Afifi and Professor MacMillan have separated the longitudinal and cross-sectional studies and then divided them into those extending from childhood and adolescence into early adulthood, and those within childhood and adolescence. …

BACKGROUND: The assessment of the psychosocial health of pregnant women and their families, although recommended, is not carried out by most practitioners. One reason is the lack of a practical and evidence-based tool. In response, a multidisciplinary group created the Antenatal Psychosocial Health Assessment (ALPHA) form. This article describes the development of this tool and experience with it in an initial field trial. METHODS: A systematic literature review revealed 15 antenatal psychosocial risk factors associated with poor postpartum family outcomes of woman abuse, child abuse, postpartum depression, marital/couple dysfunction and increased physical illness. The ALPHA form, incorporating these risk factors, was developed and refined through several focus groups. It was then used by 5 obstetricians, 10 family physicians, 7 midwives and 4 antenatal clinic nurses in various urban, rural and culturally diverse locations across Ontario. After 3 months, these health care providers met in focus groups to discuss their experiences. A sample of pregnant women assessed using the ALPHA form were interviewed about their experience as well. Results were analysed according to qualitative methods. RESULTS: The final version of the ALPHA form grouped the 15 risk factors into 4 categories--family factors, maternal factors, substance abuse and family violence--with suggested questions for each area of enquiry. The health care providers uniformly reported that the form helped them to uncover new and often surprising information, even when the women were well known to them. Incorporating the form into practice was usually accomplished after a period of familiarization. Most of the providers said the form was useful and would continue to use it if it became part of standard care. The pregnant women in the sample said they valued the enquiry and felt comfortable with the process, unless there were large cultural barriers. INTERPRETATION: The ALPHA form appears to be an important tool in assessing psychosocial health in pregnancy and to be readily integrated into practice. More study is required to quantify the number of risks identified and resources used, to determine the form's reliability and validity and, ultimately, to assess the effect of its use on postpartum outcomes.

"Twentieth-century disease", or "total allergy syndrome", is a condition attributed to hypersensitivity to the environment that may sometimes be seen as so serious that the patient is incapable of living in the modern world. Although the popular media frequently carry stories about it, there is little scientific literature. It is diagnosed by clinical ecologists, who maintain, among other theories, that susceptible individuals experience an overload in assaults by artificial materials in the environment. The patients usually have multiple ill defined symptoms for which no organic cause can be found, but they vigorously resist psychiatric referral, as they attribute their symptoms to allergy. A group of 18 patients who were purportedly suffering from 20th-century disease were referred to a university psychiatric consultation liaison service. They virtually all had a long history of visits to physicians, and their symptoms were characteristic of several well known psychiatric disorders. The case histories and management of three of them are presented. Although this group of patients may have been atypical in that they had more severe psychologic symptoms, the experience indicates that a psychiatric diagnosis ought to be considered. The symptoms of 20th-century disease have much in common with other conditions known to physicians for centuries.

Schizophrenia occurs in one percent of the population during the reproductive years. Although schizophrenics' fertility is reduced, most family doctors who practice obstetrics will occasionally care for a pregnant, schizophrenic patient. The particular problems of the prenatal period, labor and delivery, and postpartum care of these patients are discussed. The physical, psychological, and social problems of a schizophrenic patient's child are outlined, with a recommendation for careful follow up in the community of both parent and child.