[Medical child protection during the coronavirus lockdown]. / Medizinischer Kinderschutz während des Corona-Lockdowns: Vergleichende Befunde der Kinderschutzfälle aus Kliniken und Ambulanzen in Deutschland.

BACKGROUND: There are indications that during the lockdown and the measures of social distancing due to the coronavirus disease 2019 (COVID-19) pandemic, physical and sexual child abuse and neglect may have increased. Additionally, decreased social control may have led to a lower detection rate of child protection cases. OBJECTIVE: This study aimed to better understand the impact of the lockdown in Germany on the frequency and severity of child abuse and neglect. To do so the quantity and quality of cases of suspected child abuse and neglect in German pediatric departments and outpatient departments for medical child protection were examined. METHODS: In May 2020 a total of 343 institutions of medical child protection were invited to fill in a questionnaire with items describing their institution and items depicting cases of child protection in March and April 2019 and 2020 regarding age, form and severity of abuse as well as items to describe particular remarks and ideas for child protection during the pandemic. RESULTS: Out of the 343 pediatric departments and outpatient departments of medical child protection invited, the participation rate was 46%. In this study 81 institutions reported the total cases of suspected child abuse or neglect for both March and April 2019 and 2020. The number of cases dropped from 454 to 387 (-15%) in outpatient child abuse clinics and from 307 to 246 (-20%) in pediatric inpatient departments. Regarding the age of affected children and the form of abuse no significant differences were found. CONCLUSION: The study found a decrease in reported cases of suspected child abuse and neglect during the lockdown in March and April 2020 compared to 2019. While the results do not show an increase of total child abuse and neglect, as suspected by many professionals, the decrease in reported cases may be explained by a steep increase in unreported cases due to reduced social control.

Synthetic Database of Aortic Morphometry and Hemodynamics: Overcoming Medical Imaging Data Availability.

Modeling of hemodynamics and artificial intelligence have great potential to support clinical diagnosis and decision making. While hemodynamics modeling is extremely time- and resource-consuming, machine learning (ML) typically requires large training data that are often unavailable. The aim of this study was to develop and evaluate a novel methodology generating a large database of synthetic cases with characteristics similar to clinical cohorts of patients with coarctation of the aorta (CoA), a congenital heart disease associated with abnormal hemodynamics. Synthetic data allows use of ML approaches to investigate aortic morphometric pathology and its influence on hemodynamics. Magnetic resonance imaging data (154 patients as well as of healthy subjects) of aortic shape and flow were used to statistically characterize the clinical cohort. The methodology generating the synthetic cohort combined statistical shape modeling of aortic morphometry and aorta inlet flow fields and numerical flow simulations. Hierarchical clustering and non-linear regression analysis were successfully used to investigate the relationship between morphometry and hemodynamics and to demonstrate credibility of the synthetic cohort by comparison with a clinical cohort. A database of 2652 synthetic cases with realistic shape and hemodynamic properties was generated. Three shape clusters and respective differences in hemodynamics were identified. The novel model predicts the CoA pressure gradient with a root mean square error of 4.6 mmHg. In conclusion, synthetic data for anatomy and hemodynamics is a suitable means to address the lack of large datasets and provide a powerful basis for ML to gain new insights into cardiovascular diseases.

Adenocarcinoma complicating restorative proctocolectomy for ulcerative colitis with mucosectomy performed by Cavitron Ultrasonic Surgical Aspirator.

This is a report of adenocarcinoma arising in an ileal pouch after restorative proctocolectomy (RPC) with rectal mucosal stripping performed by Cavitron Ultrasonic Surgical Aspirator (CUSA) for ulcerative colitis. The CUSA was introduced to simplify and optimize ileal pouch-anal anastomosis with mucosectomy and has been shown to shorten the operative time and reduce blood loss. Its use however, may increase the number of pathology specimens made uninterpretable on account of tissue ablation. In the present case, even though preoperative colonoscopy had clearly shown dysplasia, the surgical pathology report could not detect any neoplasia in the specimen; hence, the patient was not surveyed for pouch cancer. Six years later, the patient presented with intestinal obstruction caused by cancer. While protocols for universal pouch surveillance remain somewhat controversial, we conclude on the basis of this case and a review of the literature that in RPC with mucosectomy performed by CUSA, pouch cancer surveillance is particularly important because remnants of rectal epithelium may have been left behind and tissue ablation may have made the surgical pathology report uninterpretable.

Automatic generation of 3D statistical shape models with optimal landmark distributions.

OBJECTIVES: To point out the problem of non-uniform landmark placement in statistical shape modeling, to present an improved method for generating landmarks in the 3D case and to propose an unbiased evaluation metric to determine model quality. METHODS: Our approach minimizes a cost function based on the minimum description length (MDL) of the shape model to optimize landmark correspondences over the training set. In addition to the standard technique, we employ an extended remeshing method to change the landmark distribution without losing correspondences, thus ensuring a uniform distribution over all training samples. To break the dependency of the established evaluation measures generalization and specificity from the landmark distribution, we change the internal metric from landmark distance to volumetric overlap. RESULTS: Redistributing landmarks to an equally spaced distribution during the model construction phase improves the quality of the resulting models significantly if the shapes feature prominent bulges or other complex geometry. CONCLUSIONS: The distribution of landmarks on the training shapes is -- beyond the correspondence issue -- a crucial point in model construction.

Amyloidosis and inflammatory bowel disease. A 50-year experience with 25 patients.

Amyloidosis is a rare but serious complication of inflammatory bowel disease (IBD), especially Crohn's disease (CD). It occurred in 15 of our 1709 patients with CD (0.9%) (706 with ileocolitis, 310 with colitis, and 693 with enteritis), but in only 1 of our 1341 patients with ulcerative colitis (UC) (0.07%), admitted to The Mount Sinai Hospital between 1960 and 1985. Eleven of the patients with CD who had amyloidosis had ileocolitis, 2 colitis, and 2 ileitis; these figures represent a frequency within each group of 1.6%, 0.6%, and 0.3%, respectively. Amyloidosis was thus associated 4.4 times more often with CD of the colon than with pure small bowel disease. We have added to this group of 15 patients the 5 cases of CD that were originally reported by Werther et al in 1960, plus another 4 (2 with UC and 2 with CD) who have been seen since 1985, making a total of 25 patients in this series, 22 with CD and 3 with UC. There was a striking male preponderance, 16 of 22, among patients with CD, although 2 of the 3 patients with UC were female. Amyloid disease was diagnosed at a mean age of 40 years, 15 years (range, 1-42) after the onset of CD. Six major forms of amyloidosis occurred: nephropathy, enteropathy, cardiomyopathy, hepatosplenomegaly, thyroid mass, and generalized amyloidosis. Renal disease with proteinurea and/or renal insufficiency occurred in 18 of the 22 patients with CD and in all 3 with UC. Nephropathy was by far the most common lethal manifestation of IBD-associated amyloidosis in this series. Nephrotic syndrome developed in 15 patients with CD and was accompanied by renal failure, the major contributor to mortality, in 10 of the 13 patients who died. Amyloidosis may be associated with suppurative or other extraintestinal manifestations of IBD. Fifteen of the 22 patients with CD who had amyloidosis also had suppurative complications of their bowel disease, although the other 7 had no recognizable suppuration. Extraintestinal manifestations were also common in this series, occurring in 12 of 22 patients with CD and in 2 of the 3 patients with UC; 6 of the 18 patients with nephrotic syndrome also had arthritis. However, there is no evidence that patients with IBD with amyloidosis have extraintestinal manifestations more frequently than do IBD patients without amyloidosis. Earlier reports of amyloid associated with IBD came from autopsy series. In recent years, biopsy has allowed diagnosis to be made during life.(ABSTRACT TRUNCATED AT 400 WORDS)

Regulation of nitric oxide synthase 2 in rabbit corneal cells.

PURPOSE: The purpose of these studies was to investigate the role of interferon-gamma (IFN-gamma), tumor necrosis factor-alpha (TNF-alpha), interleukin 1beta (IL-1beta), and transforming growth factor-beta (TGF-beta) in the regulation of inducible nitric oxide synthase (NOS2) activity in rabbit corneal cells. METHODS: Rabbit corneal epithelial, stromal, and endothelial cells were grown in culture and treated with cytokines and growth factors, alone or in combination. NOS activity was measured at times up to 72 hours after treatment by assaying the culture medium for nitrite using the Griess reaction. Cell lysates were analyzed by Western blot analysis for NOS2 protein. RNA was isolated and amplified with NOS1-, NOS2-, and NOS3-specific primers by RT-PCR. RESULTS: NOS2 expression was induced by combined cytokine treatment from nondetectable levels to abundant levels in low passage (<4) stromal cells and to low levels in corneal endothelial cells but not in corneal epithelial cells. In the absence of IFN-gamma, little or no nitrite accumulation was induced by TNF-alpha, IL-1beta, or lipopolysaccharide (LPS) treatment. The inductive effects of IFN-gamma were antagonized in a dose-dependent manner by the myxoma virus rabbit IFN-gamma receptor homolog, M-T7. rRaIFN-gamma, in combination with IL-1beta and TNF-alpha, induced the appearance of NOS2 mRNA within 24 hours but detectable nitrite did not accumulate in large amounts (>10 microM) until after 24 hours postinduction. NOS2 was identified as a 130 kDa protein on Western blot analysis using monoclonal antibody against murine NOS2. TGF-beta(1) and beta(2) inhibited the accumulation of cytokine-induced nitrite in a dose-dependent manner while not significantly reducing the steady state level of NOS2 mRNA. The activity of the induced NOS was inhibited by 1400W, a NOS2-selective inhibitor, but not 7-nitroindazole, a NOS1-selective inhibitor. CONCLUSIONS: In cultured corneal stromal cells, NOS2 expression was upregulated by IFN-gamma in combination with IL-1beta and TNF-alpha but not by any of these cytokines alone, while TGF-beta downregulated the activity. Cultures of corneal epithelial cells could not be induced to express NOS2, yet cultures of endothelial cells produced low amounts of NO in response to cytokines. The NOS1 and NOS3 isoforms were not detected in any of these corneal cells.

Association of hydrophobic substances with hemin. Characterization of the reverse type I binding spectrum and its relationship to cytochrome P-450.

When hydrophobic compounds were added to a solution of protoferriheme, a a reverse type I spectral change was produced when observed by difference spectroscopy. The spectrum had a peak at 422 nm and a trough at 387 nm, and the characteristics were dependent on the pH of the sample. An association constant for the complex could be determined and was also found to be pH sensitive, with the association constant dropping to zero at values below pH 7.0 and above pH 8.5. The determination of the delta Absmax for the ethylbenzene-hemin complex at various hemin concentrations indicates monomeric heme to be the species responsible for binding the hydrocarbon with the concomitant generation of the reverse type I spectral change.

Surgical complications and skin test reactivity in patients with inflammatory bowel disease.

One hundred patients with inflammatory bowel disease were admitted to the Mount Sinai Hospital, New York, for surgical treatment. These patients were studied to evaluate the association between skin test reactivity and postoperative complications. Skin tests were performed prior to surgery using four recall antigens. Sixty patients were found to be anergic. The postoperative complication rate was significantly higher in the anergic patients when compared with those patients who were able to react to at least one skin test antigen. Twenty-seven anergic patients had 34 complications and almost 60% of these complications were of the septic type. Only 11 patients who responded to the skin tests had postoperative complications. Complications in the anergic patients required longer hospitalization and more frequent operative correction. There were no deaths in this series. Although anergic patients with inflammatory bowel disease are prone to experience septic complications, their prognosis appears to be better than the morbidity and mortality reported in the literature for anergic patients with other conditions.

Familial polyposis coli. Management by total colectomy with preservation of continence.

Two cases of familial polyposis coli were managed by total colectomy and endorectal pull-through with excellent long-term results. The performance of a temporary loop ileostomy is advisable to prevent anastomotic complications. In addition, it avoids the excessive diarrhea and perianal excoriation that frequently occur in the early postoperative period until full continence is regained. This is the only method that allows the preservation of rectal function and prevents the occurrence of rectal cancer. It should be considered as a real alternative to either subtotal colectomy and ileorectal anastomosis or total colectomy with construction of an ileostomy.

Ultrasonic fragmentation. A new technique for mucosal proctectomy.

We report a new technique for mucosal proctectomy that does not require manual separation of the mucosa and submucosa from the underlying muscularis. Mucosal proctectomy using ultrasonic fragmentation of the rectal mucosa was performed in four patients. Three had severe ulcerative colitis, and one patient had radiation proctitis with a rectal stricture. In all cases an endorectal pullthrough with anastomosis to the area of the dentate line was performed. Healing after ultrasonic mucosal proctectomy occurred without infection or retraction. Ultrasonic fragmentation offers an alternative to the standard technique of mucosal proctectomy. This new method is useful in those patients in whom separation of the rectal mucosal layer is difficult to perform.

Correlation of presence of granulomas with clinical and immunologic variables in Crohn's disease.

Approximately 50% of patients with Crohn's disease have epithelioid granulomas present in the diseased intestine. Some studies have associated the presence of granulomas with a good prognosis. In this prospective study, 44 patients with Crohn's disease requiring surgery were followed up for five years. Twenty-two patients (50%) had granulomas. Patients with granulomas were younger and had a shorter duration of disease. They also had more extensive disease and a greater degree of peripheral lymphopenia. Follow-up showed a trend toward greater recurrence rate in the patients with granulomas. It seems that patients with aggressive and extensive Crohn's disease are not protected from the development of symptomatic early recurrence by the presence of epithelioid granulomas.

Surgery and its sequelae in Crohn's colitis and ileocolitis.

Indications for surgery, operative procedures, and the early and late sequelae of surgery for Crohn's ileocolitis have been studied in a series of 250 patients admitted to Mount Sinai Hospital, New York, between 1960 and 1975. The most common indications for surgery were small-bowel obstruction in ileocolitis, and medical intractability in Crohn's colitis. Early postoperative complications (within 30 days of surgery) followed 79 operative procedures (15%), and were most commonly wound infections (7%), intra-abdominal abscess (2.6%), and postoperative intestinal obstruction (2.4%). Late sequelae (30 days to 15 years following surgery) included intestinal obstruction in 36 patients, external fistulae in 41 patients, and ileostomy problems in 19 patients, and were most frequently caused by recurrent disease in the terminal portion of the ileum. Mortality following surgery for Crohn's disease may be subdivided into two groups, early and late. All eight early postoperative deaths were secondary to sepsis, present in every instance prior to operation. The eight late deaths were caused by metastatic cancer in six and recurrent disease in two. Resection of excluded segments of bowel, as in four of the patients in this series, will reduce the late cancer risk.

Urinary osmolal changes in renal dysfunction following open-heart operations.

Forty consecutive patients who underwent open-heart procedures using a hyperosmolar perfusion prime were studied to determine the significance of free-water clearance and urinary osmolality early after bypass in predicting the likelihood of postoperative renal dysfunction, defined as a blood urea nitrogen (BUN) level over 50 mg/100 ml. Urinary osmolality increased in all patients during the first 18 hours after bypass, but the increase was substantially less for those who subsequently developed renal dysfunction. Free-water clearance, which was significantly less negative in the patients with renal dysfunction by 2 hours after bypass and remained so throughout the 18 hours of this study, served as an early postoperative indicator of impaired renal function in the patients who eventually developed BUN elevation. Moreover, it was more sensitive as an index of renal dysfunction than was osmolality alone. Early recognition of renal impairment is important, as it may prevent dangerous fluid overloading and allow for corrective measures to be undertaken before frank renal failure develops.

Rat pancreatic duct epithelium cultured on a porous support coated with extracellular matrix.

A method was developed for the isolation and culture of rat pancreatic duct epithelium of predominantly interlobular duct origin. Purified duct epithelial fragments were cultured on a porous support (HATF filters, Millipore) at 37 degrees C in a 1:1 mixture of Dulbecco's Modified Eagle's and Ham's F-12 media supplemented with insulin, cholera toxin, epidermal growth factor, bovine pituitary extract (BPE), and Nu-Serum (Collaborative Research) in a humidified atmosphere of 95% air and 5% CO2. The filters were coated with an extracellular matrix of either rat tail collagen or Matrigel (Collaborative Research), both of which significantly enhanced growth of the duct epithelium in comparison with untreated filters. The cells grew from the tissue fragments as epithelial islands, which merged to form a confluent sheet of epithelium covering at least 80% of the filter within 10 days in culture. The mitotic index of the spreading epithelium increased with time, reaching a maximum of 0.6% on days 3 and 5 and then declining. The epithelial monolayer consisted of tightly packed cells, with a few large cells and a few cells undergoing abnormal mitoses. Fibroblast contamination was negligible. The cells retained carbonic anhydrase activity, consistent with their pancreatic ductal origin and with the maintenance of differentiation in culture. The epithelium could be subcultured but with a low efficiency. A defined, serum-free medium was established with the addition of ethanolamine, bovine serum albumin, and transferrin and the deletion of serum and BPE. The epithelial cells grew nearly as well in this medium as in the serum-containing medium.(ABSTRACT TRUNCATED AT 250 WORDS)

Immunoglobulins (Ig) in circulating immune complexes (CIC) in cancer and inflammatory bowel disease (IBD).

Chronically inflamed tissues and most malignancies have antigenic properties. Patients with long-standing inflammatory bowel disease (IBD) are prone to development of colorectal cancer, which is known to shed antigens in the bloodstream. In an effort to study immunological aspects of these diseases, sera from patients with IBD and colorectal cancer were evaluated for presence of circulating antigen-antibody immune complexes (CIC), and compared to normal controls. CIC were precipitated by polyethylene glycol (PEG) and found to be elevated in all diseased groups. Dissociation of CIC and quantification of their antibody component revealed significant elevation of each immunoglobulin in IBD and in patients with colorectal cancer versus control: IgG = 1.776 +/- 1.573 vs 0.734 +/- 0.618 (P less than 0.001); IgA = 0.368 +/- 0.452 vs 0.090 +/- 0.198 (P less than 0.001); IgM = 0.434 +/- 0.235 vs 0.080 +/- 0.285 (P less than 0.001) serum total Ig levels were consistently much higher than CIC Ig. No correlation was found between the individual serum Ig components and the precipitable complexes-bound Ig, suggesting a selective recognition of antigenic components in the CIC, rather than non-specific association and subsequent precipitation of serum Ig. CIC may represent an easily accessible source of immunological determinants for the study of malignant and chronic inflammatory diseases.

Comparison of open and laparoscopic treatment of acute appendicitis.

BACKGROUND: Appendectomy can be performed using either a laparoscopic or an open technique. This study compares the outcome of patients treated for acute appendicitis by open appendectomy with the outcome of those undergoing laparoscopic appendectomy. METHODS: Patients undergoing appendectomy at The Mount Sinai Hospital between 1994 and 1998 were studied. Outcome of patients having open appendectomy was compared with that of patients having laparoscopic appendectomy. RESULTS: Seven hundred fifty-eight patients underwent appendectomy for acute appendicitis during the 5-year study period. Two hundred seventy-one (36%) had open appendectomy and 487 (64%) had laparoscopic appendectomy. Patients subsequently found to have a normal appendix had the highest rate of laparoscopic appendectomy, whereas those with gangrenous appendicitis were most likely to have open appendectomy (P <0.05). There was a significant decline in the postoperative length of stay for open cases during the length of the study. In the final year, the difference in length of stay between open and laparoscopic appendectomy was only 1 day. Patients with gangrenous appendicitis had a significantly longer length of stay than did patients with a normal appendix or suppurative appendicitis. The hospital cost of laparoscopic appendectomy was greater than that for open appendectomy but the extra expenditure in the operating room was offset by the longer length of stay of the patients having open surgery. CONCLUSIONS: Differences in outcome between open and laparoscopic appendectomy are minor. In this study, more difficult cases with gangrenous appendicitis were more likely to require open appendectomy whereas milder forms of appendicitis, especially in women, were more likely to be treated by laparoscopy. Savings from the slightly shorter hospital stay after laparoscopic appendectomy are offset by the higher surgical cost of the laparoscopic equipment.

Results of surgical treatment for familial polyposis coli.

Seventy-seven patients with polyposis coli operated on at The Mount Sinai Hospital in the last 40 years were studied. Forty-two patients had a subtotal colectomy. Sixteen were found to have colon cancer at the time of operation, and a second rectal cancer developed in 50 percent of the survivors within 1 to 13 years after subtotal colectomy. Rectal cancer subsequently developed in only 3 of 23 patients without colon cancer. Thirty-five patients had total proctocolectomy or total colectomy with mucosal proctectomy and ileoanal anastomosis. Recurrent adenomatous polyps developed in two patients after mucosal proctectomy. A villous adenoma with carcinoma in situ of the ileum developed in one patient 30 years after total proctocolectomy and ileostomy. Another patient died from a periampullary carcinoma 24 years after subtotal colectomy. It seems that as the life expectancy of patients with polyposis improves, the incidence of small bowel and duodenal cancers may be expected to increase.

Mucosal proctectomy using an ultrasonic scalpel.

Mucosal proctectomy is becoming the operation of choice in the surgical treatment of patients with ulcerative colitis and familial polyposis coli. Dissection of the rectal mucosa and submucosa from the underlying muscularis is often difficult and, in some instances, impossible to perform. The feasibility of using an ultrasonic device to perform mucosal protectomy was studied in eight dogs. This technique produced coagulative necrosis of the mucosa and muscularis mucosa with marked edema and congestion of the submucosa. The muscularis propria remained intact. Complete destruction of the distal 7 cm of rectal mucosa required a total duration of exposure to the ultrasonic probe of at least 12 minutes. In another five dogs, total colectomy was performed above the area of the mucosal proctectomy followed by endorectal pull-through of the ileum. Follow-up studies revealed healing of the ileonal anastomosis without retraction or stricture. This technique should allow mucosal proctectomy to be performed in those patients in whom standard dissection is not possible due to fibrosis of the submucosal plane.

Blood transfusion, skin test reactivity, and lymphocytes in inflammatory bowel disease.

Peripheral lymphocytes, T and B cell counts, and skin test reactivity to five recall antigens were determined before operation and 6 to 18 months after operation with or without blood transfusion in 59 patients with inflammatory bowel disease. Significantly reduced preoperative peripheral lymphocyte and T cell counts reached normal levels 6 to 18 months after operation in patients who had not received perioperative blood transfusions. However, lymphocytes and T cells of transfused patients remained decreased, unchanged from preoperative levels, and significantly lower than those of control subjects (p less than 0.005) and levels of patients who had not been transfused (p less than 0.05). Before operation, transfused and untransfused patients were identical in age, Crohn's disease activity index, and peripheral lymphocyte and T and B cell counts. Equal numbers of patients were taking steroids and were anergic to skin tests with five recall antigens. Transfused patients weighed less preoperatively than untransfused patients, and these patients then gained a significant amount of weight. These results suggest that some of the immunologic abnormalities that accompany inflammatory bowel disease may be influenced by blood transfusions.