Supporting Childhood Bereavement Through School-Based Grief Group.

With 7.3% of children under the age of 18 experiencing the death of a parent and more who experience a loss of a loved one bereavement is a common experience in the lives of children and youth. The current study sought to evaluate the effectiveness of an 8-week, school-based grief group treatment program in reducing symptoms of grief, dysregulation, and improving social support. A total of 296 children and youth (age 11-18) participated in the grief programming provided by a local hospice agency. With a retention rate of 76% the researchers identified a significant reduction in grief symptomology, frequency of emotion dysregulation, and a significant increase in perceived social support from pre- to post-8-week school-based grief programming. A reduction in intensity of dysregulation was not significant. Implications for school personnel and parental support of children and youth experiencing loss are discussed.

Development and validation of a paper spray mass spectrometry method for the rapid quantitation of remdesivir and its active metabolite, GS-441524, in human plasma.

Introduction: Remdesivir (GS-5734) is a nucleoside analog prodrug with antiviral activity against several single-stranded RNA viruses, including the novel severe respiratory distress syndrome virus 2 (SARS-CoV-2). It is currently the only FDA-approved antiviral agent for the treatment of individuals with COVID-19 caused by SARS-CoV-2. However, remdesivir pharmacokinetics/pharmacodynamics (PK/PD) and toxicity data in humans are extremely limited. It is imperative that precise analytical methods for the quantification of remdesivir and its active metabolite, GS-441524, are developed for use in further studies. We report, herein, the first validated anti-viral paper spray-mass spectrometry (PS-MS/MS) assay for the quantification of remdesivir and GS-441524 in human plasma. We seek to highlight the utility of PS-MS/MS technology and automation advancements for its potential future use in clinical research and the clinical laboratory setting. Methods: Calibration curves for remdesivir and GS-441524 were created utilizing seven plasma-based calibrants of varying concentrations and two isotopic internal standards of set concentrations. Four plasma-based quality controls were prepared in a similar fashion to the calibrants and utilized for validation. No sample preparation was needed. Briefly, plasma samples were spotted on a paper substrate contained within pre-manufactured plastic cassette plates, and the spots were dried for 1 h. The samples were then analyzed directly for 1.2 min utilizing PS-MS/MS. All experiments were performed on a Thermo Scientific Altis triple quadrupole mass spectrometer utilizing automated technology. Results: The calibration ranges were 20 - 5000 and 100 - 25000 ng/mL for remdesivir and GS-441524, respectively. The calibration curves for the two antiviral agents showed excellent linearity (average R2 = 0.99-1.00). The inter- and intra-day precision (%CV) across validation runs at four QC levels for both analytes was less than 11.2% and accuracy (%bias) was within ± 15%. Plasma calibrant stability was assessed and degradation for the 4 °C and room temperature samples were seen beginning at Day 7. The plasma calibrants were stable at -20 °C. No interference, matrix effects, or carryover was discovered during the validation process. Conclusions: PS-MS/MS represents a useful methodology for rapidly quantifying remdesivir and GS-441524, which may be useful for clinical PK/PD, therapeutic drug monitoring (TDM), and toxicity assessment, particularly during the current COVID-19 pandemic and future viral outbreaks.

Why So Serious? An Attempt to Mitigate the Short-Term Harmful Effects of the Film Joker on Prejudice toward People with Mental Illness.

The media perpetuates many harmful stereotypes about people with mental illness. In two studies, we demonstrate the impact of negative media portrayals of mental illness on prejudice and attempt to mitigate these negative effects. Specifically, in Study 1, participants watched the movie Joker, a recent film which associates mental illness with violent behavior, or a control film (Terminator). Participants completed the Prejudice towards People with Mental Illness (PPMI) scale before and after viewing their respective films. The PPMI consists of four dimensions: fear/avoidance (i.e., wanting to avoid people with mental illness), malevolence (i.e., viewing people with mental illness as inferior), authoritarianism (i.e., preference for control over people with mental illness), and unpredictability (i.e., the behavior of people with mental illness is unreliable). We hypothesized that participants who watched the film Joker would display an increase in their fear/avoidance of people with mental illness and their support for authoritarian approaches to their treatment. Consistent with these hypotheses, participants who viewed Joker displayed a significant increase in the fear/avoidance and authoritarian subscales of the PPMI, relative to participants that watched Terminator. In Study 2, in an attempt to mitigate the impact of Joker on prejudice towards people with mental illness, directly after the film we displayed educational and counter-stereotypical statements on-screen that challenged the view that people with mental illness are violent. A control group viewed Joker without these statements. Identical to Study 1, all participants completed the PPMI scale before and after viewing the film. We hypothesized that participants who viewed Joker with the statements would display lower prejudice relative to the control condition. Unfortunately, participants in the experimental and control conditions displayed a comparable increase in prejudice. Together, these studies confirm the negative effect of media portrayals of mental illness (as depicted in Joker) and demonstrate that these effects are not easily mitigated.

Intensive laparoscopic training course for surgical residents: program description, initial results, and requirements.

INTRODUCTION: The Department of Surgery at the University of Arizona has created an intensive laparoscopic training course for surgical residents featuring a combined simulation laboratory and live swine model. We herein report the essential components to design and implement a rigorous training course for developing laparoscopic skills in surgical residents. MATERIALS AND METHODS: At our institution, we developed a week-long pilot intensive laparoscopic training course. Six surgical residents (ranging from interns to chief residents) participate in the structured, multimodality course, without any clinical responsibilities. It consists of didactic instruction, laboratory training, practice in the simulation laboratory, and performance (under the direction of attending laparoscopic surgeons) of surgical procedures on pigs. The pigs are anesthetized and attended by veterinarians and technicians, and then euthanized at the end of each day. Three teams of two different training-level residents are paired. Daily briefing, debriefing, and analysis are performed at the close of each session. A written paper survey is completed at the end of the course. RESULTS: This report describes the results of first 36 surgical residents trained in six courses. Preliminary data reveal that all 36 now feel more comfortable handling laparoscopic instruments and positioning trocars; they now perform laparoscopic surgery with greater confidence and favor having the course as part of their educational curriculum. CONCLUSION: A multimodality intensive laparoscopic training course should become a standard requirement for surgical residents, enabling them to acquire basic and advanced laparoscopic skills on a routine basis.

Mechanical support and medical therapy reverse heart failure in infants and children.

Most infants and children implanted with ventricular assist devices (VADs) go on to cardiac transplantation. Recovery of dilated cardiomyopathies with the combination left ventricular decompression with a VAD and treatment with maximal medical therapy has been possible in some adults, and may be more feasible in infants and children. We used pulsatile and continuous flow VADs and the total artificial heart (TAH) as bridges to transplantation or to recovery. Candidates for native heart recovery were treated with maximal medical therapy for congestive heart failure and short-term dobutamine prior to weaning off device support. Since 1997, 28 infants and children, ages 1 month to 16 years, were implanted for durations of 3-107 days (mean 27). Eighteen received left VADs (LVAD), seven biventricular assist devices (BiVADs), and three TAHs. Device-related mortality was 7/28 (25%), leaving 21/28 (75%) surviving to transplantation or weaning from device support and 20/28 (71%) discharged from the hospital and currently surviving for 2 months to 9 years. Ten of 11 transplant recipients (90%) have survived 2 to 9 years. All 10 with recovered hearts are alive and well for 2 months to 5 years. Eight of 12 (67%) LVAD patients with dilated hearts recovered. None of the recovery patients were over 6 years old. Infants and children who have failed inotropic therapy may be treated with an LVAD and medical therapy for congestive heart failure anticipating native heart recovery. A variety of devices have been tried. All small LVADs yielded comparable results. Larger and older children also have a chance of recovery, but our experience with them is too small except to note that they do well with larger devices and transplantation.

Computed tomography angiography is not accurate in predicting surgical prosthetic aortic valve implant size.

BACKGROUND: Multidetector computed tomography is vital in preoperative sizing for transcatheter aortic valve replacement. The purpose of this study is to determine whether preoperative transcatheter aortic valve replacement multidetector computed tomography accurately predicts surgical aortic valve prosthesis size. METHODS: Between July 2012 and July 2017, 102 patients who underwent surgical aortic valve replacement had preoperative aortic valve sizing by multidetector computed tomography. The aortic annulus diameter calculated using multidetector computed tomography was compared with intraoperative valve sizing during surgical aortic valve replacement. RESULTS: Forty-one (40.2%) of the 102 patients studied had multidetector computed tomography aortic valve measurements that were accurate. Implanted valves were smaller than multidetector computed tomography calculation in 40 patients (39.2%) and were larger in 21 patients (20.6%). Multidetector computed tomography measurements remained inconsistent with intraoperative sizing regardless of aortic annulus diameter. The variance between multidetector computed tomography annulus measurements and intraoperative sizing was statistically significant. CONCLUSIONS: Preoperative aortic annulus measurements by our institutional transcatheter aortic valve replacement multidetector computed tomography protocol differed substantially from surgical implant size. There was no trend toward over nor under sizing for the entire cohort. However, patients with large measured annulus diameter were more likely to have a smaller valve implanted than predicted, and patients with small measured annulus diameter were more likely to have a larger valve implanted than predicted. These results may affect preoperative planning for patients undergoing aortic valve replacement.

Human papillomavirus-58 and -73-associated digital squamous cell carcinoma in a patient with aggressive digital papillary adenocarcinoma.

Aggressive digital papillary adenocarcinoma (ADPA) is a rare tumor that is considered to arise from eccrine sweat glands of the skin. It occurs predominantly in men with a mean age in the sixth decade. It shows a strong tendency for local recurrence and has the potential to metastasize to distant sites. Prompt diagnosis and regular follow-up are important to ensure the best possible outcome. We discuss a case of recurrent ADPA associated with subsequent squamous cell carcinoma (SCC) in different contralateral digits in a 55-year-old man. One SCC lesion tested positive for human papillomavirus (HPV)-58. HPV-associated digital SCCs have been reported; most cases are HPV-16 positive. This report describes a rare case of an HPV-58-positive invasive digital SCC and an HPV-73-positive SCC in situ associated with ADPA.

List memory in young adults with language learning disability.

PURPOSE: The purpose of this study was to characterize the verbal memory limitations of young adults with language learning disability (LLD). METHOD: Sixteen young adults with LLD and 34 age- and education-matched controls with typical language participated in a Deese-Roediger-McDermott (DRM; Deese, 1959; Roediger & McDermott, 1995) list recall experiment. Participants listened to 12-item word lists that converged on a nonpresented critical item (e.g., rain) semantically (umbrella, drench, weather, hail), phonologically (train, main, ran, wren), or dually in a hybrid list (umbrella, train, drench, main) and recalled words in no particular order. Group comparisons were made on veridical recall (i.e., words that were presented) and false recall of nonpresented critical items. Recall performance was analyzed by list type and list position to examine potential differences in the quality of memorial processes. RESULTS: The LLD group produced fewer veridical recalls than the controls. Both groups demonstrated list type and list position effects in veridical recall. False recall of the critical items was comparable in the 2 groups and varied by list type in predictable ways. CONCLUSION: Young adults with LLD have verbal memory limitations characterized by quantitatively low levels of accurate recall. Qualitative patterns of recall are similar to those of unaffected peers. Therefore, the memory problem is characterized by limited capacity; memorial processes appear to be intact.

Infant myocardial recovery with device and surgical repair.

A 4-month-old female infant (weight, 6.17 kg; height, 65 cm) presenting with tachypnea and tachycardia, and a left ventricular ejection fraction of 10%, deteriorated on increasing inotropic therapy and mechanical ventilation. Implantation of a centrifugal left ventricular assist device and institution of maximal medical heart failure therapy led to reverse remodeling and discontinuation of device support after 9 days. One week later, after failure to wean from the ventilator and persistence of a severely dyskinetic septum, a ventricular septal aneurysmectomy was done. The patient was extubated 5 days later followed by hospital discharge 11 days post-septal aneurysmectomy. The patient has done well since then with the most recent echocardiogram showing a 65% ejection fraction.

Modified deep plane rhytidectomy with a lateral approach to the neck: an alternative to submental incision and dissection.

BACKGROUND: A "composite" type subplatysmal dissection with lateral advancement of the platysma-skin flap to lift the neck during rhytidectomy has been advocated by several authors. However, the limited subplatysmal dissection described in these techniques restricts the degree of mobilization of the flap. Therefore, most investigators rely on supraplatysmal dissection and medial plication of the platysma to achieve satisfactory cervical contours, especially in patients with difficult necks. METHODS: To allow for greater mobilization of composite neck flaps, the senior author (T.A.M.) extends the subplatysmal dissection to incorporate release of cervical retaining ligaments. The dissection is carried medially to just beyond the region defined by the inferomedial portion of the parotid gland, and inferiorly to where the superficial musculoaponeurotic system-platysma layer and greater auricular nerve cross the posterior border of the sternocleidomastoid muscle. Dissection of the composite flap is followed by use of fine cannula submental liposuction. RESULTS: Experience with 742 rhytidectomies performed over a 10-year period indicates that this operation can be completed safely with satisfactory results and a low incidence of complications. The use of a submental incision and medial platysma plication can be avoided almost entirely. CONCLUSIONS: Identification and release of the cervical retaining ligaments permits significant platysma-skin flap mobilization. When complemented with submental liposuction, complete cervical rejuvenation can be achieved without need for medial platysma plication. The full integration of the neck and facial plane of dissection results in a very even tension and a natural appearance, even in repeated face lifts.

Twenty-five-year survival after heart-lung transplantation: a milestone.

Limited information about long-term survivors of heart-lung transplant recipients exists. We report a 57-year-old man who has now survived 25 years after a heart-lung transplant. Initial induction and maintenance immunotherapy was rabbit anti-thymocyte globulin, cyclosporine, azathioprine, and methylprednisolone. This patient is currently alive and working 25 years later and has continued good function of the heart-lung graft,without evidence of bronchiolitis obliterans.

Left ventricular assist device support as a bridge to recovery in young children.

OBJECTIVE: Left ventricular assist device (LVAD) experience and follow-up data in children are limited. We report the deployment and successful weaning from LVAD in young children with severe heart failure (HF). DESIGN: From 2004--2009, 13 children suffering from HF were placed on LVAD. All presented with a dilated left ventricle (LV) with severely reduced contractility, secondary to myocarditis, atrial arrhythmia or idiopathic HF. This study reports their outcomes and longitudinal follow-up. RESULTS: Of 13 young children with HF (ages 1 month--6 years; mean 19.2 months) placed on LVAD: eight weaned to recovery and successful hospital discharge, one was transplanted and four died. Echo follow-up in the weaned patients (mean age 22.1 months) revealed significant improvements from pre-LVAD measurements: LV end-diastolic dimension (LVED) mean z-score decreased from +4.8 to +0.95 (P < .001); fractional shortening (FS %) improved from a mean of 9.3% to 33% (P < .001); and the degree of mitral regurgitation (MR) significantly improved (P < .05). Time to LVAD deployment from HF diagnosis was more likely to be less than 30 days in the successfully weaned patients (100%) than patients who died or were transplanted (20%); P = .007. CONCLUSIONS: LVAD support can be utilized as a bridge to recovery in young children with HF. Following LVAD weaning, children sustain improvements in LV size, function and degree of MR. LVAD deployment less than 30 days from HF diagnosis improves the likelihood of successful weaning and illustrates that children with acute etiologies of HF are more likely to achieve recovery.

Treatment of peripartum cardiomyopathy with mechanical assist devices and cardiac transplantation.

BACKGROUND: Peripartum cardiomyopathy is a life threatening illness. If maximal medical therapy fails, patients may then be treated with mechanical circulatory support devices and (or) cardiac transplantation. Our purpose is to demonstrate the long-term efficacy of these surgical interventions. METHODS: A retrospective review of 18 patients diagnosed with peripartum cardiomyopathy from 1994 to 2009 was conducted. RESULTS: Eighteen patients were referred with a median of seven year delay between onset of symptoms and presentation. Eight (44%) had medical therapy with only one death at five years, seven are alive, and two patients are awaiting transplantation. Six patients were implanted with devices. From this group, there were two hospital deaths, one native heart recovery, and three heart transplants with 100% survival. Four patients (21%) were treated with transplantation alone and all survived. Combined device and (or) transplant survival was 80% at one year. CONCLUSIONS: The natural history of this group varied; 38% of the medically treated patients are stable on medical therapy (3 of 8) and 67% of the device patients (4 of 6) are alive. One of six device patients (17%) was successfully bridged to native heart recovery. Mechanical assist devices can be used as a bridge to recovery or as a bridge to cardiac transplantation for the treatment of peripartum cardiomyopathy patients who fail medical management. In addition, cardiac transplantation alone is also a viable treatment option for patients who fail medical management and do not require a mechanical assist device.

A rare cause of graft dysfunction after a heart transplant.

A 39-year-old man with a dilated cardiomyopathy was treated for recurrent life threatening ventricular arrhythmias with an automatic defibrillator and multiple antiarrhythmic agents. After transplant, the donor heart was asystolic probably secondary to these agents. A biventricular paracorporeal device supported the patient for four days and the heart recovered. He remains NYHA class I seven years later.

Bridge to recovery with a thoratec biventricular assist device for postpartum cardiomyopathy.

A 25-year-old African-American woman developed shortness of breath 7 days after a spontaneous vaginal delivery. She was found by echocardiogram to have a left ventricular ejection fraction of 10% and was diagnosed with postpartum cardiomyopathy. Despite medical therapy including diuretics, an ace inhibitor, and a beta blocker, over the next 5 months, the patient had more than 12 hospital admissions for congestive heart failure. After accepting her in transfer, we placed her on multiple IV inotropes and observed no improvement. We then implanted a Thoratec Biventricular Assist Device. During 26 days of support, we conducted two weaning trials that documented return of cardiac function. We then pretreated her for 48 hours before device explantation. She was weaned off inotropic therapy over 2 weeks and discharged to home with normal cardiac function. Two years after explantation of the device, she has a left ventricular ejection fraction of 40% and is New York Heart Association functional class 1.

Device malfunction of the CardioWest total artificial heart secondary to catheter entrapment of the tricuspid valve.

We report two cases at a single institution, a 52-year-old man and a 25-year-old woman, who had failures of their CardioWest total artificial hearts (TAH) from central venous lines that caused obstruction of the right ventricular inflow valves. Each patient was noted to have decreasing TAH outputs for a few days before this catastrophic device arrest. Both patients died; one suddenly and one during a protracted period, as a result of catheter entrapment of the disc of the Medtronic Hall right ventricular inflow valve.

Recovery of dilated cardiomyopathies in infants and children using left ventricular assist devices.

Most infants and children implanted with left ventricular assist devices (LVADs) are bridged to cardiac transplantation. Prioritizing recovery may decrease this trend. Patients were treated with LVAD ventricular decompression, medical heart failure therapy, and bolus therapy with a beta-agonist before weaning trials. Devices were removed if adequate function was observed. Eleven patients with a mean age of 1.7 years presented for LVAD implantation. The mean Z score for left ventricular end diastolic diameter (LVEDD) was +5.5 (+1.6 to +7.3), and the mean fractional shortening was 9% (5%-14%). They were on maximal medical therapy and inotropic support. Duration of device support ranged from 6 to 22 days (mean: 13 days). There were three deaths, one from preimplant anoxic brain damage and two from thromboembolism. Eight patients (73%) recovered, were explanted, and are alive 0.6-6 years with hearts that have a mean Z score for LVEDD of 1.0 (0.09-3.7) and fractional shortening of 23%-36%. Left ventricular assist device decompression of dilated left ventricles in infants and children led to long-term survival in 73%. Ventricular size was significantly reduced and contractility significantly increased. None of these patients required transplantation.