Left Heart Decompression on Veno-Arterial Extracorporeal Membrane Oxygenation in Children With Dilated Cardiomyopathy and Myocarditis: An Extracorporeal Life Support Organization Registry Review.

OBJECTIVES: To describe the association between left heart decompression on veno-arterial extracorporeal membrane oxygenation and survival in patients with myocarditis and dilated cardiomyopathy. The secondary outcome is to study association of left heart decompression with survival in children with myocarditis compared with those with dilated cardiomyopathy. DESIGN: Retrospective study of a multicenter registry database. SETTING: Data reported to Extracorporeal Life Support Organization from international extracorporeal membrane oxygenation centers. PATIENTS: Patients less than or equal to 18 years old with a diagnosis of myocarditis or dilated cardiomyopathy receiving extracorporeal membrane oxygenation. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: A total of 1,438 pediatric extracorporeal membrane oxygenation runs were identified. Thirty-seven percent of the patients had myocarditis (n = 532), whereas the rest had dilated cardiomyopathy. Survival to hospital discharge was 63%. Median extracorporeal membrane oxygenation duration was 148 hours with interquartile range (84-248 hr). Nineteen percent of patients (n = 274) had left heart decompression. Multivariable analysis revealed using left heart decompression (adjusted odds ratio, 1.42; 95% CI, 1.06-1.89; p = 0.02), e-cardiopulmonary resuscitation (adjusted odds ratio, 0.63; 95% CI, 0.51-0.79; p < 0.001), higher pH (adjusted odds ratio, 3.69; 95% CI, 1.80-7.53; p < 0.001), and diagnosis of myocarditis (adjusted odds ratio, 1.69; 95% CI, 1.35-2.08; p < 0.001) were associated with greater odds of survival. In the multivariable analysis for patients with dilated cardiomyopathy, left heart decompression failed to reveal a significant association with survival (20% among survivors vs 17% among nonsurvivors, 95% CI, -2.2% to 8.0%). Meanwhile in patients with myocarditis, the multivariable analysis failed to exclude the possibility that left heart decompression was associated with up to a three-fold greater odds of survival (adjusted odds ratio, 1.77; 95% CI, 0.99-.15). CONCLUSIONS: Retrospective review of the Extracorporeal Life Support Organization registry revealed an association between left heart decompression and greater odds of survival in children with myocarditis and dilated cardiomyopathy on extracorporeal membrane oxygenation. When comparing patients with dilated cardiomyopathy against those with myocarditis, we could not exclude a three-fold greater odds of survival associated with the use of left heart decompression. This finding warrants further prospective evaluation.

Outcomes of Descemet Stripping Endothelial Keratoplasty in Eyes With Pars Plana Versus Anterior Chamber Glaucoma Drainage Devices.

PURPOSE: To compare visual outcomes and complications of Descemet stripping endothelial keratoplasty (DSEK) in eyes with anterior chamber (AC) versus pars plana (PP) glaucoma drainage devices (GDDs). METHODS: A retrospective chart review was conducted of 85 eyes that underwent DSEK and had previous or concurrent AC (37 eyes) or PP (48 eyes) GDD implantation. Outcome measures examined included visual acuity, donor dislocation rate, intraocular pressure, and secondary graft failure (SGF). RESULTS: The mean logarithm of the minimum angle of resolution vision improved from 1.50 (SD = 0.64) to 0.88 (SD = 0.71) in the AC group and from 1.37 (SD = 0.59) to 1.20 (SD = 0.76) in the PP group, with no significant group difference. Intraocular pressure did not differ between the groups preoperatively but was higher in the AC group compared with the PP group postoperatively [mean (SD) 14.5 (6.28) versus 11.5 (5.54) mm Hg, P = 0.03]. Graft dislocation occurred in 35.1% and 29.2% of eyes in the AC and PP groups, respectively. SGF occurred in 18.9% and 41.7% with median time 17.1 (interquartile range [IQR] 4.6-32.1) and 27.9 (IQR 15.1-34.7) months to development in the AC and PP groups, respectively. Multivariable logistic and Cox proportional hazards regression models found no statistically significant factors (tube location, age, sex, concurrent tube revision, new tube insertion) associated with either donor dislocation or SGF. CONCLUSIONS: There was no reduction in donor dislocation or SGF in eyes with PP compared with AC GDD, despite the decreased proximity of the shunt from the endothelial graft. Overall, GDD has a significantly adverse effect on long-term graft survival and close follow-up is warranted.

LigaSure Use Decreases Intraoperative Blood Loss Volume and Blood Transfusion Volume in Sarcoma Surgery.

INTRODUCTION: The LigaSure system has been successfully used in thoracic and abdominal surgery. However, to date, its use in the resection of sarcomas has not been systematically studied. We aimed to determine whether the use of the LigaSure system reduces blood loss and blood transfusion volumes in sarcoma surgery. METHODS: One hundred forty-two consecutive patients who underwent sarcoma surgeries between July 2010 and October 2016 were included. Conventional electrocautery alone (n = 91) and with LigaSure (n = 51) were compared. Case-matched samples (n = 46) from each group were additionally compared. RESULTS: The use of the LigaSure system resulted in a significant decrease in mean intraoperative blood loss (P = 0.02) and blood transfusion volume (P = 0.04). Likewise, a significant decrease in both mean and median intraoperative blood loss (P = 0.003; P < 0.0001) was seen with LigaSure in the case-matched analysis. In the soft-tissue sarcoma subgroup, a significant decrease was observed in mean hemoglobin reduction (P = 0.03) and mean intraoperative blood loss with LigaSure (P = 0.04). No adverse perioperative complications attributed to the LigaSure system were identified. CONCLUSIONS: The LigaSure vessel sealing and dividing system is a safe and effective hemostatic tool for deep dissection in bone and soft-tissue sarcoma surgery. LEVEL OF EVIDENCE: Level III, therapeutic study.

Parental warmth and psychiatric disorders among Puerto Rican children in two different socio-cultural contexts.

BACKGROUND: Parental warmth (PW) has a strong influence on child development and may precede the onset of psychiatric disorders in children. PW is interconnected with other family processes (e.g., coercive discipline) that may also influence the development of psychiatric disorders in children. We prospectively examined the association between PW and child psychiatric disorders (anxiety, major depression disorder, ADHD, disruptive behavior disorders) over the course of three years among Puerto Rican youth, above and beyond the influence of other family factors. METHODS: Boricua Youth Study participants, Puerto Rican children 5 to 13 years of age at Wave 1 living in the South Bronx (New York) (SB) and San Juan and Canguas (PR) (n = 2,491), were followed for three consecutive years. Youth psychiatric disorders were measured by the Diagnostic Interview Schedule for Children-IV (DISC-IV). Generalized Linear Mixed models tested the association between PW (Wave 1) and psychiatric disorders in the next two years adjusting for demographic characteristics and family processes. RESULTS: Higher levels of PW were related to lower odds of child anxiety and major depressive disorder over time (OR = 0.69[0.60; 0.79]; 0.49[0.41; 0.58], respectively). The strength of the association between PW and ADHD and disruptive behavior disorder declined over time, although it was still significant in the last assessment (OR = 0.44[0.37; 0.52]; 0.46[0.39; 0.54], respectively). PW had a unique influence on psychiatric disorders beyond the influence of other parenting and family processes. Stronger associations were observed among girls for depression and ADHD. CONCLUSIONS: Incorporating PW behaviors such as acceptance, support, and comforting into interventions focused on parenting skills may help prevent child psychiatric disorders.

Developmental Psychopathology in a Racial/Ethnic Minority Group: Are Cultural Risks Relevant?

OBJECTIVE: The current study examined (a) the mediating role of parenting behaviors in the relationship between parental risks and youth antisocial behaviors (YASB), and (b) the role of youth cultural stress in a racial/ethnic minority group (i.e., Puerto Rican [PR] youth). METHOD: This longitudinal study consisted of 3 annual interviews of PR youth (N = 1,150; aged 10-14 years at wave 1) and their caretakers from the South Bronx (SB) in New York City and from San Juan, Puerto Rico. Parents reported on parental risks, parenting behaviors, and YASB. Youth also self-reported on YASB and youth cultural stress. A lagged structural equation model examined the relationship between these variables across 3 yearly waves, with youth cultural stress as a moderator of the association between effective parenting behaviors and YASB. RESULTS: Findings supported the positive influence of effective parenting on YASB, independently of past parental risks and past YASB: higher effective parenting significantly predicted lower YASB at the following wave. Parenting also accounted for (mediated) the association between the composite of parental risks and YASB. Youth cultural stress at wave 1 was cross-sectionally associated with higher YASB and moderated the prospective associations between effective parenting and YASB, such that for youth who perceived higher cultural stress, the positive effect of effective parenting on YASB was weakened compared to those with lower/average cultural stress. CONCLUSION: Among PR families, both parental and cultural risk factors influence YASB. Such findings should be considered when treating racial/ethnic minority youth for whom cultural factors may be a relevant influence on determining behaviors.

Family Structure, Transitions and Psychiatric Disorders Among Puerto Rican Children.

This paper examines whether family structure and its transitions are associated with internalizing and externalizing psychiatric disorders among Puerto Rican-origin children. It uses longitudinal data (three waves) from the Boricua Youth Study, which includes probability samples of children in the South Bronx (New York) and San Juan (Puerto Rico) (n = 2,142). We also examine factors which may explain how family structure and transitions may be related to child psychiatric disorders. Our results show that for both internalizing and externalizing disorders there were no significant differences between children of cohabiting (biological or step) parents or of single parents compared to children of married biological parents. In Puerto Rico only, transitioning once from a two-parent family to a single-parent family was related to child internalizing disorders. Family transitions were not associated with externalizing disorders at either site. Context may be an important factor shaping the risk that family dissolution is followed by an internalizing disorder among children.