Real-Time Quantitative Measurements of Foot Perfusion in Patients With Critical Limb Ischemia.

INTRODUCTION: Current methods of evaluating adequacy of endovascular procedures are imperfect and do not always predict which patients will do well. The purpose of this study was to evaluate the role of real-time quantitative measurements of perfusion among patients with critical limb ischemia. MATERIALS AND METHODS: Thirty-four patients with critical limb ischemia undergoing endovascular treatment were recruited. Perfusion Images of the foot were obtained pre and post successful angioplasty using an SPY Elite System (Novadaq Technologies, Ontario, Canada). Patients were followed for 6 months. Subsequently a logistic regression was performed to determine whether intraprocedural perfusion parameters predicted the odds of wound healing. RESULTS: Twenty-nine patients had successful angioplasty. Median age was 69.5% ± 8.3; 75% were men and 64% were diabetic. Rutherford stages were (4%-39%, 5%-57%, 6%-4%), and the average target limb ankle-brachial index (ABI) was 0.58 (SD 2.24). There was no significant correlation between the ABI and perfusion parameters. Inflow perfusion rate correlated significantly with Rutherford stage (Spearman rho 0.398, P = .036). After successful angioplasty 39% had a decrease in inflow rate and 57% had a decreased total inflow. In all, 25 patients completed 6 months of follow-up. Resolution of rest pain and/or healing of the ischemic wound occurred in 10 (40%) patients at 1 month, 4 (16%) at 3 months, and 2 (8%) at 6 months. One patient underwent a major amputation at 2 months. Eight (32%) patients never healed or had persistent rest pain. None of the real-time perfusion variables were significant predictors of wound healing. CONCLUSION: Many patients experience a paradoxical decrease in perfusion following successful angioplasty suggesting perfusion may not correlate with angiographic outcome, possibly due to microemboli, microvascular disease, or vasospasm. Real-time perfusion imaging following intra-arterial infusion of indocyanine green does not predict the odds of wound healing.

[Seasonal variation in surgical diseases : Is an economic resource management necessary?] / Saisonale Verteilung chirurgischer Krankheitsbilder : Ist eine Ressourcenverteilung erforderlich?

BACKGROUND: The registration of diagnoses and diagnose-related groups (DRG) allows conclusions to be drawn about the distribution over the course of the year. Seasonal variations can be recognized and used to plan further resource management. METHODS: From 2006 to 2016 a total of 30,999 main diagnoses and DRGs were registered at the hospital for visceral surgery of the University Medical Hospital in Leipzig. The data were sorted on a monthly and seasonal basis and compared to meteorological data received from the German Meteorological Service. Furthermore, epidemiological information about the patients was recorded. RESULTS: The most frequently registered main diagnosis was malignant neoplasms of the liver and intrahepatic bile ducts with 1589 cases (C22), followed by acute appendicitis with 1557 cases (K35). There was a significant seasonal and monthly variation for cholelithiasis (K80) with 1013 cases (p = 0.002++), inguinal hernia (K40), 887 cases (p = 0.002++), ventral hernia (K43), 696 cases (p < 0.001++) and varices of the lower limbs (I83), 352 cases (p < 0.001++). A similar correlation could be shown for daily sunshine hours and case numbers for patients with the main diagnosis groups I83 (r = -0.12, p = 0.036+) and K43 (r = -0.08, p = 0.041+). Another significant correlation was observed between patients' epidemiological information and medical data: patient-related clinical severity (PCCL) ~ age (r = 0.27, p < 0.001++), length of hospital stay ~ age (r = 0.25, p < 0.001++), duration of ventilation ~ age (r = 0.07, p < 0.001++) and mortality ~ age (r = 0.09, p < 0.001++). CONCLUSION: A seasonal variation in case numbers for individual main diagnoses could be registered and elective and therefore plannable surgeries were mostly affected. An adequate resource management can reveal economic benefits. Older patients consume a high amount of resources and should be given a higher priority.

The Impact of Compliance with Imaging Follow-up on Mortality After Endovascular Abdominal Aortic Aneurysm Repair: A Population Based Cohort Study.

OBJECTIVE: Compliance with regular imaging follow-up after endovascular aortic aneurysm repair (EVAR) is inconsistent, and evidence of benefit from scheduled long-term surveillance is limited. This study sought to characterize the association between post-EVAR imaging frequency and long-term survival. METHODS: Using administrative health databases for the province of Ontario, Canada, a cohort of patients was identified who underwent EVAR between 2004 and 2014. Minimum appropriate imaging follow-up (MAIFU) was defined as a CT scan or ultrasound of the abdomen within 90 days of EVAR as well as every 15 months thereafter. Multivariate time to event analyses characterized the association between compliance with MAIFU over time and all-cause mortality. RESULTS: 4988 patients treated by EVAR were identified. Median follow-up was 3.4 years (IQR 2.0-5.3 years) and 90 day mortality was 1.6%. Among those who survived over 90 days, 87% (N = 4251 of 4902) underwent at least one CT scan or ultrasound of the abdomen within 90 days, but only 58% (N = 2859 of 4902) went on to meet MAIFU criteria. Infrequent imaging correlated with lower follow-up by a vascular surgeon, but not with infrequent primary care or specialist consultations. Consistently meeting MAIFU criteria was associated with a lower risk of death when compared with missing the first imaging follow-up within 90 days (HR 0.82, 95% CI 0.69-0.96, p = .014), or when compared with having first imaging follow-up within 90 days but subsequently not meeting MAIFU criteria (HR 0.78, 95% CI 0.68-0.91, p = .001). A larger proportion of the follow-up period meeting MAIFU criteria was associated with a lower risk of death. CONCLUSIONS: These data support efforts to improve compliance with imaging surveillance after EVAR.

Continuous regional anaesthesia provides effective pain management and reduces opioid requirement following major lower limb amputation.

OBJECTIVES: Postoperative stump pain after major lower limb amputation is a significant impediment to the recovery of amputees. The vast majority of patients require opioid analgesics following surgery, which are associated with opioid-related side-effects. Here, we investigate whether intraoperative placement of a peripheral nerve stump catheter followed by continuous infusion of local anesthetic is as effective at pain control as current analgesic practices. If beneficial, this procedure could potentially reduce post-amputation opioid consumption and opioid-related adverse effects. METHODS: A retrospective chart review was conducted of 198 patients over a 4-year period who had undergone a major lower limb amputation for indications related to peripheral vascular disease. Postoperatively, 102 patients received a perineural catheter were compared to 96 patients who did not. The primary outcomes of this study were the amount of morphine equivalents used in the first 72 hours postoperatively and postoperative pain intensity in the first 24 hours. RESULTS: A total of 198 lower-limb amputations were selected for analyses. Multiple regression analyses indicated that perineural catheter use was associated with a lower cumulative postoperative opioid consumption over the first 72 hours but not postoperative pain scores at 24 hours. Perineural catheter use led to a 40% reduction in opioid use during the first 72 hours postoperatively. Mixed model repeated measures analysis demonstrated that this opioid reduction was consistent over time. Other variables related to total opioid use included age, pre-surgical chronic pain, pre-surgical opioid use, patient-controlled analgesia. CONCLUSIONS: Continuous perineural infusions of local anesthetic are a safe and effective method for reducing post-amputation opioid analgesic medications after major lower limp amputation.

The relations of regulation and emotionality to children's externalizing and internalizing problem behavior.

The purpose of this study was to examine the relation of different types of negative emotion and regulation and control to 55- to 97-month-olds' internalizing and externalizing problem behaviors. Parents and teachers provided information on children's (N = 214) adjustment, dispositional regulation and control, and emotion, and children's regulation was observed during several behavioral tasks. Internalizing was defined in two ways: as social withdrawal (to avoid overlap of items with measures of emotionality) or, more broadly, as anxiety, depression, and psychosomatic complaints. In general, children with externalizing problems, compared with children with internalizing problems and nondisordered children, were more prone to anger, impulsivity, and low regulation. Children with internalizing symptoms were prone to sadness, low attentional regulation, and low impulsivity. Relations between internalizing problems and emotionality were more frequent when the entire internalizing scale was used. Findings suggest that emotion and regulation are associated with adjustment in systematic ways and that there is an important difference between effortful control and less voluntary modes of control.

Parental socialization of children's dysregulated expression of emotion and externalizing problems.

The relations of parents' warmth, emotional expressivity, and discussion of emotion to 2nd-5th graders' regulation of emotional expressivity, externalizing problem behaviors, and expressivity were examined. Parents' and children's facial expressions to evocative slides were observed, as was parents' discussion of the slides, and parents and teachers provided information on children's regulation of expressivity and problem behavior. Analyses supported the hypothesis that the effect of parental variables on children's problem behavior was at least partly indirect through their children's regulation of emotion. Children's low negative (versus positive) facial expressivity to negative slides was associated with problem behavior for boys. A reversed model did not support the possibility that children's functioning had causal effects on parenting. The findings suggest that parents' emotion-related behaviors are linked to children's regulation of expressivity and externalizing behaviors.

Mothers' emotional expressivity and children's behavior problems and social competence: mediation through children's regulation.

The relations between mothers' expressed positive and negative emotion and 55-79-month-olds' (76% European American) regulation, social competence, and adjustment were examined. Structural equation modeling was used to test the plausibility of the hypothesis that the effects of maternal expression of emotion on children's adjustment and social competence are mediated through children's dispositional regulation. Mothers' expressed emotions were assessed during interactions with their children and with maternal reports of emotions expressed in the family. Children's regulation, externalizing and internalizing problems. and social competence were rated by parents and teachers, and children's persistence was surreptitiously observed. There were unique effects of positive and negative maternal expressed emotion on children's regulation. and the relations of maternal expressed emotion to children's externalizing problem behaviors and social competence were mediated through children's regulation. Alternative models of causation were tested; a child-directed model in which maternal expressivity mediated the effects of child regulation on child outcomes did not fit the data as well.

Brazilian adolescents' prosocial moral judgment and behavior: relations to sympathy, perspective taking, gender-role orientation, and demographic characteristics.

The goal of this study was to examine demographic and individual difference variables that predict level of prosocial moral judgment and self-reported prosocial behavior and to test mediating or moderating relations among predictors. The relations of prosocial moral reasoning and self-reported prosocial behavior to perspective taking, sympathy, age, sociometric status, and gender-role orientation were examined with a sample of 149 Brazilian adolescents who completed a series of questionnaire measures. Prosocial moral judgment was expected to be predicted by both sympathy and perspective taking, whereas sympathy or prosocial moral judgment was expected to mediate the relations of femininity and perspective taking to prosocial behavior. Self-reported perspective taking and sympathy interacted when predicting prosocial moral judgment; adolescents who were high in either sympathy or perspective taking (or both) scored high in prosocial moral reasoning. A feminine orientation predicted sympathy and perspective taking, perspective taking predicted prosocial moral reasoning and sympathy, and sympathy had both direct and indirect paths (through moral judgment) to prosocial behavior. The findings generally were consistent with the contention that both the tendency to take others' perspectives and to sympathize are related to level of prosocial moral reasoning, which in turn motivates prosocial behavior. Moreover, patterns of correlations among variables were similar to those found in the United States.

The relations of parental emotional expressivity with quality of Indonesian children's social functioning.

In Western societies, parental expression of positive emotion has been positively related to the quality of children's social functioning, whereas their expression of negative emotion has been negatively or inconsistently related. The relations of parental expressivity to 3rd-grade Indonesian children's dispositional regulation, socially appropriate behavior, popularity, and sympathy were examined. Parents, teachers, and peers reported on children's social functioning and regulation, and parents (mostly mothers) reported on their own expression of emotion in the family. Generally, parental expression of negative emotion was negatively related to the quality of children's social functioning, and regression analyses indicated that the relations of parental negative expressivity to children's popularity and externalizing behaviors might be indirect through their effects on children's regulation. Unexpectedly, parental expression of positive emotion was unrelated to children's social functioning.

The relations of regulation and negative emotionality to Indonesian children's social functioning.

The purpose of this study was to examine the relations of individual differences in regulation and negative emotionality to 127 third-grade Indonesian children's social skills/low externalizing problem behavior, sociometric status, and shyness. Parents and multiple teachers provided information on children's regulation, negative emotionality, and social functioning; peer sociometric information on liking and social behavior was obtained; and children reported on their self-regulation. In general, children's low socially appropriate behavior/ high problem behavior and rejected peer status were related to low dispositional regulation and high negative emotionality (intense emotions and anger), and regulation and negative emotionality (especially teacher rated) sometimes accounted for unique (additive) variance in children's social functioning. Adult-reported shyness was related to low peer nominations of disliked/fights (although shy children were not especially liked), low adult-reported regulation, and (to a lesser degree) low teacher-rated negative emotionality. Findings are compared with work on regulation, negative emotionality, social competence, and shyness in other countries.

Prediction of elementary school children's externalizing problem behaviors from attentional and behavioral regulation and negative emotionality.

The purpose of this study was to examine the moderating role of individual differences in negative emotionality in the relations of behavioral and attentional (emotional) regulation to externalizing problem behaviors. Teachers' and one parent's reports of children's regulation (attentional and behavioral), emotionality, and problem behavior were obtained when children were in kindergarten to grade 3 and two years later (N = 169; 146 in major analyses); children's behavioral regulation also was assessed with a measure of persistence. According to the best fitting structural equation model, at two ages behavioral dysregulation predicted externalizing behavior problems for children both high and low in negative emotionality, whereas prediction of problem behavior from attentional control was significant only for children prone to negative emotionality. There were unique, additive effects of behavioral and attentional regulation for predicting problem behavior as well as moderating effects of negative emotionality for attentional regulation.

Dispositional emotionality and regulation: their role in predicting quality of social functioning.

Individual differences in emotionality and regulation are central to conceptions of temperament and personality. In this article, conceptions of emotionality and regulation and ways in which they predict social functioning are examined. Linear (including additive) and nonlinear effects are reviewed. In addition, data on mediational and moderational relations from a longitudinal study are presented. The effects of attention regulation on social functioning were mediated by resiliency, and this relation was moderated by negative emotionality at the first, but not second, assessment. Negative emotionality moderated the relation of behavior regulation to socially appropriate/prosocial behavior. These results highlight the importance of examining different types of regulation and the ways in which dispositional characteristics interact in predicting social outcomes.

Emotion, regulation, and moral development.

Research and theory on the role of emotion and regulation in morality have received considerable attention in the last decade. Much relevant work has concerned the role of moral emotions in moral behavior. Research on differences between embarrassment, guilt, and shame and their relations to moral behavior is reviewed, as is research on the association of these emotions with negative emotionality and regulation. Recent issues concerning the role of such empathy-related responses as sympathy and personal distress to prosocial and antisocial behavior are discussed, as is the relation of empathy-related responding to situational and dispositional emotionality and regulation. The development and socialization of guilt, shame, and empathy also are discussed briefly. In addition, the role of nonmoral emotions (e.g. anger and sadness), including moods and dispositional differences in negative emotionality and its regulation, in morally relevant behavior, is reviewed.

Right hemisphere dysfunction: therapeutic intervention from acute care to home health.

This article discusses clinical practice variances in speech-language treatment of patients with right hemisphere dysfunction by therapeutic milieu. With an eye toward enhanced cost effectiveness, a model of intervention is presented that takes a patient from acute care management through rehabilitation. Issues discussed include assessment, family training, goal setting, and documentation. A right hemisphere screening tool is included in an appendix for use in acute and transitional care settings where in-depth testing might be inappropriate because of time constraints or the acute or transitory nature of the patient's symptoms.

Evanston Northwestern Healthcare--right hemisphere screen.

This article consists of a screening test that has been developed and used by the speech-language pathologists at Evanston Northwestern Healthcare. It is an informal tool designed to quickly determine the cognitive and communication status of right hemisphere-injured patients and is most appropriate for use in acute care and transitional care settings, where speech-language pathologists are asked to determine whether or not a full evaluation is warranted.

Regulation, emotionality, and preschoolers' socially competent peer interactions.

In this study, the relations of regulatory control to the qualities of children's everyday peer interactions were examined. Effortful control (EC) and observations of peer interactions were obtained from 135 preschoolers (77 boys and 58 girls, mean ages = 50.88 and 50.52, respectively). The results generally confirmed the prediction that children who are high in EC were relatively unlikely to experience high levels of negative emotional arousal in response to peer interactions, but this relation held only for moderate to high intense interactions. Socially competent responding was less likely to be observed when the interaction was intense or when negative emotions were elicited. Moreover, when the interactions were of high intensity, highly regulated children were likely to evidence socially competent responses. The relation of EC and intensity to social competence was partially mediated by negative emotional arousal. The results support the conclusion that individual differences in regulation interact with situational factors in influencing young children's socially competent responding.

Parental reactions to children's negative emotions: longitudinal relations to quality of children's social functioning.

Relations between self-reported parental reactions to children's negative emotions (PNRs) and children's socially appropriate/problem behavior and negative emotionality were examined longitudinally. Evidence was consistent with the conclusion that relations between children's externalizing (but not internalizing) emotion and parental punitive reactions to children's negative emotions are bidirectional. Reports of PNRs generally were correlated with low quality of social functioning. In structural models, mother-reported problem behavior at ages 10-12 was at least marginally predicted from mother-reported problem behavior, children's regulation, and parental punitive or distress reactions. Moreover, parental distress and punitive reactions at ages 6-8 predicted reports of children's regulation at ages 8-10, and regulation predicted parental punitive reactions at ages 10-12. Father reports of problem behavior at ages 10-12 were predicted by earlier problem behavior and parental distress or punitive reactions; some of the relations between regulation and parental reactions were similar to those in the models for mother-reported problem behavior. Parental perceptions of their reactions were substantially correlated over 6 years. Some nonsupportive reactions declined in the early to mid-school years, but all increased into late childhood/early adolescence.

Consistency and development of prosocial dispositions: a longitudinal study.

The issue of whether there is consistency in prosocial dispositions was examined with a longitudinal data set extending from ages 4 to 5 years into early adulthood (N = 32). Spontaneous prosocial behaviors observed in the preschool classroom predicted actual prosocial behavior, other- and self-reported prosocial behavior, self-reported sympathy, and perspective taking in childhood to early adulthood. Prosocial behaviors that were not expected to reflect an other-orientation (i.e., low cost helping and compliant prosocial behavior) generally did not predict later prosocial behavior or sympathy. Sympathy appeared to partially mediate the relation of early spontaneous sharing to later prosocial dispositions. The results support the view that there are stable individual differences in prosocial responding that have their origins in early childhood.