[Clinical effect of superior oblique re-tucking for recurrent or residual compensatory head position].

Objective: To evaluate the effects of re-tucking the superior oblique muscle on recurrent or residual compensatory head position. Methods: A retrospective case series study was conducted. 12 recurrent or residual compensatory head position patients (12 eyes) with congenital superior oblique palsy who underwent superior oblique re-tucking in Tianjin Eye Hospital from March 2015 to February 2021 were included. All patients had a history of superior oblique tucking procedure and showed signs of superior oblique muscle palsy without inferior oblique muscle overaction. During surgery, the Guyton forced duction test is used to evaluate the relaxation of the superior oblique muscle tendon, which affects the re-tucking length of the muscle.Their head position, vertical deviation, eye movement, fovea-disa angle, and Bielschowsky head tilt test were assessed pre-and post-surgery. Statistical analysis was performed using ttest and paired samples Wilcoxon signed rank test. Results: Out of the 12 patients, 8 were male and 4 were female, aged between 2 and 9 years. The initial surgery was done at age 6, with a superior oblique recession length of (7.17±1.03) mm. Recurrent head tilt occurred in 11 patients after (3.82±0.98) months postoperatively, and 1 patient had residual head tilt, with a followup period of six months or more. Ocular motility examination revealed underaction of the superior oblique muscle, positive Bielschowsky's head tilt test, and Guyton forced duction tese indicating relaxation of the paralyzed superior oblique muscle tendon. Scar adhesion was observed at the stop of the superior oblique muscle, as well as the previous sutures. The scar and the sutures around the stop of the superior oblique muscle were released, the mean re-tucking amount was(7.83±1.59)mm. Follow-up at 12 to 18 months postoperatively showed disappearance of compensatory head position, significant improvement in superior oblique muscle lag, normal ocular motility, and no occurrence of Brown syndrome. The results of Bielschowsky head tilt were negative in 9 cases and still positive in 3 cases after superior oblique re-tucking. The primary vertical deviation was 2.5 (2.0, 5.3) prism diopter pre-operatively and 1 (0, 1) prism diopter post-operatively, respectively. The difference was statistically significant (U=6.00, P<0.001). The total amount of FDA in both eyes was (-22.04±5.47)° and (-15.27±6.08)° pre-and post-operatively, respectively. The difference was statistically significant (t=2.87, P=0.009). All 12 patients have normal eye movement after superior oblique re-tucking procedure. All patients had no compensatory head position at last follow-up. Conclusions: Superior oblique re-tucking is suitable for patients with relaxation of the superior oblique muscle tendon and extrocular rotation as the main sign. It can effectively and safely correct the recurrent or residual compensatory head position after re-tucking the superior oblique muscle.

[Research advances on mental disorders in patients with extensive burns].

Extensive burns can cause nonnegligible acute and chronic damage to central nervous system of patients. The damage of central nervous system may have a profound impact on patients, including neurobehavioral changes such as post-traumatic stress disorder, depression, anxiety, and sleep disorder. These changes may persist after injury, greatly affecting patients' integration into society and return to work. This paper systematically reviewed the clinical manifestations, pathogenesis, and current intervention methods of mental disorders in patients with extensive burns, aiming to provide a basis for further understanding, prevention, and treatment of patients with mental disorders after burns.

Diminished prefrontal hemodynamic response in adult attention deficit hyperactivity disorder: a multi-channel functional near-infrared spectroscopy study

Attention deficit hyperactivity disorder (ADHD) is a common neurodevelopmental disorder. Adult ADHD is currently diagnosed based only on subjective clinical and scoring measures, which inevitably lead to a low correct diagnosis rate. Hence, an effective auxiliary examination with higher sensitivity is needed. Method Twenty healthy controls (HC) subjects and 20 adults with ADHD were included in this study. The functional near-infrared spectroscopy (fNIRS) under verbal fluency test (VFT) was performed to detect cerebral cortex hemodynamics. Correlation and Receiver operating characteristic (ROC) curve analysis were employed to reveal the relationship between differences in hemodynamic response and clinical characteristics. Results The HbO response of adult ADHD in the prefrontal cortex (PFC) was significantly smaller than that of HC. HbO concentration changes in the corresponding channels were negatively correlated with the ASRS-inattention score. HbO concentration changes of channels 16 and 26 corresponding to the medial PFC might be helpful for the diagnosis of adult ADHD. Conclusion Adult ADHD patients have low activation of the PFC, changes of whose corresponding channels were significantly associated with attention deficit, indicating that fNIRS under VFT may be an effective auxiliary examination for adult ADHD. (AU)

Early, Mid-Term, and Late-Term Aseptic Femoral Revisions After THA: Comparing Causes, Complications, and Resource Utilization.

BACKGROUND: Registry data suggest increasing rates of early revisions after total hip arthroplasty (THA). We sought to analyze modes of failure over time after index THA to identify risk factors for early revision. METHODS: We identified 208 aseptic femoral revision THAs performed between February 2011 and July 2019 using an institutional database. We compared demographics, diagnoses, complications, and resource utilization between aseptic femoral revision THA occurring within 90 days (early), 91 days to 2 years (mid), and greater than 2 years (late) after index arthroplasty. RESULTS: Early revisions were 33% of revisions at our institution in the time period analyzed. Periprosthetic fractures were 81% of early, 27% of mid, and 21% of late femoral revisions (P < .01). Women were more likely to have early revisions than men (75% vs 53% of mid and 48% of late revisions; P < .01). Patients who had early revisions were older (67.97 ± 10.06) at the time of primary surgery than those who had mid and late revisions (64.41 ± 12.10 and 57.63 ± 12.52, respectively, P < .01). Index implants were uncemented in 99% of early, 96% of mid, and 64% of late revisions (P < .01). Early revisions had longer postoperative length of stay (4.4 ± 3.3) than mid and late revisions (3.0 ± 2.2 and 3.7 ± 2.1, respectively, P = .02). In addition, 58% of early revisions were discharged to an inpatient facility compared with 36% of mid and 41% of late revisions (P = .03). CONCLUSION: Early aseptic femoral revisions largely occur in older women with uncemented primary implants and primarily due to periprosthetic fractures. Reducing the incidence of periprosthetic fractures is critical to decreasing the large health care utilization of early revisions.

Patient Satisfaction After Total Hip Arthroplasty Is Not Influenced by Reductions in Opioid Prescribing.

BACKGROUND: Opioids have played an important part in post-operative analgesia, but concerns with associated morbidity and the fate of leftover pills have prompted the creation of opioid-sparing protocols. The purpose of this study is to investigate the impact of the implementation of an opioid-sparing protocol on survey-based patient satisfaction scores following total hip arthroplasty (THA). METHODS: This study is a retrospective review of prospectively collected data on patients who underwent primary THA between November 2014 and July 2019. Inclusion criteria consisted of primary elective THA with complete Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey information. Cohorts were separated based on their date of surgery relative to the start of an institutional opioid-sparing-protocol in October 2018. Discharge prescriptions and refills were recorded on chart review and converted to milligram morphine equivalents (MME) for comparison between different opioids. HCAHPS results were analyzed for percentage of "top box" ratings for comparison between the 2 groups. RESULTS: In total, 1003 patients met inclusion criteria: 804 pre-protocol and 199 post-protocol. Mean length of stay decreased from 1.74 ± 1.03 to 1.50 ± 1.11 days (P < .001). Pre-operative Visual Analog Scale pain decreased from 7.00 ± 2.30 to 6.41 ± 2.66 (P = .011) as did the rate of opioid refills (15.6%-9.1%; P = .019). Quantity of opioid medication prescribed upon discharge also decreased from 432 ± 298 to 114 ± 156 MME (P < .001). There was no change in "top box percentages" for satisfaction with pain control (79.7% pre-protocol, 82.1% post-protocol; P = .767). There was a significant increase in proportion of patients reporting top box satisfaction with their overall surgical experience after protocol implementation (88.2%-94.0%; P = .018). CONCLUSION: A reduction in opioids prescribed after THA is not associated with a decrease in patient satisfaction with regard to pain control, as measured by the HCAHPS survey, nor is it associated with an increase in post-operative opioid refills. LOE: III. CLINICAL RELEVANCE: This study suggests that HCAHP scores are not negatively impacted by a reduction in post-operative opioid analgesics.

The Impact of Arthroplasty Fellowship Training on Total Joint Arthroplasty: Comparison of Peri-Operative Metrics between Fellowship-Trained Surgeons and Non-Fellowship-Trained Surgeons.

BACKGROUND: We sought to identify differences between total joint arthroplasties (TJAs) performed by adult reconstruction fellowship-trained surgeons (FT) than non-fellowship-trained surgeons (NFT). METHODS: A single-institution database was utilized to identify patients who underwent elective TJA between 2016 and 2019. RESULTS: In total, 16,882 TJAs were identified: 9111 total hip arthroplasties (THAs) and 7771 total knee arthroplasties (TKAs). Patients undergoing THA by FT surgeons were older (63.11 vs 61.84 years, P < .001), more likely to be white, insured by Medicare, and less likely to be active smokers (P < .0001). Both surgical time (90.03 vs 113.1 minutes, P < .0001) and mean length of stay (LOS) (1.85 vs 2.72 days, P < .0001) were significantly shorter for THAs performed by FT surgeons than NFT surgeons. A significantly greater percentage of patients were discharged home after THA by FT surgeons than NFT surgeons (88.7% vs 85.2%, P = .002). FT patients were quicker to mobilize with therapy and required 25% less opioids. TKAs performed by FT surgeons were associated with shorter surgical times (87.4 vs 94.92 minutes, P < .0001), LOS (2.62 vs 2.84 days, P < .0001), and nearly 19% less opioid requirement in the peri-operative period. In addition to higher Activity Measure for Post-Acute Care scores associated with FT surgeons after TKA, a significantly greater percentage of patients were discharged home after TKA by FT surgeons than NFT surgeons (83.97% vs 80.16%, P < .001). CONCLUSION: For both THA and TKA, patients had significantly shorter surgical times, LOS, and required less opioids when their procedure was performed by FT surgeons compared to NTF surgeons. Patients who had their TJA performed by a FT surgeon achieved higher Activity Measure for Post-Acute Care scores and were discharged home more often than NFT surgeons. In an era of value-based care, more attention should be paid to the patient outcomes and financial implications associated with arthroplasty fellowship training. LEVEL III EVIDENCE: Retrospective Cohort Study.

Differences in Pain, Opioid Use, and Function Following Unicompartmental Knee Arthroplasty compared to Total Knee Arthroplasty.

BACKGROUND: We sought to determine if immediate postsurgical pain, opioid use, and clinical function differed between unicompartmental knee arthroplasty (UKA) and total knee arthroplasty (TKA). METHODS: A single-institution database was utilized to identify patients who underwent elective total joint arthroplasty between 2016 and 2019. RESULTS: In total, 6616 patients were identified: 98.20% TKA (6497) and 1.80% (119) UKA. UKA patients were younger, had lower body mass index, and more often male than the TKA cohort. Aggregate opioid consumption (75.94 morphine milligram equivalents vs 136.5 morphine milligram equivalents; P < .001) along with the first 24-hour and 48-hour usage was significantly less for UKA as compared to TKA. Similarly, pain scores (1.98 vs 2.58; P < .001) were lower for UKA while Activity Measure for Post-Acute Care mobilization scores were higher (21.02 vs 18.76; P < .001). UKA patients were able to be discharged home on the day of surgery 37% of the time as compared to 2.45% of TKA patients (P < .0001). Notably, when comparing UKA and TKA patients who were discharged home on the day of surgery, no differences regarding pain scores, opioid utilization, or mobilization were observed. CONCLUSION: UKA patients are younger, have lower body mass index and American Society of Anesthesiologists scores, and more often male than TKA patients. UKA patients had significantly shorter length of stay than TKA patients and were discharged home more often than TKA patients, on both the day of surgery and following hospital admission. Most notably, UKA patients reported lower pain scores and were found to require 45% lower opioid medication in the immediate postsurgical period than TKA patients. Surprisingly, UKA and TKA patients discharged on the day of surgery did not differ in terms of pain scores, opioid utilization, or mobilization, suggesting that our rapid rehabilitation UKA protocols can be successfully translated to outpatient TKAs with similar outcomes. LEVEL III EVIDENCE: Retrospective Cohort Study.

The Effect of Polyethylene Liner Thickness on Patient Outcomes and Failure After Primary Total Knee Arthroplasty.

BACKGROUND: The effect of using thicker liners in primary total knee arthroplasty (TKA) on functional outcomes and aseptic failure rates remains largely unknown. As such, we devised a multicenter study to assess both the clinical outcomes and survivorship of thick vs thin liners after primary TKA. METHODS: A search of our institutional databases was performed for patients having undergone bilateral (simultaneous or staged) primary TKA with similar preoperative and surgical characteristics between both sides. Two cohorts were created: thick liners and thin liners. Outcomes collected were as follows: change in Knee Society Score (ΔKSS), change in range of motion, and aseptic revision. Ad hoc power analysis was performed for ΔKSS (⍺ = 0.05; power = 80%). Differences between cohorts were assessed. RESULTS: About 195 TKAs were identified for each cohort. ΔKSS and change in range of motion in the thin vs thick cohorts were similar: 51.4 vs 51.6 (P = .86) and 11.1° vs 10.0° (P = .66), respectively. No difference in aseptic revision rates were observed between thin and thick cohorts: all cause (4.1%, 3.1%; P = .59), aseptic loosening (0.5%, 0.5%; P = 1.0), instability (0.5%, 0.5%; P = 1.0), all-cause revision for stiffness (3.1%, 2.1%; P = .52), manipulation under anesthesia (2.1%, 2.1%; P = 1.0), and liner exchange (0.5%, 0%; P = .32). CONCLUSION: The results of this study suggest that both rates of revision surgery and clinical outcomes are similar for TKAs performed with thick and thin liners. Preoperative factors are likely to play an important role in liner thickness selection, and emphasis should be placed on ensuring sound surgical technique.

Utilization of a Novel Opioid-Sparing Protocol in Primary Total Hip Arthroplasty Results in Reduced Opiate Consumption and Improved Functional Status.

BACKGROUND: Total hip arthroplasty (THA) candidates have historically received high doses of opioids within the perioperative period; however, the amounts are being continually reduced as awareness of opioid abuse spreads. Here we seek to evaluate the effectiveness of a novel opiate-sparing protocol (OSP) for primary THAs in reducing opiate administrations, while maintaining similar levels of pain control and postoperative function. METHODS: All patients undergoing primary THA between January 1, 2019 and June 30, 2019 were placed under a novel OSP. Data were prospectively collected as part of standard of care. To assess the primary outcome of opiate consumption, nursing documented opiate administration events were converted into morphine milligram equivalences (MMEs) per patient encounter per 24-hour interval. Postoperative pain and functional status were assessed as secondary outcomes using the Verbal Rating Scale for pain and the Activity Measure for Post-Acute Care scores, respectively. RESULTS: One thousand fifty primary THAs had received our institution's OSP, and 953 patients were utilized as our historical control. OSP patients demonstrated significantly lower 0-24, 24-48, and 48-72 hours with less opiate administration variance (total MME: Control 75.55 ± 121.07 MME vs OSP 57.10 ± 87.48 MME; 24.42% decrease, P < .001). Although pain scores reached statistical significance between 0 and 12 (Control 2.09 vs OSP 2.36, P < .001), their differences were not clinically significant. Finally, OSP patients demonstrated a trend toward higher Activity Measure for Post-Acute Care scores across all 6 domains (total scores: Control 20.53 ± 3.67 vs OSP 20.76 ± 3.64, P = .18). CONCLUSION: Implementation of an OSP can significantly decrease the utilization of opioids in the immediate postoperative period. Inpatient opioid administration can be significantly reduced while maintaining a comparable and non-inferior level of pain and function.

Total Hip Arthroplasty for Femoral Neck Fracture: The Economic Implications of Orthopedic Subspecialty Training.

BACKGROUND: Hip fractures have significant economic implications as a result of their associated direct and indirect medical costs. Under alternative payment models, it has become increasingly important for institutions to find avenues by which costs could be reduced while maintaining outcomes in these cases. METHODS: A multi-institutional retrospective analysis of Medicare patients who underwent total hip arthroplasty (THA) for femoral neck fracture was conducted to assess the impact of fellowship training in adult reconstruction (AR) on the total costs of the 90-day episode of care. Patients were divided into 2 cohorts according to fellowship training status of the operating surgeon: (1) AR-trained and (2) other fellowship training (non-AR). The primary outcome was the total cost of the 90-day episode of care converted to a percentage of the bundled payment target price. RESULTS: A total of 291 patients who underwent THA for the treatment of a femoral neck fracture were included. The average total cost percentage of the 90-day episode of care was significantly lower for the AR cohort 70.9% (±36.6%) than the non-AR cohort 82.6% (±36.1%) (P < .01). After controlling for baseline demographics in the multivariable logistic regression, the care episodes in which the operating surgeons were AR fellowship-trained were still found to be significantly lower, at a rate of 0.87 times the costs of the non-AR surgeons (95% confidence interval 0.78-0.97, P = .011). In addition, the non-AR cohort exceeded the bundle target price more frequently than the AR cohort, 49 (28.7%) vs 16 (13.3%) (P = .02). CONCLUSION: In an era of bundled payments, ascertaining factors that may increase the value of care while decreasing the cost is paramount for institutions and policymakers alike. The results presented in this study suggest that in the femoral neck fracture population, surgeons trained in AR achieve lower total costs for the THA episode of care. Furthermore, non-AR fellowship-trained surgeons exceeded the bundled payment target more frequently than the AR surgeons.

Orexin activated emergence from isoflurane anaesthesia involves excitation of ventral tegmental area dopaminergic neurones in rats.

BACKGROUND: Orexin can facilitate emergence after general anaesthesia via multiple neural pathways. Dopaminergic neurones in the ventral tegmental area (VTA) participate in behavioural arousal from anaesthesia. We investigated the regulation of dopaminergic VTA neurones by orexinergic neurones during emergence from general anaesthesia. METHODS: Orexins were microinjected into the VTA to determine the effects on isoflurane anaesthesia induction, emergence, and maintenance. Orexin receptors and dopaminergic neurones in the VTA were identified using immunofluorescence. Orexinergic terminals in the VTA were optogenetically regulated to detect the endogenous orexin-mediated regulation of dopaminergic neurones during anaesthesia in Hcrtcre rats. RESULTS: Injection of orexin-A (100 pmol) into the VTA reduced emergence time [from 949 (118) to 727 (101) s; P=0.0058] and reduced the electroencephalographic burst-suppression ratio (BSR) (26.6 [10.2]% vs 44.3 [6.8]%; P=0.0027) during isoflurane anaesthesia. The percentage of dopaminergic neurones that expressed either orexin-1 receptor or orexin-2 receptor was 73.4 (5.0)% and 74.4 (62.4)%, respectively. Optogenetic activation of orexinergic projections to the VTA reduced the BSR (from 40.5 [2.7]% to 22.4 [11.8]%; P=0.0019) and facilitated emergence (915 [89] vs 685 [68] s; P=0.0026), whereas optical inhibition prolonged the time to wakefulness (from 941 [92] to 1279 [250] s; P=0.011). Dopaminergic neurones in the VTA showed increased firing frequency (387 [78]% of control, P=0.005) after bath application of orexin-A. CONCLUSIONS: Orexin promotes emergence from isoflurane anaesthesia through activation of dopaminergic neurones in the VTA.

Orexin-1 receptor is involved in ageing-related delayed emergence from general anaesthesia in rats.

BACKGROUND: Previous clinical studies have shown that emergence from isoflurane anaesthesia takes longer in elderly patients compared with middle-aged patients. The current study investigated whether delayed emergence from anaesthesia in older age is associated with the age-related decrease in orexin receptors by using a rat model. METHODS: Adult and aged Sprague-Dawley rats were used to assess the time to emergence after 30 min isoflurane anaesthesia (1.4 vol%), and differences in the orexinergic systems, including the number of orexinergic neurones, plasma orexin concentrations, and expression of orexin-1 (OX1R) and orexin-2 receptors, compared using immunofluorescence, radioimmunoassay, western blot, and real-time polymerase chain reaction. The effects of OX1R expression on emergence time were determined by virus-mediated overexpression of OX1R using intra-cerebroventricular injection. RESULTS: The median (range) emergence time of aged rats was longer than that in adult rats [1082 (1010-1130) compared with 848 (829-938) s; P=0.0009]. Plasma orexin concentrations were higher in the aged group than the adult group [34 (33-37) and 25 (22-31) pg ml-1, respectively; P=0.04], but the number of orexinergic neurones was similar in both groups. Protein expression of OX1R was lower in the aged group compared with the adult group [0.47 (0.35-0.58) compared with 0.97 (0.86-1.32), respectively; P=0.002]. Overexpression of OX1R significantly shortened the emergence time in aged rats from [1120 (1040-1190) s] to [769 (576-928) s; P=0.03]. CONCLUSIONS: Age-related decrease in OX1R expression is associated with delayed emergence from isoflurane anaesthesia in aged rats.

miR-26a suppresses autophagy in swine Sertoli cells by targeting ULK2.

A large number of microRNAs (miRNAs) have been detected from porcine testicular tissues thanks to the development of high-throughput sequencing technology. However, the regulatory roles of most identified miRNAs in swine testicular development or spermatogenesis are poorly understood. In our previous study, ULK2 (uncoordinated-51-like kinase 2) was predicted as a target gene of miR-26a. In this study, we aimed to investigate the role of miR-26a in swine Sertoli cell autophagy. The relative expression of miR-26a and ULK2 levels has a significant negative correlation (R2  = .5964, p ≤ .01) in nine developmental stages of swine testicular tissue. Dual-luciferase reporter assay results show that miR-26a directly targets the 3'UTR of the ULK2 gene (position 618-624). In addition, both the mRNA and protein expression of ULK2 were downregulated by miR-26a in swine Sertoli cells. These results indicate that miR-26a targets the ULK2 gene and downregulates its expression in swine Sertoli cells. Based on the expression of marker genes (LC3, p62 and Beclin-1), overexpression of miR-26a or knock-down of ULK2 inhibits swine Sertoli cell autophagy. Taken together, these findings demonstrate that miR-26a suppresses autophagy in swine Sertoli cells by targeting ULK2.

The effectiveness of psychoeducational family intervention for patients with schizophrenia in a 14-year follow-up study in a Chinese rural area.

BACKGROUND: It is unclear if the impact of psychoeducational family intervention for patients with schizophrenia can be sustained over 10 years. In this study, we explored the 14-year effect of psychoeducational family intervention for patients with schizophrenia in a Chinese rural area. METHOD: The data from a cluster randomized control trial (CRCT) study of psychoeducational family intervention in a 14-year follow-up was analyzed. All patients with schizophrenia (n = 326) who participated in the CRCT drawn from six townships in Xinjin County of Chengdu in 1994, of whom 238 (73.0%) who were still alive, and their informants were followed up in 2008. The Patients Follow-up Scale, the Positive and Negative Syndrome Scale (PANSS) and the Global Assessment of Functioning were used in the follow-up study. RESULTS: There were no significant differences of marital status, mean scores of PANSS positive symptoms, negative symptoms, general mental health, and total scores among the psychoeducational family intervention, medication, and control groups in 2008. The psychoeducational family intervention group had a significantly higher rate of antipsychotic medication and a higher level of work ability than other two groups. The control group had a significantly higher rate of never-treated (26.0%) than psychoeducational family intervention group (6.5%). CONCLUSION: Psychoeducational family intervention might be still effective in the 14-year follow-up, especially in patients' treatment adherence/compliance and social functioning. Psychoeducational family intervention might be more effective in places where family members frequently participated in patients' care and had a lower level of knowledge on mental illness. Family intervention should be considered when making mental health policy and planning mental health services.

Prevalence of post-traumatic stress disorder among adolescents after the Wenchuan earthquake in China.

BACKGROUND: The Wenchuan earthquake was a catastrophic earthquake in China. The aim of this study is to explore longitudinally the rates of post-traumatic stress disorder (PTSD) and depression in adolescents after the Wenchuan earthquake, and to identify independent predictors of PTSD. METHOD: PTSD and depression symptoms among adolescents at 6, 12 and 18 months after the Wenchuan earthquake were investigated using the PTSD Checklist Civilian Version and the Beck Depression Inventory (BDI). Subjects in this study included 548 high school student survivors in a local boarding high school. RESULTS: The rates of PTSD symptoms were 9.7%, 1.3% and 1.6% at the 6-, 12- and 18-month follow-ups, respectively. BDI scores were found to be the best predictor of severity of PTSD at 6, 12 and 18 months. Gender was another variable contributing significantly to PTSD at 6 and 12 months after the earthquake. In the 12-month follow-up, home damage was found to be a predictor of severity of PTSD symptoms. Being a child with siblings was found to be a predictor of severity of PTSD symptoms at 12 and 18 months after the earthquake. CONCLUSIONS: PTSD symptoms changed gradually at various stages after the earthquake. Depression symptoms were predictive of PTSD symptoms in the 18-month follow-up study. Other predictors of PTSD symptoms included female gender and being a child with siblings. The results of this study may be helpful for further mental health interventions for adolescents after earthquakes.

Nitric oxide for post-liver-transplantation hypoxemia in pediatric hepatopulmonary syndrome: case report and review.

HPS is rare in the pediatric population. Liver transplantation is the ultimate treatment for severe HPS. There are only a few case reports and one series of children in whom HPS was the main indication for liver transplantation. Outcome was good in most of them, with full regression of the pulmonary process. However, hypoxemia in the early post-operative course can have severe consequences, and effective treatment modalities are needed. There are rare instances of the use of iNO for the treatment of post-operative hypoxemia. We describe a 10.5-yr-old boy with severe HPS owing to chronic liver disease after bone marrow transplantation. Liver transplantation from a living related donor (the same sister who donated the bone marrow) was complicated by severe hypoxemia on POD 2. iNO was administered via the ventilator circuit and, after extubation, through nasal prongs. It was slowly tapered down and stopped on POD 10. The child had an otherwise uneventful course and was discharged home on POD 21 with normal oxygen saturation. Liver transplantation should be offered to children with severe HPS. iNO can reverse the hypoxemia that may occur after the operation.

Children's mental health emergencies--part 2: emergency department evaluation and treatment of children with mental health disorders.

OBJECTIVE: The emergency physician should be familiar with the wide spectrum of pediatric mental health emergencies because they are commonly encountered in emergency medical practice. METHODS: A review of the literature was done in order to develop an approach for dealing with children presenting with mental health disorders in the emergency department (ED). RESULTS: Children' mental health emergencies have a wide spectrum from behavioral disturbances to major depression. An approach to the issues involved in caring for these patients is discussed which acknowledges the essential role of the emergency physician and the importance of integrating ED care with multidisciplinary services. CONCLUSIONS: The actions and directions taken in the ED are a crucial part of the child's long-term care and treatment. The ED evaluation and management of pediatric mental health emergencies may vary depending on the complaint and includes differentiation from organic etiologies, medical stabilization, and occasionally in depth psychosocial interview.

Homelessness among patients with schizophrenia in rural China: a 10-year cohort study.

OBJECTIVE: To explore the frequency and risk factors of homelessness among a previously identified cohort of patients with schizophrenia in rural China. METHOD: A 10-year follow-up investigation among a 1994 cohort (n = 510) of patients with schizophrenia was conducted in Xinjin County, Chengdu, China. RESULTS: Thirty-nine patients (7.8%) experienced homelessness during the follow-up period. The rate of homelessness was 0.9 per 100 person-years during the 10-year follow-up period. Four significant predictors of homelessness remained in the final logistic regression model: living in shabby or unstable house or shelter, positive family history of mental disorders, without income of the patient, and unmarried, divorced, or separated. Risk of homelessness increased substantially with exposure to multiple risk factors. CONCLUSION: Substantial numbers of homeless patients with schizophrenia are challenges for mental health care and public health. Appropriate community-based services, especially housing services, should be crucial for prevention of homelessness in patients with schizophrenia.