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Currently there is no in vitro diagnostic test for acute ischemic stroke (AIS), yet rapid diagnosis is crucial for effective thrombolytic treatment. We previously demonstrated the utility of CD8(+) T-cells’ mRNA expression for AIS detection; however extracellular vesicles (EVs) were not evaluated as a source of mRNA for AIS testing. We now report a microfluidic device for the rapid and efficient affinity-enrichment of CD8(+) EVs and subsequent EV’s mRNA analysis using droplet digital PCR (ddPCR). The microfluidic device contains a dense array of micropillars modified with anti-CD8α monoclonal antibodies that enriched 158 ± 10 nm sized EVs at 4.3 ± 2.1 × 109 particles/100 µL of plasma. Analysis of mRNA from CD8(+) EVs and their parental T-cells revealed correlation in the expression for AIS-specific genes in both cell lines and healthy donors. In a blinded study, 80% test positivity for AIS patients and controls was revealed with a total analysis time of 3.7 h., Wijerathne et al develop an approach to quantify mRNA amounts in extracellular vesicles (EVs) from plasma using a microfluidics device to enrich EVs. They show this method allows for the correlation of specific mRNAs with acute ischemic stroke pointing towards potential clinical use.

Background Suicide is a leading cause of death among children, adolescents, and young adults (AYA), and mental health disorders are a major contributing factor. Yet, suicidal behaviors among children and AYA with mental health concerns remain understudied and age-specific risk factors are poorly understood. We examined the risk factors for suicide attempt in children and AYA with mental health disorders across three age groups: pre-adolescent children (aged ≤ 12), adolescents (aged 13-17), and young adults (aged 18-25). Methods A cross-sectional study of children and AYA hospitalized for a mental health disorder (n = 18,018) at a private hospital system with 141 facilities across the United States (year 2014). Results Suicide attempts six months prior to hospitalization were reported in 12.1% (n = 177) pre-adolescent children, 22% (n = 1476) adolescents, and 17.9% (n = 1766) young adults. Evidence of psychological trauma was present in 55.4% of pre-adolescent children, 51.2% of adolescents, and 44.5% of young adults. Predictors for suicide attempt observed across all three age groups included the following: female sex, depressive disorder, and being a victim of bullying. Risk factors for suicide attempt specific to pre-adolescent children included being uninsured and having an unsafe home or school environment. Among AYA, suicide attempt was associated with non-Hispanic white, family history of suicide, emotional traumas, and other traumatic experiences. Alcohol use disorder was also a significant predictor of suicide attempt in young adults. Conclusions Suicide attempts among children and AYA admitted to a hospital with mental health concerns are highly prevalent. Socioeconomic stressors appeared to be an important contributing factor of suicidal behavior in pre-adolescent children but not in older AYA. Effective suicide prevention strategies targeting children and AYA would need to consider age-specific risk factors.

Due to the rapid developmental growth in preschool-aged children, more precise measurement of the effects of burns on child health outcomes is needed. Expanding upon the Shriners Hospitals for Children/American Burn Association Burn Outcome Questionnaire 0 to 5 (BOQ0–5), we developed a conceptual framework describing domains important in assessing recovery from burn injury among preschool-aged children (1–5 years). We developed a working conceptual framework based on the BOQ0–5, the National Research Council and Institute of Medicine’s Model of Child Health, and the World Health Organization’s International Classification of Functioning, Disability, and Health for Children and Youth. We iteratively refined our framework based on a literature review, focus groups, interviews, and expert consensus meetings. Data were qualitatively analyzed using methods informed by grounded theory. We reviewed 95 pediatric assessments, conducted two clinician focus groups and six parent interviews, and consulted with 23 clinician experts. Three child health outcome domains emerged from our analysis: symptoms, functioning, and family. The symptoms domain describes parents’ perceptions of their child’s pain, skin-related discomfort, and fatigue. The functioning domain describes children’s physical functioning (gross and fine motor function), psychological functioning (internalizing, externalizing, and dysregulation behavior; trauma; toileting; resilience), communication and language development (receiving and producing meaning), and social functioning (connecting with family/peers, friendships, and play). The family domain describes family psychological and routine functioning outcomes.

Background The short form, 17-item version of the Pediatric Symptom Checklist-Youth Self-Report (PSC-17-Y) is a validated measure that assesses psychosocial problems overall (OVR) and in 3 major psychopathological domains (internalizing, externalizing, and attention-deficit/hyperactivity disorder), taking 5-10 min to complete. Prior research has established sound psychometric properties of the PSC-17-Y for English speakers. Objective This study extends psychometric evidence for the acceptability of the PSC-17-Y in a large sample of Spanish adolescents, providing proof of its reliability and structure, convergent and discriminant validity, and longitudinal and gender invariance. Methods Data were collected on 5430 adolescents, aged 12-18 years, who filled out the PSC-17-Y twice during 2018-2019 (7-month interval). We calculated the Cronbach alpha and the McDonald omega coefficients to test reliability, the Pearson correlation for convergent (distress) and criterion validity (well-being, quality of life, and socioemotional skills), confirmatory factor analysis (CFA) for structure validity, and multigroup and longitudinal measurement invariance analysis for longitudinal and gender stability. Results Within structural analysis for the PSC-17-Y, CFA supported a correlated 3-factor solution, which was also invariant longitudinally and across gender. All 3 subscales showed evidence of reliability, with coefficients near or above .70. Moreover, scores of PSC-17-Y subscales were positively related with convergent measures and negatively related with criterion measures. Normative data for the PSC-17-Y are presented in the form of percentiles (75th and 90th). Conclusions This work provides the first evidence of the reliability and validity of the Spanish version of the PSC-17-Y administered over the internet to assess mental health problems among adolescents, maintaining the same domains as the long version.

Traditionally, cardiac and vascular surgeons have been treating diseases of the aorta as individual specialists. Neither cardiac nor vascular surgeons have ever considered the aorta as a whole, which can be diseased throughout its length at the same time requiring a more thoughtful and different approach. Aortic dissection and aneurysmal disease may well benefit from a multidisciplinary approach. In the context of this review, we discuss examples of joint operating between cardiac and vascular surgeons that may well become a more routine approach in more units in the future.

OBJECTIVES Point-of-care ultrasonography (POCUS) is an increasingly integral part of emergency medicine. This study investigated community emergency department physicians' choices regarding ultrasonography as a branch point in clinical decision making. METHODS During shifts covering all days of the week and all time-spans over a 3-month period, emergency department physicians were interviewed whenever POCUS was used. Questions focused on the role of POCUS in clinical management and on tests avoided because of ultrasonography use. Cost savings attributable to POCUS were calculated using Center for Medicare and Medicaid Services and FairHealth data. Anonymization of data precluded follow-up testing to account for misdiagnosis. RESULTS On average, POCUS use eliminated $1134.31 of additional testing for privately insured patients, $2826.31 for out-of-network or uninsured patients, and $181.63 for Center for Medicare and Medicaid Services patients. Differences were significant when the total cost of eliminated additional testing was compared to a baseline of no savings (p

Chemical sun filters are commonly used as active ingredients in sunscreens due to their efficient absorption of ultraviolet (UV) radiation. Yet, it is known that these compounds can photochemically react with UV light and generate reactive oxygen species and oxidative stress in vitro, though this has yet to be validated in vivo. One label-free approach to probe oxidative stress is to measure and compare the relative endogenous fluorescence generated by cellular coenzymes nicotinamide adenine dinucleotides and flavin adenine dinucleotides. However, chemical sun filters are fluorescent, with emissive properties that contaminate endogenous fluorescent signals. To accurately distinguish the source of fluorescence in ex vivo skin samples treated with chemical sun filters, fluorescence lifetime imaging microscopy data were processed on a pixel-by-pixel basis using a non-Euclidean separation algorithm based on Mahalanobis distance and validated on simulated data. Applying this method, ex vivo samples exhibited a small oxidative shift when exposed to sun filters alone, though this shift was much smaller than that imparted by UV irradiation. Given the need for investigative tools to further study the clinical impact of chemical sun filters in patients, the reported methodology may be applied to visualize chemical sun filters and measure oxidative stress in patients' skin.

Bedside ultrasound is an extremely valuable and rapidly accessible diagnostic and therapeutic modality in potentially life- and limb-threatening situations in the emergency department. In this report, the authors discuss the role of ultrasound in quick assessment of pathologic conditions and its use to aid in diagnostic and therapeutic interventions.

Objective Aortic annular erosion is a serious complication of aortic valve endocarditis or previous aortic valve replacement without endocarditis, and its surgical management is challenging. We present the early and midterm results of a technique for left ventricular outflow tract and aortic root reconstruction with a polyester tube graft and translocation of the aortic valve and coronary arteries. Methods A polyester tube graft is placed into the left ventricle and sutured to the left ventricular outflow tract below the area of erosion. The graft is then everted and sutured to a composite graft. Interposition polyester grafts from the coronary arteries are attached to the composite graft above the valve. This technique has been used in 12 cases. All but 1 patient had previously undergone aortic root or aortic valve replacement, and 4 had endocarditis of prosthetic (n = 2) or aortic allograft (n = 2) valves. Results There were no in-hospital deaths. There was 1 early death from pulmonary embolism at 1 postoperative month and 2 late deaths at 15 and 64 postoperative months, both resulting from heart failure. The remaining 9 patients are alive at 3 to 132 postoperative months. Actuarial 5-year survival is 75%. Conclusions Left ventricular outflow tract reconstruction with translocation of the aortic valve and coronary arteries for annular erosion is a useful technique that safely excludes the area of annular erosion and eliminates left ventricular outflow tract obstruction. The procedure can be safely performed with satisfactory early outcomes and 5-year survival.

There are many studies of the Pediatric Symptom Checklist (PSC), but none has followed a naturalistic sample longitudinally. We aimed to examine persistence and change in PSC scores over time in children seen in an ambulatory pediatric setting.The sample of 1033 patients was PSC screened at 2 consecutive preventive care visits (10 to 18 months apart) in 2 pediatric clinics. Longitudinal analyses were conducted to assess predictors of change in PSC category and score.Approximately 30% of the initially screened population did not return for preventive pediatric care. Those who did not return were significantly more likely to have positive PSC scores than those who returned (8% compared with 4.3%, P.01). PSC scores were highly stable at visit 2 for those who initially scored negative, but they fluctuated more for those who initially scored positive. After controlling for sociodemographic variables and counseling at either visit, referral at visit 1 (P.0001) predicted changes in mean PSC scores at visit 2. On average, PSC score decreased 3.2 points among those referred at visit 1 but increased 1.6 points in nonreferred children.This is the first study to document the stability and change in PSC scores in a sample of ambulatory pediatric patients. The statistically significant association between pediatrician referral and improved PSC scores provides evidence for the value of referral in primary care, although the study did not examine the relationship between PSC screening and referral. The high rate of positive scores in children who did not return for follow-up suggests the need for alternative strategies for this population.

Background We evaluated a one-stage technique for extensive replacement of the thoracic aorta in patients with chronic aortic dissection. Methods Fifty-one patients with chronic expanding thoracic aortic dissections (48 type A, 3 type B with proximal extension) were treated with a single procedure using a bilateral anterior thoracotomy, hypothermic circulatory arrest, and reperfusion of the arch vessels first to minimize brain ischemia. Forty-six patients had previous operations: for acute type A aortic dissection (n = 36), aortic valve disease (n = 6), or coronary artery disease (n = 4). The ascending aorta and entire arch were replaced in all patients combined with varying lengths of the descending aorta. Results Hospital mortality was 3.9% (2 patients). Five patients (10%) required reoperation for bleeding. Two patients were discharged on ventilatory support and 2 on dialysis. No patient sustained a stroke, and paraplegia developed in one. The 5- and 7-year survival rates were 79% and 68%. Freedom from reoperation on the thoracic or abdominal aorta was 92% at 5 and 7 years postoperatively. Serial tomograms have documented substantial enlargement of the residual dissected aorta in only 2 patients (reoperated). Conclusions The technique is a safe and suitable alternative to the two-stage (elephant trunk technique) and hybrid procedures for treatment of chronic dissection with aneurysm of the thoracic aorta. It eliminates the risk of rupture in the interval between staged procedures and the risks associated with a second thoracic aortic procedure, and is associated with a low rate of reoperation on the remaining aorta.

A novel microfluidic device that can selectively and specifically isolate exceedingly small numbers of circulating tumor cells (CTCs) through a monoclonal antibody (mAB) mediated process by sampling large input volumes (/=1 mL) of whole blood directly in short time periods (37 min) was demonstrated. The CTCs were concentrated into small volumes (190 nL), and the number of cells captured was read without labeling using an integrated conductivity sensor following release from the capture surface. The microfluidic device contained a series (51) of high-aspect ratio microchannels (35 mum width x 150 mum depth) that were replicated in poly(methyl methacrylate), PMMA, from a metal mold master. The microchannel walls were covalently decorated with mABs directed against breast cancer cells overexpressing the epithelial cell adhesion molecule (EpCAM). This microfluidic device could accept inputs of whole blood, and its CTC capture efficiency was made highly quantitative (97%) by designing capture channels with the appropriate widths and heights. The isolated CTCs were readily released from the mAB capturing surface using trypsin. The released CTCs were then enumerated on-device using a novel, label-free solution conductivity route capable of detecting single tumor cells traveling through the detection electrodes. The conductivity readout provided near 100% detection efficiency and exquisite specificity for CTCs due to scaling factors and the nonoptimal electrical properties of potential interferences (erythrocytes or leukocytes). The simplicity in manufacturing the device and its ease of operation make it attractive for clinical applications requiring one-time use operation.

The Pediatric Symptom Checklist (PSC) is a widely used, parent-completed measure of children’s emotional and behavioral functioning. Previous research has shown that the PSC and its subscales are responsive to patient progress over the course of psychiatric treatment. In this naturalistic study, parents and clinicians of 1736 patients aged 17 or younger completed standardized measures at intake and 3-month follow-up appointments. We assessed the 5-item PSC Attention Subscale (PSC–AS) as a longitudinal measure of attention-related symptoms in routine outpatient psychiatry treatment. Secondarily, we compared PSC–AS scores with clinician-reported diagnoses, psychomotor excitation symptoms, and overall functioning. Change scores on the PSC–AS were larger among patients with ADHD diagnoses than those with non-ADHD diagnoses. Comparisons between PSC–AS scores and clinician reports also showed acceptable levels of agreement. Given its effectiveness in tracking attention-related symptoms, the PSC may be particularly useful as a quality assurance or treatment outcome measure for clinicians treating ADHD.

We have fabricated a flow-through biochip assembly that consisted of two different microchips: (1) a polycarbonate (PC) chip for performing an allele-specific ligation detection reaction (LDR) and (2) a poly(methyl methacrylate) (PMMA) chip for the detection of the LDR products using an universal array platform. The operation of the device was demonstrated by detecting low-abundant DNA mutations in gene fragments (K-ras) that carry point mutations with high diagnostic value for colorectal cancers. The PC microchip was used for the LDR in a continuous-flow format, in which two primers (discriminating primer that carried the complement base to the mutation being interrogated and a common primer) that flanked the point mutation and were ligated only when the particular mutation was present in the genomic DNA. The miniaturized reactor architecture allowed enhanced reaction speed due to its high surface-to-volume ratio and efficient thermal management capabilities. A PMMA chip was employed as the microarray device, where zip code sequences (24-mers), which were complementary to sequences present on the target, were microprinted into fluidic channels embossed into the PMMA substrate. Microfluidic addressing of the array reduced the hybridization time significantly through enhanced mass transport to the surface-tethered zip code probes. The two microchips were assembled as a single integrated unit with a novel interconnect concept to produce the flow-through microfluidic biochip. A microgasket, fabricated from an elastomer poly(dimethylsiloxane) with a total volume of the interconnecting assembly of200 nL, was used as the interconnect between the two chips to produce the three-dimensional microfluidic network. We successfully demonstrated the ability to detect one mutant DNA in 100 normal sequences with the biochip assembly. The LDR/hybridization assay using the assembly performed the entire assay at a relatively fast processing speed: 6.5 min for on-chip LDR, 10 min for washing, and 2.6 min for fluorescence scanning (total processing time 19.1 min) and could screen multiple mutations simultaneously.

OBJECTIVES:To determine the relationship of child behavioral health (BH) screening results to receipt of BH services in Massachusetts Medicaid (MassHealth) children.METHODS:After a court decision, Massachusetts primary care providers were mandated to conduct BH screening at well-child visits and use a Current Procedural Terminology code along with a modifier indicating whether a BH need was identified. Using MassHealth claims data, a cohort of continuously enrolled (July 2007–June 2010) children was constructed. The salient visit (first use of the modifier, screening code, or claim in fiscal year 2009) was considered a reference point to examine BH history and postscreening BH services. Bivariate and multivariate logistic regression analyses were performed to determine predictors of postscreening BH services.RESULTS:Of 261 160 children in the cohort, 45% (118 464) were screened and 37% had modifiers. Fifty-seven percent of children screening positive received postscreening BH services compared with 22% of children screening negative. However, only 30% of newly identified children received BH services. The strongest predictors of postscreening BH services for children without a BH history were being in foster care (odds ratio, 10.38; 95% confidence interval, 9.22–11.68) and having a positive modifier (odds ratio, 3.79; 95% confidence interval, 3.53–4.06).CONCLUSIONS:Previous BH history, a positive modifier, and foster care predicted postscreening BH services. Only one-third of newly identified children received services. Thus although screening is associated with an increase in BH recognition, it may be insufficient to improve care. Additional strategies may be needed to enhance engagement in BH services.

In microarray studies alterations in gene expression in circulating leukocytes have shown utility for ischemic stroke diagnosis. We studied forty candidate markers identified in three gene expression profiles to (1) quantitate individual transcript expression, (2) identify transcript clusters and (3) assess the clinical diagnostic utility of the clusters identified for ischemic stroke detection. Using high throughput next generation qPCR 16 of the 40 transcripts were significantly up-regulated in stroke patients relative to control subjects (p0.05). Six clusters of between 5 and 7 transcripts were identified that discriminated between stroke and control (p values between 1.01e-9 and 0.03). A 7 transcript cluster containing PLBD1, PYGL, BST1, DUSP1, FOS, VCAN and FCGR1A showed high accuracy for stroke classification (AUC=0.854). These results validate and improve upon the diagnostic value of transcripts identified in microarray studies for ischemic stroke. The clusters identified show promise for acute ischemic stroke detection.

OBJECTIVES: To understand mandated behavioral health (BH) screening in Massachusetts Medicaid including characteristics of screened children, predictors of positive screens, and whether screening identifies children without a previous BH history. METHODS: Massachusetts mandated BH screening in particularly among underidentified groups. 2008. Providers used a billing code and modifier to indicate a completed screen and whether a BH need was identified. Using MassHealth claims data, children with ≥300 days of eligibility in fiscal year (FY) 2009 were identified and categorized into groups based on first use of the modifier, screening code, or claim. Bivariate analyses were conducted to determine differences among groups. BH history was examined by limiting the sample to those continuously enrolled in FY 2008 and 2009. Multivariate logistic regression was used to determine predictors of positive screens. RESULTS: Of 355 490 eligible children, 46% had evidence of screening. Of those with modifiers, 12% were positive. Among continuously enrolled children (FY 2008 and FY 2009) with evidence of screening, 43% with positive modifiers had no BH history. This “newly identified” group were more likely to be female, younger, minority, and from rural residences (P < .0001). Among children with modifiers; gender (male), age (5–7), being in foster care, recent BH history, and Hispanic ethnicity predicted having a positive modifier. CONCLUSIONS: The high rate of newly identified Medicaid children with a BH need suggests that screening is performing well, particularly among underidentified groups. To better assess screening value, future work on cost-effectiveness and the impact on subsequent mental health treatment is needed.

T lymphocytes may play an important role in the evolution of ischemic stroke. Depletion of γδT cells has been found to abrogate ischemia reperfusion injury in murine stroke. However, the role of γδT cells in human ischemic stroke is unknown. We aimed to determine γδT cell counts and γδT cell interleukin 17A (IL-17A) production in the clinical setting of ischemic stroke. We also aimed to determine the associations of γδT cell counts with ischemic lesion volume, measures of clinical severity and with major stroke risk factors. Peripheral blood samples from 43 acute ischemic stroke patients and 26 control subjects matched on race and gender were used for flow cytometry and complete blood count analyses. Subsequently, cytokine levels and gene expression were measured in γδT cells. The number of circulating γδT cells was decreased by almost 50% (p = 0.005) in the stroke patients. γδT cell counts did not correlate with lesion volume on magnetic resonance diffusion-weighted imaging or with clinical severity in the stroke patients, but γδT cells showed elevated levels of IL-17A (p = 0.048). Decreased γδT cell counts were also associated with older age (p = 0.004), pre-existing hypertension (p = 0.0005) and prevalent coronary artery disease (p = 0.03), with pre-existing hypertension being the most significant predictor of γδT cell counts in a multivariable analysis. γδT cells in human ischemic stroke are reduced in number and show elevated levels of IL-17A. A major reduction in γδT lymphocytes also occurs in hypertension and may contribute to the development of hypertension-mediated stroke and vascular disease.

Clinical studies of gene expression are increasingly using the whole blood, peripheral blood mononuclear cells, and leukocyte subsets involved in the innate and adaptive immune responses. However, the small amount of RNA available in the clinical setting is a limitation for commonly used methods such as quantitative polymerase chain reactions (qPCR) and microarrays. Our aim was to design 96 gene assays to simultaneously measure gene expression in the whole blood and seven leukocyte subsets using a new-generation qPCR method—high-throughput nanofluidic reverse transcription qPCR (HT RT-qPCR). The leukocyte subset purity was 94% to 98% for seven subsets and was less for the γδ T-cell receptor subset (80%). The HT RT-qPCR replicate sample measurements were highly reproducible (r = 0.997, p < 2.2 × 10 −16 ), and the ΔΔCt values from HT RT-qPCR correlated significantly with those from qPCR. The control genes were differentially expressed across the eight leukocyte subsets in the control subjects (p = 1.3 × 10 −5 , analysis of variance). Two analytical methods, absolute and relative, gave concordant results and were significantly correlated (p = 1.9 × 10 −9 ). HT RT-qPCR permits the rapid, reproducible, and quantitative measurement of multiple transcripts using minimal sample amounts. The protocol described yielded leukocyte subsets of high purity and identified two analytic methods for use.

The neutrophil respiratory burst was examined by the technique of luminol-dependent chemiluminescence (LDCL) triggered by submaximal concentrations of N-formyl-methionyl-leucyl-phenylalanine (fMLP) in diluted whole blood. We sought to identify the chemical species responsible for LDCL in whole blood, to examine the role of leukotriene B4 (LTB4) and other arachidonic acid metabolites as mediators of the fMLP signaling pathway, and to investigate the effect of peroxynitrite on this response. Both sodium azide and taurine significantly inhibited LDCL (93% inhibition with 100 μM azide, 52% inhibition with 10 mM taurine). More modest inhibition was seen with superoxide dismutase (SOD), catalase, the nitric oxide synthase inhibitor monomethyl-l-arginine (l-NMMA), and with inhibitors of the cyclooxygenase (indomethacin), lipoxygenase (AA-861; no effect), and cytochrome P-450 (SKF 525-A) pathways of arachidonic acid metabolism. The nitric oxide donor SIN-1 (1–100 μM) and peroxynitrite (10–300 μM) also augmented fMLP-induced LDCL. The augmentation seen with peroxynitrite and SIN-1 was attenuated by SOD. Despite the increase in LDCL, peroxynitrite caused a dose-related inhibition of fMLP-stimulated LTB4 release. In summary, our results indicate that (1) LDCL elicited by fMLP in diluted whole blood appears primarily mediated by hypo-chlorous acid derived from myeloperoxidase; (2) pretreatment with the nitric oxide donor SIN-1 or with peroxynitrite augments LDCL; and (3) LTB4 release does not contribute to fMLP-stimulated LDCL or in the modulation of LDCL by SIN-1 or peroxynitrite.

Infectious diseases are a major global health burden accounting for approximately 15 million deaths annually, many from drug resistant pathogenic agents, with a significant number of cases occurring in developing countries.[1–7] In particular, the resurgence of tuberculosis (TB) has been accompanied by the rapid spread of multi-drug resistance TB (MDR-TB) resulting from Mycobacterium tuberculosis (Mtb) strains that fail to respond to the first-line drugs, rifampin and isoniazid. Currently

Recognition of point mutations in the K- ras gene can be used for the clinical management of several types of cancers. Unfortunately, several assay and hardware concerns must be addressed to allow users not well trained in performing molecular analyses the opportunity to undertake these measurements. To provide for a larger user base for these types of molecular assays, a vertically stacked microfluidic analyzer with a modular architecture and process automation was developed. The analyzer employs a primary polymerase chain reaction (PCR) coupled to an allele-specific ligase detection reaction (LDR). Each functional device, including continuous flow thermal reactors for the PCR and LDR, passive micromixers, and ExoSAP-IT purification, was designed and tested. Individual devices were fabricated in polycarbonate using hot embossing and were assembled using adhesive bonding for system assembly. The system produced LDR products from a DNA sample in approximately 1 h, an 80% reduction in time compared with conventional benchtop instrumentation. Purifying the post-PCR products with the ExoSAP-IT enzyme led to optimized LDR performance, minimizing false-positive signals and producing reliable results. Mutant alleles in genomic DNA were quantified to the level of 0.25 ng of mutant DNA in 50 ng of wild-type DNA for a 25-μl sample, equivalent to DNA from 42 mutant cells.

Objective To explore rates of screening and identification and treatment for behavioral problems using billing data from Massachusetts Medicaid immediately following the start of the state's new court-ordered screening and intervention program. Design Retrospective review of the number of pediatric well-child visits, number of screens, and number of screens that identify risk for psychosocial problems from January 2008 (the month pediatric screening started) to March 2009. During the surrounding 1-year period, we also examined the number of claims with a behavioral health evaluation code. Setting Massachusetts. Participants Massachusetts Medicaid–enrolled children. Intervention Funded court-ordered mandate to screen for mental health during Medicaid well-child visits. Outcome Measures Percentage of visits with a screen, percentage of screens identified at risk, and number of children seen for behavioral health evaluations. Results Major increase from 16.6% of all Medicaid well-child visits coded for behavioral screens in the first quarter of 2008 to 53.6% in the first quarter of 2009. Additionally, the children identified as at risk increased substantially from about 1600 in the first quarter of 2008 to nearly 5000 in quarter 1 of 2009. The children with mental health evaluations increased from an average of 4543 to 5715 per month over a 1-year period. Conclusions The data suggest payment and a supported mandate for use of a formal screening tool can substantially increase the identification of children at behavioral health risk. Findings suggest that increased screening may have the desired effect of increasing referrals for mental health services.

Bentall's technique for repair of annuloaortic ectasia has been associated with postoperative bleeding and with false aneurysms at the anastomotic site between the coronary orifices and valve-containing graft. To reduce the incidence of these complications, we modified the Bentall procedure, using a simplified technique to implant the graft and to create a fistula between the closed perigraft space and right atrium to control bleeding. A continuous suture of monofilament polypropylene was used to implant the prosthetic valve ring and to anastomose the coronary orifices to the Dacron fabric. In some instances, a brief period of hypothermic circulatory arrest was needed to perform the distal aortic anastomosis. Among 562 patients undergoing operation for aneurysm of the ascending aorta between January 1, 1980, and February 28,1990, 280 underwent graft replacement with a valve-containing composite conduit. Most (82%) had annuloaortic ectasia. In 267, we performed a classic Bentall procedure with direct anastomosis between the coronary orifices and fabric graft. The remaining 13 patients underwent other procedures for coronary connection. Early mortality was 5.0%. Reoperation for bleeding was needed in 13.2% of patients who underwent operation before we used the right atrial fistula technique and in 4.4% after we began to use the technique ( p = 0.044). Actuarial survival was 71% at 5 years and 65% at 7 years. For hospital survivors, it was 76% at 5 years and 70% at 7 years. During follow-up, only 9 patients have required reoperation. A false aneurysm at the coronary anastomosis, which was associated with prosthetic valve endocarditis, developed in 1 patient. No permanent fistulas have developed. Thus, by using simplified methods to implant the graft and to control postoperative bleeding, the Bentall technique can be performed successfully with excellent early and late results.

We report a simple and effective method for the high-throughput purification of a variety of nucleic acids (NAs) from whole cell lysates or whole blood using a photactivated polycarbonate solid-phase reversible immobilization (PPC-SPRI) microfluidic chip. High-throughput operation was achieved by placing 96 purification beds, each containing an array of 3800 20 microm diameter posts, on a single 3" x 5" polycarbonate (PC) wafer fabricated by hot embossing. All beds were interconnected through a common microfluidic network that permitted parallel access through the use of a vacuum and syringe pump for delivery of immobilization buffer (IB) and effluent. The PPC-SPRI purification was accomplished by condensation of NAs onto a UV-modified PC surface in the presence of the IB comprised of polyethylene glycol, NaCl, and ethanol with a composition dependent on the length of the NAs to be isolated and the identity of the sample matrix. The performance of the device was validated by quantification of the recovered material following PCR (for DNA) or RT-PCR (for RNA). The extraction bed load capacity of NAs was 206 +/- 93 ng for gDNA and 165 +/- 81 ng for TRNA from Escherichia coli. Plate-to-plate variability was found to be 35 +/- 10%. The purification process was fast (30 min) and easy to automate, and the low cost of wafer fabrication makes it appropriate for single-use applications.

From 1964 to 1989, we performed operations on 133 patients with cardiac tumors. There were 58 male and 75 female patients ranging in age from three days to 81 years; 101 were adults, and 32 were children (less than 12 years of age). Primary tumors (102 benign and 12 malignant) were found in 114 patients and metastatic tumors in 19. Symptoms included congestive heart failure, arrhythmias, emboli, and chest pain. Diagnosis was accomplished through angiography, echocardiography, computed tomography, and magnetic resonance imaging. Operative treatment encompassed techniques ranging from biopsy to complete excision (including hypothermic circulatory arrest and cardiac autotransplantation) depending on the site of disease and the extent of involvement. Overall operative survival was 91%. Twelve patients died early (within 30 days of operation), and follow-up was obtained for 110 (90.9%) of the remaining 121 survivors (total patient-years of follow-up, 572.8; mean follow-up, 5.2 years). Of the 20 patients who died late, 15 had malignant disease. Operative survival for patients with primary cardiac malignancies and for those with metastatic disease was 83% and 68.4%, respectively, with 3 and 5 patients, respectively, still living. We advocate an aggressive surgical approach, especially in patients with benign tumors, who can expect an excellent outcome. For patients with malignant or metastatic disease, palliation and cure are also possible if aggressive surgical actions are taken.

stabilization of the long-segmental tracheobronchomalacia has been described. This report demonstrates that this concept is effective for carinal stabilization. A recent study of 40 children, 11 of whom had left PA sling, identified preoperative mechanical ventilatory support and duration of CPB to be significant risk factors for prolonged postoperative ventilatory support. Repair of PA sling complex and other cardiovascular anomalies increases the complexity of surgery and duration of CPB, thus exposing patients to a higher risk of prolonged postoperative ventilatory support. Excessive endotracheal granulation at the site of mechanical irritation by the endotracheal tube often develops in patients with PA sling complex and tracheomalacia, who require prolonged ventilatory support. External stabilization of the carina permitted an uneventful and early extubation in our patient despite prolonged CPB. Covering the trachea with the pericardial flap after tracheoplasty, as previously described, was helpful in our patient to reinforce the tracheal anastomotic seal, to prevent erosion of the polytetrafluoroethylene (GoreTex) rings into the blood vessels, and to enable safer subsequent bronchoscopic interventions. Potential long-term

During a 27-year-period, 663 adults of the Jehovah's Witness faith underwent open heart procedures at the Texas Heart Institute. To determine the effect of recent changes in operative techniques and in the patient population itself on early mortality, we reevaluated the surgical outcome in this special group of patients. We reviewed the charts of 88 consecutive Jehovah's Witness patients who had an open heart operation between January 1986 and March 1989 and compared demographic variables in this group with those of 575 patients who underwent operation between May 1963 and January 1986. In our recent series, patients were older (mean age, 61 years versus 54 years), and 16% were seen for repeat procedures. Early mortality (less than or equal to 30 days postoperatively) was lower in the recent series than in the earlier series (7.0% versus 10.7%), but the difference between the groups was not statistically significant. We identified several important factors associated with an increased risk of early death in the recent group of patients. These factors included repeat cardiac operations (p less than 0.01), especially for valvar dysfunction, severe left ventricular dysfunction (defined as an ejection fraction less than 0.35) (p less than 0.01), and a hemoglobin level lower than 80 g/L (8 g/dL) (p less than 0.01) on postoperative day 1. Although blood loss remains the leading cause of death in these patients, cardiac operations can be performed with an acceptable mortality.

Chylopericardium is a rare entity that may be congenital in origin or secondar to surgical trauma, mediastinal lymphangiomas-hygromas, or radiation. Current treatment progresses from dietary medium-chain triglycerides and pericardiocentesis, to pericardial drainage, to thoracotomy with pericardiectomy and thoracic duct ligation. Between January 1986 and January 1989, we treated four children with chylopericardium: three secondary to mediastinal lymphangioma-hygroma, and one following cardiac surgery. The patients ranged in age from newborn to 16 years. All had signs of cardiac tamponade and three underwent initial pericardiocentesis or tube drainage. One 6-week-old infant with a mediastinal cystic hygroma developed chylopericardium following resection of the hygroma and responded to 9 days of tube drainage. The remaining children did not respond to repeated pericardiocenteses or prolonged drainage and underwent pericardial-peritoneal shunting with Denver shunts. The shunt was removed in 14 days in one patient. One patient had the shunt exteriorized for 8 weeks and one patient continues to use the shunt after 3 years. The chylopericardium resolved in each case without recurrence. Pericardial-peritoneal shunting provides a simple and effective alternative to prolonged pericardial drainage or thoracotomy in patients with chylopericardium of various etiologies.

Objectives To evaluate psychosocial morbidity in pediatric primary care and to determine displaced health care utilization. Design and Setting A cross-sectional sample of parent-child dyads was screened using the Pediatric Symptom Checklist (PSC) at 6 pediatric sites of a health maintenance organization (HMO). Cost and utilization data were retrieved from regional databases for this sample. Participants Parent-child dyads from an HMO in northern California (N = 1840). The children ranged in age from 2 to 18 years. Results In all, 13.0% of children exhibited psychosocial dysfunction. The rate of children's chronic illness was 18.4%. Multiple regression analyses measured utilization and cost of health and psychiatric care for the selected population for the previous year; the average log cost of health care per child was $393. The average health care cost for children with anxious, depressed symptoms was $805. Chronically ill children were the highest utilizers of health care, with an average log cost of $1138. When psychosocial dysfunction was present, regression models showed that health care spending was highest for young children. Conclusions Health care utilization was higher for children with psychosocial morbidity, was higher among younger children, and decreased with age as psychiatric costs progressively increased.

Between June 1981 and June 1988, we placed pleuroperitoneal shunts in 16 patients for the management of refractory chylothorax on the Pediatric Surgical Service, University of Virginia. The cause of the chylothorax was caval thrombosis from central venous catheters in 5 patients, idiopathic in 3, and mediastinal lymphangioma in 2, and in 6, it developed after a cardiac procedure. Chylothorax in each patient was unresponsive to thoracentesis, tube thoracostomy, and dietary manipulations. A Denver double-valved shunt system is currently employed and is implanted using general anesthesia. Manual pumping is required postoperatively for several months. Twelve (75%) of the 16 patients had excellent results with complete elimination of the chylothorax and resolution of symptoms. In 10 of these 12, the shunt has been removed. Four had an unsatisfactory result: 3 had inferior vena cava hypertension, and 3 were low-birth-weight premature infants. Four patients seen early in this series required revision of the position of the pleural catheter, with successful drainage in each instance. Pleuroperitoneal shunting is a safe, simple, and effective treatment of chylothorax in infants and children. In view of our success in treating chylothorax with these shunts, we recommend early shunting before the development of nutritional or immunological depletion.

ContextThe 1999 surgeon general's report on mental health concluded that insufficient attention to mental health disorders is being paid in children's primary medical care services. This lack of attention has occurred despite considerable attention to this issue in the planning documents of many federal agencies.ObjectiveTo assess the extent to which federal agencies' portfolios of funded research grants were consistent with the directives for primary care–based mental health services for children and adolescents featured in their planning documents.Data SourceA cross-sectional review of the 66 749 abstracts listed in the April 2001 Computer Retrieval of Information on Scientific Projects (CRISP) database of currently funded research grants supported by the US Department of Health and Human Services. Abstracts were rated by whether they targeted primary care, examined behavioral or emotional issues, and examined or modified a facet of primary care.Data SynthesisOf the 45 022 research abstracts in the CRISP database, 2720 (6%) contained the words children, adolescents, or youth. Sixty-three abstracts contained work on children, adolescents, or youth in primary care (0.14% of the portfolio). Of these 63 abstracts, only 21 (0.05% of the portfolio) addressed behavioral or emotional issues. Of the 21 projects, only 11 examined aspects of the primary care process. When the distribution of child and adult studies on the treatment of depression within primary care settings was examined, it was found that adults received 15 times the research attention compared with children.ConclusionEven though the importance of primary care as a system for identifying and treating behavioral and emotional problems in children has been recognized for more than 20 years, little attention is being paid to this topic in the research portfolios of the National Institutes of Health and other federal agencies that support research.