Surgical outreach for the Americas: a self-sustainable model for partnership and education.

INTRODUCTION: It is estimated that up to 28% of global disease burden is surgical with hernias representing a unique challenge as the only definitive treatment is surgery. Surgical Outreach for the Americas (SOfA) is a nongovernmental organization focused primarily on alleviating the disease burden of inguinal and umbilical hernias in Central America. We present the experience of SOfA, a model focused on partnership and education. METHODS: SOfA was established in 2009 to help individuals recover from ailments that are obstacles to working and independent living. Over the past 15 years, SOfA has partnered with local healthcare providers in the Dominican Republic, El Salvador, Honduras, and Belize. The SOfA team consists of surgeons, surgery residents, triage physicians, an anesthesiologist, anesthetists, operating room nurses, recovery nurses, a pediatric critical care physician, sterile processing technicians, interpreters, and a team coordinator. Critical partnerships required include the CMO, internal medicine, general surgery, nursing, rural health coordinators and surgical training programs at public hospitals. RESULTS: SOfA has completed 24 trips, performing 2074 procedures on 1792 patients. 71.4% of procedures were hernia repairs. To enhance sustainability of healthcare delivery, SOfA has partnered with the local facilities through capital improvements to include OR tables, OR lights, anesthesia machines, monitors, hospital beds, stretchers, sterilizers, air conditioning units, and electrosurgical generators. A lecture series and curriculum on perioperative care, anesthesia, anatomy, and operative technique is delivered. Local surgery residents and medical students participated in patient care, learning alongside SOfA teammates. Recently, SOfA has partnered with SAGES Global Affairs Committee to implement a virtual Global Laparoscopic Advancement Program, a simulation-based laparoscopic training curriculum for surgeons in El Salvador. CONCLUSION: A sustainable partnership to facilitate surgical care in low resource settings requires longitudinal, collaborative relationships, and investments in capital improvements, education, and partnership with local healthcare providers, institutions, and training programs.

The phylogeny of Syntrichia: An ecologically diverse clade of mosses with an origin in South America.

PREMISE: To address the biodiversity crisis, we need to understand the evolution of all organisms and how they fill geographic and ecological space. Syntrichia is one of the most diverse and dominant genera of mosses, ranging from alpine habitats to desert biocrusts, yet its evolutionary history remains unclear. METHODS: We present a comprehensive phylogenetic analysis of Syntrichia, based on both molecular and morphological data, with most of the named species and closest outgroups represented. In addition, we provide ancestral-state reconstructions of water-related traits and a global biogeographic analysis. RESULTS: We found 10 major well-resolved subclades of Syntrichia that possess geographical or morphological coherence, in some cases representing previously accepted genera. We infer that the extant species diversity of Syntrichia likely originated in South America in the early Eocene (56.5-43.8 million years ago [Mya]), subsequently expanded its distribution to the neotropics, and finally dispersed to the northern hemisphere. There, the clade experienced a recent diversification (15-12 Mya) into a broad set of ecological niches (e.g., the S. caninervis and S. ruralis complexes). The transition from terricolous to either saxicolous or epiphytic habitats occurred more than once and was associated with changes in water-related traits. CONCLUSIONS: Our study provides a framework for understanding the evolutionary history of Syntrichia through the combination of morphological and molecular characters, revealing that migration events that shaped the current distribution of the clade have implications for morphological character evolution in relation to niche diversity.

Dry Season Transpiration and Soil Water Dynamics in the Central Amazon.

With current observations and future projections of more intense and frequent droughts in the tropics, understanding the impact that extensive dry periods may have on tree and ecosystem-level transpiration and concurrent carbon uptake has become increasingly important. Here, we investigate paired soil and tree water extraction dynamics in an old-growth upland forest in central Amazonia during the 2018 dry season. Tree water use was assessed via radial patterns of sap flow in eight dominant canopy trees, each a different species with a range in diameter, height, and wood density. Paired multi-sensor soil moisture probes used to quantify volumetric water content dynamics and soil water extraction within the upper 100 cm were installed adjacent to six of those trees. To link depth-specific water extraction patterns to root distribution, fine root biomass was assessed through the soil profile to 235 cm. To scale tree water use to the plot level (stand transpiration), basal area was measured for all trees within a 5 m radius around each soil moisture probe. The sensitivity of tree transpiration to reduced precipitation varied by tree, with some increasing and some decreasing in water use during the dry period. Tree-level water use scaled with sapwood area, from 11 to 190 L per day. Stand level water use, based on multiple plots encompassing sap flow and adjacent trees, varied from ∼1.7 to 3.3 mm per day, increasing linearly with plot basal area. Soil water extraction was dependent on root biomass, which was dense at the surface (i.e., 45% in the upper 5 cm) and declined dramatically with depth. As the dry season progressed and the upper soil dried, soil water extraction shifted to deeper levels and model projections suggest that much of the water used during the month-long dry-down could be extracted from the upper 2-3 m. Results indicate variation in rates of soil water extraction across the research area and, temporally, through the soil profile. These results provide key information on whole-tree contributions to transpiration by canopy trees as water availability changes. In addition, information on simultaneous stand level dynamics of soil water extraction that can inform mechanistic models that project tropical forest response to drought.

Genetic Characterization of Leaf and Stripe Rust Resistance in the Brazilian Wheat Cultivar Toropi.

Leaf and stripe rust are major threats to wheat production worldwide. The effective, multiple rust resistances present in the Brazilian cultivar Toropi makes it an excellent choice for a genetic study of rust resistance. Testing of DNA from different seed lots of Toropi with 2,194 polymorphic 90K iSelect single nucleotide polymorphism markers identified significant genetic divergence, with as much as 35% dissimilarity between seed lots. As a result, further work was conducted with a single plant line derived from Toropi variant Toropi-6.4. A double haploid population with 168 lines derived from the cross Toropi-6.4 × Thatcher was phenotyped over multiple years and locations in Canada, New Zealand, and Kenya, with a total of seven field trials undertaken for leaf rust and nine for stripe rust. Genotyping with the 90K iSelect array, simple sequence repeat and Kompetitive allele-specific polymerase chain reaction markers resulted in a genetic map of 3,043 cM, containing 1,208 nonredundant markers. Significant quantitative trait loci (QTL) derived from Toropi-6.4 were identified in multiple environments on chromosomes 1B (QLr.crc-1BL/QYr.crc-1BL), 3B (QLr.crc-3BS), 4B (QYr.crc-4BL), 5A (QLr.crc-5AL and QYr.crc-5AL), and 5D (QLr.crc-5DS). The QTL QLr.crc-1BL/QYr.crc-1BL colocated with the multi-rust resistance locus Lr46/Yr29, while the QTL QLr.crc-5DS located to the Lr78 locus previously found in a wheat backcross population derived from Toropi. Comparisons of QTL combinations showed QLr.crc-1BL to contribute a significantly enhanced leaf rust resistance when combined with QLr.crc-5AL or QLr.crc-5DS, more so than when QLr.crc-5AL and QLr.crc-5DS were combined. A strong additive effect was also seen when the stripe rust resistance QTL QYr.crc-1BL and QYr.crc-5AL were combined.

Species-Specific Shifts in Diurnal Sap Velocity Dynamics and Hysteretic Behavior of Ecophysiological Variables During the 2015-2016 El Niño Event in the Amazon Forest.

Current climate change scenarios indicate warmer temperatures and the potential for more extreme droughts in the tropics, such that a mechanistic understanding of the water cycle from individual trees to landscapes is needed to adequately predict future changes in forest structure and function. In this study, we contrasted physiological responses of tropical trees during a normal dry season with the extreme dry season due to the 2015-2016 El Niño-Southern Oscillation (ENSO) event. We quantified high resolution temporal dynamics of sap velocity (Vs), stomatal conductance (gs) and leaf water potential (ΨL) of multiple canopy trees, and their correlations with leaf temperature (Tleaf) and environmental conditions [direct solar radiation, air temperature (Tair) and vapor pressure deficit (VPD)]. The experiment leveraged canopy access towers to measure adjacent trees at the ZF2 and Tapajós tropical forest research (near the cities of Manaus and Santarém). The temporal difference between the peak of gs (late morning) and the peak of VPD (early afternoon) is one of the major regulators of sap velocity hysteresis patterns. Sap velocity displayed species-specific diurnal hysteresis patterns reflected by changes in Tleaf. In the morning, Tleaf and sap velocity displayed a sigmoidal relationship. In the afternoon, stomatal conductance declined as Tleaf approached a daily peak, allowing ΨL to begin recovery, while sap velocity declined with an exponential relationship with Tleaf. In Manaus, hysteresis indices of the variables Tleaf-Tair and ΨL-Tleaf were calculated for different species and a significant difference (p < 0.01, α = 0.05) was observed when the 2015 dry season (ENSO period) was compared with the 2017 dry season ("control scenario"). In some days during the 2015 ENSO event, Tleaf approached 40°C for all studied species and the differences between Tleaf and Tair reached as high at 8°C (average difference: 1.65 ± 1.07°C). Generally, Tleaf was higher than Tair during the middle morning to early afternoon, and lower than Tair during the early morning, late afternoon and night. Our results support the hypothesis that partial stomatal closure allows for a recovery in ΨL during the afternoon period giving an observed counterclockwise hysteresis pattern between ΨL and Tleaf.

Spatial phylogenetics of the vascular flora of Chile.

Current geographic patterns of biodiversity are a consequence of the evolutionary history of the lineages that comprise them. This study was aimed at exploring how evolutionary features of the vascular flora of Chile are distributed across the landscape. Using a phylogeny at the genus level for 87% of the Chilean vascular flora, and a geographic database of sample localities, we calculated phylogenetic diversity (PD), phylogenetic endemism (PE), relative PD (RPD), and relative PE (RPE). Categorical Analyses of Neo- and Paleo-Endemism (CANAPE) were also performed, using a spatial randomization to assess statistical significance. A cluster analysis using range-weighted phylogenetic turnover was used to compare among grid cells, and with known Chilean bioclimates. PD patterns were concordant with known centers of high taxon richness and the Chilean biodiversity hotspot. In addition, several other interesting areas of concentration of evolutionary history were revealed as potential conservation targets. The south of the country shows areas of significantly high RPD and a concentration of paleo-endemism, and the north shows areas of significantly low PD and RPD, and a concentration of neo-endemism. Range-weighted phylogenetic turnover shows high congruence with the main macrobioclimates of Chile. Even though the study was done at the genus level, the outcome provides an accurate outline of phylogenetic patterns that can be filled in as more fine-scaled information becomes available.

Global Outreach Using a Systematic, Competency-Based Training Paradigm for Inguinal Hernioplasty.

Importance: Sustainable, capacity-building educational collaborations are essential to address the global burden of surgical disease. Objective: To assess an international, competency-based training paradigm for hernia surgery in underserved countries. Design, Setting, and Participants: In this prospective, observational study performed from November 1, 2013, through October 31, 2015, at 16 hospitals in Brazil, Ecuador, Haiti, Paraguay, and the Dominican Republic, surgeons completed initial training programs in hernia repair, underwent interval proficiency assessments, and were appointed regional trainers. Competency-based evaluations of technical proficiency were performed using the Operative Performance Rating Scale (OPRS). Maintenance of proficiency was evaluated by video assessments 6 months after training. Certified trainees received incentives to document independent surgical outcomes after training. Main Outcomes and Measures: An OPRS score of 3.0 (scale of 1 [poor] to 5 [excellent]) indicated proficiency. Secondary outcomes included initial vs final scores by country, scores among surgeons trained by the regional trainers (second-order trainees), interval scores 6 months after training, and postoperative complications. Results: A total of 20 surgeon trainers, 81 local surgeons, and 364 patients (343 adult, 21 pediatric) participated in the study (mean [SD] age, 47.5 [16.3] years; age range, 16-83 years). All 81 surgeons successfully completed the program, and all 364 patients received successful operations. Mean (SD) OPRS scores improved from 4.06 (0.87) before the initial training program to 4.52 (0.57) after training (P < .001). No significant variation was found by country in final scores. On trainee certification, 20 became regional trainers. The mean (SD) OPRS score among 53 second-order trainees was 4.34 (0.68). After 6-month intervals, the mean (SD) OPRS score among participating surgeons was 4.34 (0.55). The overall operative complication rate during training series was 1.1%. Conclusions and Relevance: Competency-based training helps address the global burden of surgical disease. The OPRS establishes an international standard of technical assessment. Additional studies of long-term surgeon trainer proficiency, community-specific quality initiatives, and expansion to other operations are warranted.

Comparison of Primary Care Provider Office Hours and Pediatric Emergency Department Return Visits.

OBJECTIVE: The aim of this study was to evaluate the influence of primary care office hours of operation on 48-hour return visits (RVs) to a pediatric emergency department (ED). We compared characteristics of patients who return with those who follow up outpatient to determine the feasibility of opening off-hour clinics to decrease the RV rate. METHODS: The study was a retrospective chart review of patients presenting to a pediatric ED for a 3-year period. A subset of patients with a hospital-affiliated primary care provider was evaluated to compare those with 48-hour ED RVs with those with office follow-up. RESULTS: Patients with a hospital-affiliated primary care provider had 30,231 visits, of whom 842 had a 48-hour return (2.79%). A significant number (48.5%) of those who returned had seen their primary care doctor between emergency visits. The percentage of RVs occurring at night (55.7%) was slightly lower than the percentage of all visits occurring off hours (58.1%). Patients with more acute presentation at initial visit (emergency severity index level acuity 2, >20 orders placed) were more likely to follow up with their provider than return to the ED. CONCLUSIONS: The findings from this study show no significant increase in RVs during the evening and overnight hours and many patients with outpatient follow-up before returning to the ED. Opening a clinic at our hospital during nontraditional hours would not likely significantly decrease RV rate.

Around the World in Eight Million Years: Historical Biogeography and Evolution of the Spray Zone Spider Amaurobioides (Araneae: Anyphaenidae).

Closely related organisms with transoceanic distributions have long been the focus of historical biogeography, prompting the question of whether long-distance dispersal, or tectonic-driven vicariance shaped their current distribution. Regarding the Southern Hemisphere continents, this question deals with the break-up of the Gondwanan landmass, which has also affected global wind and oceanic current patterns since the Miocene. With the advent of phylogenetic node age estimation and parametric bioinformatic advances, researchers have been able to disentangle historical evolutionary processes of taxa with greater accuracy. In this study, we used the coastal spider genus Amaurobioides to investigate the historical biogeographical and evolutionary processes that shaped the modern-day distribution of species of this exceptional genus of spiders. As the only genus of the subfamily Amaurobioidinae found on three Southern Hemisphere continents, its distribution is well-suited to study in the context of Gondwanic vicariance versus long-distance, transoceanic dispersal. Ancestral species of the genus Amaurobioides appear to have undergone several long-distance dispersal events followed by successful establishments and speciation, starting from the mid-Miocene through to the Pleistocene. The most recent common ancestor of all present-day Amaurobioides species is estimated to have originated in Africa after arriving from South America during the Miocene. From Africa the subsequent dispersals are likely to have taken place predominantly in an eastward direction. The long-distance dispersal events by Amaurobioides mostly involved transoceanic crossings, which we propose occurred by rafting, aided by the Antarctic Circumpolar Current and the West Wind Drift.

A material cost-minimization analysis for hernia repairs and minor procedures during a surgical mission in the Dominican Republic.

INTRODUCTION: Expenditures on material supplies and medications constitute the greatest per capita costs for surgical missions. We hypothesized that supply acquisition at non-profit organization (NPO) costs would lead to significant cost-savings compared with supply acquisition at US academic institution costs from the provider perspective for hernia repairs and minor procedures during a surgical mission in the Dominican Republic. METHODS: Items acquired for a surgical mission were uniquely QR-coded for accurate consumption accounting. Both NPO and US academic institution unit costs were associated with each item in an electronic inventory system. Medication doses were recorded and QR codes for consumed items were scanned into a record for each sampled procedure. Mean material costs and cost-savings ± SDs were calculated in US dollars for each procedure type. Cost-minimization analyses between the NPO and the US academic institution platforms for each procedure type ensued using a two-tailed Wilcoxon matched-pairs test with α = 0.05. Item utilization analyses generated lists of most frequently used materials by procedure type. RESULTS: The mean cost-savings of supply acquisition at NPO costs for each procedure type were as follows: $482.86 ± $683.79 for unilateral inguinal hernia repair (n = 13); $332.46 ± $184.09 for bilateral inguinal hernia repair (n = 3); $127.26 ± $13.18 for hydrocelectomy (n = 9); $232.92 ± $56.49 for femoral hernia repair (n = 3); $120.90 ± $30.51 for umbilical hernia repair (n = 8); $36.59 ± $17.76 for minor procedures (n = 26); and $120.66 ± $14.61 for pediatric inguinal hernia repair (n = 7). CONCLUSION: Supply acquisition at NPO costs leads to significant cost-savings compared with supply acquisition at US academic institution costs from the provider perspective for inguinal hernia repair, hydrocelectomy, umbilical hernia repair, minor procedures, and pediatric inguinal hernia repair during a surgical mission in the Dominican Republic. Item utilization analysis can generate minimum-necessary material lists for each procedure type to reproduce cost-savings for subsequent missions.

Informing public policy toward binational health insurance: empirical evidence from California.

OBJECTIVE: To estimate reimbursement rate differences between Mexico and US based physicians reimbursed by a binational health insurance (BHI) plan and US payers, respectively; and show the relationship between plan benefit designs and health care utilization in Mexico. MATERIALS AND METHODS: Data include 33,841 and 53,909 HMO enrollees in California from Sistemas Médicos Nacionales (SIMNSA) and Salud con Health Net, respectively. We use descriptive statistical methods. RESULTS: SIMNSA's physician reimbursement rates averaged 50.7% (95% CI: 34.5%-67.0%) of Medi-Cal's, 28.3% (95% CI: 19.6%-37.0%) of Medicare's, and 22% of US private plans'. Each year, 99.4% of SIMNSA enrollees but only 0.1% of Salud con Health Net enrollees obtained care in Mexico. CONCLUSION: SIMNSA only covers emergency and urgent care in the US, while Salud con Health Net covers comprehensive care with higher patient cost sharing than in Mexico. To realize potential savings, plans need strong incentives to increase utilization in Mexico.

Informing public policy toward binational health insurance: Empirical evidence from California / Información para las políticas públicas sobre seguros binacionales de salud: evidencia empírica de California

Objective. To estimate reimbursement rate differences between Mexico and US based physicians reimbursed by a binational health insurance (BHI) plan and US payers, respectively; and show the relationship between plan benefit designs and health care utilization in Mexico. Materials and methods. Data include 33 841 and 53 909 HMO enrollees in California from Sistemas Médicos Nacionales (SIMNSA) and Salud con Health Net, respectively. We use descriptive statistical methods. Results. SIMNSA's physician reimbursement rates averaged 50.7% (95% CI: 34.5%-67.0%) of Medi-Cal's, 28.3% (95% CI: 19.6%-37.0%) of Medicare's, and 22% of US private plans'. Each year, 99.4% of SIMNSA enrollees but only 0.1% of Salud con Health Net enrollees obtained care in Mexico. Conclusion. SIMNSA only covers emergency and urgent care in the US, while Salud con Health Net covers comprehensive care with higher patient cost sharing than in Mexico. To realize potential savings, plans need strong incentives to increase utilization in Mexico.

Objetivo. Estimar diferencias en tasas de reembolso y utilización de servicios médicos cubiertos por seguros binacionales de salud (SBS) y aquellos de planes públicos y privados de EUA. Material y métodos. Con métodos estadísticos descriptivos se analizan datos de 33 841 afiliados a Sistemas Médicos Nacionales (SIMNSA) y 53 909 de Salud con Health Net en California. Resultados. Las tasas de reembolso de SIMNSA son en promedio 50.7% (95% IC: 34.5%-67.0%) de aquellas de Medi-Cal, 28.3% (95% IC: 19.6%-37.0%) de Medicare, y 22% de los planes privados de EUA. Cada año, 99.4% de afiliados a SIMNSA, pero sólo 0.1% de Salud con Health Net obtienen atención en México. Conclusión. SIMNSA sólo cubre gastos de emergencia y atención urgente en EUA, mientras que Salud con Health Net cubre servicios de atención integrales. Los planes de SBS pueden lograr ahorros importantes con más incentivos para que la atención ocurra en México.

Dermatology resources on the internet.

Both patients and medical professionals are increasingly accessing the Internet for health information. Today's Web enables features that facilitate information sharing in a social and collaborative manner, thus transforming the way we access data and communicate with our patients and colleagues. The visual nature of the field of dermatology lends itself to the use of the Internet for reference and educational purposes. To generate a list of Web sites commonly used by academic dermatologists, the authors polled the Accreditation Council for Graduate Medical Education Dermatology Program Directors for their top 3 Web resources. The purpose of this article is to identify resources used by dermatologists as well as patients and examine factors that can influence Internet search results. Concerns regarding professionalism in the era of social media are also explored. As the volume of health information on the Internet continues to increase, it is essential for physicians to be aware of what is available in cyberspace. Reference and learning tools for the physician, learning and support tools for the patient, and physician Internet presence are key aspects of modern dermatology practice.

Salinity and sodicity of weathered minesoils in northwestern new Mexico and northeastern Arizona.

Evolving relationships between electrical conductivity (EC) and sodium adsorption ratio (SAR) in reconstructed soils at surface mines have been insufficiently documented in the literature. Some minesoils (i.e., rootzone material) are classified as saline, sodic, or saline-sodic and are considered unsuitable for revegetation. Weatherable minerals such as calcite and gypsum are common in alkaline minesoils and on dissolution tend to mitigate elevated SAR levels by maintaining or increasing electrolytes in the soil and providing sources of exchangeable calcium and magnesium. Topsoils (i.e., coversoils) contribute to mitigation of sodic conditions when soluble cations are translocated from coversoils into the underlying minesoils. This study evaluated the weathering characteristics of minesoils sites from three surface coal mines in northwestern New Mexico and northeastern Arizona. Minesoils were grouped into 11 classes based on EC and SAR. After 6 to 14 yr, differences between upper and lower halves of the coversoils suggest general increases occurred with EC, SAR, chloride (Cl(-)), and sulfate (SO(4)(2-)) with depth. Within the reclaimed minesoils, there were several significant (P < 0.05 or < 0.10) relationships among EC and SAR that related to Minesoil Class. Lower SAR levels with corresponding increases in EC compared to baseline minesoils were more apparent in upper minesoil depths (0-5 and 5-15 cm). Minesoil anion concentrations suggested coversoil leachates and gypsum dissolution influenced EC and SAR chemistry. Over time, chemical changes have increased the apparent stability of the saline and sodic reclaimed minesoils studied thereby reducing risks associated with potential aggregate slaking and clay particle dispersion.

The effect of kidney morcellation on operative time, incision complications, and postoperative analgesia after laparoscopic nephrectomy.

INTRODUCTION: Compare the outcomes between kidney morcellation and two types of open specimen extraction incisions, several covariates need to be taken into consideration that have not yet been studied. MATERIALS AND METHODS: We retrospectively reviewed 153 consecutive patients who underwent laparoscopic nephrectomy at our institution, 107 who underwent specimen morcellation and 46 with intact specimen removal, either those with connected port sites with a muscle-cutting incision and those with a remote, muscle-splitting incision. Operative time, postoperative analgesia requirements, and incisional complications were evaluated using univariate and multivariate analysis, comparing variables such as patient age, gender, body mass index (BMI), laterality, benign versus cancerous renal conditions, estimated blood loss, specimen weight, overall complications, and length of stay. RESULTS: There was no significant difference for operative time between the 2 treatment groups (p = 0.65). Incision related complications occurred in 2 patients (4.4%) from the intact specimen group but none in the morcellation group (p = 0.03). Overall narcotic requirement was lower in patients with morcellated (41 mg) compared to intact specimen retrieval (66 mg) on univariate (p = 0.03) and multivariate analysis (p = 0.049). Upon further stratification, however, there was no significant difference in mean narcotic requirement between the morcellation and muscle-splitting incision subgroup (p = 0.14). CONCLUSION: Morcellation does not extend operative time, and is associated with significantly less postoperative pain compared to intact specimen retrieval overall, although this is not statistically significant if a remote, muscle-splitting incision is made. Morcellation markedly reduces the risk of incisional-related complications.

The effect of kidney morcellation on operative time, incision complications, and postoperative analgesia after laparoscopic nephrectomy

INTRODUCTION: Compare the outcomes between kidney morcellation and two types of open specimen extraction incisions, several covariates need to be taken into consideration that have not yet been studied. MATERIALS AND METHODS: We retrospectively reviewed 153 consecutive patients who underwent laparoscopic nephrectomy at our institution, 107 who underwent specimen morcellation and 46 with intact specimen removal, either those with connected port sites with a muscle-cutting incision and those with a remote, muscle-splitting incision. Operative time, postoperative analgesia requirements, and incisional complications were evaluated using univariate and multivariate analysis, comparing variables such as patient age, gender, body mass index (BMI), laterality, benign versus cancerous renal conditions, estimated blood loss, specimen weight, overall complications, and length of stay. RESULTS: There was no significant difference for operative time between the 2 treatment groups (p = 0.65). Incision related complications occurred in 2 patients (4.4 percent) from the intact specimen group but none in the morcellation group (p = 0.03). Overall narcotic requirement was lower in patients with morcellated (41 mg) compared to intact specimen retrieval (66 mg) on univariate (p = 0.03) and multivariate analysis (p = 0.049). Upon further stratification, however, there was no significant difference in mean narcotic requirement between the morcellation and muscle-splitting incision subgroup (p = 0.14). CONCLUSION: Morcellation does not extend operative time, and is associated with significantly less postoperative pain compared to intact specimen retrieval overall, although this is not statistically significant if a remote, muscle-splitting incision is made. Morcellation markedly reduces the risk of incisional-related complications.

Depression and suicide in children and adolescents.

Depression, suicide, and suicidal behavior in the pediatric population are serious public health problems. Pediatricians in collaboration with psychiatrists and other mental health professionals can make an important contribution to the mental health of children and adolescents through the identification, referral, and management of depressed and suicidal youth.

Reliability and validity of the structured interview for personality disorders in adolescents.

The Structured Interview for the DSM-III Personality Disorders was administered to 23 currently affectively ill adolescents and their parents. Interviews were videotaped and rerated; interrater agreement was moderate (weighted K = 0.49; unweighted K = 0.59). Moreover, there was evidence of convergent validity for Cluster II traits and disorders (borderline, histrionic, narcissistic), insofar as these diagnoses were associated with higher scores on the novelty-seeking subscale of the Tridimensional Personality Questionnaire as predicted. Cluster II patients tended to have higher rates of attention deficit disorder and bipolar disorder, and higher rates of suicidal gestures among second-degree relatives. Some difficulty was encountered differentiating symptoms of affective illness from those of personality disorder and in deciding when personality traits were impairing enough to call them disorders. Reliability may be improved by: (1) interviewing patients when out of affective episode; and (2) using standardized functional impairment criteria for differentiating personality style from disorder. Additional work is advocated to learn if personality disorders are precursors, epiphenomena, or the consequences of affective disorder.

Comorbidity of substance abuse and other psychiatric disorders in adolescents.

Psychopathology coexisting with substance abuse in adolescents is often encountered in a variety of clinical settings. Research findings suggest a major role for substance use in the etiology and prognosis of psychiatric disorders such as affective disorders, conduct disorder and antisocial personality disorder, attention-deficit hyperactivity disorder, and anxiety disorders. Psychiatric disorders also appear to have an important role in the etiology of and vulnerability to substance use problems in adolescents. Although the comorbidity of substance abuse and other psychiatric disorders in adolescents is recognized as an important factor in the treatment of adolescents, further research is needed to establish its prevalence, genetics, and clinical implications.