Promoting Contact for Children in State Care: Learning from Northern Ireland on the Development of a Framework for Assessing Contact

While the principle of contact between children in care and their families is enshrined in law, the precise form and frequency is at the discretion of social workers and the courts. Professionals must seek to balance the twin principles of children’s need for protection from the psychological, emotional and physical harm that may arise from having contact with parents and other family members, with the need of family members and children to have their relationships and identity promoted. Courts require clear, structured and unambiguous information about the needs of children and their parents in order to make decisions which will have potentially life-changing implications for families. In this article we explore one approach to supporting the decision making of legal and social work professionals in relation to the frequency and form of contact by reflecting upon the development by the first author of an approach to assessing the quality and benefits of contact for children in State care in Northern Ireland. We discuss the key principles that should inform decisions and good practice through reflecting on the learning gained from developing and implementing such a structured approach. We conclude that practice has been informed by promoting legal rights without sufficient consideration of the relational aspects of making contact work for each of the involved parties.     

Current management of mucosal melanoma of the head and neck

While mucosal-based melanomas of the head and neck region are uncommon lesions, when they do arise they usually follow an inexorably aggressive course. Experience with these tumors is, necessarily, limited; as such, well-worked out treatment protocols for the treatment of such lesions are in short supply. It appears as though mucosal melanomas (MuMs) develop more frequently in the nasal cavity and paranasal sinus region, and less often in the oral cavity. It seems that the incidence of nodal metastasis is significantly lower for sinonasal MuMs than it is for MuMs of the oral cavity; this observation may influence decisions about performing neck dissection as a function of location of the primary MuM. At present, surgical excision remains the mainstay of treatment; however, anatomical complexities within the region can hamper attempts at complete excision. Radiotherapy has not traditionally been relied on for routine treatment of MuM, although some recent reports have challenged this view. Chemotherapy is, at present, employed principally in the treatment of disseminated disease and for palliation. As a diagnostic matter, MuM belongs to the class of tumors that, on light microscopy, may with some regularity be confused with other malignancies (including sarcomas, plasmacytomas, and carcinomas); as a consequence, this is a diagnosis which is often best confirmed by way of ancillary testing via immunohistochemical studies. A better grasp of the best means of treating MuM will likely come only when large referral centers are able to pool their experiences with these uncommon yet virulent malignancies.     

Preoperative identification of anomalous arterial anatomy at pancreaticoduodenectomy

The understanding of abdominal vascular anatomy and its anatomical variations is of considerable importance in upper abdominal surgery. We present the rare finding of a common hepatic artery arising from the superior mesenteric artery and passing anterior to the pancreatic gland in a patient undergoing a pancreaticoduodenectomy.     

Physicians' perspectives on the uncertainties and implications of chromosomal microarray testing of children and families

Chromosomal microarray analysis (CMA) has improved the diagnostic rate of genomic disorders in pediatric populations, but can produce uncertain and unexpected findings. This article explores clinicians' perspectives and identifies challenges in effectively interpreting results and communicating with families about CMA. Responses to an online survey were obtained from 40 clinicians who had ordered CMA. Content included practice characteristics and perceptions, and queries about a hypothetical case involving uncertain and incidental findings. Data were analyzed using nonparametric statistical tests. Clinicians' comfort levels differed significantly for explaining uncertain, abnormal, and normal CMA results, with lowest levels for uncertain results. Despite clinical guidelines recommending informed consent, many clinicians did not consider it pertinent to discuss the potential for CMA to reveal information concerning biological parentage or predisposition to late‐onset disease, in a hypothetical case. Many non‐genetics professionals ordering CMA did not feel equipped to interpret the results for patients, and articulated needs for education and access to genetics professionals. This exploratory study highlights key challenges in the practice of genomic medicine, and identifies needs for education, disseminated practice guidelines, and access to genetics professionals, especially when dealing with uncertain or unexpected findings.     

Abdominal trauma in combat

Evaluating and managing patients with abdominal trauma remains one of the most challenging, resource-intensive and satisfying aspects of combat care. It demands a thorough understanding of the pathophysiology of trauma and shock, excellent clinical acumen and the ability to think and operate rationally in a chaotic milieu.     

The use of inhibitors of N-linked glycosylation and oligosaccharide processing to produce monoclonal antibodies against non-phosphorylcholine epitopes of Brugia pahangi excretory-secretory products

Adult Brugia pahangi were cultured with [³H]-choline in both the absence and the presence of either tunicamycin or 1-deoxymannojirimycin (dMM), inhibitors of N-linked glycosylation and N-linked oligosaccharide processing, respectively. Excretory-secretory products (ES) were recovered from the spent medium and examined by sodium dodecyl sulfate-polyacrylamide gel electrophoresis/fluorography. Both inhibitors were found to prevent radiolabeling of ES, a result consistent with blockage of the addition of the highly immunodominant phosphorylcholine (PC) group. Tunicamycin/dMM-treated ES were subsequently employed to immunise a mouse in an attempt to produce monoclonal antibodies (mAbs) against non-PC epitopes of ES. Three mAbs were isolated, each of which reacted with ES but not with PC. Received: 12 February 1997 / Accepted: 7 May 1997     

Interleukin-10 and antigen-presenting cells actively suppress Th1 cells in BALB/c mice infected with the filarial parasite Brugia pahangi

Infection with the third-stage larvae (L3) of the filarial nematode Brugia results in a Th2-biased immune response in mice and humans. Previously we have shown that the production of interleukin 4 (IL-4) is critical for down-regulating polyclonal Th1 responses in L3-infected mice. However, the in vitro neutralization of IL-4 did not fully recover the defective polyclonal Th1 responses, nor did it result in the production of any antigen (Ag)-specific Th1 cytokines, suggesting that perhaps infection with L3 does not result in priming of Th1 cells in vivo. In this study, we analyzed the role of IL-10 and Ag-presenting cells (APCs) in the spleen as additional factors controlling the Th2 bias in infected mice. Our data show that IL-10 and APCs also contribute to the suppression of mitogen-driven Th1 responses of spleen cells from infected mice. In addition, the neutralization of IL-10 or the replacement of the resident APC population from spleen cell cultures resulted in the production of Ag-specific Th1 cytokines. Irradiated spleen cells from either L3-infected or uninfected mice were able to restore Ag-specific Th1 responses in vitro. Therefore, it appears that Brugia-reactive Th1 cells are primed following infection with L3, but are actively suppressed in vivo by a mechanism that involves IL-10 and the resident APC population, but not IL-4. These results indicate that a complex interplay of cytokines and cell populations underscores the Th2-polarized response in L3-infected mice.     

The role of oxygen therapy in the recovery phase of day surgery

Oxygen therapy in the inpatient setting is standard practice in the postoperative phase. The aim of this study was to evaluate the need for the routine use of oxygen in the transit phase from the operating theatre to recovery, and its continued use in recovery, in patients undergoing day surgery. ASA I–II patients undergoing body surface surgery, using anaesthetic agents with a rapid recovery profile, are not subject to many of the factors that predispose to postoperative hypoxaemia. This study showed that in our unit the majority of patients do not require oxygen therapy in the theatre-recovery transit phase, and that attention to patient positioning, airway patency, and elimination of the second gas effect may be sufficient. Each day surgery unit (DSU) must make decisions on the need for postoperative oxygen therapy based on the unit layout and the condition of the patient.