Understanding the inflammatory response to cardiac surgery

The systemic inflammatory response to cardiac surgery is common, and resultant impairment of multiple organ function is generally mild or subclinical due to physiological reserve within organ systems. Unfortunately, the changing profile of patients referred for surgery suggests that the systemic inflammatory response may prominently influence surgical outcome in the future. Older, co-morbid patients with more limited physiological reserve are being referred for complex lengthy procedures, and paediatric surgery has witnessed a shift to earlier complex primary correction or palliation involving long cardiopulmonary bypass times or a period of suboptimal organ perfusion using circulatory arrest or low flow cardiopulmonary bypass. Unique to cardiac surgery is the predictability of the inflammatory response, but prophylactic therapies have not translated into clinical benefit, which the preconditioning phenomenon may address.     

Catchers in the Rye: Treatment Foster Parents as a System of Care

PROBLEM: Similar to the children in J. D. Salinger's novel, The Catcher in the Rye, youth in foster care face the specter of "going over the cliff." METHODS: The empirical basis for "treatment foster care" is reviewed, concluding that treatment foster care is both a clinically and cost-effective form of community-based treatment. FINDINGS: Treatment foster parents prevent the fall of foster youth into the chasm of school failure, involvement with juvenile justice, and dependent living as adults. CONCLUSION: Treatment foster care is an evidence-based approach that is less restrictive and offers troubled youth an opportunity to engage and grow within a family setting.     

Team management in community mental health

The community mental health team is now the established model for mental health service delivery in the community. Managing CMHTs requires a diverse range of managerial skills, role clarity and authority. More research needs to be undertaken on the role and effectiveness of the CMHT manager.     

The effect of prenatal and postnatal exposure to polychlorinated biphenyls and child neurodevelopment at age twenty four months

We examined the association between prenatal and postnatal exposure to PCBs and development at age 24 months as measured by the Bayley Scales of Infant Development II. 44 (85%) of 52 children had information available. When prenatal and postnatal exposure were modeled together, we found no association between total PCB exposure and the mental development index (MDI) or the physical development index (PDI). In examining PCB 153, we found no association between PCB 153 and MDI, while higher levels of postnatal exposure was associated with a decrease in PDI after adjustment [β for highest tertile=-24.9; 95% CI (-44.3, -5.5)]. Higher levels of prenatal PCB 153 exposure were associated with a statistically significant increased odds of screening positive for a motor delay. In sum, when prenatal and postnatal exposures were considered together, breast milk exposure to PCB 153 appears to be associated with decrements in motor development; however, we cannot rule out that the finding was due to chance.     

A Multiple Indicators Multiple Causes (MIMIC) model of Behavioural and Psychological Symptoms in Dementia (BPSD)

Introduction

Although there is evidence for distinct behavioural sub-phenotypes in Alzheimer's disease (AD), their inter-relationships and the effect of clinical variables on their expression have been little investigated.

Methods

We have analysed a sample of 1850 probable AD patients from the UK and Greece with 10 item Neuropsychiatric Inventory (NPI) data. We applied a Multiple Indicators Multiple Causes (MIMIC) approach to investigate the effect of MMSE, disease duration, gender, age and age of onset on the structure of a four-factor model consisting of “psychosis”, “moods”, “agitation” and “behavioural dyscontrol”.

Results

Specific clinical variables predicted the expression of individual factors. When the inter-relationship of factors is modelled, some previously significant associations are lost. For example, lower MMSE scores predict psychosis, agitation and behavioural dyscontrol factors, but psychosis and mood predict the agitation factor. Taking these associations into account MMSE scores did not predict agitation.

Conclusions

The complexity of the inter-relations between symptoms, factors and clinical variables is efficiently captured by this MIMIC model.     

Interventional radiology in the treatment of intracranial vascular injuries and fistulae

Traumatic intracranial vascular injuries are uncommon. However prompt diagnosis and management is essential because of the high morbidity and mortality associated with these conditions. The imaging evaluation and potential endovascular management of traumatic intracranial aneurysms and traumatic intracranial fistulae is discussed.     

Plasma exchange in the management of severe rhesus haemolytic disease

Over a ten year period from 1977 to 1987, 30 mothers with severe rhesus haemolytic disease and expected fetal loss were treated by plasma exchange using a blood cell separator. All patients had at least on previous stillborn or neonatal death due to haemolytic disease of the newborn. Of the 30 patients, 19 pregnant women were successfully treated. Overall, 53% (16 babies) survived intact. Three of the deaths were due to causes other than erythroblastosis foetalis.