Predictors, costs and characteristics of out of area placement for people with intellectual disability and challenging behaviour

Background Out of area placements for people with challenging behaviour represent an expensive and often ineffective strategy for meeting the needs of this service user group. Methods More than 800 agencies and service settings in a large area of South Wales were screened to identify children and adults with challenging behaviour against a number of defined operational criteria. Detailed data on identified individuals and the services they received were collected by interviewing key informants. Univariate and multivariate statistics were employed to identify predictors of out of area placement. Results In total, 1458 people were identified. Full data were available for 901 participants, 97 of whom were placed out of area. Predictors of out of area placement included behaviours resulting in physical injury and exclusion from service settings, a history of formal detention under the mental health act, the presence of mental health problems, a diagnosis of autism and higher total score on the Adaptive Behaviour Scale. Out of area placements were typically of high cost, and associated with only limited evidence of improved service quality. Conclusions Identifying predictors for out of area placement can be used to highlight deficiencies in local services and individuals at increased risk of exclusion from local services.     

Respiratory muscle function in cystic fibrosis.

Maximal static expiratory and inspiratory mouth pressures (PEmax and PImax) and quadriceps femoris muscle strength were measured in 25 patients aged 16-28 years with cystic fibrosis (mean FEV1 46% predicted). Mean (SD) PEmax was 64% (18%) predicted (below 75% predicted in 16 of the 25 patients), and PImax was 64% (24%) predicted (below 75% predicted in 14 patients). Quadriceps muscle strength was 68% (20%) predicted (below 75% predicted in 17 patients). The relatively small reduction in respiratory muscle strength in these patients was unlikely to have contributed appreciably to their respiratory problems.     

Epidemiology of congestive heart failure: Canadian data from 1970 to 1989.

OBJECTIVE: To assess mortality rates from congestive heart failure in Canada from 1970 to 1989. DESIGN: Observational, retrospective design using national population and mortality data. MAIN RESULTS: There is a definite age gradient for deaths from congestive heart failure which, combined with a general ageing of the Canadian population, has lead to an increase in the absolute number of deaths. However, Standardized Mortality Ratios, which account for shifting population distributions, have shown steadily decreasing values for both men and women since 1980. CONCLUSIONS: Recent improvements in cardiology care demonstrated in controlled clinical trials appear also to be present in epidemiological studies.     

Enhanced hemolysis in pediatric patients requiring extracorporeal membrane oxygenation and continuous renal replacement therapy

PURPOSE: Hemolysis during extracorporeal membrane oxygenation (ECMO) may be associated with the development of hemoglobinuria (Hb) nephropathy and acute renal failure. For patients requiring ECMO, continuous renal replacement therapy (CRRT) can be simultaneously performed by attaching a hemofilter to the ECMO circuit, thereby shunting part of the ECMO blood flow through the hemofilter. However, the possibility that CRRT may further enhance hemolysis (and the risk of Hb nephropathy) in patients on ECMO has not been previously investigated. METHODS: Medical records of 42 children (1 day-12 years old) who required ECMO (ECMO group, n=25) or ECMO and CRRT (ECMO+CRRT group, n=17) after cardiac surgery were reviewed. RESULTS: Forty-one out of 42 patients had elevated plasma-free hemoglobin (FHb) on the first day of ECMO. For all subjects, peak change (mean+/-SD) in FHb (Peak%C-FHb, 83.6+/-183%) correlated with serum lactic dehydrogenase (150+/-324%, r=0.49, p<0.05) and marginally with ECMO blood flow rate (BFR) (Peak%C-BFR, 36.8+/-51.0%, r=0.29, p=0.06). Compared with the ECMO group, the ECMO+CRRT group had a higher Peak%C-FHb (160+/-259%, p<0.05) and Peak%C-BFR (62+/-64%, p<0.05). Also, there was a significant increase in FHb one day after the initiation of CRRT compared with the level prior to CRRT (73.3+/-49.2 vs. 50.0+/-30.3 mg/dL, respectively, p=0.012). Serum creatinine (but not blood urea nitrogen) was significantly higher in the ECMO+CRRT group compared with the ECMO group. The percent change in serum creatinine during ECMO did not correlate with Peak%C-FHb in the ECMO group. CONCLUSION: Our findings suggest that there is enhanced hemolysis during combined ECMO and CRRT compared with ECMO alone. However, the clinical impact of increased hemolysis on renal function in patients receiving ECMO with or without CRRT remains to be determined.     

Thrombin contraction of vascular smooth muscle: implications for vasospasm

Thrombin contributes to hemostasis by activating platelets, the formation of fibrin, and contraction of the injured vessel. These effects are mediated through the proteolytic activity of thrombin. We hypothesized that thrombin may have a role in vasospasm after arterial injury and examined the physiologic and cellular signaling events of thrombin in intact vascular smooth muscles. Thrombin stimulation of strips of bovine carotid artery smooth muscle led to contractions which relaxed with the addition of the nitric oxide donor, sodium nitroprusside. However, washout of the thrombin and SNP resulted in the re-generation of force. This was not observed with other agonists such as endothelin, thromboxane analogues, or serotonin. Using two-dimensional immunoblotting we demonstrate that thrombin stimulation leads to increases in the tyrosine phosphorylation of 4 proteins, three different isoforms of P44 mitogen activated protein kinase (MAPK) and one isoform of P38 stress activated protein kinase (SAPK). Activation of P38 SAPK leads to activation of MAPKAP kinase-2 and a major substrate protein of MAPKAP kinase-2 is the small heat shock protein, HSP27. HSP27 has been implicated in mediating smooth muscle contraction. These data suggest that in the setting of arterial injury, thrombin-induced contraction may supercede over short acting vasorelaxants such as NO resulting in vasospasm. In addition to stress, physiologic substances such as thrombin, activate SAPKs leading to increases in the phosphorylation of HSP27. Thus, thrombin may play a central role in hemostasis after vascular injury and in the pathologic responses to plaque rupture and thrombosis in atherosclerosis.