Management of blunt thoracic aortic injury.

Blunt traumatic aortic transection (TAT) is an uncommon injury in clinical practice that is associated with a high morbidity and mortality. The approach to patients with such an injury is controversial with specific regard to the most effective diagnostic tools, timing of surgical intervention and mechanisms of spinal cord protection. Chest X-ray with widening of the mediastinum is unreliable as a diagnostic tool. Contrast enhanced helical CT Scan has replaced the traditional angiography as the screening diagnostic tool of choice Emergency thoracotomy and repair should be reserved for the few patients with isolated TAT without any major concomitant injuries. Delayed management approach with aggressive blood pressure control and serial radiological monitoring is a safe and recommended option for those with severe concomitant injuries or other medical co-morbidity that puts surgery at high risk. Active augmentation of the distal perfusion pressure during cross clamp offers the best protection against development of paraplegia during open surgical repair. Endovascular stenting offers a minimally invasive method of treatment but the long-term durability of the endovascular stent is still unknown. We feel that the greater feasibility of the endovascular repair in the acute phase of the thoracic injury is an advantage over the open surgery and should be the treatment of choice in patients with severe concomitant injuries.     

Cor triatriatum sinister presenting in the adult as mitral stenosis

Cor triatriatum sinister is a rare congenital defect in which the left atrium is divided by a fibromuscular membrane into two distinct chambers. Classically, patients present in infancy although in some cases they remain asymptomatic until adulthood. The clinical features on presentation can mimic those of mitral stenosis due to the obstructive properties of the membrane. Cor triatriatum sinister presented in this case in an adult as mitral stenosis. Factors that may be relevant in determining late presentation are also discussed.     

Non-invasive assessment of bleeding pulmonary artery aneurysms due to Behçet disease

Because of its ability to depict intravascular, intramural, and extramural pathology, non-invasive imaging is well suited to assessing life-threatening hemoptysis that may complicate Beh?et disease. We made exclusive use of CT angiography supplemented by MR to identify pulmonary thromboembolism, mediastinal lymphadenopathy, and bilateral pulmonary artery aneurysms with signs of previous unilateral rupture. Two-dimensional reformatted CT images provided surgeons with a road map of upstream and downstream vascular relationships prior to aneurysm resection. Imaging findings were confirmed by surgery and pathology. Non-invasive imaging proved to be a useful alternative to standard catheter arteriography in the preoperative assessment of hemoptysis in this patient with Beh?et disease. Received 2 April 1997; Revision received 20 June 1997; Accepted 1 September 1997     

Preoperative angiotensin-converting enzyme inhibition can cause severe post CPB vasodilation--current UK opinion

Preoperative use of angiotensin-converting enzyme inhibitors in cardiac surgery patients is thought to cause extreme vasodilatation in post cardiopulmonary bypass period. Opinions are divided as to whether it is beneficial or not to stop it prior to operation. A national survey in the UK was carried out on this issue. Questionnaires were sent to 167 currently practicing UK cardiac surgeons, out of which 105 (62%) replied back. Their responses were analyzed. Among the surgeons who replied to the questionnaires, the majority (63%) were of the opinion that the use of angiotensin-converting enzyme inhibitors leads to vasodilatation resulting in increased usage of fluids, inotropes and vasoconstrictors. However, there was no agreement on the issue of stopping it prior to surgery. Forty one (39%) felt it was beneficial to stop the angiotensin-converting enzyme inhibitors prior to surgery whereas 40 (38%) of them thought it was harmful to stop it. Twenty one (20%) were of the opinion that it made no difference. 39% of respondents practiced stopping the drug prior to planned operation. This national survey revealed differences in management of patients on angiotensin-converting enzyme inhibitors undergoing cardiac surgery. Recommendations from available literature are equally varied, highlighting the need for multicenter randomized trials to address this clinical problem.     

Investigating the Effectiveness of the Incredible Years Basic Parenting Programme for Foster Carers in Northern Ireland

Children who are looked after experience significantly higher levels of social, emotional and behavioural difficulties than children who live with their family of origin. Such difficulties tend to be pervasive and can have detrimental consequences for placement stability, and ultimately for the child's ability to reach their potential. Government documents such as Care matters highlight the importance of providing ongoing training and support to foster carers to equip them with the necessary skills to manage the complex needs presented by children who are looked after. The nature of this training and support is often debated. With this in mind, Barnardo's Professional Fostering Service piloted the Incredible Years Basic Parenting Programme with 13 foster carers. The 12-week programme was evaluated using the Eyberg Child Behaviour Inventory pre and post intervention. Results provide a promising insight into the potential of the Incredible Years Basic Parenting Programme as a method of training and supporting foster carers.