“Driven and Tense,Stressed Out and Anxious”: Clinicians’ Perceptions of Post-Traumatic Stress Disorder Symptom Expressions in Adults with Autism and Intellectual Disability

ABSTRACT

Introduction

Individuals with autism spectrum disorder (ASD) and intellectual disability (ID) seem to be at increased risk for post-traumatic stress disorder (PTSD), but knowledge is sparse regarding its identification in this population. Previous research indicates that certain symptoms of PTSD may be more easily recognized, and that identifying reexperiencing and avoidance is particularly challenging.     

Occult cardiac tamponade detected by transesophageal echocardiography.

Transesophageal echocardiography is a safe, minimally invasive procedure that should be considered when the diagnosis of cardiac tamponade is a possibility and when conventional methods fail to provide conclusive diagnostic information. In this report, we describe a 74-year-old man in the intensive-care unit whose condition was unstable postoperatively because of an occult loculated pericardial effusion and cardiac tamponade. Routine noninvasive and invasive monitoring, including hemodynamic monitoring and transthoracic echocardiography, failed to confirm definitively the suspected diagnosis of cardiac tamponade. In addition, because of the hemodynamic instability of the patient, transporting him for definitive tests (such as fast computed tomographic scanning of the mediastinum, which could not be performed at the bedside) for assessment of cardiac tamponade was relatively contraindicated. In our patient, the diagnostic information obtained by transesophageal echocardiography may have been lifesaving.     

Prospective, randomized trial on the effect of cyclic versus continuous enteral nutrition on postoperative gastric function after pylorus-preserving pancreatoduodenectomy.

OBJECTIVE: The effect of a cyclic versus a continuous enteral feeding protocol on postoperative delayed gastric emptying, start of normal diet, and hospital stay was assessed in patients undergoing pylorus-preserving pancreatoduodenectomy (PPPD). SUMMARY BACKGROUND DATA: Delayed gastric emptying occurs in approximately 30% of patients after PPPD and causes prolonged hospital stay. Enteral nutrition through a catheter jejunostomy is used to provide postoperative nutritional support. Enteral infusion of fats and proteins activates neurohumoral feedback mechanisms and therefore can potentially impair gastric emptying and prolong postoperative gastroparesis. METHODS: From September 1995 to December 1996, 72 consecutive patients underwent PPPD at the Academic Medical Center, Amsterdam. Fifty-seven patients were included and randomized for either continuous (CON) jejunal nutrition (0-24 hr; 1500 kCal/24 hr) or cyclic (CYC) enteral nutrition (6-24 hr; 1125 kCal/18 hr). Both groups had an equal caloric load of 1 kCal/min. The following parameters were assessed: days of nasogastric intubation, days of enteral nutrition, days until normal diet was tolerated orally, and hospital stay. On postoperative day 10, plasma cholecystokinin (CCK) levels were measured during both feeding protocols. RESULTS: Nasogastric intubation was 9.1 days in the CON group (n = 30) and 6.7 days in the CYC group (n = 27) (not statistically significant). First day of normal diet was earlier for the CYC group (15.7 vs. 12.2 days, p < 0.05). Hospital stay was shorter in the CYC group (21.4 vs. 17.5 days, p < 0.05). CCK levels were lower in CYC patients, before and after feeding, compared with CON patients (p < 0.05). CONCLUSIONS: Cyclic enteral feeding after PPPD is associated with a shorter period of enteral nutrition, a faster return to a normal diet, and a shorter hospital stay. Continuously high CCK levels could be a cause of prolonged time until normal diet is tolerated in patients on continuous enteral nutrition. Cyclic enteral nutrition is therefore the feeding regimen of choice in patients after PPPD.     

Boundary Ambiguity in Parents With Chronically Ill Children: Integrating Theory and Research

Abstract: This article integrates theory and research related to boundary ambiguity in parents of children with a chronic health condition. We propose that boundary ambiguity is a risk factor for psychological distress in these parents. Clinical applications and a case example highlight how boundary ambiguity can be assessed and managed in clinical settings by professionals working with parents with chronically ill children. Questions are provided for assessing boundary ambiguity in clinical and research settings, and implications for research are discussed.     

Pedal and distal lower leg bypasses with a distal arteriovenous fistula

In forty patients 41 feet were revascularised by means of distal tibial (the distal 10 cm of the lower leg) (17) or pedal bypasses (24). Angiographically the preoperative state was best defined as a lower leg block (LLB); All three arteries showing occlusions at several levels, leaving only isolated functioning arterial segments in the distal leg or foot with relatively good femoral and popliteal arteries. As might be expected this condition was mainly found in diabetics (75%). Only feet with severe rest pain (4) or rest pain with gangrene (37) were operated upon. To improve the distal outflow a side-to-side arteriovenous fistula (AVF) was added to the distal anastomosis. With a mean follow-up of 21 months (1-40 months) the limb salvage rate was 79% and the patency rate 67%. Special problems were experienced with cellulitis of the foot, causing the loss of three feet despite an open bypass and sufficient revascularisation. Furthermore, occlusion of the bypass after healing of the lesion did not necessarily mean a recurrence of gangrene. As this series shows, even in angiographically apparently hopeless cases, a bypass to the foot can prevent an otherwise unavoidable amputation.