A controlled evaluation of inpatient family intervention. I. Preliminary results of the six-month follow-up.

Although family intervention is practiced in most psychiatric hospitals, there are no adequately controlled studies of its efficacy. This study was designed to answer, in part, the following question: What is the relative efficacy of hospitalization with family intervention as compared with hospitalization without family intervention for patients with major psychiatric disorders who are in need of hospital treatment and for whom both treatments are judged clinically feasible? This is our first report, presenting preliminary data on six-month follow-up for the first three quarters of the total sample of 144 patients (80 with schizophrenic disorder and 64 with major affective disorder).

Inpatient family intervention: a randomized clinical trial. II. Results at hospital discharge.

Although family intervention is practiced in most psychiatric hospitals, to our knowledge, no adequately controlled studies of its efficacy exist. This study was designed to answer, in part, the question of the relative efficacy of hospitalization with family intervention as compared with hospitalization without family intervention for patients (1) with major psychiatric disorders, (2) in need of hospital treatment, and (3) for whom both treatments are judged clinically feasible. This article compares treatment results at the time of hospital discharge for 169 patients randomly assigned to the inpatient Family Intervention or comparison conditions. Inpatient Family Intervention had greater efficacy than the comparison treatment, mostly attributable to its effect on female patients, especially those patients (and their families) with affective disorder.

A randomized clinical trial of inpatient family intervention, III: Effects at 6-month and 18-month follow-ups.

This paper focuses on the follow-up results of a randomized clinical trial of inpatient family intervention (IFI) that emphasized psychoeducation. Results for the sample of 169 psychiatric patients suggested that adding family treatment to standard hospital treatment was effective; however, the statistical interactions indicated that this therapeutic effect was restricted to female patients with schizophrenia or major affective disorder. The effect of family treatment on male patients with these diagnoses was minimal or slightly negative. In a group of patients with other diagnoses, the Treatment by Sex effect was reversed: male patients did better with the family treatment.

Prolonged prostaglandin E1 infusion in an infant with cyanotic congenital heart disease.

A small-for-gestational-age premature infant with severe tetralogy of Fallot was treated with prostaglandin E1 to dialate the ductus arteriosus and increase pulmonary blood flow. The infusion was continued for 29 days without complication at which time surgery was performed.

Recovery of left ventricular function following discontinuation of anthracycline chemotherapy in children.

Echocardiographic evaluation of left ventricular (LV) performance was performed in 41 children during and following anthracycline chemotherapy. Prior to treatment LV function was normal in all patients; LV shortening fraction was 35.2 +/- 0.7% and percent of predicted velocity of circumferential fiber shortening was 110 +/- 20%. However, the indices measured concurrent with the final anthracycline dose (mean = 308 +/- 16 mg/sq m) demonstrated a significant decline in LV function. The LV shortening fraction had decreased to 29.5 +/- 0.8% and percent of predicted velocity of circumferential fiber shortening decreased to 94 +/- 4% (P less than .01). Four of the eight patients with evidence of significant LV dysfunction had received thoracic or upper abdominal irradiation. Following cessation of anthracycline therapy, LV function improved within one to six months and had returned to normal in all but two patients, both of whom received irradiation. Echocardiography is useful for the identification of anthracycline-induced LV dysfunction. With discontinuation of further anthracycline administration the functional decline in LV performance appears to be reversible.

Systemic to pulmonary collaterals in very low birth weight infants: color doppler detection of systemic to pulmonary connections during neonatal and early infancy period.

OBJECTIVE: Angiographic visualization of systemic to pulmonary collaterals (SPC) has been documented in premature infants needing prolonged ventilatory support. Noninvasive identification of such communications in premature infants was reported recently. The purpose of this study was to describe: 1) incidence, 2) clinical findings and implications, and 3) short-term follow-up of SPC diagnosed by echocardiography in very low birth weight (VLBW) infants admitted to the neonatal intensive care unit. METHODS: From December 1, 1994 to August 31, 1996, 196 infants with birth weight <1500 g were admitted to the neonatal intensive care unit; 133 of them received serial echocardiographic evaluations at 1 to 2 days, at 2 weeks, and at 1, 2, and 3 months of life. Follow-up echocardiograms were scheduled at 6 months and 1 year of age for patients with SPC persisting at 3 months of age. RESULTS: SPC were demonstrated in 88 patients (66%) at 1 to 90 days of life (mean 28 days). In most cases, the SPC originated at the distal aortic arch or the proximal descending aorta. Ten patients (11%) were treated for congestive heart failure. The symptoms improved and anticongestive therapy was discontinued in 9. One patient with persistent congestive heart failure underwent therapeutic cardiac catheterization and 1 prominent SPC was embolized. CONCLUSIONS: The incidence of SPC in VLBW infants is much higher than previously reported. We postulate that SPC are bronchopulmonary communications that enlarge and/or proliferate in response to a given stimulus. These communications are associated with increased time on positive pressure ventilation and length of stay in the hospital. SPC may lead to pulmonary edema and should be searched for in VLBW infants with a more complicated course. Echocardiographic examination with color Doppler performed in premature infants to evaluate left to right shunts should include careful search for systemic to pulmonary collaterals.echocardiography, systemic to pulmonary collaterals, aortopulmonary collaterals, prematurity, pulmonary edema.

Poor stereopsis can support size constancy in albinism.

PURPOSE: The size of a retinal image is inversely related to the distance to the object that generates the image. Normal subjects therefore exhibit size constancy, in which the perceived size of an image is scaled according to its perceived distance. Albinos usually have such poor binocular vision that they perform very poorly on clinical tests for stereopsis. To investigate the functional consequences of this poor stereopsis, we investigated whether stereopsis in these subjects could support size constancy. METHODS: The stereothresholds of 10 albinos and 12 normal control subjects were measured. The presence of absence of size constancy was investigated by having subjects equate the subjective size of stereoscopically presented images whose image disparity indicated that they were at different distances. RESULTS: Laboratory results indicated that eight albinos (including five whose clinical tests indicated a lack of stereopsis) had measurable stereopsis of several thousand are seconds or better. Of these, four also exhibited size constancy. CONCLUSIONS: Albinos who do not demonstrate stereopsis on clinical tests can have stereoscopic perception that commonly used clinical tests do not detect. Moreover, some of these patients even use this poor stereopsis in judging the size of stereoscopically presented images.

Outcome of infants and children with dilated cardiomyopathy.

A review of 81 infants and children with dilated, poorly contracting left ventricles without associated structural abnormalities was undertaken to identify risk factors for poor outcome, which could be used in selecting candidates for cardiac transplantation. Significant atrial or ventricular dysrhythmias, or both, were detected on presentation or during follow-up in 24 patients. Arrhythmias were present in only 8 of 51 survivors (16%) but were detected in 16 of 30 patients (53%) who died (p less than 0.05). Patients dying suddenly were even more likely to have had documented dysrhythmias (8 of 11, p less than 0.05). Left ventricular shortening fraction was similar in survivors and nonsurvivors (14.9 +/- 1.0% vs 15.3 +/- 1.7%). Left ventricular end-diastolic pressure in 44 patients who had cardiac catheterization averaged 20.8 +/- 1.6 mm Hg. Left ventricular end-diastolic pressure was significantly higher in patients who died than in those who survived (29.5 +/- 2.2 vs 15.0 +/- 1.6 mm Hg, p less than 0.001). Analysis of actuarial survival revealed that mortality was highest during the first 6 months after presentation (19% mortality). Survival declined more gradually thereafter and was 70% at 2 years, 64% at 5 years and 52% after 11.5 years. Age at initial presentation did not have any significant impact on survival. However, left ventricular end-diastolic pressure greater than 25 torr was associated with a significantly increased mortality rate (p less than 0.05). Early cardiac transplantation should be considered in patients with markedly elevated left ventricular end-diastolic pressure or complex atrial or ventricular arrhythmias.

Findings on endomyocardial biopsy in infants and children with dilated cardiomyopathy.

Fifteen infants and children with dilated cardiomyopathy underwent transvascular endomyocardial biopsy. The light and electron microscopic findings were reviewed to evaluate the presence of lymphocytes as an indicator of active myocarditis. Both ventricles were biopsied in 13 patients, and the right ventricle only was biopsied in 2. None of the endomyocardial specimens obtained by biopsy revealed an inflammatory process. Interstitial fibrosis, myofiber hypertrophy, degeneration and necrosis were found. Ultrastructural abnormalities of the mitochondria, T tubules or Z bands were noted in approximately one-third of patients. Persistent, active myocarditis is an uncommon cause of dilated cardiomyopathy in children. Immunosuppressive therapy, which may be harmful, should be considered only after myocardial inflammation has been documented by endomyocardial biopsy.

Radionuclide angiographic evaluation of ventricular function in isolated congenitally corrected transposition of the great arteries.

Eight asymptomatic patients (mean age 19 years, range 7 to 32) with congenitally corrected transposition of the great arteries (CCTGA) underwent equilibrium gated radionuclide angiocardiography at rest and during supine bicycle exercise to assess systemic (morphologic right) and pulmonary (morphologic left) ventricular function. Five patients had normal intracardiac hemodynamic values, 2 had trivial atrioventricular valve regurgitation and 1 patient had trivial pulmonary ventricular outflow tract obstruction. Average exercise duration was 11 +/- 1 minute, with limitation due only to fatigue. At peak exercise, heart rate increased 225% and systolic blood pressure 152% over the rest value. Pulmonary ventricular ejection fraction at rest was 51 +/- 3% (mean +/- standard error of the mean); it did not change significantly at peak stress, 53 +/- 2%. Systemic ventricular ejection fraction was 48 +/- 4% at rest and increased to 64 +/- 4% at peak exercise (p less than 0.01). Count-based volume changes for the pulmonary chamber showed no significant change in end-diastolic or systolic counts at peak exercise (109 +/- 8% and 106 +/- 9% of rest value, respectively). However, end-diastolic counts decreased 13% (87 +/- 3% of rest value) and end-systolic counts 34% (62 +/- 7% of rest value) at peak exercise in the systemic ventricle. These data suggest normal systemic and impaired pulmonary ventricular function in patients with congenitally corrected transposition of the great arteries unaccompanied by significant associated lesions. These findings have important clinical implications in the setting of complex congenital heart disease in patients in whom a morphologic right ventricle functions as the systemic pumping chamber. Despite the pulmonary ventricular dysfunction, symptoms were not apparent at rest or during exercise.

Right ventricular growth potential in neonates with pulmonary atresia and intact ventricular septum.

The cardiac catheterization data and angiograms of 30 infants with pulmonary atresia and intact ventricular septum were reviewed to evaluate the growth potential of the right ventricle after transventricular pulmonary valvotomy. An index of right ventricular size based upon the tricuspid valve anulus, right ventricular inlet, and right ventricular outlet dimensions was used. Fourteen infants (Group I) were treated with systemic-pulmonary arterial shunts only, whereas 16 infants (Group II) underwent pulmonary valvotomy and 14 had shunting as well. Follow-up studies demonstrated the lack of right ventricular growth in Group I (right ventricular index of 7.0 +/- 3.2 preoperatively versus 7.0 +/- 2.0 postoperatively) and persistence of severe right ventricular hypertension (systolic pressure of 121 +/- 31 versus 120 +/- 48 mm Hg). In contrast, the right ventricular cavity increased in nine of 11 Group II infants who underwent valvotomy. Right ventricular index increased from 7.7 +/- 1.6 to 11.0 +/- 3.1 (p less than 0.01) and systolic pressure fell from 132 +/- 31 to 83 +/- 50 mm Hg (p less than 0.1). Early and late mortality in Group I was 50% (7/14), whereas only three of 16 Group II infants died (p greater than 0.1). It is concluded that pulmonary valvotomy should be attempted in all neonates with pulmonary atresia and intact ventricular septum in whom an outflow tract is identified angiographically to maximize the potential for right ventricular growth and increase its functional contribution to normal circulation.

Echocardiography and perfusion scintigraphy in the diagnosis of pulmonary arteriovenous fistula.

The echocardiographic and perfusion scintigraphic evaluation of an adolescent boy with a pulmonary arteriovenous fistula is reported. Contrast echocardiography following the rapid intravenous injection of indocyanine green dye was utilized to document extracardiac right-to-left shunting. Perfusion lung scintigraphy demonstrated the presence of a single large pulmonary arteriovenous fistula. Contrast echocardiography and perfusion scintigraphy are minimally invasive, safe and easily performed techniques for the rapid diagnosis of pulmonary arteriovenous fistula.

Update on infections involving permanent pacemakers. Characterization and management.

From January, 1974, to December, 1983, 75 patients with infections related to permanent pacemakers were successfully treated. Demographic characterization, mode of presentation, types of infecting organisms, potential predisposing factors, significance of a retained infected pacemaker lead, and various medical and surgical treatment methods were analyzed. Likely infecting organisms depended on the mode of presentation and the time of the infection. Dermatologic diseases accounted for a significant number of secondary infections. Removal of the entire infected pacing system was required for eradication of infection in 74 of 75 patients. In 31 patients, the infected system was removed at the same time that the new system was implanted. In 26 patients, a two-stage procedure was used that included a period of temporary pacing between explantation of the old system and implantation of the new. No difference in complications or incidence of reinfection was found between these two groups. Infections occurring within 2 weeks after operation accounted for 15% of the cases. In these patients, Staphylococcus aureus was the most common organism. In patients with later infections, Staphylococcus epidermidis was the most common.

A randomized clinical trial of inpatient family intervention. IV. Followup results for subjects with schizophrenia.

This is the last of a series of four papers, here focussing on schizophrenia, which report followup data up to 18 months from a randomized clinical trial of a psychoeducational family intervention (IFI), which was added to medication and limited to the inpatient phase of treatment, after which post-hospital care was not controlled. Our data suggested that patients with poor prehospital functioning (i.e., the chronic patients) may benefit from inpatient family intervention, but this therapeutic effect appears to be limited to females and does not appear until 18 months postadmission. Families of patients with schizophrenia also show benefit from having received IFI, the effect is seen earlier than with the patients, and is associated with achieving the goals of IFI. The results in the IFI group could not be accounted for by improved post-hospital medication compliance, but they may be related to this group's greater tendency to obtain further family treatment after discharge.

Aortic root replacement with the pulmonary autograft in children with complex left heart obstruction.

BACKGROUND: The optimal surgical treatment of complex (multiple level or recurrent) left ventricular outflow tract obstruction (LVOTO) in infancy is controversial. Staged procedures expose the children to the need for reoperation, and currently available techniques of aortoventriculoplasty are associated with the morbidities of biological and mechanical prostheses. METHODS: Between July 1992 and January 1996, we have performed 24 aortic root replacements with the pulmonary autograft in pediatric patients (< 18 years). Of this group, 8 were infants and children with complex LVOTO aged 9 days to 22 months (mean, 8.6 +/- 8 months) and weighing 3.3 to 10.2 kg (mean, 6.3 +/- 2.6 kg). The diagnoses were interrupted aortic arch/ventricular septal defect/subaortic stenosis in 3, recurrent aortic stenosis in 2, aortic stenosis and subaortic stenosis in 1, and aortic stenosis/subaortic stenosis/mitral stenosis/regurgitation in 2. All patients had undergone one to three previous operative procedures (mean, 1.5 +/- 0.8 procedures/patient). Preoperative echocardiographic peak LVOT gradient was 71.7 +/- 25 mm Hg (range, 40 to 110 mm Hg) and aortic annulus size was 7.2 +/- 2.3 mm (range, 4 to 10.6 mm). The surgical technique included replacement of the aortic root with the pulmonary autograft combined with incision of the conal septum to relieve subaortic stenosis or accommodate for size discrepancy between the aortic and pulmonary autograft root and a pulmonary homograft placed in the right ventricular outflow tract. RESULTS: There were no perioperative or late deaths at follow-up (range, 2 to 25 months; mean, 13.5 +/- 8 months). Mean hospital stay was 15 +/- 17 days (range, 4 to 53 days). Three children had the following complications: diaphragmatic paresis (1), delayed pericardial effusion (1), and atrioventricular block requiring a pacemaker (1). In follow-up, echocardiographic findings showed absent aortic regurgitation in 3 and trivial aortic regurgitation in 5, and no significant LVOTO (mean peak gradient, 6.2 +/- 7.6 mm Hg; range, 0 to 16 mm Hg). Pulmonary homograft regurgitation was absent in 5, trivial in 2, and moderate in 1. Peak right ventricular outflow tract gradient by echocardiogram was trivial in 7, and a significant gradient of 55 mm Hg has developed in 1 infant. There were no infective or embolic complications during follow-up. CONCLUSIONS: Our experience shows that aortic root replacement with the pulmonary autograft can be performed in children with excellent clinical results. The technique of root replacement combined with ventriculoplasty allows definitive and simultaneous relief of complex and multiple-level obstructive lesions. Considering the growth potential of the pulmonary autograft, this should be regarded as the optimal treatment modality in infants with complex LVOTO:

Gender and schizophrenia outcome: a clinical trial of an inpatient family intervention.

Several studies document sex differences in premorbid and intermorbid role functioning, showing less functional deficit among females. The specific nature of sex differences in role functioning is still poorly understood. The purpose of the present study was to investigate sex differences in symptomatology and role functioning in a sample of 92 inpatients hospitalized for an episode of DSM-III-diagnosed schizophrenic disorder. Patients were randomized at hospital admission to either of two treatment conditions: (1) multimodal hospital treatment with the addition of an inpatient family intervention (IFI) or (2) multimodal hospital treatment without IFI. Results indicated (1) sex differences in levels of substance abuse and antisocial behavior (worse for males both at admission and followup)--dimensions of psychopathology unrelated to the core features of schizophrenia; (2) superior family and occupational functioning in females at followup; and (3) superior clinical response of females to IFI. Data on family response to IFI suggest some ameliorative effects of IFI on critical family attitudes toward female patients as well as greater family compliance with IFI treatment among the families of females. Sex differences in intermorbid family and occupational functioning and response to a family-based psychosocial intervention are discussed in light of data on rejecting family attitudes toward the patient and sex differences in symptomatology. The possible influence of sex-differentiated social role demands on response to IFI is also discussed.

Late elongation of the cranial base.

A single logistic curve was fitted to serial data for three cranial base lengths (S-N, Ba-N, and Ba-S) in 33 boys and 26 girls. Elongation during pubescence plus adolescence is greater in boys than girls for each length. The maximum rate of pubescent elongation occurs earliest in Ba-N. There are no consistent sex differences in the maximum rates of elongation but they occur considerably earlier in girls. Similarly, girls reach 95% of their adult lengths at younger ages than boys.

Monocular dot-density cues in random-dot stereograms.

In the original random-dot stereograms (RDSs) invented by Julesz, binocular disparity could only take on values that were integral multiples of dot width. The other common method for constructing RDSs (the projection method) relaxes this restriction. However, the projection method can introduce dot-density cues into the monocular images. When polar projection is employed, density variation is introduced as an expression of perspective cues; when parallel projection is employed, there are no perspective cues, but density variation is nonetheless introduced whenever disparity varies as a function of horizontal position. de Vries, Kappers, and Koenderink [(1994) Vision Research, 34, 2409-2423] proposed to minimize the density cues by selecting half of the random dots from a uniform random distribution in the right-eye image, projecting them onto the cyclopean surface, and then projecting them back to the left eye image and vice versa. In this paper the precise nature of the density cues introduced by the projection method, and by de Vries et al.'s modification of that method, are derived. It is also shown that the projection method and its modification have very similar density cues near the medial sagittal plane when polar projection is employed, and that they have identical density cues over the entire random-dot field when parallel projection is employed.

Selectivity of cyclopean masking for the spatial frequency of binocular disparity modulation.

Previous studies have presented evidence for the existence of channels tuned to the spatial frequency (SF) of binocular disparity modulation. Bandwidths reported for masking curves were extremely narrow, possibly because of off-frequency viewing, whereby observers can best detect a signal with a channel tuned to an SF on the opposite side of the signal from the masker's SF, rather than with a channel tuned directly to the signal's SF. Herein are reported the results of four detection experiments. Experiment 1 measures unmasked threshold for detection of a cyclopean grating. Experiments 2-4 are masking experiments. Experiment 2 demonstrates that threshold for detection of a cyclopean grating is proportional to the intensity of masking noise, which is consistent with the operation of linear channels. Experiments 3 and 4 demonstrate that masking curves are narrower when obtained with narrowband-noise maskers than when obtained with notched-noise maskers, which render the off-frequency viewing ineffective. Implications for understanding the processing of cyclopean images are discussed.

A randomized clinical trial of inpatient family intervention. V. Results for affective disorders.

This paper reports the results at follow-up of a randomized clinical trial of combining family intervention with drug treatment during hospitalization for patients with affective disorder. The results suggest that female bipolar patients and their families benefited from family intervention, whereas unipolar patients and families did not. Patient outcome was positively correlated with the achievement of the goals of family intervention.