Diabetic charcot neuroarthropathy: prevalence, demographics and outcome in a regional referral centre.

BACKGROUND: Diabetic Charcot neuroarthropathy (DCN) is a devastating complication for people with diabetes mellitus. The failure to diagnose DCN and institute treatment in the acute phase leads to permanent deformity and significant morbidity. There is a paucity of data on the prevalence and characteristics of patients who have developed this complication of diabetes. AIMS: To determine the prevalence, clinical characteristics and outcomes of patients with DCN from 2006 to 2012. METHODS: Case finding was performed by searching three independent lists for the period 2006-2012 including: SYNGO radiology database, HIPE database of hospital discharges, and, combined list from podiatry, endocrinology, vascular surgery and orthopaedic clinics. A consensus meeting with chart review was undertaken to confirm diagnosis of DCN. A proforma was completed from chart review to determine clinical characteristics, initial treatment and outcomes for patients with DCN. RESULTS: Forty cases of DCN were identified, resulting in an estimated period prevalence of 0.3 %. The majority of patients were male (68 %); most patients had T2DM (73 %). Mean ± SD for age was 58 ± 10 years and mean duration of diabetes was 15 ± 9 years. In the acute phase of DCN, offloading was performed in 50 %. Bisphosphonates were administered to 5 % and surgery undertaken in 5 % of cases. 38 % of patients developed subsequent foot ulceration and 20 % required amputation. CONCLUSIONS: This is the first prevalence estimate of DCN in Ireland. These data suggest diagnosis of DCN is missed in the acute phase. There exists a significant risk of diabetic foot ulceration and amputation with DCN.

Primary immunodeficiency for the primary care provider.

Primary immunodeficiencies are a group of heterogeneous disorders resulting from defects affecting the function of ≥1 parts of the immune system. Current estimates of the prevalence of primary immunodeficiency disease are one in 1200 patients. In Ontario, where the average general practitioner follows 1300 to 2000 patients, an estimated two patients will have primary immunodeficiency. With new primary immunodeficiencies being described at an exponential rate, and those previously described becoming better understood, it is challenging for health care providers to stay up to date. Knowledge gaps delay diagnosis and treatment, leading to increased morbidity and mortality. The present review aims to provide the primary care provider with the tools necessary to recognize primary immunodeficiency and assist in establishing diagnoses.

Les immunodéficiences primaires désignent un groupe de troubles hétérogènes causés par des déficits de la fonction d'au moins une partie du système immunitaire. Les évaluations actuelles de la prévalence des immunodéficiences primaires sont de un cas sur 1 200 patients. En Ontario, où l'omnipraticien moyen suit de 1 300 à 2 000 patients, on estime que deux de ces patients seront atteints d'une immunodéficience primaire. Puisque de nouvelles immunodéficiences primaires sont décrites à un taux exponentiel et que celles qui sont déjà décrites sont de mieux en mieux comprises, il est difficile pour les professionnels de la santé de demeurer à jour. Les lacunes sur le plan du savoir retardent le diagnostic et le traitement, ce qui accroît la morbidité et la mortalité. La présente analyse vise à fournir au dispensateur de soins de première ligne les outils nécessaires pour identifier les immunodéficiences primaires et contribuer à poser les diagnostics.

TGF-ß-mediated airway tolerance to allergens induced by peptide-based immunomodulatory mucosal vaccination.

We sought to modulate mucosal immune responses using neonatal vaccination to avert the development of allergic airways disease (AAD). Pulmonary pathology in AAD is driven by T helper (TH)2 cytokines, in particular interleukin (IL)4 and IL13, the expression and actions of which are regulated by the transcription factor STAT6. We developed a peptide homolog of STAT6, STAT6-IP. Neonatal mice given, intranasally, STAT6-IP, in an effort to modulate de novo airways immune responses, developed tolerance following subsequent allergen sensitization, with either ovalbumin or ragweed allergens, as demonstrated by reduced TH2 cytokines and specific immunoglobulin (Ig)E and the significant increases in the latency-associated peptide (LAP)(+) T-regulatory (Treg) cell subset and expression of transforming growth factor (TGF)-ß. This regulatory phenotype was transferrable by CD4(+) T cells or CD11c(+) dendritic cells (DCs) derived from STAT6-IP-vaccinated mice. Anti-TGF-ß treatment during allergen sensitization, however, re-established the pro-inflammatory TH2 response. Thus, neonatal STAT6-IP vaccination induces prospective TGF-ß-dependent tolerance to allergen and constitutes a novel highly effective immunomodulatory allergy prevention strategy.

Exercise training improves activity in adolescents with congenital heart disease.

OBJECTIVES: To ascertain if motivational techniques and a structured exercise programme can increase activity in adolescents afflicted with congenital heart disease (CHD). DESIGN: Prospective randomised controlled trial. SETTING: One hundred and forty-three patients aged 12-20 years attending the tertiary centre for paediatric cardiology in Northern Ireland. MAIN OUTCOME MEASURES: Increase in exercise capacity as assessed by duration of exercise stress test, and number of minutes spent in moderate to vigorous physical activity (MVPA) per day. RESULTS: Eighty-six patients were men (60%), mean age was 15.60 ± 2.27 years. Seventy-three percent were considered to have major CHD. Seventy-two participants were randomised to the intervention group. Following intervention, duration of exercise test increased by 1 min 5 s for the intervention group (p value 0.02) along with increase in predicted VO2Max (p value 0.02). There was a significant increase in minutes of MVPA per day for the intervention group from baseline to reassessment (p value <0.001) while MVPA remained much the same for the control group. Fourteen patients met the current recommendation for more than 60 min MVPA per day at baseline. This doubled to 29 participants at reassessment. There were no adverse effects or mortalities reported. CONCLUSIONS: Exercise training is safe, feasible and beneficial in adolescents with CHD. Psychological techniques can be employed to maximise the impact of interventions. TRIAL REGISTRATION NUMBER: ISRCTN27986270.

Preceptorship: professional development and support for newly registered practitioners.

Preceptorship is one aspect of continuous professional development which is vital to support healthcare professionals in the delivery of safe, effective, person-centred care. This article outlines the various aspects of preceptorship for nurses, midwives and specialist community public health nurses in Northern Ireland. It is hoped that the elements within it have transferability across other healthcare professions. The article will help the reader understand where preceptorship fits within a professional development and support continuum.

Effective treatment of experimental ragweed-induced asthma with STAT-6-IP, a topically delivered cell-penetrating peptide.

BACKGROUND: Treatment of allergic airways disease including asthma remains primarily local immunosuppression with topical corticosteroid and symptomatic management with antihistamines and anti-leucotrienes. We have developed a novel topical therapy designed to specifically inhibit the events associated with Th2 cell activation. OBJECTIVE: We assessed the efficacy of our cell-penetrating STAT-6 inhibitory peptide (STAT-6-IP), a novel treatment for allergic airways disease, in a model of chronic ragweed-induced asthma. METHODS: Six- to eight-week-old mice were sensitized over 5 weeks with intranasal (IN) exposures to whole ragweed allergen without adjuvant. Mice were then IN challenged with Amba 1 with and without treatment IN with STAT-6-IP and allergic responses assessed. Two weeks later, some animals were rechallenged with Amba 1 with or without STAT-6-IP. RESULTS: Animals exposed to IN ragweed developed significant airway hyperresponsiveness and airways inflammation upon challenge. Cell cultures showed increases in Th2 cytokines IL-4 and IL-13. Topical STAT-6-IP treatment reduced production of Th2 cytokines, demonstrated increased expression of IL-10 and reduced frequency of cultured IL-4 positive CD4+ T cells derived from treated mice, suggesting that STAT-6-IP treatment may be immunomodulatory. Airway responsiveness to methacholine challenge in the treatment group was similarly reduced to that of the non-allergic PBS-exposed animals. Importantly, STAT-6-IP-treated mice remained hyporesponsive following second ragweed challenge 2 weeks after treatment. CONCLUSIONS AND CLINICAL RELEVANCE: These data suggest that topical application of the STAT-6-IP is sufficient to inhibit allergic airways responses in animals chronically sensitized and challenged with ragweed. Data show that a single topical treatment course is sufficient to block signs of allergic responses to ragweed in the airways for at least 2 weeks. STAT-6-IP is a novel potential treatment for chronic allergic asthma.

Intravenous immunoglobulin attenuates airway hyperresponsiveness in a murine model of allergic asthma.

BACKGROUND: Intravenous immunoglobulin (IVIG) has potent anti-inflammatory and immune-modulating properties. IVIG has been utilized as a steroid-sparing agent in severe asthma, but the results of clinical trials have been conflicting. OBJECTIVE: To determine whether IVIG is able to attenuate bronchial reactivity, pulmonary inflammation and T cell function using a murine model of allergic airways disease. METHODS: BALB/c or C57BL/6 mice were sensitized to ovalbumin (OVA) or a phosphate-buffered saline control using local nasal sensitization, and then received five intranasal challenges on days 28-32 before sacrifice. Mice were treated intraperitoneally with either IVIG (1-2 g/kg) or equivalent human serum albumin 24 h before the first OVA challenge. Bronchial reactivity to methacholine was examined using the FlexiVent small animal ventilator. We evaluated pulmonary histology, mRNA from lung digests for T-helper type 2 (Th2)-related genes and bronchoalveolar lavage for cell counts and cytokines. Splenocytes were utilized to study OVA-induced cell proliferation, cytokine production and dendritic cell maturation. RESULTS: IVIG markedly attenuated the perivascular and peribronchial pulmonary inflammation, and decreased bronchial hyperresponsiveness to methacholine. IVIG treatment of splenocytes from sensitized animals diminished cellular proliferation to OVA, whereas IVIG treatment in vivo markedly attenuated OVA-driven splenocyte proliferation. This is accompanied by diminished IL-13 and TNF-α levels in splenocyte culture, decreased expression of Jagged-1, increased Delta-4 and decreased GATA-3 mRNA levels, signs that IVIG has suppressed the expected Th2 response that accompanies repeated allergen exposure. Increased regulatory T cells were found in draining pulmonary lymph nodes in IVIG-treated mice but not in controls. CONCLUSIONS AND CLINICAL RELEVANCE: IVIG was effective in ameliorating allergic airway disease in our model. IVIG may be a promising adjunct therapy requiring further study for patients with severe asthma.

Examination of the physical and psychosocial determinants of health behaviour in 4-5-year-old children with congenital cardiac disease.

OBJECTIVES: To assess the general health and activity levels of 4- and 5-year-old children after intervention for congenital cardiac disease. METHODS: Health behaviour outcomes were assessed in 91 children who had surgery or catheter intervention for congenital cardiac disease. The children were classified into four groups according to severity. The main parameters of classification were the presence of residual symptoms, frequency of visits to general practitioner or the Accident and Emergency Department, and ability to participate in physical activity according to a calculated "activity score". RESULTS: Children had very few residual symptoms after "corrective surgery". Those with complex congenital cardiac disease post-Fontan-type repair still had symptoms on average 18.2 days per month. Surprisingly, the complex group had fewer days "sick" from non-cardiac causes and had fewer visits to general practitioner or Accident and Emergency Departments. Regression analysis indicates that three variables had significant relevance to the general practitioner or Accident and Emergency visits: complex congenital cardiac disease, fewer visits; Townsend score - more deprivation - more visits; and maternal worry - higher maternal worry score - more visits. Regression analysis indicates that lower activity score is significantly related to complex cardiac disease and higher maternal worry score. CONCLUSIONS: The majority of this group of 4- and 5-year-old children had few residual symptoms and had good exercise tolerance. Maternal worry is a significant factor in influencing both activity levels and frequency of unscheduled health service demands - general practitioner or Accident and Emergency visits.

A controlled trial of early interventions to promote maternal adjustment and development in infants born with severe congenital heart disease.

Abstract Background Congenital heart disease can have a negative impact on both infant development and maternal adjustment. This study considered the impact of a new programme of early psychosocial interventions on such outcomes, following the birth of a child with severe congenital heart disease. Methods Seventy infants and their mothers were assigned to an intervention or control group based on order of presentation to the unit. Interventions aimed at bolstering mother-infant transactions, through psychoeducation, parent skills training and narrative therapy techniques were implemented. Results Clinically and statistically significant gains were observed at 6-month follow-up on the mental (but not the psychomotor) scale of the Bayleys-II. Positive gains were also manifested on feeding practices, maternal anxiety, worry and appraisal of their situation. Conclusions A programme of generalizable psychosocial interventions is shown to have a positive impact on the infant with severe congenital heart disease and the mother.

Using pedometers to monitor walking activity in outcome assessment for pulmonary rehabilitation.

BACKGROUND: The purpose of this study was to determine whether a commercially available pedometer could detect changes in home-based walking activity among chronic obstructive pulmonary disease (COPD) patients completing pulmonary rehabilitation (PR). METHODS: Patients with COPD referred to outpatient PR wore a pedometer to count steps for 1 week at the beginning and 1 week at the end of PR. Patients also completed the 6-min walk test (6MWT), the Medical Research Council (MRC) dyspnea scale and the self-administered chronic respiratory disease questionnaire (CRQ) at the beginning and the end of PR. Paired t tests were used to compare pre- and post-PR changes in outcome variables. RESULTS: 45 patients with severe COPD (forced expiratory volume in 1 second [FEV(1)] 45% +/- 18% of predicted) participated in a total of 17.4 +/- 4.6 PR sessions. Significant improvements in 6MWT (49 +/- 59 m; p < .0001), MRC dyspnea score (-0.64 +/- 0.96 units; p = .003) and CRQ score (10 +/- 18 units; p = .0007) were noted following PR. Patients whose pedometer-measured steps were within 20% of observed counted steps were included in the analysis. Pedometer counts increased by 33 +/- 149 steps per hour worn after, as compared with before PR (p = .14). There was a significant inverse relationship between baseline pedometer counts and change in pedometer counts per hour post-PR (r = -.46; p = .001). Patients with low baseline activity levels had significant increases in pedometer activity (88 +/- 30 counts per hour worn) and a greater reduction in MRC dyspnea score (-0.94 vs -0.29; p = .04) following PR, whereas those with higher baseline activity levels had a decrease in pedometer activity (-19 +/- 29 counts/hour; p = .015). CONCLUSIONS: A standard pedometer worn at the waist did not detect changes in lower extremity activity following PR. This negative finding occurred despite demonstrated improvements in dyspnea, exercise tolerance and quality of life measures. Although pedometers are inexpensive and easy to use, they may not be sensitive enough to be used routinely as an outcome measure for PR.

The influence of obesity on pulmonary rehabilitation outcomes in patients with COPD.

Although obesity is increasing in prevalence, relatively little attention has been given to its impact on outcomes in patients with chronic obstructive pulmonary disease (COPD) completing pulmonary rehabilitation. We conducted a retrospective chart review of 114 patients with COPD who completed outpatient pulmonary rehabilitation at our center. Body habitus categories were determined based on body mass index (BMI). Underweight patients (BMIA 30A kg/m(2)) were compared with non-obese patients in the following areas: forced expiratory volume in 1A s (FEV(1)) percent predicted, the 6-min walk distance (6MWD), health status, the number of unsupported arm lifts per minute, and functional performance. Health status was determined using the Self-Reported Chronic Respiratory Questionnaire (CRQ-SR), which has dimensions of dyspnea, fatigue, emotion, and mastery. Functional performance was determined using the Pulmonary Functional Status Scale Daily Activities subscore. Compared with non-obese patients, obese patients had a higher FEV(1) percent-predicted (44A +/-A 15% vs 52A +/-A 16%; PA =A 0.01), yet had lower 6MWD (269A +/-A 11 vs 203A +/-A 13; PA =A 0.0002), lower functional status, and greater fatigue at initial evaluation. However, the two groups had similar walk-work, which adjusts for differences in weight. Despite the baseline differences, both groups improved similarly following pulmonary rehabilitation (change in 6MWD was 52A +/-A 7A m in the non-obese patients versus 47A +/-A 9 in the obese patients; PA =A 0.65). Our study suggests that obese COPD patients are referred to pulmonary rehabilitation at an earlier spirometric stage of their disease, but have a poorer exercise performance, a greater degree of functional impairment and greater fatigue levels. This is probably, largely because of the effect of an increased weight burden. However, obesity did not seem to adversely affect the pulmonary rehabilitation outcomes.

Determinants of neuropsychological and behavioural outcomes in early childhood survivors of congenital heart disease.

AIMS: To evaluate the relative effect of cyanosis, surgical interventions and family processes on neuropsychological and behavioural outcomes in 4-year-old survivors of serious congenital heart disease (CHD). METHODS: 90 children with a range of cyanotic and acyanotic conditions, who underwent either corrective or palliative surgery, completed a neuropsychological and behavioural evaluation. Families of participants were also profiled by evaluation of maternal mental health, worry, social support, parenting style and family functioning. RESULTS: Compromised neuropsychological outcomes were associated with a combination of cyanotic conditions and open-heart surgery, but this was not exacerbated by having a complex, palliative, status. Both cyanotic and acyanotic conditions were associated with specific sensorimotor delays, regardless of method of the correction. Only children with complex conditions and palliative interventions seemed at risk of poor behavioural outcomes; indeed, children with cyanosis with complete repair showed favourable behavioural outcomes compared with controls. Multivariate analyses highlighted the sometimes greater relevance of family processes (eg parenting style, maternal mental health and worry), rather than disease or surgical factors, in predicting especially behavioural outcomes. CONCLUSIONS: The findings (1) suggest a more complex relationship between cyanosis, surgical methods of correction, neuropsychological and behavioural outcomes than previously charted, (2) highlight that family processes may be aetiologically more important than disease and surgical factors, and (3) indicate specific targets for secondary prevention programmes for this at-risk population.

The trajectory of change over multiple outcome areas during comprehensive outpatient pulmonary rehabilitation.

Although pulmonary rehabilitation has proven effectiveness in multiple outcome areas, the optimum duration of this intervention is not clear. We evaluated in an observational study the trajectory of change in upper and lower extremity exercise performance, exertional dyspnea and health status over the course of 12 weeks (24 sessions) of pulmonary rehabilitation in individuals with chronic obstructive pulmonary disease. Demonstrating a plateau in response in these areas might be of practical use for pulmonary rehabilitation programs. We measured outcomes at baseline and at four-session (two week) intervals over the course of our comprehensive outpatient pulmonary rehabilitation program. These included treadmill endurance time at approximately 85% of initial maximal workrate, the number of arm lifts per minute, dyspnea at isotime during treadmill walking and the Chronic Respiratory Disease Questionnaire (CRQ) total score. Thirteen patients with chronic obstructure pulmonary disease (COPD) (five male, eight female) were studied; their age was 66 +/- 8 years and their FEV1 was 34 +/- 11% of predicted. Improvement was noted in all four outcome areas very early in the course of pulmonary rehabilitation. Treadmill endurance time and arm lifts increased significantly over baseline by the fourth and eighth session, respectively, and both increased in a near-linear fashion throughout pulmonary rehabilitation. Exertional dyspnea and CRQ also improved very early, with each showing a significant change from baseline by the fourth session. Their improvement, however, appeared to plateau relatively early during the course of pulmonary rehabilitation. Although the numbers studied are small and the applicability of these results to other programs is undetermined, this study does suggest that 20 or more sessions are needed for optimal acute changes in exercise performance, but improvement in dyspnea and quality of life may occur earlier.

Interleukin-13-dependent bronchial hyper-responsiveness following isolated upper-airway allergen challenge in a murine model of allergic rhinitis and asthma.

BACKGROUND: We have previously shown that isolated allergic sensitization and challenge of the upper airway results in lower-airway inflammation, which supports the concept of the united airways. OBJECTIVE: This study investigates the hypothesis that isolated upper-airway allergic sensitization is sufficient to induce bronchial hyper-responsiveness (BHR), characteristic of asthma, and that IL-13 is an essential mediator in both the upper and lower airways. METHODS: BALB/c mice were sensitized and challenged by intranasal instillation of allergen ovalbumin (OVA) using our standard protocol. BHR to methacholine was determined and inflammation in nares and lung was assessed. RESULTS: Isolated intranasal application of allergen in awake animals resulted in almost exclusive deposition in the upper airways while in anaesthetized mice there was almost equal distribution in the upper and lower airways. We have demonstrated significant BHR to methacholine challenge in animals receiving OVA only in the upper airway. Also noted was concomitant increase in eosinophilic infiltrates in lung and nares as well as increased granulocytes and IL-13 levels in bronchoalveolar lavage (BAL) fluid. Using a polyclonal anti-IL-13 antibody we have shown inhibition of airways inflammation, both in nares and in lung with significant reduction of granulocytes in BAL from anti-IL-13 treated mice (P<0.0001). Anti-IL-13 treatment also abrogates allergen-induced BHR (P<0.01). CONCLUSION: These data suggest that isolated upper-airway allergen deposition initiates allergic responses along the entire airway. IL-13 mediates both airway inflammation and BHR and may play a role in the communication between the upper and lower airways.

A prospective cohort study comparing hospital admission for gastro-enteritis with home management.

OBJECTIVES: To compare physical and psychological outcomes in children presenting at Accident and Emergency Departments (A&E), diagnosed with gastro-enteritis and admitted to hospital with those of a similar age, sex and severity of illness discharged home. The physical and psychological well-being of children in these two groups, in the month after the episode, were compared as was further use of health care services. DESIGN: A prospective cohort study. METHODS: A comparison of 116 children aged 1-6 years with gastro-enteritis, presenting at A&E over a 6 months period. Admitted children were compared with children discharged, of a similar age, sex and illness severity (triage score) with follow-up at 1 week and 1 month. Clinical history, psychosocial factors, investigations and outcomes were recorded at presentation and physical, psychological and family outcomes at 1 week and 1 month. RESULTS: Of 116 children, 112 (97%) completed the study (56 in each group). No differences were detected in psychosocial factors, socio-economic status, family factors, time of arrival at A&E or waiting times. Parental perception of illness was greater in the admitted group (P < 0.005), but was recorded after the decision on admission was made. At 1 week follow-up admitted children had increased separation anxiety compared with children who were discharged (P < 0.05), but this difference disappeared at 1 month. Clinical outcomes were the same for both groups, although admitted children had more investigations (91% vs. 39%). Parents were equally satisfied with their child's treatment, but one-third of children in both groups sought further consultation with a health professional in the following week. CONCLUSIONS: There is no statistically significant difference in socio-demographic data, time of arrival at A&E, waiting times, clinical and psychosocial outcomes in children with acute gastro-enteritis admitted to hospital compared with a group of children of similar age, gender and severity of illness managed at home. However, parents seek reassurance and follow-up of acutely ill children, even if the child is admitted to hospital, which has service and resource implications.

Cognitive biases and addiction: an evolution in theory and method.

An evolution in theoretical models and methodological paradigms for investigating cognitive biases in the addictions is discussed. Anomalies in traditional cognitive perspectives, and problems with the self-report methods which underpin them, are highlighted. An emergent body of cognitive research, contextualized within the principles and paradigms of cognitive neuropsychology rather than social learning theory, is presented which, it is argued, addresses these anomalies and problems. Evidence is presented that biases in the processing of addiction-related stimuli, and in the network of propositions which motivate addictive behaviours, occur at automatic, implicit and pre-conscious levels of awareness. It is suggested that methods which assess such implicit cognitive biases (e.g. Stroop, memory, priming and reaction-time paradigms) yield findings which have better predictive utility for ongoing behaviour than those biases determined by self-report methods of introspection. The potential utility of these findings for understanding "loss of control" phenomena, and the desynchrony between reported beliefs and intentions and ongoing addictive behaviours, is discussed. Applications to the practice of cognitive therapy are considered.

Building Canada's health research capacity within the framework of the Canadian Institutes of Health Research.

The establishment of the Canadian Institutes of Health Research (CIHR) generated considerable excitement about the capacity for health research in Canada. The long term success of the CIHR will be determined, in part, by its ability to recruit, train and retain a cadre of talented researchers. During a workshop to develop the research agenda for one of the proposed institutes within the CIHR, a national, multidisciplinary group of clinical and basic science research trainees were invited to present their views about the challenges that face Canadian researchers of tomorrow. The objective of this paper is to present the challenges associated with recruiting, training and retaining health researchers, and to identify new opportunities provided by the creation of the CIHR. The present paper concludes with suggestions that may improve the success of researchers and, ultimately, the success of the CIHR.

Isolated extra-corporeal coronary perfusion circuit for use during off-pump coronary artery bypass grafting.

Cardiovascular surgery would not have developed into its present form without the heart-lung machine. In coronary artery bypass grafting (CABG), cardiopulmonary bypass allows accurate, all site, complete revascularization in a way convenient to the surgeon. The aim of this circuit is to find new ways to reduce invasiveness of CABG and to create new basis conditions for successful coronary bypass grafting on the beating heart. Manipulation of the heart compromises collateral coronary flow, especially to critically narrowed coronaries. This circuit standardizes our method for perfusing blood through the coronary bypass grafts with controlled positive pressure as each distal anastomosis is made, and it preserves collateral coronary flow, while facilitating construction of the remaining distal anastomoses.

Psychological management of intractable seizures in an adolescent with a learning disability.

Psychological interventions aimed at seizure management are described with a 14-year-old boy with a learning disability and intractable epilepsy. Baseline records suggested that a majority of tonic seizures and 'drop attacks' were associated with going off to sleep and by environmental 'startles'. Psychological formulation implicated sudden changes in arousal levels as an underlying mechanism of action. Cognitive-behavioural countermeasures were employed to alter arousal levels and processes in different ways in different 'at-risk' situations. A multiple baseline design was used to control for non-specific effects of interventions on non-targeted seizures. Results suggested significant declines in the number of sleep onset and startle-response seizures were attained by these methods. Gains were maintained at 2-month follow-up.

A long-term follow-up of cognitive, emotional, and behavioural sequelae to Reye syndrome.

Eighteen adolescents who had survived Reye syndrome (RS) in early childhood were assessed on cognitive, emotional, and behavioural variables in a second follow-up study tracking this group. Siblings were used as controls. The entire group with RS had survived with no obvious neurological damage at the first follow-up study. Indeed, current findings suggested that long-term cognitive, emotional, and behavioural functioning was comparable to siblings in approximately half of the group with RS. However, two factors were associated with a less favourable outcome. Cognitive, emotional, and behavioural functioning were significantly poorer in the subgroup of survivors whose illness had occurred in the first year of life. In addition, loss of consciousness, although the association with poor outcome was not as noticeable, was also associated with relative deficits on some scales of cognitive ability. Many of these deficits had not been obvious at the first follow-up and the importance of neurodevelopmental factors are considered. Finally, the implications of these findings for research and interventions in RS and other such encephalopathies are discussed.