Burden Experienced by Primary Caregivers of Children With Psychotic Disorders and at Clinical High Risk for Psychosis.

BACKGROUND: Despite the existing research exploring caregiver burden in adult psychosis, few studies have examined the experience of providing care to children diagnosed with psychotic disorders (PDs) and those identified as having clinical high risk for psychosis (CHR-P). OBJECTIVE: This study measured the level of burden in caregivers of children with PD and CHR-P and examined associated risk factors, including social support, caregiver-child relationship, severity of illness, and frequency of psychiatric hospitalizations. METHODS: A total of 56 caregivers completed validated measures and provided demographic information. Measures included the Zarit Burden Interview, the Multidimensional Scale of Perceived Social Support, the Behavior Assessment System for Children, Third Edition, Parenting Relationship Questionnaire-Child and Adolescent Form (BASC-3 PRQ-CA), and the Clinical Global Impression-Severity scale. RESULTS: The majority of caregivers were women (86%), mothers (84%), White (63%), married (66%), working full-time (50%), college-educated (79%), and whose mean age was 45.7 years (SD = 8.09). Nearly half of the caregivers (45%) reported a high level of caregiver burden, 39% rated their burden in the mild to moderate range, and 16% reported little to no burden. There was no significant difference in mean burden between PD and CHR-P groups. Higher caregiver burden was associated with lower levels of social support (r = -.408, p = .002), lower levels of parenting confidence (r = -.514, p < .001), higher levels of relational frustration (r = .612, p < .001), and higher severity of illness (r = .316 p = .025). CONCLUSIONS: These findings underscore the critical unmet need for support for caregivers of children with PD and CHR-P. Applications to clinical practice are discussed.

Adolescent Beliefs About Hookah and Hookah Tobacco Use and Implications for Preventing Use.

INTRODUCTION: Hookah tobacco use is popular among youths and there is evidence that perceived risks and normative beliefs are associated with hookah use. The aim of this study was to further examine associations between perceived risks of hookah use, normative beliefs, and lifetime hookah use among youths. METHODS: Participants were adolescents aged 12 to 17 years (n = 257, mean [standard deviation] age, 14.9 [1.6] years, 40% nonwhite, 66% female) attending well-visit checkups at an urban pediatric clinic. Participants completed a survey of measures of cigarette smoking, risk factors for smoking, hookah use, perceived risks, and normative beliefs. Analyses examined associations among lifetime hookah use, beliefs about hookah use, and other smoking risk factors. RESULTS: Overall, 15% of the sample had ever tried hookah smoking and 60% had ever tried cigarette smoking or were susceptible to cigarette smoking. Of those who had tried hookah smoking, 84% had also tried cigarettes or were susceptible to trying cigarettes (P < .001). One-third (33%) indicated that hookah smoking was less harmful than cigarettes, 38% indicated hookah smoking is less addictive than cigarettes, and 48% perceived that hookah smoking is somewhat or very socially acceptable among friends. In multivariable analyses adjusting for demographic and cigarette smoking-related factors, perceiving hookah use to be somewhat or very socially acceptable was associated with a significantly higher odds of ever having tried hookah smoking. CONCLUSION: The study findings indicate that stronger perceived social acceptability of hookah use is associated with a higher likelihood of trying hookah smoking among youths. These normative beliefs may be important targets of interventions aimed at preventing hookah use among youths.

"Blended" therapy: The development and pilot evaluation of an internet-facilitated cognitive behavioral intervention to supplement face-to-face therapy for hoarding disorder.

Mixed findings regarding the long-term efficacy of cognitive behavior therapy (CBT) for the treatment of hoarding has led to the investigation of novel treatment approaches. "Blended" therapy, a combination of face-to-face (f2f) and online therapy, is a form of therapy that enables longer exposure to therapy in a cost-effective and accessible format. Blended therapy holds many benefits, including increased access to content, lower time commitment for clinicians, and lower costs. The aim of the present study was to develop and evaluate a "blended" treatment program for hoarding disorder (HoPE), involving 12-weeks of face-to-face group therapy, and an 8 week online therapist assisted program. A sample of 12 participants with hoarding symptomology were recruited from the Melbourne Metropolitan area, and were involved in one of two conditions; 12 weeks group therapy +8 weeks online therapy (bCBT) or 12 weeks group therapy +8 weeks waitlist +8 weeks online therapy. Questionnaires were completed at all time points. The 8-week online component consists of 8 CBT-based modules, addressing psychoeducation, goal setting, motivation, relapse prevention and other key components. No significant differences were found over time between the bCBT group and waitlist control group, however trends suggested continued improvement in overall hoarding scores for the bCBT group, when compared to the waitlist control group. There were significant differences in scores from pre-treatment to 28 weeks, suggesting that all participants who were involved in the online intervention showed continued improvement from pre-treatment to post-treatment. This study highlights the potential benefit of novel formats of treatment. Future research into the efficacy of blended therapy would prove beneficial.

Mindfulness- and acceptance-based interventions for psychosis: Our current understanding and a meta-analysis.

In promoting optimal recovery in persons with psychosis, psychological interventions have become a key element of treatment, with cognitive behavioural therapy being widely recommended in clinical practice guidelines. One key area of development has been the trialling of "third wave" cognitive behavioural interventions, which promote mindfulness, acceptance and compassion as means of change. Trials to date have demonstrated encouraging findings, with beneficial effects observed on measures of psychotic symptoms. This meta-analysis evaluated the efficacy of third wave interventions for the treatment of psychosis in randomised controlled trials, with psychotic symptoms as the primary outcome. Overall, 10 studies were included. The primary outcome demonstrated a small but significant effect (g=0.29) for third wave interventions compared with control post-treatment. Trials of group format mindfulness-based interventions showed larger effects (g=0.46) than individual acceptance and commitment therapy based interventions (g=0.08), although methodological differences between trials were noted. Among secondary outcomes, a moderate, significant treatment effect (g=0.39) was found for depressive symptoms, but no significant effects were found on specific measures of positive and negative symptoms, hallucination distress, or functioning/disability. A moderate effect on mindfulness (g=0.56) was observed, but not on acceptance. Overall, findings indicate that third wave interventions show beneficial effects on symptoms in persons with psychotic disorders. However, further research is required to determine the efficacy of specific models of treatment.

Totally endoscopic robotic coronary artery bypass surgery.

PURPOSE OF REVIEW: To assess the current status and methods of robotic totally endoscopic coronary artery bypass (TECAB) surgery and discuss important anesthetic considerations. RECENT FINDINGS: Technological and surgical advances in robotics have led to the evolution of TECAB surgery from a single-vessel procedure to quadruple-vessel bypass. TECAB is now a reproducible technique, with a low incidence of mortality and morbidity and superior quality of life. Although early cohorts of patients are still being observed for long-term outcomes, initial and midterm outcomes are comparable to those of conventional coronary artery bypass. TECAB is also associated with specific challenges for the anesthesiologist. SUMMARY: TECAB surgery is a feasible alternative to open coronary artery bypass surgery in selected patient populations. Appropriate patient selection, team training, and stepwise application of the procedure are crucial. TECAB is associated with a unique set of challenges, requiring a skilled operative team. As robotic technology and surgical expertise evolve, this technology will find wider application in an increasing high-risk patient population that will require the support of a skilled anesthesiology team.

Use of partial venovenous cardiopulmonary bypass in percutaneous hepatic perfusion for patients with diffuse, isolated liver metastases: a case series.

OBJECTIVES: Diffuse isolated liver metastases are the dominant mode of tumor progression in a number of cancers and present a major treatment challenge for oncologists. An experimental treatment, percutaneous hepatic perfusion (PHP), utilizes partial venovenous cardiopulmonary bypass to allow administration of high-dose chemotherapy directly and solely to the liver with filtration of chemotherapeutic agents from the blood prior to its return to the systemic circulation, thereby minimizing toxic systemic effects. The following case series describes the management of 5 patients with metastatic melanoma undergoing serial PHPs. DESIGN: A single-center experience from a national multi-center random-assignment trial comparing PHP to best alternative care (BAC) in patients with diffuse melanoma liver metastases. SETTING: A tertiary care hospital. PARTICIPANTS: Five patients with metastatic melanoma to the liver. INTERVENTION: Five patients underwent a total of fifteen PHPs using a venovenous bypass circuit with hemofiltration, receiving hepatic intra-arterial melphalan, 3 mg/kg of ideal body weight, for 30 minutes with a total of 60 minutes of hemofiltration. MEASUREMENTS AND MAIN RESULTS: Five patients tolerated the procedure well with transient hemodynamic and metabolic changes. CONCLUSIONS: In patients with diffuse isolated liver metastases, PHP is a safe and well-tolerated procedure that can be performed more than once and is associated with marked anti-tumor activity in some patients.

Is an intraaortic balloon pump a contraindication to robotic totally endoscopic coronary artery bypass?

BACKGROUND: The success of robotic totally endoscopic coronary artery bypass (TECAB) in recent years has led to the expansion of the procedure to patients with more severe disease. Outcomes with these patients have not yet been well characterized, and no reports on TECAB performed in patients with a preoperatively placed intraaortic balloon pump (IABP) are available. We present our initial experience with this patient population. PATIENTS AND METHODS: We evaluated 5 patients with unstable angina or impaired left ventricular function requiring a preoperatively placed IABP who underwent TECAB using the daVinci telemanipulation system. Procedures were performed either on the beating heart using an endostabilizer (n = 2) or on the arrested heart using remote access perfusion and aortic balloon endoocclusion (n = 3). The median patient age was 67 years (range, 41-73 years), with a median preoperative ejection fraction of 43% (range, 26%-58%) and median EuroSCORE of 5 (range, 3-8). RESULTS: There were no major intraoperative technical issues. The median length of stay in the hospital and intensive care unit was 8 days (range, 5-13 days) and 66 hours (range, 41-142 hours), respectively. There were no intraoperative or 30-day mortalities. CONCLUSIONS: This early experience suggests that TECAB is feasible in patients with a preoperatively placed IABP. Both the beating heart and arrested heart versions can be used in this patient population, further broadening the spectrum of applicability of this procedure.