Operationalization, implications and correlates of the cultural deviance criterion for ICD-11 and DSM-5 prolonged grief disorder.

Prolonged Grief Disorder (PGD) is included in ICD-11 and DSM-5-TR and includes a requirement of cultural deviance. This study examined endorsement rates and factors associated with endorsement of this criterion among Danish bereaved spouses (n = 425) and their adult children (n = 159) four years post-loss. In total, 7.5% (n = 44) participants endorsed this criterion. Both including and excluding the criterion, the prevalence rates for probable DSM-5-TR PGD were 1.4% (n = 8) and 1.7% (n = 10), respectively and for probable ICD-11 PGD were 1.4% (n = 8) and 2.2% (n = 13), respectively. Age and gender of the deceased, age of the bereaved, greater grief severity, and comorbid psychopathology were positively associated with endorsement of the criterion. Findings demonstrate low endorsement of the cultural deviation criterion, that its inclusion excludes several potential PGD cases, and unanticipated associations with several factors raise questions about the criterion's validity.

Do we all grieve the same? A multigroup test of the dimensional structure of prolonged grief disorder among Danish bereaved partners and children.

Prolonged Grief Disorder (PGD) is a newly recognized mental disorder in ICD-11 and DSM-5-TR. Several studies using exploratory factor analysis have found a unidimensional structure of the Prolonged Grief-13 (PG-13) measure of PGD. The recently published ICD-11 proposal proposes a distinction between two clusters of symptoms: Separation distress symptoms and associated cognitive, emotional and behavioral symptoms. The aim of the current study is to test competing factor structures of PGD in Danish samples of bereaved. Confirmatory factor analysis was used to test competing models of PGD among two samples of in total 1093 adults that completed the questionnaires 6 months post loss of either a parent or a partner. Convergent and divergent validity was tested via the relationship to depression, anxiety, post-traumatic stress disorder (PTSD) and general wellbeing using regression analysis. The Danish version of the PG 13 appeared to be both valid and reliable. A two-factor model reflecting the division of core- and associated symptoms of prolonged grief disorder provided the best description of the PG-13 among Danish bereaved adults and there was evidence of partial structural invariance of the latent structure of PGD across bereavement types. Convergent and divergent validity analysis supported the validity of the two-factor model of PGD. SIGNIFICANT OUTCOMES: : A latent variable model differing between core- and associated symptomatology of grief is supported. The Danish translation of PG-13 is a valid measure of prolonged grief symptomatology.

Assessing the factorial validity and the internal reliability of the International Trauma Questionnaire (ITQ); PTSD and complex PTSD among survivors of sexual violence in Ireland.

AIMS: To assess the factorial validity and internal reliability of the International Trauma Questionnaire (ITQ) among a treatment-seeking sample of survivors of sexual violence in Ireland. In addition, to assess the diagnostic rate of post-traumatic stress disorder (PTSD) and complex post-traumatic stress disorder (CPTSD) among the samples. METHODS: Participants were adult survivors of sexual violence (N = 114) in receipt of therapeutic support at the Dublin Rape Crisis Centre. The ITQ was utilised to measure PTSD and CPTSD symptoms and confirmatory factor analysis was employed to assess the factorial validity of the ITQ. Composite reliability was employed to assess the internal reliability of the ITQ scale scores. RESULTS: The confirmatory factor analysis results indicated that a six-factor correlated model and a two-factor higher model were good representations of the latent structure of the ITQ, both models are consistent with the conceptualisation of CPTSD. All ITQ subscales possessed satisfactory internal reliability except for the affective dysregulation subscale. Of the sample, 56.1% met the criteria for CPTSD and 20.2% met the criteria for PTSD. CONCLUSIONS: The ITQ captured a distinction between PTSD and CPTSD symptoms and produced reliable scores within the sample, but replication with a larger sample size is required. In addition, the study findings demonstrated that CPTSD was relatively common among those seeking psychological support following sexual violence.

Secondary traumatisation, burn-out and functional impairment: findings from a study of Danish child protection workers.

Background: Child-protection workers are at elevated risk for secondary traumatization. However, research in the area of secondary traumatization has been hampered by two major obstacles: the use of measures that have unclear or inadequate psychometric properties and equivocal findings on the degree of associated functional impairment. Objective: To assess the relationship between secondary traumatization and burnout using exploratory structural equation modelling (ESEM) and to assess the relationship between secondary traumatization and functional impairment. Methods: A survey of Danish child-protection workers was conducted through the Danish Children Centres (N = 667). Secondary traumatization was measured using the Professional Quality of Life-5 (ProQoL-5) and burnout using the Oldenburg Burnout Inventory. Results: A three-factor ESEM model provided the best fit to the data, reflecting factors consistent with the structure of secondary traumatization and burnout. The factors were differentially related to trauma-related and organizational variables in ways consistent with existing evidence. All factors were significantly related to functional impairment. Conclusion: The findings supported the discriminant validity of secondary traumatization and burnout while highlighting methodological issues around the current use of sum-score approaches to investigating secondary traumatization. The current study supported the clinical relevance of secondary traumatization by linking it explicitly to social and cognitive functional impairment.

Antecedentes: los trabajadores de protección infantil tienen un riesgo elevado de traumatización secundaria. Sin embargo, la investigación en el área de la traumatización secundaria se ha visto obstaculizada por dos trabas principales: el uso de variables que tienen propiedades psicométricas poco claras o inadecuadas y hallazgos equívocos sobre el grado de deterioro funcional asociado.Objetivo: evaluar la relación entre la traumatización secundaria y el agotamiento utilizando el modelo exploratorio de ecuaciones estructurales (ESEM, por sus siglas en inglés) y evaluar la relación entre la traumatización secundaria y el deterioro funcional.Metodología: se realizó una encuesta a los trabajadores daneses de protección infantil a través de los Centros de Niños Daneses (N = 667). La traumatización secundaria se midió utilizando la Calidad de vida profesional-5 (ProQoL-5) y el agotamiento fue evaluado utilizando el Inventario de Agotamiento de Oldenburg.Resultados: Un modelo ESEM de tres factores proporcionó el mejor ajuste a los datos, reflejando factores consistentes con la estructura de la traumatización secundaria y el agotamiento. Los factores se relacionaron de manera diferencial con las variables relacionadas con el trauma y la organización, de manera consistente con la evidencia existente. Todos los factores estaban significativamente relacionados con el deterioro funcional.Conclusión: Los hallazgos respaldaron la validez discriminante de la traumatización secundaria y el agotamiento, al tiempo que resaltaron los problemas metodológicos en torno al uso actual de los enfoques de suma de puntajes para investigar la traumatización secundaria. El presente estudio apoyó la relevancia clínica de la traumatización secundaria al vincularla explícitamente con el deterioro funcional social y cognitivo.

The role of age and mode of delivery in the STEPS intervention: a longitudinal pilot-study in treatment of posttraumatic stress symptoms in Danish survivors of sexual assault.

Background: The STEPS programme has been succesfully implemented as a group-based treatment of trauma symptoms after rape for adolescents. The STEPS intervention was translated from Dutch to Danish and offered to adults in addition to adolescents as well as an individual intervention in addition to a group-based intervention at a Danish Centre for Rape Victims through 2011 to 2014. The programme was translated from Dutch to Danish and expanded to adults in addition to adolescents as well as to an individual intervention in addition to a group-based intervention at a Danish Centre for Rape Victims through 2011 to 2014. Objective: The present study observes  development in trauma symptoms and ICD-11 diagnostic status during an adapted version of the intervention programme 'STEPS' for survivors of sexual assault. Methods: A prospective uncontrolled study was conducted, monitoring symptoms of posttraumatic stress and other trauma-related symptomatology before treatment, after treatment and at 6 and 12 months' follow up for 103 referrals receiving individual or group-based STEPS. Tentative diagnoses of posttraumatic stress disorder (PTSD) and complex PTSD were assigned to participants according to the ICD-11 to observe the development in diagnostic status across time, and multilevel modelling was used to assess the development of symptom severity and to assess the moderating effect of age-group and mode of delivery. Results: A loglinear function representing large and statistically significant decline in symptomatology over time provided the best fit for all measures of trauma-related symptomatology. The decline was not moderated by age-group or mode of intervention. Dropout rates were independent of mode of intervention and age. Conclusion: The adaption of the STEPS programme to adults and as an individual intervention is feasible and maintains effect sizes comparable to those observed in the original intervention. Further research using randomized controlled trials is needed to ascribe the observed effect to the STEPS programme.

Antecedentes: El programa STEPS se ha implementado con éxito como un tratamiento grupal de síntomas de trauma después de una violación en adolescentes. La intervención STEPS se tradujo del holandés al danés y se ofreció a adultos además de adolescentes, así como una intervención individual además de una intervención grupal en un Centro danés para víctimas de violación hasta el 2011 y el 2014.Objetivo: El presente estudio observa el desarrollo de síntomas de trauma y el estado de diagnóstico de la CIE-11 durante una versión adaptada del programa de intervención "PASOS" para los sobrevivientes de agresión sexual.Métodos: Se realizó un estudio prospectivo no controlado, monitorizando los síntomas de estrés postraumático y otras sintomatologías relacionadas con trauma antes del tratamiento, después del tratamiento y a los 6 y 12 meses de seguimiento para 103 derivaciones. Se asignaron a los participantes los diagnósticos tentativos de trastorno de estrés postraumático (TEPT) y TEPT complejo según la CIE-11 para observar el desarrollo en el estado de diagnóstico a través del tiempo, y se usó un modelado multinivel para evaluar el desarrollo de la severidad de los síntomas y evaluar el efecto moderador del grupo de edad y modo de entrega.Resultados: Un función lineal logarítmica que representa una disminución grande y estadísticamente significativa de la sintomatología a lo largo del tiempo proporcionó el mejor ajuste para todas las medidas de la sintomatología relacionada con trauma. El efecto no fue moderado por grupo de edad o tipo de intervención. Las tasas de abandono fueron independientes del tipo de intervención y edad.Conclusión:: La adaptación del programa STEPS para adultos y como una intervención individual es factible y mantiene el tamaño del efecto comparable con aquellos observados en la intervención original. Se necesita más investigación usando estudios controlados aleatorizados para atribuir el efecto observado al programa STEPS.

Implementing point-of-care ultrasonography of the heart and lungs in an anesthesia department.

BACKGROUND: Implementation of point-of-care ultrasonography (POCUS) of the heart and lungs requires image acquisition skills among providers. We aimed to determine the effect of POCUS implementation using a systematic education program on image acquisition skills and subsequent use and barriers in a department of anesthesiology. METHODS: Twenty-five anesthesiologists underwent a systematic education program in POCUS during the fall of 2012. A POCUS expert evaluated images from baseline and evaluation examinations performed on two healthy individuals as useful or not useful for clinical interpretation. In August 2016, anesthesiologists employed at the department answered a questionnaire regarding the use of POCUS and perceived barriers to its use. RESULTS: The systematic education program increased the proportion of images useful for clinical interpretation from 0.70 (95% CI 0.65-0.75) to 0.98 (95% CI 0.95-0.99). This difference was significant when adjusted for prior cardiac ultrasonography courses, prior clinical cardiac ultrasonography experience, ultrasonography view, and ultrasound model (P < 0.001). After 3.5 years, 15/25 (60%) of perioperative medicine providers, 22/24 (92%) of intensive care providers, and 21/21 (100%) of pre-hospital care providers used POCUS either routinely, in selected patient groups, or sporadically. CONCLUSION: Implementation of POCUS by a systematic education program increased image acquisition skills across anesthesiologists employed at the department. POCUS was used in the intensive care setting, the pre-hospital setting, and to a lesser extent in the perioperative setting. Educational strategies for obtaining images under difficult conditions, practical equipment and evidence for effect on patient outcomes are required for full implementation of POCUS.

Routine pre-operative focused ultrasonography by anesthesiologists in patients undergoing urgent surgical procedures.

BACKGROUND: Unexpected cardiopulmonary complications are well described during surgery and anesthesia. Pre-operative evaluation by focused cardiopulmonary ultrasonography may prevent such mishaps. The aim of this study was to determine the frequency of unexpected cardiopulmonary pathology with focused ultrasonography in patients undergoing urgent surgical procedures. METHODS: We performed pre-operative focused cardiopulmonary ultrasonography in patients aged 18 years or above undergoing urgent surgical procedures at pre-defined study days. Known and unexpected cardiopulmonary pathology was recorded, and subsequent changes in the anesthesia technique or supportive actions were registered. RESULTS: A total of 112 patients scheduled for urgent surgical procedures were included. Their mean age (standard deviation) was 62 (21) years. Of these patients, 24% were American Society of Anesthesiologists (ASA) class 1, 39% were ASA class 2, 32% were ASA class 3, and 4% were ASA class 4. Unexpected cardiopulmonary pathology was disclosed in 27% [95% confidence interval (CI) 19-36] of the patients and led to a change in anesthesia technique or supportive actions in 43% (95% CI 25-63) of these. Unexpected pathology leading to changes in anesthesia technique or supportive actions was only disclosed in a group of patients above the age of 60 years and/or in ASA class ≥ 3. CONCLUSION: Focused cardiopulmonary ultrasonography disclosed unexpected pathology in patients undergoing urgent surgical procedures and induced changes in the anesthesia technique or supportive actions. Pre-operative focused ultrasonography seems feasible in patients above 60 year and/or with physical limitations but not in young, healthy individuals.

Urgent reversal of vitamin K antagonist therapy.

In the developed world, an increasing number of patients receive therapy with vitamin K antagonists (VKA). This group of patients poses an additional challenge in the perioperative management of emergency surgery and trauma. The present review offers a detailed description of some treatment options for reversal of VKA therapy. Optimal treatment of the anticoagulated patient requires a well-balanced intervention securing a reduced risk of haemorrhagic surgical complications as well as optimal anticoagulation post-operatively without exposing the patient to an increased risk of thromboembolic complications. The following factors must be considered in VKA-treated patients scheduled for emergency surgery: (1) the indication for VKA therapy, including the risk of thromboembolic events when the International normalized ratio (INR) is reduced, (2) type of surgery, including the risk of haemorrhagic complications and (3) the pharmacodynamic/-kinetic profile of the therapy used to revert the VKA therapy. Therapeutic options for acute reversal of VKA therapy include: vitamin K, fresh frozen plasma (FFP), prothrombin complex concentrate (PCC) and perhaps activated recombinant factor VII. PCC is a relatively new drug in some European countries and clinical experience is limited compared with the use of FFP. Reversal of VKA anticoagulation with PCC is faster and more efficient compared with FFP, but there are currently no randomized studies demonstrating an improved clinical outcome.

Association analyses suggest GPR24 as a shared susceptibility gene for bipolar affective disorder and schizophrenia.

Linkage analyses suggest that chromosome 22q12-13 may harbor a shared susceptibility locus for bipolar affective disorder (BPD) and schizophrenia (SZ). In a study of a sample from the Faeroe Islands we have previously reported association between both disorders and microsatellite markers in a 3.6 cM segment on 22q13. The present study investigated three candidate genes located in this segment: GPR24, ADSL, and ST13. Nine SNPs located in these genes and one microsatellite marker (D22S279) were applied in an association analysis of two samples: an extension of the previously analyzed Faeroese sample comprising 28 distantly related cases (17 BPD, 11 SZ subjects) and 44 controls, and a Scottish sample including 162 patients with BPD, 103 with SZ, and 200 controls. In both samples significant associations were observed in both disorders with predominantly GPR24 SNPs and haplotypes. In the Faeroese sample overall P-values of 0.0009, 0.0054, and 0.0023 were found for haplotypes in BPD, SZ, and combined cases, respectively, and in the Scottish sample overall P-values of 0.0003, 0.0005, and 0.016 were observed for similar groupings. Specific haplotypes showed associations with lowest P-values of 7 x 10(-5) and 0.0006 in the combined group of cases from the Faeroe Islands and Scotland, respectively. The G protein-coupled receptor 24 encoded by GPR24 binds melanin-concentrating hormone (MCH) and has been implicated with feeding behavior, energy metabolism, and regulation of stress and mood. To our knowledge this is the first study reporting association between GPR24 and BPD and SZ, suggesting that GPR24 variants may confer susceptibility to both disorders.

A genome-wide search for alleles and haplotypes associated with autism and related pervasive developmental disorders on the Faroe Islands.

The involvement of genetic factors in the etiology of autism has been clearly established. We undertook a genome-wide search for regions containing susceptibility genes for autism in 12 subjects with childhood autism and related pervasive developmental disorders (PDDs) and 44 controls from the relatively isolated population of the Faroe Islands. In total, 601 microsatellite markers distributed throughout the human genome with an average distance of 5.80 cM were genotyped, including 502 markers in the initial scan. The Faroese population structure and genetic relatedness of cases and controls were also evaluated. Based on a combined approach, including an assumption-free test as implemented in CLUMP, Fisher's exact test for specific alleles and haplotypes, and IBD(0) probability calculations, we found association between autism and microsatellite markers in regions on 2q, 3p, 6q, 15q, 16p, and 18q. The most significant finding was on 3p25.3 (P(T1)=0.00003 and P(T4)=0.00007), which was also supported by other genetic studies. Furthermore, no evidence of population substructure was found, and a higher degree of relatedness among cases could not be detected, decreasing the risk of inflated P-values. Our data suggest that markers in these regions are in linkage disequilibrium with genes involved in the etiology of autism, and we hypothesize susceptibility genes for autism and related PDDs to be localized within these regions.

Intra-arterial cisplatin and concomitant radiation therapy followed by surgery for advanced paranasal sinus cancer.

OBJECTIVE: To report the long-term efficacy of a combined regimen of intra-arterial high-dose cisplatin chemotherapy and concomitant radiation therapy followed by organ-sparing surgery when possible in the treatment of advanced paranasal sinus cancer. DESIGN: Review of prospectively collected data. SETTING: Academic referral center. Patients Nineteen patients with advanced paranasal sinus malignancies with a minimum follow-up of 2 years. Malignancies included 14 squamous cell carcinomas (74%), 2 adenocarcinomas (10%), 2 adenoid cystic carcinomas (10%), and 1 undifferentiated carcinoma (5%). Sixteen patients (84%) had T4 disease. Intervention Treatment consisted of preoperative radiation therapy (2.0 Gy/fraction per day; total dose, 50 Gy in 5 weeks) given concomitantly with 3 to 4 weekly infusions of intra-arterial cisplatin (150 mg/m(2) per week) and systemic sodium thiosulfate neutralization. The regimen included planned surgery performed approximately 8 weeks after completion of radiation therapy. Ten patients underwent a transcranial anterior craniofacial resection; 1, a medial maxillectomy; and 1, an endoscopic restaging only. RESULTS: After a median follow-up of 53 months, actuarial overall survival at 2 and 5 years was 68% and 53%, respectively. One patient died of myocardial infarction during treatment. No other treatment-limiting toxic effect was noted. Although 3 patients had persistence of disease, delayed local failure occurred only in 2 and distant metastasis in 3. Except for cataract in 2 patients, no visual loss developed. CONCLUSION: Despite the advanced stage and unfavorable nature of cancer in this cohort, our results indicate that this regimen holds promise and merits further study.

Possible evidence for a common risk locus for bipolar affective disorder and schizophrenia on chromosome 4p16 in patients from the Faroe Islands.

Patients with schizophrenia (n=11) and bipolar affective disorder (n=17) from the relatively isolated population of the Faroe Islands were genotyped for 34 polymorphic markers on chromosome 4 in a search for allelic association and haplotype sharing among distantly related patients. When considering bipolar patients only, there was no clearcut support for any region on chromosome 4. The two-marker segment D4S394-D4S2983 at 4p16.1 was, however, supported by a P-value of 0.0162. For patients with schizophrenia, there was reasonable support for 4p16.1 as marker D4S2281 (P=0.0019), a two-marker segment (D4S2281-D4S1605, P=0.0009) and a three-marker segment (D4S2923-D4S2928-D4S1582, P-0.0005) appeared to be associated with schizophrenia, with some alleles/haplotypes occurring with different frequencies in patients compared to controls. When combining both psychiatric disorders, chromosome 4p16.1 received further support from five partially overlapping two- and three-marker segments (D4S394-D4S2983, P=0.0039; D4S2281-D4S1605, P=0.0027 and D4S394-D4S2983-D4S2923, P=0.006; D4S2923-D4S2928-D4S1582, P=0.00007; D4S1582-D4S1599-D4S2281, P=0.005). Increased haplotype sharing in patients with schizophrenia and in the combined data set was partly supported by Fisher's exact test and tests based on the genealogy. Our study yields support for a common risk gene for schizophrenia and bipolar affective disorder on the short arm of chromosome 4, as suggested by previous findings in the neighbouring Scottish population.

Search for common haplotypes on chromosome 22q in patients with schizophrenia or bipolar disorder from the Faroe Islands.

Chromosome 22q may harbor risk genes for schizophrenia and bipolar affective disorder. This is evidenced through genetic mapping studies, investigations of cytogenetic abnormalities, and direct examination of candidate genes. Patients with schizophrenia and bipolar affective disorder from the Faroe Islands were typed for 35 evenly distributed polymorphic markers on 22q in a search for shared risk genes in the two disorders. No single marker was strongly associated with either disease, but five two-marker segments that cluster within two regions on the chromosome have haplotypes occurring with different frequencies in patients compared to controls. Two segments were of most interest when the results of the association tests were combined with the probabilities of identity by descent of single haplotypes. For bipolar patients, the strongest evidence for a candidate region harboring a risk gene was found at a segment of at least 1.1 cM including markers D22S1161 and D22S922 (P=0.0081 in the test for association). Our results also support the a priori evidence of a susceptibility gene to schizophrenia at a segment of at least 0.45 cM including markers D22S279 and D22S276 (P=0.0075). Patients were tested for the presence of a missense mutation in the WKL1 gene encoding a putative cation channel close to segment D22S1161--D22S922, which has been associated with schizophrenia. We did not find this mutation in schizophrenic or bipolar patients or the controls from the Faroe Islands.

Further evidence for a bipolar risk gene on chromosome 12q24 suggested by investigation of haplotype sharing and allelic association in patients from the Faroe Islands.

A number of studies have strongly suggested a susceptibility locus for bipolar affective disorder on chromosome 12q24. The present study investigates for a shared chromosomal segment among distantly related patients with bipolar affective disorder from the Faroe Islands, using 17 microsatellite markers covering 24 cM in the previously suggested region on chromosome 12q24. D12S342 showed possible allelic association to bipolar affective disorder (P-value using CLUMP below 0.01). Increased sharing among cases of two-marker haplotypes were suggested at D12S1614--D12S342 (P-values using CLUMP below 0.01), and D12S2075--D12S1675 (P-values using CLUMP around 0.001). The region of most interest is around 6 cM and bounded by markers D12S1614 and D12S1675 as suggested by the interesting two-marker haplotypes. This area contains the minimum interesting region between D12S342 and D12S1658 suggested by the previously reported haplotypes in the two Danish families with bipolar affective disorder.

The class I metabotropic glutamate receptor antagonist, AIDA, improves short-term and impairs long-term memory in a spatial task for rats.

Effects of the class I selective metabotropic glutamate receptor antagonist, 1-aminoindan-1,5-dicarboxylic acid (AIDA), on spatial procedural learning and episodic short-term memory of rats were investigated in an appetitively reinforced 3-choice delayed match-to-position task. First, an acute intraperitoneal injection of AIDA (2 mg/kg) was given 20 min before a single training session of 20 trials using repeated reward position in one alcove out of three. AIDA caused facilitated short-term acquisition within such a session compared to saline treated controls. Secondly, injections were given before each of ten sessions (48 h intervals) also using constant reward position. The results showed AIDA induced inhibition of procedural between-session acquisition. Finally, the use of reward positions in a non-repetitive but trial-specific version of the 3-choice test revealed a facilitating effect of AIDA on episodic short-term memory.

A haplotype-based study of lithium responding patients with bipolar affective disorder on the Faroe Islands.

The Faroe Islands are a small group of islands in the North Atlantic Ocean, situated between Norway, Iceland and Scotland. The origin of the population is thought to be a mixture of Norwegian, Danish and British. The islands were populated at the same time as Iceland, i.e. around 1100 years ago, and the size of the population was around, and occasionally below, 4000 inhabitants until 1800, after which it increased to its present-day level of around 45,000. The population is descended from Scandinavian and British ancestors. Because of the low number of founders and small size for many centuries, the Faroese population is perhaps the most valuable European population for genetic mapping of complex disease genes. The present study searched for haplotype sharing on chromosome 18 among eight lithium responding patients with bipolar affective disorder related, on average, 6.2 generations ago, using 30 DNA markers. In order to obtain as homogeneous a sample as possible, strict inclusion criteria based on severity of phenotype, geography and treatment response, were applied. Evidence suggestive of increased haplotype sharing on the distal part of chromosome 18q23 in the region implicated by Freimer and co-workers was found. However, methods of genetic analysis which might provide a conclusive result are not yet available.

Adenosine-induced cardiac pause for endovascular embolization of cerebral arteriovenous malformations: technical case report.

OBJECTIVE: Extremely high flow through arteriovenous malformations (AVMs) may limit the safety and effectiveness of endovascular glue therapy. To achieve a more controlled deposition of glue, we used transient but profound systemic hypotension afforded by an intravenously administered bolus of adenosine to induce rapidly reversible high-degree atrioventricular block. METHODS AND CASE REPORT: A patient with a large high-flow occipital AVM fed primarily by the posterior cerebral artery underwent n-butyl cyanoacrylate glue embolization. Nitroprusside-induced systemic hypotension did not adequately reduce flow through the nidus, as determined by contrast injection in the feeding artery. In a dose-escalation fashion, boluses of adenosine were administered to optimize the dose and verify that there was no flow reversal in the AVM and no other unexpected hemodynamic abnormalities by arterial pressure measurements and transcranial Doppler monitoring of the posterior cerebral artery feeding the AVM. Thereafter, 64 mg of adenosine was rapidly injected as a bolus to provide 10 to 15 seconds of systemic hypotension (approximately 20 mm Hg). Although there were conducted beats and some residual forward flow through the AVM during this time, the mean systemic and feeding artery pressures were roughly similar and remained relatively constant. A slow controlled injection of n-butyl cyanoacrylate glue was then performed, with excellent filling of the nidus. CONCLUSION: Adenosine-induced cardiac pause may be a viable method of partial flow arrest in the treatment of cerebral AVMs. Safe, deep, and complete embolization with a permanent agent may increase the likelihood of endovascular therapy's being curative or may further improve the safety of microsurgical resection.

The feasibility of intracarotid adenosine for the manipulation of human cerebrovascular resistance.

UNLABELLED: To assess the feasibility of manipulating human cerebrovascular resistance with adenosine, we measured cerebral blood flow (CBF) by determining the initial slope (IS) of tracer washout 20-80 s after intracarotid 133Xe injection (standard IS) during sequential 3-min intracarotid infusions of (a) saline; (b) adenosine 1.2-mg bolus followed by an infusion of 1 mg/min (bolus + infusion); (c) saline; and (d) nicardipine (0.1 mg/min). During 133Xe washout, adenosine caused a rapidly clearing compartment. Therefore, tracer washout was also analyzed 5-25 s after injection (early IS). Nicardipine (n = 8) increased both standard IS (from 39+/-12 to 53+/-16 mL 100g.min(-1); P < 0.005) and early IS (from 40+/-9 to 55+/-20 arbitrary units; P < 0.02) to a similar degree. Adenosine bolus + infusion increased early IS (from 33+/-6 to 82+/-43 arbitrary units; P < 0.02) but did not increase standard IS (from 41+/-12 to 43 +/-16 mL 100g(-1) min(-1)). Standard and early IS values were then determined before and after adenosine delivered either by infusion alone (2 mg/min for 3 min, n = 5) or bolus alone (2 mg in 1 s, n = 3). Neither standard nor early IS changed after adenosine infusion alone. Early IS increased after adenosine bolus alone. Increase in early IS, but not standard IS, suggests a transient (<30 s) increase in CBF. IMPLICATIONS: Intracarotid adenosine, in the 1- to 2-mg dose range, may cause a transient, but not a sustained, increase in cerebral blood flow. Intracarotid adenosine in such a dose range does not seem to be an appropriate drug for sustained manipulation of cerebrovascular resistance.

Feeding artery pressure and venous drainage pattern are primary determinants of hemorrhage from cerebral arteriovenous malformations.

PURPOSE: The purpose of this study was to define the influence of feeding mean arterial pressure (FMAP) in conjunction with other morphological or clinical risk factors in determining the probability of hemorrhagic presentation in patients with cerebral arteriovenous malformations (AVMs). METHODS: Clinical and angiographic data from 340 patients with cerebral AVMs from a prospective database were reviewed. Patients were identified in whom FMAP was measured during superselective angiography. Additional variables analyzed included AVM size, location, nidus border, presence of aneurysms, and arterial supply and venous drainage patterns. The presence of arterial aneurysms was also correlated with site of bleeding on imaging studies. RESULTS: By univariate analysis, exclusively deep venous drainage, periventricular venous drainage, posterior fossa location, and FMAP predicted hemorrhagic presentation. When we used stepwise multiple logistic regression analysis in the cohort that had FMAP measurements (n = 129), only exclusively deep venous drainage (odds ratio [OR], 3.7; 95% confidence interval [CI], 1.4 to 9.8) and FMAP (OR, 1.4 per 10 mm Hg increase; 95% CI, 1.1 to 1.8) were independent predictors (P < 0.01) of hemorrhagic presentation; size, location, and the presence of aneurysms were not independent predictors. There was also no association (P = 0.23) between the presence of arterial aneurysms and subarachnoid hemorrhage. CONCLUSIONS: High arterial input pressure (FMAP) and venous outflow restriction (exclusively deep venous drainage) were the most powerful risk predictors for hemorrhagic AVM presentation. Our findings suggest that high intranidal pressure is more important than factors such as size, location, and the presence of arterial aneurysms in the pathophysiology of AVM hemorrhage.

Hmong/medicine interactions: improving cross-cultural health care.

BACKGROUND AND OBJECTIVES: There are now more than 100,000 Hmong (Southeast Asian) refugees in the United States. This study examined interactions between Hmong patients and their health care providers and identified specific factors that either enable or obstruct health care delivery. METHODS: We used semistructured interview techniques to investigate patients' and providers' experiences, looking for attitudes, ideas, or behaviors that could be modified to improve health care delivery. Interviews with 23 Hmong patients, 18 health care providers, and six translators were audiotaped, transcribed, and analyzed by a multidisciplinary team. Methods included text analysis, theme identification, rank ordering, participant observation, immersion-crystallization, and open-ended discussion. RESULTS: Hmong patients and their US-trained health care providers have different health belief systems. Both linguistic and cultural translation were seen as problematic. Additionally, an overwhelming number of patients identified kindness, caring, and a positive attitude as important provider characteristics. Providers noted difficulties in understanding Hmong conceptions of acute versus chronic diseases, illness prevention, and pain, both physical and psychological. Many respondents gave suggestions for improvement: 1) learn more about each other's cultures, 2) be patient, kind, and positive, 3) avoid negative statements or predictions, 4) improve translation quality, 5) explain medical terms using visual aids, 6) respect Hmong family-centered decision making, 7) increase the time allotted for translated clinical encounters, and 8) train Hmong health care providers. CONCLUSIONS: Many basic issues in relations between clinicians and Hmong patients must be addressed to improve health care communication.