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We describe an 11-year-old child who presented with a traumatic aortic transection. This is an extremely rare occurrence in this age group. In managing the injury the future growth of the child must be considered. Primary repair is ideal when possible, but in choosing a graft, the choice of size and material should take cognisance of the risk of a coarctation-like syndrome in the future. [ABSTRACT FROM AUTHOR]

BACKGROUND: Management of patients with severe concomitant carotid and coronary disease remains controversial. We report our experience of combined carotid endarterectomy (CEA) and coronary artery bypass surgery (CABG) over a fifteen year period using strict patient selection criteria. METHODS: From 1st January 1995 to December 31st 2009 165 patients underwent combined CABG/CEA procedures at the Mater Hospital. Mean age was 68.2 years (range 43-88) and 127 (77%) were male. Fifty-three (32%) had symptomatic carotid disease. Indications for combined procedures were the presence of symptomatic >70% or asymptomatic >80% internal carotid artery stenosis in a patient requiring urgent CABG because of either unstable angina, recent MI, severe triple vessel disease or severe Left Anterior Descending or Left Main Stem stenosis. RESULTS: Thirty-day stroke and death rate was 3%. All neurological events were in the hemisphere contralateral to the carotid surgery and symptoms had completely resolved prior to discharge from hospital. One patient required evacuation of a cervical haematoma and there were two transient XII nerve palsies. CONCLUSION: Combined CEA/CABG can be performed safely with acceptable morbidity and mortality in patients selected in accordance with strict criteria in a centre with a large experience of both cardiac and carotid surgery. [ABSTRACT FROM AUTHOR]

Comparing self-reported symptom scores across time requires longitudinal measurement invariance (LMI), a psychometric property that means the measure is functioning identically across all time points. Despite its prominence as a measure of depression symptom severity in both research and health care, LMI has yet to be firmly established for the Patient Health Questionnaire-9 depression module (PHQ-9), particularly over the course of antidepressant pharmacotherapy. Accordingly, the objective of this study was to assess for LMI of the PHQ-9 during pharmacotherapy for major depressive disorder. This was a secondary analysis of data collected during a randomized controlled trial. A total of 1,944 veterans began antidepressant monotherapy and completed the PHQ-9 six times over 24 weeks of treatment. LMI was assessed using a series of four confirmatory factor analysis models that included all six time points, with estimated parameters increasingly constrained across models to test for different aspects of invariance. Root-mean-square error of approximation of the chi-square difference test values below 0.06 indicated the presence of LMI. Exploratory LMI analyses were also performed for separate sex, age, and race subgroups. Root-mean-square error of approximation of the chi-square difference test showed minimal change in model fits during invariance testing (≤ 0.06 for all steps), supporting full LMI for the PHQ-9. LMI was also supported for all tested veteran subgroups. As such, PHQ-9 sum scores can be compared across extended pharmacotherapy treatment durations. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

NASA's space life sciences research programs established a decades-long legacy of enhancing our ability to safely explore the cosmos. From Skylab and the Space Shuttle Program to the NASA Balloon Program and the International Space Station National Lab, these programs generated priceless data that continue to paint a vibrant picture of life in space. These data are available to the scientific community in various data repositories, including the NASA Ames Life Sciences Data Archive (ALSDA) and NASA GeneLab. Here we recognize the 30-year anniversary of data access through ALSDA and the 10-year anniversary of GeneLab., (Published by Oxford University Press on behalf of GigaScience 2024. This work is written by (a) US Government employee(s) and is in the public domain in the US.)

Introduction: Molecularly targeted therapies such as tyrosine kinase inhibitors (TKI) are effective treatments for B-cell receptor (BCR)-ABL-bearing leukemias. We evaluated the impact of TKIs on historical chronic myeloid leukemia (CML) mortality trends compared with acute lymphoblastic leukemia (ALL) and chronic lymphoblastic leukemia (CLL)., Methods: Because mortality trends reflect combined effects of leukemia incidence and survival, we also evaluated the contribution of incidence and survival trends to mortality trends by subtypes. We used data from 13 U.S. (SEER) registries (1992-2017) among U.S. adults. We utilized histology codes to identify cases of CML, ALL, and CLL and death certificate data to calculate mortality. We used Joinpoint to characterize incidence (1992-2017) and mortality (1992-2018) trends by subtype and diagnosis year., Results: For CML, mortality rates started declining in 1998 at an average rate of 12% annually. Imatinib was approved by the FDA for treating CML and ALL in 2001, leading to clear benefits for patients with CML. Five-year CML survival increased dramatically over time, especially between 1996 to 2011, 2.3% per year on average. ALL incidence increased 1.5% annually from 1992 to 2017. ALL mortality decreased 0.6% annually during 1992 to 2012 and then stopped declining. CLL incidence fluctuated during 1992 to 2017 while mortality decreased 1.1% annually during 1992 to 2011 and at a faster rate of 3.6% per year from 2011. Five-year survival increased 0.7% per year on average during 1992 to 2016., Conclusions: Survival benefit from TKIs and other novel therapies for treating leukemia subtypes has been demonstrated in clinical trials., Impact: Our study highlights the impact of molecularly targeted therapies at the population level., (©2023 American Association for Cancer Research.)

Silver and gold nanoparticle-aptamer conjugates have been extensively utilized as biosensors and microscopic vehicles that deliver a therapeutic cargo to cells. Here, we describe facile procedures to attach nucleic acid aptamers with a free thiol group to silver or gold nanoparticles. Methods to purify the nanoparticle-aptamer conjugates, verify aptamer attachment, and quantify aptamer-nanoparticle ratios are also discussed and compared. Additionally, a simple protocol that describes the aqueous synthesis of gold nanoparticles (~10 nm) is included., (© 2023. The Author(s), under exclusive license to Springer Science+Business Media, LLC, part of Springer Nature.)

Importance: Selecting effective antidepressants for the treatment of major depressive disorder (MDD) is an imprecise practice, with remission rates of about 30% at the initial treatment., Objective: To determine whether pharmacogenomic testing affects antidepressant medication selection and whether such testing leads to better clinical outcomes., Design, Setting, and Participants: A pragmatic, randomized clinical trial that compared treatment guided by pharmacogenomic testing vs usual care. Participants included 676 clinicians and 1944 patients. Participants were enrolled from 22 Department of Veterans Affairs medical centers from July 2017 through February 2021, with follow-up ending November 2021. Eligible patients were those with MDD who were initiating or switching treatment with a single antidepressant. Exclusion criteria included an active substance use disorder, mania, psychosis, or concurrent treatment with a specified list of medications., Interventions: Results from a commercial pharmacogenomic test were given to clinicians in the pharmacogenomic-guided group (n = 966). The comparison group received usual care and access to pharmacogenomic results after 24 weeks (n = 978)., Main Outcomes and Measures: The co-primary outcomes were the proportion of prescriptions with a predicted drug-gene interaction written in the 30 days after randomization and remission of depressive symptoms as measured by the Patient Health Questionnaire-9 (PHQ-9) (remission was defined as PHQ-9 ≤ 5). Remission was analyzed as a repeated measure across 24 weeks by blinded raters., Results: Among 1944 patients who were randomized (mean age, 48 years; 491 women [25%]), 1541 (79%) completed the 24-week assessment. The estimated risks for receiving an antidepressant with none, moderate, and substantial drug-gene interactions for the pharmacogenomic-guided group were 59.3%, 30.0%, and 10.7% compared with 25.7%, 54.6%, and 19.7% in the usual care group. The pharmacogenomic-guided group was more likely to receive a medication with a lower potential drug-gene interaction for no drug-gene vs moderate/substantial interaction (odds ratio [OR], 4.32 [95% CI, 3.47 to 5.39]; P < .001) and no/moderate vs substantial interaction (OR, 2.08 [95% CI, 1.52 to 2.84]; P = .005) (P < .001 for overall comparison). Remission rates over 24 weeks were higher among patients whose care was guided by pharmacogenomic testing than those in usual care (OR, 1.28 [95% CI, 1.05 to 1.57]; P = .02; risk difference, 2.8% [95% CI, 0.6% to 5.1%]) but were not significantly higher at week 24 when 130 patients in the pharmacogenomic-guided group and 126 patients in the usual care group were in remission (estimated risk difference, 1.5% [95% CI, -2.4% to 5.3%]; P = .45)., Conclusions and Relevance: Among patients with MDD, provision of pharmacogenomic testing for drug-gene interactions reduced prescription of medications with predicted drug-gene interactions compared with usual care. Provision of test results had small nonpersistent effects on symptom remission., Trial Registration: ClinicalTrials.gov Identifier: NCT03170362.

The use of polypharmacy has become significantly more common over the past two decades, increasing the risk of drug-drug interactions and adverse drug reactions. Pharmacogenomic (PGx) assays have the purported benefit of being able to predict an individual's response to a specific medication based on genetic markers, which may facilitate the development of optimized medication regimens for patients prescribed polypharmacy. This 12-week pilot study examined the impact of the PGx results on the clinical management of Veterans who were prescribed psychiatric polypharmacy. Psychiatric medication providers were given access to the PGx assay results, including notification of drug-drug-gene interactions computed from an algorithm decision tool, to assist with medication management decisions. Veteran outpatients (N = 53) prescribed polypharmacy (mean = 13.15 medications) were enrolled into the study. In 92.4% of cases, providers changed medications at baseline, with 83% of providers indicating that they changed their original medication plan based on the PGx results. Clinical improvement over the 12-week treatment phase was seen in depression (F(1.63, 45) = 5.45, P = .01, η 2  = .11) and mental health quality of life (F(2.00, 45) = 4.16, P < .05, η 2  = .16). Adverse drug effects were unchanged or improved over time. Rates of polypharmacy remained unchanged. The results suggest that medication changes based on the PGx assay may be beneficial in a complex patient population prescribed polypharmacy., (Published 2022. This article is a U.S. Government work and is in the public domain in the USA.)

Background: Emergency airway management may be required at any hospital location. Remote site management is associated with increased airway morbidity and mortality. Poor planning and interrupted workflow are significant contributors. Equipment may be unfamiliar, difficult to locate or inadequate.The SCRAM (Structured CRitical Airway Management) bag aims to provide a portable, structured and reproducible approach to airway management preparation. We hypothesised that SCRAM bag use reduces equipment preparation time, the rate of error and operator cognitive load., Methods: Fifty experienced anaesthetists were randomised into two groups and asked to prepare (kit dump) for and manage a simulated remote site difficult airway scenario. The control group ( n = 25) used a standard resuscitation trolley while the experimental group used the SCRAM bag ( n = 25). The primary outcome was time taken to kit dump completion (seconds). Secondary outcomes were the number of errors and self-reported difficulty (100 mm visual analogue scale)., Results: Using the SCRAM bag, a 29% reduction in kit dump time (111.7 ± 29.5 vs 156.7 ± 45.1, p = 0.0001) was noted. Participants using the SCRAM bag reported it to be less challenging to use (18.36 ± 16.4 mm vs 50.64 ± 22.9 mm, p < 0.001), and significantly fewer errors were noted (1 (IQR 1-3) vs 8 (IQR 5-9), p = 0.03) (87.5% reduction in the total number of errors)., Conclusion: The SCRAM bag facilitates a quicker, less challenging kit dump with significantly fewer errors. We propose that this would reduce delay to airway management, reduce cognitive load and provide an improved capability to manage anticipated and unanticipated airway events., Competing Interests: Competing interestsBS, AW and SS have no commercial interests to declare. PS is the co-designer and developer of the SCRAM bag and receives royalties for products sold., (© The Author(s) 2020.)

Objective: The Caring Contacts intervention has been implemented with a variety of methodologies. The purpose of this study was to examine high-risk inpatient preferences for the Caring Contacts intervention., Method: Veteran psychiatric inpatients (N = 154) completed an anonymous patient preferences survey to obtain feedback on Caring Contact methods such as message wording, preferred correspondent, frequency of contact, duration of the intervention, imagery, and mailing modality., Results: Eighty-five percent of veterans Agreed or Strongly Agreed that they would like to receive Caring Contacts from at least one of the correspondent options, with inpatient or outpatient mental health counselor, or primary care physician most preferred. Example messages based on prior studies were overwhelmingly rated as caring and helpful; 84% believed that Caring Contacts could help suicidal individuals. Letters or postcards sent through postal mail were preferred over e-mail or text messages. Participants most commonly thought Caring Contacts should be sent monthly for a period of a year., Conclusions: The results of this study suggest that most high-risk veterans would perceive Caring Contacts as helpful and caring. The results provide several practical, helpful tips for programs seeking to establish a Caring Contacts program., (© 2018 The American Association of Suicidology.)

Background: We describe the long-term results of partial atrioventricular septal defect (AVSD) repair in a single centre encompassing a 22-year period. Described are rates of survival, reoperation and complications., Methods: We performed a retrospective review of 556 patients undergoing AVSD repair to identify the 51 patients who underwent partial AVSD repair in Our Lady's Children's Hospital, Crumlin, Ireland, between 1993 and 2015 with long-term follow-up where available., Results: A total of 29 (56.8%) of patients were male and mean age at operation was 3.32 years. Mean weight was 13.2 kg. Trisomy 21 was present in 29 (56.8%). Five patients (9.6%) had undergone prior surgery. Mean cardiopulmonary bypass time was 89 ± 36 min and mean aortic cross-clamp time was 57 ± 28 min. One patient underwent partial AVSD repair and concomitant tracheal resection and extracorporeal membrane oxygenation decannulation. One patient was managed with suture atrial septal defect (ASD) closure, the remainder with patch repair of ASD and mitral cleft closure. The length of hospital stay was 9 ± 5 days. Median follow-up was 6.06 years (IQR, 1.65-10.2 years). There were no early mortalities. One patient died 1 year following surgery (1.9%). One patient required reoperation at an interval of 2 years for severe mitral regurgitation (1.9%)., Conclusions: Short- and long-term survival following partial AVSD repair in Ireland revealed excellent results compared with other published series. Reoperation incidence also compared excellently with other reports published in the literature.

Introduction: The annual cost of treatment and lost productivity due to chronic pain is estimated to be $635 billion within the USA. Self-management treatments for chronic pain result in lower health care costs and lower utilization of provider-management treatments, such as hospitalization and medication use. The current study sought to identify and characterize patient factors and health conditions associated with chronic pain treatment utilization to inform ways to improve engagement in self-management pain treatment (e.g., applying heat or ice, exercising, or practicing relaxation). This study predicted (1) greater pain intensity and pain interference would be associated with greater utilization of self-management treatments and (2) this association would be moderated by patient factors (gender and age) and health comorbidities (anxiety, trauma, depression, and sleep disturbance)., Materials and Methods: Baseline data from a three-arm clinical trial were collected for 127 Veterans seeking treatment for chronic pain. Veterans were recruited via clinician referral and medical record review at the Veterans Affairs Puget Sound Health Care System, Washington, USA., Results: Self-management treatments were more utilized than provider-management treatments. Pain intensity and pain interference were not uniquely associated with provider-management or self-management treatment utilization after controlling for demographics and mental health status. Sleep disturbance moderated the relationship between pain interference and provider-management treatment utilization. Depression moderated the relationship between pain intensity and provider-management treatment utilization., Conclusions: While study conclusions may not generalize to all Veteran populations, findings suggest that Veterans with chronic pain were more likely to seek provider-management treatments when experiencing high-pain interference and high-sleep disturbance. In addition, Veterans were more likely to seek provider-management treatments when experiencing low-pain intensity and high-depression symptoms., (© Published by Oxford University Press on behalf of the Association of Military Surgeons of the United States 2018.)

Background: Tropical orchids need more study with respect to their mycorrhizal associations. For researchers in distant countries who aspire to study these orchids augmenting their conservation, the great distances involved, coupled with limited funds, pose formidable challenges. These challenges are sometimes exacerbated by political unrest, delays in securing permits, unexpected hardships, and the risk that the biological samples collected (e.g., roots harboring mycorrhizal fungi) will not survive long-distance transport., Results: We describe a protocol for the collection and transport of root samples from Madagascar orchids to labs in the United Kingdom (Kew) and the United States (Illinois) where Rhizoctonia-like fungi were subsequently isolated. Three separate trips were made spanning 4 years (2012-2015), with emphasis on the collection of roots from epiphytic, lithophytic, and terrestrial orchids inhabiting the Itremo Massif of the Central Highlands. Collectively, the trips to Madagascar resulted in the isolation of all major groups of Rhizoctonia-like fungi (Ceratobasidium, Tulasnella, Sebacina) from all three orchid growth forms (terrestrials, epiphytes and lithophytes). Sampling of terrestrial and epiphytes during the rainy season (January) yielded best results., Conclusions: Our study demonstrates that peloton-forming fungi in root samples can retain viability up to 3 weeks after collection.

This pilot study examined the usability, acceptability, and effectiveness of a free Provider Resilience (PR) mobile application (app) designed by the National Center for Telehealth and Technology to reduce provider burnout. Outpatient mental health providers (N = 30) used the PR app for 1 month. Participants rated the PR app on the System Usability Scale with an overall score of 79.7, which is in the top quartile for usability. Results of paired sample t tests on the Professional Quality of Life Scale indicated significant decreases on the Burnout (t = 3.65, p < .001) and Compassion Fatigue (t = 4.54, p < .001) subscales. The Provider Resilience app shows promise in reducing burnout and compassion fatigue in mental health care providers.

Objective: This study assessed whether adding telephone care management to usual outpatient mental health care improved treatment attendance, medication compliance, and clinical outcomes of veterans with posttraumatic stress disorder (PTSD)., Methods: In a multisite randomized controlled trial, 358 veterans were assigned to either usual outpatient mental health treatment (N=165) or usual care plus twice-a-month telephone care management (TCM) and support in the first three months of treatment (N=193). Treatment utilization and medication refills were determined from U.S. Department of Veterans Affairs administrative data. PTSD, depression, quality of life, aggressive behavior, and substance use were assessed with self-report questionnaires at intake, four months, and 12 months., Results: Telephone care managers reached 95% of TCM participants (N=182), completing an average 5.1 of 6.0 planned telephone calls. During the three-month intervention period, TCM participants completed 43% more mental health visits (M±SD=5.9±6.8) than did those in usual care (4.1±4.2) (incident rate ratio=1.36, χ 2 =6.56, df=1, p<.01). Treatment visits in the nine-month follow-up period and medication refills did not differ by condition. Only 9% of participants were scheduled to receive evidence-based psychotherapy. Slopes of improvement in PTSD, depression, alcohol misuse, drug problems, aggressive behavior, and quality of life did not differ by condition or treatment attendance., Conclusions: TCM improved PTSD patients' treatment attendance but not their outcomes. TCM can enhance treatment engagement, but outcomes depend on the effectiveness of the treatments that patients receive.

The current study investigated the utility of the Dementia Severity Rating Scale (DSRS) total score to identify individuals at the earliest stage of impairment (ie, mild cognitive impairment/MCI). In addition, the authors sought to investigate how well the measure correlates with an expanded battery of cognitive tests and other measures of functional abilities. Of the 320 participants included in this study, 85 were normal controls, 96 had single-domain or multiple-domain amnestic MCI, and 139 had possible or probable Alzheimer disease (AD). Each participant underwent a thorough cognitive, neurological, and physical examination. Results from this study indicated that the DSRS total scores differed significantly between the 3 groups (P<0.001) and accurately identified 81% of the control group, 60% of the MCI group, and 78% of the AD group in a post hoc discriminant analysis. When combined with a brief cognitive measure (ie, Consortium to Establish a Registry for Alzheimer's Disease Word List 5 min recall test), the DSRS accurately identified 98% of the control group, 76% of the MCI group, and 82% of the AD group. Implications for clinical practice and proposed areas of future research are discussed.

Background: Cocaine addiction continues to be a significant healthcare issue, yet there are no FDA approved medications for the treatment of cocaine use disorder within the United States., Methods: This 12-week, prospective, double-blind, randomized, placebo-controlled study examined the effectiveness of quetiapine (Seroquel XR™) versus matched placebo for the treatment of DSM-IV cocaine dependence in non-psychotic individuals. Subjects randomized to quetiapine (N = 29) were titrated up to a target dose of 400mg/day of quetiapine, while those in the placebo arm (N = 31) were given a matched placebo. All subjects had weekly clinic visits and a cognitive-behavioral therapy group session. Outcome measures included self-report of cocaine use and money spent on cocaine as well as urine drug screens (UDS)., Results: The drop-out rate was substantial at 68%. Logistic regression analysis did not find significant differences between groups in predicting end-of trial abstinence, defined as three consecutive weekly negative UDS (13.7% in the quetiapine group versus 12.9% in the placebo group; p = .92). Based upon a repeated measures analysis of variance, subjects in this study, as a whole, demonstrated reductions in their self-reported use of cocaine, self-reported money spent on cocaine, and number of days per week using cocaine. However, the quetiapine group did not differ significantly from the placebo group., Conclusions: This study did not find group differences between the quetiapine and placebo arms, suggesting that quetiapine is not an efficacious treatment for DSM-IV cocaine dependence., (Published by Elsevier Ireland Ltd.)

Background: This study tested the hypothesis that surgical stress and the host response to this trauma trigger an inflammatory cascade in which the neutrophil plays a central role. We hypothesised that pre-operative neutrophil migratory responses will correlate with post-operative clinical outcome in our shock model of open-heart surgery patients. We also tested the hypothesis that surface expression of adhesion molecules involved in the migratory process - CD11b, CD47 and CD99 - could be used to predict outcome. We believe that combining neutrophil migratory response, CD11b, CD47 and CD99 with the logistic European System for Cardiac Operative Risk Evaluation (EuroSCORE) will strengthen the power of the EuroSCORE not only in predicting post-operative mortality but also other clinical endpoints., Materials and Methods: Neutrophils were isolated pre-operatively from n = 31 patients undergoing open-heart surgery and allowed to migrate across endothelial monolayers in response to N-formyl-methionine-leucine-phenylalanine (fMLP). Isolated neutrophils were also assessed for surface expression of CD11b, CD47 and CD99 in response to fMLP by flow cytometry. Post-operative clinical parameters collected included days 1-5 white cell count and creatinine levels as well as intensive care unit (ICU) and post-operative hospital stay., Results: Pre-operative surface expression of CD99 and CD47 correlates with post-operative creatinine levels (P < 0·05), a measurement of renal injury. We also show that while the logistic EuroSCORE alone can be used as a predictor of ICU stay, when combined with pre-operative CD99 surface expression, it improves its AUC value (0·794)., Conclusion: Immunological markers, specifically the ability of the neutrophil to migrate, combined with the logistic EuroSCORE lead to improved sensitivity and specificity to predict patient outcome., (© 2012 The Authors. European Journal of Clinical Investigation © 2012 Stichting European Society for Clinical Investigation Journal Foundation.)

Rationale: Cardiac surgery presents a risk to all major organs due to activation of the systemic inflammatory response. Patients referred for cardiac surgery are typically older, usually have comorbid conditions, and are thus at higher risk of postoperative multiorgan dysfunction. Patients demonstrating evidence of organ dysfunction require intensive postoperative management. Any means to predict and reduce the inflammatory response mounted postcardiac surgery could translate into a clinical benefit for the patient and reduce the length of stay in intensive care., Objective: Statins are commonly used to prevent primary and secondary cardiovascular disease through their cholesterol-lowering effects. However, they have been shown to have anti-inflammatory properties, which may help reduce postoperative mortality and morbidity for patients undergoing cardiac surgery. The purpose of this study was to analyze the in vivo effects of high-dose atorvastatin (statin) on ex vivo neutrophil migration in healthy volunteers., Methods: Thirteen healthy male volunteers consented and were placed on high-dose (40 mg) statin therapy for 2 weeks. At week 0 and week 2, full blood count, liver function, serum cholesterol and creatine kinase were assessed, as was neutrophil migration., Results: Neutrophil migration of healthy volunteers was significantly reduced after 2 weeks of high-dose statin therapy (p = 0.002), as was serum cholesterol (p <0.001). There was no change in liver function during statin treatment., Conclusion: Statins have an established role as cholesterol-lowering agents, and this study demonstrates that they also potentially have an anti-inflammatory effect in healthy male volunteers.

We report the use of the Novalung pumpless device in self-ventilating patients awaiting a lung transplantation. Two patients developed carbon dioxide retention with respiratory acidosis that did not respond to maximum medical therapy. The Novalung interventional lung assist was established as a bridge to lung transplantation. The first patient was successfully transplanted after 140 days, and this is the longest support that has been reported so far. The second patient was weaned off the Novalung after a short period. The Novalung is a valuable device for self-ventilating patients with carbon dioxide retention being bridged to lung transplantation.

Human donor heart valves remain essential for many reconstructive heart procedures. Heart valve donations are a scarce resource which must be used efficiently and safely. Infection transmission remains a potential risk with homograft valve use. Early experience with homograft valves identified high rates of microbial contamination at collection and initiated the practise of immersion in an antibiotic cocktail. Many centres rely on the microbiology screening after exposure to the antibiotic cocktail. We in our centre accept or reject valves on the basis of the microbiology screening at the time of collection prior to immersion in antibiotic solution. We wanted to compare our rate of valve discard and the rate of microbial contamination at implant with other centres. Valves are collected for the Irish Heart Valve Tissue Bank through partnership between the National Centre for Cardiothoracic Surgery and the Irish Blood Transfusion Service. Valves are collected in a surgical theatre setting and processed in dedicated section of the Irish Blood Transfusion Board. Tissues are screening for microbiology at collection and also at implantation. A total of 564 human heart valves and valve conduits were processed through the service during the study period. 167 (29.6%) were discarded during the processing and storage stages. The major reason for this in 117 cases was unsatisfactory microbiology on initial tissue screening. Repeat screening of accepted valves at the time of implantation identified positive cultures in only 0.9%. Optimal use of these limited resources is clearly important. However recipient safety remains paramount. One-fifth of collected valves are discarded at the processing stage due to positive microbiology screening. This is a higher rate of discard then other centres which reject 5.6-10% due to positive microbiology. However our rate of contamination at time of implant is lower then the 3% rate reported elsewhere. We are satisfied that our current discard rate, although significant, reflects rigorous quality control and the optimal balance between valve availability and patient safety.

Neutrophils, cells of the innate immune system, contain an array of proteases and reactive oxygen species-generating enzymes that assist in controlling the invasion of bacteria and pathogens. The high content of intracellular proteolytic enzymes makes them difficult cells to work with as they can degrade proteins of potential interest. Here, we describe the benefits of heat treatment of neutrophils in reducing protein degradation for subsequent proteome analysis. Neutrophils isolated from four healthy volunteers were each divided into three aliquots and subjected to different preparation methods for 2-DE: (i) Heat treatment, (ii) resuspension in NP40 lysis buffer and (iii) resuspension in standard 2-DE lysis buffer. Representative spots found to be statistically significant between groups (p<0.01) were excised and identified by LC-MS/MS, three of which were validated by immunoblotting. Heat-treated samples contained proteins in the high-molecular-weight range that were absent from NP40-treated samples. Moreover, NP40-treated samples showed an increase in spot number and volume at lower molecular weights suggestive of protein degradation. Incorporating heat treatment into sample preparation resulted in the identification of proteins that may not have previously been detected due to sample degradation, thus leading to a more comprehensive 2-DE map of the human neutrophil proteome., (Copyright © 2011 WILEY-VCH Verlag GmbH & Co. KGaA, Weinheim.)

Background: Balloon angioplasty for infant coarctation is associated with a high recurrence rate, making operative repair the gold standard for low-risk infants. Debate exists as to whether high-risk infants might be better served with primary angioplasty. We compared the outcome in high-risk versus low-risk infants over 20 years, in a center that always used surgical repair as the primary intervention., Methods: Of 192 infants from 1986 to 2005, 56 were considered "high-risk," defined as requiring prostaglandin infusion together with either epinephrine infusion for 24 hours preoperatively, or ventilation and milrinone infusion for 24 hours preoperatively. All high-risk patients had a period of ventricular dysfunction prior to surgery, ranging from mild to severe. Outcomes were compared using Bonferroni comparison of means or the Fischer exact test as appropriate., Results: Although the high-risk patients were smaller (3.3 ± 0.1 vs 4.2 ± 0.2 kg, p < 0.01), younger (18 ± 4 vs 57 ± 7 days, p < 0.01), and more often required a concomitant pulmonary artery band (25% vs 15%, p = 0.05), their cross-clamp times were the same as the low-risk patients (18.9 ± 0.9 vs 18.0 ± 0.4 minutes, p = 0.27) and there was no difference in postoperative morbidity (7% vs 3%, p = 0.11). However, there was a trend toward higher perioperative mortality (7% vs 2%, p = 0.07). When compared with the published studies of primary angioplasty in comparable high-risk infants, the mortality rate in our surgically treated high-risk group is much lower. Additionally, only 11% of our high-risk group required reintervention, with two-thirds treated successfully with a single angioplasty at 3.8 ± 2.2 years later, far lower than recurrence rates with primary angioplasty., Conclusions: We propose that primary surgical repair of coarctation in infants who are high risk should be the primary treatment, with angioplasty reserved for recurrent coarctation., (Copyright © 2010 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Objectives: Open heart surgery is associated with a massive systemic inflammatory response. Neutrophils, are the main mediator of this response. We hypothesised that the degree of neutrophil activation and inflammatory response to open heart surgery varies individually and correlates with clinical outcome. The aim of this study was to determine if individual clinical outcome can be predicted preoperatively through assessment of in-vitro stimulated neutrophil responses. Following that, the effects of neutrophil depletion through leukocyte filters are examined., Methods: Neutrophil responses were assessed preoperatively (n=40) through change in neutrophil adhesion molecule [CD11b, CD62L and P Selectin Glycoprotein-1 (PSGL-1)] expression before and after in-vitro stimulation with Phorbol 12-myristate 13-acetate, PMA (1 ng/ml), lipopolysaccharide, LPS (1 μg/ml) and N-Formyl-Met-Leu-Phe, fMLP (1 ng/ml). Stimulated neutrophil responses were then correlated with postoperative clinical outcome. Patients were then randomised to leukocyte filtration (n=20) and a control group (n=20) and the effect of leukocyte filtration on neutrophil response and clinical outcome were investigated., Results: An individual variation in in-vitro stimulated neutrophil responses was demonstrated. Significant correlations were shown between neutrophil responses and maximum serum creatinine change, CKMB-fraction, adrenaline requirement, noradrenaline requirement, duration of adrenaline required and time to extubation. White cell count and percentage neutrophils were lower in the LD group (P=0.05). CD11b expression (P=0.005) and PSGL-1 expression (P=0.043) across leukocyte filters were also increased. However, no significant difference was detected in clinical outcome between the LD and control groups., Conclusion: Preoperative neutrophil responses to in-vitro stimuli can predict clinical outcome following open heart surgery. However, leukocyte filtration did not offer significant benefit in clinical outcome in our study.

Immunologic surveillance for rejection detection in human heart transplantation offers many potential advantages. To date, investigative efforts have focused primarily on the acquired immune system, particularly the lymphocyte. Little attention has been given to aspects of innate immune function. We have previously reported that perioperative neutrophil adhesion molecule expression is associated with early rejection episodes after human cardiac transplantation. Herein we have investigated the utility of neutrophil immunosurveillance in human heart transplant recipients at later time points. We recruited patients more than 3 months after transplantation. Neutrophil assessment was performed simultaneously with an endomyocardial biopsy that showed rejection. No significant relationship was seen between neutrophil maturity (P = .622; n = 34), adhesion marker expression (P = .567; n = 34), respiratory burst (P = .604; n = 34), or apoptosis rates (P = .662; n = 34) and contemporary rejection status at >3 months after transplantation. However, interesting relationships were noted between neutrophil adhesion markers at this late stage and historical rejection status. Higher levels of the adhesion protein CD11b observed at this late stage were significantly associated with a history of higher rejection grades in the first postoperative biopsy (Spearman rank coefficient 0.359; R = 0.304; P = .005; n = 62). Other aspects of neutrophil function and persistence were not significantly associated with rejection history. This finding, combined with the previously reported findings, supports a role for an individual phenotype in neutrophil function in early rejection episodes after transplantation.

Pleuropulmonary blastoma (PPB) is an aggressive tumour accounting for less than 1% of all primary malignant lung tumours in the paediatric population. It can be associated with cystic pulmonary lesions, which may be evident at the time of diagnosis or predate the appearance of the tumour. There are contradictory reports about the value of prophylactic resection of pulmonary cysts in protecting patients from developing PPB. We report an individual case where asymptomatic congenital lobar emphysema was incidentally picked up on CXR. Following a period of surveillance the lesion was resected due to increasing size. The histology of the lesion revealed PPB Type I.

Objective: Lung transplantation is a recognised surgical option for patients with end stage respiratory disease. We present data relating to the initiation of the Irish lung transplant programme in 2005., Methods: Seventeen patients: 7 male and 10 female have undergone lung transplantation. The indications for lung transplantation included COPD (n=8), idiopathic pulmonary fibrosis (n=5), bronchiolitis obliterans (n=2), lymphangioleiomyomatosis (n=1), and cystic fibrosis (n=1). Eleven single lungs transplants were completed, while six patients underwent double sequential lung transplantation. The immunosuppression regimen included basiliximab as induction therapy, with steroids, mycophenolate mofetil nd cyclosporine or tacrolimus., Results: The operative mortality was zero. One patient died at 10 months post double lung transplantation secondary to bronchiolitis obliterans. Primary graft dysfunction was observed in two patients who required ventilatory support for 3 and 5 days respectively. Acute cellular rejection was observed in four patients (grade A2 n=3, grade A3 n=2). The cumulative 1-year survival was 94.1%, which compares favourably to an international standard of 78%., Conclusions: The initiation of a lung transplant programme in Ireland has been successfully undertaken and initially provided results comparable to established lung transplant programs.

The ability of neutrophils to sense and migrate toward damaged tissue is a vital component of the innate immune response. Paradoxically, this same migration serves as the hallmark of a number of inflammatory conditions, including ischemic reperfusion injury, atherosclerosis, arthritis, and Crohn's disease. More recent evidence suggests that neutrophil infiltration into the cardiac allograft following transplantation is a contributing factor in allograft rejection. We have demonstrated previously a positive correlation between the degree of neutrophil migration and subsequent rejection grades in a cohort of cardiac transplant recipients. Intracellular signaling pathways that are intimately involved in neutrophil migration thus offer potential targets of manipulation in the treatment of such conditions. 3-hydroxy-3-methylyglutaryl-coenzyme A reductase inhibitors or statins are emerging as potential anti-inflammatory agents and have a proven survival benefit in the transplant population. Yet, little is known about their ability to modulate neutrophil function and their subsequent mechanism of action. We demonstrate here that pravastatin, simvastatin, and atorvastatin significantly reduce neutrophil transendothelial migration toward the chemoattractant fMLP. This effect is independent of any change in neutrophil adhesion or adhesion molecule expression but is related to the ability of statins to reduce fMLP-induced Rho activity in neutrophils. This was confirmed by the ability of the Rho precursor geranylgeranyl pyrophosphate to rescue the statin-mediated reduction in neutrophil transendothelial migration. Understanding the mechanisms of action of statins in the neutrophil allows for their use in targeting excessive migration in inappropriate inflammatory conditions.

The quality of tissue studied impacts greatly on oligonucleotide microarray results, emphasizing the importance of harvesting techniques. The analyzed RNA extracted from human lung samples preserved via 4 different storage conditions (RNAlater, phosphate-buffered saline, TRIzol, liquid nitrogen). RNA was assessed by denaturing gel electrophoresis, Agilent bioanalysis, real-time polymerase chain reaction (PCR), and Test3 Affymetrix chip hybridization. Results revealed better quality RNA from RNAlater samples on gel electrophoresis and bioanalysis. RNAlater samples also showed greater yield (r18s via PCR P < .05) and resulted in better Test3 chips hybridization (p < .05), suggesting RNAlater was superior at preserving lung tissue nucleic acid.

Background: Depression is the most common mental disease in patients hospitalized with physical illness. Disorders of anxiety and depression in general hospitals are frequently underdiagnosed and inappropriately treated., Aim: To assess the prevalence of undiagnosed anxiety and depression in surgical inpatients and assess the referral rate and utilization of liaison psychiatry services., Methods: A prospective study of surgical admissions (n = 96) to two surgical services at two separate institutions between 01/01/05 and 31/12/05. The Hospital Anxiety and Depression (HADS) scale was used to evaluate all patients., Results: About 12.5% of patients had significant depression, 18.75% had significant anxiety, and 8.3% had significant mixed anxiety and depression. About 22.9% of patients warranted referral to liaison psychiatry services for further assessment and management., Conclusions: Anxiety and depression are highly prevalent in surgical inpatients. An increased awareness of the possibility of undiagnosed psychiatric disorders is required, along with prompt and appropriate use of liaison psychiatry services.

Background: Anomalous left coronary artery from the pulmonary artery (ALCAPA) is a rare condition presenting in infancy with acute myocardial ischaemia., Aims: A retrospective study was undertaken to assess the presenting features and long-term outcome of all cases of ALCAPA presenting to our institution over a 15-year period., Methods: All the cases were located using the hospital discharge system and charts were reviewed., Results: The mean age at diagnosis was 4.5 months (2 weeks to 16 months). The predominant presenting symptoms were irritability, pallor, and tachypnoea. The predominant electrocardiogram findings were Q waves and ST segment changes in the anterolateral chest leads. One died from the 11 patients in our series., Conclusion: The outcome for surgical re-implantation in infants with a diagnosis of ALCAPA is very good however, early diagnosis is crucial to survival. Although once successfully repaired, patients in general were free of symptoms, ventricular dysfunction was usually present, requiring long-term follow-up.

The monaminergic properties of second generation antipsychotics are prompting research on their use to treat cocaine dependence, with inconclusive results to date. In preliminary reports, the atypical antipsychotic quetiapine has shown promise for the treatment of substance abuse disorders. The primary objective of the current study was to assess the efficacy of quetiapine in reducing cocaine cravings and use in nonpsychotic subjects with cocaine dependence over 6 weeks of open-label treatment. Twenty-two cocaine-dependent, nonpsychotic men were initiated to open-label treatment with quetiapine (300-600 mg/d). The primary outcome measure was weekly self-report of cocaine cravings as assessed with the Brief Substance Craving Scale. Cocaine use was captured with a self-report Timeline Follow-back calendar, administered every 2 weeks. Side effect monitoring was conducted weekly, and movement disorders were assessed every 2 weeks. Intent-to-treat regression analyses (n = 22) indicated that the Brief Substance Craving Scale total score decreased significantly overtime (P < 0.001). Self-reports also suggested decreased cocaine use. There was no treatment-related increase in movement disorders, and most side effects were mild. However, all subjects did experience sedation, and several subjects dropped out because of it. What is more, weight increased significantly over time (P < 0.001). Open-label quetiapine treatment reduced cravings and improved some aspects of cocaine dependence in nonpsychotic individuals. Additional research is needed to confirm the current findings and to further delineate the role quetiapine may play in the treatment of cocaine use disorders.

We present a congenital giant left atrial appendage in an asymptomatic 18-month-old girl featuring two morphological aspects not yet described, namely, a common wall between the giant left atrial appendage and the left ventricle and an abnormal course of the circumflex coronary artery across the surface of the grossly dilated left atrial appendage which prohibited its radical resection. Surgery was performed off-bypass, via anterolateral thoracotomy with plication of the aneurysm, leaving a residual pouch. A patch closure of the communicating os between the left atrium and the residual aneurysm was therefore undertaken later. Radical surgical resection is recommended for giant left atrial appendage if complications are to be avoided, as there is potential for progressive growth, intracardiac thrombosis, systemic embolization, cardiac arrhythmia, and need for life-long anticoagulation.

Background: Although efficacy of antipsychotic medications is well documented, their effectiveness in real-world practice is less robust. We examined the effectiveness of olanzapine and risperidone in schizophrenia in a naturalistic setting., Methods: We used an electronic medical records database at a Veterans Affairs Medical Center to conduct a retrospective study of all new outpatient medication trials of olanzapine (n = 221) and risperidone (n = 274) over a 2-year period beginning January 1999 in patients diagnosed with schizophrenia or schizoaffective disorder. We defined medication discontinuation as a switch between the 2 agents (most switches) or self-discontinuation when a patient is without medication supply for longer than 1 month., Results: Sample mean age (+/-SD) was 48.4 (+/-11.6) years; 91% were men. Discontinuation rates were high (73%), trending lower in olanzapine (70%) than risperidone (76%) (P = 0.12). Median time to discontinuation was 120 days (95% confidence interval [CI], 105-135), longer for olanzapine (150 days; 95% CI, 120-180) than risperidone (90 days; 95% CI, 71-109) (P = 0.04). Self-discontinuation was high (48%), with no significant difference between olanzapine (50%) and risperidone (46%). Switching rate was 25% and more likely to occur in risperidone (30%) than olanzapine (20%) (odds ratio, 1.72; 95% CI, 1.13-2.61)., Conclusions: Effectiveness of antipsychotic medications in schizophrenia may be hampered by high rates of medication self-discontinuation in outpatient practice settings. Time to discontinuation suggests that olanzapine may be more effective than risperidone. Strategies to address causes of poor adherence should be incorporated in medication algorithms to optimize their effectiveness.

The introduction of the European Working Time Directive has led to intensive debate regarding the working conditions, training and service delivery of Non Consultant Hospital Doctors. Surgical specialties are especially affected by the directive as they have always been associated with long working hours. These have been defended on the basis that these were required to achieve surgical competence. This study aims to survey the working hours and examine the activity of cardiothoracic surgery trainees, who traditionally worked long hours, in a single institution. Arising from the survey results, a novel working model is proposed.

Objective: Perioperative upregulation of the neutrophil adhesion molecule CD11b is associated with the development of renal impairment. We hypothesised that individual variation in neutrophil adhesion molecule responses to surgery influences renal outcomes and that this individual variability could be modelled prior to surgery and used to predict high risk patients. The developed model uses preoperative exposure of an individual patient's neutrophils to a fixed inflammatory stimulus and assessment of the basal and stimulated adhesion molecule CD11b expression., Methods: Neutrophils were isolated from human volunteers undergoing cardiac surgery with cardiopulmonary bypass support. Basal and stimulated CD11b expression was measured using flow cytometry in preoperative neutrophil samples and compared to postoperative clinical performance., Results: Patients with low levels of preoperative basal neutrophil CD11b expression had the greatest increase in CD11b following phorbol-12-myristate-13-acetate stimulation. This stimulated CD11b response correlated with changes in CD11b expression from preoperative to postoperative sampling. Preoperative basal CD11b expression showed a significant inverse relationship with postoperative creatinine levels. However, preoperative CD11b stimulation was not related to postoperative renal function. In addition preoperative basal CD11b expression correlated with adrenaline requirements and intra-aortic balloon pump usage. In contrast stimulated CD11b expression was significantly related to length of hospital stay and changes in the A-a gradient., Conclusions: Preoperative CD11b expression assessment might enable preoperative identification of patients who will mount an exaggerated and damaging neutrophil response to surgery which contributes to renal injury. Identification of these patients would then allow selective application of immunomodulatory therapies.

The focus of research in allograft rejection has targeted the lymphocyte, with little attention given to the neutrophil. Recent data indicate that a perioperative neutrophil influx into the cardiac allograft influences early rejection. Factors that influence neutrophil transendothelial migration might offer predictive markers of rejection. We explored the relationship between the number of circulating neutrophils in heart transplant recipients and the development of rejection. Differential white cell counts were obtained prior to transplantation and concurrently with subsequent endomyocardial rejection surveillance biopsies for 53 heart transplant recipients undergoing 410 biopsies. Preoperative differential white cell counts had no relationship with rejection. In the first 3 months after transplantation, no relationship was found between contemporary differential white cell counts and rejection. However, more than 3 months following surgery, rejection grade positively correlated on univariate analysis with neutrophil counts and the usage of cyclosporine, prednisolone, and mycophenolate. There was no relationship with eosinophils or lymphocytes. Multivariate analysis demonstrated a persistent relationship among rejection severity, neutrophil count, and prednisolone usage. A significant positive association of higher steroid usage with higher rejection grades must reflect efforts to treat patients with rejection. The significant association of higher neutrophil counts with higher rejection severity might suggest a pathological contribution to rejection. However, given the neutrophilia response to acute steroid administration, we must conclude that the neutrophil association was related to steroid administration. The absence of a relationship between white cell counts and rejection suggests that functional rather than antiproliferative strategies may offer the greatest therapeutic potential.

Background: The aim of the study was to assess the utility of alpha glutathione S-transferase (alphaGST) as a potential marker of intestinal ischemia-reperfusion injury in children after cardiac surgery., Methods: Twenty-six patients undergoing cardiac surgery were enrolled in this longitudinal experimental study. Blood samples were drawn for analysis at specified time points during surgery and analyzed for alphaGST levels. Clinical indices of splanchnic morbidity were assessed up to discharge from hospital. Results were analyzed using Mann-Whitney tests and linear mixed effects models., Results: Two groups were identified. Group 1 (n = 16) showed no intestinal morbidity and group 2 (n = 10) had signs of intestinal morbidity. Statistical differences were shown between the 2 groups with respect to time with aortic cross-clamp (ACC) in situ, time on cardiac bypass, duration of operation, time to enteral feeding and full feeding, time on mechanical ventilation, and time in the intensive care unit postoperatively. The serum concentration of alphaGST was significantly higher for group 2 and this rise was greatest after removal of the ACC., Conclusions: AlphaGST showed significant elevation in patients with prolonged bypass times and ACC times. These patients also displayed signs of intestinal morbidity, suggesting that this marker may be useful in screening patients at risk for intestinal pathology. This rise in alphaGST was associated with a prolonged ischemia time, and was greatest after the cross-clamp was released, suggesting that it is a postischemic reperfusion phenomenon leading to its elevation. A low alphaGST level appears to exclude significant intestinal ischemia.

We report a 7-day-old boy referred to our institution with tachypnea and cardiomegaly who was discovered to have an intrapericardial extra-lobar pulmonary sequestration containing a cystic pulmonary adenomatoid malformation type II. He underwent successful surgical resection of the intrapericardial mass, which we believe represents the first reported case of this rare entity.

A premature twin of 1.9 kg had mitral valve endocarditis develop during neonatal intensive care. Vegetation involving the entire anterior mitral valve leaflet was identified. Reconstruction was achieved by near complete resection of the anterior mitral valve leaflet and retention of the peripheral margin of coaptation including primary and secondary chordae. The body of the anterior mitral valve leaflet was reconstructed using fresh autologous pericardium, a technique not previously reported in an infant of this size. Three and a half years later, the child is well and has required no further intervention.

Objective: Transplant rejection remains a clinical problem despite therapies that focus on lymphocyte suppression, with little attention focused on the neutrophil. Neutrophils are however the first leukocyte to infiltrate the allograft, are capable of causing myocardial damage and may facilitate lymphocytes recruitment. We hypothesised that an early allograft neutrophil infiltration influences rejection severity., Methods: Myocardial neutrophil infiltration was assessed using CD15 and myeloperoxidase immunohistochemistry of rejection surveillance endomyocardial biopsy specimens from human cardiac transplant recipients (n=18). In patients undergoing cardiac transplantation (n=10), neutrophils were isolated from multiple perioperative blood samples using a ficoll-based density gradient centrifugation method. The expression of the neutrophil adhesion protein CD11b was then assessed using flow cytometry and compared to subsequent endomyocardial biopsy rejection grades. The effects of contemporary immunosuppressive agents on human neutrophil CD11b were also assessed using healthy control volunteers., Results: Myeloperoxidase staining of endomyocardial biopsies from human heart transplant recipients demonstrated a positive correlation between the degree of neutrophil infiltration and rejection severity at the first postoperative biopsy. Rejection severity was unrelated to ischaemic time. Functional assessment of neutrophils obtained from recipients was then performed. Perioperative transplant sampling demonstrated a significant correlation between the preoperative expression of CD11b and rejection grade at the first postoperative biopsy. In addition, dynamic changes in CD11b expression in the first 24 h positively correlated with subsequent rejection severity. In vitro experiments showed that transplant immunosuppression did not alter neutrophil CD11b expression., Conclusion: This study demonstrates a potentially greater role for neutrophils in cardiac transplantation than previously recognised, and suggests that blockade of the early allograft neutrophil infiltration might prevent subsequent lymphocyte recruitment and attenuate rejection.

Background: The first Irish heart transplant was performed on the 10th of September 1985. Over the next 20 years, 229 transplants were performed in 228 recipients., Aims: To evaluate the success of the first generation of cardiac transplantation in Ireland., Methods: Analysis of clinical outcomes and survival statistics for patients undergoing heart transplantation in Ireland and comparison with international standards., Results: There has been a steady improvement in transplant outcome over this time and survival figures for recipients between 2000 and 2004 show a hospital, 1-year and 5-year survival rate of 85.7%, 84.1% and 76.8% respectively. Thirty-eight of the 99 heart transplants performed between 1985 and 1994 are still alive more than 10 years later and the longest survivor is now 19 years post transplantation., Conclusions: The results compare favourably with international figures. Heart transplantation offers excellent longterm survival and quality of life but remains challenged by a shortage of suitable donor organs.

Antipsychotic medications, specifically the atypical agents, serve as first-line treatment options for patients with psychotic disorders, including individuals with schizophrenia or schizoaffective disorder. Atypical antipsychotics are also often prescribed off-label as either the primary treatment or as an adjunctive treatment for individuals with other disorders, including mood disorders without psychosis, behavioral disorders, and insomnia. Despite the generally superior side-effect profiles of atypical antipsychotics compared with typical antipsychotic agents, the atypicals have been associated with a number of serious side effects, including metabolic disorders, cardiovascular disorders, seizures, hyperprolactinemia, and movement disorders. This article offers a stepwise approach to the management of antipsychotic side effects: Abstinence, Anticipation, Reduction, and Treatment (AART). The steps in AART are hierarchical, but often overlap in the areas of risk prevention and minimization. The authors discuss issues relevant to each level of intervention and provide suggestions for integrating the AART approach into a comprehensive treatment plan. By incorporating this stepwise approach into their clinical decision-making process, prescribers may be able to optimize the risk:benefit ratio associated with the prescription of atypical antipsychotics.

Background: The placement of preoperative intra-aortic balloon pumps (IABP) in high-risk patients has been described, although controversy remains regarding the appropriate selection of these patients. The EuroSCORE is a proven predictor of operative mortality for coronary artery bypass surgery (CABG). Our objective was to assess whether patients with a preoperative IABP had a 30-day mortality consistent with their predicted mortality., Methods: Sixty-sis patients who had had an IABP sited while undergoing CABG were retrospectively identified. The additive EuroSCORE was calculated with omission of the IABP preoperative placement score of 3 points. Patients with a EuroSCORE <5 were considered low risk, and those > or = m5 as high risk., Results: High-risk patients with preoperative IABP placement had a significantly lower mortality (1/16, 6.25%) than predicted. The predicted versus actual mortality was 12.6% versus 6.25%., Conclusion: Correct identification of appropriate patients who would benefit from pre-emptive placement of IABP could potentially be performed using the EuroSCORE.

Cardiac transplantation is a successful treatment for end-stage heart disease. However the number of potential candidates is significantly greater then number of suitable organ donors. We reviewed the characteristics of new transplant candidates presenting for assessment for cardiac transplantation to the Irish Heart & Lung Transplant programme over a one year period. Of 44 patients referred for assessment, 24 (54.5%) were listed for cardiac transplantation. Six have died while awaiting transplantation, seven have been transplanted and eleven remain on the active transplant list. The six month survival rate on the transplant waiting list is 74%. Although the Irish system of organ donation has traditionally provided high organ donation rates in comparison with other countries, the demand for suitable heart donors exceeds supply. Newer methods of promoting and facilitating organ donation may prove beneficial in improving the number of donations and addressing the long waiting time for cardiac transplantation.