Trauma Informed Interventions to Reduce Seclusion, Restraint and Restrictive Practices Amongst Staff Caring for Children and Adolescents with Challenging Behaviours: A Systematic Review

Engaging with children and adolescents in mental health settings who are exhibiting behaviours that challenge can often result in the use of seclusion, restraint and coercive practices. It is recognised that more therapeutic ways to engage this population are needed, adopting trauma informed interventions may provide a solution. The aim of this systematic review is to synthesize the evidence in relation to the effect of trauma-informed interventions on coercive practices in child and adolescent residential settings. The review is guided by elements of the Cochrane Handbook for Systematic Reviews of Interventions and reported using the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) checklist. Results were synthesized and reported narratively. Nine studies met the eligibility criteria for this review. There was a lack of homogeneity amongst the studies. The trauma-informed interventions used were typically multi-faceted, underpinned by a variety of approaches and sought to bring about changes to clinical practice. Most studies (n = 8) reported significant reductions in the use of restrictive practices following the implementation of a trauma informed approach. The use of a trauma-informed approach, underpinned by an organisational change or implementation strategy, have the potential to reduce coercive practices with children and adolescents. However, the included interventions were insufficiently described to draw strong conclusions.

Abortion and Ulcerative Posthitis Associated with Caprine Herpesvirus–1 Infection in Goats in California

Three outbreaks of late-gestation abortions in does and ulcerative posthitis in bucks, associated with caprine herpes virus–1 (CHV-1), in California are described. In herd A, 10 of 17 does aborted in a 7-day period, whereas in herd B, 4 of 130 does aborted in a 45-day period and in herd C, 100 of 300 does aborted in a 3-week period. Most fetuses had multifocal pinpoint depressed foci with a zone of hyperemia on external and cut surfaces of the kidneys, liver, lungs, and adrenal glands. Histologically, scattered multifocal areas of necrosis with mild neutrophilic infiltrate were observed in kidneys, brain, liver, adrenal glands, and lungs of most fetuses of the 3 herds. Large amphophilic intranuclear inclusion bodies, which displaced the chromatin, were observed in cells within and around the necrotic foci in kidneys and adrenal glands. Particles 85–113 nm in size with morphology compatible with herpes virus were observed in the nuclei of these cells when examined by electron microscopy. Irregular, shallow, red ulcers were observed in the prepuce of 1 buck from herd C. Prepuce biopsies from this animal had necrosis of the superficial mucosal epithelium and severe submucosal lymphoplasmocytic infiltrates. Large intranuclear amphophilic inclusion bodies were observed in most cells of the stratum spinosum of the preputial epithelium, but no viral particles were observed in these cells. Caprine herpes virus–1 was isolated from tissue pools of fetuses from the 3 herds but not from prepuce biopsies. Positive results were obtained when tissues of a fetus from herd C were processed by a polymerase chain reaction technique to amplify the amino terminus of the glycoprotein C gene of CHV-1. Sera from aborted does from herds B and C and from the 3 bucks from herd C had high antibody titers to CHV-1. The results presented here support the hypothesis that the male goat is involved in the transmission of CHV-1. However, other forms of transmission cannot be ruled out.

Propane spectral resolution enhancement by the maximum entropy method

The Burg algorithm for maximum entropy power spectral density estimation is applied to a time series of data obtained from a Michelson interferometer and compared with a standard fast Fourier transform (FFT) estimate for resolution capability. The propane transmittance spectrum was estimated by use of the FFT with a 2(18)-data sample interferogram, giving a maximum unapodized resolution of 0.06 cm(-1). This estimate was then interpolated by zero filling an additional 2(18) points, and the final resolution was taken to be 0.06 cm(-1). Comparison of the maximum entropy method (MEM) estimate with the FFT was made over a 45-cm(-1) region of the spectrum for several increasing record lengths of interferogram data beginning at 2(10). It is found that over this region of 45 cm(-1), the MEM estimate with 2(16) data samples is in close agreement with the FFT estimate using 2(18) samples.

Blunt cardiac trauma

The diagnosis of blunt cardiac injury is often difficult to make because of the multiple associated injuries, the lack of specific physical findings, and the lack of sensitivity and specificity of the electrocardiograms and enzyme changes. The two-dimensional echocardiogram and the monitoring of filling pressures and cardiac indexes by pulmonary artery catheterization have an advantage over the electrocardiogram, CPK isoenzymes and technetium pyrophosphate scans because both anatomic and functional data are obtained, data are rapidly available, and the tests can be used repeatedly at the bedside.

Cardiac valve replacement in systemic lupus erythematosus. A review

Three cases of cardiac valve replacement for Libman-Sacks endocarditis and their long-term follow-up are described. From the review of the literature, an additional nine patients who required cardiac valve replacement are studied. Steroids probably increase the incidence of valve incompetence, but most patients presumably die of other associated organ involvement before undergoing a cardiac operation. Operation is indicated because of change in the intensity or character of the murmur, and a new murmur with resultant, resistant congestive cardiac failure. Both the aortic and mitral valves should be explored. Valve reconstruction in these young patients, with the expectation of avoiding prosthetic valve dysfunction and repeat operation, is not possible. Bioprosthetic valve replacement may be preferable, since it eliminates the need for anticoagulation during steroid treatment. Overall mortality was 25%.

Postoperative hemodynamic and electrophysiological evaluation of the Senning procedure

To determine efficacy of the Senning procedure for correction of transposition of the great arteries we performed detailed hemodynamic and electrophysiological studies in 6 consecutive children operated upon at 5-18 months of age. Cardiac catheterizations were performed 10-19 months following surgery. All patients were asymptomatic on no medication. Hemodynamic studies demonstrated no evidence of pulmonary venous obstruction, pulmonary hypertension, or left ventricular outflow tract obstruction. 1 patient had mild upper baffle limb obstruction. Angiography demonstrated tricuspid insufficiency in 2 patients and a small atrial level shunt in 1. Ambulatory electrocardiographic monitoring in 5 of 6 patients revealed multiple premature ventricular contractions in 1. Invasive electrophysiological studies for sinus node function were normal. Corrected sinus node recovery time was 36-348 ms while total sinoatrial conduction time, determined in 4 patients, ranged between 83 and 128 ms. At our institution the Senning procedure has a low incidence of residual hemodynamic or electrophysiological abnormalities. Detailed postoperative evaluation is necessary to determine extent of residual problems.

Use of propranolol to control rate-pressure product during cardiac anesthesia

The use of propranolol to control heart rate (HR), systolic pressure, and rate-pressure product (RPP) during laryngoscopy and sternotomy was studied in 21 patients, New York Heart Association functional Classes 1 and 2, scheduled for coronary artery bypass graft surgery. All patients were anesthetized in an identical fashion, but the treatment group (N = 13) received propranolol, 0.5 to 1 mg IV, 4 minutes before laryngoscopy and again, in most cases, before skin incision. Patients not given propranolol (N = 8) showed a clinically and statistically significant increase in HR and RPP, whereas HR and RPP remained essentially unchanged from the preanesthetic period in patients given propranolol.

Diaphragmatic injuries

From 1973 through 1978, 48 patients with diaphragmatic injuries from blunt or penetrating trauma to the chest and the upper part of the abdomen were seen at this medical center. Penetrating injuries were the cause of diaphragmatic perforation in 40 patients, while blunt injury was responsible in the remaining eight patients. The mean age of the patients was 30 years. Associated major trauma to other organ systems which accompanied the diaphragmatic lacerations accounted for three deaths. The extent of the diaphragmatic disruptions varied from 1 to 12 centimeters. There was not correlation between the size and location of the laceration and morbidity or mortality. The sequelae of strangulation of gastrointestinal viscera, mediastinal shift and delayed hernia were found in four patients. Eight patients had herniation of intra-abdominal contents, two as a result of penetrating trauma and six as a result of blunt trauma. Strangulation and necrosis of the intestine occurred in three patients, two of whom had delayed treatment. Deliberate effort must be made to identify diaphragmatic perforation at the time of the initial evaluation of injured patients with trauma to the thorax and abdomen. Prompt recognition and repair are required for survival.

Spontaneous heterograft aortic valve failure

Glutaraldehyde-treated porcine aortic valve prostheses have been in clinical use for ten years. The long-term durability of these valves remains unknown although they have functioned well in most large clinical series for more than five years. At the present time, several manufacturers produce bioprostheses mounted on flexible stents. This report concerns the failure of an Edwards porcine xenograft in the aortic position 15 months following implantation. At reoperation, the right and left coronary leaflets of the explanted valve were torn from the aortic wall. The loss of wall integrity suggests that during the process of mounting the xenograft on the flexible stent, the aortic walls of the bioprosthesis may have been thinned beyond a critical point of maintenance of wall strength. The pathological and clinical findings of similar cases are reviewed.

Heterograft cardiac valve prostheses: a five-year follow-up

The major advance in the management of valvular heart disease over the past twenty years has been due to prosthetic valve operation. The bioprostheses have good hemodynamic function and a low rate of thromboembolism although the long-term durability is unknown. In this series of 25 patients with 27 valves implanted over five years, there was an 9% early mortality and a 12% late mortality. There have been no thromboembolic episodes. Primary valvular dysfunction requiring operation occurred in 7.4% (2 out of 27). All surviving patients are in New York Heart Association Functional Class I or II.

Surgical treatment of post-myocardial infarction ventricular septal defects

Ventricular septal defect (VSD) following myocardial infarction has long been recognized as a lethal complication of severe coronary artery disease. Between 1969 and 1978, 13 patients underwent operative repair of post-myocardial infarction VSDs associated with large left-to-right shunts and markedly impaired left ventricular performance. Emergency cardiac catheterization in 12, coronary cineangiography in 11, and operative repair in 13 were performed 1 to 15 days after ventricular septal perforation. The surgical approach consisted of left ventricular aneurysmectomy or infarctectomy with VSD repair and with coronary revascularization when indicated. Survival could not be predicted on the basis of preoperative hemodynamics, extent of coronary artery disease, age, time from the appearance of the VSD or myocardial infarction to definitive surgical therapy, or preoperative functional class. There were six survivors, all of whom had anterior septal defects. All but one of the nonsurvivors had posterior VSDs. The one patient who died with anterior VSD had the highest left-to-right shunt--2.6 L/min/m2. Emergency operative repair of acute post-myocardial infarction VSD is warranted in this high-risk group of patients who otherwise have little chance of survival.

Cardial myxomas: a clinical diagnostic challenge

Our experience consists of seven intracardiac myxomas in five patients seen over an 8 year period. It includes one patient who had three primary tumors, each anatomically distinct, occurring at 4 year intervals. The initial clinical presentation included embolic phenomena, unexplained neurologic symptoms, hemodynamic obstruction, and vague systemic illness. Preoperative diagnosis was confirmed by echocardiography or angiocardiography in all cases. At operation, only two of seven tumors were found to arise from the vicinity of the fossa ovalis; the other five arose from the atrial wall or ventricular septum. Wide resection of the tumors constituted the key to successful treatment. All patients have done well for periods of follow-up ranging from 6 months to 8 years. Awareness of cardiac myxoma is the key to diagnosis; treatment should be uniformly successful in all instances once the proper diagnosis has been made. Although recurrences are rare, all patients must be followed up closely for the development of new tumors, and a thorough investigation of all chambers must be conducted in patients with suspected recurrence.

Incremental intravenous nitroglycerin for control of afterload during anesthesia in patients undergoing myocardial revascularization

In 25 patients undergoing coronary artery bypass grafting hemodynamic measurements (including values obtained with Swan-Ganz catheterization in 21 of the patients) were made before and after administering a bolus injection of 64 or 96 mcg of nitroglycerin to relieve intraoperative hypertension. This pharmacological agent reduced afterload and preload without raising heart rate. The effect was apparent within 1-3 min and lasted 5-10 min. Untoward hypotension was not encountered in any instance. This intervention appears to be a safe approach to the treatment of intraoperative hypertension in patients with coronary artery disease.

Immunopathogenesis of Libman-Sacks endocarditis. Assessment by light and immunofluorescent microscopy in two patients

The possible contribution of immunological mechanisms in the development of Libman-Sacks endocarditis was studied in 2 patients with systemic lupus erythematosus who underwent aortic valve replacement. Sections of verrucous lesions, stained with haematoxylin and eosin, showed three apparently distinct zones: an outer exudative zone of fibrin, nuclear debris, and haematoxylin-stained bodies; a middle organizing zone of proliferating capillaries and fibroblasts; and an inner zone of neovascularization which showed distinct, thin-walled junctional vessels. The striking finding was the apparently selective deposition of immunoglobulins and complement identified by direct immunofluorescence, within the walls of the small junctional vessels of the zone of neovascularization. We suggest that the observed immune deposits are immune complexes and that circulating immune complexes may play a critical role in the growth and proliferation of the verrucous lesion.

Hemodynamic assessment of the glutaraldehyde-preserved porcine heterograft in the aortic and mitral positions

Although glutaraldehyde-preserved porcine heterograft (PH) valves may have a lowered incidence of thromboembolism compared to mechanical valves, data concerning postoperative function in PH valves are incomplete. Accordingly, 26 patients receiving PH in the aortic (AO) or mitral position (MIT) were studied at cardiac postoperative catheterization (mean 19 weeks). The 12 AO patients had an average peak systolic gradient of 19 mm Hg (range 3-52 mm Hg); mean valve area (VA) 1.33 cm2 (0.75-2.5; two patients had postoperative aortic insufficiency. The 14 MIT patients had a mean gradient of 7.9 mm Hg (0-13.1); VA 1.84 cm2 (0.70-3.2; postoperative mitral regurgitation occurred in two patients. AO stent diameter (SD) related to VA, r = 0.85; and peak gradient, r = -0.75. However, MIT SD did not relate to VA or peak gradient. At the 14-month follow-up examination 9 of 11 AO and 7 of 11 MIT patients improved by at least one functional class. Thus, with the advantage of reduced thromboembolism and generally satisfactory valve hemodynamics, further clinical trial of glutaraldehyde-preserved porcine heterografts is justified.

Determination of improved myocardial perfusion after aortocoronary bypass surgery by exercise rubidium-81 scintigraphy

Practical and noninvasive means are needed for evaluating efficacy of coronary bypass surgery (CBS) in improving blood flow (CBF) to ischemic myocardium in coronary patients. Revascularization was assessed in 15 patients by pre- and post-CBS rest and exercise rubidium-81 myocardial images with a scintillation camera equipped with pinhole collimator and high-energy shield. Ischemic areas were detected by decreased 81Rb activity after exercise compared to rest. Before CBS all patients had exercise angina (EA), positive treadmill ECG (TECG), and abnormal exercise 81Rb scans. After CBS all 15 patients had increased physical activity before angina or completion of treadmill exercise with increased heart rate-blood pressure product (HRBP) (+ 63 +/- 3.2 X 10(2) bpm - mm Hg) in 14 of 15 patients indicating increased CBF; four had positive TECG, and five had EA. The increased HRBP in 14 patients was associated with improved post-CBS exercise 81Rb scans: six had normal patterns while nine were improved with less ischemic patterns. Further, lack of angina and increased exercise tolerance correlated closely with increased 81Rb myocardial perfusion. Thus pre- and postoperative rest and exercise 81Rb scintigraphy gives an accurate, noninvasive, objective approach for evaluation of CBF following CBS and demonstrates the usefulness of this revascularization procedure in coronary patients.

Rapid overdrive pacing of refractory tachyarrhythmias in patients after open-heart surgery

The efficacy of rapid ventricular pacemaker overdrive in the treatment of supraventricular and ventricular tachyarrhythmias is presented as a new approach to the management of these rhythm disorders inpatients after cardiac surgery. This mode of therapy is exemplified in the control of heart rate and return of normal sinus rhythm in patients with both types of tachyarrhythmias refractory to conventional antiarrhythmic agents. In addition, the pathogenesis and mechanisms of pacemaker overdrive in termination these rhythm disturbances are delineated.

Contralateral recurrent myxoma of the heart

Nineteen recurrences of a left atrial myxoma have been reported in 16 patients. This paper deals with the removal of a right ventricular myxoma three and one-half years following excision of a left atrial tumor. Because of the possibility of recurrence, postoperative follow-up of all patients with intracardiac myxomas is mandatory.

Surgical correction of congenital left coronary artery-main pulmonary artery fistula in association with anomalous right coronary artery

The association of a left coronary artery-main pulmonary artery fistula and an anomalous right coronary artery originating from the main pulmonary artery is the subject of this report. This unique combination of congenital cardiac anomalies establishes a double coronary steal from the left coronary artery, which hemodynamically represents the sole source of myocardial perfusion. The left coronary artery-main pulmonary artery fistula was closed and the coexisting anomalous right coronary artery reimplanted into the anterior aspect of the ascencing aorta. A dual coronary supply was therefore established and thus eliminated the potential threat of total myocardial ischemia should the left coronary artery become critically compromised. Patency of both the left coronary artery and the transplanted right coronary artery was documented 1 year postoperatively by aortic root angiography.

Corrosive injury to oro-pharynx and esophagus. Eighty-five consecutive cases

In 85 consecutive cases of ingestion of caustic material, 70 patients had oral burns, 29 incurred esophageal burns, and in three esophageal stricture developed, requiring repeated dilatation. Management involves early endoscopy to determine the extent of mucosal injury, antibiotics to reduce local or mediastinal infection, and steroids to prevent the chance for esophageal stricture.

Early functional and ultrastructural recovery of canine cadaver hearts

Simulation of sudden death in a potential heart graft donor was accomplished by producing acute anoxic arrest in canine hearts that were then maintained at cadaver temperature for periods of from 15 to 60 minutes prior to reperfusion with oxygenated blood. Functional recovery of reperfused hearts measured by contractile force was more rapid for hearts that had undergone shorter periods of anoxic arrest. The rates of recovery were nearly identical within the group for 15 to 25 minutes and for 30 to 45 minutes of anoxic arrest, but not for the 60-minute anoxic arrest group in which two of four hearts made no recovery at all.

Ultrastructural reactions to anoxic arrest were evident at 15 minutes and found to progress in a predictable manner as the duration of anoxia increased. Changes occurring during anoxic periods of up to 30 minutes were for the most part reversed within 1 hour of perfusion during which time characteristic nuclear, cytoplasmic, and mitochondrial "recovery patterns" were encountered. With a "pump-dog" preparation, these reperfused hearts were well kept for up to 7 hours. Anoxic arrest of 45 minutes or more produced ultrastructural changes that were less consistently reversed by reperfusion of 1 hour. The sensitivity of mitochondrial structure to anoxic arrest and reperfusion was demonstrated, and suggested that irreversible cell damage (i.e., cell death) in anoxia is due to mitochondrial failure. The techniques of perfusion and ultrastructural sampling employed in these experiments should prove useful in studying the effects of hypothermia, drug application and other measures in the preservation and restoration of isolated hearts.

The mechanism of canine atrial flutter

In anesthetized dogs, electrograms were recorded simultaneously from six atrial epicardial sites and a limb or esophageal lead in order to study the mechanism of atrial flutter induced electrically after an intercaval crush in comparison with atrial tachysystole induced by aconitine. In the former, with limb lead records resembling classical human flutter in form and regularity, activation occupied most of the atrial cycle and progressed in sequence caudally in the right atrium and cranially in the left (counterclockwise flutter); flutter was usually terminated by another crush extending from the initial one to the right atrioventricular junction. The most prominent wave in limb and esophageal leads coincided with left atrial activity. Sometimes activation proceeded clockwise. The two atrial appendages may be activated simultaneously during counterclockwise flutter. These findings support the circus movement hypothesis as the mechanism of pure atrial flutter. In contrast, with aconitine tachysystole, activation proceeded over both atria at once and was so brief that it left most of the slightly irregular atrial cycle electrically silent. Although limb leads after aconitine sometimes resembled those of flutter, the contrast in direction and duration of excitation demonstrates profound physiological differences between the two arrhythmias.