On The Carlos Castilla Del Pino “Axiom of Behavioral Significance” and Its Relevance in Philosophy of Psychiatry: The Unification of Clinical Neuroscience

Carlos Castilla del Pino (1922-2009) was a Spanish psychiatrist and essayist with a wide work ranging from neuropsychiatry to social psychiatry. His essays include interesting psychopathological, anthropological and semiotic ideas.

The “axiom of behavioural significance” proposes that human behaviour is not an objective event but a meaningful act. As the objective of human behaviour is relation between human beings, it must be studied only under this communicative perspective.

Based in this axiomatic approach of Castilla del Pino, some arguments of interest to philosophy of psychiatry will be exposed:

– Mind is based in language and language is a communicative acts system in need of a dialogic community, namely, in need of a group of interacting brains. So, referring to the “brains-mind problem” is proposed to be preferred instead of referring to the “brain-mind problem”. Mind is a language-based emergent property of the social group, not a property of a single brain.

– The intention of human behaviour and the content of mental subjective phenomena should not be taken as a sign of any brain disease. Human behavior and mental representations always refers to a social group and a social context, not to a single brain. The only disease indicators we can take as disease signs are the formal aspects of behaviour and mind contents, as disexecutive syndrome or mental automatism are.

– As a corollary, it is proposed that neurology and psychiatry do not have any epistemic difference, leading to defence the unification of clinical neuroscience.

Disclosure of interest

The authors have not supplied their declaration of competing interest.

On the prediction of Hodgkin lymphoma treatment response

PURPOSE

The cure rate in Hodgkin lymphoma is high, but the response along with treatment is still unpredictable and highly variable among patients. Detecting those patients who do not respond to treatment at early stages could bring improvements in their treatment. This research tries to identify the main biological prognostic variables currently gathered at diagnosis and design a simple machine learning methodology to help physicians improve the treatment response assessment.

METHODS

We carried out a retrospective analysis of the response to treatment of a cohort of 263 Caucasians who were diagnosed with Hodgkin lymphoma in Asturias (Spain). For that purpose, we used a list of 35 clinical and biological variables that are currently measured at diagnosis before any treatment begins. To establish the list of most discriminatory prognostic variables for treatment response, we designed a machine learning approach based on two different feature selection methods (Fisher's ratio and maximum percentile distance) and backwards recursive feature elimination using a nearest-neighbor classifier (k-NN). The weights of the k-NN classifier were optimized using different terms of the confusion matrix (true- and false-positive rates) to minimize risk in the decisions.

RESULTS AND CONCLUSIONS

We found that the optimum strategy to predict treatment response in Hodgkin lymphoma consists in solving two different binary classification problems, discriminating first if the patient is in progressive disease; if not, then discerning among complete and partial remission. Serum ferritin turned to be the most discriminatory variable in predicting treatment response, followed by alanine aminotransferase and alkaline phosphatase. The importance of these prognostic variables suggests a close relationship between inflammation, iron overload, liver damage and the extension of the disease.

INSECTICIDAL ACTIVITY OF PROTEIN EXTRACTS OBTAINED FROM BULBS OF CHILEAN AMARYLLIDACEAE AGAINST TRIALEURODES VAPORARIORUM WESTWOOD AND PSEUDOCOCCUS VIBURNI SIGNORET

Entomotoxic proteins are produced by plants in defence against insect herbivory. Some carbohydrate-binding proteins exhibit strong insecticidal activity affecting the survival, growth, development and feeding behavior of phytophagous insects. The occurrence of entomotoxic lectins is well documented in the Amaryllidaceae, a plant family spread world-wide. In Chile, this family is represented by numerous species, many of which are also of high ornamental value. Protein extracts were obtained from bulbs of five different species of Chilean Amaryllidaceae. A dose-response assay was carried out with two important pests: the greenhouse whitefly Trialeurodes vaporariorum Westwood and the mealybug Pseudococcus viburni Signoret. The extracts were offered to insects in a liquid artificial diet for three days and the mortality was scored. The Phycella australis Ravenna extract caused the highest insecticidal activity (T. vaporariorum LC₅₀: 7200 µg/mL; P. viburni LC₅₀: 9500 µg/mL). Applied at 1000 µg/mL in the diet the P. australis extract did not repel feeding of these pests. A mannose-binding lectin isolated from the bulbs of P. australis proved to be moderately toxic for these pests (T. vaporariorum LC₅₀: 1127 µg/mL; P. viburni LC₅₀: 2320 µg/mL).

Ventilatory targets after cardiac arrest

The mortality of postcardiac arrest patients has gradually reduced in years but it still is as high as 50%, despite advancements in the diagnostic and therapeutic approaches, i.e. revascularization and therapeutic moderate hypothermia. However, recent evidence suggests that other therapeutic interventions aimed to minimize progressive deterioration of the brain and other organs function might be helpful to reduce in-hospital mortality and improve neurologic outcome as well as quality of life after cardiac arrest. In this article, we discuss the role of ventilator management on the prognosis after cardiac arrest. We performed a meta-analysis showing that in adult patients not only hypoxia but also hyperoxia was associated with higher in-hospital mortality, while hypercapnia and hypocapnia worse neurologic outcome. In pediatric patients, hypoxia and hyperoxia were not associated with higher in-hospital mortality, while hypocapnia and hypercabia with higher in-hospital mortality worse neurologic outcome. We propose a general bundle for ventilator treatment after cardiac arrest, including: 1) therapeutic hypothermia for 12-24 hours; 2) mean arterial pressure ≥65-75 mmHg; 3) PaO2 between 60-200 mmHg and PCO2 between 30 and 50 mmHg; 4) protective MV with tidal volume of 6-8 mL/kg and positive end expiratory pressure of between 5-10 cmH2O; 5) monitoring of respiratory mechanics, extravascular lung water, hemodynamics, non-invasive transcranial Doppler and intracranial pressure monitoring; and 6) others supportive care, i.e. blood sugar and seizures control.

Human plasma-derived immunoglobulin G fractionated by an aqueous two-phase system, caprylic acid precipitation, and membrane chromatography has a high purity level and is free of detectable in vitro thrombogenic activity

BACKGROUND AND OBJECTIVES

Instituto Clodomiro Picado has developed an immunoglobulin G (IgG) plasma fractionation process combining a polyethylene glycol/phosphate aqueous two-phase system (ATPS), caprylic acid precipitation and anion-exchange membrane chromatography. We evaluated the purity and in vitro thrombogenicity of such IgG, in line with current international requirements.

MATERIALS AND METHODS

Contributions of the different production steps to reduce thrombogenicity were assessed at 0·2 l-scale, and then the methodology was scaled-up to a 10 l-scale and final products (n = 3) were analysed. Purity, immunoglobulin composition, and subclass distribution were determined by electrophoretic and immunochemical methods. The in vitro thrombogenic potential was determined by a thrombin generation assay (TGA) using a Technothrombin fluorogenic substrate. Prekallikrein activator (PKA), plasmin, factor Xa, thrombin and thrombin-like activities were assessed using S-2302, S-2251, S-2222, S-2238 and S-2288 chromogenic substrates, respectively, and FXI by an ELISA.

RESULTS

The thrombogenicity markers were reduced mostly during the ATPS step and were found to segregate mostly into the discarded liquid upper phase. The caprylic acid precipitation eliminated the residual procoagulant activity. The IgG preparations made from the 10 l-batches contained 100% gamma proteins, low residual IgA and undetectable IgM. The IgG subclass distribution was not substantially affected by the process. TGA and amidolytic activities revealed an undetectable in vitro thrombogenic risk and the absence of proteolytic enzymes in the final product.

CONCLUSIONS

Fractionating human plasma by an ATPS combined with caprylic acid and membrane chromatography resulted in an IgG preparation of high purity and free of a detectable in vitro thrombogenic risk.

PEEP role in ICU and operating room: from pathophysiology to clinical practice

Positive end expiratory pressure (PEEP) may prevent cyclic opening and collapsing alveoli in acute respiratory distress syndrome (ARDS) patients, but it may play a role also in general anesthesia. This review is organized in two sections. The first one reports the pathophysiological effect of PEEP on thoracic pressure and hemodynamic and cerebral perfusion pressure. The second section summarizes the knowledge and evidence of the use of PEEP in general anesthesia and intensive care. More specifically, for intensive care this review refers to ARDS and traumatic brain injured patients.

Informed consent for tracheostomy procedures in Intensive Care Unit: an Italian national survey

BACKGROUND

Critically ill patients in Intensive Care Unit (ICU), due to their temporary or permanent incompetence, are often not capable to provide informed consent (IC), although required, for not emergency invasive procedures, like elective tracheostomy. By Italian law, a person with partially/temporarily physical/mental impairment needs a legal tutorship appointed by the court (Support Administrator, SA). We performed a national survey in Italy to investigate IC practice for elective tracheostomy procedure in critically ill conscious and unconscious patients in ICU.

METHODS

Questions about IC were included in a survey concerning the clinical practice of tracheostomy in ICU. The survey was approved by the Italian Society of Anesthesia, Analgesia and Intensive Care (SIAARTI, n° 434 - 28 March 2012) and sent by e-mail to all members included in its mailing list. The duration of the survey was three months from April to June 2012. All required information was referred to the year 2011.

RESULTS

The mailed questionnaire correctly fulfilled was sent back by 131/427 (30%) national ICUs. Our data showed 1) in conscious patients, IC was obtained by 82.4% of ICUs; 2) in unconscious patients, IC was obtained in only 61.8% with different procedures not following the current Italian law, 3) for surgical tracheostomy performed in operating room, IC was obtained in conscious and unconscious patients in only 69.8% and 47.2% of ICUs, respectively, 4) risk/benefit informative document was provided in 61.1% ICUs, but available only in 47.2% of ICUs performing tracheostomy in operating room.

CONCLUSION

In Italian ICUs, participating to this study, the procedures related to IC for conscious and unconscious critically ill patients requiring surgical or percutaneous tracheostomy are not in line with current legal rules and procedures.

Table-top laser-based source of femtosecond, collimated, ultrarelativistic positron beams

The generation of ultrarelativistic positron beams with short duration (τ(e+) ≃ 30  fs), small divergence (θ(e+) ≃ 3  mrad), and high density (n(e+) ≃ 10(14)-10(15)  cm(-3)) from a fully optical setup is reported. The detected positron beam propagates with a high-density electron beam and γ rays of similar spectral shape and peak energy, thus closely resembling the structure of an astrophysical leptonic jet. It is envisaged that this experimental evidence, besides the intrinsic relevance to laser-driven particle acceleration, may open the pathway for the small-scale study of astrophysical leptonic jets in the laboratory.

Scaling high-order harmonic generation from laser-solid interactions to ultrahigh intensity

Coherent x-ray beams with a subfemtosecond (<10(-15)  s) pulse duration will enable measurements of fundamental atomic processes in a completely new regime. High-order harmonic generation (HOHG) using short pulse (<100  fs) infrared lasers focused to intensities surpassing 10(18)  W cm(-2) onto a solid density plasma is a promising means of generating such short pulses. Critical to the relativistic oscillating mirror mechanism is the steepness of the plasma density gradient at the reflection point, characterized by a scale length, which can strongly influence the harmonic generation mechanism. It is shown that for intensities in excess of 10(21)  W cm(-2) an optimum density ramp scale length exists that balances an increase in efficiency with a growth of parametric plasma wave instabilities. We show that for these higher intensities the optimal scale length is c/ω0, for which a variety of HOHG properties are optimized, including total conversion efficiency, HOHG divergence, and their power law scaling. Particle-in-cell simulations show striking evidence of the HOHG loss mechanism through parametric instabilities and relativistic self-phase modulation, which affect the produced spectra and conversion efficiency.

Tracheostomy in Intensive Care Unit: a national survey in Italy

BACKGROUND

The aim of the present study was to evaluate the frequency of different techniques, indications, timing, as well as procedural features, sedation and ventilation protocols, early and late complications of tracheostomy in Intensive Care Unit (ICU).

METHODS

This was a retrospective survey on data collected in 2011. A questionnaire was mailed to all members of the Italian Society of Anesthesia, Analgesia and Intensive Care (SIAARTI).

RESULTS

We included in the analysis 131 questionnaires. We found that: 1) Ciaglia Blue-Rhino® (CBR) was the most commonly used tracheostomy (32.8%; N.=1953) and the main indication was prolonged mechanical ventilation (58.8%; N.=77); 2) tracheostomy was performed between 7-15 days (71.8%; N.=94) from ICU admission by a dedicated team (62.6%; N.=82) involving more than one intensive care physician and a nurse; 3) tracheostomy was frequently guided by fiberoptic bronchoscope (93.1%, N.=122) while neck ultrasounds were used as a screening procedure to assess at-risk structure often in presence of pathological anatomical structures (68.7%; N.=90); 4) ventilation protocol and sedation-analgesia-neuromuscular blocking protocol were available in 83.2% and 58.8% of ICUs, respectively; 5) minor bleeding controlled by compression was the most common early and late complication.

CONCLUSION

Percutaneous tracheostomy is well established in Italian ICUs and CBR is the most popular technique performed in patients requiring prolonged mechanical ventilation. Tracheostomy is usually performed by a dedicated team using a specific sedation-analgesia-neuromuscular blocking and ventilation protocol, guided by fiberoptic bronchoscope and/or neck ultrasounds. Bleeding controlled by compression was the most common early and late complication.

Effect of long-term starvation conditions on polyphosphate- and glycogen-accumulating organisms

Endogenous processes such as biomass decay and intracellular polymers degradation of polyphosphate-accumulating organisms (PAOs) and glycogen-accumulating organisms (GAOs) were investigated. Cultures enriched in Accumulibacter (a well known PAO) or Competibacter (a well known GAO) were subjected to 21 and 26 days of alternating anaerobic/aerobic conditions respectively. The main energy source for PAOs during starvation was their intracellular polyphosphate released into the medium during the first 14 days of starvation. In contrast, GAOs used their intracellular glycogen during the 26 days of starvation. Biomass decay rates were 0.029 d(-1) for PAOs and almost negligible for GAOs. The reduction in acetate uptake rate during the starvation period, referred to as activity decay, was 0.25 and 0.047 d(-1) for PAOs and GAOs, respectively. Once wastewater was reintroduced, both populations recovered their initial substrate uptake rate after 1 day. The results obtained show that PAOs are more affected than GAOs by starvation conditions.