How mood is affected by environment and upsetting events: The moderating role of psychological flexibility

OBJECTIVE

Patients suffering from psychological disorders report decreased quality of life and low mood. The relationship of these symptoms to daily upsetting events or environments, and in the context of active coping mechanisms is poorly understood. The present study thus investigates the association between mood, psychological flexibility, upsetting events, and environment in the daily life of outpatients.

METHOD

We investigated 80 outpatients at the beginning of treatment, using event sampling methodology (ESM). Patients' mood, occurrence of upsetting events, current environment, and psychological flexibility were sampled six times per day during a one-week intensive longitudinal examination. Data were analyzed using linear mixed models (LMMs).

RESULTS

Participants reported worse mood the more upsetting events they experienced. Further, participants reported better mood when in private environments (e.g., with friends), and worse mood when at the hospital, compared to being at home. Higher levels of psychological flexibility, however, were associated with better mood, irrespective of the occurrence of upsetting events or current environment.

CONCLUSION

Results suggest that mood is positively associated with psychological flexibility, not despite, but especially during the dynamic and context-specific challenges of daily life. Psychological flexibility may thus potentially act as a buffer against distress-provoking situations as patients go about their daily lives.

TRIAL REGISTRATION

ISRCTN.org identifier: ISRCTN11209732.

Psychotherapy for Chronic In- and Outpatients with Common Mental Disorders: The "Choose Change" Effectiveness Trial

INTRODUCTION

Treatment non-response occurs regularly, but psychotherapy is seldom examined for such patients. Existing studies targeted single diagnoses, were relatively small, and paid little attention to treatment under real-world conditions.

OBJECTIVE

The Choose Change trial tested whether psychotherapy was effective in treating chronic patients with treatment non-response in a transdiagnostic sample of common mental disorders across two variants of treatment delivery (inpatient and outpatient).

METHODS

The controlled nonrandomized effectiveness trial was conducted between May 2016 and May 2021. The study took place in two psychiatric clinics with N = 200 patients (n = 108 inpatients and n = 92 outpatients). Treatment variants were integrated inpatient care versus outpatient care based on acceptance and commitment therapy (ACT) for approximately 12 weeks. Therapists delivered individualized and non-manualized ACT. Main outcome measures were symptoms (Brief Symptom Checklist [BSCL]); well-being (Mental Health Continuum-Short Form [MHC-SF]), and functioning (WHO Disability Assessment Schedule [WHO-DAS]).

RESULTS

Both inpatients and outpatients showed decreases in symptomatology (i.e., BSCL: d = 0.68) and increases in well-being and functioning (MHC-SF: d = 0.60 and WHO-DAS: d = 0.70), with more improvement in the inpatients during treatment. Both groups maintained gains 1 year following treatment, and the groups did not significantly differ from each other at this timepoint. Psychological flexibility moderated impact of stress on outcomes.

CONCLUSIONS

Psychotherapy as practiced under routine conditions is effective for a sample of patients with common mental disorders, a long history of treatment experience and burden of disease, in both inpatient and outpatient settings.

TRIAL REGISTRATION

This study was registered in the ISRCTN registry on May 20, 2016, with the registration number ISRCTN11209732.

Systematic mapping review of interventions to prevent blood loss, infection and relapse in orthognathic surgery

BACKGROUND

This systematic mapping review aims to identify, describe, and organize the currently available evidence in systematic reviews (SR) and primary studies regarding orthognathic surgery (OS) co-interventions and surgical modalities, focusing on the outcomes blood loss, infection and relapse.

MATERIAL AND METHODS

A comprehensive search strategy was performed to identify all SRs, randomized controlled trials and observational studies that evaluate surgical modalities and perioperative co-interventions in OS that evaluate the outcomes blood loss, infection and relapse, regardless of language or publication date. Searches were conducted in MEDLINE, EMBASE, Epistemonikos, Lilacs, Web of Science, and CENTRAL. In addition, grey literature was screened.

RESULTS

27 SRs and 150 primary studies fulfilled the inclusion criteria, 91 from SRs, and 59 from our search strategy. Overall, the quality of the SRs was graded as "Critically low," and only two SRs were rated as "High" quality. 11 PICO questions were extracted from SRs and 31 from primary studies, which focused on osteosynthesis methods, surgical cutting devices, use of antibiotics, and induced hypotension. In addition, evidence bubble maps for each outcome were created to analyze in a visual manner the existing evidence.

CONCLUSIONS

Future primary and secondary high-quality research should be addressed focused on the eight knowledge gaps identified in this mapping review. We concluded that the evidence mapping approach is a practical methodology for organizing the current evidence and identifying knowledge gaps in OS, helping to reduce research waste and canalize future efforts in developing studies for unsolved questions.

Meaningful Relationships in Community and Clinical Samples: Their Importance for Mental Health

Meaningful relationships are centrally important for human functioning. It remains unclear, however, which aspects of meaningful relationships impact wellbeing the most and whether these differ between psychiatric patients and members of the community. Information about relationship attributes and functions were collected in community members (N = 297) and psychiatric patients (N = 177). Relationship attributes and functions were examined for differences between groups (community vs. patients), their impact on wellbeing and symptoms, and the size of network (one vs. many relationships). Community members reported fewer relationships, higher frequency of contact and less desire for change when compared to the psychiatric patients. Nevertheless, both groups reported relatively high levels of fulfilled functions. Quality of the relationship and investment into the relationship was associated with both wellbeing and symptoms for both the community and the patient group. Almost all functions were associated with wellbeing and symptoms for the community group. However, for the patient group, only few functions (sexual partner, go-to person for compassion, go-to person when happy) were associated with wellbeing and no functions were associated with symptoms. Contrary to our hypotheses, the results show that psychiatric patients do not have a deficit in fulfilling relationships. Most people report a well-functioning network of meaningful, high-quality relationships. Patients benefit from meaningful, function-fulfilling relationships just as much as community members. Results are discussed with respect to how targeting relationships can be used clinically.

Effect of antibiotic prophylaxis for preventing infectious complications following impacted mandibular third molar surgery. A randomized controlled trial

Background

The objective of this study was to determine the effect of antibiotic prophylaxis in preventing postoperative infections after extraction of impacted mandibular third molars.

Material and Methods

A Parallel-group, randomized, blind, placebo-controlled trial was performed. 154 patients were randomly allocated to 2 groups; experimental (n=77) receiving 2g amoxicillin 1 hour prior to surgery and control (n=77) receiving placebo. Primary outcome was postoperative infections and secondary outcome was the need for rescue analgesia.

Results

4.5% of patients developed postoperative infections, five patients of the control group (4 alveolar osteitis, 1 surgical site infection) and two of the experimental group (1 alveolar osteitis, 1 surgical site infection). Difference between groups was not statistically significant, RR=0.4 (95%CI 0.08-1.99, 𝘱=0.41) NNTB=26. Rescue analgesia intake was significantly higher in the control group (41 vs 18 patients of experimental group) RR=0.49 (95%CI 0.32-0.75, 𝘱<0.05) NNTB=3.

Conclusions

The use of 2g amoxicillin 1 hour before surgery was not effective in significantly reducing the risk of postoperative infections from impacted mandibular third molars extraction, when compared to placebo. Nevertheless, antibiotic prophylaxis was associated with a reduced need for rescue analgesia.

Key words:Antibiotic prophylaxis, third molar, tooth extraction, impacted tooth, dry socket, surgical wound infection, oral surgery.

Clinical characteristics and outcomes of 1,331 patients with COVID-19: HM Spanish Cohort

OBJECTIVE

Spain is one of the European countries most affected by the COVID-19 pandemic. Epidemiologic studies are warranted to improve the disease understanding, evaluate the care procedure and prepare for futures waves. The aim of the study was to describe epidemiologic characteristics associated with hospitalized patients with COVID-19.

METHODS

This real-world, observational, multicenter and retrospective study screened all consecutive patients admitted to 8 Spanish private hospitals. Inclusion criteria: hospitalized adults (age≥18 years old) with clinically and radiologically findings compatible with COVID-19 disease from March 1st to April 5th, 2020. Exclusion criteria: patients presenting negative PCR for SARS-CoV-2 during the first 7 days from hospital admission, transfer to a hospital not belonging to the HM consortium, lack of data and discharge against medical advice in emergency departments.

RESULTS

One thousand and three hundred thirty-one COVID-19 patients (medium age 66.9 years old; males n= 841, medium length of hospital stayed 8 days, non-survivors n=233) were analyzed. One hundred and fifteen were admitted to intensive care unit (medium length of stay 16 days, invasive mechanical ventilation n= 95, septic shock n= 37 and renal replacement therapy n= 17). Age, male gender, leukocytes, platelets, oxygen saturation, chronic therapy with steroids and treatment with hydroxychloroquine/azithromycin were independent factors associated with mortality. The proportion of patients that survive and received tocilizumab and steroids were lesser and higher respectively than those that die, but their association was not significant.

CONCLUSIONS

Overall crude mortality rate was 17.5%, rising up to 36.5% in the subgroup of patients that were admitted to the intensive care unit. Seven factors impact in hospital mortality. No immunomodulatory intervention were associated with in-hospital mortality.

Having versus not having social interactions in patients diagnosed with depression or social phobia and controls

Humans need meaningful social interactions, but little is known about the consequences of not having them. We examined meaningful social interactions and the lack thereof in patients diagnosed with major depressive disorder (MDD) or social phobia (SP) and compared them to a control group (CG). Using event-sampling methodology, we sampled participants’ everyday social behavior 6 times per day for 1 week in participants’ natural environment. We investigated the quality and the proportion of meaningful social interactions (when they had meaningful social interactions) and degree of wishing for and avoidance of meaningful social interactions (when they did not have meaningful social interactions). Groups differed on the quality and avoidance of meaningful social interactions: Participants with MDD and SP reported perceiving their meaningful social interactions as lower quality (in terms of subjective meaningfulness) than the CG, with SP patients reporting even lower quality than the MDD patients. Further, both MDD and SP patients reported avoiding meaningful social interactions significantly more often than the CG. Although the proportion of meaningful social interactions was similar in all groups, the subjective quality of meaningful social interactions was perceived to be lower in MDD and SP patients. Future research might further identify what variables influenced the reinforcement of the MDD and SP patients so that they engaged in the same number of meaningful social interactions even though the quality of their meaningful social interactions was lower. Increasing awareness of what happens when patients do or do not have meaningful social interactions will help elucidate a potentially exacerbating or maintaining factor of the disorders.

The spatiotemporal movement of patients in and out of a psychiatric hospital: an observational GPS study

BACKGROUND

Movement is a basic component of health. Little is known about the spatiotemporal movement of patients with mental disorders. The aim of this study was to determine how spatiotemporal movement of patients related to their symptoms and wellbeing.

METHOD

A total of 106 patients (inpatients (n = 69) and outpatients (n = 37)) treated for a wide range of mental disorders (transdiagnostic sample) carried a GPS-enabled smartphone for one week at the beginning of treatment. Algorithms were applied to establish spatiotemporal clusters and subsequently related to known characteristics of these groups (i.e., at the hospital, at home). Symptomatology, Wellbeing, and Psychological flexibility were also assessed.

RESULTS

Spatiotemporal patterns of inpatients and outpatients showed differences consistent with predictions (e.g., outpatients showed higher active areas). These patterns were largely unassociated with symptoms (except for agoraphobic symptoms). Greater movement and variety of movement were more predictive of wellbeing, however, in both inpatients and outpatients.

CONCLUSION

Measuring spatiotemporal patterns is feasible, predictive of wellbeing, and may be a marker of patient functioning. Ethical issues of collecting GPS data are discussed.

Thyroid and Parathyroid Neoplasms with Lipomatous Stroma: Report of Three Cases and Review of the Literature

Introduction/Objective

Tumors with mixed adipose tissue and epithelial components are rare in thyroid and parathyroid glands. Most of them are benign and referred to as adenolipoma (or lipoadenoma). A handful of malignant tumors of thyroid follicular cell origin have been reported with abundant adipose tissue known as thyroid carcinoma with lipomatous stroma (TCLS). Adenolipomas of thyroid or TCLS are usually manifested as large thyroid nodules and evaluated by fine needle aspiration biopsy (FNAB) which frequently yield low-cellularity samples due to abundant adipose tissue. On FNAB, the adipose tissue usually interpreted as contamination of subcutaneous or perithyroid origin. Similarly, adenolipomas of the parathyroid are not frequently identified because of presence of adipose tissue which is a feature associated with normal parathyroid glands. Therefore, these tumors are not often correctly diagnosed preoperatively. For that reason, pathologist should report additional cases about this rare entity to increase our understanding and to decrease preoperative diagnostic error.

Methods

We report three cases of thyroid and parathyroid tumors with abundant adipose tissue with sonographic, cytologic and histologic features along with literature review.

Results

Among the reported cases in the literature and our cases; 10 out of 17 cases of thyroid carcinoma with lipomatous stroma are papillary thyroid carcinomas (58.8%), 3 out of 17 cases are papillary microcarcinomas (17.6%), 2 out of 17 cases are noninvasive follicular thyroid neoplasm with papillary-like nuclear features (NIFTP) (11.7%), and 2 out of 17 cases are minimally invasive follicular carcinomas (11.7%). No cases of poorly differentiated or anaplastic thyroid carcinomas have been reported.

Conclusion

Lipomatous stroma in thyroid carcinoma appears to be associated with differentiated carcinomas since no reported cases of poorly differentiated or anaplastic thyroid carcinomas are present to our knowledge. Although the presence of fatty tissue does not appear to alter the prognosis of these lesions, the question of the histogenesis of the adipose component is intriguing. Awareness of this unusual feature and increased utilization of multimodal approaches in the evaluation of this entity may increase preoperative detection and the understanding of the histogenesis and its possible significance.

Poorly Differentiated Chordoma with Rhabdoid Features

Casestudy: Chordoma is an uncommon primary malignant tumor of the bone showing notochordal differentiation. The current World Health Organization classifies chordoma into three subtypes: conventional, chondroid, and dedifferentiated.

Poorly differentiated chordoma (PDC) is a newly described variant of chordoma, with its own distinct features in terms of age distribution (common in pediatric and young adults), histopathology (lack of physaliphorous cells and chondromyxoid matrix), immunohistochemical and molecular characteristics (loss of SMARCB1/INI1 expression) and clinical outcome (poor prognosis with rapid onset of local recurrence and metastasis).

Herein, we report the case of a 43 year old man with history of fall and injury of tailbone 2 years prior, who presented with pain and swelling at the sacrcoccygeal region and intermittent numbness in the legs. MRI of the pelvis showed a 9.8 cm lobulated mass centered on the sacrum with osseous destruction of S5 through coccyx, with intralesional hemorrhage, and mild heterogeneous enhancement. Biopsy of the sacrococcygeal mass demonstrated a malignant neoplasm composed of lobules of epithelioid cells with abundant eosinophilic cytoplasm showing focal vacuolization, and mild to moderate nuclear pleomorphism with an average 3 mitoses per high power field (400x). Immunohistochemically, the neoplastic cells were positive for pancytokeratin, CAM 5.2, vimentin and brachyury. They had loss of SMARCB1 (INI1) and were negative for S100, CK7, CK20, desmin and actin. The location, imaging studies, morphologic features and immunohistochemical profile were consistent with poorly differentiated chordoma with rhabdoid features. With its specific clinical, morphologic, immunophenotypical, and molecular features, PDC may be recognized as a chordoma subtype in a future WHO classification. According to current knowledge, the diagnosis of PDC should be restricted to cases with brachyury expression (specific for notochord tumors) and INI1 protein loss, especially in tumors of pediatric and young patients, regardless of cellular characteristics.

Development of a predictive model for hospital mortality and re-admission in a cohort of infected patients that require hospitalization

Introducción

Los objetivos del estudio fueron: identificar variables asociadas a mortalidad intrahospitalaria y reingreso hospitalario a 3 meses; identificar el impacto de la demora en el inicio de la antibioticoterapia en la mortalidad y reportar la tasa de antibioticoterapia inapropiada.

Material y métodos

Estudio observacional de cohortes retrospectivo realizado en el Hospital Universitario HM Sanchinarro en Madrid. Los criterios de inclusión fueron: edad> 18 años de edad, hospitalización desde urgencias durante el periodo 1 de septiembre 2012 al 31 de marzo del 2013 con diagnóstico de infección bacteriana. Los criterios de exclusión fueron: sospecha de infección viral y cultivos bacteriológicos negativos, expectativa de vida inferior a 6 meses, falta de información clínica, asistencia exclusivamente por el servicio de urgencias traumatológicas. Se realizaron dos modelos logísticos (mortalidad y reingreso hospitalarios).

Resultados

Se incluyeron 517 pacientes. Variables asociadas a mortalidad (30 fallecidos): frecuencia respiratoria (OR 1,12; IC95% 1,02; 1,22), saturación de oxígeno (OR 0,92; IC95% 0,87; 0,98), creatinina (OR 2,33; IC95% 1,62; 3,36), EPOC (OR 3,02; IC95% 1,06; 8,21), cáncer OR 3,34; IC95% 1,07; 9,98) y quimioterapia en los últimos 3 meses (OR 4,83; IC95% 1,54; 16,41). Variables asociadas a reingreso hospitalario (28 fallecidos): hepatopatía, GPT, antecedente de ictus e hipertensión arterial. Ambos modelos se destacan por su elevada especificidad y capacidad discriminativa pero baja sensibilidad. La demora en el inicio de la antibioticoterapia no influyo en la mortalidad ni reingreso. En 56 pacientes se identificó el microorganismo causal y el tratamiento antibiótico fue inapropiado en 11.

Conclusiones

Se registro un 5,8% de mortalidad hospitalaria y un 5,7% de reingresos. Las variables asociadas a la mortalidad intrahospitalaria difieren de las asociadas al reingreso. La demora en el inicio de la antibioticoterapia no se asoció a un efecto deletéreo. La antibioticoterapia inadecuada fue de casi el 20%.

The everyday lives of in- and outpatients when beginning therapy: The importance of values-consistent behavior

Background/Objective

The manifestation of functional impairment in patients’ daily lives and interference with things they value is poorly understood. If values are compromised in patients, as theory suggests, social contexts (and the lack thereof) are especially important – though this is currently unexplored. We therefore examined whether daily values-consistent behavior was associated with the importance of a value and whether it involved social or non-social activity.

Method

Using Event Sampling Methodology, we examined daily values-consistent behavior in 57 transdiagnostic inpatients and 43 transdiagnostic outpatients at the beginning of treatment. Patients’ values-consistent behavior, its importance, and (social vs non-social) context was sampled six times per day during a one-week intensive longitudinal examination.

Results

Across both groups, the probability of subsequent values-consistent behavior increased if (1) it was judged as more important by the patient or (2) if it was embedded in a social context. The probability of reporting values-consistent behavior was higher for outpatients than inpatients.

Conclusions

Clinicians are encouraged to examine the values of their patients more closely and to especially monitor important and/or social values. Incorporating these into clinical work might increase patients’ values-consistent behavior, which can play a role in reducing suffering.

Infectious postoperative complications in oral surgery. An observational study

Background

The main objective of this investigation was to determine the incidence of infectious postoperative complications in oral surgery.

Material and Methods

A observational and descriptive study was developed, with the use of prospective registry of the patients admitted for oral surgery at the San Borja Arriarán Hospital Complex during twelve months observation period (April 2017 to March 2018).

Results

The sample consisted of 532 patients undergoing surgical procedures of oral surgery and 19 cases of infectious postoperative complications. The incidence of complications reached 3,57% and it was observed predominantly in exodontic type interventions. The most commonly observed complication was dry socket, reaching 2,5% of third molar surgeries and 3,7% of extractions of other teeth. Other postoperative complication were 7 cases of facial spaces abscesses, also observed predominantly in exodontic type interventions.

Conclusions

The results were similar to those reported in the literature both in their frequency and in the type of complication.

Key words:Oral surgery, incidence, postoperative complications, dry socket, third molar.

Interictal Hyperperfusion in the Higher Visual Cortex in Patients With Episodic Migraine

BACKGROUND

Migraine pathophysiology is complex and probably involves cortical and subcortical alterations. Structural and functional brain imaging studies indicate alterations in the higher order visual cortex in patients with migraine. Arterial spin labeling magnetic resonance imaging (ASL-MRI) is a non-invasive imaging method for assessing changes in cerebral blood flow (CBF) in vivo.

OBJECTIVE

To examine if interictal CBF differs between patients with episodic migraine (EM) with or without aura and healthy controls (HC).

METHODS

We assessed interictal CBF using 2D pseudo-continuous ASL-MRI on a 3 Tesla Philips scanner (University Hospital Zurich, Switzerland) in EM (N = 17, mean age 32.7 ± 9.9, 13 females) and HC (N = 19, mean age 31.0 ± 9.3, 11 females).

RESULTS

Compared to HC, EM showed exclusively hyperperfusion in the right MT+ and Cohen's d effect size was 0.99 (HC mean CBF ± SD: 33.1 ± 5.9 mL/100 g/minutes; EM mean CBF: 40.9 ± 9.4 mL/100 g/minutes). EM with aura (N = 13, MwA) revealed hyperperfusion compared to HC in the right MT+ and superior temporal gyrus. For MT, Cohen's d effect size was 1.34 (HC mean CBF ± SD: 33.1 ± 5.9 mL/100 g/minutes; MwA mean CBF: 43.3 ± 8.6 mL/100 g/minutes). For the superior temporal gyrus, Cohen's d effect size was 1.28 (HC mean CBF ± SD: 40.1 ± 4.9 mL/100 g/minutes; MwA mean CBF: 47.4 ± 6.4 mL/100 g/minutes). In EM, anxiety was positively associated with CBF in the parietal operculum and angular gyrus.

CONCLUSIONS

Our results suggest that extrastriate brain regions probably involved in cortical spreading depression are associated with CBF changes in the interictal state. We conclude that ASL-MRI is a sensitive method to identify local neuro-functional abnormalities in CBF in patients with EM in the interictal state.

"Choose change": design and methods of an acceptance and commitment therapy effectiveness trial for transdiagnostic treatment-resistant patients

BACKGROUND

Acceptance and Commitment Therapy (ACT) has been successfully established in hundreds of efficacy trials. It is less understood, however, how ACT works in real-world settings. Furthermore, little is known about how contextual variables such as treatment setting (inpatient vs. outpatient), social network and environment of the patient impact outcome.

METHODS

This paper describes the methods of the Choose Change study that compares transdiagnostic inpatients (n = 85) and outpatients (n = 85) with varying degrees of treatment experience and treatment success (i.e., no previous treatment vs. previous remission vs. treatment-resistant). Patients received ACT during an intensive treatment phase lasting approximately twelve treatment sessions, and were accompanied up to twelve months following intensive treatment. Main outcomes include symptoms, functioning, and well-being. Multiple levels of data are investigated, including treatment context, weekly assessments, a behavioral approach test, multiple follow-up phases, and ambulatory assessment using Event Sampling Methodology, to examine patients' daily context.

DISCUSSION

We aim to investigate antecedents, consequences, and inherent processes that contribute to the maintenance or fluctuations of psychological disorders and the efficacy of ACT treatment. Furthermore, this study intends to increase understanding of how accurately participants can report on their own experiences, in order to expand our knowledge of how to probe for such information in the future. The results of Choose Change will provide basic clinical theory and clinical care with important and meaningful insights into the effectiveness of ACT, trans diagnostically, in in- and outpatients, and in a naturalistic setting.

TRIAL REGISTRATION

This study was retrospectively registered in the ISRCTN Registry (registration number ISRCTN11209732 ) on May 20th 2016.

Antiplatelet therapy in patients undergoing oral surgery: A systematic review and meta-analysis

Background

The number of patients under antiplatelet therapy (APT) continues to raise as current recommendations foster this practice. Although some recommendations to manage this treatment during oral surgery procedures exist, these have methodological shortcomings that preclude them from being conclusive.

Material and Methods

A systematic review and meta-analysis of the best current evidence was carried out; The Cochrane Library, EMBASE and MEDLINE databases were searched for Randomized Controlled Trials (RCT) concerning patients undergoing oral surgery with APT, other relevant sources were searched manually.

Results

5 RCTs met the Inclusion criteria. No clear tendency was observed (RR= 0.97 CI 95%: 0,41–2,34; p=0,09; I2= 51%), moreover, they weren’t clinically significant.

Conclusions

According to these findings and as bleeding is a manageable complication it seems unreasonable to undermine the APT, putting the patient in danger of a thrombotic event and its high inherent morbidity, which isn’t comparable in severity and manageability to the former.”

Key words:Antiplatelet therapy, aspirin, oral surgery, platelet aggregation inhibitors, oral surgical procedures, systematic reviews.

Pathophysiological Trends During Withdrawal of Life Support: Implications for Organ Donation After Circulatory Death

BACKGROUND

Donation after circulatory death (DCD) provides an alternative pathway to deceased organ transplantation. Although clinical DCD lung, liver, and kidney transplantation are well established, transplantation of hearts retrieved from DCD donors has reached clinical translation only recently. Progress has been limited by concern regarding the viability of DCD hearts. The aim of this study was to document the pathophysiological changes that occur in the heart and circulation during withdrawal of life (WLS) support.

METHODS

In a porcine asphyxia model, we characterized the hemodynamic, volumetric, metabolic, biochemical, and endocrine changes after WLS for up to 40 minutes. Times to circulatory arrest and electrical asystole were recorded.

RESULTS

After WLS, there was rapid onset of profound hypoxemia resulting in acute pulmonary hypertension and right ventricular distension. Concurrently, progressive systemic hypotension occurred with a fall in left atrial pressure and little change in left ventricular volume. Mean times to circulatory arrest and electrical asystole were 8 ± 1 and 16 ± 2 minutes, respectively. Hemodynamic changes were accompanied by a rapid fall in pH, and rise in blood lactate, troponin-T, and potassium. Plasma noradrenaline and adrenaline levels rose rapidly with dramatic increases in coronary sinus levels indicative of myocardial release.

CONCLUSIONS

These findings provide insight into the nature and tempo of the damaging events that occur in the heart and in particular the right ventricle during WLS, and give an indication of the limited timeframe for the implementation of potential postmortem interventions that could be applied to improve organ viability.

Measuring laboratory-based influenza surveillance capacity: development of the 'International Influenza Laboratory Capacity Review' Tool

OBJECTIVES

The 2005 International Health Regulations (IHR 2005) emphasized the importance of laboratory capacity to detect emerging diseases including novel influenza viruses. To support IHR 2005 requirements and the need to enhance influenza laboratory surveillance capacity, the Association of Public Health Laboratories (APHL) and the Centers for Disease Control and Prevention (CDC) Influenza Division developed the International Influenza Laboratory Capacity Review (Tool).

STUDY DESIGN

Data from 37 assessments were reviewed and analyzed to verify that the quantitative analysis results accurately depicted a laboratory's capacity and capabilities.

METHODS

Subject matter experts in influenza and laboratory practice used an iterative approach to develop the Tool incorporating feedback and lessons learnt through piloting and implementation. To systematically analyze assessment data, a quantitative framework for analysis was added to the Tool.

RESULTS

The review indicated that changes in scores consistently reflected enhanced or decreased capacity. The review process also validated the utility of adding a quantitative analysis component to the assessments and the benefit of establishing a baseline from which to compare future assessments in a standardized way.

CONCLUSIONS

Use of the Tool has provided APHL, CDC and each assessed laboratory with a standardized analysis of the laboratory's capacity. The information generated is used to improve laboratory systems for laboratory testing and enhance influenza surveillance globally. We describe the development of the Tool and lessons learnt.

Sphingomyelin derivatives increase the frequency of microvesicle and granule fusion in chromaffin cells

Sphingomyelin derivatives like sphingosine have been shown to enhance secretion in a variety of systems, including neuroendocrine and neuronal cells. By studying the mechanisms underlying this effect, we demonstrate here that sphingomyelin rafts co-localize strongly with synaptosomal-associated protein of 25Kda (SNAP-25) clusters in cultured bovine chromaffin cells and that they appear to be linked in a dynamic manner. In functional terms, when cultured rat chromaffin cells are treated with sphingomyelinase (SMase), producing sphingomyelin derivatives, the secretion elicited by repetitive depolarizations is enhanced. This increase was independent of cell size and it was significant 15min after initiating stimulation. Interestingly, by evaluating the membrane capacitance we found that the events in control untreated cells corresponded to two populations of microvesicles and granules, and the fusion of both these populations is clearly enhanced after treatment with SMase. Furthermore, SMase does not increase the size of chromaffin granules. Together, these results strongly suggest that SNARE-mediated exocytosis is enhanced by the generation of SMase derivatives, reflecting an increase in the frequency of fusion of both microvesicles and chromaffin granules rather than an increase in the size of these vesicles.

MEK inhibition affects STAT3 signaling and invasion in human melanoma cell lines

Elevated activity of the mitogen-activated protein kinase (MAPK) signaling cascade is found in the majority of human melanomas and is known to regulate proliferation, survival and invasion. Current targeted therapies focus on decreasing the activity of this pathway; however, we do not fully understand how these therapies impact tumor biology, especially given that melanoma is a heterogeneous disease. Using a three-dimensional (3D), collagen-embedded spheroid melanoma model, we observed that MEK and BRAF inhibitors can increase the invasive potential of ∼20% of human melanoma cell lines. The invasive cell lines displayed increased receptor tyrosine kinase (RTK) activity and activation of the Src/FAK/signal transducers and activators of transcription-3 (STAT3) signaling axis, also associated with increased cell-to-cell adhesion and cadherin engagement following MEK inhibition. Targeting various RTKs, Src, FAK and STAT3 with small molecule inhibitors in combination with a MEK inhibitor prevented the invasive phenotype, but only STAT3 inhibition caused cell death in the 3D context. We further show that STAT3 signaling is induced in BRAF-inhibitor-resistant cells. Our findings suggest that MEK and BRAF inhibitors can induce STAT3 signaling, causing potential adverse effects such as increased invasion. We also provide the rationale for the combined targeting of the MAPK pathway along with inhibitors of RTKs, SRC or STAT3 to counteract STAT3-mediated resistance phenotypes.

National Ignition Facility system alignment

The National Ignition Facility (NIF) is the world's largest optical instrument, comprising 192 37 cm square beams, each generating up to 9.6 kJ of 351 nm laser light in a 20 ns beam precisely tailored in time and spectrum. The Facility houses a massive (10 m diameter) target chamber within which the beams converge onto an ∼1 cm size target for the purpose of creating the conditions needed for deuterium/tritium nuclear fusion in a laboratory setting. A formidable challenge was building NIF to the precise requirements for beam propagation, commissioning the beam lines, and engineering systems to reliably and safely align 192 beams within the confines of a multihour shot cycle. Designing the facility to minimize drift and vibration, placing the optical components in their design locations, commissioning beam alignment, and performing precise system alignment are the key alignment accomplishments over the decade of work described herein. The design and positioning phases placed more than 3000 large (2.5 m×2 m×1 m) line-replaceable optics assemblies to within ±1 mm of design requirement. The commissioning and alignment phases validated clear apertures (no clipping) for all beam lines, and demonstrated automated laser alignment within 10 min and alignment to target chamber center within 44 min. Pointing validation system shots to flat gold-plated x-ray emitting targets showed NIF met its design requirement of ±50 μm rms beam pointing to target chamber. Finally, this paper describes the major alignment challenges faced by the NIF Project from inception to present, and how these challenges were met and solved by the NIF design and commissioning teams.