Effect of Sleep Disturbance Symptoms on Treatment Outcome in Blended Cognitive Behavioral Therapy for Depression (E-COMPARED Study): Secondary Analysis

Background

Sleep disturbance symptoms are common in major depressive disorder (MDD) and have been found to hamper the treatment effect of conventional face-to-face psychological treatments such as cognitive behavioral therapy. To increase the dissemination of evidence-based treatment, blended cognitive behavioral therapy (bCBT) consisting of web-based and face-to-face treatment is on the rise for patients with MDD. To date, no study has examined whether sleep disturbance symptoms have an impact on bCBT treatment outcomes and whether it affects bCBT and treatment-as-usual (TAU) equally.

Objective

The objectives of this study are to investigate whether baseline sleep disturbance symptoms have an impact on treatment outcomes independent of treatment modality and whether sleep disturbance symptoms impact bCBT and TAU in routine care equally.

Methods

The study was based on data from the E-COMPARED (European Comparative Effectiveness Research on Blended Depression Treatment Versus Treatment-as-Usual) study, a 2-arm, multisite, parallel randomized controlled, noninferiority trial. A total of 943 outpatients with MDD were randomized to either bCBT (476/943, 50.5%) or TAU consisting of routine clinical MDD treatment (467/943, 49.5%). The primary outcome of this study was the change in depression symptom severity at the 12-month follow-up. The secondary outcomes were the change in depression symptom severity at the 3- and 6-month follow-up and MDD diagnoses at the 12-month follow-up, assessed using the Patient Health Questionnaire-9 and Mini-International Neuropsychiatric Interview, respectively. Mixed effects models were used to examine the association of sleep disturbance symptoms with treatment outcome and treatment modality over time.

Results

Of the 943 patients recruited for the study, 558 (59.2%) completed the 12-month follow-up assessment. In the total sample, baseline sleep disturbance symptoms did not significantly affect change in depressive symptom severity at the 12-month follow-up (β=.16, 95% CI –0.04 to 0.36). However, baseline sleep disturbance symptoms were negatively associated with treatment outcome for bCBT (β=.49, 95% CI 0.22-0.76) but not for TAU (β=–.23, 95% CI −0.50 to 0.05) at the 12-month follow-up, even when adjusting for baseline depression symptom severity. The same result was seen for the effect of sleep disturbance symptoms on the presence of depression measured with Mini-International Neuropsychiatric Interview at the 12-month follow-up. However, for both treatment formats, baseline sleep disturbance symptoms were not associated with depression symptom severity at either the 3- (β=.06, 95% CI −0.11 to 0.23) or 6-month (β=.09, 95% CI −0.10 to 0.28) follow-up.

Conclusions

Baseline sleep disturbance symptoms may have a negative impact on long-term treatment outcomes in bCBT for MDD. This effect was not observed for TAU. These findings suggest that special attention to sleep disturbance symptoms might be warranted when MDD is treated with bCBT. Future studies should investigate the effect of implementing modules specifically targeting sleep disturbance symptoms in bCBT for MDD to improve long-term prognosis.

Nonlinear complexification of periodic orbits in the generalized Landau scenario

We have found a way for penetrating the space of the dynamical systems toward systems of arbitrary dimension exhibiting the nonlinear mixing of a large number of oscillation modes through which extraordinarily complex time evolutions may arise. The system design is based on assuring the occurrence of a number of Hopf bifurcations in a set of fixed points of a relatively generic system of ordinary differential equations, in which the main peculiarity is that the nonlinearities appear through functions of a linear combination of the system variables. The paper outlines the design procedure and presents a selection of numerical simulations with a variety of designed systems whose dynamical behaviors are really rich and full of unknown features. For concreteness, the presentation is focused on illustrating the oscillatory mixing effects on the periodic orbits, through which the harmonic oscillation born in a Hopf bifurcation becomes successively enriched with the intermittent incorporation of other oscillation modes of higher frequencies while the orbit remains periodic and without the necessity of bifurcating instabilities. Even in the absence of a proper mathematical theory covering the nonlinear mixing mechanisms, we find enough evidence to expect that the oscillatory scenario be truly scalable concerning the phase-space dimension, the multiplicity of involved fixed points, and the range of time scales so that extremely complex but ordered dynamical behaviors could be sustained through it.

Stakeholders' views on online interventions to prevent common mental health disorders in adults implemented into existing healthcare systems in Europe

BACKGROUND

Online preventive interventions can help to reduce the incidence of mental disorders. Whereas knowledge on stakeholders' attitudes and factors relevant for successfully integrating online treatment into existing healthcare systems is available, knowledge is scarce for online prevention.

METHODS

Stakeholders from Germany, Switzerland, Austria and Spain were surveyed. Potential facilitators/delivery staff (e.g. psychologists, psychotherapists) completed an online questionnaire (n = 183), policy makers (i.e. from the governing sector or health insurance providers) participated in semi-structured interviews (n = 16) and target groups/potential users of mental illness prevention (n = 49) participated in ten focus groups. Thematic analysis was used to identify their experiences with and attitudes and needs regarding online programmes to prevent mental disorders. Additionally, it was examined which groups they consider underserved and which factors they consider as fostering and hindering for reach, adoption, implementation and maintenance (cf. RE-AIM model) when integrating online prevention into existing healthcare systems.

RESULTS

Main advantages of online mental illness prevention are perceived in low structural and psychological barriers. Lack of personal contact, security, privacy and trust concerns were discussed as disadvantages. Relevant needs are high usability and target group appropriateness, evidence for effectiveness and the use of motivational tools.

CONCLUSIONS

Positive attitudes among stakeholders are the key for successful integration of online mental illness prevention into existing healthcare systems. Potential facilitators/delivery staff must receive training and support to implement these programmes; the programmes must be attractive and continuously evaluated, updated and promoted to ensure ongoing reach; and existing infrastructure and contextual factors must be considered.

Online prevention programmes for university students: stakeholder perspectives from six European countries

Background

Students beginning university are at a heightened risk for developing mental health disorders. Online prevention and early intervention programmes targeting mental health have the potential to reduce this risk, however, previous research has shown uptake to be rather poor. Understanding university stakeholders’ (e.g. governing level and delivery staff [DS] and students) views and attitudes towards such online prevention programmes could help with their development, implementation and dissemination within university settings.

Methods

Semi-structured interviews, focus groups and online surveys were completed with staff at a governing level, university students and DS (i.e. student health or teaching staff) from six European countries. They were asked about their experiences with, and needs and attitudes towards, online prevention programmes, as well as the factors that influence the translation of these programmes into real-world settings. Results were analyzed using thematic analysis.

Results

Participating stakeholders knew little about online prevention programmes for university settings; however, they viewed them as acceptable. The main themes to emerge were the basic conditions and content of the programmes, the awareness and engagement, the resources needed, the usability and the responsibility and ongoing efforts to increase reach.

Conclusions

Overall, although these stakeholders had little knowledge about online prevention programmes, they were open to the idea of introducing them. They could see the potential benefits that these programmes might bring to a university setting as a whole and the individual students and staff members.

Non-Hermitian arrangement for stable semiconductor laser arrays

We propose and explore a physical mechanism for the stabilization of the complex spatiotemporal dynamics in arrays (bars) of broad area laser diodes taking advantage of the symmetry breaking in non-Hermitian potentials. We show that such stabilization can be achieved by specific pump and index profiles leading to a PT-symmetric coupling between nearest neighboring lasers within the semiconductor bar. A numerical analysis is performed using a complete (2 + 1)-dimensional space-temporal model, including transverse and longitudinal spatial degrees of freedom and temporal evolution of the electric field and carriers. We show regimes of temporal stabilization and light emission spatial redistribution and enhancement. We also consider a simplified (1 + 1)-dimensional model for an array of lasers holding the proposed non-Hermitian coupling with a global axisymmetric geometry. We numerically demonstrate a two-fold benefit: the control over the temporal dynamics over the EELs bar and the field concentration on the central lasers leading to a brighter output beam, facilitating a direct coupling to an optical fiber.

Online interventions to prevent mental health problems implemented in school settings: the perspectives from key stakeholders in Austria and Spain

BACKGROUND

Schools are key settings for delivering mental illness prevention in adolescents. Data on stakeholders' attitudes and factors relevant for the implementation of Internet-based prevention programmes are scarce.

METHODS

Stakeholders in the school setting from Austria and Spain were consulted. Potential facilitators (e.g. teachers and school psychologists) completed an online questionnaire (N=50), policy makers (e.g. representatives of the ministry of education and health professional associations) participated in semi-structured interviews (N=9) and pupils (N=29, 14-19 years) participated in focus groups. Thematic analysis was used to identify experiences with, attitudes and needs towards Internet-based prevention programmes, underserved groups, as well as barriers and facilitators for reach, adoption, implementation and maintenance.

RESULTS

Experiences with Internet-based prevention programmes were low across all stakeholder groups. Better reach of the target groups was seen as main advantage whereas lack of personal contact, privacy concerns, risk for misuse and potential stigmatization when implemented during school hours were regarded as disadvantages. Relevant needs towards Internet-based programmes involved attributes of the development process, general requirements for safety and performance, presentation of content, media/tools and contact options of online programmes. Positive attitudes of school staff, low effort for schools and compatibility to schools' curriculum were seen as key factors for successful adoption and implementation. A sound implementation of the programme in the school routine and continued improvement could facilitate maintenance of online prevention initiatives in schools.

CONCLUSIONS

Attitudes towards Internet-based mental illness prevention programmes in school settings are positive across all stakeholder groups. However, especially safety concerns have to be considered.

Theoretical adequacy, methodological quality and efficacy of online interventions targeting resilience: a systematic review and meta-analysis

BACKGROUND

There is a growing interest in the promotion of mental health, and concepts as resilience are re-emerging and taking relevance. In addition, Information and Communication Technologies can provide potential benefits in the field of mental health, and the treatment of mental disorders in particular. This study aims to synthesize the evidence of internet-based resilience interventions, analyzing the theoretical adequacy, methodological quality and efficacy.

METHODS

A systematic search was performed. The eligibility criteria stated for this article were: randomized controlled trials targeted at adults or adolescents and including any psychological intervention focussing on resilience in its rationale or design. Studies with direct (e.g. resilience scales) and proximal resilience measures (e.g. scales on well-being) were included. Risk of bias was assessed for each trial using Cochrane's Collaboration Tool. Two reviewers worked independently in order to identify potential articles. A total of 11 articles were selected. A random-effects pooling model using the Hartung-Knapp-Sidik-Jonkman method based on direct and proximal resilience measures at post-test was used.

RESULTS

The overall effects of online resilience training compared to control groups at post-test were not significant; the effect size concerning the improvement of resilience was g=0.12 (95% CI: -0.14 to 0.38). In addition, a potential association between the type of outcome and the effect size could be revealed.

CONCLUSIONS

The results of the present meta-analysis showed that the overall effect of online resilience trainings was not significant. Nonetheless, a tendency for a higher benefit for resilience was found in the studies with a clear assessment theory, indicating some promising effects.

REGISTRATION NUMBER

PROSPERO CRD42018083339.

Internet-delivered Cognitive-Behavioral Therapy (iCBT) for Adults with Prolonged Grief Disorder (PGD): A Study Protocol for a Randomized Feasibility Trial

INTRODUCTION

Grief is an emotional reaction to the loss of a loved one with a natural recovery. Approximately 10% of people who lose a loved one develop prolonged grief disorder (PGD). Internet-based and computer-based interventions (ie, internet-delivered cognitive-behavioural therapy, iCBT) are a cost-effective alternative that makes it possible to reach more people with PGD. The main aim of this study is to assess the feasibility of a new iCBT-called GROw-for PGD. As a secondary objective, the potential effectiveness of GROw will be explored.

METHODS AND ANALYSIS

This study is a two-arm feasibility randomised trial. A total of 48 adults with PGD who meet the eligibility criteria will be randomised to the experimental group (iCBT: GROw) or the active control group (face-to-face CBT treatment). The treatment is organised sequentially in eight modules in the iCBT format and 8-10 sessions in the face-to-face format, and both formats have the same therapeutic components. There will be five assessment points with qualitative and quantitative evaluations: screening, baseline, after the intervention, 3-month follow-up and 12-month follow-up. Consistent with the objectives, the measures are related to the feasibility outcomes for the main aim of the study (participant adherence, expectations and satisfaction with the treatment, preferences, alliance and utility) and psychological and mental health outcomes for secondary analyses (symptoms of grief, symptoms of depression, symptoms of anxiety, affectivity, quality of life, work and social adaptation, post-traumatic growth, purpose in life, mindfulness and compassion).

ETHICS AND DISSEMINATION

The Ethics Committee of the Universitat Jaume I (Castellón, Spain) granted approval for the study (CD/002/2019). Dissemination will include publications and presentations at national and international conferences.

TRIAL REGISTRATION NUMBER

NCT04462146.

Features of Clostridioides difficile infection (CDI) in patients with cancer: A seven-year study

e13606

Background: Clostridioides difficile infection (CDI) is frequently seen in patients with cancer. However, information of the features and clinical course of CDI in this specific setting is lacking. Our objective was to describe the clinical picture of CDI in patients with cancer and to compare it with that observed in patients without cancer. Methods: This was an observational cohort study which included all consecutive patients diagnosed of CDI at the Hospital Universitario de Valme (Sevilla, Spain) between January 2014 and October 2020. Recurrence was defined as the reappearance of symptoms of CDI with microbiologic confirmation of toxigenic Clostridioides difficile in the first 8 weeks after the end of CDI treatment according to the Infectious Diseases Society of America criteria. Results: 481 patients had a first episode of CDI during the study period, 102 (21%) had an active neoplasm at CDI diagnosis and 379 (79%) did not had history of active cancer. The proportion of CDI cases in patients with cancer among the total cases of CDI per year was: 2014: 10/70 (17%); 2015: 10/47 (21%); 2016: 17/59 (29%); 2017: 12/80 (15%); 2018: 23/82 (28%); 2019: 16/80 (20%); 2020: 14/73 (19%); p=0.3). When compared with patients without cancer, those with cancer showed differences in: age (68 [58-79] vs 77 [61-84] years; p=0.002); male sex (68 [58-79] vs 77 [61-84]; p=0.002); Charlson comorbidity index > 2 (93 [92%] vs 234 [63%]; p<0.001); nosocomial or healthcare related CDI (90 [88%] vs 275 [72%]; p<0.001); immunosuppression (72 [70%] vs 52 [14%]; p<0.001); hospitalization during the last year (78 [76%] vs 224 [59%]; p=0.001); concomitant use of proton bomb inhibitors (89 [87%] vs 265 [70%]; p=0.001) and concomitant use of antibiotics (45 [45%] vs 125 [33%]; p<0.03). Regarding CDI treatment, 64 (69%), 25 (27%) and 2 (2%) patients in the cancer-group were treated with metronidazole, vancomycin and fidaxomicin, respectively, whereas the corresponding figures in non-cancer patients were 228 (67%), 102 (30%) and 5 (1.5%) (p=0.8). The proportion of oncologic patients receiving vancomycin increased after implementing an antimicrobial stewardship program focused on CDI management during 2017 (2014-2017: 2 [4%]; 2018: 3 (17%); 2019: 11 (73%); 2020: 10 (83%); p<0.001). CDI recurrence could not be assessed in 23 (5%) patients who died during the first 8 weeks of follow-up for reasons other than CDI, including 8 patients with CDI and cancer. Among evaluable patients, 16 (17%) of those with cancer and 61 (17%) of those without cancer had a first CDI recurrence (p=0.9). Conclusions: CDI recurrence rates in cancer patients are similar to that observed in non-cancer patients in spite of a higher frequency of risk factors for recurrence. Appropriate CDI therapy could have counterbalanced this worse profile during recent years. Our study shows that CDI should be included among the scenarios covered by antimicrobial stewardship programs in oncologic patients.

ADVANCED CHARACTERIZATION OF RECYCLED RUBBER FROM END-OF-LIFE TIRES

There are currently many well-established applications for recycled rubber from end-of-life tires (ELT), but it is essential to investigate and seek new approaches to enhance the value of these products. Recent developments in new technologies and innovative recycling and devulcanization processes have opened up new perspectives for ELT crumb rubber. To promote the use of these products in newly added value applications, it is essential to develop and optimize methods that allow the characterization of parameters related to the ultimate properties of potential final applications. In this respect, a novel characterization methodology based on advanced 1H double-quantum (DQ) nuclear magnetic resonance experiments has been applied for the first time to quantify the key parameters that characterize the structure of ELT crumb rubber after diverse recycling processes: from simple mechanical grinding to complex devulcanization methods. This experimental approach enables the quantification of parameters that define the network structure of rubber, such as the nonelastic network defects (sol fraction, dangling chain ends, loops), the cross-link density, and the heterogeneity of the network, directly from rubber granulate and powder (without any additional sample preparation steps), overcoming most of the drawbacks and uncertainties that limit the application of traditional rubber characterization methods (e.g., equilibrium swelling experiments). By applying this experimental approach, it is possible to identify and quantify the actual technical limits for a complete selective devulcanization process of ELT crumb rubber.

Misalignments measurement of CPV optical components through image acquisition

Concentrator Photovoltaics (CPV) technology relies on optical systems that concentrate sunlight on solar cells in exchange for a reduction of the permitted angular tolerance when pointing at the sun. A proper alignment between optics and photovoltaic receivers is crucial for the performance of this technology, particularly point focus CPV systems with concentration ratios above 100X that have narrow angular tolerances. This study presents the theoretical fundamentals of a method for evaluating misalignments in a CPV module. The method is based on the acquisition and analysis of images, taken by a camera, of the photovoltaic receivers magnified through the primary optics. The method has been successfully validated by empirical measurements and ray tracing simulations of a single lens-receiver unit.

Efficacy and cost-effectiveness of guided and unguided internet- and mobile-based indicated transdiagnostic prevention of depression and anxiety (ICare Prevent): A three-armed randomized controlled trial in four European countries

BACKGROUND

Depression and anxiety are highly prevalent and often co-occur. Several studies indicate the potential of disorder-specific psychological interventions for the prevention of each of these disorders. To treat comorbidity, transdiagnostic treatment concepts seem to be a promising approach, however, evidence for transdiagnostic concepts of prevention remains inconclusive. Internet- and mobile-based interventions (IMIs) may be an effective means to deliver psychological interventions on a large scale for the prevention of common mental disorders (CMDs) such as depression and anxiety. IMIs have been shown to be effective in treating CMDs, e.g. in reducing symptoms of depression and anxiety. However, there is a lack of studies examining the efficacy of interventions reducing the incidence of CMDs. Moreover, the comparative cost-effectiveness of guided versus unguided IMIs for the prevention of depression and anxiety has not been studied yet. Hence, this study aims at investigating the (cost-) effectiveness of guided and unguided internet- and mobile-based transdiagnostic individually tailored indicated prevention of depression and anxiety.

METHODS

A multi-country three-armed randomized controlled trial will be conducted to compare a guided and unguided intervention to treatment as usual (TAU). Both active conditions are based on the same intervention, ICare Prevent, and differ only with regard to guidance format. Altogether, 954 individuals with subclinical symptoms of depression (CES-D ≥ 16) and anxiety (GAD-7 ≥ 5) who do not have a full-blown disorder will be recruited in Germany, Switzerland, Spain and the Netherlands, and randomized to one of three conditions (guided intervention, unguided intervention, or TAU). The TAU arm will receive access to the training after a 12-month waiting period. The primary outcome will be time to CMD onset (any depression/anxiety disorder) within a follow-up period of 12 months after baseline. Secondary outcomes will include disorder-specific symptom severity (depression/anxiety) assessed by diagnostic raters blinded to intervention condition at post-intervention, self-reports, acceptability, health related quality of life, and psychosocial variables associated with developing a CMD. Assessments will take place at baseline, mid-intervention (5 weeks into the intervention), post-intervention (8 weeks after randomization) and follow-up (6 and 12 months after randomization). Data will be analyzed on an intention-to-treat basis and per protocol. Cost-effectiveness will be evaluated from a public health and a societal perspective, including both direct and indirect costs.

DISCUSSION

The present study will further enhance the evidence-base for transdiagnostic preventive interventions and provide valuable information about optimal trade-off between treatment outcome and costs.

TRIAL REGISTRATION

German Clinical Trial Registration (DRKS - http://www.drks.de/drks_web/): DRKS00011099.

Nonlinear oscillatory mixing in the generalized Landau scenario

We present a set of phase-space portraits illustrating the extraordinary oscillatory possibilities of the dynamical systems through the so-called generalized Landau scenario. In its simplest form the scenario develops in N dimensions around a saddle-node pair of fixed points experiencing successive Hopf bifurcations up to exhausting their stable manifolds and generating N-1 different limit cycles. The oscillation modes associated with these cycles extend over a wide phase-space region by mixing ones within the others and by affecting both the transient trajectories and the periodic orbits themselves. A mathematical theory covering the mode-mixing mechanisms is lacking, and our aim is to provide an overview of their main qualitative features in order to stimulate research on it.

Assessing the costs and cost-effectiveness of ICare internet-based interventions (protocol)

BACKGROUND

Mental health problems are common and place a burden on the individual as well as on societal resources. Despite the existence of evidence-based treatments, access to treatment is often prevented or delayed due to insufficient health care resources. Effective internet-based self-help interventions have the potential to reduce the risk for mental health problems, to successfully bridge waiting time for face-to-face treatment and to address inequities in access. However, little is known about the cost-effectiveness of such interventions. This paper describes the study protocol for the economic evaluation of the studies that form the ICare programme of internet-based interventions for the prevention and treatment of a range of mental health problems.

METHODS

An overarching work package within the ICare programme was developed to assess the cost-effectiveness of the internet-based interventions alongside the clinical trials. There are two underlying tasks in the ICare economic evaluation. First, to develop schedules that generate equivalent and comparable information on use of services and supports across seven countries taking part in clinical trials of different interventions and second, to estimate unit costs for each service and support used. From these data the cost per person will be estimated by multiplying each participant's use of each service by the unit cost for that service. Additionally, productivity losses will be estimated. This individual level of cost data matches the level of outcome data used in the clinical trials. Following the analyses of service use and costs data, joint analysis of costs and outcomes will be undertaken to provide findings on the relative cost-effectiveness of the interventions, taking both a public sector and a societal perspective. These analyses use a well-established framework, the Production of Welfare approach, and standard methods and techniques underpinned by economic theory.

DISCUSSION/CONCLUSION

Existing research tends to support the effectiveness of internet-based interventions, but there is little information on their cost-effectiveness compared to 'treatment as usual'. The economic evaluation of ICare interventions will add considerably to this evidence base.

Common haplotypes in CD209 promoter and susceptibility to HIV-1 infection in intravenous drug users

INTRODUCTION

CD209 is a receptor expressed in the dendritic cells involved in recognition of oligosaccharides present in several pathogens with a relevant impact on human health. SNPs located in the promoter region have been associated with HIV-1 susceptibility, although this finding has not been replicated in other populations. The objective of this study is to evaluate the association of CD209 promoter haplotypes with risk of HIV-1 infection in a cohort of Spanish male intravenous drug users (IDU) infected with hepatitis C virus (HCV) and to characterize the phenotypic effects of the associated variants.

METHODS

We genotyped 4 SNPs of CD209 promoter in 295 HCV males exposed to HIV-1 infection by IDU, 165 HIV-1-infected and 130 exposed uninfected (EUI) and 142 healthy controls (HC). We have cloned the promoter variants in a reporter vector and evaluated the promoter activities in a cell culture model. CD209 mRNAs were measured in PBMC.

RESULTS

Single-marker analysis revealed no significant allelic association with the risk of HIV-1 infection by parenteral route. Nevertheless, one haplotype was significantly overrepresented in EUI compared with HIV-1 positive patients and was associated with HIV-1 status (P=0.0008; OR: 0.43). Functional experiments suggested that the protective haplotype displayed lower transcriptional activity in vitro (P<0.05) and this was correlated with lower CD209 mRNA expression in PBMC (P=0.014).

CONCLUSIONS

This study suggests that the promoter haplotypes of CD209 influence the risk of HIV-1 acquisition in IDU and that this association is correlated with the mRNA expression level.

Suppression of pattern-forming instabilities by genetic optimization

We propose a versatile "stabilization on demand" method for the suppression of modulation instability in oscillatory spatially extended nonlinear systems, based on a genetically optimized multifrequency spatiotemporal modulation of the potential. The method, which ensures full stabilization even for very strong nonlinearities, forms a powerful tool allowing for an arbitrary design of the instability spectrum. The stabilization method is universal for complex oscillatory systems, based on a general complex Ginzburg-Landau model with varying degrees of nonlinearity, and could lead to the stabilization of arbitrarily complex systems-from high power lasers and Bose-Einstein condensates of attracting atoms, to spatially extended chemical and biological pattern-forming systems.

A new experimental model of acid- and endotoxin-induced acute lung injury in rats

The majority of the animal models of acute lung injury (ALI) are focused on the acute phase. This limits the studies of the mechanisms involved in later phases and the effects of long-term treatments. Thus the goal of this study was to develop an experimental ALI model of aspiration pneumonia, in which diffuse alveolar damage continues for 72 h. Rats were intratracheally instilled with one dose of HCl (0.1 mol/l) followed by another instillation of one dose of LPS (0, 10, 20, 30, or 40 μg/g body weight) 2 h later, which models aspiration of gastric contents that progresses to secondary lung injury from bacteria or bacterial products. The rats were euthanized at 24, 48, and 72 h after the last instillation. The results showed that HCl and LPS at all doses caused activation of inflammatory responses, increased protein permeability and apoptosis, and induced mild hypoxemia in rat lungs at 24 h postinstillation. However, this lung damage was present at 72 h only in rats receiving HCl and LPS at the doses of 30 and 40 μg/g body wt. Mortality (∼50%) occurred in the first 48 h and only in the rats treated with HCl and LPS at the highest dose (40 μg/g body wt). In conclusion, intratracheal instillation of HCl followed by LPS at the dose of 30 μg/g body wt results in severe diffuse alveolar damage that continues at least 72 h. This rat model of aspiration pneumonia-induced ALI will be useful for testing long-term effects of new therapeutic strategies in ALI.

Methodology of quantifying curvature of Fresnel lenses and its effect on CPV module performance

Fresnel lenses used as primary optics in concentrating photovoltaic modules may show warping produced by lens manufacturing or module assembly (e.g., stress during molding or weight load) or due to stress during operation (e.g., mismatch of thermal expansion between different materials). To quantify this problem, a simple method called "checkerboard method" is presented. The proposed method identifies shape errors on the front surface of primary lenses by analyzing the Fresnel reflections. This paper also deals with the quantification of the effects these curvatures have on their optical performance and on the electrical performance of concentrating modules incorporating them. This method can be used to perform quality control of Fresnel lenses in scenarios of high volume production.

Association of complement receptor 2 polymorphisms with innate resistance to HIV-1 infection

HIV-1 induces activation of complement through the classical and lectin pathways. However, the virus incorporates several membrane-bound or soluble regulators of complement activation (RCA) that inactivate complement. HIV-1 can also use the complement receptors (CRs) for complement-mediated antibody-dependent enhancement of infection (Ć-ADE). We hypothesize that hypofunctional polymorphisms in RCA or CRs may protect from HIV-1 infection. For this purpose, 139 SNPs located in 19 RCA and CRs genes were genotyped in a population of 201 Spanish HIV-1-exposed seronegative individuals (HESN) and 250 HIV-1-infected patients. Two SNPs were associated with infection susceptibility, rs1567190 in CR2 (odds ratio (OR) = 2.27, P = 1 × 10(-4)) and rs2842704 in C4BPA (OR = 2.11, P = 2 × 10(-4)). To replicate this finding, we analyzed a cohort of Italian, sexually HESN individuals. Although not significant (P = 0.25, OR = 1.57), similar genotypic proportions were obtained for the CR2 marker rs1567190. The results of the two association analyses were combined through a random effect meta-analysis, with a significant P-value of 2.6 x 10(-5) (OR = 2.07). Furthermore, we found that the protective CR2 genotype is correlated with lower levels CR2 mRNA as well as differences in the ratio of the long and short CR2 isoforms.

Suppression of modulation instability in broad area semiconductor amplifiers

We show that a two-dimensional periodic modulation of the pump profile (modulation both along and perpendicular to the optical axis) can suppress the modulation instability in broad emission area semiconductor amplifiers. In the case of a realistic finite-width amplifier the modulation instability can be completely eliminated.

Association of low-density lipoprotein receptor genotypes with hepatitis C viral load

Several data suggest that low-density lipoprotein receptor (LDLR) is a co-receptor for hepatitis C virus (HCV). Soluble LDLR can inhibit HCV infectivity; greater plasma low-density lipoprotein levels are associated with treatment success; LDLR genotypes have a synergistic impact on the likelihood of achieving SVR with Peg-IFN plus RBV, as well as on viral kinetics after starting treatment. The objective of this study was to assess the impact of genetic polymorphisms in genes related to cholesterol synthesis and transport pathways on pre-treatment plasma HCV viral load (VL). A total of 442 patients infected with HCV and treatment naive were prospectively recruited. One hundred forty-four SNPs located in 40 genes from the cholesterol synthesis/transport and IL28B were genotyped and analyzed for genetic association with pre-treatment plasma HCV VL. SNPs rs1433099 and rs2569540 of LDLR showed association with plasma HCV VL (P=4 × 10(-4) and P=2 × 10(-3)) in patients infected with genotypes 1 and 4. A haplotype including the last three exons of LDLR showed association with the cutoff level of 600 000 IU ml(-1) VL for genotypes 1 and 4 (OR=0.27; P=8 × 10(-6)), as well as a quantitative VL (mean±s.d.: 6.19±0.9 vs CC+CG 5.58±1.1 logIU ml(-1), P=8 × 10(-5)). LDLR genotypes are a major genetic factor influencing HCV VL in patients infected with genotypes 1 and 4.

Retinal thinning and correlation with functional disability in patients with Parkinson's disease

AIMS

To determine whether there is an association between retinal thinning and functional rating scales in patients with Parkinson's disease (PD).

MATERIALS AND METHODS

Patients with PD (n=153) and controls (n=242) underwent evaluations of the macula and retinal nerve fibre layer (RNFL) using two new-generation Fourier domain optical coherence tomography (OCT) devices (Cirrus, Carl Zeiss Meditec, Dublin, California, USA; Spectralis, Heidelberg Engineering, Heidelberg, Germany). PD severity was assessed using the Schwab-England Activities of Daily Living scale, the Unified Parkinson Disease Rating Scale, the Hoehn and Yahr (HY) scale. Retinal and RNFL thicknesses were compared between patients and controls. Correlations between structural parameters and the scores of the neurologic scales were evaluated.

RESULTS

RNFL parameters were significantly reduced in patients with PD, especially when using the Spectralis OCT device. All macular parameters, except for foveal thickness, differed significantly between controls and patients with PD (p<0.001). HY scores were significantly and inversely correlated with all macular parameters when measured with the Spectralis OCT device (p<0.05) and with RNFL thickness when measured with the Cirrus OCT device (nasal quadrant, sectors 2 and 5).

CONCLUSIONS

The neurodegeneration caused by PD can be detected using Fourier domain OCT. RNFL and macular thicknesses correlate with PD severity.

Ecological momentary assessment for chronic pain in fibromyalgia using a smartphone: a randomized crossover study

BACKGROUND

Daily diaries are a useful way of measuring fluctuations in pain-related symptoms. However, traditional diaries do not assure the gathering of data in real time, not solving the problem of retrospective assessment. Ecological momentary assessment (EMA) by means of electronic diaries helps to improve repeated assessment. However, it is important to test its feasibility in specific populations in order to reach a wider number of people who could benefit from these procedures.

METHODS

The present study compares the compliance and acceptability of an electronic diary running on a smartphone using a crossover design for a sample with a specific pain condition, fibromyalgia and low familiarity with technology. Forty-seven participants were randomly assigned to one of two conditions: (1) paper diary - smartphone diary and (2) smartphone diary - paper diary, using each assessment method for 1 week.

RESULTS

The findings of this study showed that the smartphone diary made it possible to gather more accurate and complete ratings. Besides, this method was well accepted by a sample of patients with fibromyalgia referred by a public hospital, with an important proportion of participants with low level of education and low familiarity with technology.

CONCLUSIONS

The findings of this study support the use of smartphones for EMA even in specific populations with a specific pain condition, fibromyalgia and with low familiarity with technology. These methods could help clinicians and researchers to gather more accurate ratings of relevant pain-related variables even in populations with low familiarity with technology.

Luminescence inverse method For CPV optical characterization

The luminescence inverse method may be used to optically characterize a concentrator photovoltaic module. With this method, the module angular transmission is obtained by evaluating the light emission of a forward biased module. The influence of the emission of the cell when measuring the angular transmission is evaluated, and the process of building a global angular transmission from the set of individual optics-cell unit functions is explained. A case study of a module composed by several optics-cell units is presented. In order to validate the proposed measurement, results for five different CPV technologies are compared for both direct methods (i.e., solar simulator) and indirect methods (i.e., Luminescence inverse method).

Virtual reality in the treatment of fibromyalgia: a pilot study

The aim of this article is to present preliminary data on the effectiveness of virtual reality (VR) as an adjunct to cognitive behavioral therapy (CBT) in the treatment of fibromyalgia (FM). The sample comprised six women diagnosed with FM according to the American College of Rheumatology guidelines (1990). The treatment program consisted of 10 sessions of group CBT with the support of an adaptive virtual environment containing a specific content for developing relaxation and mindfulness skills. Patients were assessed at pretreatment, post-treatment, and at a 6-month follow-up for the following outcome variables: functional status related to pain, depression, a negative and positive affect, and coping skills. The results showed the long-term benefits of significantly reduced pain and depression and an increased positive affect and use of healthy coping strategies. This is the first study showing a preliminary utility of VR in treating FM.

Three-dimensional geometries representing the retinal nerve fiber layer in multiple sclerosis, optic neuritis, and healthy eyes

BACKGROUND

To represent and interpret the three-dimensional (3D) geometry and the distribution of the axonal damage to the retinal nerve fiber layer (RNFL) in patients with multiple sclerosis (MS) compared with healthy subjects. To analyze alterations in RNFL morphology in eyes of MS patients with or without previous episodes of optic neuritis (ON).

METHODS

MS patients (n = 122) and age-matched healthy subjects (n = 108) were enrolled. The Spectralis optical coherence tomography system was used to determine the circumpapillary RNFL thickness. The 768 RNFL thickness measurements were used to evaluate thickness measurements in patients with or without antecedent ON and to design a 3D reconstruction of the RNFL thickness representing the mechanobiologic tissue response to neurodegeneration caused by MS and ON episodes.

RESULTS

RNFL thickness was decreased in MS patients, and was higher in the MS group with previous ON. Statistical analysis and 3D RNFL reconstruction revealed greater damage to the ganglionar cells in the superonasal RNFL area (101.77 µm in MS vs. 125.47 µm in healthy subjects) and in the inferotemporal RNFL (119.05 µm in MS eyes and 149.26 µm in healthy eyes).

CONCLUSIONS

The 3D representation of RNFL thickness based on measurements allows physicians to better observe damage in the temporal areas, especially in patients with previous ON.

Design considerations of a randomized clinical trial on a cognitive behavioural intervention using communication and information technologies for managing chronic low back pain

Background

Psychological treatments have been successful in treating chronic low back pain (CLBP). However, the effect sizes are still modest and there is room for improvement. A way to progress is by enhancing treatment adherence and self-management using information and communication technologies (ICTs). Therefore, the objective of this study was to design a trial investigating the short- and long-term efficacy of cognitive behavioural treatment (CBT) for CLBP using or not ICTs. A secondary objective of this trial will be to evaluate the influence of relevant variables on treatment response. Possible barriers in the implementation of CBT with and without ICT will also be investigated.

Methods

A randomised controlled trial with 180 CLBP patients recruited from specialised care will be conducted. Participants will be randomly assigned to three conditions: Control group (CG), CBT, and CBT supported by ICTs (CBT + ICT). Participants belonging to the three conditions will receive a conventional rehabilitation program (back school). The CBT group program will last six sessions. The CBT + ICT group will use the internet and SMS to practice the therapeutic strategies between sessions and in the follow-ups at their homes. Primary outcome variables will be self-reported disability and pain intensity. Assessment will be carried out by blinded assessors in five moments: pre-treatment, post-treatment and 3-, 6-, and 12-month follow-ups. The influence of catastrophizing, fear-avoidance beliefs, anxiety and depression in response to treatment in the primary outcomes will also be analysed.

Discussion

This study will show data of the possible benefits of using ICTs in the improvement of CBT for treating CLBP.

Trial registration

ClinicalTrials.gov, NCT01802671

Use of Fourier-domain OCT to detect retinal nerve fiber layer degeneration in Parkinson's disease patients

PURPOSE

To demonstrate axonal loss in the retinal nerve fiber layer (RNFL) of patients with Parkinson's disease (PD) and to evaluate the ability of Fourier-domain optical coherence tomography (OCT) to detect RNFL degeneration and retinal thinning in these patients.

METHODS

PD patients (n=100) and healthy subjects (n=100) were included in the study and underwent visual acuity, color vision, and OCT examinations using two next-generation Fourier-domain devices (Spectralis and Cirrus). Differences in the RNFL thicknesses were compared between patients and controls.

RESULTS

RNFL thicknesses were significantly reduced in PD patients compared with healthy subjects, especially those obtained using the Spectralis OCT, in the inferotemporal quadrant (155.6±16.5 μm in healthy eyes vs 142.1±24.9 μm in patients, P=0.040) and in the superotemporal quadrant (142.6±20.9 μm in healthy eyes vs 132.77±18.6 μm in PD patients, P=0.046). Significant differences were observed between controls and patients in relation to mean macular thickness (P=0.031), foveal thickness (P=0.030), and inferior outer thickness (P=0.019).

CONCLUSION

PD is associated with RNFL loss and retinal thinning, which is detectable by Fourier-domain OCT measurements.

Beam shaping in spatially modulated broad-area semiconductor amplifiers

We propose and analyze a beam-shaping mechanism that in broad-area semiconductor amplifiers occurs due to spatial pump modulation on a micrometer scale. The study, performed under realistic parameters and conditions, predicts a spatial (angular) filtering of the radiation, which leads to a substantial improvement of the spatial quality of the beam during amplification. Quantitative analysis of spatial filtering performance is presented based on numerical integration of the paraxial propagation model and on analytical estimations.

Solving Vehicle Routing Problems Using Constraint Programming and Lagrangean Relaxation in a Metaheuristics Framework

This paper presents a methodology based on the Variable Neighbourhood Search metaheuristic, applied to the Capacitated Vehicle Routing Problem. The presented approach uses Constraint Programming and Lagrangean Relaxation methods in order to improve algorithm’s efficiency. The complete problem is decomposed into two separated subproblems, to which the mentioned techniques are applied to obtain a complete solution. With this decomposition, the methodology provides a quick initial feasible solution which is rapidly improved by metaheuristics’ iterative process. Constraint Programming and Lagrangean Relaxation are also embedded within this structure to ensure constraints satisfaction and to reduce the calculation burden. By means of the proposed methodology, promising results have been obtained. Remarkable results presented in this paper include a new best-known solution for a rarely solved 200-customers test instance, as well as a better alternative solution for another benchmark problem.

Two-dimensional angular transmission characterization of CPV modules

This paper proposes a fast method to characterize the two-dimensional angular transmission function of a concentrator photovoltaic (CPV) system. The so-called inverse method, which has been used in the past for the characterization of small optical components, has been adapted to large-area CPV modules. In the inverse method, the receiver cell is forward biased to produce a Lambertian light emission, which reveals the reverse optical path of the optics. Using a large-area collimator mirror, the light beam exiting the optics is projected on a Lambertian screen to create a spatially resolved image of the angular transmission function. An image is then obtained using a CCD camera. To validate this method, the angular transmission functions of a real CPV module have been measured by both direct illumination (flash CPV simulator and sunlight) and the inverse method, and the comparison shows good agreement.

Differences in the risk of cervical cancer and human papillomavirus infection by education level

BACKGROUND

Cervical cancer risk is associated with low education even in an unscreened population, but it is not clear whether human papillomavirus (HPV) infection follows the same pattern.

METHODS

Two large multicentric studies (case-control studies of cervical cancer and HPV prevalence survey) including nearly 20 000 women. GP5+/GP6+ PCR was used to detect HPV.

RESULTS

Education level was consistently associated with cervical cancer risk (odds ratio (OR) for 0 and >5 years vs 1-5 years=1.50, 95% confidence interval (CI): 1.25-1.80 and 0.69, 95% CI: 0.57-0.82, respectively, P for trend <0.0001). In contrast, no association emerged between education level and HPV infection in either of the two IARC studies. A majority of the women studied had never had a Pap smear. The association between low education level and cervical cancer was most strongly attenuated by adjustment for age at first sexual intercourse and first pregnancy. Parity and screening history (but not lifetime number of sexual partners, husband's extramarital sexual relationships, and smoking) also seemed to be important confounding factors.

CONCLUSION

The excess of cervical cancer found in women with a low socio-economic status seems, therefore, not to be explained by a concomitant excess of HPV prevalence, but rather by early events in a woman's sexually active life that may modify the cancer-causing potential of HPV infection.

Early age at first sexual intercourse and early pregnancy are risk factors for cervical cancer in developing countries

Early age at first sexual intercourse (AFSI) has long been associated with an increased risk of invasive cervical carcinoma (ICC). Age at first pregnancy (AFP) and ICC have been investigated less, although AFSI and AFP are strongly interrelated in most developing countries. A pooled analysis of case–control studies on ICC from eight developing countries with 1864 cases and 1719 controls investigated the roles of AFSI, AFP, and ICC risk. Age at first sexual intercourse, AFP and age at first marriage (AFM) were highly interrelated and had similar ICC risk estimates. Compared with women with AFSI ⩾21 years, the odds ratio (OR) of ICC was 1.80 (95% CI: 1.50–2.39) among women with AFSI 17–20 years and 2.31 (95% CI: 1.85–2.87) for AFSI ⩽16 years (P-trend <0.001). No statistical interaction was detected between AFSI and any established risk factors for ICC. The ICC risk was 2.4-fold among those who reported AFSI and AFP at ⩽16 years compared with those with AFSI and AFP at ⩾21 years. These data confirm AFSI and AFB as risk factors for ICC in eight developing countries, but any independent effects of these two events could not be distinguished.