Ischemic injury of the upper gastrointestinal tract after out-of-hospital cardiac arrest: a prospective, multicenter study

Background

The consequences of cardiac arrest (CA) on the gastro-intestinal tract are poorly understood. We measured the incidence of ischemic injury in the upper gastro-intestinal tract after Out-of-hospital CA (OHCA) and determined the risk factors for and consequences of gastrointestinal ischemic injury according to its severity.

Methods

Prospective, non-controlled, multicenter study in nine ICUs in France and Belgium conducted from November 1, 2014 to November 30, 2018. Included patients underwent an esophago-gastro-duodenoscopy 2 to 4 d after OHCA if still intubated and the presence of ischemic lesions of the upper gastro-intestinal tract was determined by a gastroenterologist. Lesions were a priori defined as severe if there was ulceration or necrosis and moderate if there was mucosal edema or erythema. We compared clinical and cardiac arrest characteristics of three groups of patients (no, moderate, and severe lesions) and identified variables associated with gastrointestinal ischemic injury using multivariate regression analysis. We also compared the outcomes (organ failure during ICU stay and neurological status at hospital discharge) of the three groups of patients.

Results

Among the 214 patients included in the analysis, 121 (57%, 95% CI 50–63%) had an upper gastrointestinal ischemic lesion, most frequently on the fundus. Ischemic lesions were severe in 55/121 (45%) patients. In multivariate regression, higher adrenaline dose during cardiopulmonary resuscitation (OR 1.25 per mg (1.08–1.46)) was independently associated with increased odds of severe upper gastrointestinal ischemic lesions; previous proton pump inhibitor use (OR 0.40 (0.14–1.00)) and serum bicarbonate on day 1 (OR 0.89 (0.81–0.97)) were associated with lower odds of ischemic lesions. Patients with severe lesions had a higher SOFA score during the ICU stay and worse neurological outcome at hospital discharge.

Conclusions

More than half of the patients successfully resuscitated from OHCA had upper gastrointestinal tract ischemic injury. Presence of ischemic lesions was independently associated with the amount of adrenaline used during resuscitation. Patients with severe lesions had higher organ failure scores during the ICU stay and a worse prognosis.

Clinical Trial RegistrationNCT02349074.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13054-022-03939-9.

Practice Improvement Projects in an Interdisciplinary Palliative Care Training Program

CONTEXT

Demand for palliative care (PC) continues to increase with an insufficient number of specialists to meet the need. This requires implementation of training curricula to expand the workforce of interdisciplinary clinicians who care for persons with serious illness.

OBJECTIVES

To evaluate the impact of utilizing individual practice improvement projects (PIP) as part of a longitudinal PC curriculum, the Coleman Palliative Medicine Training Program (CPMTP-2).

METHODS

Participants developed their PIPs based on their institutional needs and through a mentor, and participated in monthly meetings and bi-annual conferences, thereby allowing for continued process improvement and feedback.

RESULTS

Thirty-seven interdisciplinary participants implemented 30 PIPs encompassing 7 themes: (1) staff education; (2) care quality and processes; (3) access to care; (4) documentation of care delivered; (5) new program development; (6) assessing gaps in care/patient needs; and (7) patient/family education. The majority of projects did achieve completion, with 16 of 30 projects reportedly being sustained several months after conclusion of the required training period. Qualitative feedback regarding mentors' expertise and availability was uniformly positive.

CONCLUSION

The CPMTP-2 demonstrates the positive impact of PIPs in the development of skills for interdisciplinary learners as part of a longitudinal training program in primary PC. Participation in a PIP with administrative support may lead to operational improvement within PC teams.

Expanding the Interdisciplinary Palliative Medicine Workforce: A Longitudinal Education and Mentoring Program for Practicing Clinicians

CONTEXT

The disparity between gaps in workforce and availability of palliative care (PC) services is an increasing issue in health care. To meet the demand, team-based PC requires additional educational training for all clinicians caring for persons with serious illness.

OBJECTIVES

To describe the educational methodology and evaluation of an existing regional interdisciplinary PC training program that was expanded to include chaplain and social worker trainees.

METHODS

From 2015 to 2017, 26 social workers, chaplains, physicians, nurses, and advanced practice providers representing 22 health systems completed a two-year training program. The curriculum comprises biannual interdisciplinary conferences, individualized mentoring and clinical shadowing, self-directed e-learning, and profession-focused seminar series for social workers and chaplains. Site-specific practice improvement projects were developed to address gaps in PC at participating sites.

RESULTS

PC and program development skills were self-assessed before and after training. Among 12 skills common to all disciplines, trainees reported significant increases in confidence across all 12 skills and significant increases in frequency of performing 11 of 12 skills. Qualitative evaluation identified a myriad of program strengths and challenges regarding the educational format, mentoring, and networking across disciplines.

CONCLUSION

Teaching PC and program development knowledge and skills to an interdisciplinary regional cohort of practicing clinicians yielded improvements in clinical skills, implementation of practice change projects, and a sense of belonging to a supportive professional network.

Vaccinia-based oncolytic immunotherapy Pexastimogene Devacirepvec in patients with advanced hepatocellular carcinoma after sorafenib failure: a randomized multicenter Phase IIb trial (TRAVERSE)

Pexastimogene devacirepvec (Pexa-Vec) is a vaccinia virus-based oncolytic immunotherapy designed to preferentially replicate in and destroy tumor cells while stimulating anti-tumor immunity by expressing GM-CSF. An earlier randomized Phase IIa trial in predominantly sorafenib-naïve hepatocellular carcinoma (HCC) demonstrated an overall survival (OS) benefit. This randomized, open-label Phase IIb trial investigated whether Pexa-Vec plus Best Supportive Care (BSC) improved OS over BSC alone in HCC patients who failed sorafenib therapy (TRAVERSE).

129 patients were randomly assigned 2:1 to Pexa-Vec plus BSC vs. BSC alone. Pexa-Vec was given as a single intravenous (IV) infusion followed by up to 5 IT injections. The primary endpoint was OS. Secondary endpoints included overall response rate (RR), time to progression (TTP) and safety.

A high drop-out rate in the control arm (63%) confounded assessment of response-based endpoints. Median OS (ITT) for Pexa-Vec plus BSC vs. BSC alone was 4.2 and 4.4 months, respectively (HR, 1.19, 95% CI: 0.78–1.80; p = .428). There was no difference between the two treatment arms in RR or TTP. Pexa-Vec was generally well-tolerated. The most frequent Grade 3 included pyrexia (8%) and hypotension (8%). Induction of immune responses to vaccinia antigens and HCC associated antigens were observed.

Despite a tolerable safety profile and induction of T cell responses, Pexa-Vec did not improve OS as second-line therapy after sorafenib failure. The true potential of oncolytic viruses may lie in the treatment of patients with earlier disease stages which should be addressed in future studies.

ClinicalTrials.gov: NCT01387555

Incorporating Older Adults as "Trained Patients" to Teach Advance Care Planning to Third-Year Medical Students

BACKGROUND

Advance care planning (ACP) is a critical component of end-of-life (EoL) care, yet infrequently taught in medical training.

OBJECTIVE

We designed a novel curriculum that affords third-year medical students (MS3s) the opportunity to practice EoL care discussions with a trained older adult in the patient's home.

DESIGN

Volunteers were instructed as trained patients (TPs) to evaluate MS3s interviewing and communication skills. The MS3s received a didactic lecture and supplemental material about ACP. Pairs of MS3s conducted ACP interviews with TPs who gave verbal and written feedback to students. Student evaluations included reflective essays and pre/postsurveys in ACP skills.

SETTINGS AND PARTICIPANTS

A total of 223 US MS3s participated in the curriculum.

RESULTS

Qualitative analysis of reflective essays revealed 4 themes: (1) students' personal feelings, attitudes, and observations about conducting ACP interviews; (2) observations about the process of relationship building; (3) learning about and respecting patients' values and choices; and (4) the importance of practicing the ACP skills in medical school. Students' confidence in skills significantly improved in all 7 domains ( P < .001): (1) introduce subject of EoL; (2) define advance directives; (3) assess values, goals, and priorities; (4) discuss prior experience with death; (5) assess expectations about treatment and hospitalization; (6) explain cardiopulmonary resuscitation and outcomes; and (7) deal with own feelings about EoL and providers' limitations.

CONCLUSIONS

The use of older adults as TPs in an ACP curriculum provides students an opportunity to practice skills and receive feedback in the nonmedical setting, thereby improving comfort and confidence in approaching these conversations for future patients.

How Artificial Intelligence Can Improve Our Understanding of the Genes Associated with Endometriosis: Natural Language Processing of the PubMed Database

Endometriosis is a disease characterized by the development of endometrial tissue outside the uterus, but its cause remains largely unknown. Numerous genes have been studied and proposed to help explain its pathogenesis. However, the large number of these candidate genes has made functional validation through experimental methodologies nearly impossible. Computational methods could provide a useful alternative for prioritizing those most likely to be susceptibility genes. Using artificial intelligence applied to text mining, this study analyzed the genes involved in the pathogenesis, development, and progression of endometriosis. The data extraction by text mining of the endometriosis-related genes in the PubMed database was based on natural language processing, and the data were filtered to remove false positives. Using data from the text mining and gene network information as input for the web-based tool, 15,207 endometriosis-related genes were ranked according to their score in the database. Characterization of the filtered gene set through gene ontology, pathway, and network analysis provided information about the numerous mechanisms hypothesized to be responsible for the establishment of ectopic endometrial tissue, as well as the migration, implantation, survival, and proliferation of ectopic endometrial cells. Finally, the human genome was scanned through various databases using filtered genes as a seed to determine novel genes that might also be involved in the pathogenesis of endometriosis but which have not yet been characterized. These genes could be promising candidates to serve as useful diagnostic biomarkers and therapeutic targets in the management of endometriosis.

Training the Workforce: Description of a Longitudinal Interdisciplinary Education and Mentoring Program in Palliative Care

CONTEXT

The rapid increase in demand for palliative care (PC) services has led to concerns regarding workforce shortages and threats to the resiliency of PC teams.

OBJECTIVES

To describe the development, implementation, and evaluation of a regional interdisciplinary training program in PC.

METHODS

Thirty nurse and physician fellows representing 22 health systems across the Chicago region participated in a two-year PC training program. The curriculum was delivered through multiple conferences, self-directed e-learning, and individualized mentoring by expert local faculty (mentors). Fellows shadowed mentors' clinical practices and received guidance on designing, implementing, and evaluating a practice improvement project to address gaps in PC at their institutions.

RESULTS

Enduring, interdisciplinary relationships were built at all levels across health care organizations. Fellows made significant increases in knowledge and self-reported confidence in adult and pediatric PC and program development skills and frequency performing these skills. Fellows and mentors reported high satisfaction with the educational program.

CONCLUSION

This interdisciplinary PC training model addressed local workforce issues by increasing the number of clinicians capable of providing PC. Unique features include individualized longitudinal mentoring, interdisciplinary education, on-site project implementation, and local network building. Future research will address the impact of the addition of social work and chaplain trainees to the program.

Compassion Fatigue Among Palliative Care Clinicians: Findings on Personality Factors and Years of Service

Objectives:

Palliative medicine is a rewarding field, but providers encounter patient trauma on a routine basis. Compassion fatigue, marked by burnout, secondary traumatic stress, and low satisfaction may result. However, professionals differ markedly in how they respond to patient trauma. The objective of the current study was to determine whether personality traits of neuroticism and agreeableness relate to aspects of compassion fatigue, after accounting for time spent working in the field.

Methods:

Sixty-six palliative medicine physicians, nurses, social workers, and chaplains completed validated measures of personality traits, compassion fatigue, and work background.

Results:

Providers who had worked longer reported higher levels of satisfaction and lower levels of burnout. Neuroticism demonstrated strong significant associations with secondary traumatic stress and burnout ( Ps < .001). Agreeableness was significantly and strongly associated with compassion satisfaction ( P < .001). These associations held after accounting for years spent working in the field.

Significance of Results:

Personality traits of neuroticism and agreeableness may convey risk and resilience, respectively, for palliative care professionals. More research is needed to determine if assessing personality traits can help identify providers at risk for adverse reactions to patient trauma.

Palliative Workforce Development and a Regional Training Program

Aims:

Our primary aims were to assess growth in the local hospital based workforce, changes in the composition of the workforce and use of an interdisciplinary team, and sources of support for palliative medicine teams in hospitals participating in a regional palliative training program in Chicago.

Methods:

PC program directors and administrators at 16 sites were sent an electronic survey on institutional and PC program characteristics such as: hospital type, number of beds, PC staffing composition, PC programs offered, start-up years, PC service utilization and sources of financial support for fiscal years 2012 and 2014.

Results:

The median number of consultations reported for existing programs in 2012 was 345 (IQR 109 – 2168) compared with 840 (IQR 320 – 4268) in 2014. At the same time there were small increases in the overall team size from a median of 3.2 full time equivalent positions (FTE) in 2012 to 3.3 FTE in 2013, with a median increase of 0.4 (IQR 0-1.0). Discharge to hospice was more common than deaths in the acute care setting in hospitals with palliative medicine teams that included both social workers and advanced practice nurses ( p < .0001).

Conclusions:

Given the shortage of palliative medicine specialist providers more emphasis should be placed on training other clinicians to provide primary level palliative care while addressing the need to hire sufficient workforce to care for seriously ill patients.

Passive absorption in a classical photonic crystal-based organic solar cell

We study the light trapping efficiency of a bidimensional photonic crystal (PC) integrated in a classical organic multilayer solar cell. The role of the PC is to enhance light absorption in the active layer by leveraging resonant mode excitation. However the light trapping efficiency is drastically inhibited by the overall absorption of the entire multilayer, which includes absorption by the passive layers that do not contribute to the photocurrent. This study focuses on the impact of passive absorption in ITO and PEDOT, which is often neglected in the study of light trapping organic solar cell systems, despite the significant role it plays in highly absorbing devices. Indeed, we show here that the absorption enhancement in the active layer can vary between 23% and 46% depending on the optical properties of the passive layers, which are dependent on fabrication conditions. We also detail how the PC behaves with coupled parameters such as the optical indices of the passive layers, as well as the period and the air filling fraction of the PC.

Coupling light into a slow-light photonic-crystal waveguide from a free-space normally-incident beam

We present a coupler design allowing normally-incident light coupling from free-space into a monomode photonic crystal waveguide operating in the slow-light regime. Numerical three-dimensional calculations show that extraction efficiencies as high as 80% can be achieved for very large group indices up to 100. We demonstrate experimentally the device feasibility by coupling and extracting light from a photonic crystal waveguide over a large group-index range (from 10 to 60). The measurements are in good agreement with theoretical predictions. We also study numerically the impact of various geometrical parameters on the coupler performances.

Quantitative summaries of single-subject studies: What do group comparisons tell us about individual performances?

Kollins, Newland, and Critchfield (1999) responded to our comments about their review by arguing that their quantitative summary was not a meta-analysis and should not be criticized in these terms. We reply that regardless of what they call their review, it included confounding effects that make interpretations of the results problematic. Kollins et al. also argued that unexpected findings of the sort they reported can serve as a spur for further research. We reply that the understanding of findings that deviate from existing knowledge may well require empirical investigation. Such endeavors, however, should begin with an evaluation of the review procedures that suggested the existence of the differences. Finally, we emphasize that quantitative summaries of individual data are, in the end, a form of group comparison. The implications of using group methods to clarify individual data deserve frank recognition in discussions of the outcomes.

Statistical inference in behavior analysis: Friend or foe?

Behavior analysts are undecided about the proper role to be played by inferential statistics in behavioral research. The traditional view, as expressed in Sidman's Tactics of Scientific Research (1960), was that inferential statistics has no place within a science that focuses on the steady-state behavior of individual organisms. Despite this admonition, there have been steady inroads of statistical techniques into behavior analysis since then, as evidenced by publications in the Journal of the Experimental Analysis of Behavior. The issues raised by these developments were considered at a panel held at the 24th annual convention of the Association for Behavior Analysis, Orlando, Florida (May, 1998). The proceedings are reported in this and the following articles.

Human sensitivity to reinforcement: A comment on Kollins, Newland, and Critchfield's (1997) quantitative literature review

In a quantitative review of human operant experiments, Kollins, Newland, and Critchfield (1997) found that humans are less sensitive to reinforcement contingencies than nonhumans are. Human performances were not as consistent with the matching law, and they were more variable from subject to subject. Some of the variables correlated with reduced human sensitivity were surprising. These included collection of the data under more controlled conditions (laboratory rather than naturalistic settings), and inclusions of discriminative stimuli correlated with alternative sources of reinforcement. We discuss these unexpected findings in the light of criticisms that have been leveled against meta-analytic literature reviews (e.g., the wisdom of grouping studies with widely diverse methods), and we suggest ways of improving future analyses of the behavior-analytic literature.

Analyzing the reinforcement process at the human level: can application and behavioristic interpretation replace laboratory research?

Critics have questioned the value of human operant conditioning experiments in the study of fundamental processes of reinforcement. Contradictory results from human and animal experiments have been attributed to the complex social and verbal history of the human subject. On these grounds, it has been contended that procedures that mimic those conventionally used with animal subjects represent a "poor analytic preparation" for the explication of reinforcement principles. In defending the use of conventional operant methods for human research, we make three points: (a) Historical variables play a critical role in research on processes of reinforcement, regardless of whether the subjects are humans or animals. (b) Techniques are available for detecting, analyzing, and counteracting such historical and extra-experimental influences; these include long-term observations, steady state designs, and, when variables are not amenable to direct control (e.g., age, gender, species), selection of subjects with common characteristics. (c) Other forms of evidence that might be used to validate conditioning principles-applied behavior analysis and behavioristic interpretation-have inherent limitations and cannot substitute for experimental analysis. We conclude that human operant conditioning experiments are essential for the analysis of the reinforcement process at the human level, but caution that their value depends on the extent to which the traditional methods of the experimental analysis of behavior are properly applied.

Attenuation coefficient of single-mode periodic waveguides

It is widely accepted that, on ensemble average, the transmission T of guided modes decays exponentially with the waveguide length L due to small imperfections, leading to the important figure of merit defined as the attenuation-rate coefficient α=-⟨ln(T)⟩/L. In this Letter, we evidence that the exponential-damping law is not valid in general for periodic monomode waveguides, especially as the group velocity decreases. This result, that contradicts common beliefs and experimental practices aiming at measuring α, is supported by a theoretical study of light transport in the limit of very small imperfections, and by numerical results obtained for two waveguide geometries that offer contrasted damping behaviors.

Demonstration of ignition radiation temperatures in indirect-drive inertial confinement fusion hohlraums

We demonstrate the hohlraum radiation temperature and symmetry required for ignition-scale inertial confinement fusion capsule implosions. Cryogenic gas-filled hohlraums with 2.2 mm-diameter capsules are heated with unprecedented laser energies of 1.2 MJ delivered by 192 ultraviolet laser beams on the National Ignition Facility. Laser backscatter measurements show that these hohlraums absorb 87% to 91% of the incident laser power resulting in peak radiation temperatures of T(RAD)=300 eV and a symmetric implosion to a 100 μm diameter hot core.

Density and delay of punishment of free-operant avoidance

In two experiments, the free-operant shock-avoidance behavior of rats was punished by electric shock. Two aspects of the schedule of response-produced shock were varied: the frequency of punishment over time (punishment density) and the temporal interval between the punished response and the punishment (punishment delay). The general finding was that response-produced shock suppressed avoidance responding under most of the density-delay combinations studied, and suppression increased as a function of increases in density and decreases in delay. Rate increases of small magnitude also were observed, usually as an initial reaction to the lesser densities and longer delays. Response suppression, while decreasing the number of punishment shocks received, also increased the number of avoidance shocks, so that the total number of shocks received usually was greater than the minimal number possible. The results were discussed from the standpoint of similarities between the effects of punishing positively and negatively reinforced behavior. The finding that subjects did not minimize the total number of shocks suggested that when avoidance behavior is punished, responding is controlled more by the local consequences of responding than by overall shock frequencies during the course of the session.

Effects of instructions and reinforcement-feedback on human operant behavior maintained by fixed-interval reinforcement

In three experiments, human subjects were trained on a five-component multiple schedule with different fixed intervals of monetary reinforcement scheduled in the different components. Subjects uninstructed about the fixed-interval schedules manifested high and generally equivalent rates regardless of the particular component. By comparison, subjects given instructions about the schedules showed orderly progressions of rates and temporal patterning as a function of the interreinforcement intervals, particularly when feedback about reinforcement was delivered but also when reinforcement-feedback was withheld. Administration of the instructions-reinforcement combination to subjects who had already developed poorly differentiated behavior, however, did not make their behavior substantially better differentiated. When cost was imposed for responding, both instructed and uninstructed subjects showed low and differentiated rates regardless of their prior histories. It was concluded that instructions can have major influences on the establishment and maintenance of human operant behavior.

Response-dependent and response-independent timeout from an avoidance schedule

While rats were responding in a single-lever apparatus to avoid electric shock, a signal was presented and followed by a 5-min timeout period when all shocks were omitted. For the response-dependent member of each yoked pair, the first response 60 sec after onset of the pre-timeout signal terminated the signal and initiated timeout. The other, yoked animal was exposed to the same sequence except that signal termination and timeout onset were response independent. Under the response-dependent condition, response rates in the presence of the signal increased relative to baseline rates. Rate increases also occurred when timeout was response independent, but were of lesser magnitude and reliability. Subsequent reversal of the yoking arrangement produced stable and equivalent rate increases under both conditions. Other findings were that increased rates in the presence of the signal diminished when timeout was omitted but were maintained for a time on an avoidance-extinction baseline. In general, the results supported the conclusion of previous experiments that timeout from avoidance can serve as a positive reinforcer. The finding that response-independent presentation of timeout produced rate increases, particularly after a history with response-dependent timeout, was interpreted in terms of adventitious reinforcement of previously established behavior.

Reinforcement magnitude and pausing on progressive-ratio schedules

Rats responded under progressive-ratio schedules for sweetened milk reinforcers; each session ended when responding ceased for 10 min. Experiment 1 varied the concentration of milk and the duration of postreinforcement timeouts. Postreinforcement pausing increased as a positively accelerated function of the size of the ratio, and the rate of increase was reduced as a function of concentration and by timeouts of 10 s or longer. Experiment 2 varied reinforcement magnitude within sessions (number of dipper operations per reinforcer) in conjunction with stimuli correlated with the upcoming magnitude. In the absence of discriminative stimuli, pausing was longer following a large reinforcer than following a small one. Pauses were reduced by a stimulus signaling a large upcoming reinforcer, particularly at the highest ratios, and the animals tended to quit responding when the past reinforcer was large and the stimulus signaled that the next one would be small. Results of both experiments revealed parallels between responding under progressive-ratio schedules and other schedules containing ratio contingencies. Relationships between pausing and magnitude suggest that ratio pausing is under the joint control of inhibitory properties of the past reinforcer and excitatory properties of stimuli correlated with the upcoming reinforcer, rather than under the exclusive control of either factor alone.

Reinforcement of human observing behavior by a stimulue correlated with extinction or increased effort

Young men pulled a plunger on mixed and multiple schedules in which periods of variable-interval monetary reinforcement alternated irregularly with periods of extinction (Experiment 1), or in which reinforcement was contingent on different degrees of effort in the two alternating components (Experiment 2). In the baseline conditions, the pair of stimuli correlated with the schedule components could be obtained intermittently by pressing either of two observing keys. In the main conditions, pressing one of the keys continued to produce both discriminative stimuli as appropriate. Pressing the other key produced only the stimulus correlated with variable-interval reinforcement or reduced effort; presses on this key were ineffective during periods of extinction or increased effort. In both experiments, key presses producing both stimuli occurred at higher rates than key presses producing only one, demonstrating enhancement of observing behavior by a stimulus correlated with the less favorable of two contingencies. A control experiment showed that stimulus change alone was not an important factor in the maintenance of the behavior. These findings suggest that negative as well as positive stimuli may play a role in the conditioned reinforcement of human behavior.