Role of relaxation and specific suggestions in hypnotic emotional numbing.

The cognitive characteristics of highly hypnotizable subjects (Highs) allow them to easily modify their cognitive and autonomic state. Under hypnosis, Highs receiving cognitive, fear-like stimulation exhibit the cardiovascular changes typical of fear/stress, but also show an EEG pattern indicating a balance between fear-induced arousal and hypnotic relaxation. Indeed, hypnosis is effective in the attenuation of both emotional experience and behaviour (emotional numbing). The aim of the present experiment was to investigate the possible different role of relaxation and suggestion in hypnotic emotional numbing. Tonic skin conductance, respirogram, heart rate, systolic and diastolic blood pressure were recorded in 3 groups of hypnotized subjects: Group 1 received a fearful guided imagery associated with threat suggestions (Threat) followed by the same fearful suggestion associated with numbing instructions (relaxation and "No-Threat"); Group 2 received the same instructions in the opposite order of presentation; Group 3 received the fearful suggestion with threat instructions twice. The numbing suggestion reduced fear-related emotional experience and autonomic responses; if No-Threat preceded Threat, the heart rate, heart rate variability and blood pressure were also reduced during Threat, in spite of self reports of high negative emotion. Thus, 1) the subjective experience and the autonomic response to fear can be dissociated; 2) the efficacy of numbing suggestion is extended to a subsequent Threat stimulation; 3) habituation does not contribute to the numbing effect. The results indicate that the specific numbing suggestion is the main factor in hypnotic modulation of the experience of fear.     

Polycyclic aromatic hydrocarbon patterns in the city of Rio de Janeiro

In this study, the concentrations of 16 Polycyclic Aromatic Hydrocarbon (PAH), considered priority by US EPA (US Environmental Protection Agency), in fine particulate matter (PM_2.5), were determined in a forest reserve and in an urban area in the city of Rio de Janeiro. The PM_2.5 samples were collected in the Tijuca Forest (TF) and on the Maracanã campus of the State University of Rio de Janeiro (UERJ), using PM_2.5 high-volume air samplers, from November 2015 to April 2016. The organic matter was extracted, separated by liquid chromatography, and analyzed by gas chromatography-mass spectrometry (GC-MS). The mean total PAH (excluding naphthalene, acenaphthene, and acenaphthylene) concentrations were 0.46?±?0.61 ng m^?3 and 1.12?±?0.71 ng m^?3 in PM_2.5 collected at TF and UERJ, respectively. The diagnostic ratios suggested vehicular sources for both sites with no clear distinction between light and heavy vehicular sources. Cluster and principal component analyses were also used to clarify the possible PAH sources. Simulations of air mass trajectories confirmed the transport of pollutants from the city to the forest. Mutagenicity tests revealed that the PM collected in the UERJ presented mutagenic positive activity, likely for nitro-PAH and amino-PAH, which may be related to vehicular emissions. For the TF, although the forest was impacted by the pollutants, no positive activity was detected. Correlation and cluster analyses showed different PAH distributions for the TF and UERJ sites, which indicates that the TF receives the air masses from the city but is also impacted by local emissions.     

Quality assurance in drug demand reduction in European countries: an overview

Background: The EMCDDA, through its network of National Focal Points, collects information on the quality assurance systems for drugs-related interventions across European countries. European National Drug Strategies include recommendations for systems and approaches for the assurance of the quality of interventions.

Methods: We searched National Drug Strategies for elements related to quality assurance in drug demand reduction and summarised information through questionnaires administered to the EMCDDA Network of National Focal Points.

Results: In total, 15 National Drug Strategies and 60 questionnaires were analysed. Almost all the strategies include quality-related topics. Frequently, the Ministry of Health leads quality assurance although sometimes jointly with the Ministries of Education, Labour, Family and Social Welfare. Accreditation systems are common, but implemented in different ways. Training and education are widely provided, for the vast majority of countries, consisting of short-term training to keep professionals updated. Guidelines and Standards are gathering momentum as the major tools for the implementation of evidence-based recommendations and are usually available across countries.

Conclusions: Although the evidence base for interventions in drug demand reduction is becoming available and accepted, attention needs to be given to implementation issues. The European countries are rapidly moving towards paying greater attention to the quality of interventions.     

Determinants of post-intensive care mortality in high-level treated critically ill patients

Objective To assess the predictive ability of preillness and illness variables, impact of care, and discharge variables on the post-intensive care mortality.Setting and patients 5,805 patients treated with high intensity of care in 89 ICUs in 12 European countries (EURICUS-I study) surviving ICU stay.Methods Case-mix was split in training sample (logistic regression model for post-ICU mortality: discrimination assessed by area under ROC curve) and in testing sample. Time to death was studied by Cox regression model validated with bootstrap sampling on the unsplit case-mix.Results There were 5,805 high-intensity patients discharged to ward and 423 who died in hospital. Significant odds ratios were observed for source of admission, medical/surgical unscheduled admission, each year age, each SAPSII point, each consecutive day in high-intensity treatment, and each NEMS point on the last ICU day. Time to death in ward was significantly shortened by different source of admission; age over 78 years, medical/unscheduled surgical admission; SAPSII score without age, comorbidity and type of admission over 16 points; more than 2 days in high-intensity treatment; all days spent in high treatment; respiratory, cardiovascular, and renal support at discharge; and last ICU day NEMS higher than 27 pointsConclusions Worse outcome is associated with the physiological reserve before admission in the ICU, type of illness, intensity of care required, and the clinical stability and/or the grade of nursing dependence at discharge.This study was supported in part, by the Foundation for Research on Intensive Care in Europe (FRICE) and by a grant from the Commission of the European communities (BMH1-CT93-1340)     

Results obtained with level II oncoplastic surgery spanning 20 years of breast cancer treatment: Do we really need further demonstration of reliability?

Oncoplastic surgery (OPS) has demonstrated its superiority above traditional breast conserving surgery, but is still struggling to consolidate its role in breast cancer therapeutic protocols mainly because of contrasting scientific evidences and reduced follow‐up results available. The objective of our contribution is to analyze results obtained with 381 patients consecutively treated in our Multidisciplinary Breast Center by means of level II OPS between January 1998 and January 2018 for unilateral, primary breast cancer. Surgical endpoints were mean specimen weight and volume, mean diameter of main lesion (MLD), rates of positive margins (PMR), re‐excision (RR), conversion to mastectomy (CMR), complications (CR) and oncological endpoints as overall survival (OS), disease‐free survival (DFS), and local recurrence rate (LR). About 29.1% were treated for multifocal/multicentric disease, and 29.1% previously underwent neo‐adjuvant chemotherapy (NACT). Regarding surgical techniques, 53.0% of patients received “inverted T” and 30.1% “J” mammoplasties, whereas 13.6% underwent “round block,” 2.3% “Grisotti,” and 1% “batwing” techniques. Regarding surgical outcomes, mean specimen weight was 215 g (50‐2157) and volume 345 mm³ (21‐7980). MLD 23 mm, PMR 7.6%, RR 3.6%, CMR 1.6%, and CR 5.8%. With a mean follow‐up of 118 months, oncological outcomes were: OS 93.7%, DFS 82.3%, LR 4.4%. In conclusion, our analysis confirmed level II OPS reliability even for longer follow‐up timing and in difficult situations as multifocal disease or after NACT.     

Re-Validating the Observational Teamwork Assessment for Surgery Tool (OTAS-D): Cultural Adaptation, Refinement, and Psychometric Evaluation

Background

The nontechnical and team skills of surgical teams are critical for safety and efficiency in the operating room. Assessment of nontechnical and team skills can facilitate improvement by encouraging both self-reflection and team reflection, identifying training needs, and informing operating room (OR) team training approaches. The observational teamwork assessment for surgery (OTAS) tool is a well-validated and robust tool for capturing teamwork in the operating room. The aims of the present study were to systematically adapt and refine the OTAS for German-speaking OR staff and to test the adapted assessment tool (OTAS-D) for psychometric properties and metric equivalence.

Methods

The study was carried out in three stages: at stage 1, OTAS was translated into German. At stage 2, experienced German OR experts (surgeons, OR nurses, anesthetists) were interviewed. At stage 3, two blinded assessors observed 11 general surgical operations (general surgical and vascular procedures) and interrater reliability was tested for refined OTAS-D behavioral exemplars and scorings.

Results

The German OR experts confirmed the applicability and content validity of the vast majority of translated behavioral exemplars. After their evaluation, 32 items were changed slightly, six were changed substantially, and one item was added. During observations, perfect and substantial interobserver agreement was found for 77 behavioral exemplars (67.1 % of the items, kappa coefficient >0.60). Rating at all OTAS behaviors showed acceptable levels of reliability (intraclass correlation coefficients >0.72).

Conclusions

The OTAS-D is a tool for valid and reliable assessment of nontechnical skills that contribute to safe and effective surgical performance in ORs staffed by German-speaking professionals. Furthermore, our study serves as an example for systematically adapting and customizing well-established observational tools across different healthcare environments.     

HDL in Children with CKD Promotes Endothelial Dysfunction and an Abnormal Vascular Phenotype

Endothelial dysfunction begins in early CKD and contributes to cardiovascular mortality. HDL is considered antiatherogenic, but may have adverse vascular effects in cardiovascular disease, diabetes, and inflammatory conditions. The effect of renal failure on HDL properties is unknown. We studied the endothelial effects of HDL isolated from 82 children with CKD stages 2–5 (HDL^CKD), who were free of underlying inflammatory diseases, diabetes, or active infections. Compared with HDL from healthy children, HDL^CKD strongly inhibited nitric oxide production, promoted superoxide production, and increased vascular cell adhesion molecule-1 expression in human aortic endothelial cells, and reduced cholesterol efflux from macrophages. The effects on endothelial cells correlated with CKD grade, with the most profound changes induced by HDL from patients on dialysis, and partial recovery observed with HDL isolated after kidney transplantation. Furthermore, the in vitro effects on endothelial cells associated with increased aortic pulse wave velocity, carotid intima-media thickness, and circulating markers of endothelial dysfunction in patients. Symmetric dimethylarginine levels were increased in serum and fractions of HDL from children with CKD. In a longitudinal follow-up of eight children undergoing kidney transplantation, HDL-induced production of endothelial nitric oxide, superoxide, and vascular cell adhesion molecule-1 in vitro improved significantly at 3 months after transplantation, but did not reach normal levels. These results suggest that in children with CKD without concomitant disease affecting HDL function, HDL dysfunction begins in early CKD, progressing as renal function declines, and is partially reversed after kidney transplantation.Patients with CKD no longer die from renal failure but from cardiovascular disease. There is an independent, graded association between a reduced eGFR and the risk of death and cardiovascular events.¹ Typically, patients with CKD develop calcification in the tunica media of their arteries,² but a concomitant process of endothelial damage leading to atherosclerosis is also³ present beginning in predialysis CKD.^4,5LDL is crucially involved in the pathogenesis of atherosclerotic cardiovascular disease in the general population,⁶ whereas HDL is thought to be antiatherogenic by promoting reverse cholesterol transport and exerting direct protective endothelial effects.⁷ HDL from healthy participants increases the bioavailability of nitric oxide (NO) by activating endothelial NO synthase inducing vasodilation and decreasing arterial BP. Moreover, HDL diminishes the production of reactive oxygen species such as superoxide (SO) radicals, which have been demonstrated to reduce NO bioavailability leading to endothelial dysfunction and promoting atherogenesis. However, recent evidence suggests that HDL may lose its vasoprotective properties in patients with manifest cardiovascular disease (e.g., coronary artery disease), diabetes, or inflammatory disease states (e.g., antiphospholipid syndrome).^8–10 Similarly, in adults on dialysis, HDL has reduced cholesterol efflux capacity and proinflammatory effects on mononuclear cells.^11–13 Observational studies have shown a strong association between high HDL levels and reduced risk of cardiovascular disease in the general population¹⁴ but not in dialysis patients.¹⁵Cardiac and vascular damage has also been documented in children on dialysis,^2,16,17 and cardiovascular disease accounts for the majority of deaths in pediatric dialysis patients.¹⁷ In contrast with adult patients with CKD, in whom cardiovascular risk factors such as diabetes dyslipidemia, hypertension, and smoking are highly prevalent,¹⁸ CKD in children is mainly caused by inherited disorders such as malformations of the kidney or urinary tract.¹⁸ Accordingly, examining HDL function in children who are free of “traditional” cardiovascular risk factors and underlying inflammatory diseases and who are nonsmokers gives us an unique opportunity to study the effects of renal failure on the vascular functions of HDL.We studied the endothelial properties of HDL in a cohort of children at different stages of CKD on dialysis and after transplantation and compared them with healthy children. Furthermore, to determine the clinical relevance of in vitro effects of HDL, we examined its relationship with clinical measures of the vascular phenotype as well as circulating markers of endothelial dysfunction. Finally, to show a causal link between renal function and HDL properties, we examined children on dialysis and 3 months after kidney transplantation. This study allowed us to examine when HDL dysfunction develops during the natural history of renal decline, its effects on vascular function, and the potential for recovery after kidney transplantation.     

Combined Peridynamics and Discrete Multiphysics to Study the Effects of Air Voids and Freeze-Thaw on the Mechanical Properties of Asphalt

This paper demonstrates the use of peridynamics and discrete multiphysics to assess micro crack formation and propagation in asphalt at low temperatures and under freezing conditions. Three scenarios are investigated: (a) asphalt without air voids under compressive load, (b) asphalt with air voids and (c) voids filled with freezing water. The first two are computed with Peridynamics, the third with peridynamics combined with discrete multiphysics. The results show that the presence of voids changes the way cracks propagate in the material. In asphalt without voids, cracks tend to propagate at the interface between the mastic and the aggregate. In the presence of voids, they ‘jump’ from one void to the closest void. Water expansion is modelled by coupling Peridynamics with repulsive forces in the context of Discrete Multiphysics. Freezing water expands against the voids’ internal surface, building tension in the material. A network of cracks forms in the asphalt, weakening its mechanical properties. The proposed methodology provides a computational tool for generating samples of ‘digital asphalt’ that can be tested to assess the asphalt properties under different operating conditions.