CBT for difficult-to-treat depression: self-regulation model.

BACKGROUND: Cognitive behavioural therapy (CBT) is an effective treatment for depression but a significant minority of clients do not complete therapy, do not respond to it, or subsequently relapse. Non-responders, and those at risk of relapse, are more likely to have adverse childhood experiences, early-onset depression, co-morbidities, interpersonal problems and heightened risk. This is a heterogeneous group of clients who are currently difficult to treat. AIM: The aim was to develop a CBT model of depression that will be effective for difficult-to-treat clients who have not responded to standard CBT. METHOD: The method was to unify theory, evidence and clinical strategies within the field of CBT to develop an integrated CBT model. Single case methods were used to develop the treatment components. RESULTS: A self-regulation model of depression has been developed. It proposes that depression is maintained by repeated interactions of self-identity disruption, impaired motivation, disengagement, rumination, intrusive memories and passive life goals. Depression is more difficult to treat when these processes become interlocked. Treatment based on the model builds self-regulation skills and restructures self-identity, rather than target negative beliefs. A bespoke therapy plan is formed out of ten treatment components, based on an individual case formulation. CONCLUSIONS: A self-regulation model of depression is proposed that integrates theory, evidence and practice within the field of CBT. It has been developed with difficult-to-treat cases as its primary purpose. A case example is described in a concurrent article (Barton et al., 2022) and further empirical tests are on-going.

Solvation of NiOxfor hole transport layer deposition in perovskite solar cells.

A series of nickel oxide (NiOx) inks, in the perovskite antisolvent chlorobenzene (CB) containing 15% ethanol, were prepared for the fabrication of p-i-n perovskite solar cells by blade coating. The inks included triethylamine (Et3N) and alkyl xanthate salts as ligands to disperse NiOxparticle aggregates and stabilize suspension. A total of four inks were evaluated: 0X (Et3N with no alkyl xanthate), 4X (Et3N + potassiumn-butyl xanthate), 12X (Et3N + potassiumn-dodecyl xanthate), and 18X (Et3N + potassiumn-octadecyl xanthate). The inks were characterized by UV-visible spectroscopy and FT-IR spectroscopy and the resulting films analyzed by thermogravimetry and scanning electron microscopy. Devices prepared using the 0X ink resulted in a peak power conversion efficiency (PCE) of 14.47% (0.25 cm2) and 9.96% (1 cm2). The 0X devices showed no significant loss of PCE after 100 days in a nitrogen flow box. Devices prepared with inks containing alkyl xanthate ligand had lower PCE that decreased with decreasing chain length, 18X > 12X > 4X.

Synthesizing and formulating metal oxide nanoparticle inks for perovskite solar cells.

The perovskite solar cell has commercial potential due to the low-cost of materials and manufacturing processes with cell efficiencies on par with traditional technologies. Nanomaterials have many properties that make them attractive for the perovskite devices, including low-cost inks, low temperature processing, stable material properties and good charge transport. In this feature article, the use of nanomaterials in the hole transport and electron transport layers are reviewed. Specifically, SnO2 and NiOx are the leading materials with the most promise for translation to large scale applications. The review includes a discussion of the synthesis, formulation, and processing of these nanoparticles and provides insights for their further deployment towards commercially viable perovskite solar cells.

Energy dissipation distributions and dissipative atomic processes in amplitude modulation atomic force microscopy.

Instantaneous and average energy dissipation distributions in the nanoscale due to short and long range interactions are described. We employ both a purely continuous and a semi-discrete approach to analyze the consequences of this distribution in terms of rate of heat generation, thermal flux, adhesion hysteresis, viscoelasticity and atomic dissipative processes. The effects of peak values are also discussed in terms of the validity of the use of average values of power and energy dissipation. Analytic expressions for the instantaneous power are also derived. We further provide a general expression to calculate the effective area of interaction for fundamental dissipative processes and relate it to the energy distribution profile in the interaction area. Finally, a semi-discrete approach to model and interpret atomic dissipative processes is proposed and shown to lead to realistic values for the atomic bond dissipation and viscoelastic atomic processes.

Brachial artery fibromuscular dysplasia.

Fibromuscular dysplasia is a rare vascular disease that is characterized as nonatherosclerotic and noninflammatory in nature. This disease most commonly afflicts the renal and cerebrovascular beds but can rarely affect the upper extremity. We present the case of a 76-year-old woman who complained of a symptom complex, congruent with Raynaud's phenomenon on the right side. The patient had evidence of distal ischemia without the classic angiographic evidence of fibromuscular dysplasia on arteriography. The abnormal arterial section of the right brachial artery was resected and grafted with reversed saphenous vein. She has had no reoccurrence of her symptoms and no stenosis of her graft over a 3-year follow-up period.

Is there thermal benefit from preoperative warming in children?

AIM: We aimed to quantify the impact of a raised preoperative ambient temperature (T(ambient)) on core temperature (T(core)) after induction of anesthesia in children. BACKGROUND: It has been suggested that prewarming of patients before anesthesia induction reduces postinduction drop in T(core). Neither the prewarming temperature nor its duration is established for adults or children. Nevertheless, it remains common practice to either warm the operating theatre and induction room or employ radiant heaters prior to induction of anesthesia, particularly for infants and neonates. We aimed to quantify the benefit, if any, of this warming practice. METHODS: We conducted a prospective clinical study to assess T(core) behavior in children randomized to either raised or standard ambient temperature as a prewarming technique prior to induction and until the operation commenced. We have called this 'preoperative' warming. Well, children scheduled for elective surgery where presurgical anesthetic duration exceeded 20 min were randomized to a T(ambient) of either 26 or 21 degrees C. Esophageal temperature was monitored continuously until the operative procedure commenced. RESULTS: There were 30 children in each group. Those in the warmed group (26 degrees C) had a statistically significant higher initial T(core) (0.4 degrees C warmer) and less drop in their T(core) (0.18 degrees C benefit at 20 min). Although younger/lighter/shorter individuals were more likely to drop their T(core), a warmer T(ambient) had only 0.1 degrees C thermal benefit irrespective of age. CONCLUSIONS: There are statistically significant thermal advantages to preoperative environmental warming. This study provides data to assist the anesthetist in deciding when these are likely to be clinically relevant.

Impact of senior clinical review on patient disposition from the emergency department.

INTRODUCTION: The delivery of high quality emergency medicine ideally involves input from senior doctors 24 h a day. This study aims to assess the influence of 'real-time' senior clinician supervision on patient disposition from a UK emergency department. METHODS: The study was set in a UK teaching hospital with 24 h senior cover. Patients were initially seen by a junior doctor who completed a plan for the patient before seeking senior advice. Primary outcome measures were a change in patient outcome of discharge, admit, telephone speciality for opinion or outpatient follow-up. RESULTS: 556 patients underwent senior review during the study period. Review reduced inpatient admissions by 11.9% (95% CI 7.2% to 18.2%) and specifically reduced admissions to the acute medical assessment unit by 21.2% (95% CI 13.5% to 30.8%). Inappropriate discharge was prevented in 9.4% (95% CI 6.2% to 13.7%) and appropriate use of outpatient facilities resulted in a rise of 34.6% in appointments. CONCLUSIONS: Senior doctor input in patient care in the ED adds accuracy to disposition decisions, impacting on patient safety and improving departmental flow.

Reduced productivity among junior trainees in the emergency department and the impact on senior clinicians.

UNLABELLED: Emergency medicine has recently undergone significant changes, with training, staffing and service delivery attracting particular attention. Senior doctors are under increased pressure to ensure the prompt delivery of service and to provide a smooth patient journey. It has been suggested that junior trainees see fewer patients than their predecessors, resulting in the burden of clinical work being transferred to senior clinicians, representing a shift away from the traditional model of service delivery. This study charts the work rate trends among junior doctors and the proportion of work performed by senior doctors over a 3-year period. RESULTS: The number of patients seen by junior trainees fell by 4% and was associated with a statistically significant 16.6% reduction in the mean number of patients seen per hour. The number of patients seen purely by senior clinicians increased to over 35%, in addition to reviewing those seen by junior trainees. This highlights reduced clinical exposure and productivity among juniors, but also shows the significant knock-on effect on the workload of senior clinicians. CONCLUSIONS: There will need to be an increase in the number of trained clinicians within emergency medicine to continue to deliver effective training and supervision and ensure a safe, good quality service to patients.

Comparison of Surgisis, AlloDerm, and Vicryl Woven Mesh grafts for abdominal wall defect repair in an animal model.

BACKGROUND: Surgisis and AlloDerm, two biosynthetic materials, have been previously used with success in abdominal wall repairs in the setting of contaminated fields. Historically, Vicryl Woven Mesh, a synthetic material, has also been used in such settings as a temporary bridge for abdominal wall reconstruction. This study compares Surgisis and AlloDerm with Vicryl Woven Mesh with respect to tensile strength, collagen remodeling, and neovascularization using a rat hernia model. METHODS: A prospective randomized trial of 54 Sprague-Dawley rats were assigned to the Surgisis, AlloDerm, or Vicryl Woven Mesh group with baseline, 30-day, and 60-day end points. A 1.5-cm x 5.0-cm defect was created in the right abdominis rectus muscle and repaired with an underlay bridge graft using the different treatment materials. Tensile strength was measured using an Instron tensiometer. Histologic specimens were evaluated for neovascularization, collagen deposition, and collagen organization at the 30- and 60-day time points. RESULTS: Surgisis had significantly greater tensile strength compared to Vicryl Woven Mesh at the baseline time point (0.142 vs. 0.091 MPa, p < 0.05). There were no differences between groups tensile strength at 30 or 60 days postoperatively. The Vicryl Woven Mesh and AlloDerm groups showed increases in tensile strength at 30 days postoperatively versus baseline (p < 0.05). Vicryl Woven Mesh, Surgisis, and AlloDerm all showed increases in tensile strength at 60 days postoperatively compared to 30 days postoperatively and at baseline (p < 0.05). Surgisis and AlloDerm had significantly greater (p < 0.05) amounts of collagen deposition and organization at 30 and 60 days compared to Vicryl Woven Mesh. There was no significant difference between AlloDerm and Surgisis with respect to collagen deposition and organization. Surgisis and AlloDerm showed a significantly greater amount (p < 0.05) of neovascularization than Vicryl Woven Mesh at both time points. In addition, Surgisis had a significantly greater amount (p < 0.05) of neovascularization than AlloDerm at both 30 and 60 days. CONCLUSION: Surgisis has increased baseline tensile strength compared to Vicryl Woven Mesh. Tensile strength in Vicryl Woven Mesh is equal to biosynthetic grafts after tissue incorporation. Biosynthetic grafts showed superior collagen deposition and organization. Surgisis mesh showed increased neovascularization over both AlloDerm and Vicryl Woven Mesh.

Permacol (porcine dermal collagen) and Alloderm (acellular cadaveric dermis) as a vascular patch repair for common carotid arteriotomy in a rabbit model.

Occult injuries to arteries are common in trauma and evolution of their repair has been observed throughout military conflicts. Currently, autogenous vein and polytetrafluoroethylene (PTFE) are used as patch agents for arterial trauma. However, suitable vein is often lacking in multitrauma patients, and PTFE is prone to infection in the contaminated combat wound. The purpose of this study is to evaluate Permacol, porcine dermal collagen, and Alloderm, acellular cadaveric dermis, as suitable alternatives to PTFE with the potential benefit of being used in contaminated wounds. A New Zealand White rabbit common carotid arteriotomy model was used to compare Permacol (n = 12), Alloderm (n = 11), and PTFE (n = 13) for patch repair. Thrombin generation was examined using an enzyme-linked immunosorbent assay for thrombin-antithrombin complex. Histological samples were taken to analyze vessel lumen area, vessel diameter, intimal thickness, and medial thickness. Pathological examinations were made to compare rates of intimal hyperplasia, aneurysm, patency, and thrombus formation. The Permacol group showed equivalent rates of thrombus, aneurysm, and patency compared with PTFE. Increased lumen area was seen in the Permacol group, 0.344 mm2 (p = 0.02) compared with the PTFE group, 0.204 mm2. Permacol also had decreased incidence of intimal hyperplasia compared with PTFE, 50.0% versus 92% (p < 0.05). Alloderm had increased rates of aneurysm formation, 63.6% (p = 0.004) compared with PTFE, 0.0%, and Permacol groups, 8.3%. Alloderm also had increased intimal thickness through the patch, 0.076 mm (p = 0.18), compared with PTFE, 0.026 mm, and Permacol groups, 0.024 mm. Vessel diameter through the patch showed the Alloderm group, 1.87 mm (p = 0.004), was significantly larger than both the Permacol, 1.41 mm, and PTFE groups, 1.28 mm. Furthermore, Alloderm showed leukocyte migration around the patch. Enzyme-linked immunosorbent assay for thrombin-antithrombin complex was only elevated for PTFE in the 7-day postoperative measurement but was not statistically different from the other groups. Permacol has characteristics to be an effective alternative for PTFE for patch arteriotomy repair in our rabbit model. Futher studies need to be conducted to investigate the potential of Permacol in vascular trauma. Alloderm is not a suitable alternative to PTFE for patch arteriotomy repair.

Membrane pore formation by pentraxin proteins from Limulus, the American horseshoe crab.

The pentraxins are a family of highly conserved plasma proteins of metazoans known to function in immune defence. The canonical members, C-reactive protein and serum amyloid P component, have been identified in arthropods and humans. Mammalian pentraxins are known to bind lipid bilayers, and a pentraxin representative from the American horseshoe crab, Limulus polyphemus, binds and permeabilizes mammalian erythrocytes. Both activities are Ca(2+)-dependent. Utilizing model liposomes and planar lipid bilayers, in the present study we have investigated the membrane-active properties of the three pentraxin representatives from Limulus and show that all of the Limulus pentraxins permeabilize lipid bilayers. Mechanistically, Limulus C-reactive protein forms transmembrane pores in asymmetric planar lipid bilayers that mimic the outer membrane of Gram-negative bacteria and exhibits a Ca(2+)-independent form of membrane binding that may be sufficient for pore formation.

Cerebral air embolism following removal of central venous catheter.

Cerebral air embolism occurs very seldom as a complication of central venous catheterization. We report a 57-year-old female with cerebral air embolism secondary to removal of a central venous catheter (CVC). The patient was treated with supportive measures and recovered well with minimal long-term injury. The prevention of air embolism related to central venous catheterization is discussed.

Removing barriers? An overview of the Canadian Access to Medicines Regime.

As a result of significant public health issues in the developing world, there has been a strong desire to increase access to available treatments. In 2005, Canada amended its Patent Act to create the Canadian Access to Medicines Regime ("CAMR") to provide a mechanism whereby a Canadian manufacturer could produce patented pharmaceutical products for export to countries experiencing public health crises. As one of the first countries to enact such a detailed legislative regime, Canada attempted to create a model for addressing the problems created by the intersection of public health and patents. In 2007, Rwanda indicated its intention to import an HIV-drug from the Canadian generic manufacture Apotex. Rwanda's application marked the first time a country had utilized the CAMR in order to obtain essential medicines. This article examines the Canadian CAMR model, its origins, and its effectiveness to date.

Use of parecoxib by continuous subcutaneous infusion for cancer pain in a hospice population.

OBJECTIVES: To characterise the use of the parenteral non-steroidal anti-inflammatory drug parecoxib when given by continuous subcutaneous infusion (CSCI) in a hospice population. Clinical experience suggests parecoxib CSCI may be of benefit in this population, but empirical evidence in relation to its safety and efficacy is lacking. METHODS: Retrospective chart review of patients with a cancer diagnosis receiving parecoxib CSCI from 2008 to 2013 at the Marie Curie Hospice, Belfast. Data were collected on treatment regime, tolerability and, in patients receiving at least 7 days treatment, baseline opioid dose and changes in pain scores or opioid rescue medication requirements. RESULTS: Parecoxib CSCI was initiated in 80 patients with a mean administration of 17.9 days (median 11, range 1-94). When used for a period of 7 days, there was a statistically significant reduction in pain scores (p=0.002) and in the number of rescue opioid doses required (p=0.001), but no statistically significant opioid-sparing effect (p=0.222). It was generally well tolerated, although gastrointestinal, renal adverse effects and local site irritation were reported. CONCLUSIONS: Parecoxib may have a valuable place in the management of cancer pain, especially towards the end of life when oral administration is no longer possible and CSCI administration is relied on. Further studies into the efficacy and tolerability of parecoxib CSCI are merited.

Histochemical evidence for lipid A (endotoxin) in eukaryote chloroplasts.

Lipopolysaccharide (LPS) (a.k.a., endotoxin) is an essential component of the outer leaflet of the outer membrane of gram-negative bacteria and is a potent activator of the innate immune system of animals. Lipid A, the glycolipid core of LPS, is the agent responsible for disease and death from gram-negative sepsis, an important cause of human mortality and morbidity. Although it is generally accepted that lipid A is restricted to the prokaryotes, recent efforts to purify molecules from green algae with structural features unique to lipid A have met with success. Furthermore, the vascular plant Arabidopsis thaliana has been found to contain genes that encode all of the enzymes of the biosynthetic pathway for lipid A. It is not known whether vascular plants synthesize lipid A or where lipid A might be located in the tissues. For the present study, we used affinity reagents for lipid A to probe green alga and tissues of the garden pea for a light microscopic localization of lipid A in these eukaryote cells. We find staining for lipid A in free-living and endosymbiotic green algae and in the chloroplasts of vascular plants, indicating that this molecule is not restricted to prokaryotes, but is found also in select eukaryotes.

Proteases and protease inhibitors: a balance of activities in host-pathogen interaction.

The immune system is the collection of effector molecules and cells of the host that act against invading parasites and their products. Secreted proteases serve important roles in parasitic metabolism and virulence and the several families of protein protease inhibitors of the plasma and blood cells play an important role in immunity by inactivating and clearing the protease virulence factors of parasites. The protease inhibitors are of two classes, the active-site inhibitors and the alpha2-macroglobulins. Inhibitors for the first class bind and inactivate the active site of the target protease. Proteins of the second class bind proteases by a unique molecular trap mechanism and deliver the bound protease to a receptor-mediated endocytic system for degradation in secondary lysosomes. Proteins of the alpha2-macroglobulin family are present in a variety of animal phyla, including the nematodes, arthropods, mollusks, echinoderms, urochordates, and vertebrates. A shared suite of unique functional characteristics have been documented for the alpha2-macroglobulins of vertebrates, arthropods, and mollusks. The alpha2-macroglobulins of nematodes, arthropods, mollusks, and vertebrates show significant sequence identity in key functional domains. Thus, the alpha2-macroglobulins comprise an evolutionarily conserved arm of the innate immune system with similar structure and function in animal phyla separated by 0.6 billion years of evolution.

Porcine dermal collagen (Permacol) for abdominal wall reconstruction.

OBJECTIVE: A review of Eisenhower Army Medical Center's experience using Permacol (Tissue Science Laboratories, Covington, Georgia) for the repair of abdominal wall defects. METHODS: Retrospective review of medical records of patients undergoing abdominal wall reconstruction with Permacol. RESULTS: From July 30, 2003 to February 12, 2005, 9 patients underwent repair of complicated fascial defects with Permacol. Indications for surgery included reoperative incisional hernia repair after removal of a infected mesh (3 patients), reconstruction of a fascial defect after resection of an abdominal wall tumor (2 patients), incisional hernia repair in a patient with a previous abdominal wall infection after a primary incisional hernia repair (1 patient), incisional hernia repair in a patient with an ostomy and an open midline wound (1 patient), emergent repair of incisional hernia with strangulated bowel and multiple intra-abdominal abscesses (1 patient), and excision of infected mesh and drainage of intra-abdominal abscess with synchronous repair of the abdominal wall defect (1 patient). At a median follow-up of 18.2 months, 1 recurrent hernia existed after intentional removal of the Permacol. This patient developed an abdominal wall abscess 7 months after hernia repair secondary to erosion from a suture. Overall, 1 patient developed exposure of the Permacol after a skin dehiscence. The wound was treated with local wound care, and the Permacol was salvaged. Despite the presence of contamination (wound classification II, III, or IV) in 5 of 9 patients (56%), no infectious complications occurred. CONCLUSION: Complex reconstruction of the abdominal wall can be associated with a high complication rate. Placement of a permanent prosthetic mesh in a contaminated field is associated with a high rate of wound infections and subsequent mesh removal. Permacol becomes incorporated by tissue ingrowth and neovascularization. Permacol is a safe and acceptable alternative to prosthetic mesh in the repair of complicated abdominal wall defects.