Manualized group cognitive behavioral therapy for social anxiety in first-episode psychosis: a randomized controlled trial.

BACKGROUND: Social anxiety (SA), a prevalent comorbid condition in psychotic disorders with a negative impact on functioning, requires adequate intervention relatively early. Using a randomized controlled trial, we tested the efficacy of a group cognitive-behavioral therapy intervention for SA (CBT-SA) that we developed for youth who experienced the first episode of psychosis (FEP). For our primary outcome, we hypothesized that compared to the active control of group cognitive remediation (CR), the CBT-SA group would show a reduction in SA that would be maintained at 3- and 6-month follow-ups. For secondary outcomes, it was hypothesized that the CBT-SA group would show a reduction of positive and negative symptoms and improvements in recovery and functioning. METHOD: Ninety-six patients with an FEP and SA, recruited from five different FEP programs in the Montreal area, were randomized to 13 weekly group sessions of either CBT-SA or CR intervention. RESULTS: Linear mixed models revealed that multiple measures of SA significantly reduced over time, but with no significant group differences. Positive and negative symptoms, as well as functioning improved over time, with negative symptoms and functioning exhibiting a greater reduction in the CBT-SA group. CONCLUSIONS: While SA decreased over time with both interventions, a positive effect of the CBT-SA intervention on measures of negative symptoms, functioning, and self-reported recovery at follow-up suggests that our intervention had a positive effect that extended beyond symptoms specific to SA.ClinicalTrials.gov identifier: NCT02294409.

Unique static discharge events on two CentriMag® (2nd Gen) ECMO patients causing console failure.

The use of ECMO for cardiovascular support continues to increase in the United States and around the world. It is not a benign endeavor as serious complications may occur. We present our experience of two second generation CentriMag® (Abbott formerly Thoratec Inc.) console failures that occurred while transporting the patients to other areas of the hospital. In each incident, the patients were immediately placed on back-up units and the transport continued. No patient complications could be attributed to the failures. An investigation by Abbott engineers traced the failure to a static build-up and discharge caused by a non-manufacturer-approved metal rod that was utilized to mount the external monitor. The static discharge caused a disruption of electrical continuity between the control system and the motor, stopping the motor as well as the monitoring system. Removal of the mounting rod prevented replication of the situation in the lab. We have removed the rod from our clinical units and have not experienced any other pump failures.

Laboratory Evaluation of Hemolysis and Systemic Inflammatory Response in Neonatal Nonpulsatile and Pulsatile Extracorporeal Life Support Systems.

The objective of this study was to compare the systemic inflammatory response and hemolytic characteristics of a conventional roller pump (HL20-NP) and an alternative diagonal pump with nonpulsatile (DP3-NP) and pulsatile mode (DP3-P) in simulated neonatal extracorporeal life support (ECLS) systems. The experimental neonatal ECLS circuits consist of a conventional Jostra HL20 roller pump or an alternative Medos DP3 diagonal pump, and Medos Hilite 800 LT hollow-fiber oxygenator with diffusion membrane. Eighteen sterile circuits were primed with freshly donated whole blood and divided into three groups: conventional HL20 with nonpulsatile flow (HL20-NP), DP3 with nonpulsatile flow (DP3-NP), and DP3 with pulsatile flow (DP3-P). All trials were conducted for durations of 12 h at a flow rate of 500 mL/min at 36°C. Simultaneous blood flow and pressure waveforms were recorded. Blood samples were collected to measure plasma-free hemoglobin (PFH), human tumor necrosis factor-alpha, interleukin-6 (IL-6), and IL-8, in addition to the routine blood gas, lactate dehydrogenase, and lactic acid levels. HL20-NP group had the highest PFH levels (mean ± standard error of the mean) after a 12-h ECLS run, but the difference among groups did not reach statistical significance (HL20-NP group: 907.6 ± 253.1 mg/L, DP3-NP group: 343.7 ± 163.2 mg/L, and DP3-P group: 407.6 ± 156.6 mg/L, P = 0.06). Although there were similar trends but no statistical differences for the levels of proinflammatory cytokines among the three groups, the HL20-NP group had much greater levels than the other groups (P > 0.05). Pulsatile flow generated higher total hemodynamic energy and surplus hemodynamic energy levels at pre-oxygenator and pre-clamp sites (P < 0.01). Our study demonstrated that the alternative diagonal pump ECLS circuits appeared to have less systemic inflammatory response and hemolysis compared with the conventional roller pump ECLS circuit in simulated neonatal ECLS systems. Pulsatile flow delivered more hemodynamic energy to the pseudo-patient without increased odds of hemolysis compared with the conventional, nonpulsatile roller pump group.

Predictors of treatment attrition of cognitive health interventions in first episode psychosis.

AIM: Dropping out of psychological interventions is estimated to occur in up to a third of individuals with psychosis. Given the high degree of attrition in this population, identifying predictors of attrition is important to develop strategies to retain individuals in treatment. We observed a particularly high degree of attrition (48%) in a recent randomized controlled study assessing cognitive health interventions for first-episode psychosis participants with comorbid social anxiety. Due to the importance of developing interventions for social anxiety in first episode psychosis, the aim of the present study was to identify putative predictors of attrition through a secondary analysis of data. METHODS: Participants (n = 96) with first episode psychosis and comorbid social anxiety were randomized to receive cognitive behavioural therapy for social anxiety or cognitive remediation. Differences between completers and non-completers (<50% intervention completed) were compared using t-tests or chi-square analyses; statistically significant variables were entered into a multivariate logistic regression model. RESULTS: Non-completers tended to be younger, had fewer years of education and had lower levels of social anxiety compared to completers. Lower baseline social anxiety and younger age were statistically significant predictors of non-completion in the logistic regression model. CONCLUSIONS: Age and social anxiety were predictors of attrition in cognitive health interventions in first episode psychosis populations with comorbid social anxiety. In the ongoing development of social anxiety interventions for this population, future studies should investigate specific engagement strategies, intervention formats and outcome monitoring to improve participant retention in treatment.

Hemodynamic evaluation of the Avalon Elite bi-caval dual lumen cannulae.

In previous studies, we have evaluated the hemodynamic properties of selected oxygenators, pumps (centrifugal and roller), and single lumen cannulae. Because the dual lumen cannulae are widely used in veno-venous extracorporeal life support (ECLS) and are receiving popularity due to their advantages over the single lumen cannulae, we evaluated the flow ranges and pressure drops of three different sizes of Avalon Elite dual lumen cannulae (13Fr, 16Fr, and 19Fr) in a simulated neonatal ECLS circuit primed with human blood. The experimental ECLS circuit was composed of a RotaFlow centrifugal pump, a Capiox BabyRX05 oxygenator, 3 ft of 1/4-in venous and arterial line tubing, an Avalon Elite dual lumen cannula, and a soft reservoir as a pseudo-right atrium. All experiments were conducted at 37°C using an HCU 30 heater-cooling unit and with human blood at a hematocrit of 36%. The blood pressure in the pseudo-right atrium was continuously monitored and maintained at 4-5 mm Hg. For each cannula, pump flow rates and pressures at both the arterial and venous sides were recorded at revolutions per minute (RPMs) from 1750 to 3750 in 250 intervals. For each RPM, six data sets were recorded for a total of 162 data sets. The total volume of the system was 300 mL. The flow range for the 13Fr, 16Fr, and 19Fr cannulae were from 228 to 762 mL/min, 478 to 1254 mL/min, and 635 to 1754 mL/min, respectively. The pressure drops at the arterial side were higher than the venous side at all tested conditions except at 1750 rpm for the 19Fr cannula. The results of this study showed the flow ranges and the pressure drops of three different sized dual lumen cannulae using human blood, which is more applicable in clinical settings compared with evaluations using water.

Air-handling capabilities of blood cardioplegia delivery systems in a simulated pediatric model.

Blood cardioplegia delivery systems are employed in most pediatric open heart cases to arrest the heart and keep it preserved during aortic cross-clamping. They are also used as part of a modified ultrafiltration system at the end of cardiopulmonary bypass. We evaluated and compared the air-handling capabilities of different types of blood cardioplegia delivery devices. A simple circuit incorporating a cardiotomy reservoir, a roller pump, a cardioplegia test system, and two emboli detection and classification sensors were used to investigate the air-handling capabilities of the following cardioplegia delivery systems: GISH Vision, Maquet Plegiox, Medtronic Trillium MYOtherm XP, Sorin Group BCD Vanguard, Sorin Group CSC14, and Terumo Sarns Conducer and Bubble Trap. The 0.25-in. circuit was primed with 400mL of Lactated Ringer's. Outdated packed red blood cells were added to obtain a hematocrit of 24-28%. System pressure was maintained at 50mmHg. Air (0.1, 0.3, 0.5mL) was injected at a speed of 0.1mL/s into the circuit just after the pump head. Gaseous microemboli (GME) were measured prior to the cardioplegia system and after the device to evaluate the air-handling characteristics. The tests were run at 100, 200, and 400mL/min blood flow for both 4 and 37°C. There were no significant differences among the groups when comparing precardioplegia delivery system GME, thus demonstrating that all devices received the same amount of injected air. When comparing the groups for postcardioplegia delivery system GME, significant differences were noted especially at the 400mL/min blood flow rate. These results suggest that for the devices compared in this study, the Maquet Plegiox and the Medtronic Trillium MYOtherm XP eliminated GME the best.

The new role of the perfusionist in adult extracorporeal life support.

Adult and pediatric extracorporeal life support (ECLS) has been transformed by the European(1) and Australian( 2) experiences with a reduction of the circuit to its most basic form (Figure 1). Many factors have converged at this point in time to allow us to offer this support. The availability in the U.S.A. of an advanced oxygenator (Quadrox(D)) (Maquet Inc., Bridgewater, NJ), long-term centrifugal pumps and circuit coatings offers us the means to provide ECLS. The other equally important factor is the intensivist trained in extracorporeal therapies. Once the intensive care unit registered nurse (ICU RN) is trained to safely and effectively manage both the patient and ECLS circuit, this support may be offered. The perfusionist is in an unique position to educate and mentor the ICU RN in ECLS. There is, perhaps, no one in a better position to explain this equipment and its uses in an interdisciplinary-oriented pediatric and adult ECLS program than a perfusionist.

Translational research in pediatric extracorporeal life support systems and cardiopulmonary bypass procedures: 2011 update.

Over the past 6 years at Penn State Hershey, we have established the pediatric cardiovascular research center with a multidisciplinary research team with the goal to improve the outcomes for children undergoing cardiac surgery with cardiopulmonary bypass (CPB) and extracorporeal life support (ECLS). Due to the variety of commercially available pediatric CPB and ECLS devices, both in vitro and in vivo translational research have been conducted to achieve the optimal choice for our patients. By now, every component being used in our clinical settings in Penn State Hershey has been selected based on the results of our translational research. The objective of this review is to summarize our translational research in Penn State Hershey Pediatric Cardiovascular Research Center and to share the latest results with all the interested centers.

Delivery of gaseous microemboli with vacuum-assisted venous drainage during pulsatile and nonpulsatile perfusion in a simulated neonatal cardiopulmonary bypass model.

This study investigated delivery of gaseous microemboli (GME) with vacuum-assisted venous drainage (VAVD) at various flow rates and perfusion modes in a simulated neonatal cardiopulmonary bypass (CPB) model. Four transducers (postpump, postoxygenator, postfilter, and venous line) of the emboli detection and classification (EDAC) quantifier were inserted into the CPB circuit to detect and classify GME. Four negative pressures (0, -15, -30, and -45 mm Hg), 3 flow rates (750, 1,000, and 1,250 ml/min), and 2 perfusion modes (pulsatile and nonpulsatile) were tested. After injecting 10 ml air into the venous line via an 18G needle, 2-minute segments of data were recorded simultaneously through 4 transducers. This entire process was repeated 6 times for each unique combination of pressure, flow rate, and perfusion mode, yielding a total of 144 experiments. Independent of perfusion mode and flow rate, the use of VAVD with higher negative pressures delivered significantly more GME at the postpump site. There was no difference in delivery at the postfilter site. The majority of GME were trapped by the Capiox Baby-RX hollow-fiber membrane oxygenator. Compared with nonpulsatile flow, pulsatile flow transferred more GME at the postpump site at all 3 flow rates. Our results suggest that VAVD with higher negative pressures, increased flow rates, and pulsatile flow could deliver more GME at the postpump site when a fixed volume air is introduced into the venous line. The Emboli Detection and Classification Quantifier is a sensitive tool for the detection and classification of GME as small as 10 microns in this simulated neonatal model.

Comparison of hollow-fiber membrane oxygenators with different perfusion modes during normothermic and hypothermic CPB in a simulated neonatal model.

PURPOSE: The objectives of this investigation were (1) to compare two hollow-fiber membrane oxygenators (Capiox Baby RX versus Lilliput 1-D901) in terms of pressure drops and surplus hemodynamic energy (SHE) during normothermic and hypothermic cardiopulmonary bypass (CPB) in a simulated neonatal model; and (2) to evaluate pulsatile and non-pulsatile perfusion modes for each oxygenator in terms of SHE levels. METHODS: In a simulated patient, CPB was initiated at a constant pump flow rate of 500 mL/min. The circuit was primed with fresh bovine blood. After 5 min of normothermic CPB, the pseudo-patient was cooled down to 25 degrees C for 10 min followed by 30 min of hypothermic CPB. The pseudo-patient then underwent 10 min of rewarming and 5 min of normothermic CPB. At each experimental site (pre- and post-oxygenator and pre-aortic cannula), SHE was calculated using the following formula {SHE (ergs/cm3) = 1332 [((integralfpdt)/(integralfdt)) - mean arterial pressure]} (f = pump flow and p = pressure). A linear mixed-effects model that accounts for the correlation among repeated measurements was fit to the data to assess differences in SHE between oxygenators, pumps, and sites. Tukey's multiple comparison procedure was used to adjust p-values for post-hoc pairwise comparisons. RESULTS: The pressure drops in the Capiox group compared to the Lilliput group were significantly lower during hypothermic non-pulsatile (21.3 +/- 0.5 versus 50.7 +/- 0.9 mmHg, p < 0.001) and pulsatile (22 +/- 0.0 versus 53.3 +/- 0.5 mmHg, p < 0.001) perfusion, respectively. Surplus hemodynamic energy levels were significantly higher in the pulsatile group compared to the non-pulsatile group, with Capiox (1655 +/- 92 versus 10008 +/- 1370 ergs/cm3, p < 0.001) or Lilliput (1506 +/- 112 versus 7531 +/- 483 ergs/cm3, p < 0.001) oxygenators. During normothermic CPB, both oxygenators had patterns similar to those observed under hypothermic conditions. CONCLUSIONS: The Capiox oxygenator had a significantly lower pressure drop in both pulsatile and non-pulsatile perfusion modes. For each oxygenator, the SHE levels were significantly higher in the pulsatile mode.