One-Lung Ventilation and Postoperative Pulmonary Complications After Major Lung Resection Surgery. A Multicenter Randomized Controlled Trial.

OBJECTIVES: The effect of one-lung ventilation (OLV) strategy based on low tidal volume (TV), application of positive end-expiratory pressure (PEEP), and alveolar recruitment maneuvers (ARM) to reduce postoperative acute respiratory distress syndrome (ARDS) and pulmonary complications (PPCs) compared with higher TV without PEEP and ARM strategy in adult patients undergoing lobectomy or pneumonectomy has not been well established. DESIGN: Multicenter, randomized, single-blind, controlled trial. SETTING: Sixteen Italian hospitals. PARTICIPANTS: A total of 880 patients undergoing elective major lung resection. INTERVENTIONS: Patients were randomized to receive lower tidal volume (LTV group: 4 mL/kg predicted body weight, PEEP of 5 cmH2O, and ARMs) or higher tidal volume (HTL group: 6 mL/kg predicted body weight, no PEEP, and no ARMs). After OLV, until extubation, both groups were ventilated using a tidal volume of 8 mL/kg and a PEEP value of 5 cmH2O. The primary outcome was the incidence of in-hospital ARDS. Secondary outcomes were the in-hospital rate of PPCs, major cardiovascular events, unplanned intensive care unit (ICU) admission, in-hospital mortality, ICU length of stay, and in-hospital length of stay. MEASUREMENTS AND MAIN RESULTS: ARDS occurred in 3 of 438 patients (0.7%, 95% CI 0.1-2.0) and in 1 of 442 patients (0.2%, 95% CI 0-1.4) in the LTV and HTV group, respectively (Risk ratio: 3.03 95% CI 0.32-29, p = 0.372). Pulmonary complications occurred in 125 of 438 patients (28.5%, 95% CI 24.5-32.9) and in 136 of 442 patients (30.8%, 95% CI 26.6-35.2) in the LTV and HTV group, respectively (risk ratio: 0.93, 95% CI 0.76-1.14, p = 0.507). The incidence of major complications, in-hospital mortality, and unplanned ICU admission, ICU and in-hospital length of stay were comparable in both groups. CONCLUSIONS: In conclusion, among adult patients undergoing elective lung resection, an OLV with lower tidal volume, PEEP 5 cmH2O, and ARMs and a higher tidal volume strategy resulted in low ARDS incidence and comparable postoperative complications, in-hospital length of stay, and mortality.

Multiple Electrode Aggregometry After Cardiopulmonary Bypass to Assess Platelet (Dys)-Function and Transfusion Threshold: A Concordance Study.

OBJECTIVE: Cardiac surgery patients have a high risk of postoperative bleeding. Historically, the platelet count has been one of the main parameters used to establish the need for platelet transfusions, and the recent introduction of point-of-care tests for platelet function has allowed clinicians to rationalize platelet transfusion needs by assessing the platelet (dys-)function of the patient. For the present study, the authors evaluated how the introduction of one of these systems-the adenosine diphosphate (ADP) test, performed using a Multiplate electrode analyzer (Roche Diagnostics, Basel, Switzerland)-into their clinical practice had modified their platelet transfusion practice. The relationship between the platelet count and the functional evaluation of platelet aggregation (via the ADP test) also was examined. DESIGN: This was a retrospective, single-center, observational study. SETTING: Cardiac surgery department of a tertiary care center in North-east Italy. PARTICIPANTS: Cardiac surgery patients requiring cardiac bypass in 2017 and 2019. INTERVENTIONS: The primary outcome was to compare platelet transfusion practice before and after the implementation of a platelet function test (the ADP test) into the institution's transfusion algorithm, which replaced the platelet count as the trigger. Secondary outcomes were assessing whether the incorporation of the ADP test into their transfusion algorithm brought about a reduction in the frequency of platelet transfusions compared with previous rates (when only platelets counts were used); assessing patient blood loss in the first 12 postoperative hours; and ascertaining the percentage of patients requiring surgical reexplorations. MEASUREMENTS AND MAIN RESULTS: The study comprised 110 patients undergoing cardiac surgery from the platelet count period (2017) and 110 patients from the ADP test period (2019). Agreement between platelet counts versus ADP tests in determining the need for platelet transfusion was moderate (κ = 0.483; 95% confidence interval [CI] 0.239-0.728), and the general linear regression relationship between platelet counts and the ADP test (Akaike information criterion = 2536; p < 0.001) was determined. Since the introduction of ADP testing, a highly significant reduction in platelet transfusions has occurred: 41.82% (platelet count period) versus 13.64% (ADP test period) (p < 0.001); average blood loss in the 12 hours postsurgery also was less in the ADP test period (p < 0.001) at 300 mL (95% CI 150-730) compared with 440 mL in the platelet count period (95% CI 135-900). Furthermore, a decreasing trend was observed in the number of patients requiring reexploration to optimize hemostasis in the first 12 hours postsurgery (6.36% v 2.73%); however, this trend did not achieve statistical significance (p = 0.195). CONCLUSION: The application of new Multiplate analyzer technologies, like the ADP test, have the potential to reduce platelet transfusion rates in cardiac surgery patients compared with the use of platelet counts alone; this point-of-care test may constitute an important strategy to help spare the use of allogeneic blood products. Additional studies are needed to confirm this trend and establish the best cutoff values to apply.

Neurobiological and clinical effect of metacognitive interpersonal therapy vs structured clinical model: study protocol for a randomized controlled trial.

BACKGROUND: Borderline Personality Disorder (BPD) is a complex and debilitating disorder, characterized by deficits in metacognition and emotion dysregulation. The "gold standard" treatment for this disorder is psychotherapy with pharmacotherapy as an adjunctive treatment to target state symptoms. The present randomized clinical trial aims to assess the clinical and neurobiological changes following Metacognitive Interpersonal Therapy (MIT) compared with Structured Clinical Management (SCM) derived from specific recommendations in APA (American Psychiatric Association) guidelines for BPD. METHODS: The study design is a randomized parallel controlled clinical trial and will include 80 BPD outpatients, aged 18-45 enrolled at 2 recruitment centers. Primary outcome will be the clinical change in emotion regulation capacities assessed with the Difficulties in Emotion Regulation Scale (DERS). We will also investigated the effect of psychotherapy on metacognitive abilities and several clinical features such as BPD symptomatology, general psychopathology, depression, personal functioning, and trait dimensions (anger, impulsivity, alexithymia). We will evaluate changes in brain connectivity patterns and during the view of emotional pictures. A multidimensional assessment will be performed at the baseline, at 6, 12, 18 months. We will obtain structural and functional Magnetic Resonance Images (MRIs) in MIT-Treated BPD (N = 30) and SCM-treated BPD (N = 30) at baseline and after treatment, as well as in a group of 30 healthy and unrelated volunteers that will be scanned once for comparison. DISCUSSION: The present study could contribute to elucidate the neurobiological mechanisms underlying psychotherapy efficacy. The inclusion of a multidisciplinary study protocol will allow to study BPD considering different features that can affect the treatment response and their reciprocal relationships. TRIAL REGISTRATION: NCT02370316 . Registered 02/24/2015.

Perfectionism and Personality Disorders as Predictors of Symptoms and Interpersonal Problems.

Maladaptive perfectionism is a common factor in many disorders and is correlated with some personality dysfunctions. Less clear is how dimensions, such as concern over mistakes, doubts about actions, and parental criticism, are linked to overall suffering. Additionally, correlations between perfectionism and personality disorders are poorly explored in clinical samples. In this study we compared a treatment seeking individuals (n=93) and a community sample (n=100) on dimensions of maladaptive perfectionism, personality disorders, symptoms, and interpersonal problems. Results in both samples revealed maladaptive perfectionism was strongly associated with general suffering, interpersonal problems, and a broad range of personality disordered traits. Excessive concern over one's errors, and to some extent doubts about actions, predicted unique additional variance beyond the presence of personality pathology in explaining symptoms and interpersonal problems.

The adolescent emotional coping after an earthquake: a risk factor for suicidal ideation.

The study aims to investigate the relationship of suicidal ideation with coping and resilience in a sample of adolescents who survived an earthquake. Three hundred forty-three adolescents who had experienced the L'Aquila earthquake were investigated for a screening distinguishing Suicidal Screen-Negative (SSN) from the Positive (SSP) subjects. Resilience Scale for Adolescents (READ) and Brief Cope were administered. Emotion-focused coping score was significantly higher in SSP subjects. In the SSN but not in the SSP sample the READ total score correlated with problem-focused total score. A positive correlation was seen between emotion-focused and problem-focused scores in both samples, with a higher coefficient in SSP sample. Externalising problems and maladaptive behaviours can arise in adolescents exposed to traumatic events. Attention should be paid in reducing risk factors and in the development of psychological abilities, improving the coping strategies that can protect from emotional despair and suicidal ideation.

Spirituality and religiosity in the aftermath of a natural catastrophe in Italy.

The aim of this study is to assess the influence of spirituality and religiousness on the psychological traumatic effects of a catastrophic event in a population that had been exposed to an earthquake compared with a control population that had not been exposed. A total of 901 people have been evaluated using: (1) Brief Multidimensional Measure of Religiousness/Spirituality; (2) Impact of Event Scale and (3) Trauma and Loss Spectrum-Self Report (TALS-SR). Self-perceptions of spirituality and religiousness were used to rank the samples, distinguishing between spiritual and religious, spiritual-only, religious-only and neither spiritual nor religious groups. The sample that had experienced the earthquake showed lower scores in spiritual dimension. The religious-only group of those who were exposed to the earthquake demonstrated TALS-SR re-experiencing and arousal domain scores similar to the population that was not exposed. A weakening of spiritual religiosity in people having difficulty coping with trauma is a consistent finding. We further observed that the religious dimension helped to buffer the community against psychological distress caused by the earthquake. The religiosity dimension can positively affect the ability to cope with traumatic experiences.

Acute acquired immune thrombocytopenia after cardiac surgery: A challenging case.

Thrombocytopenia is a common condition that recognizes an infinite number of possible causes, especially in specific settings like the one covered in this case report: the postoperative period of cardiac surgery. We report a case of an old male with multiple comorbidities who underwent a coronary angioplasty procedure and aortic valve replacement. He showed severe thrombocytopenia in the postoperative days. Differential diagnosis required a big effort, also for the experts in the field. Our goal was to aggressively treat the patient with prednisolone, platelets, and intravenous immunoglobulins to maximize the prognosis. Our patient developed no complications and was discharged successfully.

Metacognitive interpersonal therapy in borderline personality disorder: Clinical and neuroimaging outcomes from the CLIMAMITHE study-A randomized clinical trial.

Different psychotherapeutic approaches demonstrated their efficacy but the possible neurobiological mechanism underlying the effect of psychotherapy in borderline personality disorder (BPD) patients is poorly investigated. We assessed the effects of metacognitive interpersonal therapy (MIT) on BPD features and other dimensions compared to structured clinical management (SCM). We also assessed changes in amygdala activation by viewing emotional pictures after psychotherapy. One hundred forty-one patients were referred and 78 BPD outpatients were included and randomized to MIT or SCM. Primary outcome was emotional dysregulation assessed with the Difficulties in Emotion Regulation Scale (DERS). We also assessed BPD symptomatology, number of PD criteria, metacognitive abilities, state-psychopathology, depression, impulsiveness, interpersonal functioning, and alexithymia. A subset of 60 patients underwent functional magnetic resonance imaging before and after 1 year of psychotherapy to assess amygdala activation by viewing standardized emotional pictures (secondary outcome). DERS scores decreased in both groups (time effect p < .001). The Cohen's d effect size for change (baseline posttreatment) on DERS was very large (d = 0.84) in MIT, and large (d = 0.76) in SCM. Both groups significantly improved in depressive symptoms, state-psychopathology, alexithymia, and interpersonal functioning. MIT showed larger effect on metacognitive functions than SCM (Time × Group p < .001). Both interventions showed a significant effect on BPD symptomatology although SCM group showed a larger decrease. On the contrary, MIT group showed larger decrease in impulsivity and number of PD criteria. Interestingly, both MIT and SCM modulated amygdala activation in BPD patients. MIT is a valid and effective psychotherapy for BPD with an impact on amygdala activation. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

How much stress is needed to increase vulnerability to psychosis? A community assessment of psychic experiences (CAPE) evaluation 10 months after an earthquake in L'Aquila (Italy).

Since severe stress can induce mental disorder symptoms that interact with vulnerability factors, the Community Assessment of Psychic Experiences (CAPE) was evaluated in a population of 419 young adults who survived an earthquake; results were compared to a database of 1,057 'non-exposed' subjects. Unexpectedly, earthquake survivors showed lower CAPE scores for 'small' to 'medium' effect size. Post-trauma positive changes or re-appraisal for successful adaptation may explain these findings.

Temperament and Character Inventory-R (TCI-R) and Big Five Questionnaire (BFQ): convergence and divergence.

This study evaluated the correspondence between measures of two competing theories of personality, the five-factor model as measured by the Big Five Questionnaire (BFQ), and Cloninger's psychobiological theory measured by the Temperament and Character Inventory-Revised (TCI-R). A sample of 900 Italian participants, balanced with respect to sex (393 men and 507 women), and representative of the adult population with respect to age (range 18 to 70 years; M = 39.6, SD = 15.7) completed the TCI-R and the Big Five Questionnaire. All TCI-R personality dimensions except Self-Transcendence were moderately correlated with one or more of the Big Five dimensions (from r = .40 to .61), and the two instruments showed areas of convergence. However, the differences outweighed the similarities, indicating that these current conceptualizations and measures of personality are somewhat inconsistent with each other.

Aberrant Structural Connectivity of the Triple Network System in Borderline Personality Disorder Is Associated with Behavioral Dysregulation.

BACKGROUND: Core symptoms of Borderline Personality Disorder (BPD) are associated to aberrant connectivity of the triple network system (salience network [SN], default mode network [DMN], executive control network [ECN]). While functional abnormalities are widely reported, structural connectivity (SC) and anatomical changes have not yet been investigated. Here, we explored the triple network's SC, structure, and its association with BPD clinical features. METHODS: A total of 60 BPD and 26 healthy controls (HC) underwent a multidomain neuropsychological and multimodal MRI (diffusion- and T1-weighted imaging) assessment. Metrics (fractional anisotropy [FA], mean diffusivity [MD], cortical thickness) were extracted from SN, DMN, ECN (triple network), and visual network (control network) using established atlases. Multivariate general linear models were conducted to assess group differences in metrics and associations with clinical features. RESULTS: Patients showed increased MD in the anterior SN, dorsal DMN, and right ECN compared to HC. Diffusivity increases were more pronounced in patients with higher behavioral dysregulation, i.e., suicidal attempting, self-harm, and aggressiveness. No differences were detected in network structure. CONCLUSIONS: These results indicate that the triple network system is impaired in BPD at the microstructural level. The preferential involvement of anterior and right-lateralized subsystems and their clinical association suggests that these abnormalities could contribute to behavioral dysregulation.

Platelet Dysfunction in Cardiac Surgery: When is the Best Time to Assess It? An Observational Single Center Study.

Purpose. Cardiac surgery is characterized by a high risk of complications related to perioperative bleeding. Guidelines suggest the use of local algorithms based on perioperative point-of-care tests to assess and manage potential coagulation abnormalities. We investigated whether heparin reversal administration affects the adenosine-5-diphosphate (ADP) test values, thus identifying the earliest time point following cardio-pulmonary bypass that permits the promptest detection and treatment of potential platelet dysfunctions. Methods. This was a retrospective, single-center, observational study enrolling cardiac surgery patients requiring cardiac bypass. ADP-tests at 4 different time-points during surgery (T0: baseline, T1: at aortic de-clamping, T2: 10 minutes after protamine administration, and T3: at the end of surgery) were performed. Results. 63 patients undergoing elective cardiac surgery were studied. Baseline ADP-test values were almost constantly greater than intraoperative values, and end of surgery values were often greater than previous intraoperative values. The only difference that proved to be not statistically significant was between T1 and T2, with a clinically insignificant mean difference of -.2 U (95%CI of difference: -6.9 - 6.5 U). There was no correlation between the variation in ADP-test values pre- and post-protamine administration and the protamine-to-heparin ratio. Conclusion. The results of the present study support the hypothesis that the ADP-test could be performed early, at aortic de-clamping before protamine administration. This approach allows for the promptest assessment of a potential impairment in platelet function, and its timely correction.

Deconstructing theory of mind in schizophrenia.

First- and second-order theory of mind (ToM) abilities seem to form a hierarchy of mind states within the same construct. If so, no ability in higher comprehension of intentionality would be possible when the previous one is failing. The purpose of the study is to investigate this hierarchy in a sample of schizophrenic subjects. Insofar as ToM defines processes involved in a multi-level social cognitive processing, they could be part of a scenario of specialized areas performing different parallel computations. Therefore, we further investigated the relationship of ToM scores to metacognitive indexes, widely demonstrated to be involved in social cognition, symptomatology and global functionality, in two independent samples of subjects with schizophrenia. Thirty-eight subjects with schizophrenia were preliminarily examined for first- and second-order ToM, using only one story in each order. Cross-tabulation of subjects according to their answers revealed that 13.2% of subjects gave incorrect answers to ToM I but correct answers to ToM II. A more extensive examination of first- and second-order ToM in a sample of 42 subjects with schizophrenia was then performed. The results confirmed the existence of a group of subjects (11.9%) scoring incorrectly at ToM I but correctly at ToM II, which is unexplainable if the hierarchical hypothesis were true. While both ToM scores were highly correlated with metacognitive scores on the Positive and Negative Syndrome Scale (PANSS), for both positive and negative clusters, and only second-order ToM was correlated with scores on the Global Assessment of Function (GAF). On the other hand, meta-cognitive indexes were correlated with both PANSS and GAF scores. First-order ToM was found to play an essential role in determining clinical severity. ToM I and II order scores share a minor part of variance. Instead of hierarchically ordered mind states, first- and second-order intentionality can represent different constructs. The ability to 'understand others', i.e. ToM, can be dissociable, suggesting the existence of an interconnected network of different constructs deputed to an adequate understanding and management of the social world complexity.

A quantitative analysis of antidepressant and antipsychotic prescriptions following an earthquake in Italy.

Because natural disasters provoke an increase in mental and medical disorders in survivors, an increase in psychotropic prescriptions has been observed following disasters. This study assesses the pharmacoepidemiology of antidepressant and antipsychotic drug prescriptions after an earthquake in Italy by using an administrative database. Statins and diabetic medications served as control medications. Comparison of the rates in the 6 months after the earthquake to the same period one year before revealed a 37% increase of new prescriptions for antidepressants and a 129% increase for antipsychotic prescriptions. Older age and female gender was associated with the increased number of prescriptions.

Esoteric power, useless, useful: considerations about dreams in cognitive-behavioural therapy.

For a long time dreamwork in cognitive-behavioural therapy (CBT) was considered useless and as a technique specific to psychodynamic approaches, consequently overlooked in the treatment course. In the last twenty years, thanks to the contribution of neuroscience studies on sleep and dreams, dreams joined the attention and interest of authors belonging to the CBT field. The central feature of dreamwork in CBT is the abandonment of the exploration of latent meaning, which is instead considered in continuity with the waking life. Dreams reflect a patient's view of self, world, and future, and are subject to the same cognitive biases as the waking state. Consequently, the dreamwork can be used to get information about the patient, overcome impasses in therapy, restructure self and interpersonal schemas, and stimulate reflective functioning. Therefore, guidelines have been defined and models of well-articulated intervention in terms of process and content, replicable and teachable through specific training structured. This paper aims to provide an overview of theories regarding the use of dreams in CBT, from a clinical perspective, from Beck to more recent proposals.

A Rare Cause of Respiratory Insufficiency in a 30-Year-Old Transgender Woman.

CASE PRESENTATION: A 30-year-old transgender woman who was HIV positive presented to the ED with progressive severe dyspnea and hemoptysis that started 1 day earlier. The patient was undergoing antiretroviral therapy with emtricitabine-rilpivirine-tenofovir with good compliance and feminizing hormone therapy with cyproterone acetate. She was otherwise healthy and was not taking any other medications.

Emotion Regulation, Physical Diseases, and Borderline Personality Disorders: Conceptual and Clinical Considerations.

This perspective paper aims at discussing theoretical principles that could explain how emotion regulation and physical diseases mutually influence each other in the context of borderline personality disorder (BPD). Furthermore, this paper discusses the clinical implications of the functional relationships between emotion regulation, BPD and medical conditions considering dialectical behavior therapy (DBT) as a well-validated therapeutic intervention, which encompasses these issues. The inflexible use of maladaptive emotion regulation strategies (e.g., suppression, experiential avoidance, and rumination) might directly increase the probability of developing physical diseases through a physiological pathway, or indirectly through a behavioral pathway. Some metabolic and chronic medical conditions could significantly impact emotional functioning through biological alterations involved in emotion regulation. Several empirical studies have shown high co-occurrence rates between BPD and several chronic physical diseases, especially ones linked to emotion-based maladaptive behaviors. DBT addresses physical diseases reported by individuals with BPD reducing problematic behaviors functionally associated to emotion dysregulation and identifying physical health as a goal for Building a Life Worth Living.

Metacognition as a Predictor of Improvements in Personality Disorders.

Personality Disorders (PDs) are particularly hard to treat and treatment drop-out rates are high. Several authors have agreed that psychotherapy is more successful when it focuses on the core of personality pathology. For this reason, therapists dealing with PDs need to understand the psychopathological variables that characterize this pathology and exactly what contributes to maintaining psychopathological processes. Moreover, several authors have noted that one key problem that characterizes all PDs is an impairment in understanding mental states - here termed metacognition - which could also be responsible for therapy failures. Unfortunately, a limited number of studies have investigated the role of mentalization in the process of change during psychotherapy. In this paper, we assume that poor metacognition corresponds to a core element of the general pathology of personality, impacts a series of clinical variables, generates symptoms and interpersonal problems, and causes treatment to be slower and less effective. We explored whether changes in metacognition predicted an improvement among different psychopathological variables characterizing PDs; 193 outpatients were treated at the Third Center of Cognitive Psychotherapy in Rome, Italy, and followed a structured path tailored for the different psychopathological variables that emerged from a comprehensive psychodiagnostic assessment that considered patients' symptoms, metacognitive abilities, interpersonal relationships, personality psychopathology, and global functioning. The measurements were repeated after a year of treatment. The results showed that changes in metacognitive abilities predicted improvements in the analyzed variables.

Opioids prescriptions in pain therapy and risk of addiction: a one-year survey in Italy. Analysis of national opioids database.

BACKGROUND: An "epidemic use" of legal opioids in the USA and other countries has been reported in the last 15 years. We have analysed the database of the Italian Ministry of Health regarding the prescription of opioids for pain management to verify the trend of opioids uses in Italy. METHODS: The amount of opioids prescribed for every single Italian patient in 2013 was anonymously recorded and transformed in daily MED (morphine equivalent dose). We considered every monthly percentage increase of MED during the entire period of chronic therapy for each patient. RESULTS: Classes of dosage increase for all patients in chronic therapy, distinguished between cancer and non-cancer ones, were created. We deduce that decreases or increases of small proportions prevailed in the observation period. CONCLUSIONS: The opioids "plague" that is striking the USA is not registered in Italy during the observation period. The reasons might be due to the innovative and effective law 38/2010 and a health care system able to guarantee appropriate prescriptions for major analgesics.