Investigating the impact of alliance-focused training on interpersonal process and therapists' capacity for experiential reflection.

OBJECTIVE: In this article we present preliminary findings from a research program designed to investigate the value of alliance-focused training (AFT), a supervision approach designed to enhance therapists' ability to work constructively with negative therapeutic process. METHOD: In the context of a multiple baseline design, all therapists began treating their patients using cognitive therapy and then joined AFT supervision groups at either session 8 or 16 of a 30 session protocol. Study I investigated the impact of AFT on patient and therapist interpersonal process as assessed through the Structural Analysis of Social Behavior (SASB). Study 2 investigated the impact of AFT on therapists' tendency to reflect on their relationships with their patients in an experientially grounded fashion, as assessed via the Experiencing Scale (EXP). Since one of the goals of AFT is to train therapists to use their own emerging feelings as important clues regarding what may be taking place in the therapeutic relationship, we hypothesized that they would show increased levels of EXP after undergoing AFT. RESULTS AND CONCLUSION: The results of both studies 1 and 2 were for the most part consistent with hypotheses. Implications and future research directions are discussed.

Accelerating spirocyclic polyketide synthesis using flow chemistry.

Over the past decade, the integration of synthetic chemistry with flow processing has resulted in a powerful platform for molecular assembly that is making an impact throughout the chemical community. Herein, we demonstrate the extension of these tools to encompass complex natural product synthesis. We have developed a number of novel flow-through processes for reactions commonly encountered in natural product synthesis programs to achieve the first total synthesis of spirodienal A and the preparation of spirangien A methyl ester. Highlights of the synthetic route include an iridium-catalyzed hydrogenation, iterative Roush crotylations, gold-catalyzed spiroketalization and a late-stage cis-selective reduction.

How many mountains can we mine? Assessing the regional degradation of Central Appalachian rivers by surface coal mining.

Surface coal mining is the dominant form of land cover change in Central Appalachia, yet the extent to which surface coal mine runoff is polluting regional rivers is currently unknown. We mapped surface mining from 1976 to 2005 for a 19,581 km(2) area of southern West Virginia and linked these maps with water quality and biological data for 223 streams. The extent of surface mining within catchments is highly correlated with the ionic strength and sulfate concentrations of receiving streams. Generalized additive models were used to estimate the amount of watershed mining, stream ionic strength, or sulfate concentrations beyond which biological impairment (based on state biocriteria) is likely. We find this threshold is reached once surface coal mines occupy >5.4% of their contributing watershed area, ionic strength exceeds 308 µS cm(-1), or sulfate concentrations exceed 50 mg L(-1). Significant losses of many intolerant macroinvertebrate taxa occur when as little as 2.2% of contributing catchments are mined. As of 2005, 5% of the land area of southern WV was converted to surface mines, 6% of regional streams were buried in valley fills, and 22% of the regional stream network length drained watersheds with >5.4% of their surface area converted to mines.

An empirical model for the equivalent translational compliance of steel studs.

The effect of the resilience of the steel studs on the sound insulation of steel stud cavity walls can be modeled as an equivalent translational compliance in simple models for predicting the sound insulation of walls. Recent numerical calculations have shown that this equivalent translational compliance varies with frequency. This paper determines the values of the equivalent translational compliance of steel studs which make a simple sound insulation theory agree best with experimental sound insulation data for 126 steel stud cavity walls with gypsum plaster board on each side of the steel studs and sound absorbing material in the wall cavity. These values are approximately constant as a function of frequency up to 400 Hz. Above 400 Hz they decrease approximately as a non-integer power of the frequency. The equivalent translational compliance also depends on the mass per unit surface area of the cladding on each side of the steel studs and on the width of the steel studs. Above 400 Hz, this compliance also depends on the stud spacing. The best fit approximation is used with a simple sound insulation prediction model to predict the sound insulation of steel stud cavity walls whose sound insulation has been determined experimentally.

The prediction of flanking sound transmission below the critical frequency.

Although reliable methods exist to predict the apparent sound reduction index of heavy, homogeneous isotopic building constructions, these methods are not appropriate for use with lightweight building constructions which typically have critical frequencies in or above the frequency range of interest. Three main methods have been proposed for extending the prediction of flanking sound transmission to frequencies below the critical frequency. The first method is the direct prediction which draws on a database of measurements of the flanking transmission of individual flanking paths. The second method would be a modification of the method in existing standards. This method requires the calculation of the resonant sound transmission factors. However, most of the approaches proposed to calculate the resonant sound transmission factor work only for the case of single leaf homogeneous isotropic building elements and therefore are not readily applicable to complex building elements. The third method is the measurement or prediction of the resonant radiation efficiency and the airborne diffuse field excited radiation efficiency which includes both the resonant and the non-resonant radiation efficiencies. The third method can currently deal with complex building elements if the radiation efficiencies can be measured or predicted. This paper examines these prediction methods.

Quantitative naturalistic methods for detecting change points in psychotherapy research: an illustration with alliance ruptures.

Analysis of change points in psychotherapy process could increase our understanding of mechanisms of change. In particular, naturalistic change point detection methods that identify turning points or breakpoints in time series data could enhance our ability to identify and study alliance ruptures and resolutions. This paper presents four categories of statistical methods for detecting change points in psychotherapy process: criterion-based methods, control chart methods, partitioning methods, and regression methods. Each method's utility for identifying shifts in the alliance is illustrated using a case example from the Beth Israel Psychotherapy Research program. Advantages and disadvantages of the various methods are discussed.

Association of types of diabetes and insulin dependency on birth outcomes.

BACKGROUND: Diabetes rates among pregnant women in the United States have been increasing and are associated with adverse pregnancy outcomes. AIM: To investigate differences in birth outcomes (preterm birth, macrosomia, and neonatal death) by diabetes status. METHODS: Cross-sectional design, using linked Missouri birth and death certificates (singleton births only), 2010 to 2012 (n = 204057). Exposure was diabetes (non-diabetic, pre-pregnancy diabetes-insulin dependent (PD-I), pre-pregnancy diabetes-non-insulin dependent (PD-NI), gestational diabetes- insulin dependent (GD-I), and gestational diabetes-non-insulin dependent (GD-NI)]. Outcomes included preterm birth, macrosomia, and infant mortality. Confounders included demographic characteristics, adequacy of prenatal care, body mass index, smoking, hypertension, and previous preterm birth. Bivariate and multivariate logistic regression assessed differences in outcomes by diabetes status. RESULTS: Women with PD-I, PD-NI, and GD-I remained at a significantly increased odds for preterm birth (aOR 2.87, aOR 1.77, and aOR 1.73, respectively) and having a very large baby [macrosomia] (aOR 3.01, aOR 2.12, and aOR 1.96, respectively); in reference to non-diabetic women. Women with GD-NI were at a significantly increased risk for macrosomia (aOR1.53), decreased risk for their baby to die before their first birthday (aOR 0.41) and no difference in risk for preterm birth in reference to non-diabetic women. CONCLUSION: Diabetes is associated with the poor birth outcomes. Clinical management of diabetes during pregnancy and healthy lifestyle behaviors before pregnancy can reduce the risk for diabetes and poor birth outcomes.

Diastereoselective chain-elongation reactions using microreactors for applications in complex molecule assembly.

Diastereoselective chain-elongation reactions are important transformations for the assembly of complex molecular structures, such as those present in polyketide natural products. Here we report new methods for performing crotylation reactions and homopropargylation reactions by using newly developed low-temperature flow-chemistry technology. In-line purification protocols are described, as well as the application of the crotylation protocol in an automated multi-step sequence.

Yoga to treat nonspecific low back pain.

Low back pain is common and poses a challenge for clinicians to find effective treatment to prevent it from becoming chronic. Chronic low back pain can have a significant impact on an employee's ability to remain an active and productive member of the work force due to increased absenteeism, duty restrictions, or physical limitations from pain. Low back pain is the most common cause of work-related disability among employees younger than 46 years. Advancing technology and less invasive surgical procedures have not improved outcomes for employees who suffer from low back pain. Most continue to experience some pain and dysfunction after conventional treatments such as injections and surgery. An alternative treatment that could reduce nonspecific chronic low back pain would benefit both employees and employers. Exercising and remaining active are part of most guidelines' routine care recommendations but are not well defined.

An engineered ligand trap inhibits leukemia inhibitory factor as pancreatic cancer treatment strategy.

Leukemia inhibitory factor (LIF), a cytokine secreted by stromal myofibroblasts and tumor cells, has recently been highlighted to promote tumor progression in pancreatic and other cancers through KRAS-driven cell signaling. We engineered a high affinity soluble human LIF receptor (LIFR) decoy that sequesters human LIF and inhibits its signaling as a therapeutic strategy. This engineered 'ligand trap', fused to an antibody Fc-domain, has ~50-fold increased affinity (~20 pM) and improved LIF inhibition compared to wild-type LIFR-Fc, potently blocks LIF-mediated effects in pancreatic cancer cells, and slows the growth of pancreatic cancer xenograft tumors. These results, and the lack of apparent toxicity observed in animal models, further highlights ligand traps as a promising therapeutic strategy for cancer treatment.

The continuous flow synthesis of butane-2,3-diacetal protected building blocks using microreactors.

The continuous flow synthesis of butane-2,3-diacetal protected derivatives has been achieved using commercially available flow chemistry microreactors in concert with solid supported reagents and scavengers to provide in-line purification systems. The BDA protected products are all obtained in superior yield to the corresponding batch processes.

The clinical utility of brain natriuretic peptide in paediatric left ventricular failure.

AIMS: To assess the role of brain natriuretic peptide (BNP) in both the acute and chronic settings in children with left ventricular (LV) failure. METHODS AND RESULTS: We undertook a retrospective review of all BNP levels taken over a 2-year period in our institution. Minimum follow-up was 90 days. Ninety-two BNP samples from 48 patients were reviewed. Twenty patients (42%) reached the combined endpoint of death, transplantation, or listing for transplantation. Median age was 3 years and 3 months. Mean BNP levels in NYHA or Ross classes I-IV were 29, 239, 744, and 1593 pg/mL, respectively, with significant differences between mean logBNP in classes I-III (P < 0.001). LogBNP levels correlated with fractional shortening (P < 0.001), LVEDd z-score (P < 0.001), and tissue Doppler velocities (P < 0.02). From serial data there was a strong correlation between change in BNP and change in clinical status (F 9.5, P < 0.001). Receiver-operator curve (ROC) demonstrated that BNP > 290 pg/mL predicts poor outcome with sensitivity of 0.80, specificity of 0.87, and likelihood ratio of 6.4 in paediatric patients with chronic LV dysfunction. A separate ROC from acute presentations did not demonstrate superiority of BNP over other assessments. CONCLUSION: BNP levels in paediatric heart failure (HF) patients show a strong correlation to both impaired heart function on echocardiogram and clinical status. Serial BNP levels follow the clinical course. In chronic HF, a BNP level of >290 pg/mL is predictive of an adverse outcome.

Synthesis of acetal protected building blocks using flow chemistry with flow I.R. analysis: preparation of butane-2,3-diacetal tartrates.

The syntheses of butane-2,3-diacetal protected tartrate derivatives are described using continuous flow processing techniques with in-line purification and I.R. analytical protocols.

The relationship of early alliance ruptures and their resolution to process and outcome in three time-limited psychotherapies for personality disorders.

This study examined the relationship of early alliance ruptures and their resolution to process and outcome in a sample of 128 patients randomly assigned to 1 of 3 time-limited psychotherapies for personality disorders: cognitive-behavioral therapy, brief relational therapy, or short-term dynamic psychotherapy. Rupture intensity and resolution were assessed by patient- and therapist-report after each of the first 6 sessions. Results indicated that lower rupture intensity and higher rupture resolution were associated with better ratings of the alliance and session quality. Lower rupture intensity also predicted good outcome on measures of interpersonal functioning, while higher rupture resolution predicted better retention. Patients reported fewer ruptures than did therapists. In addition, fewer ruptures were reported in cognitive-behavioral therapy than in the other treatments. (PsycINFO Database Record (c) 2010 APA, all rights reserved).

Alliance-focused training.

Alliance-focused training (AFT) aims to increase therapists' ability to recognize, tolerate, and negotiate alliance ruptures by increasing the therapeutic skills of self-awareness, affect regulation, and interpersonal sensitivity. In AFT, therapists are encouraged to draw on these skills when metacommunicating about ruptures with patients. In this article, we present the 3 main supervisory tasks of AFT: videotape analysis of rupture moments, awareness-oriented role-plays, and mindfulness training. We describe the theoretical and empirical support for each supervisory task, provide examples based on actual supervision sessions, and present feedback about the usefulness of the techniques from trainees in our program. We also note some of the challenges involved in conducting AFT and the importance of maintaining a strong supervisory alliance when using this training approach.

On the need for a new psychotherapy research paradigm: comment on Westen, Novotny, and Thompson-Brenner (2004).

Basic, process, and outcome research have the potential to inform clinical practice. However, as D. Westen, C. M. Novotny, and H. Thompson-Brenner observed in their timely analysis, the current dominant paradigm for psychotherapy outcome research--the randomized clinical trial--is not fulfilling this potential. The field's reliance on the medical model and manual-based interventions has contributed to the gap between research and clinical practice. Greater collaboration between practitioners and researchers, a focus on therapeutic principles rather than treatment packages, and systemic changes in how scholarly efforts are reinforced are needed to shift the current research paradigm.

Comparison of intracardiac echocardiography versus transesophageal echocardiography guidance for percutaneous transcatheter closure of atrial septal defect.

Transcatheter closure of interatrial septal defects is guided by transesophageal echocardiography (TEE), which requires general anesthesia in most cases. Using a new intracardiac echocardiographic (ICE) catheter may avoid endotracheal and esophageal intubation while using only local anesthesia. Forty-two patients underwent transcatheter interatrial septal defect closure; half of them underwent TEE guidance with general anesthesia and the other half underwent ICE guidance with local anesthesia. Device deployment success rate, adequate 2-dimensional and Doppler visualization of the defect and deployment steps, interatrial communication closure at 24 hours, and at 3 and 6 months, procedure time length, complications, fluoroscopic time, and length of hospitalization were compared between both methods. All interventions were completed successfully with no complications, except for 1 patient in the TEE group who had a minor oral trauma. Echocardiographic visualization of the septal defect and deployment was adequate by both methods. Catheterization laboratory time (92 +/- 18 vs 50 +/- 12 minutes, p <0.001) and interventional procedure length (47 +/- 8 vs 35 +/- 6 minutes, p <0.001) were shortened using ICE. There was no difference in the rate of closure after 6-month follow-up by either method. ICE guidance offers equivalent echocardiographic views compared with TEE and similar rates of closure. ICE is associated with decreased procedure length while eliminating the risks of endotracheal or esophageal intubation and general anesthesia.

Appraisals of daily romantic relationship experiences in individuals with borderline personality disorder features.

The current study examined the relationship between borderline personality disorder (BPD) features and appraisals of daily romantic relationship experiences. The sample included 114 ethnically diverse, young adult dating couples (total N = 228). Participants completed a 14-day daily diary study and reported negative impact and emotional loss to their romantic partner in response to daily positive and negative self-initiated and partner-initiated romantic experiences. Results indicated that BPD features, even when controlling for relationship satisfaction, total number of relationship experiences, and depressive symptoms, were associated with reporting greater negative impact and greater emotional loss to both partner-initiated negative and positive experiences. BPD features were generally not associated with reporting greater negative impact and emotional loss in response to self-initiated negative and positive experiences. The results suggest that individuals with BPD features have a negative interpretation bias to both negative and positive experiences and the effect is generally specific to partner-initiated experiences. Negative appraisals may be one mechanism underlying interpersonal dysfunction in those with BPD features and interventions that directly assess and target these cognitive biases may help improve individual well-being and overall couple functioning.

Increasing donor-recipient weight mismatch in pediatric orthotopic heart transplantation does not adversely affect outcome.

OBJECTIVE: The aim of the study was to show the effect of heart transplant donor-recipient weight mismatch on mortality, right-ventricular (RV) failure, and medium-term control of systemic blood pressure. METHODS: From 2000 to 2008 inclusive, 161 patients undergoing orthotopic heart transplantation at our unit were retrospectively analyzed. The cohort was divided into three groups of similar size depending on the tertile ranges of the donor-recipient weight ratio. Median follow-up was 4.81 years. Donor-recipient body weight ratio was analyzed with respect to intubation time, time in intensive care unit (ITU), development of RV failure, medium-term survival, and freedom from medium-term hypertension. RESULTS: The median age was 115 months (23 days to 18 years), at a median weight of 26.9 kg (3-88 kg) at transplant. Median donor-recipient weight ratio was 1.61 (0.62-3.25). Mean intubation time was 448 h (SD 749.2), mean time in the ITU 302.7 h (SD 617.8). On linear regression, these were not related to donor-recipient weight ratio. A total of 38 patients (23.6%) developed postoperative RV failure. Nearly one-fifth (18.9) of patients in the lowest tertile group developed RV failure. In the middle tertile group, 24.5% developed RV failure and 28.8% in the upper tertile of weight mismatch, although this was not statistically significant (p = 0.48). On survival analysis, there was a higher mortality among those with the lowest tertile of mismatch (log-rank p = 0.04), but there was no difference in midterm survival on condition of survival to discharge (log-rank p = 0.14). There was also no association between weight ratio and freedom from medium-term hypertension as measured on serial 24-h ambulatory blood pressure monitoring (log-rank p = 0.39). There were nine patients in whom the weight mismatch was 3 or greater. There was no association between this 'extreme' mismatch group and either midterm mortality (p = 0.76) or freedom from hypertension (p = 0.62), but this was associated with the need for postoperative extracorporeal membrane oxygenator (ECMO) support (p < 0.01). CONCLUSIONS: Our current policy involves accepting a maximum donor-recipient weight ratio of 3. These encouraging findings cautiously justify this policy, in an era when marginal donors are increasingly sought.