ANTIFON-CLIC®, a new clinical decision support system for the treatment of invasive aspergillosis: is it clinically relevant?

BACKGROUND: Invasive aspergillosis (IA) is increasing especially in new groups of patients. Despite advances in management, morbidity and mortality related to IA remain high. Thus, Clinical Decision Support System (CDSS) dedicated to IA are needed to promote the optimal antifungal for each group of patients. PATIENTS AND METHODS: This was a retrospective multicenter cohort study involving intensive care units and medical units. Adult patients who received caspofungin, isavuconazole, itraconazole, liposomal amphotericin B, posaconazole, or voriconazole, for the treatment of IA were eligible for enrollment. The primary objective was the concordance between the clinician's prescription and the prescription recommended by the CDSS. The secondary objective was the concordance according to different hospitals, departments, and indications. RESULTS: Eighty-eight patients (n=88) from three medical hospitals were included. The overall concordance was 97% (85/88) including 100% (41/41) for center A, 92% (23/25) for center B, and 95% (21/22) for center C. There was no significant difference in concordance among the hospitals (P=0.973), the departments (P=1.000), and the indications (P=0.799). The concordance was 70% (7/10) for isavuconazole due to its use as an empirical treatment and 100% (78/78) for the other antifungals. DISCUSSION: The concordance rate was high whatever the hospital, the department, and the indication. The only discrepancy was attributed to the use of isavuconazole as an empirical treatment which is a therapeutic option not included in the CDSS. CONCLUSIONS: This new CDSS dedicated to IA is meeting the clinical practice. Its implementation in routine will help to support antifungal stewardship.

Atypical phenotype associated with reported GCK exon 10 deletions: Clinical judgement is needed alongside appropriate genetic investigations.

BACKGROUND: Maturity-onset diabetes of the young (MODY) caused by heterozygous mutations in the glucokinase (GCK) gene typically presents with lifelong, stable, mild fasting hyperglycaemia. With the exception of pregnancy, patients with GCK-MODY usually do not require pharmacological therapy. We report two unrelated patients whose initial genetic test results indicated a deletion of GCK exon 10, but whose clinical phenotypes were not typical of GCK-MODY. CASE REPORTS: In case 1, the patient was hyperglycaemic at diagnosis (glucose > 30 mmol/l) and elevated glucose levels > 10 mmol/l persisted after withdrawal of insulin therapy. The patient in case 2 was also hyperglycaemic at diagnosis [HbA1c > 86 mmol/mol (10%)], which improved with the introduction of oral hypoglycaemic agents. These clinical features were not consistent with GCK-MODY. Both patients had a single nucleotide variant that prevented multiplex ligation-dependent probe analysis, which generated a false positive result of a GCK exon 10 deletion. CONCLUSION: False positive genetic results in these two unrelated cases were attributable to the presence of a rare single nucleotide variant that prevented ligation of the probe in the multiplex ligation-dependent probe analysis kit used and falsely indicated deletion of exon 10 within GCK. Both cases had clinical features that did not tally with the typical GCK-MODY phenotype. These cases emphasize the need to interpret the results of definitive genetic tests within the specific clinical context. Increased medical sequencing is likely to lead to more reports of novel mutations of uncertain significance. If genetic investigations do not agree with the clinical picture, clinicians should exercise caution when making therapeutic changes based on these results.

Increasing access to pain management: Feasibility of a self-compassion psychoeducational website using a minimally monitored delivery model.

Self-compassion has been associated with several positive pain-related outcomes. However, little is known about the impact of targeting self-compassion on pain management. This study assesses the feasibility of a self-compassion psychoeducation website among adults with chronic pain using a minimally monitored delivery model. Participants (N = 26) were recruited online and a single group pre-test and post-test design with a 3-month follow-up was used. The intervention was a 6-week program comprised of a video, writing exercises, guided meditations and automated emails. Feasibility outcome measures were grouped into the following categories: study engagement (ease of recruitment, attrition, adherence, satisfaction), pain vulnerability variables (intensity, interference, catastrophizing, mood) and protective pain variables (self-compassion, resilience and acceptance). Challenges pertaining to uptake were encountered. Attrition was higher (n = 11/26; 42%) and adherence to the full treatment protocol lower (n = 6/26; 23%) than expected. Treatment satisfaction was high with nearly all study completers (93%) reporting that they would recommend the program to a friend. Intent-to-treat mixed effects models showed a significant and large increase of self-compassion (d = 0.92) and a significant impact on several outcome variables (ds from 0.24 to 1.15) with most gains either maintained or increased at follow-up. The recruitment strategy may have negatively impacted participant engagement. Methodological modifications are proposed to improve the feasibility of the program. Minimally monitored web-based programs targeting self-compassion may benefit adults with chronic pain who may have limited access to traditional psychological services or who prefer online-based interventions.

A review of the relationship between depression and diabetes in adults: is there a link?

OBJECTIVE: To review the support for two hypotheses concerning the interrelationship between depression and diabetes and to identify areas in which more research is needed. RESEARCH DESIGN AND METHODS: A review was conducted using primarily electronic databases. Articles relating to diabetes and depressive symptomatology, depressive disorder, and dysthymic disorder were selected. The study focuses mainly on adults with diabetes. RESULTS: The initial onset of major depressive disorder (MDD) seems to be independent of the onset of type 2 diabetes, but results remain equivocal for type 1 diabetes. However, in both type 1 and type 2 diabetes, diabetes-related psychological and physiological processes may be involved in the higher recurrence and longer duration of MDD and depressive symptomatology CONCLUSIONS: The hypotheses that the initial occurrence of clinically significant depression, MDD, results from either biochemical changes directly due to type 2 diabetes or its treatment or from the psychosocial demands imposed by the illness or its treatment do not seem to be supported. MDD in diabetic individuals represents a multidetermined phenomenon resulting from interactions between biologic and psychosocial factors. This interaction may increase the probability of developing type 2 diabetes in otherwise healthy individuals.

Assessing the dimensions of pain: a multitrait-multimethod evaluation of seven measures.

A multitrait-multimethod design was used to examine the convergent and discriminant validity of seven pain measures from three widely used self-report instruments designed to assess the sensory, affective and intensity dimensions of pain. The instruments were the McGill Pain Questionnaire, the Pain Perception Profile and Numerical Ratings. Three distinct factor models, each corresponding to a different hypothesis about how these pain measures are related, were tested using confirmatory factor analysis in a sample of 419 headache sufferers. A three-factor model, postulating three correlated factors defined by the three assessment instruments best explained the correlations between the pain measures. Measures of sensory, affective and intensity dimensions from the three instruments failed to exhibit convergent or discriminant validity. Rather, instrument variance obscured the pain qualities the three pain instruments were designed to assess. These findings suggest that greater attention needs to be paid to how formal characteristics of pain assessment instruments influence patients' descriptions of their pain.

Enrichment of murine splenic natural killer (NK) cells by the sequential elimination of non-NK cells.

A simple and reliable three-step procedure to enrich for murine endogenous splenic NK cells is described. The method is based on the sequential elimination of non-NK cell subsets by standard and inexpensive techniques executed in a specific order. First, macrophages and other adherent cells are eliminated by incubation on plastic surface. Secondly, the T cells are excluded from the multicellular aggregates formed by agglutination of the remaining cells with wheat germ lectin. Thirdly, after dissociation of the aggregates with N-acetyl-D-glucosamine and osmotic lysis of erythrocytes, NK cells are separated from other nucleated cells by nylon wool filtration. C57BL/6 spleen cells were used to establish the enrichment procedure. Usually their NK cell activity is intermediate but occasionally either low or high NK cell activity was observed in input cell suspensions. The NK cell activity recovery and the degree of enrichment varied inversely with the initial NK cell activity level of the input cell suspension. When initial NK cell activity was intermediate, it was enriched 10-30-fold. Experiments were done to establish if suppressor cells, and nylon wool-adherent, naturally activated NK cells, putatively present in input cells, could have been responsible for the abnormal initial NK cell activity detected in some C57BL/6 spleen cell suspensions and for the variations in the degree of enrichment achieved by the method here described. Either no or negligeable suppressor cell activity was noted in the cell fractions normally discarded at each step of the procedure. On the other hand, nylon wool-adherent NK cells were eliminated during the fractionation of spleen cells with higher than average initial NK cell activity and would account for the lower NK cell enrichment obtained in these conditions.

The development of an empirical psychosocial taxonomy for patients with diabetes.

The main purpose of this study was to develop and to cross-validate an empirically derived psychosocial taxonomy of patients with diabetes. In the first study, 101 patients with Type I or Type II diabetes completed the Multidimensional Diabetes Questionnaire. Cluster analysis identified three clusters, labeled adaptive copers, low support-low involvement, and spousal overinvolvement. In the second study, the taxonomy was cross-validated using an independent sample of 132 patients with long-standing Type II diabetes. The results confirmed that the multivariate classification system was unique and highly accurate. External validation, using general psychological as well as diabetes-specific measures, supported the validity and distinctiveness of the patients' profiles. These findings help establish a multiaxial psychosocial taxonomy of diabetes and may have significant implications for the management of patients with diabetes.

Relations of diabetes intrusiveness and personal control to symptoms of depression among adults with diabetes.

The generalizability of a model linking illness characteristics to psychosocial well-being was tested in a cross-sectional study of 237 adults with type 2 diabetes. It was hypothesized that diabetic complications increase illness intrusiveness, which in turn increases depressive symptomatology either directly or indirectly by reducing personal control over health outcomes. Illness intrusiveness was defined as the result of disruptions of valued activities and interests due to constraints imposed by the illness. An excellent fit of this model to the data was found using structural equation modeling. The model explained 65% of the variance in depressive symptomatology. Assessment of an alternative model excluding personal control suggested that the extent to which diabetes intrudes in life, rather than diabetic complications per se or personal control, is a key factor in relation to depressive symptomatology in individuals with diabetes.

Prediction of prognosis in patients with uveal melanoma using fluorescence in situ hybridisation.

BACKGROUND/AIMS: Uveal melanoma is the commonest malignancy of the eye, with a high proportion of patients dying of metastatic disease. Tumours showing a loss of chromosome 3 and gains of chromosome 8 are associated with a worse prognosis. The efficiency of fluorescence in situ hybridisation (FISH) in determining copy numbers of these chromosomes was assessed in individual tumours and related to patient survival. METHODS: 33 fresh frozen samples were analysed with centromeric probes for chromosomes 3 and 8. Patient outcomes were divided into two groups: (1) absence of genetic abnormalities (no genetic imbalance) and (2) presence of genetic abnormalities (genetic imbalance). The log rank test was used to compare survival, which was represented by Kaplan-Meier survival curves. RESULTS: Of the 33 tumours analysed, 16 showed evidence of genetic imbalances. Of these 16 tumours, 14 patients had died by the end of the study, with 10 having died of liver metastases. Of the tumours without evidence of genetic imbalances, five patients had died by the end of the study, although none had died as a result of either liver metastases or from the primary uveal melanoma. The difference in survival between the two groups was highly significant (p<0.0001). CONCLUSION: The authors have shown that FISH analysis for chromosome 3 and 8 is a reliable and efficient technique in the analysis of fresh frozen tumour specimens and is valuable in the prediction of prognosis in individuals with uveal melanomas.

Functional and dysfunctional perfectionists: are they different on compulsive-like behaviors?

Both perfectionism and excessive responsibility have been linked to obsessive compulsive disorder (OCD). Up to now however, a greater number of studies have focused on the role of responsibility. The present study compared compulsive-like behavior of people with different styles of perfectionism. Sixteen functional perfectionists (FP) and 16 dysfunctional perfectionists (DP) were compared on three different tasks in order to explore OC type behavior such as doubting, checking and intrusions. Results show that DP participants, compared to FP participants, scored higher on an OC behavior scale, took significantly more time to complete a precision task and precipitated their decision when confronted with ambiguity. The two groups also tended to differ in their intrusive thoughts following an unsolved problem; FP participants were more preoccupied about solving the problem than about the quality of their performance, contrary to DP subjects. Results are discussed according to theoretical models of OCD.

Production of monoclonal antibodies against the outer cell wall of Clostridium tyrobutyricum.

Several hybridoma cell lines producing murine monoclonal antibodies (mAbs) directed to the Clostridium tyrobutyricum outer cell wall have been established and characterized. Whole bacteria, crude extract of cell wall, and polysaccharide fraction of crude extract have been used as immunogens. The immunizations were performed either in vivo or in vitro after priming in vivo. Amongst the clones obtained, six hybridoma cell lines were selected. Four mAbs recognized only the immunizing strain (ATCC 25755), while two mAbs recognized all the C. tyrobutyricum tested strains. Three mAbs were IgM, one IgG3, and two IgG1 isotypes. The antigens (proteins or polysaccharides) recognized by these mAbs have been characterized by Western Blot. These mAbs could be used for an early detection of C. tyrobutyricum in milk.

Behavioral expressions of intolerance of uncertainty in worry. Experimental findings.

Intolerance of uncertainty has been related to increased worry in recent conceptual models of Generalized Anxiety Disorder (GAD). The present study examines the relationship between a measure of intolerance of uncertainty, the Intolerance of Uncertainty scale (IU), and behaviors associated with GAD, such as slowness of execution and amount of evidence required before decision making. A total of 49 individuals participated in the study. Three experimental tasks varying in level of ambiguity and difficulty were used. The analyses show a positive correlation between scores on the IU and number of cues required before responding in a moderately ambiguous inference task. However, scores on the IU were not significantly related to responses in an unambiguous task (regardless of the level of difficulty) or in a highly ambiguous task. The results suggest that high worriers have a lower threshold of tolerance of uncertainty for intermediate levels of ambiguity. The results are discussed in terms of theoretical models of GAD.

Computerized cognitive training with learning disabled students: a pilot study.

The effects of practicing computerized exercises in class by 59 learning disabled students who received an 8-hr. training program, 30 min. per week, were evaluated. Six exercises designed to facilitate basic cognitive skills development were used. Twelve subjects were assigned to a control group without any form of intervention. Covariance analysis (pretest scores used as covariates) showed a significant effect of training on mental arithmetic. These results suggest that practicing a computerized exercise of mental arithmetic can facilitate the automatization of basic arithmetic skills (addition, subtraction, and multiplication). The nature, progress, and evaluation of such types of intervention are discussed.

Green roof valuation: a probabilistic economic analysis of environmental benefits.

Green (vegetated) roofs have gained global acceptance as a technologythat has the potential to help mitigate the multifaceted, complex environmental problems of urban centers. While policies that encourage green roofs exist atthe local and regional level, installation costs remain at a premium and deter investment in this technology. The objective of this paper is to quantitatively integrate the range of stormwater, energy, and air pollution benefits of green roofs into an economic model that captures the building-specific scale. Currently, green roofs are primarily valued on increased roof longevity, reduced stormwater runoff, and decreased building energy consumption. Proper valuation of these benefits can reduce the present value of a green roof if investors look beyond the upfront capital costs. Net present value (NPV) analysis comparing a conventional roof system to an extensive green roof system demonstrates that at the end of the green roof lifetime the NPV for the green roof is between 20.3 and 25.2% less than the NPV for the conventional roof over 40 years. The additional upfront investment is recovered at the time when a conventional roof would be replaced. Increasing evidence suggests that green roofs may play a significant role in urban air quality improvement For example, uptake of N0x is estimated to range from $1683 to $6383 per metric ton of NOx reduction. These benefits were included in this study, and results translate to an annual benefit of $895-3392 for a 2000 square meter vegetated roof. Improved air quality leads to a mean NPV for the green roof that is 24.5-40.2% less than the mean conventional roof NPV. Through innovative policies, the inclusion of air pollution mitigation and the reduction of municipal stormwater infrastructure costs in economic valuation of environmental benefits of green roofs can reduce the cost gap that currently hinders U.S. investment in green roof technology.

Is health locus of control a 3-factor or a 2-factor construct?

Although the Multidimensional Health Locus of Control (MHLC) scales are commonly used, uncertainty about their factorial validity still remains. In the present study, confirmatory factor analyses of a French-Canadian adaptation of the Multidimensional Health Locus of Control scales (MHLC) were conducted to compare in a non-clinical group of 224 adults two factor models. Multigroup analyses were also conducted using this group and a clinical group of 132 diabetics to assess the equivalence of the MHLC factor structure across these two groups. A 3-factor model postulating an internal, external, and chance dimension, and accounting for measurement errors provided the best fit to the data. Multigroup analyses failed to support the equivalence of the MHLC factor loadings across the non-clinical and clinical group. These findings suggest that comparisons of MHLC scores across such groups may be problematic.

Characteristics of an antigen-specific helper factor that enhances the in vitro generation of cytotoxic cells directed against a syngeneic tumor.

An antigen-specific helper factor (Hf) that enhances the in vitro generation of tumor-specific cytotoxic T cells (CL) has been isolated from the spleens of DBA/2 mice bearing the syngeneic mastocytoma, P815. This factor enhances the CL response to P815 but not to L1210 (a syngeneic T cell leukemia in DBA/2 mice), B10 minor antigens, or DBA/2 alloantigens. The factor binds specifically to P815 membrane immunoadsorbent columns and can be eluted with 2 M NaCl. P815 Hf did not resemble the lymphokine Il 2 because it did not enhance the proliferative or CL response of thymocytes nor would it support the growth of an IL 2-requiring line of T cells. This factor acted optimally if added late in the culture period in contrast to IL 2, which was more effective if added early. In limiting dilution experiments P815 Hf enhanced the level of CL activity generated but not the number of precursors triggered. IL 2 markedly amplified both of these parameters.

A single amino acid substitution strongly modulates the activity and substrate specificity of the mouse mdr1 and mdr3 drug efflux pumps.

Specific protein domains and amino acids responsible for the apparent capacity of P-glycoprotein (mdr) to recognize and transport a large group of structurally unrelated drugs have not been identified. We have introduced a single Ser----Phe substitution within the predicted TM11 domain of mdr1 (position 941) and mdr3 (position 939) and analyzed the effect of these substitutions on the drug-resistance profiles of these two proteins. Mutations at this residue drastically altered the overall degree of drug resistance conveyed by mdr1 and mdr3. The modulating effect of this mutation on mdr1 and mdr3 varied for the drugs tested: it was very strong for colchicine and adriamycin and moderate for vinblastine. For mdr1, the Ser941----Phe941 substitution produced a unique mutant protein that retained the capacity to confer vinblastine resistance but lost the ability to confer adriamycin and colchicine resistance. These results strongly suggest that the predicted TM11 domain of proteins encoded by mdr and mdr-like genes plays an important role in the recognition and transport of their specific substrates.

Demonstration of a surface antigen of Clostridium tyrobutyricum by use of immunoblotting with a monoclonal antibody.

A monoclonal antibody, prepared against whole cells of Clostridium tyrobutyricum, recognized a surface antigen extracted by heat treatment or by hot phenol-water treatment. This antigen, after analysis by polyacrylamide gel electrophoresis and immunoblotting, has been shown to present a regularly-spaced ladder pattern similar to those shown by the lipopolysaccharide of many gram-negative bacteria. The proteinase K has been shown to have no effect on the recognition of this epitope by the monoclonal antibody. On the contrary, the inhibition of the antigen reactivity to the monoclonal antibody after a mild periodate oxidation suggests the involvement of a carbohydrate moiety in the epitope. Moreover, the SDS-PAGE analysis of phenol-water extracts has shown an additional compound, detected by silver staining but not recognized by the monoclonal antibody.