VR-assisted aggression treatment in forensic psychiatry: a qualitative study in patients with severe mental disorders.

Introduction: Improvements in virtual reality (VR) have made it possible to create realistic, virtual settings for behavioral assessment and skills training that cannot otherwise be accessed in a safe way in forensic psychiatric settings. VR interventions are under development but little is known how forensic psychiatric patients with severe mental disorders experience VR-assisted assessments or treatments. Methods: The present study aimed to help fill this knowledge gap via qualitative interviews with seven patients with severe mental disorders at a high-security forensic psychiatric clinic who had completed the newly revised Virtual Reality Aggression Prevention Training (VRAPT). All participants were interviewed 12 weeks after the VRAPT intervention, and interview data analyzed with manifest inductive content analysis. Results: Six manifest content categories were identified: 1. Therapeutic process, 2. VRAPT method, 3. VR technology, 4. Previous treatment experiences, 5. Challenges to treatment of aggression, and 6. Unexpected experiences. The participants had diverse experiences related to both the VRAPT intervention and forensic psychiatric care. Participants described a mixture of positive experiences in relation to VR-assisted role-plays, and less positive in relation to motivation for aggression-focused treatment and technological limitations. Discussion: The present findings suggest further studies are needed on how to best implement VR-assisted treatments for aggression in forensic settings, and potentially further modification of treatment content in interventions like VRAPT.

Mandibular Myxoid Liposarcoma: a Case Study.

Liposarcomas are described as soft tissue sarcomas derived from adipose tissue. The finding of this tumor in the mandibular region is exceedingly rare. As of now, it has been described mainly in case reports and small series. A multidisciplinary approach is required to offer optimal treatment and may involve surgery, radiation and systemic therapies. Surgical repair of these defects represents a major challenge in oral and maxillofacial reconstructive surgery. We present the case of a 54-year-old man referred to our center with a progressively increasing mass in the anterior portion of the mandible. Biopsy revealed a well-differentiated myxoid liposarcoma. Resection of the tumor was performed with an additional primary reconstruction.

Post-intubation double tracheal stenosis.

Post-intubation tracheal stenosis is a condition that can occur as a consequence of tracheostomy or prolonged intubation. The development of two levels of airway narrowing is rare. We present the case of a 43-year-old male with a history of prolonged mechanical ventilation, who presented to our center with progressive respiratory impairment. Computed tomography with three-dimensional reconstruction demonstrated complex tracheal anatomy with double-level stenosis. The patient underwent successful endoscopic procedure. Supplementary Information: The online version contains supplementary material available at 10.1007/s12055-022-01426-y.

Massive hemoptysis as a complication of pulmonary actinomycosis: a case report.

Massive hemoptysis is a rare life-threatening complication of pulmonary actinomycosis that should be treated promptly due to the risk of asphyxiation and hemodynamic instability. We present the case of a 57-year-old female who was presented to our center with massive hemoptysis. Thoracic computed tomography scan revealed a cavitated lesion with perilesional ground-glass opacity. Right lower lobectomy was then performed using uniportal video-assisted thoracic surgery, excising a 13 × 12 × 8 cm cavitated lung fragment. The pathology service reported the presence of microscopical evidence of filamentous gram positive bacterial colonies, showing compatible features of pulmonary actinomycosis. The patient was discharged with oral penicillin with an uneventful post-operative course.

La hemoptisis masiva es una complicación poco frecuente de la actinomicosis pulmonar que pone en peligro la vida del paciente y que debe ser tratada con prontitud debido al riesgo de asfixia e inestabilidad hemodinámica. Presentamos una mujer de 57 años que acudió a nuestro centro con hemoptisis masiva. La tomografía reveló una cavitación con opacidad perilesional en vidrio deslustrado. Realizamos lobectomía mediante cirugía uniportal, extirpando un fragmento de lesión. Patología informó de la presencia de colonias bacterianas filamentosas grampositivas, mostrando características compatibles con actinomicosis pulmonar. El paciente fue dado de alta con penicilina oral, con un curso postoperatorio sin incidentes.

Differential effects of high-altitude exposure on markers of oxidative stress, antioxidant capacity, and iron profiles.

High-altitude (HA) exposure may stimulate significant physiological and molecular changes, resulting in HA-related illnesses. HA may impact oxidative stress, antioxidant capacity, and iron homeostasis, yet it is unclear how both repeated exposure and HA acclimatization may modulate such effects. Therefore, we assessed the effects of weeklong repeated daily HA exposure (2,900-5,050 m) in altitude-naïve individuals (n = 21 individuals, 13 females, mean ± SD, 25.3 ± 3.7 yr) to mirror the working schedule of HA workers (n = 19 individuals, all males, 41.1 ± 9.4 yr) at the Atacama Large Millimeter Array (ALMA) Observatory (San Pedro de Atacama, Chile). Markers of oxidative stress, antioxidant capacity, and iron homeostasis were measured in blood plasma. Levels of protein oxidation (P < 0.001) and catalase activity (P = 0.023) increased and serum iron (P < 0.001), serum ferritin (P < 0.001), and transferrin saturation (P < 0.001) levels decreased with HA exposure in both groups. HA workers had lower levels of oxidative stress, and higher levels of antioxidant capacity, iron supply, and hemoglobin concentration as compared with altitude-naïve individuals. On a second week of daily HA exposure, changes in levels of protein oxidation, glutathione peroxidase, and nitric oxide metabolites were lower as compared with the first week in altitude-naïve individuals. These results indicate that repeated exposure to HA may significantly alter oxidative stress and iron homeostasis, and the degree of such changes may be dependent on if HA is visited naïvely or routinely. Further studies are required to fully elucidate differences in HA-induced changes in oxidative stress and iron homeostasis profiles among visitors of HA.

Cinaciguat (BAY-582667) Modifies Cardiopulmonary and Systemic Circulation in Chronically Hypoxic and Pulmonary Hypertensive Neonatal Lambs in the Alto Andino.

Neonatal pulmonary hypertension (NPHT) is produced by sustained pulmonary vasoconstriction and increased vascular remodeling. Soluble guanylyl cyclase (sGC) participates in signaling pathways that induce vascular vasodilation and reduce vascular remodeling. However, when sGC is oxidized and/or loses its heme group, it does not respond to nitric oxide (NO), losing its vasodilating effects. sGC protein expression and function is reduced in hypertensive neonatal lambs. Currently, NPHT is treated with NO inhalation therapy; however, new treatments are needed for improved outcomes. We used Cinaciguat (BAY-582667), which activates oxidized and/or without heme group sGC in pulmonary hypertensive lambs studied at 3,600 m. Our study included 6 Cinaciguat-treated (35 ug kg-1 day-1 x 7 days) and 6 Control neonates. We measured acute and chronic basal cardiovascular variables in pulmonary and systemic circulation, cardiovascular variables during a superimposed episode of acute hypoxia, remodeling of pulmonary arteries and changes in the right ventricle weight, vasoactive functions in small pulmonary arteries, and expression of NO-sGC-cGMP signaling pathway proteins involved in vasodilation. We observed a decrease in pulmonary arterial pressure and vascular resistance during the acute treatment. In contrast, the pulmonary pressure did not change in the chronic study due to increased cardiac output, resulting in lower pulmonary vascular resistance in the last 2 days of chronic study. The latter may have had a role in decreasing right ventricular hypertrophy, although the direct effect of Cinaciguat on the heart should also be considered. During acute hypoxia, the pulmonary vascular resistance remained low compared to the Control lambs. We observed a higher lung artery density, accompanied by reduced smooth muscle and adventitia layers in the pulmonary arteries. Additionally, vasodilator function was increased, and vasoconstrictor function was decreased, with modifications in the expression of proteins linked to pulmonary vasodilation, consistent with low pulmonary vascular resistance. In summary, Cinaciguat, an activator of sGC, induces cardiopulmonary modifications in chronically hypoxic and pulmonary hypertensive newborn lambs. Therefore, Cinaciguat is a potential therapeutic tool for reducing pulmonary vascular remodeling and/or right ventricular hypertrophy in pulmonary arterial hypertension syndrome.

Oxygen use in Atacama large millimeter and submillimeter (ALMA) arrays in Chajnantor valley at 5050 m / Uso de oxígeno en Atacama large millimeter and submillimeter (ALMA) en el valle de Chajnantor a 5050 m

The Chilean workforce has over 200,000 people that are intermittently exposed to altitudes over 4000 m. In 2012, the Ministry of Health provided a technical guide for high altitude workers that included a series of actions to mitigate the effects of hypoxia. Previous studies have shown the positive effect of oxygen enrichment at high altitudes. The Atacama Large Millimeter / submillimeter Arrays (ALMA) radiotelescope operate at 5,050 m (Array Operation Site, AOS) and is the only place in the world where Pressure Swing Adsorption (PSA) and Liquid Oxygen technologies have been installed at a large scale. Here we discuss our experience using oxygen supplementation at ALMA, to prevent the malaise and/or risks associated with exposure at 5,050 m. Antenna operators experienced chronic intermittent hypobaric hypoxia (CIHH, shiftwork 8 days HA*6 days rest SL) over 4 years. Studies to define normal O2 saturation values were performed in OSF and AOS by continuous recording during the shift. The outcomes showed no differences between production procedures (PSA or Liquid oxygen) in regulating oxygen availability at AOS facilities. As a result, big-scale installations have difficulties reaching the appropriate oxygen concentration due to leaks in high mobility areas. In addition, the PSA plant requires adequation and maintenance to operate at a very high altitude.

La fuerza laboral chilena cuenta con más de 200.000 personas que están expuestas intermitentemente a altitudes superiores a los 4000 m. En 2012, el Ministerio de Salud entregó una guía técnica para trabajadores de altura que incluía una serie de acciones para mitigar los efectos de la hipoxia. Estudios anteriores han demostrado el efecto positivo del enriquecimiento de oxígeno en altitudes elevadas. El radiotelescopio Atacama Large Millimeter/submillimeter Arrays (ALMA) opera a 5.050 m (Array Operation Site, AOS) y es el único lugar en el mundo donde se han instalado tecnologías de adsorción por cambio de presión (PSA) y oxígeno líquido a gran escala. Aquí discutimos nuestra experiencia usando suplementos de oxígeno en ALMA, para prevenir el malestar y/o los riesgos asociados con la exposición a 5.050 m. Los operadores de antena experimentaron hipoxia hipobárica intermitente crónica (CIHH, trabajo por turnos 8 días HA*6 días descanso SL) durante 4 años. Se realizaron estudios para definir valores normales de saturación de O2 en OSF y AOS mediante registro continuo durante el turno. Los resultados no mostraron diferencias entre los procedimientos de producción (PSA u oxígeno líquido) en la regulación de la disponibilidad de oxígeno en las instalaciones de AOS. Como resultado, las instalaciones a gran escala tienen dificultades para alcanzar la concentración de oxígeno adecuada debido a fugas en áreas de alta movilidad. Además, la planta de PSA requiere de adecuación y mantenimiento para operar a gran altura.

Comparison Between Pressure Swing Adsorption and Liquid Oxygen Enrichment Techniques in the Atacama Large Millimeter/Submillimeter Array Facility at the Chajnantor Plateau (5,050 m).

The Chilean workforce has over 200,000 people that are intermittently exposed to altitudes over 4,000 m. In 2012, the Ministry of Health provided a technical guide for high-altitude workers that included a series of actions to mitigate the effects of hypoxia. Previous studies have shown the positive effect of oxygen enrichment at high altitudes. The Atacama Large Millimeter/submillimeter Array (ALMA) radiotelescope operates at 5,050 m [Array Operations Site (AOS)] and is the only place in the world where pressure swing adsorption (PSA) and liquid oxygen technologies have been installed at a large scale. These technologies reduce the equivalent altitude by increasing oxygen availability. This study aims to perform a retrospective comparison between the use of both technologies during operation in ALMA at 5,050 m. In each condition, variables such as oxygen (O2), temperature, and humidity were continuously recorded in each AOS rooms, and cardiorespiratory variables were registered. In addition, we compared portable O2 by using continuous or demand flow during outdoor activities at very high altitudes. The outcomes showed no differences between production procedures (PSA or liquid oxygen) in regulating oxygen availability at AOS facilities. As a result, big-scale installations have difficulties reaching the appropriate O2 concentration due to leaks in high mobility areas. In addition, the PSA plant requires adequacy and maintenance to operate at a very high altitude. A continuous flow of 2-3 l/min of portable O2 is recommended at 5,050 m.

Enhanced Vasoconstriction Mediated by α1-Adrenergic Mechanisms in Small Femoral Arteries in Newborn Llama and Sheep Gestated at Low and High Altitudes.

The authors previously demonstrated that newborn llama (NBLL) express high levels of α1 adrenergic receptors, which provide a potent vasoconstriction response when compared with newborn sheep (NBSH) gestated at sea level. However, data regarding the impact of chronic gestational hypobaric hypoxia on α-adrenergic vasoconstriction in the neonatal life has not been studied. We evaluated if gestation under chronic hypobaric hypoxia modifies α1-adrenergic vasoconstrictor function in NBLL and NBSH. We compared the vasoconstrictor response induced by potassium and α-adrenergic stimuli in isolated small femoral arteries of NBLL and NBSH gestated at high altitude (HA; 3,600 m) or low altitude (LA; 580 m). The maximal contraction (R MAX) and potency (EC50) to potassium, noradrenaline (NA), and phenylephrine (PHE) were larger in HA-NBLL than LA-NBLL. R MAX to potassium, NA, and PHE were lower in HA-NBSH when compared with LA-NBSH and potency results were similar. Competitive blockade with prazosin showed that RNLL LA/HA have a similar pA2. In contrast, NBSH had increased pA2 values in HA when compared with LA. Finally, small femoral arteries denudated or treated with LNAME in LA and HA lacked NO or endothelium participation in response to PHE stimulation. In contrast, NBSH displayed that denudation or blockade with LNAME support NO or endothelium participation in response to PHE activation. In conclusion, HA chronic hypoxia enhances α1 adrenergic receptor activity in small femoral arteries in NBLL to a higher degree than NBSH, implying a higher vasoconstriction function.

Coccidioidomycosis mimicking testicular cancer: A case report.

We present the case of a 48 year-old man with a history of pulmonary tuberculosis who was brought to our centre with a progressively increasing left testicular mass. Radiological findings were not conclusive on whether the mass was neoplastic or infectious in nature. Therefore, an orchiectomy was performed. Pathology examination revealed coccidioidomycosis of the left testicle, highlighting an exceedingly rare presentation of disseminated genitourinary coccidioidomycosis.

Cardiovascular Risk Is Increased in Miner's Chronic Intermittent Hypobaric Hypoxia Exposure From 0 to 2,500 m?

Over the past 40 years, mining activities in Chile have relocated miners who normally live at sea level to work at high altitudes. This results in a form of chronic intermittent hypobaric hypoxia (CIHH) characterized by alternating periods of work at high altitude and rest periods at sea level. Previous studies performed in our laboratory showed that aerobic capacity is reduced at 3,800 m, even when oxygen content is maintained. Our study aimed to determine the corporal composition, food intake, maximum oxygen uptake, and concentration of high sensitivity C reactive protein (hsCRP) in an acclimatized miner population that work from 0 to 2,500 m with CIHH exposure over 4 years. All miners recruited for our study were operators of heavy trucks with CIHH for over 4 years (shiftwork 7*7 days), and our experimental population was composed of 54 miners at sea level, 61 at 1,600 m, and 38 at 2,500 m. All evaluations were performed on the 3rd or 4th day of diurnal shiftwork. To determine corporal composition, we measured weight and height (to calculate body mass index, BMI), skinfolds (to calculate body fatty, BF), and waist circumference (WC); maximal aerobic capacity was evaluated using a ramp-incremental cycling to exhaustion protocol and a venous blood sample before the exercise test to measure (hsCRP) via an ELISA test. We found higher values of BMI, BF, and WC, in the miners' population but observed no significant difference between populations. We found a decrease in VO2 of 11.6% at 1,600 m and 25.9% at 2,500 m compared to miners at sea level. An increase in (hsCRP) at 1,600 and 2,500 m regards sea level. We observed a high prevalence of overweight and obese subjects, which was related to the ad libitum availability of food and low physical activity (sedentarism). We found that work capacity was maintained despite a decreased VO2 max at moderate altitude. However, overweight and obesity support an increased risk of cardiometabolic disease in miner's which is unrelated to altitude. In contrast, an increased hsCRP level could be associated with increased inflammatory mechanisms at 1,600 and 2,500 m.

Surgical activation protocol COVID-19 (SAP COVID).

BACKGROUND: The coronavirus disease 2019 (COVID-19) outbreak have major implications in conventional surgical practice. As the number of patients with this diagnosis is rising, the infection risk for the surgical staff will be higher. Few publications have addressed the surgical management of patients diagnosed with COVID-19. OBJECTIVE: To assess recommendations for care of patients and surgical team during the COVID-19 pandemic. METHOD: MEDLINE, Embase and the Cochrane Database of Systematic Reviews (April 2020) were searched the key words "COVID-19", "PROTOCOL" and "SURGERY". Relevant recommendations, guidelines and cases series were checked for the most accurate information for apply to our center. RESULTS: We found 379 papers that included the key words. A total of 25 papers were included in the manuscript based in the pertinence of the recommendations. Three major topics were selected: perioperative, intraoperative and postoperative. CONCLUSION: As an attempt to regulate the surgical team approach, we present recommendations to preserve patients and surgical staff safety with high quality standards of care through reproducible strategies applicable in most hospital centers.

ANTECEDENTES: La pandemia de COVID-19 ha tenido un gran impacto en la práctica quirúrgica convencional. Conforme el número de pacientes diagnosticados con esta enfermedad vaya en aumento, el riesgo de contagio para el equipo quirúrgico será mayor. Pocas publicaciones han abordado el manejo del paciente diagnosticado con COVID-19 dentro del quirófano. OBJETIVO: Evaluar las recomendaciones para el cuidado de pacientes y del equipo quirúrgico durante la pandemia de COVID-19. MÉTODO: La búsqueda bibliográfica principal utilizó las bases de datos MEDLINE, Embase y Cochrane, utilizando las palabras clave "COVID-19", "PROTOCOL" y "SURGERY". Se verificaron recomendaciones, guías y series de casos relevantes para obtener la información más precisa y aplicable. RESULTADOS: Se hizo la revisión de 379 artículos que contenían las palabras clave. Se incluyeron 25 artículos basándose en la pertinencia de las recomendaciones. Los tres temas principales seleccionados fueron las fases preoperatoria, transoperatoria y posoperatoria. CONCLUSIÓN: En un esfuerzo por tratar de normar el manejo quirúrgico, presentamos recomendaciones para preservar la seguridad del paciente y del equipo quirúrgico con estándares de alta calidad, mediante estrategias reproducibles en la mayoría de los centros hospitalarios.

The Action of 2-Aminoethyldiphenyl Borinate on the Pulmonary Arterial Hypertension and Remodeling of High-Altitude Hypoxemic Lambs.

Calcium signaling is key for the contraction, differentiation, and proliferation of pulmonary arterial smooth muscle cells. Furthermore, calcium influx through store-operated channels (SOCs) is particularly important in the vasoconstrictor response to hypoxia. Previously, we found a decrease in pulmonary hypertension and remodeling in normoxic newborn lambs partially gestated under chronic hypoxia, when treated with 2-aminoethyldiphenyl borinate (2-APB), a non-specific SOC blocker. However, the effects of 2-APB are unknown in neonates completely gestated, born, and raised under environmental hypoxia. Accordingly, we studied the effects of 2-APB-treatment on the cardiopulmonary variables in lambs under chronic hypobaric hypoxia. Experiments were done in nine newborn lambs gestated, born, and raised in high altitude (3,600 m): five animals were treated with 2-APB [intravenous (i.v.) 10 mg kg-1] for 10 days, while other four animals received vehicle. During the treatment, cardiopulmonary variables were measured daily, and these were also evaluated during an acute episode of superimposed hypoxia, 1 day after the end of the treatment. Furthermore, pulmonary vascular remodeling was assessed by histological analysis 2 days after the end of the treatment. Basal cardiac output and mean systemic arterial pressure (SAP) and resistance from 2-APB- and vehicle-treated lambs did not differ along with the treatment. Mean pulmonary arterial pressure (mPAP) decreased after the first day of 2-APB treatment and remained lower than the vehicle-treated group until the third day, and during the fifth, sixth, and ninth day of treatment. The net mPAP increase in response to acute hypoxia did not change, but the pressure area under the curve (AUC) during hypoxia was slightly lower in 2-APB-treated lambs than in vehicle-treated lambs. Moreover, the 2-APB treatment decreased the pulmonary arterial wall thickness and the α-actin immunoreactivity and increased the luminal area with no changes in the vascular density. Our findings show that 2-APB treatment partially reduced the contractile hypoxic response and reverted the pulmonary vascular remodeling, but this is not enough to normalize the pulmonary hemodynamics in chronically hypoxic newborn lambs.

The Effect of Chronic Intermittent Hypobaric Hypoxia on Sleep Quality and Melatonin Serum Levels in Chilean Miners.

High-altitude mining is an important economic resource for Chile. These workers are exposed to chronic intermittent hypobaric hypoxia (CIHH), which reduces their sleep quality and increases the risk of accidents and long-term illnesses. Melatonin, a hormone produced by the pineal gland, is a sleep inducer that regulates the circadian cycle and may be altered in populations subjected to CIHH. This work aimed to assess the relationship between altitude, sleep quality, and plasma melatonin concentrations in miners with CIHH exposure. 288 volunteers were recruited from five altitudes (0, 1,600, 2,500, 3,500, and 4,500 m). All volunteers worked for 7 days at altitude, followed by 7 days of rest at sea level. We performed anthropometric assessments, nocturnal oximetry, sleep quality and sleepiness surveys, and serum melatonin levels upon awakening. Although oxygen saturation progressively decreased and heart rate increased at higher altitudes, subjective perception of sleep quality was not significantly different, and sleepiness increased in all groups compared to population at sea level. Similarly, melatonin levels increased at all assessed altitudes compared to the population at sea level. These data confirm that sleep disturbances associated with CIHH increase morning melatonin levels. Therefore, this hormone and could potentially serve as a biomarker of sleep quality.

Activation of arginase II by asymmetric dimethylarginine and homocysteine in hypertensive rats induced by hypoxia: a new model of nitric oxide synthesis regulation in hypertensive processes?

In recent years, the increase in blood pressure at high altitudes has become an interesting topic among high-altitude researchers. In our animal studies using Wistar rats, we observed the existence of two rat populations that exhibit differential physiological responses during hypoxic exposure. These rats were classified as hypoxia-induced hypertensive rats and nonhypertensive rats. A decrease in nitric oxide levels was reported in different hypertension models associated with increased concentrations of asymmetric dimethylarginine (ADMA) and homocysteine, and we recently described an increase in arginase type II expression under hypoxia. ADMA and homocysteine decrease nitric oxide (NO) bioavailability; however, whether ADMA and homocysteine have a regulatory effect on arginase activity and therefore regulate another NO synthesis pathway is unknown. Therefore, the aim of this study was to measure basal ADMA and homocysteine levels in hypoxia-induced hypertensive rats and evaluate their effect on arginase II activity. Our results indicate that hypoxia-induced hypertensive rats presented lower nitric oxide concentrations than nonhypertensive rats, associated with higher concentrations of homocysteine and ADMA. Hypoxia-induced hypertensive rats also presented lower dimethylarginine dimethylaminohydrolase-2 and cystathionine ß-synthase levels, which could explain the high ADMA and homocysteine levels. In addition, we observed that both homocysteine and ADMA had a significant effect on arginase II activation in the hypertensive rats. Therefore, we suggest that ADMA and homocysteine have dual regulatory effects on NO synthesis. The former has an inhibitory effect on eNOS, and the latter has a secondary activating effect on arginase II. We propose that arginase II is activated by AMDA and homocysteine in hypoxia-induced hypertensive rats.