Combining a deep learning model with clinical data better predicts hepatocellular carcinoma behavior following surgery.

Hepatocellular carcinoma (HCC) is among the most common cancers worldwide, and tumor recurrence following liver resection or transplantation is one of the highest contributors to mortality in HCC patients after surgery. Using artificial intelligence (AI), we developed an interdisciplinary model to predict HCC recurrence and patient survival following surgery. We collected whole-slide H&E images, clinical variables, and follow-up data from 300 patients with HCC who underwent transplant and 169 patients who underwent resection at the Cleveland Clinic. A deep learning model was trained to predict recurrence-free survival (RFS) and disease-specific survival (DSS) from the H&E-stained slides. Repeated cross-validation splits were used to compute robust C-index estimates, and the results were compared to those obtained by fitting a Cox proportional hazard model using only clinical variables. While the deep learning model alone was predictive of recurrence and survival among patients in both cohorts, integrating the clinical and histologic models significantly increased the C-index in each cohort. In every subgroup analyzed, we found that a combined clinical and deep learning model better predicted post-surgical outcome in HCC patients compared to either approach independently.

Co-use of MDMA with psilocybin/LSD may buffer against challenging experiences and enhance positive experiences.

Psilocybin and lysergic acid diethylamide (LSD) experiences can range from very positive to highly challenging (e.g., fear, grief, and paranoia). These challenging experiences contribute to hesitancy toward psychedelic-assisted psychotherapy among health care providers and patients. Co-use of 3,4-Methylenedioxy methamphetamine (MDMA) with psilocybin/LSD anecdotally reduces challenging experiences and enhances positive experiences associated with psilocybin/LSD. However, limited research has investigated the acute effects of co-use of MDMA and psilocybin/LSD. In a prospective convenience sample (N = 698) of individuals with plans to use psilocybin/LSD, we examined whether co-use of MDMA with psilocybin/LSD (n = 27) is associated with differences in challenging or positive experiences. Challenging experiences were measured using the Challenging Experiences Questionnaire and positive experiences were measured using the Mystical Experience Questionnaire and single-item measures of self-compassion, compassion, love, and gratitude. Potentially confounding variables were identified and included as covariates. Relative to psilocybin/LSD alone, co-use of psilocybin/LSD with a self-reported low (but not medium-high) dose of MDMA was associated with significantly less intense total challenging experiences, grief, and fear, as well as increased self-compassion, love and gratitude. Co-use of psilocybin/LSD and MDMA was not associated with differences in mystical-type experiences or compassion. Findings suggest co-use of MDMA with psilocybin/LSD may buffer against some aspects of challenging experiences and enhance certain positive experiences. Limitations include use of a convenience sample, small sample size, and non-experimental design. Additional studies (including controlled dose-response studies) that examine the effects and safety of co-administering MDMA with psilocybin/LSD (in healthy controls and clinical samples) are warranted and may assist the development of personalized treatments.

MDMA-Assisted Psychotherapy for Borderline Personality Disorder.

Borderline personality disorder is a complex psychiatric disorder with limited treatment options that are associated with large heterogeneity in treatment response and high rates of dropout. New or complementary treatments for borderline personality disorder are needed that may be able to bolster treatment outcomes. In this review, the authors comment on the plausibility for research on 3,4-methylenedioxymethamphetamine (MDMA) used in conjunction with psychotherapy for borderline personality disorder (i.e., MDMA-assisted psychotherapy [MDMA-AP]). On the basis of the promise of MDMA-AP in treating disorders overlapping with borderline personality disorder (e.g., posttraumatic stress disorder), the authors speculate on initial treatment targets and hypothesized mechanisms of change that are grounded in prior literature and theory. Initial considerations for designing MDMA-AP clinical trials to investigate the safety, feasibility, and preliminary effects of MDMA-AP for borderline personality disorder are also presented.

Multiorgan Dysfunction Related to Kratom Ingestion.

Consumption of herbal supplements has been linked to multiorgan toxicities. Kratom is an herbal extract that has gained popularity for its analgesic and psychotropic properties. Several cases of kratom-induced liver injury have been reported, but data on multiorgan involvement remain scarce. We present the case of a 37-year-old woman who developed a mixed hepatocellular and cholestatic pattern of acute liver injury, acute kidney injury, and pancolitis after prolonged use of kratom-containing herbal supplements.

Suicidality Among Psychiatrically Hospitalized Lesbian, Gay, Bisexual, Transgender, Queer, and/or Questioning Youth: Risk and Protective Factors.

Purpose: The study purpose was to compare suicide risk between lesbian, gay, bisexual, transgender, queer, and/or questioning (LGBTQ) and non-LGBTQ adolescents in a psychiatric hospital. Methods: Data were obtained from self-report measures completed by patients 12-17 years of age (n = 334) in a Midwestern psychiatric hospital from 2016 to 2017. Factors analyzed included sexual orientation, gender identity, suicidality, depression, nonsuicidal self-injury, abuse, substance use, bullying, perceived discrimination, and adult support. Results: Nearly one-third of patients identified as LGBTQ. A lifetime suicide attempt was reported by 69.6% of LGBTQ patients compared with 43.6% of non-LGBTQ patients. However, the prevalence of suicide attempts among LGBTQ patients with high adult support did not differ from that of non-LGBTQ patients. In the full logistic regression model adjusting for 13 factors, the adjusted odds ratio of a suicide attempt was 5.25 among transgender/questioning patients and 2.41 among nontransgender lesbian, gay, bisexual, queer, or questioning patients. All risk factors, apart from substance use, were more prevalent among LGBTQ than non-LGBTQ patients (p < 0.005). Among LGBTQ patients of color (Black/Latinx/Other), 91.3% had a lifetime suicide attempt versus 62.3% of White LGBTQ patients (p = 0.009). Conclusion: LGBTQ patients overall, and LGBTQ patients of color in particular, had higher rates of suicide attempts than non-LGBTQ patients. LGBTQ patients also had a higher prevalence of risk factors for suicide; however, the study variables did not fully explain the higher prevalence of suicide attempts. Future research should further examine possible risk factors for suicide among LGBTQ youth, such as stigma and discrimination.

Diagnosis and Use of Psychotherapy Among Children and Adolescents Prescribed Antipsychotics.

OBJECTIVE: To examine the diagnoses, demographics, and prevalence of psychotherapy use among children and adolescents prescribed antipsychotics by psychiatric providers in a community setting. METHODS: Medical records from 1127 children aged 0 to 17 years who were prescribed antipsychotics in 2014-2015 at Pine Rest Christian Mental Health Services (PRCMHS) outpatient network were analyzed. Antipsychotics, diagnosis codes, demographics, and number of psychotherapy sessions during this time frame were analyzed using χ and logistic regression analyses. RESULTS: During this year, 50.8% of the patients attended psychotherapy, and 35.6% attended 5 or more sessions of psychotherapy. The most prevalent primary diagnosis was bipolar disorder (37.1%), followed by attention-deficit/hyperactivity disorder (19.7%). Females being treated with antipsychotics were significantly more likely to attend psychotherapy than their male peers (55.7% vs. 47.9%, P=0.01). In the fully adjusted models, patients with diagnoses of bipolar disorder or disorders first diagnosed in infancy, childhood, or adolescence were less than half as likely to attend psychotherapy as patients with depressive disorders, with adjusted odds ratios of 0.41 and 0.42, respectively. CONCLUSIONS: Approximately half of the child and adolescent patients prescribed antipsychotics in this community sample did not attend psychotherapy, and 39% of the patients did not have a diagnosis of bipolar disorder, psychotic disorder, or autistic disorder.

A Point-based Histologic Scoring System for Hepatocellular Carcinoma Can Stratify Risk of Posttransplant Tumor Recurrence.

Eligibility for liver transplant is most commonly decided by measuring tumor size and number on radiographic imaging. However, this method often underestimates the extent of disease. Evaluation of tumor histology has been shown to improve risk stratification when compared with imaging-based transplant criteria, but the World Health Organization (WHO) guidelines for grading hepatocellular carcinoma (HCC) are imprecise and require subjective interpretation by the pathologist. We performed a retrospective analysis of 190 explanted livers containing HCC and correlated histologic features with posttransplant recurrence to formulate a three-tiered, point-based scoring system that categorizes tumors as having a low, intermediate, or high risk of recurrence. Our Recurrence Risk Assessment Score (RRAS) evaluates tumor architecture and specific cytologic features-nuclear pleomorphism, cytoplasmic amphophilia, and nuclear-to-cytoplasmic ratio-showing superior stratification of HCC recurrence risk compared with imaging criteria and grade assigned by WHO methodology. Stratifying tumors using RRAS criteria, the rate of recurrence after transplant was 0% among low-risk tumors (compared with 3% of well-differentiated tumors), 12% among intermediate-risk tumors (compared with 15% of moderately differentiated tumors), and 54% among high-risk tumors (compared with 29% of poorly differentiated tumors). Receiver operating characteristic analysis shows significantly improved performance of RRAS criteria in predicting HCC recurrence compared with WHO grade (area under curve of 0.841 and 0.671, respectively; P=0.0061). Our results indicate that evaluation of tumor histology offers superior prediction of recurrence risk following liver transplantation compared with radiographic criteria, and that the RRAS system better stratifies recurrence risk compared with HCC grading by WHO methodology.

Serous carcinoma of the ovary with squamous differentiation: a case report and a literature review.

Serous carcinoma of the ovary showing squamous differentiation is a rarely reported neoplasm. We present 1 case of such a tumor extensively involving the adnexa and the pelvis, which shows these 2 intimately entwined, yet with morphologically and immunohistochemically distinct patterns of differentiation. We also report immunohistochemical evidence of protein expression changes in areas of this carcinoma that provide evidence for differentiation from a serous to a squamous phenotype.

The prevalence and clinical significance of inhalant withdrawal symptoms among a national sample.

BACKGROUND: Inhalants are among the most common and dangerous forms of substance use, but very little research on inhalant use disorders exist. Unlike other substances, the Diagnostic and Statistical Manual, 4th edition (DSM-IV) indicates that inhalants do not have an associated withdrawal syndrome among persons who meet criteria for inhalant dependence. METHODS: Using data from the National Epidemiologic Survey on Alcohol and Related Conditions, this study examines the prevalence of withdrawal symptoms among inhalant users. Prevalence of inhalant withdrawal symptoms for inhalants was also compared with the prevalence of cocaine withdrawal symptoms to help determine the presence of an inhalant withdrawal syndrome. RESULTS: Approximately 47.8% of persons who met criteria for inhalant dependence reported experiencing three or more inhalant-related withdrawal symptoms that were clinically significant. Among those with inhalant dependence, almost half of the withdrawal symptoms were as common as the corresponding withdrawal symptoms experienced by persons with cocaine dependence. Furthermore, the percentage of persons with inhalant dependence reporting clinically significant inhalant withdrawal symptoms was almost equal to the percentage of persons with cocaine dependence reporting clinically significant cocaine withdrawal symptoms. CONCLUSIONS: These data provide evidence for an inhalant-related withdrawal syndrome among persons with inhalant dependence. Revisions to DSM-IV should consider including inhalant withdrawal as a diagnostic criterion for this disorder.

High occupancy increases the risk of early death or readmission after transfer from intensive care.

OBJECTIVE: To determine whether a lack of intensive care unit beds was leading to premature patient discharge from the intensive care unit and subsequent early readmission or death. DESIGN: Prospective cohort study. SETTING: A single Canadian tertiary care teaching hospital. PATIENTS: All intensive care unit admissions between January 1, 1989 and December 31, 1996 were collected prospectively for inclusion in a registry database. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: There was a positive correlation between early readmission or death and average quarterly intensive care unit percent occupancy (p = .001). During the study period, 8693 patients experienced 10,185 admissions to intensive care. Of the 8222 patients remaining under active treatment (patients under palliative care were excluded), there were 455 (5.5%) adverse events (431 intensive care unit readmissions and 24 deaths) in the first 7 days post intensive care unit discharge. Patients requiring a new surgical intervention with postoperative intensive care unit admission were not considered readmissions. In a multivariate analysis, significant risk factors for an adverse event included age >35 yrs, particular diagnoses (respiratory diagnoses, sepsis, neurosurgery, thoracic surgery, and gastrointestinal diagnoses), Acute Physiology and Chronic Health Evaluation II score, and intensive care unit length of stay. Discharge from the intensive care unit at a time of no vacancy was also a significant risk factor for intensive care unit readmission or unexpected death with an adjusted relative risk of 1.56 (95% confidence interval 1.05, 2.31). CONCLUSIONS: Increased patient occupancy within an intensive care unit is associated with an increased risk of early death or intensive care unit readmission post intensive care unit discharge. Overloading the capacity of an intensive care unit to care for critically ill patients may affect physician decision-making, resulting in premature discharge from the intensive care unit.

Effects of lateral diffusion on morphology and dynamics of a microscopic lattice-gas model of pulsed electrodeposition.

The influence of nearest-neighbor diffusion on the decay of a metastable low-coverage phase (monolayer adsorption) in a square lattice-gas model of electrochemical metal deposition is investigated by kinetic Monte Carlo simulations. The phase-transformation dynamics are compared to the well-established Kolmogorov-Johnson-Mehl-Avrami theory. The phase transformation is accelerated by diffusion, but remains in accord with the theory for continuous nucleation up to moderate diffusion rates. At very high diffusion rates the phase-transformation kinetic shows a crossover to instantaneous nucleation. Then, the probability of medium-sized clusters is reduced in favor of large clusters. Upon reversal of the supersaturation, the adsorbate desorbs, but large clusters still tend to grow during the initial stages of desorption. Calculation of the free energy of subcritical clusters by enumeration of lattice animals yields a quasiequilibrium distribution which is in reasonable agreement with the simulation results. This is an improvement relative to classical droplet theory, which fails to describe the distributions, since the macroscopic surface tension is a bad approximation for small clusters.