Dynamic Interactive Social Cognition Training in Virtual Reality (DiSCoVR) versus Virtual Reality Relaxation (VRelax) for People With a Psychotic Disorder: A Single-Blind Multicenter Randomized Controlled Trial.

BACKGROUND AND HYPOTHESIS: Social cognition training (SCT), an intervention for social cognition and social functioning, might be improved by using virtual reality (VR), because VR may offer better opportunities to practice in a potentially more realistic environment. To date, no controlled studies have investigated VR-SCT. This study investigated a VR-SCT, "DiSCoVR". We hypothesized that DiSCoVR would improve social cognition and social functioning. STUDY DESIGN: Participants were randomized to DiSCoVR (n = 41) or VR relaxation ('VRelax', n = 40), an active control condition, and completed 16 twice-weekly sessions. Three assessments (baseline, posttreatment, and 3-month follow-up) were performed by blinded assessors. The primary outcome was social cognition (emotion perception and theory of mind). Secondary outcomes included social functioning (measured with an interview and experience sampling), psychiatric symptoms, information processing, and self-esteem. Data were analyzed using mixed-models regression analysis. Treatment effects were evaluated by the time by condition interaction terms. STUDY RESULTS: No significant time by condition interactions were found for any of the outcome variables, indicating an absence of treatment effects. Between-group effect sizes ranged from negligible to moderate (Cohen's d < |0.53|). Main effects of time were found for several outcomes. CONCLUSIONS: These results suggest that DiSCoVR was not effective, possibly because of inadequate simulation of emotional expressions in VR. This lack of efficacy may indicate that current SCT protocols are relatively unsuitable for improving social functioning. Previous studies showed small to moderate effects on higher order social cognition, but the SCT approach may need critical reevaluation, as it may not sufficiently lead to functional improvement.

[Differential diagnosis in patients with suspected anoxic-ischaemic coma]. / Differentiaaldiagnose bij patiënten bij wie een anoxisch-ischemisch coma wordt vermoed.

Three case studies illustrate that suspected anoxic-ischaemic coma often requires careful differential diagnosis to detect treatable conditions. A 47-year-old man underwent cardiopulmonary resuscitation for ventricular fibrillation caused by myocardial ischaemia. He exhibited rhythmic eyelid movements while in a coma. Epilepsy was suspected, and the patient regained consciousness after being treated with antiepileptic drugs. A 34-year-old man underwent cardiopulmonary resuscitation for multiple episodes of ventricular fibrillation. Treatment was directed toward myocardial ischaemia and included anticoagulants. The patient had bilateral, fixed dilated pupils. A CT of the brain showed traumatic contrecoup haemorrhage in the left temporal lobe with signs of transtentorial herniation. The patient died. A 74-year-old woman was found unconscious at home. An ECG performed by the paramedics showed ST segment elevation in the precordial leads. Anoxic-ischaemic coma following cardiac arrest was suspected. However, a coronary angiogram was normal and a CT of the brain revealed subarachnoid haemorrhage caused by a ruptured intracranial aneurysm. She recovered after cranial surgery.

Low-dose fondaparinux in suspected heparin-induced thrombocytopenia in the critically ill.

BACKGROUND: In critically ill patients, heparin-induced thrombocytopenia (HIT) is estimated to account for approximately 1 to 10% of all causes of thrombocytopenia. HIT exerts a strong procoagulant state. In case of suspected HIT, it is an important clinical decision to stop heparin and start treatment with alternative nonheparin anticoagulation, awaiting the results of laboratory testing for the final diagnosis of HIT (bridging therapy). Fondaparinux acts by factor Xa inhibition and expresses no cross-reactivity with HIT antibodies. Excretion of fondaparinux is mainly renal. We describe our early experience with fixed low-dose fondaparinux bridging therapy and monitoring of anticoagulant activity for safety reasons. METHODS: This retrospective cohort study was conducted in a closed format general intensive care unit in a teaching hospital. Consecutive critically ill patients suspected of HIT were treated with fondaparinux after discontinuation of unfractionated heparin or nadroparin. Anti-Xa levels were determined afterwards. RESULTS: Seven patients were treated with fondaparinux 2.5 mg/day for 1.8 to 6.5 days. Anti-Xa levels varied from 0.1 to 0.6 U/ml. A negative correlation was found between creatinine clearance and mean and maximum anti-Xa levels. No thromboembolic complications occurred. Bleeding complications were only minor during fondaparinux treatment. Transfusion requirements did not differ significantly between treatment episodes with fondaparinux or with heparin anticoagulants. CONCLUSION: In this small sample of critically ill patients suspected of HIT, bridging therapy with fixed low-dose fondaparinux resulted in prophylactic and therapeutic anti-Xa levels. Monitoring of anticoagulant activity is advised in patients with renal insufficiency.

Interventions to support shared decision-making for women with heavy menstrual bleeding: A systematic review.

This review studies women's preferences for shared decision-making about heavy menstrual bleeding treatment and evaluates interventions that support shared decision-making and their effectiveness. PubMed, Cochrane, Embase, Medline and ClinicalTrials.gov were searched. Three research questions were predefined: 1) What is the range of perspectives gathered in studies that examine women facing a decision related to heavy menstrual bleeding management?; 2) What types of interventions have been developed to support shared decision-making for women experiencing heavy menstrual bleeding?; and 3) In what way might women benefit from interventions that support shared decision-making? All original studies were included if the study population consisted of women experiencing heavy menstrual bleeding. We used the TIDieR (Template for Intervention: Description and Replication) checklist to assess the quality of description and the reproducibility of interventions. Interventions were categorized using Grande et al. guidelines and collated and summarized outcomes measures into three categories: 1) patient-reported outcomes; 2) observer-reported outcomes; and 3) doctor-reported outcomes. Fifteen studies were included. Overall, patients preferred to decide together with their doctor (74%). Women's previsit preference was the strongest predictor for treatment choice in two studies. Information packages did not have a statistically significant effect on treatment choice or satisfaction. However, adding a structured interview or decision aid to increase patient involvement did show a positive effect on treatment choice and results, patient satisfaction and shared decision-making related outcomes. In conclusion shared decision-making is becoming more important in the care of women with heavy menstrual bleeding. Structured interviews or well-designed (computerized) tools such as decision aids seem to facilitate this process, but there is room for improvement. A shared treatment choice is only possible after careful provision of information, elicitation of patients' preferences and integrating those preferences. Interventions should be designed accordingly.

Cefotaxime combined with selective decontamination in long term intensive care unit patients. Virtual absence of emergence of resistance.

Emergence of bacterial resistance to antimicrobial agents was studied during a period of 30 months of continuous use of parenteral cefotaxime combined with oral non-absorbable polymyxin E and tobramycin (selective decontamination) in a surgical intensive care unit (ICU). No increase in drug-resistance micro-organisms was found. Colonisation of the oropharyngeal cavity or intestine or both by strains resistant to polymyxin E occurred in 8% of patients (invariably Proteus and Morganella species). Tobramycin-resistant strains (Escherichia coli, Acinetobacter and Pseudomonas species) were found in 4% of patients. Intestinal colonisation with cefotaxime-resistant bacilli (e.g. Enterobacter, Pseudomonas and Acinetobacter species) occurred in 10% of patients, but in most patients these strains were eliminated by therapy with the topical antibiotics within one week. The control of emergence of resistance has major implications for the antibiotic policy in the ICU: firstly, the number of different antimicrobials used is sharply reduced since the switching of antibiotics to treat suprainfections is seldom necessary; secondly, it is possible to use a third generation cephalosporin such as cefotaxime for systemic prophylaxis, without risk of induction of resistance.

Monitoring differential CO2 excretion during differential lung ventilation in asymmetric pulmonary contusion. Clinical implications.

Eighteen severely injured polytrauma patients (ISS 38 +/- 18) with severe asymmetric pulmonary contusion were ventilated with differential lung ventilation (DLV) to improve oxygenation and/or to prevent further unnecessary barotrauma to the lesser involved lung. Differential VCO2 was studied as a parameter for indirect measurement of effective individual pulmonary perfusion. One hour after starting DLV, difference in differential VCO2 (delta VCO2) was 81 +/- 57 ml/min. In 16 patients this had fallen significantly (p less than 0.001) to 32 +/- 30 ml/min, 1 h before DLV was discontinued. In 2 patients, VCO2 remained greater than 200 ml/min, coinciding with clinical deterioration and increasing consolidation of the pulmonary contusion. Bilobectomies were performed in both patients. The excised lobes appeared to be destroyed as the result of laceration, bleeding and subsequent haematomas. This clinical study supports laboratory studies suggesting the usefulness of monitoring differential VCO2 to assess effective differential pulmonary perfusion during DLV.

Reflection of differential pulmonary perfusion in polytrauma patients on differential lung ventilation (DLV). A comparison of two CO2-derived methods.

Seventeen polytrauma patients with asymmetric pulmonary contusion were treated with differential lung ventilation (DLV). The ratios of differential values of end-tidal CO2 concentration (ETCO2) and CO2 excretion ml/min (VCO2) were compared as indirect parameters for differential pulmonary perfusion. Both CO2-derived methods indicated asymmetry after starting DLV suggesting asymmetric pulmonary perfusion as a consequence of contusion. Prior to stopping DLV a significant improvement in asymmetry was indicated by the differential ratios of ETCO2 and VCO2 values. The ETCO2 ratio increased from 0.74 +/- 0.17 to 0.88 +/- 0.10, the VCO2 ratio from 0.57 +/- 0.23 to 0.86 +/- 0.11. In two patients with very severe contusion who underwent bilobectomies a marked difference between the ratios of ETCO2 and VCO2 was observed. It is concluded that differential measurement of CO2-derived variables may be useful in indicating differential perfusion in clinical practice on DLV. In very severe asymmetric contusion ETCO2 ratios may underestimate the differential perfusion ratio.

Treatment of massive unilateral pulmonary embolism by differential lung ventilation.

A patient with massive unilateral pulmonary embolism was treated with thrombolytic therapy and differential lung ventilation and selective PEEP. Differential lung ventilation affords besides therapy, selective monitoring of VCO2. Effects of thrombolytic therapy and SPEEP were evaluated by monitoring differential VCO2. Hypercapnia persisting in spite of conventional mechanical ventilation reduced remarkably after starting differential lung ventilation with selective PEEP on the noninjured lung.

The virtual absence of stress-ulceration related bleeding in ICU patients receiving prolonged mechanical ventilation without any prophylaxis. A prospective cohort study.

OBJECTIVE: To study the incidence of stress-ulcer related bleeding in ICU patients receiving prolonged (> 2 days) mechanical ventilation without any stress ulceration prophylaxis. DESIGN: A prospective cohort study in 183 patients. INTERVENTIONS: All patients received clinical treatment including maintenance of adequate tissue perfusion (with low dose inotropes and vasodilators), infection prevention (by selective decontamination of the digestive tract) throughout ICU stay and suppression of generalized inflammatory reaction (by steroids). SETTING: Medical/surgical ICU of a major teaching hospital in Amsterdam (Onze Lieve Vrouwe Gasthuis). MEASUREMENTS AND RESULTS: 167 patients were evaluated during 2182 treatment days in the ICU and during 1753 days on mechanical ventilation without stress ulceration prophylaxis. The mean total risk score for stress ulceration related bleeding was 38 (Tryba score). Stress ulceration related bleeding developed in 1 patient (0.6%). CONCLUSIONS: The incidence of SURB was less then 1% in this cohort of ICU patients receiving longterm mechanical ventilation with a high risk for SURB (mean total risk score 38). All patients received agressive shock resuscitation, infection prevention with selective decontamination of the digestive tract (SDD) and suppression of inflammatory response with steroids. Further studies are needed to evaluate the contribution of each of these elements of the integral approach.

A new hygroscopic condenser humidifier.

A new hygroscopic condenser humidifier for the mechanically ventilated patient has been tested. It functions as a heat and moisture exchange device (HME) with an additional hygroscopic sponge to minimize the water loss from the breathing circuit. A comparative in vitro study was undertaken with a conventional HME. The influence of tidal volume, inspiratory flow rate and minute volume on the relative humidity of the inspiratory gas and on the water loss was investigated. The new device provides adequate humidification within a broad scale of ventilatory settings. In a subsequent clinical test the hygroscopic condenser humidifier proved to be a simple and reliable way of humidification.

Non-invasive pulmonary blood flow measurement by means of CO2 analysis of expiratory gases.

Two different methods of CO2-derived non-invasive assessment of the pulmonary blood flow were evaluated. The principle of the formula, as proposed by Gedeon et al., is based on a rapid change in arterial CO2 content and subsequent changes in endtidal PCO2 and CO2 elimination. Both methods were compared to thermodilution cardiac output in 44 postoperative patients after CABG. The first method consisted of a short period of hyperventilation followed by hypoventilation. Comparison with the thermodilution cardiac output showed a low correlation coefficient: using a measured arterial--end-tidal PCO2 difference (E) r = 0.397 was found. Entering a fixed E of 0.53 kPa resulted in r = 0.454. These disappointing figures may be explained by procedural mistakes. The second method, based on partial rebreathing by means of adding an additional dead space of 220 ml for 30-45 s, correlated very well with the thermodilution findings. Correlation coefficients of r = 0.925 (measured E) and r = 0.925 (fixed E) were found. Considering the simplicity of the method, the additional dead space approach seems to be an easy and reliable way to determine pulmonary blood flow.

Efficacy of a heat and moisture exchange device during high-frequency jet ventilation.

A hygroscopic condensor humidifier has been tested during high-frequency jet ventilation, in an experimental set up. The influence of various ventilator settings on relative humidity, temperature and water content of the inspiratory and expiratory gases was investigated. The device provides adequate conditioning of the inspired gases with regard to relative humidity, temperature and water content at various ventilator settings.

Low dose amiodarone pulmonary toxicity in a patient with a history of pneumonectomy.

A case of amiodarone pulmonary toxicity (APT) is described following a low dosage of amiodarone (200 mg/day) with serious respiratory insufficiency in a patient after right pneumonectomy. The patient was successfully treated by discontinuation of amiodarone, mechanical ventilation and prednisolone (40 mg/day). A literature study indicates that APT is a dose related toxicity. In our opinion a higher pulmonary drug concentration of amiodarone could exist from a change in pharmacokinetics because of a low fat storage in a thin patient and compensatory growth of the remaining lung which occurs after pneumonectomy. Given these findings we suggest that if amiodarone is indicated in such patients both loading and maintenance doses should be adapted.

Monitoring lung mechanics and airway pressures during differential lung ventilation (DLV) with emphasis on weaning from DLV.

Fifteen polytrauma patients with asymmetric pulmonary contusion were treated with differential lung ventilation (DLV) for a mean of 106 hours (range 24-298, median 83). The differential time constant (Tc), compliance (Ct), inspiratory and expiratory airway resistance (Rawinsp, Rawexp) and peak-airway pressure (Pawpeak) were monitored to evaluate the function of each lung. Values measured after starting DLV were compared to those obtained prior to stopping DLV in order to analyse whether these parameters had returned to symmetrical values when recommencement of conventional mechanical ventilation was considered on clinical parameters and also whether these could be useful criteria for weaning from DLV. The significant difference in Tc of the contused lung compared to the contralateral lung after starting DLV is mainly determined by altered Ct resulting from contusion. During DLV improvement of Ct resulted in identical Tc of both lungs prior to stopping DLV. Changes in the Rawinsp contributed little to changes in Tc. Identical Tc prior to stopping DLV coincided with identical Pawpeak on symmetrical ventilator settings. These data suggest that when less advanced monitoring equipment is available, the differential Pawpeak might be used as a measure of differential lung mechanics in asymmetrical pulmonary contusion.