Parent-led, stepped-care cognitive-behavioral therapy for youth with autism and co-occurring anxiety: study rationale and method

Anxiety disorders affect up to 50% of individuals with autism spectrum disorder (ASD) and are significantly impairing to the person affected, as well as to their loved ones. Cognitive-behavioral therapy (CBT) has been established as the gold-standard treatment for anxiety disorders among typically developing youth and adults, and demonstrates similar efficacy among youth with high-functioning autism (HFA). Many CBT interventions utilize a "full-package" treatment approach to treat co-occurring anxiety in youth with ASD. However, these service delivery systems are often therapist-intensive, costly, and impractical, thereby compromising full engagement and treatment adherence. This paper describes the design, rationale, and methodology of a study examining stepped-care CBT for youth with HFA and co-occurring anxiety - a clinical trial examining the efficacy of low-intensity, parent-led CBT as the first line of treatment and utilizing a more intensive, therapist-led intervention for nonresponders. The study will evaluate the potential benefits of stepped-care and parent-led therapist-assisted interventions, predictors of treatment response, and the economic value of using a stepped-care model. Implications for practice will be discussed.

Efficacy of low residue enteral formula versus clear liquid diet during bowel preparation for colonoscopy: a randomised controlled pilot trial / Eficácia da fórmula enteral pobre em resíduo versus dieta líquida clara durante o preparo intestinal para colonoscopia: um estudo piloto controlado e randomizado

ABSTRACT Objectives: Conventional bowel preparation for colonoscopy confines patient to clear liquid diet the day before and such non-nutritive dietary regimen often caused discomfort and hunger. The purpose of this study is to determine the feasibility of feeding patient with low-residue, lactose-free semi-elemental enteral formula (PEPTAMEN®) compare to conventional clear liquid diet during bowel preparation before colonoscopy. Methods: This was a randomised, endoscopist-blinded study. Patients were randomised into two groups, those receiving oral PEPTAMEN® and mechanical bowel preparation (A) and those receiving clear liquid while undergoing mechanical bowel preparation (B). Documentation was made with regard to the type of bowel cleansing agents used, completeness of the colonoscopy, cleanliness quality score, and hunger score. Results: A total of 97 patients were included in the study, A = 48 and B = 49. Eight patients, who were not compliant to the bowel-cleansing agent or had an incomplete colonoscopic examination, were excluded from the study. In terms of the overall cleanliness score, no statistical significant difference was seen (p = 0.25) between the two groups, A (fair or poor 37.5%, good or excellent 62.5%) and B (fair or poor 49%, good or excellent 51%) whereas the hunger score showed a significant difference (p = 0.016), A (no hunger 41.7%, slight hunger 12.5%, hungry 12.5%) and B (no hunger 24.5%, slight hunger 38.8%, hungry 36.7%). Conclusions: These data suggest that the addition of oral PEPTAMEN® as part of the bowel preparation regimen did not significantly alter the luminal cleanliness score during colonoscopy while alleviating hunger.

RESUMO Objetivo: A preparação intestinal convencional para a colonoscopia confina o paciente à dieta líquida clara no dia anterior; esse regime dietético não nutritivo frequentemente causa desconforto e fome. O presente estudo teve como objetivo determinar a viabilidade de alimentar o paciente com fórmula enteral semielementar sem lactose e pobre em resíduos (PEPTAMEN®) em comparação com a dieta líquida clara convencional no preparo intestinal para colonoscopia. Métodos: Este foi um estudo randomizado no qual o endoscopista foi cego quanto ao tipo de preparo. Os pacientes foram randomizados em dois grupos: aqueles que receberam PEPTAMEN® oral e preparo intestinal mecânico (A) e aqueles que receberam dieta líquida clara e preparo intestinal mecânico (B). Os pacientes foram avaliados quanto ao tipo de agente de limpeza intestinal utilizado, a completude da colonoscopia, o escore de qualidade de limpeza e o escore de fome. Resultados: Um total de 97 pacientes foram incluídos no estudo, 48 no grupo A e 49 no grupo B. Oito pacientes foram excluídos por não aderirem ao agente de limpeza intestinal ou apresentarem um exame incompleto de colonoscopia. Quanto ao escore geral de limpeza, não se observou diferença estatisticamente significativa (p = 0,25) entre os grupos A (resultado regular ou ruim, 37,5%; bom ou excelente, 62,5%) e B (resultado regular ou ruim, 49%; bom ou excelente, 51%). Por outro lado, o escore de fome apresentou diferença significativa (p = 0,016) entre os grupos A (sem fome, 41,7%; fome leve, 12,5%; fome, 12,5%) e B (sem fome, 24,5%; fome leve, 38,8%; fome, 36,7%). Conclusões: Os dados sugerem que a adição de PEPTAMEN® oral como parte do regime de preparo intestinal não altera significativamente o escore de limpeza luminal durante a colonoscopia, mas alivia a fome.

Are critical size bone notch defects possible in the rabbit mandible?

OBJECTIVES@#Small animal maxillofacial models, such as non-segmental critical size defects (CSDs) in the rabbit mandible, need to be standardized for use as preclinical models of bone regeneration to mimic clinical conditions such as maxillofacial trauma. The objective of this study is the establishment of a mechanically competent CSD model in the rabbit mandible to allow standardized evaluation of bone regeneration therapies.@*MATERIALS AND METHODS@#Three sizes of bony defect were generated in the mandibular body of rabbit hemi-mandibles: 12 mm×5 mm, 12 mm×8 mm, and 15 mm×10 mm. The hemi-mandibles were tested to failure in 3-point flexure. The 12 mm×5 mm defect was then chosen for the defect size created in the mandibles of 26 rabbits with or without cautery of the defect margins and bone regeneration was assessed after 6 and 12 weeks. Regenerated bone density and volume were evaluated using radiography, micro-computed tomography, and histology.@*RESULTS@#Flexural strength of the 12 mm×5 mm defect was similar to its contralateral; whereas the 12 mm×8 mm and 15 mm×10 mm groups carried significantly less load than their respective contralaterals (P<0.05). This demonstrated that the 12 mm×5 mm defect did not significantly compromise mandibular mechanical integrity. Significantly less (P<0.05) bone was regenerated at 6 weeks in cauterized defect margins compared to controls without cautery. After 12 weeks, the bone volume of the group with cautery increased to that of the control without cautery after 6 weeks.@*CONCLUSION@#An empty defect size of 12 mm×5 mm in the rabbit mandibular model maintains sufficient mechanical stability to not require additional stabilization. However, this defect size allows for bone regeneration across the defect. Cautery of the defect only delays regeneration by 6 weeks suggesting that the performance of bone graft materials in mandibular defects of this size should be considered with caution.

Are critical size bone notch defects possible in the rabbit mandible?

OBJECTIVES: Small animal maxillofacial models, such as non-segmental critical size defects (CSDs) in the rabbit mandible, need to be standardized for use as preclinical models of bone regeneration to mimic clinical conditions such as maxillofacial trauma. The objective of this study is the establishment of a mechanically competent CSD model in the rabbit mandible to allow standardized evaluation of bone regeneration therapies. MATERIALS AND METHODS: Three sizes of bony defect were generated in the mandibular body of rabbit hemi-mandibles: 12 mm×5 mm, 12 mm×8 mm, and 15 mm×10 mm. The hemi-mandibles were tested to failure in 3-point flexure. The 12 mm×5 mm defect was then chosen for the defect size created in the mandibles of 26 rabbits with or without cautery of the defect margins and bone regeneration was assessed after 6 and 12 weeks. Regenerated bone density and volume were evaluated using radiography, micro-computed tomography, and histology. RESULTS: Flexural strength of the 12 mm×5 mm defect was similar to its contralateral; whereas the 12 mm×8 mm and 15 mm×10 mm groups carried significantly less load than their respective contralaterals (P<0.05). This demonstrated that the 12 mm×5 mm defect did not significantly compromise mandibular mechanical integrity. Significantly less (P<0.05) bone was regenerated at 6 weeks in cauterized defect margins compared to controls without cautery. After 12 weeks, the bone volume of the group with cautery increased to that of the control without cautery after 6 weeks. CONCLUSION: An empty defect size of 12 mm×5 mm in the rabbit mandibular model maintains sufficient mechanical stability to not require additional stabilization. However, this defect size allows for bone regeneration across the defect. Cautery of the defect only delays regeneration by 6 weeks suggesting that the performance of bone graft materials in mandibular defects of this size should be considered with caution.

Clinically localized type 1 and 2 papillary renal cell carcinomas have similar survival outcomes following surgery / Los carcinomas papilares de células renales tipo 1 y 2 localizados clínicamente tienen resultados de supervivencia similares después de la cirugía

Propósito Se intentó determinar la incidencia, hallazgos patológicos, factores pronósticos y resultados clínicos para pacientes con CCR papilar clínicamente localizado. Métodos Demográfico, Se recopilaron hallazgos clínicos y patológicos en todos los pacientes con CCRP sometidos a cirugía en cuatro centros médicos académicos. El punto final primario fue la supervivencia específica del cáncer (CSS). La supervivencia sin recaída (RFS) y la supervivencia general (OS) fueron puntos finales secundarios. Kaplan- Se obtuvieron estimaciones de Meier y se usaron modelos de regresión de riesgos proporcionales de Cox para evaluar predictores de mortalidad y recaída. Resultados Identificamos 626 CCPR, de los cuales 373 (60por ciento) fueron del tipo 1 y 253 (40 por ciento) fueron del tipo 2, con tres cuartas partes de todos los tumores siendo pT1. En comparación con los pacientes con tipo 1, aquellos con tipo 2 eran mayores (edad media: 63 frente a 61; (AU)

Purpose We aimed to determine incidence, pathologic fndings, prognostic factors and clinical outcomes for patients with clinically localized papillary RCC. Methods Demographic, clinical and pathologic fndings were collected on all patients with PRCC undergoing sur-gery at four academic medical centers. The primary end-point was cancer-specifc survival (CSS). Relapse-free survival (RFS) and overall survival (OS) were secondary endpoints. Kaplan­ Meier estimates were obtained, and Cox proportional hazard regression models were used to assess predictors of mortality and relapse. Results We identifed 626 PRCC, of which 373 (60 pertcent) were type 1 and 253 (40 pertcent) were type 2, with three-quar-ters of all tumors being pT1. Compared to patients with type 1, those with type 2 were older (mean age: 63 vs 61; (AU)

A physical fitness profile of state highway patrol officers by gender and age

BACKGROUND: Law enforcement officers perform physically demanding tasks that generally remain constant as they age. However, there is limited population-specific research on age, gender and normative fitness values for law enforcement officers as opposed to those of the general population. The purpose of this study was to profile the current level of fitness for highway patrol officers based on age and gender and provide percentile ranking charts unique to this population. METHODS: Retrospective data for six-hundred and thirty-one state troopers (♂ = 597; mean age = 39.52 ± 8.09 yrs; mean height = 180.72 ± 7.06 cm; mean weight = 93.66 ± 15.72 kg: ♀ = 34; mean age = 36.20 ± 8.45 years; mean height = 169.62 ± 6.65 cm; mean weight = 74.02 ± 14.91 kg) collected in 2014–2015 were provided for analysis. Data included demographic (age), anthropometric (height and weight), and select fitness (VJ, push-ups, sit ups, isometric leg/back strength, isometric grip strength and 20 m shuttle run test) information. RESULTS: There were generally significant differences between genders for all anthropometric and fitness measures, most consistently in the 30–39 age groups. While there was a general decline in push-up and shuttle run performance in female officers, these results did not reach significance. For male officers, there were significant differences between the 20–29 year-old age group and the 30–39, 40–49 and 50–59 year-old groups with the younger group performing better in VJ, push-ups, sit ups and number of shuttle runs than the older groups. There were no differences in isometric grip strength and leg back dynamometer measures between age groups. CONCLUSION: Male officers tended to be heavier, taller and perform significantly better than female officers in all measures bar sit-ups. While there appeared to be a general decline in certain physical characteristics across genders with increasing age the notable differences were between the youngest male age group (20–29 years) and all other male age groups with a potential reason being the lack of fitness requirements once typically younger cadets leave the academy. Percentile rankings for the assessed measures were found to have elements very specific to this population when compared to the general population and those provided in this paper can be used to inform future profiling and research in this population.

Investigation of a pre-clinical mandibular bone notch defect model in miniature pigs: clinical computed tomography, micro-computed tomography, and histological evaluation

OBJECTIVES: To validate a critical-size mandibular bone defect model in miniature pigs. MATERIALS AND METHODS: Bilateral notch defects were produced in the mandible of dentally mature miniature pigs. The right mandibular defect remained untreated while the left defect received an autograft. Bone healing was evaluated by computed tomography (CT) at 4 and 16 weeks, and by micro-CT and non-decalcified histology at 16 weeks. RESULTS: In both the untreated and autograft treated groups, mineralized tissue volume was reduced significantly at 4 weeks post-surgery, but was comparable to the pre-surgery levels after 16 weeks. After 16 weeks, CT analysis indicated that significantly greater bone was regenerated in the autograft treated defect than in the untreated defect (P=0.013). Regardless of the treatment, the cortical bone was superior to the defect remodeled over 16 weeks to compensate for the notch defect. CONCLUSION: The presence of considerable bone healing in both treated and untreated groups suggests that this model is inadequate as a critical-size defect. Despite healing and adaptation, the original bone geometry and quality of the pre-injured mandible was not obtained. On the other hand, this model is justified for evaluating accelerated healing and mitigating the bone remodeling response, which are both important considerations for dental implant restorations.

Psychosis, Catatonia and Post-psychosis PTSD.

We are describing the case of a 27-year-old female with no previous psychiatric history who developed post-psychotic PTSD after presenting with first episode catatonia and psychosis. The patient initially presented to the emergency department with increasingly disorganized behavior and paranoid thinking over the course of one week in the context of multiple life stressors. Soon after admission, the patient became catatonic; demonstrating mutism, stereotyped behaviors, and echolalia. After ruling out an organic cause for the catatonia, the patient was treated with Lorazepam, which minimaly improved her catatonia, but revealed active psychosis. In particular, she voiced a scenario that she was sexually assaulted by several men at her mother’s home in the time leading up to her admission. An investigation by law enforcement ruled out the occurrence of assault. However, the patient, expressed vivid dreams, nightmares, and distress centered on her assault. Various anti-psychotics were trialed with little effect (Risperidone, Olanzapine, Haloperidol, and Clozapine). Given that she exhibited several characteristics of PTSD, other agents inlucluding: Escitalopram, Prazosin, and Divalproic were initiated to target her PTSD-like symptoms. On this regimen, the patient showed significant improvement in her mental status and functioning. Thiothixene was added to target residual symptoms of her psychosis. She was discharged to home in the care of her mother and on follow-up remembered little of her psychosis and denied any trauma or occurrence of sexual assault in the past.

Writing on One’s Own Demise: Suicide Notes in the Age of the Internet.

One to two people out of six who attempt suicide will leave a note behind. In comparison to notes written on paper, internet suicide notes may differ in a variety of characteristics, as they illustrate different degrees of real-time experiences. Given continuous internet traffic, awareness, likelihood of rapid detection and discovery by potential readers is more likely online. Therefore, internet traffic may change the communication dynamic of suicidal wish and intent. The question posed then is: are internet suicide note writers a different population of suicidal individuals compared to those who leave behind paper suicide notes? While some strides on suicide prevention on the internet are emerging, we propose that four areas of exploration on cybersuicide could benefit from the development of safeguards and intervention: exploration of suicide sites; Facebook traffic on suicide; Suicide blogs and bloggers, and personal communication via email and social media. While many unanswered questions remain regarding the feasibility of a unified approach, in the long run the development of intervention strategies should become a priority in research. Such strategies would include the development of extended online professional networks. While these networks would create a major privacy challenge for the online community, they may also become a model for addressing healthcare issues online. In order to accomplish such an online community, allocation of significant resources, the development of specialized technology and the worldwide cooperation of mental health professionals would be necessary.

Periodic Catatonia after Thyroid Cancer.

We are presenting the case of a 52 year old female with three distinct episodes of clinical deterioration over a 20 year period after thyroid cancer treatment. The first decrease in functioning happened after the diagnosis of thyroid cancer, resulting in the patient not achieving her PhD thesis. The second deterioration happened ten years later when she presented with psychotic symptoms and the symptoms of anorexia. The last period of deterioration occurred one year before this hospitalization. During that time the patient worsened to the point where she became bedbound and dependent on a PEG tube for feeding. Once hospitalized, the patient had partial response to lorazepam (27 mg a day) and so dextroamphetamine was added with positive response. The addition of memantine helped with the residual symptoms. The PEG tube was finally able to be removed and the patient was discharged home in stable condition.

Exploring the Non-Linear Relationship between Alcohol Consumption and Depression in an Elderly Population in Gangneung: The Gangneung Health Study

PURPOSE: The purpose of this study was to examine a J-shaped relationship between alcohol consumption and depression among the elderly in South Korea. MATERIALS AND METHODS: Cross-section data were drawn from a community-based sample of individuals 60 years of age and older (n=1819). Respondents completed the Alcohol Use Disorders Intensification Test (AUDIT) and the Korean Beck Depression Inventory. Using a regression approach, the effect of alcohol consumption as a non-linear effect was assessed in relation to gender, marital status, exercise, smoking, age, education, and physical and mental health. RESULTS: AUDIT total score were found to exert linear and quadratic effects that were significantly associated with higher depression scores among sample respondents. The results lend support to a J-shaped relationship between alcohol use and depression, wherein abstainers and problem drinkers were at a higher risk of depression. CONCLUSION: This study confirms a J-shaped (i.e., curvilinear) relationship between alcohol consumption and depression among elderly South Koreans, similar to that frequently found in studies of Western-based samples. The findings of this study, therefore, imply the applicability of the J-shaped relationship hypothesis for non-Western society samples and within different cultural contexts.

Exploring the Non-Linear Relationship between Alcohol Consumption and Depression in an Elderly Population in Gangneung: The Gangneung Health Study

PURPOSE: The purpose of this study was to examine a J-shaped relationship between alcohol consumption and depression among the elderly in South Korea. MATERIALS AND METHODS: Cross-section data were drawn from a community-based sample of individuals 60 years of age and older (n=1819). Respondents completed the Alcohol Use Disorders Intensification Test (AUDIT) and the Korean Beck Depression Inventory. Using a regression approach, the effect of alcohol consumption as a non-linear effect was assessed in relation to gender, marital status, exercise, smoking, age, education, and physical and mental health. RESULTS: AUDIT total score were found to exert linear and quadratic effects that were significantly associated with higher depression scores among sample respondents. The results lend support to a J-shaped relationship between alcohol use and depression, wherein abstainers and problem drinkers were at a higher risk of depression. CONCLUSION: This study confirms a J-shaped (i.e., curvilinear) relationship between alcohol consumption and depression among elderly South Koreans, similar to that frequently found in studies of Western-based samples. The findings of this study, therefore, imply the applicability of the J-shaped relationship hypothesis for non-Western society samples and within different cultural contexts.

A Negative Association between Social Support and Depression in the Elderly Population of Amirkola City.

Introduction: Depression is one of the most common psychiatric disorders in old age. The aim of the study was to investigate the relationship between social support and depression in elderly population of Amirkola city, northern Iran. Also, a few studies have been conducted to determine whether there is any association between social support and depression in different cultural settings, e.g. in western countries. Methodology: This cross sectional study came from the Amirkola Health and Ageing Project (AHAP), that was undertaken among 1612 older people aged 60 years and over (881 males and 731 females) in Amirkola. The sampling method was done using the census records. Depression was assessed via the shortened 15 item version of Geriatric Depression Scale (GDS) and social support measured by the shortened 11 item version of the Duke Social Support Index (DSSI). Results: The prevalence of depressive symptoms was 43.4%. The mean social support score in the subjects without depressive symptoms was 28.32±2.79 which has been significantly higher than those with depressive symptoms 25.86±3.44. Linear regression analysis displays the variables in the final model like social support, age, gender, education, living status; social support was negatively the most associated variable with depression (β for social satisfaction= -0.245, P<0.001 and for social interaction 0 -0.199 P<0.001). Thus for the males, those who are younger, those who are more educated, those who are married and those who are employed, their social support scores were higher. Conclusions: Lack of social support is negatively associated with depression in the elderly people in Iran.

Fluid distribution kinetics during cardiopulmonary bypass

OBJECTIVE: The purpose of this study was to examine the isovolumetric distribution kinetics of crystalloid fluid during cardiopulmonary bypass. METHODS: Ten patients undergoing coronary artery bypass grafting participated in this prospective observational study. The blood hemoglobin and the serum albumin and sodium concentrations were measured repeatedly during the distribution of priming solution (Ringer's acetate 1470 ml and mannitol 15% 200 ml) and initial cardioplegia. The rate of crystalloid fluid distribution was calculated based on 3-min Hb changes. The preoperative blood volume was extrapolated from the marked hemodilution occurring during the onset of cardiopulmonary bypass. Clinicaltrials.gov: NCT01115166. RESULTS: The distribution half-time of Ringer's acetate averaged 8 minutes, corresponding to a transcapillary escape rate of 0.38 ml/kg/min. The intravascular albumin mass increased by 5.4% according to mass balance calculations. The preoperative blood volume, as extrapolated from the drop in hemoglobin concentration by 32% (mean) at the beginning of cardiopulmonary bypass, was 0.6-1.2 L less than that estimated by anthropometric methods (p<0.02). The mass balance of sodium indicated a translocation from the intracellular to the extracellular fluid space in 8 of the 10 patients, with a median volume of 236 ml. CONCLUSIONS: The distribution half-time of Ringer's solution during isovolumetric cardiopulmonary bypass was 8 minutes, which is the same as for crystalloid fluid infusions in healthy subjects. The intravascular albumin mass increased. Most patients were hypovolemic prior to the start of anesthesia. Intracellular edema did not occur. .

Fluid volume kinetics of dilutional hyponatremia; a shock syndrome revisited

OBJECTIVE: To evaluate whether the pathophysiology of shock syndromes can be better understood by comparing central hemodynamics with kinetic data on fluid and electrolyte shifts. METHODS: We studied the dilutional hyponatremic shock that developed in response to overhydration with electrolyte-free irrigating fluid - the so-called ‘transurethral resection syndrome' - by comparing cardiac output, arterial pressures, and volume kinetic parameters in 17 pigs that were administered 150 ml/kg of either 1.5% glycine or 5% mannitol by intravenous infusion over 90 minutes. RESULTS: Natriuresis appeared to be the key factor promoting hypovolemic hypotension 15-20 minutes after fluid administration ended. Excessive sodium excretion, due to osmotic diuresis caused by the irrigant solutes, was associated with high estimates of the elimination rate constant (k10) and low or negative estimates of the rate constant describing re-distribution of fluid to the plasma after translocation to the interstitium (k21). These characteristics indicated a high urinary flow rate and the development of peripheral edema at the expense of plasma volume and were correlated with reductions in cardiac output. The same general effects of natriuresis were observed for both irrigating solutions, although the volume of infused 1.5% glycine had a higher tendency to enter the intracellular fluid space. CONCLUSION: Comparisons between hemodynamics and fluid turnover showed a likely sequence of events that led to hypovolemia despite intravenous administration of large amounts of fluid. .

Evolution of Minimally Invasive Approaches to the Sella and Parasellar Region

Introduction: Given advancements in endoscopic image quality, instrumentation, surgical navigation, skull base closure techniques, and anatomical understanding, the endonasal endoscopic approach has rapidly evolved into a widely utilized technique for removal of sellar and parasellar tumors. Although pituitary adenomas and Rathke cleft cysts constitute the majority of lesions removed via this route, craniopharyngiomas, clival chordomas, parasellar meningiomas, and other lesions are increasingly removed using this approach. Paralleling the evolution of the endonasal route to the parasellar region, the supraorbital eyebrow craniotomy has also been increasingly used as an alternative minimally invasive approach to reach this skull base region. Similar to the endonasal route, the supraorbital route has been greatly facilitated by advances in endoscopy, along with development of more refined, low-profile instrumentation and surgical navigation technology. Objectives: This review, encompassing both transcranial and transsphenoidal routes, will recount the high points and advances that have made minimally invasive approaches to the sellar region possible, the evolution of these approaches, and their relative indications and technical nuances. Data Synthesis: The literature is reviewed regarding the evolution of surgical approaches to the sellar region beginning with the earliest attempts and emphasizing technological advances, which have allowed the evolution of the modern technique. The surgical techniques for both endoscopic transsphenoidal and supraorbital approaches are described in detail. The relative indications for each approach are highlighted using case illustrations. Conclusions: Although tremendous advances have been made in transitioning toward minimally invasive transcranial and transsphenoidal approaches to the sella, furtherwork remains to be done. Together, the endonasal endoscopic and the supraorbital endoscope-assisted approaches are...

Dehydration, hemodynamics and fluid volume optimization after induction of general anesthesia

OBJECTIVES: Fluid volume optimization guided by stroke volume measurements reduces complications of colorectal and high-risk surgeries. We studied whether dehydration or a strong hemodynamic response to general anesthesia increases the probability of fluid responsiveness before surgery begins. METHODS: Cardiac output, stroke volume, central venous pressure and arterial pressures were measured in 111 patients before general anesthesia (baseline), after induction and stepwise after three bolus infusions of 3 ml/kg of 6% hydroxyethyl starch 130/0.4 (n = 86) or Ringer's lactate (n = 25). A subgroup of 30 patients who received starch were preloaded with 500 ml of Ringer's lactate. Blood volume changes were estimated from the hemoglobin concentration and dehydration was estimated from evidence of renal water conservation in urine samples. RESULTS: Induction of anesthesia decreased the stroke volume to 62% of baseline (mean); administration of fluids restored this value to 84% (starch) and 68% (Ringer's). The optimized stroke volume index was clustered around 35-40 ml/m2/beat. Additional fluid boluses increased the stroke volume by ≥10% (a sign of fluid responsiveness) in patients with dehydration, as suggested by a low cardiac index and central venous pressure at baseline and by high urinary osmolality, creatinine concentration and ...

Therapeutic modalities in systemic lupus erythematosus

Systemic lupus erythematosus [SLE] is a complex autoimmune disease with significant clinical heterogeneity. Its pathogenesis is complex and involves multigenic components, dysregulation of T and B lymphocytes and the presence of autoantibodies, which form the basis for inflammation, and the pathology found in the various organ systems. Traditional treatments for SLE have included non-steroidal anti-inflammatory drugs, antimalarials, corticosteroids, and cytotoxic/immunosuppressants, but a recent emphasis on the development of biological agents that inhibit autoreactive B cells, interrupt cytokine signaling and facilitate the development of regulatory T cells has become a new modality in treating the disease. This review will delve into the pathogenesis of the disease process, as well as the current and up and coming novel biological treatment and other therapies for specific disease manifestations, such as neuropsychiatric SLE and cutaneous lupus erythematosus, and detail the shift to immune targeted therapies and novel treatments being developed for specific manifestations of the disease