Dealing with a Modern Crisis: Physicians and End of Life Care

As medicine in the United States has progressed, physicians have been posed with a unique task of shepherding patients into the end of their life. This research sought to determine the effect this has on physicians in the form of what has been coined “professional grief.” In this, we look at preparation through medical school and residency then support once acting as a practicing physician. In order to analyze the experiences of physicians with professional grief, I performed a literature search and conducted interviews with current and retired physicians. This yielded results that demonstrated a lack of preparatory learning activities at both the medical school and resident levels and lack of subsequent support once practicing. However, physicians have found ways to cope such as community, religion, marriage, and narrative medicine. This demonstrates that this may be a crisis, but it is not an inevitable path physicians must take.Keywords: Physician Mental Health, End of Life Care, Professional Grie

Understanding visual attention with RAGNAROC: A Reflexive Attention Gradient through Neural AttRactOr Competition

A quintessential challenge for any perceptual system is the need to focus on task-relevant information without being blindsided by unexpected, yet important information. The human visual system incorporates several solutions to this challenge, one of which is a reflexive covert attention system that is rapidly responsive to both the physical salience and the task-relevance of new information. This paper presents a model that simulates behavioral and neural correlates of reflexive attention as the product of brief neural attractor states that are formed across the visual hierarchy when attention is engaged. Such attractors emerge from an attentional gradient distributed over a population of topographically organized neurons and serve to focus processing at one or more locations in the visual field, while inhibiting the processing of lower priority information. The model moves towards a resolution of key debates about the nature of reflexive attention, such as whether it is parallel or serial, and whether suppression effects are distributed in a spatial surround, or selectively at the location of distractors. Most importantly, the model develops a framework for understanding the neural mechanisms of visual attention as a spatiotopic decision process within a hierarchy and links them to observable correlates such as accuracy, reaction time, and the N2pc and PD components of the EEG. This last contribution is the most crucial for repairing the disconnect that exists between our understanding of behavioral and neural correlates of attention

I tried a bunch of things: The dangers of unexpected overfitting in classification of brain data

Machine learning has enhanced the abilities of neuroscientists to interpret information collected through EEG, fMRI, and MEG data. With these powerful techniques comes the danger of overfitting of hyperparameters which can render results invalid. We refer to this problem as ‘overhyping’ and show that it is pernicious despite commonly used precautions. Overhyping occurs when analysis decisions are made after observing analysis outcomes and can produce results that are partially or even completely spurious. It is commonly assumed that cross-validation is an effective protection against overfitting or overhyping, but this is not actually true. In this article, we show that spurious results can be obtained on random data by modifying hyperparameters in seemingly innocuous ways, despite the use of cross-validation. We recommend a number of techniques for limiting overhyping, such as lock boxes, blind analyses, pre-registrations, and nested cross-validation. These techniques, are common in other fields that use machine learning, including computer science and physics. Adopting similar safeguards is critical for ensuring the robustness of machine-learning techniques in the neurosciences

Clinical features of idiopathic inflammatory polymyopathy in the Hungarian Vizsla

Background A retrospective study of the clinicopathological features of presumed and confirmed cases of idiopathic inflammatory polymyopathy in the Hungarian Vizsla dog and guidelines for breeding. Results 369 medical records were reviewed (1992–2013) and 77 Hungarian Vizslas were identified with a case history consistent with idiopathic inflammatory polymyopathy. Inclusion criteria were: group 1 (confirmed diagnosis); histopathology and clinical findings compatible with an inflammatory polymyopathy and group 2 (probable diagnosis); clinical findings compatible with a polymyopathy including dysphagia, sialorrhea, temporal muscle atrophy, elevated serum creatine kinase (CK) activity, and sufficient clinical history to suggest that other neuromuscular disorders could be ruled out. Some group 2 dogs had muscle biopsy, which suggested muscle disease but did not reveal an inflammatory process. The mean age of onset was 2.4 years; male dogs were slightly overrepresented. Common presenting signs were dysphagia, sialorrhea, masticatory muscle atrophy, and regurgitation. Common muscle histopathological findings included degenerative and regenerative changes, with multifocal mononuclear cell infiltration with lymphoplasmacytic myositis of variable severity. A positive response to immunosuppressive treatment supported an immune-mediated aetiology. The mean age at death and survival time were 6.4 and 3.9 years, respectively. Recurrence of clinical signs and aspiration pneumonia were common reasons for euthanasia. Conclusions Diagnosis of Vizsla idiopathic inflammatory polymyopathy can be challenging due to lack of specific tests, however the presence of dysphagia, regurgitation and masticatory muscle atrophy in this breed with negative serological tests for masticatory muscle myositis and myasthenia gravis, along with muscle biopsies suggesting an inflammatory process, support the diagnosis. However, there is an urgent need for a more specific diagnostic test. The average of inbreeding coefficient (CoI) of 16.3% suggests an increased expression of a Dog Leukocyte Antigen Class II haplotype, leading to an increased disease risk. The prognosis remains guarded, as treatment can only manage the disease. Recurrence of clinical signs and perceived poor quality of life are the most common reasons for humane euthanasia.</p

Convalescent plasma in patients admitted to hospital with COVID-19 (RECOVERY): a randomised controlled, open-label, platform trial

SummaryBackground Azithromycin has been proposed as a treatment for COVID-19 on the basis of its immunomodulatoryactions. We aimed to evaluate the safety and efficacy of azithromycin in patients admitted to hospital with COVID-19.Methods In this randomised, controlled, open-label, adaptive platform trial (Randomised Evaluation of COVID-19Therapy [RECOVERY]), several possible treatments were compared with usual care in patients admitted to hospitalwith COVID-19 in the UK. The trial is underway at 176 hospitals in the UK. Eligible and consenting patients wererandomly allocated to either usual standard of care alone or usual standard of care plus azithromycin 500 mg once perday by mouth or intravenously for 10 days or until discharge (or allocation to one of the other RECOVERY treatmentgroups). Patients were assigned via web-based simple (unstratified) randomisation with allocation concealment andwere twice as likely to be randomly assigned to usual care than to any of the active treatment groups. Participants andlocal study staff were not masked to the allocated treatment, but all others involved in the trial were masked to theoutcome data during the trial. The primary outcome was 28-day all-cause mortality, assessed in the intention-to-treatpopulation. The trial is registered with ISRCTN, 50189673, and ClinicalTrials.gov, NCT04381936.Findings Between April 7 and Nov 27, 2020, of 16 442 patients enrolled in the RECOVERY trial, 9433 (57%) wereeligible and 7763 were included in the assessment of azithromycin. The mean age of these study participants was65·3 years (SD 15·7) and approximately a third were women (2944 [38%] of 7763). 2582 patients were randomlyallocated to receive azithromycin and 5181 patients were randomly allocated to usual care alone. Overall,561 (22%) patients allocated to azithromycin and 1162 (22%) patients allocated to usual care died within 28 days(rate ratio 0·97, 95% CI 0·87–1·07; p=0·50). No significant difference was seen in duration of hospital stay (median10 days [IQR 5 to >28] vs 11 days [5 to >28]) or the proportion of patients discharged from hospital alive within 28 days(rate ratio 1·04, 95% CI 0·98–1·10; p=0·19). Among those not on invasive mechanical ventilation at baseline, nosignificant difference was seen in the proportion meeting the composite endpoint of invasive mechanical ventilationor death (risk ratio 0·95, 95% CI 0·87–1·03; p=0·24).Interpretation In patients admitted to hospital with COVID-19, azithromycin did not improve survival or otherprespecified clinical outcomes. Azithromycin use in patients admitted to hospital with COVID-19 should be restrictedto patients in whom there is a clear antimicrobial indication

Magnetic resonance spectroscopic investigation of central nervous system metabolites in the canine brain as a tool for the investigation of epilepsy

© 2014 Chloe Anne BowmanIdiopathic epilepsy is a common disease causing seizures, and is the most common medical neurological disease of dogs. Idiopathic epilepsy must be differentiated from symptomatic epilepsy in which there is an underlying disease process resulting in seizure activity. Brain tumours, malformations of cortical development, inflammatory or infectious disease processes can all cause seizures. The incidence of idiopathic epilepsy is estimated at around 0.86% to 2% of the canine population and roughly 25% of dogs have refractory epilepsy. Seizures, whether they are secondary to tumours, or from drug resistant epilepsy, are a major cause of morbidity and mortality. A greater understanding of cerebral metabolites and neurotransmitters may provide an opportunity for the instigation of therapy directly targeted at the underlying trigger to recurrent seizure activity. Magnetic resonance spectroscopy is a useful means of analysing brain metabolites in vivo in a non-invasive manner. It is performed by recording the spectroscopic data from a small region of brain, and can be performed during traditional magnetic resonance imaging sequencing. Metabolites examined include N-acetyl-aspartate, a marker of neuronal viability, choline, a marker of membrane turnover, creatine, needed for cellular energy, myo-inositol, found in astrocytes, and lipids and lactate, present in areas of necrosis. Recently magnetic resonance spectroscopy has also been used to identify the presence of altered concentrations of glutamate in brain lesions and in the peritumoural tissue of humans with symptomatic epilepsy, and also in the brain tissue of patients with idiopathic epilepsy. By examining metabolites in normal canine controls, this project has quantified the absolute concentrations of the main central nervous system metabolites in the hippocampus of normal dogs. This is an area of interest in human research, as it is a common source of an epileptic focus. Twenty control dogs were placed under general anaesthesia, and a voxel of interest was placed over the hippocampus in the left and right hemispheres. The spectra were then analysed using the LC computer software model of analysis. Results of this analysis found that the main cerebral metabolites in dogs differ in concentration to those in people. A normal range for the metabolites choline, creatine, glutamate, myo-inositol and N-acetyl-aspartate was generated, and will allow analysis of these metabolites in disease states in dogs in future studies

A crisis of underinsurance threatens to scar rural Australia permanently

Australia is in the midst of a bushfire crisis that will affect local communities for years, if not permanently, due to a national crisis of underinsurance. Already more than 1,500 homes have been destroyed - with months still to go in the bushfire season. Compare this to 2009, when Victoria\u27s Black Saturday fires claimed more than 2,000 homes in February, or 1983, when the Ash Wednesday fires destroyed about 2,400 homes in Victoria and South Australia, also in February. The 2020 fire season could end up surpassing these tragedies, despite the lessons learned and improvements in preparedness. One lesson not really learned, though, is that home insurance is rarely sufficient to enable recovery. The evidence is many people losing their homes will find themselves unable to rebuild, due to lack of insurance. We know this from interviews with those affected by the October 2013 Blue Mountains bushfires (in which almost 200 homes were destroyed). Despite past disasters, more than 65% of households affected were underinsured. Research published by the Victorian government in 2017, meanwhile, estimated just 46% Victorian households have enough insurance to recover from a disaster, with 28% underinsured and 26% having no insurance. The consequences aren\u27t just personal. They potentially harm local communities permanently, as those unable to rebuild move away. Communities lose the vital knowledge and social networks that make them resilient to disaster

Weight loss after weight-loss surgery: The mediating role of dichotomous thinking

Purpose: Overly rigid forms of dietary restraint are associated with poorer weight loss outcomes. Dichotomous (“all or nothing”) thinking has been shown to mediate this relationship in non-clinical participants, but this finding has yet to be replicated in clinical samples of individuals who have had weight-loss surgery. Materials and Methods: A cross-sectional design was used, adopting quantitative questionnaires with 129 individuals who had previously underwent bariatric surgery at least 12 months prior to participation. Bootstrapped mediation analysis was used to establish the mediating role of dichotomous thinking. Results: Eating-specific dichotomous thinking was shown to fully mediate the relationship between dietary restraint and post-surgical weight loss. In contrast, no mediation effect was found for generalised dichotomous thinking. Conclusion: Dichotomous thinking specifically about food/eating may play a central role in weight loss maintenance after weight-loss surgery. Pre-surgical assessment of dichotomous thinking, and provision of psychological therapy to think more flexibly about food, is suggested

Weight loss after weight-loss surgery: The mediating role of dichotomous thinking

Purpose: Overly rigid forms of dietary restraint are associated with poorer weight loss outcomes. Dichotomous (“all or nothing”) thinking has been shown to mediate this relationship in non-clinical participants, but this finding has yet to be replicated in clinical samples of individuals who have had weight-loss surgery. Materials and Methods: A cross-sectional design was used, adopting quantitative questionnaires with 129 individuals who had previously underwent bariatric surgery at least 12 months prior to participation. Bootstrapped mediation analysis was used to establish the mediating role of dichotomous thinking. Results: Eating-specific dichotomous thinking was shown to fully mediate the relationship between dietary restraint and post-surgical weight loss. In contrast, no mediation effect was found for generalised dichotomous thinking. Conclusion: Dichotomous thinking specifically about food/eating may play a central role in weight loss maintenance after weight-loss surgery. Pre-surgical assessment of dichotomous thinking, and provision of psychological therapy to think more flexibly about food, is suggested