Pro/con debate: Should synthetic colloids be used in patients with septic shock?

You have recently heard reports that synthetic colloids may be associated with renal failure and other morbidities in certain populations of critically ill patients. You have been asked by the hospital chief of staff whether there should be a suspension of the use of synthetic colloids until further information is available. You need to make a decision

Factors influencing communication and decision-making about life-sustaining technology during serious illness: A qualitative study

© 2016, BMJ Publishing Group. All rights reserved. Objectives: We aimed to identify factors influencing communication and decision-making, and to learn how physicians and nurses view their roles in deciding about the use of life-sustaining technology for seriously ill hospitalised patients and their families. Design: The qualitative study used Flanagan\u27s critical incident technique to guide interpretive description of open-ended in-depth individual interviews. Setting: Participants were recruited from the medical wards at 3 Canadian hospitals. Participants: Interviews were completed with 30 healthcare professionals (9 staff physicians, 9 residents and 12 nurses; aged 25-63 years; 73% female) involved in decisions about the care of seriously ill hospitalised patients and their families. Measures: Participants described encounters with patients and families in which communication and decision-making about life-sustaining technology went particularly well and unwell (ie, critical incidents). We further explored their roles, context and challenges. Analysis proceeded using constant comparative methods to form themes independently and with the interprofessional research team. Results: We identified several key factors that influenced communication and decision-making about life-sustaining technology. The overarching factor was how those involved in such communication and decision-making (healthcare providers, patients and families) conceptualised the goals of medical practice. Additional key factors related to how preferences and decision-making were shaped through relationships, particularly how people worked toward \u27making sense of the situation\u27, how physicians and nurses approached the inherent and systemic tensions in achieving consensus with families, and how physicians and nurses conducted professional work within teams. Participants described incidents in which these key factors interacted in dynamic and unpredictable ways to influence decision-making for any particular patient and family. Conclusions: A focus on more meaningful and productive dialogue with patients and families by (and between) each member of the healthcare team may improve decisions about life-sustaining technology. Work is needed to acknowledge and support the non-curative role of healthcare and build capacity for the interprofessional team to engage in effective decision-making discussions

Self-harm and suicidal acts: a suitable case for treatment of impulsivity-driven behaviour with repetitive transcranial magnetic stimulation (rTMS).

SUMMARY: Suicidal thinking, self-harm and suicidal acts are common, although determining their precise prevalence is complex. Epidemiological work has identified a number of associated demographic and clinical factors, though, with the exception of past acts of self-harm, these are non-specific and weak future predictors. There is a critical need shift focus from managing 'suicidality-by-proxy' through general mental health treatments, to better understand the neuropsychology and neurophysiology of such behaviour to guide targeted interventions. The model of the cognitive control of emotion (MCCE) offers such a paradigm, with an underlying pan-diagnostic pathophysiology of a hypoactive prefrontal cortex failing to suitably inhibit an overactive threat-responding limbic system. The result is a phenotype - from any number of causative gene-environment interactions - primed to impulsively self-harm. We argue that such neural dysconnectivity is open to potential therapeutic modification from repetitive transcranial magnetic stimulation (rTMS). The current evidence base for this is undoubtedly extremely limited, but the societal and clinical burden self-harm and suicide pose warrants such investigation. DECLARATION OF INTEREST: K.B. is the Editor of BJPsych Open, but had no editorial involvement in the review or decision process regarding this paper. COPYRIGHT AND USAGE: © The Royal College of Psychiatrists 2015. This is an open access article distributed under the terms of the Creative Commons Non-Commercial, No Derivatives (CC BY-NC-ND) licence.D.K.T., S.S.S. and A.S.D. are supported by the National Institute of Health Research Biomedical Research Centre (BRC) at the South London & Maudsley NHS Foundation Trust and the Institute of Psychiatry, Psychology and Neuroscience, King’s College London

Hemispheric Asymmetry in White Matter Connectivity of the Temporoparietal Junction with the Insula and Prefrontal Cortex

The temporoparietal junction (TPJ) is a key node in the brain's ventral attention network (VAN) that is involved in spatial awareness and detection of salient sensory stimuli, including pain. The anatomical basis of this network's right-lateralized organization is poorly understood. Here we used diffusion-weighted MRI and probabilistic tractography to compare the strength of white matter connections emanating from the right versus left TPJ to target regions in both hemispheres. Symmetry of structural connectivity was evaluated for connections between TPJ and target regions that are key cortical nodes in the right VAN (insula and inferior frontal gyrus) as well as target regions that are involved in salience and/or pain (putamen, cingulate cortex, thalamus). We found a rightward asymmetry in connectivity strength between the TPJ and insula in healthy human subjects who were scanned with two different sets of diffusion-weighted MRI acquisition parameters. This rightward asymmetry in TPJ-insula connectivity was stronger in females than in males. There was also a leftward asymmetry in connectivity strength between the TPJ and inferior frontal gyrus, consistent with previously described lateralization of language pathways. The rightward lateralization of the pathway between the TPJ and insula supports previous findings on the roles of these regions in stimulus-driven attention, sensory awareness, interoception and pain. The findings also have implications for our understanding of acute and chronic pains and stroke-induced spatial hemineglect

The role of the right temporoparietal junction in perceptual conflict: detection or resolution?

The right temporoparietal junction (rTPJ) is a polysensory cortical area that plays a key role in perception and awareness. Neuroimaging evidence shows activation of rTPJ in intersensory and sensorimotor conflict situations, but it remains unclear whether this activity reflects detection or resolution of such conflicts. To address this question, we manipulated the relationship between touch and vision using the so-called mirror-box illusion. Participants' hands lay on either side of a mirror, which occluded their left hand and reflected their right hand, but created the illusion that they were looking directly at their left hand. The experimenter simultaneously touched either the middle (D3) or the ring finger (D4) of each hand. Participants judged, which finger was touched on their occluded left hand. The visual stimulus corresponding to the touch on the right hand was therefore either congruent (same finger as touch) or incongruent (different finger from touch) with the task-relevant touch on the left hand. Single-pulse transcranial magnetic stimulation (TMS) was delivered to the rTPJ immediately after touch. Accuracy in localizing the left touch was worse for D4 than for D3, particularly when visual stimulation was incongruent. However, following TMS, accuracy improved selectively for D4 in incongruent trials, suggesting that the effects of the conflicting visual information were reduced. These findings suggest a role of rTPJ in detecting, rather than resolving, intersensory conflict

Common cortical responses evoked by appearance, disappearance and change of the human face

<p>Abstract</p> <p>Background</p> <p>To segregate luminance-related, face-related and non-specific components involved in spatio-temporal dynamics of cortical activations to a face stimulus, we recorded cortical responses to face appearance (Onset), disappearance (Offset), and change (Change) using magnetoencephalography.</p> <p>Results</p> <p>Activity in and around the primary visual cortex (V1/V2) showed luminance-dependent behavior. Any of the three events evoked activity in the middle occipital gyrus (MOG) at 150 ms and temporo-parietal junction (TPJ) at 250 ms after the onset of each event. Onset and Change activated the fusiform gyrus (FG), while Offset did not. This FG activation showed a triphasic waveform, consistent with results of intracranial recordings in humans.</p> <p>Conclusion</p> <p>Analysis employed in this study successfully segregated four different elements involved in the spatio-temporal dynamics of cortical activations in response to a face stimulus. The results show the responses of MOG and TPJ to be associated with non-specific processes, such as the detection of abrupt changes or exogenous attention. Activity in FG corresponds to a face-specific response recorded by intracranial studies, and that in V1/V2 is related to a change in luminance.</p

Development of a Finite Volume Inter-cell Polynomial Expansion Method for the Neutron Diffusion Equation

Heterogeneous nuclear reactors require numerical methods to solve the neutron diffusion equation (NDE) to obtain the neutron flux distribution inside them, by discretizing the heterogeneous geometry in a set of homogeneous regions. This discretization requires additional equations at the inner faces of two adjacent cells: neutron flux and current continuity, which imply an excess of equations. The finite volume method (FVM) is suitable to be applied to NDE, because it can be easily applied to any mesh and it is typically used in the transport equations due to the conservation of the transported quantity within the volume. However, the gradient and face-averaged values in the FVM are typically calculated as a function of the cell-averaged values of adjacent cells. So, if the materials of the adjacent cells are different, the neutron current condition could not be accomplished. Therefore, a polynomial expansion of the neutron flux is developed in each cell for assuring the accomplishment of the flux and current continuity and calculating both analytically. In this polynomial expansion, the polynomial terms for each cell were assigned previously and the constant coefficients are determined by solving the eigenvalue problem with SLEPc. A sensitivity analysis for determining the best set of polynomial terms is performed.This work has been partially supported by the Spanish Ministerio de Eduacion Cultura y Deporte [grant number FPU13/01009]; the Spanish Ministerio de Ciencia e Innovacion [project number ENE2014-59442-P], [project number ENE2012-34585]; the Generalitat Valenciana [project number PROMETEOII/2014/008]; the Universitat Politecnica de Valencia [project number UPPTE/2012/118]; and the Spanish Ministerio de Economia y Competitividad [project number TIN2013-41049-P].Bernal García, Á.; Román Moltó, JE.; Miró Herrero, R.; Ginestar Peiro, D.; Verdú Martín, GJ. (2016). Development of a Finite Volume Inter-cell Polynomial Expansion Method for the Neutron Diffusion Equation. Journal of Nuclear Science and Technology. 53(8):1212-1223. https://doi.org/10.1080/00223131.2015.1102661S1212122353