PhD

dissertationThe physiological consequences of major thermal injury center around profound, life-threatening shock occurring in conjunction with the burn and consisting of two pathological syndromes: hypovolemic and cellular shock. Intravascular hypovolemia following major thermal injury results from increased capillary permeability with subsequent loss of intravascular fluid into the interstitium. The purpose of this study was to evaluate the effect of a therapeutic regime involving the removal of the circulating factors by performing plasma exchange. Fourteen adult patients with burns of 40% total body surface area (TBSA) served as subjects. Seven were randomly assigned to the control group which received standard burn shock resuscitation. Seven were randomly assigned to the treatment group which received the same resuscitation in combination with plasma exchange. The study period was the first 48 hours postburn with the plasma exchange procedures performed as soon as was clinically feasible. A total of 937 measurements of physiological variables were made on each patient. These included vital signs, cardiopulmonary parameters, respiratory status, and serum content analysis measured upon admission and every 4 hours thereafter during the study period. Hourly fluid intake and output records were compiled. Data were analyzed for statistical significance. The findings were as follows: the sample was unevenly distributed, with the treatment group more critically ill than the control on the basis of the variable or percent TBSA full-thickness injury (p < .01) and the incidence of documented inhalation injury. No significant difference was found between the groups on the variable of fluid requirement, either in subjects with or without associated inhalation injury. Plasma exchange significantly decreased platelet count (p < .05) in the treatment group when compared with the control but did not alter other serum chemistry values. The coagulopathy reported to occur in burn patients was not observed in this group of 14 subjects. The plasma exchange group was in significantly (p < .05) more normal base excess balance at both postburn hour 16 and 24 than the control. There was no evidence that plasma exchange performed during burn shock for the purpose of removing circulating factors was harmful in any way to the treatment subjects

Vicarious Experience Affects Patients' Treatment Preferences for Depression

Depression is common in primary care but often under-treated. Personal experiences with depression can affect adherence to therapy, but the effect of vicarious experience is unstudied. We sought to evaluate the association between a patient's vicarious experiences with depression (those of friends or family) and treatment preferences for depressive symptoms.We sampled 1054 English and/or Spanish speaking adult subjects from July through December 2008, randomly selected from the 2008 California Behavioral Risk Factor Survey System, regarding depressive symptoms and treatment preferences. We then constructed a unidimensional scale using item analysis that reflects attitudes about antidepressant pharmacotherapy. This became the dependent variable in linear regression analyses to examine the association between vicarious experiences and treatment preferences for depressive symptoms.Our sample was 68% female, 91% white, and 13% Hispanic. Age ranged from 18-94 years. Mean PHQ-9 score was 4.3; 14.5% of respondents had a PHQ-9 score >9.0, consistent with active depressive symptoms. Analyses controlling for current depression symptoms and socio-demographic factors found that in patients both with (coefficient 1.08, p = 0.03) and without (coefficient 0.77, p = 0.03) a personal history of depression, having a vicarious experience (family and friend, respectively) with depression is associated with a more favorable attitude towards antidepressant medications.Patients with vicarious experiences of depression express more acceptance of pharmacotherapy. Conversely, patients lacking vicarious experiences of depression have more negative attitudes towards antidepressants. When discussing treatment with patients, clinicians should inquire about vicarious experiences of depression. This information may identify patients at greater risk for non-adherence and lead to more tailored patient-specific education about treatment

Identifying the sources of uncertainty in climate model simulations of solar radiation modification with the G6sulfur and G6solar Geoengineering Model Intercomparison Project (GeoMIP) simulations

We present here results from the Geoengineering Model Intercomparison Project (GeoMIP) simulations for the experiments G6sulfur and G6solar for six Earth system models participating in the Climate Model Intercomparison Project (CMIP) Phase 6. The aim of the experiments is to reduce the warming that results from a high-tier emission scenario (Shared Socioeconomic Pathways SSP5-8.5) to that resulting from a medium-tier emission scenario (SSP2-4.5). These simulations aim to analyze the response of climate models to a reduction in incoming surface radiation as a means to reduce global surface temperatures, and they do so either by simulating a stratospheric sulfate aerosol layer or, in a more idealized way, through a uniform reduction in the solar constant in the model. We find that over the final two decades of this century there are considerable inter-model spreads in the needed injection amounts of sulfate (29±9Tg-SO2/yr between 2081 and 2100), in the latitudinal distribution of the aerosol cloud and in the stratospheric temperature changes resulting from the added aerosol layer. Even in the simpler G6solar experiment, there is a spread in the needed solar dimming to achieve the same global temperature target (1.91±0.44). The analyzed models already show significant differences in the response to the increasing CO2 concentrations for global mean temperatures and global mean precipitation (2.05K±0.42K and 2.28±0.80, respectively, for SSP5-8.5 minus SSP2-4.5 averaged over 2081-2100). With aerosol injection, the differences in how the aerosols spread further change some of the underlying uncertainties, such as the global mean precipitation response (-3.79±0.76 for G6sulfur compared to -2.07±0.40 for G6solar against SSP2-4.5 between 2081 and 2100). These differences in the behavior of the aerosols also result in a larger uncertainty in the regional surface temperature response among models in the case of the G6sulfur simulations, suggesting the need to devise various, more specific experiments to single out and resolve particular sources of uncertainty. The spread in the modeled response suggests that a degree of caution is necessary when using these results for assessing specific impacts of geoengineering in various aspects of the Earth system. However, all models agree that compared to a scenario with unmitigated warming, stratospheric aerosol geoengineering has the potential to both globally and locally reduce the increase in surface temperatures. © 2021 Daniele Visioni et al