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Lammers-Lietz F, Borchers F, Feinkohl I, Hetzer S, Kanar C, Konietschke F, Lachmann G, Chien C, Spies C, Winterer G, Zaborszky L, Zacharias N, Paul F. An exploratory research report on brain mineralization in postoperative delirium and cognitive decline. Eur J Neurosci 2024; 59:2646-2664. [PMID: 38379517 PMCID: PMC11108748 DOI: 10.1111/ejn.16282] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2023] [Revised: 01/20/2024] [Accepted: 01/30/2024] [Indexed: 02/22/2024]
Abstract
Delirium is a severe postoperative complication associated with poor overall and especially neurocognitive prognosis. Altered brain mineralization is found in neurodegenerative disorders but has not been studied in postoperative delirium and postoperative cognitive decline. We hypothesized that mineralization-related hypointensity in susceptibility-weighted magnetic resonance imaging (SWI) is associated with postoperative delirium and cognitive decline. In an exploratory, hypothesis-generating study, we analysed a subsample of cognitively healthy patients ≥65 years who underwent SWI before (N = 65) and 3 months after surgery (N = 33). We measured relative SWI intensities in the basal ganglia, hippocampus and posterior basal forebrain cholinergic system (pBFCS). A post hoc analysis of two pBFCS subregions (Ch4, Ch4p) was conducted. Patients were screened for delirium until the seventh postoperative day. Cognitive testing was performed before and 3 months after surgery. Fourteen patients developed delirium. After adjustment for age, sex, preoperative cognition and region volume, only pBFCS hypointensity was associated with delirium (regression coefficient [90% CI]: B = -15.3 [-31.6; -0.8]). After adjustments for surgery duration, age, sex and region volume, perioperative change in relative SWI intensities of the pBFCS was associated with cognitive decline 3 months after surgery at a trend level (B = 6.8 [-0.9; 14.1]), which was probably driven by a stronger association in subregion Ch4p (B = 9.3 [2.3; 16.2]). Brain mineralization, particularly in the cerebral cholinergic system, could be a pathomechanism in postoperative delirium and cognitive decline. Evidence from our studies is limited because of the small sample and a SWI dataset unfit for iron quantification, and the analyses presented here should be considered exploratory.
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Affiliation(s)
- Florian Lammers-Lietz
- Department of Anesthesiology and Intensive Care Medicine, Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt Universität zu Berlin, Berlin, Germany
- PI Health Solutions GmbH, Berlin, Germany
| | - Friedrich Borchers
- Department of Anesthesiology and Intensive Care Medicine, Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt Universität zu Berlin, Berlin, Germany
| | - Insa Feinkohl
- Max-Delbrück-Center for Molecular Medicine in the Helmholtz Association (MDC), Molecular Epidemiology Research Group, Berlin, Germany
- Faculty of Health at Department of Medicine, Witten/Herdecke University, Witten, Germany
| | - Stefan Hetzer
- Berlin Center for Advanced Neuroimaging, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Cicek Kanar
- Department of Anesthesiology and Intensive Care Medicine, Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt Universität zu Berlin, Berlin, Germany
| | - Frank Konietschke
- Institute of Biometry and Clinical Epidemiology, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Gunnar Lachmann
- Department of Anesthesiology and Intensive Care Medicine, Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt Universität zu Berlin, Berlin, Germany
- BIH Academy, Clinician Scientist Program, Berlin Institute of Health at Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Claudia Chien
- Experimental and Clinical Research Center, Max Delbrück Center for Molecular Medicine and Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Claudia Spies
- Department of Anesthesiology and Intensive Care Medicine, Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt Universität zu Berlin, Berlin, Germany
| | - Georg Winterer
- Department of Anesthesiology and Intensive Care Medicine, Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt Universität zu Berlin, Berlin, Germany
- PI Health Solutions GmbH, Berlin, Germany
- Pharmaimage Biomarker Solutions Inc., Cambridge, Massachusetts, USA
| | - Laszlo Zaborszky
- Center for Molecular and Behavioral Neuroscience, Rutgers University, Newark, New Jersey, USA
| | - Norman Zacharias
- Department of Anesthesiology and Intensive Care Medicine, Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt Universität zu Berlin, Berlin, Germany
- Pharmaimage Biomarker Solutions Inc., Cambridge, Massachusetts, USA
- Department of Otorhinolaryngology, Head and Neck Surgery, Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt Universität zu Berlin, Berlin, Germany
| | - Friedemann Paul
- Experimental and Clinical Research Center, Max Delbrück Center for Molecular Medicine and Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
- Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt Universität zu Berlin, Berlin, Germany
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Heinrich M, Spies C, Borchers F, Feinkohl I, Pischon T, Slooter AJC, von Haefen C, Zacharias N, Winterer G, Lammers-Lietz F. Perioperative Levels of IL8 and IL18, but not IL6, are Associated with Nucleus Basalis Magnocellularis Atrophy Three Months after Surgery. J Neuroimmune Pharmacol 2024; 19:10. [PMID: 38483732 PMCID: PMC10940494 DOI: 10.1007/s11481-024-10110-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2023] [Accepted: 02/18/2024] [Indexed: 03/17/2024]
Abstract
Past studies have observed that brain atrophy may accelerate after surgical procedures. Furthermore, an association of systemic inflammation with neurodegeneration has been described. We hypothesize that postoperative interleukin (IL) levels in circulation as well as the perioperative change in interleukin levels are associated with increased postoperative atrophy in the Nucleus basalis magnocellularis (of Meynert, NBM) which is the major source of cortical acetylcholine. We analyzed data from the BioCog cohort which included patients ≥ 65 years presenting for elective major surgery (≥ 60min). Blood samples were taken before surgery and on the first postoperative day. Magnetic resonance imaging of the brain and neuropsychological assessments were conducted before surgery and after three months follow-up. We used linear regression analysis to determine the association of three interleukins (IL6, IL8 and IL18) with NBM atrophy (in % volume change from baseline before surgery to follow-up), as well as to examine the associations of NBM atrophy and volume with postoperative cognitive ability and perioperative cognitive change. Receiver-operating curves were used to determine the prognostic value of preoperative interleukin levels. For IL8 (N = 97) and IL18 (N = 217), but not IL6 (N = 240), we observed significant associations of higher postoperative IL levels at the first postoperative day with higher NBM atrophy at three months after surgery. Subsequent analyses suggested that in both IL8 and IL18, this association was driven by a more general association of chronically elevated IL levels and NBM atrophy, reflected by preoperative IL concentrations, rather than IL response to surgery, measured as the difference between pre- and postoperative IL concentrations. At follow-up, NBM volume was positively associated with the level of cognitive performance, but NBM atrophy was not significantly related to perioperative cognitive change. Prognostic value of preoperative IL concentrations for NBM atrophy was low. Our results suggest that an association of postoperative interleukin levels with NBM atrophy is driven by preoperatively elevated interleukins due to pre-existing inflammation, rather than perioperative change in interleukin levels in response to surgery and anesthesia. The BioCog study has been registered at clinicaltrials.gov on Oct 15, 2014 (NCT02265263).
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Affiliation(s)
- Maria Heinrich
- Charité-Universitätsmedizin Berlin, Department of Anesthesiology and Intensive Care Medicine, Corporate member of Freie Universität Berlin and Humboldt-Universität Zu Berlin, Augustenburger Platz 1, 13353, Berlin, Germany
- Berlin Institute of Health at Charité -Universitätsmedizin Berlin, Berlin, Germany
| | - Claudia Spies
- Charité-Universitätsmedizin Berlin, Department of Anesthesiology and Intensive Care Medicine, Corporate member of Freie Universität Berlin and Humboldt-Universität Zu Berlin, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Friedrich Borchers
- Charité-Universitätsmedizin Berlin, Department of Anesthesiology and Intensive Care Medicine, Corporate member of Freie Universität Berlin and Humboldt-Universität Zu Berlin, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Insa Feinkohl
- Faculty of Health/Department of Medicine at Witten/Herdecke University, Witten/Herdecke, Germany
- Molecular Epidemiology Research Group, Max-Delbrück-Center for Molecular Medicine in the Helmholtz Association (MDC), Berlin, Germany
| | - Tobias Pischon
- Molecular Epidemiology Research Group, Max-Delbrück-Center for Molecular Medicine in the Helmholtz Association (MDC), Berlin, Germany
- Biobank Technology Platform, Max-Delbrück-Center for Molecular Medicine in the Helmholtz Association (MDC), Berlin, Germany
- Charité-Universitätsmedizin Berlin, Corporate member of Freie Universität Berlin and Humboldt-Universität Zu Berlin, Berlin, Germany
- Core Facility Biobank, Berlin Institute of Health at Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Arjen J C Slooter
- Department of Intensive Care Medicine and Brain Center, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
- Department of Psychiatry, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
- UMC Utrecht Brain Center, Utrecht University, Utrecht, the Netherlands
- Department of Neurology, UZ Brussel and Vrije Universiteit Brussel, Brussels, Belgium
| | - Clarissa von Haefen
- Charité-Universitätsmedizin Berlin, Department of Anesthesiology and Intensive Care Medicine, Corporate member of Freie Universität Berlin and Humboldt-Universität Zu Berlin, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Norman Zacharias
- Charité-Universitätsmedizin Berlin, Department of Anesthesiology and Intensive Care Medicine, Corporate member of Freie Universität Berlin and Humboldt-Universität Zu Berlin, Augustenburger Platz 1, 13353, Berlin, Germany
- Pharmaimage Biomarker Solutions GmbH, Berlin, Germany
- PI Health Solutions GmbH, Berlin, Germany
| | - Georg Winterer
- Charité-Universitätsmedizin Berlin, Department of Anesthesiology and Intensive Care Medicine, Corporate member of Freie Universität Berlin and Humboldt-Universität Zu Berlin, Augustenburger Platz 1, 13353, Berlin, Germany
- Pharmaimage Biomarker Solutions GmbH, Berlin, Germany
- PI Health Solutions GmbH, Berlin, Germany
| | - Florian Lammers-Lietz
- Charité-Universitätsmedizin Berlin, Department of Anesthesiology and Intensive Care Medicine, Corporate member of Freie Universität Berlin and Humboldt-Universität Zu Berlin, Augustenburger Platz 1, 13353, Berlin, Germany.
- Pharmaimage Biomarker Solutions GmbH, Berlin, Germany.
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Evans T, Binns H, Mandal AK, De'Ath HD, Missouris CG. The impact of anticholinergic burden on clinical outcomes in older hospitalised surgical patients. Br J Hosp Med (Lond) 2024; 85:1-9. [PMID: 38300682 DOI: 10.12968/hmed.2023.0034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2024]
Abstract
Polypharmacotherapy is an ever-increasing issue with an ageing patient population. Anticholinergic medications make up a large proportion of patient medication but cause significant side effects, contributing to well-documented issues within the older population and in hospital medicine. This review explores the documented impact of anticholinergic burden in older surgical patients on postoperative delirium, infection, length of stay and readmission, urinary retention, ileus and mortality. It also highlights the need for further high-quality research into anticholinergic burden management among older surgical patients to further impact practice and policy in the area.
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Affiliation(s)
- Thomas Evans
- Department of General Internal Medicine, Wexham Park Hospital, Frimley Health NHS Foundation Trust, Slough, UK
| | - Hannah Binns
- Department of General Internal Medicine, Wexham Park Hospital, Frimley Health NHS Foundation Trust, Slough, UK
| | - Amit Kj Mandal
- Department of General Internal Medicine, Wexham Park Hospital, Frimley Health NHS Foundation Trust, Slough, UK
| | - Henry D De'Ath
- Department of General Surgery, Frimley Park Hospital, Frimley Health NHS Foundation Trust, Frimley, Surrey UK
| | - Constantinos G Missouris
- Department of Cardiology, Wexham Park Hospital, Frimley Health NHS Foundation Trust, Slough, UK
- University of Nicosia Medical School, Cyprus, UK
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Association between cholinesterase activity and critical illness brain dysfunction. Crit Care 2022; 26:377. [PMID: 36474266 PMCID: PMC9724294 DOI: 10.1186/s13054-022-04260-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2022] [Accepted: 11/29/2022] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Delirium is a frequent manifestation of acute brain dysfunction and is associated with cognitive impairment. The hypothesized mechanism of brain dysfunction during critical illness is centered on neuroinflammation, regulated in part by the cholinergic system. Point-of-care serum cholinesterase enzyme activity measurements serve as a real-time index of cholinergic activity. We hypothesized that cholinesterase activity during critical illness would be associated with delirium in the intensive care unit (ICU) and cognitive impairment after discharge. METHODS We enrolled adults with respiratory failure and/or shock and measured plasma acetylcholinesterase (AChE) and butyrylcholinesterase (BChE) activity on days 1, 3, 5, and 7 after enrollment. AChE values were also normalized per gram of hemoglobin (AChE/Hgb). We assessed for coma and delirium twice daily using the Richmond Agitation Sedation Scale and the Confusion Assessment Method for the ICU to evaluate daily mental status (delirium, coma, normal) and days alive without delirium or coma. Cognitive impairment, disability, and health-related quality of life were assessed at up to 6 months post-discharge. We used multivariable regression to determine whether AChE, AChE/Hgb, and BChE activity were associated with outcomes after adjusting for relevant covariates. RESULTS We included 272 critically ill patients who were a median (IQR) age 56 (39-67) years and had a median Sequential Organ Failure Assessment score at enrollment of 8 (5-11). Higher daily AChE levels were associated with increased odds of being delirious versus normal mental status on the same day (Odds Ratio [95% Confidence Interval] 1.64 [1.11, 2.43]; P = 0.045). AChE/Hgb and BChE activity levels were not associated with delirious mental status. Lower enrollment BChE was associated with fewer days alive without delirium or coma (P = 0.048). AChE, AChE/Hgb, and BChE levels were not significantly associated with cognitive impairment, disability, or quality of life after discharge. CONCLUSION Cholinesterase activity during critical illness is associated with delirium but not with outcomes after discharge, findings that may reflect mechanisms of acute brain organ dysfunction. TRIAL REGISTRATION NCT03098472. Registered 31 March 2017.
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Heinrich M, Woike JK, Spies CD, Wegwarth O. Forecasting Postoperative Delirium in Older Adult Patients with Fast-and-Frugal Decision Trees. J Clin Med 2022; 11:jcm11195629. [PMID: 36233496 PMCID: PMC9571735 DOI: 10.3390/jcm11195629] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2022] [Revised: 09/20/2022] [Accepted: 09/21/2022] [Indexed: 11/16/2022] Open
Abstract
Postoperative delirium (POD) is associated with increased complication and mortality rates, particularly among older adult patients. However, guideline recommendations for POD detection and management are poorly implemented. Fast-and-frugal trees (FFTrees), which are simple prediction algorithms, may be useful in this context. We compared the capacity of simple FFTrees with two more complex models—namely, unconstrained classification trees (UDTs) and logistic regression (LogReg)—for the prediction of POD among older surgical patients in the perioperative setting. Models were trained and tested on the European BioCog project clinical dataset. Based on the entire dataset, two different FFTrees were developed for the pre-operative and postoperative settings. Within the pre-operative setting, FFTrees outperformed the more complex UDT algorithm with respect to predictive balanced accuracy, nearing the prediction level of the logistic regression. Within the postoperative setting, FFTrees outperformed both complex models. Applying the best-performing algorithms to the full datasets, we proposed an FFTree using four cues (Charlson Comorbidity Index (CCI), site of surgery, physical status and frailty status) for the pre-operative setting and an FFTree containing only three cues (duration of anesthesia, age and CCI) for the postoperative setting. Given that both FFTrees contained considerably fewer criteria, which can be easily memorized and applied by health professionals in daily routine, FFTrees could help identify patients requiring intensified POD screening.
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Affiliation(s)
- Maria Heinrich
- Department of Anesthesiology and Operative Intensive Care Medicine (CCM, CVK), Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, 13353 Berlin, Germany
- Berlin Institute of Health@Charité (BIH), Anna-Louisa-Karsch 2, 10178 Berlin, Germany
| | - Jan K. Woike
- School of Psychology, University of Plymouth, Plymouth PL4 8AA, UK
- Max Planck Institute for Human Development, Center for Adaptive Rationality, 14195 Berlin, Germany
| | - Claudia D. Spies
- Department of Anesthesiology and Operative Intensive Care Medicine (CCM, CVK), Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, 13353 Berlin, Germany
| | - Odette Wegwarth
- Department of Anesthesiology and Operative Intensive Care Medicine (CCM, CVK), Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, 13353 Berlin, Germany
- Max Planck Institute for Human Development, Center for Adaptive Rationality, 14195 Berlin, Germany
- Heisenberg Chair for Medical Risk Literacy and Evidence-Based Decisions, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, 10117 Berlin, Germany
- Correspondence: ; Tel.: +49-30-450-531-056; Fax: +49-30-450-551-909
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Abstract
PURPOSE OF REVIEW Perioperative neurocognitive disorders (PNDs) are among the most frequent complications after surgery and are associated with considerable morbidity and mortality. We analysed the recent literature regarding risk assessment of PND. RECENT FINDINGS Certain genetic variants of the cholinergic receptor muscarinic 2 and 4, as well as a marked degree of frailty but not the kind of anaesthesia (general or spinal) are associated with the risk to develop postoperative delirium (POD). Models predict POD with a discriminative power, for example, area under the receiver operating characteristics curve between 0.52 and 0.94. SUMMARY Advanced age as well as preexisting cognitive, functional and sensory deficits remain to be the main risk factors for the development of PND. Therefore, aged patients should be routinely examined for both preexisting and new developing deficits, as recommended in international guidelines. Appropriate tests should have a high discrimination rate, be feasible to be administered by staff that do not require excessive training, and only take a short time to be practical for a busy outpatient clinic. Models to predict PND, should be validated appropriately (and externally if possible) and should not contain a too large number of predictors to prevent overfitting of models.
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Heinrich M, Sieg M, Kruppa J, Nürnberg P, Schreier PH, Heilmann-Heimbach S, Hoffmann P, Nöthen MM, Janke J, Pischon T, Slooter AJC, Winterer G, Spies CD. Association between genetic variants of the cholinergic system and postoperative delirium and cognitive dysfunction in elderly patients. BMC Med Genomics 2021; 14:248. [PMID: 34674705 PMCID: PMC8529799 DOI: 10.1186/s12920-021-01071-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2021] [Accepted: 08/19/2021] [Indexed: 11/18/2022] Open
Abstract
Background Postoperative delirium (POD) and postoperative cognitive dysfunction (POCD) are frequent and serious complications after surgery. We aim to investigate the association between genetic variants in cholinergic candidate genes according to the Kyoto encyclopedia of genes and genomes - pathway: cholinergic neurotransmission with the development of POD or POCD in elderly patients. Methods This analysis is part of the European BioCog project (www.biocog.eu), a prospective multicenter observational study with elderly surgical patients. Patients with a Mini-Mental-State-Examination score ≤ 23 points were excluded. POD was assessed up to seven days after surgery using the Nursing Delirium Screening Scale, Confusion Assessment Method and a patient chart review. POCD was assessed three months after surgery with a neuropsychological test battery. Genotyping was performed on the Illumina Infinium Global Screening Array. Associations with POD and POCD were analyzed using logistic regression analysis, adjusted for age, comorbidities and duration of anesthesia (for POCD analysis additionally for education). Odds ratios (OR) refer to minor allele counts (0, 1, 2). Results 745 patients could be included in the POD analysis, and 452 in the POCD analysis. The rate of POD within this group was 20.8% (155 patients), and the rate of POCD was 10.2% (46 patients). In a candidate gene approach three genetic variants of the cholinergic genes CHRM2 and CHRM4 were associated with POD (OR [95% confidence interval], rs8191992: 0.61[0.46; 0.80]; rs8191992: 1.60[1.22; 2.09]; rs2067482: 1.64[1.10; 2.44]). No associations were found for POCD. Conclusions We found an association between genetic variants of CHRM2 and CHRM4 and POD. Further studies are needed to investigate whether disturbances in acetylcholine release and synaptic plasticity are involved in the development of POD. Trial registration: ClinicalTrials.gov: NCT02265263. Supplementary Information The online version contains supplementary material available at 10.1186/s12920-021-01071-1.
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Affiliation(s)
- Maria Heinrich
- Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Anesthesiology and Operative Intensive Care Medicine (CCM, CVK), Berlin, Germany.,Berlin Institute of Health at Charité - Universitätsmedizin Berlin, Charitéplatz 1, 10117, Berlin, Germany
| | - Miriam Sieg
- Berlin Institute of Health at Charité - Universitätsmedizin Berlin, Charitéplatz 1, 10117, Berlin, Germany.,Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Institute of Medical Informatics, Charitéplatz 1, 10117, Berlin, Germany.,QUEST Center for Transforming Biomedical Research, Berlin Institute of Health, Berlin, Germany
| | - Jochen Kruppa
- Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Anesthesiology and Operative Intensive Care Medicine (CCM, CVK), Berlin, Germany.,Berlin Institute of Health at Charité - Universitätsmedizin Berlin, Charitéplatz 1, 10117, Berlin, Germany.,Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Institute of Medical Informatics, Charitéplatz 1, 10117, Berlin, Germany
| | - Peter Nürnberg
- Institute of Genetics, University of Cologne, Cologne, Germany.,Atlas Biolabs GmbH, Berlin, Germany
| | - Peter H Schreier
- Institute of Genetics, University of Cologne, Cologne, Germany.,Pharmaimage Biomarker Solutions GmbH, Berlin, Germany
| | - Stefanie Heilmann-Heimbach
- Institute of Human Genetics, School of Medicine and University Hospital Bonn, University of Bonn, Bonn, Germany
| | - Per Hoffmann
- Institute of Human Genetics, School of Medicine and University Hospital Bonn, University of Bonn, Bonn, Germany.,Human Genomics Research Group, Department of Biomedicine, University of Basel, Basel, Switzerland
| | - Markus M Nöthen
- Institute of Human Genetics, School of Medicine and University Hospital Bonn, University of Bonn, Bonn, Germany
| | - Jürgen Janke
- MDC/BIH Biobank, Max Delbrück Center for Molecular Medicine in the Helmholtz Association (MDC), Berlin, Germany
| | - Tobias Pischon
- Berlin Institute of Health at Charité - Universitätsmedizin Berlin, Charitéplatz 1, 10117, Berlin, Germany.,MDC/BIH Biobank, Max Delbrück Center for Molecular Medicine in the Helmholtz Association (MDC), Berlin, Germany.,Molecular Epidemiology Research Group, Max-Delbrück Center for Molecular Medicine in the Helmholtz Association (MDC), Berlin, Germany.,Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin, Germany
| | - Arjen J C Slooter
- Department of Intensive Care Medicine, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands.,UMC Utrecht Brain Center, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands.,Department of Neurology, UZ Brussel, Vrije Universiteit Brussel, Brussels, Belgium
| | - Georg Winterer
- Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Anesthesiology and Operative Intensive Care Medicine (CCM, CVK), Berlin, Germany.,Pharmaimage Biomarker Solutions GmbH, Berlin, Germany.,Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, ECRC Experimental and Clinical Research Center, Lindenberger Weg 80, 13125, Berlin, Germany
| | - Claudia D Spies
- Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Anesthesiology and Operative Intensive Care Medicine (CCM, CVK), Berlin, Germany.
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