Update of the European Society of Anaesthesiology and Intensive Care Medicine evidence-based and consensus-based guideline on postoperative delirium in adult patients

Postoperative delirium (POD) remains a common, dangerous and resource-consuming adverse event but is often preventable. The whole peri-operative team can play a key role in its management. This update to the 2017 ESAIC Guideline on the prevention of POD is evidence-based and consensus-based and considers the literature between 01 April 2015, and 28 February 2022. The search terms of the broad literature search were identical to those used in the first version of the guideline published in 2017. POD was defined in accordance with the DSM-5 criteria. POD had to be measured with a validated POD screening tool, at least once per day for at least 3 days starting in the recovery room or postanaesthesia care unit on the day of surgery or, at latest, on postoperative day 1. Recent literature confirmed the pathogenic role of surgery-induced inflammation, and this concept reinforces the positive role of multicomponent strategies aimed to reduce the surgical stress response. Although some putative precipitating risk factors are not modifiable (length of surgery, surgical site), others (such as depth of anaesthesia, appropriate analgesia and haemodynamic stability) are under the control of the anaesthesiologists. Multicomponent preoperative, intra-operative and postoperative preventive measures showed potential to reduce the incidence and duration of POD, confirming the pivotal role of a comprehensive and team-based approach to improve patients' clinical and functional status.

Psilocybin and Other Classic Psychedelics in Depression

Psychedelic drugs such as psilocybin and ketamine are returning to clinical research and intervention across several disorders including the treatment of depression. This chapter focusses on psychedelics that specifically target the 5-HT2A receptor such as psilocybin and DMT. These produce plasma-concentration related psychological effects such as hallucinations and out of body experiences, insightful and emotional breakthroughs as well as mystical-type experiences. When coupled with psychological support, effects can produce a rapid improvement in mood among people with depression that can last for months. In this chapter, we summarise the scientific studies to date that explore the use of psychedelics in depressed individuals, highlighting key clinical, psychological and neuroimaging features of psychedelics that may account for their therapeutic effects. These include alterations in brain entropy that disrupt fixed negative ruminations, a period of post-treatment increased cognitive flexibility, and changes in self-referential psychological processes. Finally, we propose that the brain mechanisms underlying the therapeutic effect of serotonergic psychedelics might be distinct from those underlying classical serotonin reuptake-blocking antidepressants.

Canalization and plasticity in psychopathology

This theoretical article revives a classical bridging construct, canalization, to describe a new model of a general factor of psychopathology. To achieve this, we have distinguished between two types of plasticity, an early one that we call 'TEMP' for 'Temperature or Entropy Mediated Plasticity', and another, we call 'canalization', which is close to Hebbian plasticity. These two forms of plasticity can be most easily distinguished by their relationship to 'precision' or inverse variance; TEMP relates to increased model variance or decreased precision, whereas the opposite is true for canalization. TEMP also subsumes increased learning rate, (Ising) temperature and entropy. Dictionary definitions of 'plasticity' describe it as the property of being easily shaped or molded; TEMP is the better match for this. Importantly, we propose that 'pathological' phenotypes develop via mechanisms of canalization or increased model precision, as a defensive response to adversity and associated distress or dysphoria. Our model states that canalization entrenches in psychopathology, narrowing the phenotypic state-space as the agent develops expertise in their pathology. We suggest that TEMP - combined with gently guiding psychological support - can counter canalization. We address questions of whether and when canalization is adaptive versus maladaptive, furnish our model with references to basic and human neuroscience, and offer concrete experiments and measures to test its main hypotheses and implications. This article is part of the Special Issue on "National Institutes of Health Psilocybin Research Speaker Series".

A221 CONGENITAL PORTOSYSTEMIC SHUNTS: FROM PRENATAL DIAGNOSIS TO LONG- TERM POSTNATAL OUTCOME

Background

Congenital portosystemic shunts (CPSS) are rare vascular malformations that result in blood bypassing the liver and re-entering the systemic circulation unfiltered. The outcomes of CPSS diagnosed prenatally are unknown. Previously published data is related to patients diagnosed after symptom appearance, including hepatic encephalopathy, liver tumors and portal hypertension.

Aims

To describe a cohort of prenatally diagnosed children with CPSS and report on the natural history and outcomes.

Methods

The study was conducted between 2006 and 2019. Prenatal diagnosis was performed during routine prenatal ultrasound. Patients were followed by the pediatric gastroenterologists’ unit.

Results

32 patients were identified; 28 patients with intrahepatic shunts and four patients with extrahepatic shunts. During follow up, Failure to Thrive (FTT) was observed in three of the patients with one shunt (16.7%), and five of the patients with two shunts or more (55.6%). The difference is significant (p- value=0.037). 24 patients with intrahepatic shunts had their shunts closed spontaneously. Median time for closure of the shunt was seven months (IQR 2–14 months, range 0–35 months). No predicting factor was detected for closure of the shunt before the age of one year. All extrahepatic shunts required surgical closure.

Conclusions

Congenital intrahepatic shunts usually close spontaneously and do not need intervention. All patients in our prenatally diagnosed cohort survived with limited to no sequelae.

Funding Agencies

None

Association between ACTH stimulation test results and clinical signs in dogs with hyperadrenocorticism treated with trilostane

Trilostane is the recommended medical treatment for dogs with hyperadrenocorticicm (HAC). The objective of this study was to investigate the association between ACTH stimulation test (ACTHST) results, and relevant clinical signs, in dogs treated with trilostane. A disease-specific questionnaire was developed, which included the owner's assessment of polydipsia, polyuria, polyphagia, panting, and satisfaction with the treatment, based on a 5-response category rating scale. Forty-nine dogs with HAC were prospectively enrolled. Dogs were grouped according to their recheck appointment (first recheck, 710 days after commencement of treatment or change of trilostane dose; second recheck, 4 weeks after the first recheck; third recheck, performed at 3-6 months intervals once the dog was well controlled). At the recheck appointment, the owner's questionnaire responses were recorded, and an ACTHST was performed, along with urine specific gravity measurement. Linear mixed effects models were used to assess differences among the three recheck time points and to test possible associations between ACTHST results and clinical signs. Significant differences between rechecks were present for stimulated cortisol (first to third recheck, P < 0.001; second to third recheck, P < 0.01), polydipsia (first to second recheck, P = 0.001), polyuria (first to second recheck, P < 0.001; first to third recheck, P = 0.001), and owner satisfaction (first to second recheck, P < 0.001; first to third recheck, P < 0.001). Backward stepwise variable elimination did not identify any significant associations between ACTHST results and clinical signs. Therefore, clinical signs of HAC were not predicted based on the ACTHST results.

Clinical practice in the management of postoperative delirium by Chinese anesthesiologists: a cross-sectional survey designed by the European Society of Anaesthesiology

Objective

In this survey, we assessed the current clinical management of postoperative delirium (POD) among Chinese anesthesiologists, after publishing the European POD guideline.

Methods

We administered an electronic survey, designed according to the European POD guideline. The survey was completed using mobile devices.

Results

In total, 1,514 respondents from China participated in the survey. Overall, 74.4% of participants reported that delirium is very important. More than 95% of participants stated that they routinely assessed POD. In total, 61.4% screened for POD using clinical observation and 37.6% used a delirium screening tool. Although the depth of anesthesia (a POD risk factor) was monitored, electroencephalogram monitoring was unavailable to 30.6% of respondents. Regarding treatment, only 24.1% of respondents used a standard algorithm; 58.5% used individualized treatment.

Conclusion

Our survey showed that there are high awareness levels among Chinese anesthesiologists regarding the importance of POD. However, routine assessment and monitoring of all patients, including perioperative anesthesia depth monitoring, and a treatment algorithm need to be implemented on a larger scale. According to the results, efforts should be made to improve the knowledge of POD among Chinese anesthesiologists.

Telemedicine in Intensive Care Units: Protocol for a Scoping Review

Background

Telemedicine has been deployed to address issues in intensive care delivery, as well as to improve outcome and quality of care. Implementation of this technology has been characterized by high variability. Tele-intensive care unit (ICU) interventions involve the combination of multiple technological and organizational components, as well as interconnections of key stakeholders inside the hospital organization. The extensive literature on the benefits of tele-ICUs has been characterized as heterogeneous. On one hand, positive clinical and economical outcomes have been shown in multiple studies. On the other hand, no tangible benefits could be detected in several cases. This could be due to the diverse forms of organizations and the fact that tele-ICU interventions are complex to evaluate. The implementation context of tele-ICUs has been shown to play an important role in the success of the technology. The benefits derived from tele-ICUs depend on the organization where it is deployed and how the telemedicine systems are applied. There is therefore value in analyzing the benefits of tele-ICUs in relation to the characteristics of the organization where it is deployed. To date, research on the topic has not provided a comprehensive overview of literature taking both the technology setup and implementation context into account.

Objective

We present a protocol for a scoping review of the literature on telemedicine in the ICU and its benefits in intensive care. The purpose of this review is to map out evidence about telemedicine in critical care in light of the implementation context. This review could represent a valuable contribution to support the development of tele-ICU technologies and offer perspectives on possible configurations, based on the implementation context and use case.

Methods

We have followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) checklist and the recommendations of the Joanna Briggs Institute methodology for scoping reviews. The scoping review and subsequent systematic review will be completed by spring 2021.

Results

The preliminary search has been conducted. After removing all duplicates, we found 2530 results. The review can now be advanced to the next steps of the methodology, including literature database queries with appropriate keywords, retrieval of the results in a reference management tool, and screening of titles and abstracts.

Conclusions

The results of the search indicate that there is sufficient literature to complete the scoping review. Upon completion, the scoping review will provide a map of existing evidence on tele-ICU systems given the implementation context. Findings of this research could be used by researchers, clinicians, and implementation teams as they determine the appropriate setup of new or existing tele-ICU systems. The need for future research contributions and systematic reviews will be identified.

International Registered Report Identifier (IRRID)

DERR1-10.2196/19695

Enhanced Recovery after Intensive Care (ERIC): study protocol for a German stepped wedge cluster randomised controlled trial to evaluate the effectiveness of a critical care telehealth program on process quality and functional outcomes

INTRODUCTION

Survival after critical illness has noticeably improved over the last decades due to advances in critical care medicine. Besides, there is an increasing number of elderly patients with chronic diseases being treated in the intensive care unit (ICU). More than half of the survivors of critical illness suffer from medium-term or long-term cognitive, psychological and/or physical impairments after ICU discharge, which is recognised as post-intensive care syndrome (PICS). There are evidence-based and consensus-based quality indicators (QIs) in intensive care medicine, which have a positive influence on patients' long-term outcomes if adhered to.

METHODS AND ANALYSIS

The protocol of a multicentre, pragmatic, stepped wedge cluster randomised controlled, quality improvement trial is presented. During 3 predefined steps, 12 academic hospitals in Berlin and Brandenburg, Germany, are randomly selected to move in a one-way crossover from the control to the intervention condition. After a multifactorial training programme on QIs and clinical outcomes for site personnel, ICUs will receive an adapted, interprofessional protocol for a complex telehealth intervention comprising of daily telemedical rounds at ICU. The targeted sample size is 1431 patients. The primary objective of this trial is to evaluate the effectiveness of the intervention on the adherence to eight QIs daily measured during the patient's ICU stay, compared with standard of care. Furthermore, the impact on long-term recovery such as PICS-related, patient-centred outcomes including health-related quality of life, mental health, clinical assessments of cognition and physical function, all-cause mortality and cost-effectiveness 3 and 6 months after ICU discharge will be evaluated.

ETHICS AND DISSEMINATION

This protocol was approved by the ethics committee of the Charité-Universitätsmedizin, Berlin, Germany (EA1/006/18). The results will be published in a peer-reviewed scientific journal and presented at international conferences. Study findings will also be disseminated via the website (www.eric-projekt.net).

TRIAL REGISTRATION NUMBER

ClinicalTrials.gov Registry (NCT03671447).

Effects of pain, sedation and delirium monitoring on clinical and economic outcome: A retrospective study

BACKGROUND

Significant improvements in clinical outcome can be achieved by implementing effective strategies to optimise pain management, reduce sedative exposure, and prevent and treat delirium in ICU patients. One important strategy is the monitoring of pain, agitation and delirium (PAD bundle). We hypothesised that there is no sufficient financial benefit to implement a monitoring strategy in a Diagnosis Related Group (DRG)-based reimbursement system, therefore we expected better clinical and decreased economic outcome for monitored patients.

METHODS

This is a retrospective observational study using routinely collected data. We used univariate and multiple linear analysis, machine-learning analysis and a novel correlation statistic (maximal information coefficient) to explore the association between monitoring adherence and resulting clinical and economic outcome. For univariate analysis we split patients in an adherence achieved and an adherence non-achieved group.

RESULTS

In total 1,323 adult patients from two campuses of a German tertiary medical centre, who spent at least one day in the ICU between admission and discharge between 1. January 2016 and 31. December 2016. Adherence to PAD monitoring was associated with shorter hospital LoS (e.g. pain monitoring 13 vs. 10 days; p<0.001), ICU LoS, duration of mechanical ventilation shown by univariate analysis. Despite the improved clinical outcome, adherence to PAD elements was associated with a decreased case mix per day and profit per day shown by univariate analysis. Multiple linear analysis did not confirm these results. PAD monitoring is important for clinical as well as economic outcome and predicted case mix better than severity of illness shown by machine learning analysis.

CONCLUSION

Adherence to PAD bundles is also important for clinical as well as economic outcome. It is associated with improved clinical and worse economic outcome in comparison to non-adherence in univariate analysis but not confirmed by multiple linear analysis.

TRIAL REGISTRATION

clinicaltrials.gov NCT02265263, Registered 15 October 2014.

Routine management of postoperative delirium outside the ICU: Results of an international survey among anaesthesiologists

BACKGROUND

Postoperative delirium (POD) is a severe brain dysfunction. Although data indicate a high relevance, no survey has investigated the routine practice to monitor delirium outside the ICU setting after surgery. Prior to publishing of the new European Society of Anaesthesiology (ESA) guidelines on POD, an international survey was conducted to assess current practice.

METHODS

European Society of Anaesthesiology-endorsed online survey; Trial Registration: NCT-identifier: 02513537.

RESULTS

In total, 566 respondents from 62 countries accessed, and 564 (99.6%) completed the survey (completion rate). Overall, 385 (68%) of the respondents reported that delirium is either "very relevant" or "relevant" for their daily clinical practice. In all, 38 (7%) of the respondents routinely monitor for delirium in >50% of all patients. Asked on the monitoring time point, more than half (n = 308, 55%) indicated to screen before or at recovery room discharge, 235 (42%) up to the first postoperative day, 143 (25%) up to 3 days, and 77 (14%) up to 5 postoperative days. Although there is a lack of long-term monitoring, nearly all respondents (n = 530, 94%) reported to treat delirium. Availability of EEG/EMG-based monitoring to assess the depth of anaesthesia was high in the study group (n = 547, 97%) and was used by more than one-third of the respondents to reduce risk of burst suppression (n = 189, 34%).

CONCLUSION

Although delirium is perceived as a relevant condition among anaesthesiologists, there is a high demand for implementing monitoring strategies after publishing of the POD Guideline. The survey shows that tools necessary for POD Guideline implementation are available in the centres represented by the respondents.

Innovative ICU Solutions to Prevent and Reduce Delirium and Post–Intensive Care Unit Syndrome

Delirium, the most common form of acute brain dysfunction affecting up to 80% of intensive care unit (ICU) patients, has been shown to predict long-term cognitive impairment, one of the domains in “Post-ICU Syndrome” (PICS). The ICU environment affects several potentially modifiable risk factors for delirium, such as disorientation and disruption, of the sleep–wake cycle. Innovative solutions aim to transform standard concepts of ICU room design to limit potential stressors, and utilizing the patient care space as a treatment tool, exerting positive, therapeutic effects. The main areas affected by most architectural and interior design modifications are sound environment, light control, floor planning, and room arrangement. Implementation of corresponding solutions is challenging considering the significant medical and technical demands of ICUs. This article discusses innovative concepts and promising approaches in ICU design that may be used to prevent stress and to support the healing process of patients, potentially limiting the impact of delirium and PICS.

Altered T cell receptor beta repertoire patterns in pediatric ulcerative colitis

The antigenic specificity of T cells occurs via generation and rearrangement of different gene segments producing a functional T cell receptor (TCR). High-throughput sequencing (HTS) allows in-depth assessment of TCR repertoire patterns. There are limited data concerning whether TCR repertoires are altered in inflammatory bowel disease. We hypothesized that pediatric ulcerative colitis (UC) patients possess unique TCR repertoires, resulting from clonotypical expansions in the gut. Paired blood and rectal samples were collected from nine newly diagnosed treatment-naive pediatric UC patients and four healthy controls. DNA was isolated to determine the TCR-β repertoire by HTS. Significant clonal expansion was demonstrated in UC patients, with inverse correlation between clinical disease severity and repertoire diversity in the gut. Using different repertoire variables in rectal biopsies, a clear segregation was observed between patients with severe UC, those with mild-moderate disease and healthy controls. Moreover, the overlap between autologous blood-rectal samples in UC patients was significantly higher compared with overlap among controls. Finally, we identified several clonotypes that were shared in either all or the majority of UC patients in the colon. Clonal expansion of TCR-β-expressing T cells among UC patients correlates with disease severity and highlights their involvement in mediating intestinal inflammation.

Neuroplasticity following short-term strength training occurs at supraspinal level and is specific for the trained task

AIMS

Different modalities of strength training cause performance enhancements, which are specific for the trained task. However, the involved mechanisms are still largely unknown. It has been demonstrated that strength training could induce neuroplasticity, which might underlie the performance improvements during the first training sessions. Thus, we hypothesized to find task-specific neuroplasticity after a short-term strength training of two distinct strength tasks.

METHODS

Young healthy male subjects were exposed to 4 sessions of either maximal isometric explosive (EXPL group, N = 9) or slow sustained (SUS group, N = 10) knee extensions. Pre- and post-training, we measured H-reflexes and motor evoked potentials (MEPs) in the vastus lateralis (VL) at the onset of both strength tasks.

RESULTS

Pre- and post-training, H-reflexes remained unchanged in both groups. MEP areas were lower in the trained task in both groups and remained unchanged in the untrained task.

CONCLUSION

This study demonstrated that short-term strength training induces specific neuroplasticity for the trained task only. The fact that MEPs were lower but H-reflex amplitudes remained unchanged at the onset of the trained tasks suggests that strength training elicited neuroplasticity at supraspinal level that most likely reflect an improved task-specific corticospinal efficiency.

Caseness rates and risk factors for depression among Vietnamese cancer patients

OBJECTIVE

Research suggests that rates of depression among general population samples in Asia may be significantly lower than in much of the rest of the world. However, whether this applies to depression among cancer patients is unclear, which is important to determine in order to identify depression treatment needs among cancer patients in this region. The purpose of the present study was to assess caseness rates of serious depression among general cancer patients in the Southeast Asian nation of Viet Nam.

METHOD

A total of 695 adult cancer patients from three hospitals in Da Nang, Viet Nam served as study participants. They were assessed at one time point for (a) demographic and (b) cancer characteristics, and (c) depression symptoms.

RESULTS

The overall caseness rate for serious depression was 28%. Although rates of depression in general population samples usually are significantly higher in women than men, rates of depression among men and women did not differ significantly among our cancer patients. Higher levels of depressive symptoms were found, however, as a function of lower patient income and education, occupation, cancer stage, and type of cancer, but not marital status or age.

CONCLUSIONS

Caseness rates of depression are significantly elevated by a factor of 10-15 among Vietnamese cancer patients relative to general population epidemiological studies in the same region. Although a number of studies have found that rates of depression tend to be lower in Asian as compared to Western general population samples, depression rates among our Vietnamese cancer patients were similar to those reported among Western cancer patients. This suggests that whatever factors are responsible for the relatively low rates of depression observed in Asian general population samples may not be operating in regards to cancer-related depression. Overall, the value of these findings are not only that they provide information for policy makers in Viet Nam to support depression treatment among cancer patients, but also that they suggest that despite the apparent relatively low overall rates of depression it may be useful for cancer and mental health researchers in the region to conduct similar assessments for their policy makers.

Effects of the family schizophrenia psychoeducation program for individuals with recent onset schizophrenia in Viet Nam

OBJECTIVE

Although psychoeducation has been found effective for improving the life functioning of patients with schizophrenia in high income countries, there have been relatively few studies of schizophrenia psychoeducation adapted for low and middle-income countries (LMIC), particularly in Southeast Asia. The present study assessed effects of the Family Schizophrenia Psychoeducation Program (FSPP) among Vietnamese patients and their families on the patients' (1) quality of life and (2) medication non-compliance, and the family and patients' (3) stigma towards schizophrenia, and (4) consumer satisfaction.

METHOD

This intervention study involved 59 patients, and their families, from the Da Nang Psychiatric Hospital, randomly assigned to treatment (n=30) or control (n=29) conditions. Control subjects received services as usual (antipsychotic medication); treatment group subjects received the FSPP as well. Blind-rater assessments were conducted at T1 immediately after project enrollment (prior to participating in the FSPP) and at T2 six months later.

RESULTS

There were significant treatment effects on: (1) quality of life, (2) stigma, (3) medication compliance, and (4) consumer satisfaction, with all effects favoring the treatment group. Effect sizes were moderate to large.

CONCLUSIONS

This psychoeducation program appears to reduce stigma, improve quality of life and medication compliance, and increase consumer satisfaction of Vietnamese patients with schizophrenia and their families, beyond the effects of antipsychotic medication. It involves relatively little cost, and it may be useful for it or equivalent programs to be implemented in other hospitals in Viet Nam, and potentially other low-income Asian countries to improve the lives of patients with schizophrenia.

Routine delirium monitoring is independently associated with a reduction of hospital mortality in critically ill surgical patients: A prospective, observational cohort study

PURPOSE

Although delirium monitoring is recommended in international guidelines, there is lacking evidence for improved outcome due to it. We hypothesized that adherence to routine delirium monitoring would improve clinical outcome in adult critically ill patients.

MATERIAL AND METHODS

We present the results of a prospective, noninterventional, observational cohort study that was conducted on 2 intensive care units (ICUs) of a tertiary care medical center between July and October 2007 (International Standard Registered Clinical Trial Record identifier: 76100795). We assessed delirium-monitoring and outcome parameters on a daily basis. Besides multivariate logistic and robust linear regression to analyze the relationship between delirium monitoring and outcome, we used the doubly robust augmented inverse probability weighting method for observational data to estimate effect sizes.

RESULTS

Of 355 screened patients, we included 185 surgical ICU patients into our final analysis, of which 87 were mechanically ventilated. We found an independent association between delirium-monitoring adherence and in-hospital mortality for ventilated patients (odds ratio, 0.973; P= .041). Estimating the effect size, delirium monitoring indicated a reduction of 22% of in-hospital mortality if conducted 50% or more of ICU days per patient. The average ICU length of stay of 46 days was estimated to be reduced by 19 days (P= .031) if patients were sufficiently monitored.

CONCLUSION

Our data suggest an improved outcome for mechanically ventilated patients being screened for delirium in clinical routine.

Operative Outcomes with Myxomatous Mitral Valve Repair: Experience with 586 Patients

INTRODUCTION

American Heart Association (AHA) guidelines recommend mitral valve repair for myxomatous mitral regurgitation whenever possible to prevent LV dysfunction and early mortality. Here we review our early operative outcomes with mitral valve repair for myxomatous mitral regurgitation.

METHODS

We collected data from 586 consecutive patients that underwent mitral repair for myxomatous disease at the Prince Henry and Prince of Wales Hospitals Sydney between 1997 and 2012. All patients had pre- and postoperative transthoracic echocardiograms.

RESULTS

In the first 30 days postoperatively there were five deaths (0.9%), four strokes (0.7%) and five transient ischaemic attacks (TIAs) (0.9%). Repair involved resection in 55.5%, neochordal reconstruction in 41.6%, and in 2.9% a combination of both. There was increasing use of neochordae since 2006. At discharge 99% had mitral regurgitation (MR) ≤ mild and ≤ trivial in 79.5%. For posterior leaflet disease neochordae had improved MR at discharge compared with resection (85% vs 78%, P<0.05). Preoperative triscupid regurgitation (TR) and pulmonary hypertension > mild were associated with a greater degree of MR at discharge (P<0.05) for reasons that are unclear.

CONCLUSION

We have shown excellent early results for mitral repair with very low operative mortality and excellent freedom from significant MR. Successful mitral repairs with low morbidity have resulted in a pattern of early referral in keeping with the current guidelines.

SmartSenior@home: Acceptance of an integrated ambient assisted living system. Results of a clinical field trial in 35 households

AIMS

The primary objective of the SmartSenior@home study was to examine the acceptance of the SmartSenior system by older adults.

METHODS

Twenty-eight partners from industry and research, including the health care sector, worked collaboratively to implement services aiming to maximize independence in old age. The prospective cohort study was conducted in Potsdam, Germany, with n = 35 older adults between 55 and 88 years of age in their apartments. All participants underwent extensive pre- and post-study visits with in-home interviews, functional assessments for cognition, fine motor skills, and mobility as well as responding to questionnaires on user acceptance and quality of life.

RESULTS

The results indicate moderate-to-high user acceptance for the SmartSenior system. In particular, the services for general assistance and health, such as audio/video communication, blood pressure monitoring, and communication with a health professional, were rated as very attractive. Less used and less accepted services were those promoting social interaction and reminder services.

CONCLUSION

Besides reliable functioning of the SmartSenior system, the availability of a confidant seems to be the most significant acceptance factor. As one conclusion of this trial, it is possible to develop, integrate, and test an infrastructure for ambient assisted living services in real life.

Identification and functional characterization of rare SHANK2 variants in schizophrenia

Recent genetic data on schizophrenia (SCZ) have suggested that proteins of the postsynaptic density of excitatory synapses have a role in its etiology. Mutations in the three SHANK genes encoding for postsynaptic scaffolding proteins have been shown to represent risk factors for autism spectrum disorders and other neurodevelopmental disorders. To address if SHANK2 variants are associated with SCZ, we sequenced SHANK2 in 481 patients and 659 unaffected individuals. We identified a significant increase in the number of rare (minor allele frequency<1%) SHANK2 missense variants in SCZ individuals (6.9%) compared with controls (3.9%, P=0.039). Four out of fifteen non-synonymous variants identified in the SCZ cohort (S610Y, R958S, P1119T and A1731S) were selected for functional analysis. Overexpression and knockdown-rescue experiments were carried out in cultured primary hippocampal neurons with a major focus on the analysis of morphological changes. Furthermore, the effect on actin polymerization in fibroblast cell lines was investigated. All four variants revealed functional impairment to various degrees, as a consequence of alterations in spine volume and clustering at synapses and an overall loss of presynaptic contacts. The A1731S variant was identified in four unrelated SCZ patients (0.83%) but not in any of the sequenced controls and public databases (P=4.6 × 10(-5)). Patients with the A1731S variant share an early prodromal phase with an insidious onset of psychiatric symptoms. A1731S overexpression strongly decreased the SHANK2-Bassoon-positive synapse number and diminished the F/G-actin ratio. Our results strongly suggest a causative role of rare SHANK2 variants in SCZ and underline the contribution of SHANK2 gene mutations in a variety of neuropsychiatric disorders.

Evidence and consensus based guideline for the management of delirium, analgesia, and sedation in intensive care medicine. Revision 2015 (DAS-Guideline 2015) - short version

In 2010, under the guidance of the DGAI (German Society of Anaesthesiology and Intensive Care Medicine) and DIVI (German Interdisciplinary Association for Intensive Care and Emergency Medicine), twelve German medical societies published the “Evidence- and Consensus-based Guidelines on the Management of Analgesia, Sedation and Delirium in Intensive Care”. Since then, several new studies and publications have considerably increased the body of evidence, including the new recommendations from the American College of Critical Care Medicine (ACCM) in conjunction with Society of Critical Care Medicine (SCCM) and American Society of Health-System Pharmacists (ASHP) from 2013. For this update, a major restructuring and extension of the guidelines were needed in order to cover new aspects of treatment, such as sleep and anxiety management. The literature was systematically searched and evaluated using the criteria of the Oxford Center of Evidence Based Medicine. The body of evidence used to formulate these recommendations was reviewed and approved by representatives of 17 national societies. Three grades of recommendation were used as follows: Grade “A” (strong recommendation), Grade “B” (recommendation) and Grade “0” (open recommendation). The result is a comprehensive, interdisciplinary, evidence and consensus-based set of level 3 guidelines. This publication was designed for all ICU professionals, and takes into account all critically ill patient populations. It represents a guide to symptom-oriented prevention, diagnosis, and treatment of delirium, anxiety, stress, and protocol-based analgesia, sedation, and sleep-management in intensive care medicine.

Undetectable anti-TNF drug levels in patients with long-term remission predict successful drug withdrawal

BACKGROUND

Low drug levels are associated with emerging loss of response to anti-TNF. However, this may not be the case in patients with long-term remission.

AIM

To investigate the outcome of anti-TNF discontinuation in patients with long-term remission and incidental undetectable drug levels.

METHODS

A retrospective cohort study examining the duration of relapse-free survival in IBD patients in remission who discontinued infliximab or adalimumab having undetectable drug levels.

RESULTS

Forty eight patients who discontinued anti-TNF while in remission and had available drug levels were identified in two centres in France and Israel (infliximab-treated 35, adalimumab-13, Crohn's disease 30, ulcerative colitis 18, mean treatment duration of 22.7 ± 12.4 months). Endoscopy/MRE before stopping showed absence of active inflammation in 40/42 (95%) of evaluated patients, while inflammatory biomarkers (CRP and/or Calprotectin) were completely normal in only 31/48 (65%) of patients. During 12 months median follow-up, relapse occurred in 16/20 (80%) of patients who stopped anti-TNF while having measurable drug levels compared with 9/28 (32%) of patients who had undetectable drug levels (OR: 8.4, 95% CI: 2.2-32, P = 0.002). Relapse-free survival after anti-TNF cessation was significantly longer in patients with absent drug compared to those with detectable drug (P < 0.001, log rank test). On multivariate analysis, a patient's decision to stop therapy was weakly associated and abnormal inflammatory biomarkers and detectable drug levels were both strongly and independently associated with a higher risk of relapse after drug discontinuation.

CONCLUSION

Incidental finding of undetectable anti-TNF drug levels in patients with stable long-term deep remission may identify a subset of patients whose clinical remission is no longer dependent on anti-TNF treatment.

Evidence for herbaceous seed dispersal by small-bodied fishes in a Pantanal seasonal wetland

We analysed the germination of seeds after their passage through the digestive tract of small floodplain fishes. Samples were collected in five open flooded fields of the northern Pantanal in March 2011. All fishes were sacrificed and their intestinal contents were removed. The fecal material was weighed and stored at 4°C in a GF/C filter wrapped in aluminum foil. The material was then transferred to a receptacle containing sterilised soil from the sampling area. The fecal samples were kept in a germination chamber for 68 days and then transferred to a greenhouse for another 67 days. We collected a total of 45 fish species and 1014 individuals which produced a total amount of 32 g of fresh fecal mass and 11 seedlings. We were able to identify six seedlings: two Banara arguta, two Steinchisma laxa, one Hymenachne amplexicaulis and one Luziola sp.. The fish species that produced samples with seedlings were Astyanax assuncionensis, Metynnis mola, Plesiolebias glaucopterus, Acestrorhyncus pantaneiro and Anadoras wendelli. With the exception of B. arguta the remaining plant species and all fish species were not known to be associated with the seed dispersal process of these plants. We found a ratio of 0.435 seedlings.g-1 of fresh fecal material, which is 100 times higher than the amount of seedlings encountered in fresh soil mass (92,974 grams) in seed bank studies conducted in the same study area. In particular, Astyanax assuncionensis and Metynnis mola were among the most frequent and most abundant fish taxa in the area. Together with the high seed concentration in the fish fecal material, this evidence allows us to conclude that such fish species may play an important role in seed dispersal in the herbaceous plants of the Pantanal.

Consensus guidelines of ECCO/ESPGHAN on the medical management of pediatric Crohn's disease

Children and adolescents with Crohn's disease (CD) present often with a more complicated disease course compared to adult patients. In addition, the potential impact of CD on growth, pubertal and emotional development of patients underlines the need for a specific management strategy of pediatric-onset CD. To develop the first evidenced based and consensus driven guidelines for pediatric-onset CD an expert panel of 33 IBD specialists was formed after an open call within the European Crohn's and Colitis Organisation and the European Society of Pediatric Gastroenterolog, Hepatology and Nutrition. The aim was to base on a thorough review of existing evidence a state of the art guidance on the medical treatment and long term management of children and adolescents with CD, with individualized treatment algorithms based on a benefit-risk analysis according to different clinical scenarios. In children and adolescents who did not have finished their growth, exclusive enteral nutrition (EEN) is the induction therapy of first choice due to its excellent safety profile, preferable over corticosteroids, which are equipotential to induce remission. The majority of patients with pediatric-onset CD require immunomodulator based maintenance therapy. The experts discuss several factors potentially predictive for poor disease outcome (such as severe perianal fistulizing disease, severe stricturing/penetrating disease, severe growth retardation, panenteric disease, persistent severe disease despite adequate induction therapy), which may incite to an anti-TNF-based top down approach. These guidelines are intended to give practical (whenever possible evidence-based) answers to (pediatric) gastroenterologists who take care of children and adolescents with CD; they are not meant to be a rule or legal standard, since many different clinical scenario exist requiring treatment strategies not covered by or different from these guidelines.

Thirteen Patients with MAT1A Mutations Detected Through Newborn Screening: 13 Years' Experience

BACKGROUND

Methionine adenosyltransferase I/III (MATI/III) deficiency is the most common genetic cause of persistent isolated hypermethioninemia. Patients and Methods : This is a retrospective data analysis of 62 newborns with elevated methionine detected by newborn screening between January 2000 and June 2013. The clinical, biochemical, and molecular findings of a subset of these children with MAT1A mutations associated with MATI/III deficiency are presented.

RESULTS

Of the 62 newborns with elevated methionine, 12 were identified as having classical homocystinuria; 37 were false-positives; and 13 were found to have isolated persistent hypermethioninemia in the absence of biochemical markers of homocystinuria, abnormal liver function studies, or other causes of elevated methionine. These 13 individuals underwent genetic testing for changes in the MAT1A gene, associated with MATI/III deficiency. Three of 13 were found to have the common autosomal dominant R264H mutation, one was found to be a compound heterozygote for two novel pathogenic mutations, and three were found to be heterozygotes for previously reported mutations shown to cause autosomal recessive MATI/III deficiency when present in homozygous or a compound heterozygous configuration. The remaining six patients had variants of unknown clinical significance or novel mutations. For the majority of individuals, methionine persisted above the normal range but trended downward over time. None of these 13 individuals was started on a low-methionine diet, and all have age-appropriate growth and development.

CONCLUSION

These cases show that individuals with even single changes in the MAT1A gene may have elevations in methionine identified by newborn screening, which may persist for months after birth without any clinical consequences.

Prenatal methyl mercury exposure in relation to neurodevelopment and behavior at 19 years of age in the Seychelles Child Development Study

BACKGROUND

Fish are important sources of protein and contain a variety of nutrients, such as n-3 long-chain polyunsaturated fatty acids (PUFA), essential for normal brain development. Nevertheless, all fish also contain methyl mercury (MeHg), a known neurotoxicant in adequate dosage. Our studies of the Seychelles Child Development Study (SCDS) Main Cohort enrolled in 1989-1990 (n=779) have found no consistent pattern of adverse MeHg effects at exposures achieved by daily fish consumption. Rather, we have observed evidence of improved performance on some cognitive endpoints as prenatal MeHg exposure increases in the range studied. These observations cannot be related to MeHg and may reflect the role of unmeasured covariates such as essential nutrients present in fish. To determine if these associations persist into young adulthood, we examined the relationship between prenatal MeHg exposure, recent PUFA exposure and subjects' neurodevelopment and behavior at 19 years of age.

METHODS

We examined 533 participants using the following test battery: the Profile of Mood States-Bipolar (POMS-Bi); Finger Tapping; Kaufman Brief Intelligence Test (K-BIT); measures of Fine Motor Control and Complex Perceptual Motor Control; and Visual Spatial Contrast Sensitivity. We collected the following covariates: maternal IQ, family life course stressors, socioeconomic status, and subjects' recent postnatal MeHg, sex, and computer use. Primary analyses (based on N=392-475) examined covariate-adjusted associations in multiple linear regression models with prenatal MeHg as the primary exposure measure. Secondary analyses additionally adjusted for total n-6 and fish-related n-3 PUFA measured in the subjects' serum at the 19-year examination.

RESULTS

Study participants had a mean prenatal MeHg exposure of 6.9 ppm, and a mean recent postnatal exposure of 10.3 ppm. There were no adverse associations between prenatal MeHg and any of the measured endpoints. For recent postnatal MeHg exposure, however, adverse associations were observed for Finger Tapping (non-dominant hand) among women and for the K-BIT Matrices for both sexes, with or without adjustment for PUFA.

CONCLUSION

Our findings continue to provide no evidence for an adverse effect of prenatal MeHg exposure on development in a cohort that consumes fish daily. Observations for postnatal MeHg exposure will need to be confirmed using more comprehensive exposure measures.

Genome-wide linkage disequilibrium in the Blonde d'Aquitaine cattle breed

We present here the first genome-wide characterization of linkage disequilibrium (LD) in the French Blonde d'Aquitaine (BLA) breed, a well-muscled breed renowned for producing high-yielding beef carcasses. To assess the pattern and extent of LD, we used a sample of 30 unrelated bulls and 36 923 single nucleotide polymorphisms (SNPs) covering all cattle autosomes. The squared correlation of the alleles at two loci (r(2) ) was used as a measure of LD. The analysis of adjacent marker pairs revealed that the level of LD decreases rapidly with physical distance between SNPs. Overall mean r(2) was 0.205 (±0.262). Strong LD (r(2)  > 0.8) and useful LD (measured as r(2 ) > 0.2) were observed within genomic regions of up to 720 and 724 kb, respectively. We analysed the genetic structure of the BLA population and found stratification. The observed genetic sub-structuring is consistent with the known recent demographic history that occurred during BLA breed formation. Our results indicate that LD mapping of phenotypic traits in the BLA population is feasible; however, because of this sub-structuring, special care is needed to reduce the likelihood of false-positive associations between marker loci and traits of interest.