Characterizing the Relationship Between Arterial Carbon Dioxide Trajectory and Serial Brain Biomarkers with Central Nervous System Injury During Veno-Venous Extracorporeal Membrane Oxygenation: A Prospective Cohort Study

BACKGROUND

Central nervous system (CNS) injury following initiation of veno-venous extracorporeal membrane oxygenation (VV-ECMO) is common. An acute decrease in partial pressure of arterial carbon dioxide (PaCO2) following VV-ECMO initiation has been suggested as an etiological factor, but the challenges of diagnosing CNS injuries has made discerning a relationship between PaCO2 and CNS injury difficult.

METHODS

We conducted a prospective cohort study of adult patients undergoing VV-ECMO for acute respiratory failure. Arterial blood gas measurements were obtained prior to initiation of VV-ECMO, and at every 2-4 h for the first 24 h. Neuroimaging was conducted within the first 7-14 days in patients who were suspected of having neurological injury or unable to be examined because of sedation. We collected blood biospecimens to measure brain biomarkers [neurofilament light (NF-L); glial fibrillary acidic protein (GFAP); and phosphorylated-tau 181] in the first 7 days following initiation of VV-ECMO. We assessed the relationship between both PaCO2 over the first 24 h and brain biomarkers with CNS injury using mixed methods linear regression. Finally, we explored the effects of absolute change of PaCO2 on serum levels of neurological biomarkers by separate mixed methods linear regression for each biomarker using three PaCO2 exposures hypothesized to result in CNS injury.

RESULTS

In our cohort, 12 of 59 (20%) patients had overt CNS injury identified on head computed tomography. The PaCO2 decrease with VV-ECMO initiation was steeper in patients who developed a CNS injury (- 0.32%, 95% confidence interval - 0.25 to - 0.39) compared with those without (- 0.18%, 95% confidence interval - 0.14 to - 0.21, P interaction < 0.001). The mean concentration of NF-L increased over time and was higher in those with a CNS injury (464 [739]) compared with those without (127 [257]; P = 0.001). GFAP was higher in those with a CNS injury (4278 [11,653] pg/ml) compared with those without (116 [108] pg/ml; P < 0.001). The mean NF-L, GFAP, and tau over time in patients stratified by the three thresholds of absolute change of PaCO2 showed no differences and had no significant interaction for time.

CONCLUSIONS

Although rapid decreases in PaCO2 following initiation of VV-ECMO were slightly greater in patients who had CNS injuries versus those without, data overlap and absence of relationships between PaCO2 and brain biomarkers suggests other pathophysiologic variables are likely at play.

Extracorporeal life support in trauma: Indications and techniques

BACKGROUND

Clarity about indications and techniques in extracorporeal life support (ECLS) in trauma is essential for timely and effective deployment, and to ensure good stewardship of an important resource. Extracorporeal life support deployments in a tertiary trauma center were reviewed to understand the indications, strategies, and tactics of ECLS in trauma.

METHODS

The provincial trauma registry was used to identify patients who received ECLS at a Level I trauma center and ECLS organization-accredited site between January 2014 and February 2021. Charts were reviewed for indications, technical factors, and outcomes following ECLS deployment. Based on this data, consensus around indications and techniques for ECLS in trauma was reached and refined by a multidisciplinary team discussion.

RESULTS

A total of 25 patients underwent ECLS as part of a comprehensive trauma resuscitation strategy. Eighteen patients underwent venovenous ECLS and seven received venoarterial ECLS. Nineteen patients survived the ECLS run, of which 15 survived to discharge. Four patients developed vascular injuries secondary to cannula insertion while four patients developed circuit clots. On multidisciplinary consensus, three broad indications for ECLS and their respective techniques were described: gas exchange for lung injury, extended damage control for severe injuries associated with the lethal triad, and circulatory support for cardiogenic shock or hypothermia.

CONCLUSION

The three broad indications for ECLS in trauma (gas exchange, extended damage control and circulatory support) require specific advanced planning and standardization of corresponding techniques (cannulation, circuit configuration, anticoagulation, and duration). When appropriately and effectively integrated into the trauma response, ECLS can extend the damage control paradigm to enable the management of complex multisystem injuries.

LEVEL OF EVIDENCE

Therapeutic/Care Management; Level IV.

Fatal cerebral air embolism post esophageal endoscopy with dilatation: A case report

This is a case of a patient who underwent an esophageal dilatation for benign esophageal strictures. As a consequence of the procedure, she developed an esophageal rupture and multiple cerebral and cerebellar air emboli resulting in infarction. The patient died after being placed on comfort care measures. The postmortem examination revealed focal breach of the esophageal mucosa but no sites of cardiac or vascular shunting that could account for the transit of air from the esophagus to the central nervous system. The phenomenon of vascular air entry as a consequence of upper gastrointestinal endoscopic intervention is an uncommon but very serious complication of balloon dilatation therapy. Instances of progression to intracranial arterial gas embolism are even less common, but are well described in a small number of case reports. We present a fatal case of central nervous system air embolism post-balloon dilatation therapy with associated antemortem imaging, autopsy, and microscopic images followed by a discussion of potential mechanisms of entry of air into the brain.

Seventy-seven days on veno-venous extracorporeal membrane oxygenation for severe acute respiratory distress syndrome from SARS-CoV-2

Throughout the COVID-19 pandemic veno-venous extracorporeal membrane oxygenation (VV ECMO) has emerged as a valid supportive intervention for severe COVID-19 pneumonia. In this report we describe the use of prolonged ECMO (77 days) to support a patient with COVID-19, ultimately resulting in lung recovery and discharge home. This report also emphasizes the value of physiotherapy in patients on ECMO and the importance of collaboration between ECMO programs and lung transplant teams in the care of these patients.

Development, sensitivity and reliability of a French version of the Leeds Food Preference Questionnaire (LFPQ-fr) for the evaluation of food preferences and reward

BACKGROUND

. There is a growing global interest in the evaluation of food reward, necessitating the adaptation of culturally appropriate instruments for use in empirical studies. This work presents the development and validation of a culturally adapted French version of the Leeds Food Preference Questionnaire (LFPQ-fr).

METHODS

. The LFPQ-fr was developed and validated in healthy-weight adults using the following systematic approach: i) selection and validation of appropriate food pictures; ii) linguistic translation of liking and wanting constructs in the target population (n=430; 81% female; 42.2 ± 12.7 years); iii) validation of the sensitivity and reliability of the task performed in a fasted state and in response to a standardized test meal (n=50; 50% female; 30.0 ± 8.4 years).

RESULTS

. During the first and second phases, the nutritional and perceptual validation of culturally appropriate food pictures and pertinent reward constructs, respectively, was demonstrated in a healthy-weight French sample. Findings from the third phase indicated that all food reward components were sensitive to the test meal and showed moderate to high agreement in both fasted (Lin's CCC =.72-.94) and fed (Lin's CCC = .53-.80) appetitive states between visit 1 (V1) and visit (V2). Except for explicit liking fat bias, all primary outcomes were statistically consistent in fasted and fed states between V1 and V2. Changes in fat and taste biases in response to a standardized meal for all primary outcomes were also consistent between V1 and V2 except for explicit liking fat bias (Lin's CCC = .49- .72).

CONCLUSION

. The LFPQ-fr developed and tested in this study is a reproducible and reliable method to assess food reward in both the fasted and fed states in a healthy-weight French population.

Effects of aquatic exercise on appetitive responses in adolescents with obesity: An exploratory study

Aquatic exercise has been suggested as a beneficial modality to improve weight loss, cardiorespiratory fitness and quality of life in adolescents with obesity; however, its impact on appetite control in youth remains unknown. The aim of this preliminary study was to examine the effect of an acute aquatic exercise session on energy intake (EI), appetite feelings and food reward in adolescents with obesity. Twelve adolescents with obesity (12-16 years, Tanner stage 3-5, 9 males) randomly completed two conditions: i) control (CON); ii) aquatic exercise session (AQUA). One hour before lunch, the adolescents stayed at rest outside the water in a quiet room for 45 min on CON while they performed a 45-min aquatic exercise session on AQUA. Ad libitum EI and macronutrients were assessed at lunch and dinner, subjective appetite feelings taken at regular intervals, and food reward measured before and after lunch. Paired T-test showed that EI was not different between CON and AQUA at lunch (1333 ± 484 kcal vs 1409 ± 593 kcal; p = 0.162) and dinner (528 ± 218 kcal vs 513 ± 204 kcal; p = 0.206). Total daily ad libitum EI was significantly higher on AQUA (1922 ± 649 kcal) compared with CON (1861 ± 685 kcal; p = 0.044) but accounting for the exercise-induced energy expenditure, relative energy intake did not differ (2263 ± 732 kcal vs 2117 ± 744 kcal, p = 0.304). None of the appetite feelings (hunger, fullness, prospective food consumption and desire to eat) and food reward dimensions were significantly different between conditions. These preliminary and exploratory results suggest that an acute aquatic-exercise session might not induce energy compensatory responses in adolescents with obesity.

Lung Transplantation for COVID-19 Acute Respiratory Distress Syndrome: The British Columbian Experience With New Disease Pathology

Lung transplantation is a life-saving treatment for patients with end-stage lung disease. COVID-19 has been associated with a severe and rapid decline in pulmonary function, in which case lung transplantation has been described to be effective. We herein describe 9 patients who underwent lung transplantation for COVID-19 acute respiratory distress syndrome, of whom 6 were bridged with extracorporeal membrane oxygenation (ECMO). The median time of pre-operative observation periods was 54 days to ensure no lung function recovery and the time to wean off extracorporeal membrane oxygenation was 3 days. Patients had comparable short-term survival outcomes to non-COVID-19 lung transplant recipients at our institution during the same time period. Lung transplantation for COVID-19-associated lung disease is feasible with comparable short-term outcomes and may liberate patients from extracorporeal supports.

The validity of two widely used commercial and research-grade activity monitors, during resting, household and activity behaviours

Wearable devices are increasingly prevalent in research environments for the estimation of energy expenditure (EE) and heart rate (HR). The aim of this study was to validate the HR and EE estimates of the Fitbit charge 2 (FC2), and the EE estimates of the Sensewear armband mini (SWA). We recruited 59 healthy adults to participate in walking, running, cycling, sedentary and household tasks. Estimates of HR from the FC2 were compared to a HR chest strap (Polar) and EE to a stationary metabolic cart (Vyntus CPX). The SWA overestimated overall EE by 0.03 kcal/min−1 and was statistically equivalent to the criterion measure, with a mean absolute percentage error (MAPE) of 29%. In contrast, the FC2 was not equivalent overall (MAPE = 44%). In household tasks, MAPE values of 93% and 83% were observed for the FC2 and SWA, respectively. The FC2 HR estimates were equivalent to the criterion measure overall. The SWA is more accurate than the commercial-grade FC2. Neither device is consistently accurate across the range of activities used in this study. The HR data obtained from the FC2 is more accurate than its EE estimates and future research may focus more on this variable.

Homeostatic and neurocognitive control of energy intake in response to exercise in pediatric obesity: a psychobiological framework

While energy intake and energy expenditure have long been studied independently, the alarming progression of obesity has led to a more integrative approach to energy balance considering their potential interactions. Although the available literature concerned with the effect of chronic and acute exercise on energy intake and appetite control in adults is considerable, these questions remain less explored among children and adolescents. Based on the search of four databases (Medline, Embase, PsycINFO and Cochrane Library; articles published until May 2018), the objective of this review is to summarize and discuss the effect of acute and chronic physical exercise on energy intake and appetite control in children and adolescents with obesity, and to identify the physiological and neurocognitive signals and pathways involved. Evidence suggested that acute intensive exercise has the potential to reduce subsequent energy intake in children and adolescents with obesity but not healthy weight, through both peripheral (mainly gastro-peptides) and neurocognitive (neural responses to food cues) pathways. The nutritional responses to chronic physical activity remain less clear and require further consideration, especially from an anti-obesity perspective.

Changes in food reward during weight management interventions - a systematic review

BACKGROUND

Does food reward increase or decrease during weight management attempts? Excessive food intake is the main behavioural determinant of obesity; therefore, a better understanding of food reward and its relationship with food intake and weight outcomes could contribute to more effective weight management solutions.

METHODS

This systematic review assessed the role of changes in food reward (directly or indirectly measured) during weight management interventions. Four databases were searched for articles published until April 2018 involving weight management interventions (all types and designs) in healthy adults with overweight or obesity.

RESULTS

Of 239 full-text articles assessed, 17 longitudinal studies were included. Twelve studies reported a significant change in food reward over time. When compared with control interventions, dietary, pharmacological, behavioural and cognitive interventions were effective in decreasing liking and/or wanting for high-energy food using a range of methodologies to assess food reward. Three studies reported that decreased food reward was associated with improved weight management outcomes.

CONCLUSION

Food reward appears to decrease rather than increase during weight management interventions. Future studies specifically targeting the hedonic aspects of food intake (liking/wanting) are needed to gain a better understanding of how to uncouple the obesogenic relationship between food reward and overeating.

Study protocol: a randomised controlled trial of supervised resistance training versus aerobic training in Sri Lankan adults with type 2 diabetes mellitus: SL-DART study

Background

The prevalence of type 2 diabetes mellitus (T2DM) and cardiovascular diseases (CVD) is rising globally. T2DM is particularly problematic in South Asia with an estimated 10–15% of Sri Lankans diagnosed with the disease. Exercise is known to improve blood glucose, lipid profiles, blood pressure and adiposity, key goals in the management of T2DM. However, much of the evidence to date has been gained from white Caucasians who have a different body composition and disease profile compared to South Asians. Similarly, the recreational exercise culture is new to Sri Lankans and the effects of exercise on T2DM has not been studied in this population.

Methods

The Sri Lanka Diabetes Aerobic and Resistance Training (SL-DART) Study will be comprised of 2 components. Component 1 is a 12-week randomized controlled trial (RCT) to compare the effects of a supervised progressive resistance exercise program (RT) and aerobic exercise program (AT) with standard treatment/control (CN). Sedentary Sri Lankan adults with T2DM (aged 35–65 years) and with no contraindications to exercise will be randomized into one of 3 groups (AT, RT, CN). Exercise sessions will be conducted 2 days/week for 3 months. Baseline and post-intervention biochemical (glycemic control, lipid and liver profiles, inflammatory markers), anthropometric (height, weight, body circumferences), body composition, physical fitness, food preference (liking and wanting food) and quality of life parameters will be measured and compared between groups. Component 2 will be a qualitative study conducted immediately post-intervention via in-depth interviews to assess the barriers and facilitators for adherence to each exercise program.

Discussion

SL-DART Study represents one of the first adequately powered methodologically sound RCTs conducted in South Asia to assess the effects of resistance and aerobic exercise in participants with T2DM. Triangulation of quantitative and qualitative outcomes will enable the design of a culturally appropriate therapeutic physical activity intervention for Sri Lankans with T2DM, and the initiation of a professionally driven and specialized clinical exercise prescription service.

Trial registration

Sri Lanka Clinical Trials Registry; SLCTR/2016/017. Date registered 17.06.2016. Universal trial number U1111–1181-7561.

Corticosterone stress hormone responses in oil rehabilitated and non-rehabilitated little penguins

Whether oiled wildlife should be rehabilitated during an oil spill is internationally debated. Research on little penguins (LP, Eudyptula minor) rehabilitated and released back into a cleaned environment after the New Zealand C/V Rena grounding oil spill in 2011 found the rehabilitation process was effective at treating and reversing the negative effects of oil-contamination on penguin post-release survival, productivity and diving behaviour. Here we investigated the acute corticosterone stress response of LPs to determine if responses of rehabilitated birds differed from those of "control" birds. Corticosterone responses of LPs two years after an oil spill did not differ between rehabilitated and non-rehabilitated penguins. These results show that the rehabilitation process for LP did not affect their long-term physiological responses to humans. This indicates that wildlife can be rehabilitated and returned to the wild with similar human tolerance levels to non-rehabilitated birds and an absence of habituation.

Is the way an oil spill response is reported in the media important for the final perception of the clean-up?

This research investigates the media coverage during the C/V Rena grounding in New Zealand (NZ), in 2011, to analyze if information reported in printed media is important for the final perception of the overall oil spill response. We took all articles available from NZ's largest circulated newspaper and the regional newspaper closest to the incident and analyzed the themes within each article; the article's tone (positive, neutral or negative); the time of the report relative to incident events and any differences between the regional and national papers. This analysis indicates that oil spills are reported and perceived as inherently negative incidents. However, along with coordinating an effective spill response, fast, factual and frequent media releases and increased effect in media liaison in areas of response with high public intrinsic value such as oiled wildlife response can significantly influence tone of media coverage and likely overall public perception.

Diving behaviour of wildlife impacted by an oil spill: A clean-up and rehabilitation success?

The value of rehabilitating oiled wildlife is an on-going global debate. On October 5, 2011, the cargo vessel C/V Rena grounded on Astrolabe Reef, New Zealand (NZ), spilling over 300 tonnes of heavy fuel oil. As part of the Rena oil spill response, 383 little blue penguins (LBP, Eudyptula minor) were captured, cleaned, rehabilitated and released back into a cleaned environment. This research investigates foraging behaviour changes due either to the oil spill or by the rehabilitation process by comparing the diving behaviour of rehabilitated (n=8) and non-rehabilitated (n=6) LBPs and with LBP populations throughout NZ. Stabile isotope analysis of feathers was also used to investigate diet. There were no foraging behaviour differences between rehabilitated and non-rehabilitated LBPs and the overall diving behaviour of these LBPs have similar, if not less energetic, foraging behaviour than other LBPs in NZ. This suggests the rehabilitation process and clean-up undertaken after the Rena appears effective and helps justify the rehabilitation of oiled wildlife across the world.

Appetite control and energy balance: impact of exercise

Exercise is widely regarded as one of the most valuable components of behaviour that can influence body weight and therefore help in the prevention and management of obesity. Indeed, long-term controlled trials show a clear dose-related effect of exercise on body weight. However, there is a suspicion, particularly fuelled by media reports, that exercise serves to increase hunger and drive up food intake thereby nullifying the energy expended through activity. Not everyone performing regular exercise will lose weight and several investigations have demonstrated a huge individual variability in the response to exercise regimes. What accounts for this heterogeneous response? First, exercise (or physical activity) through the expenditure of energy will influence the energy balance equation with the potential to generate an energy deficit. However, energy expenditure also influences the control of appetite (i.e. the physiological and psychological regulatory processes underpinning feeding) and energy intake. This dynamic interaction means that the prediction of a resultant shift in energy balance, and therefore weight change, will be complicated. In changing energy intake, exercise will impact on the biological mechanisms controlling appetite. It is becoming recognized that the major influences on the expression of appetite arise from fat-free mass and fat mass, resting metabolic rate, gastric adjustment to ingested food, changes in episodic peptides including insulin, ghrelin, cholecystokinin, glucagon-like peptide-1 and tyrosine-tyrosine, as well as tonic peptides such as leptin. Moreover, there is evidence that exercise will influence all of these components that, in turn, will influence the drive to eat through the modulation of hunger (a conscious sensation reflecting a mental urge to eat) and adjustments in postprandial satiety via an interaction with food composition. The specific actions of exercise on each physiological component will vary in strength from person to person (according to individual physiological characteristics) and with the intensity and duration of exercise. Therefore, individual responses to exercise will be highly variable and difficult to predict.

Risk of suicide and suicide attempts associated with physical disorders: a population-based, balancing score-matched analysis

BACKGROUND

The association between physical disorders and suicide remains unclear. The aim of this study was to examine the relationship between physical disorders and suicide after accounting for the effects of mental disorders.

METHOD

Individuals who died by suicide (n = 2100) between 1996 and 2009 were matched 3:1 by balancing score to general population controls (n = 6300). Multivariate conditional logistic regression compared the two groups across physician-diagnosed physical disorders [asthma, chronic obstructive pulmonary disease (COPD), ischemic heart disease, hypertension, diabetes, cancer, multiple sclerosis and inflammatory bowel disease], adjusting for mental disorders and co-morbidity. Secondary analyses examined the risk of suicide according to time since first diagnosis of each physical disorder (1-90, 91-364, ⩾ 365 days). Similar analyses also compared individuals with suicide attempts (n = 8641) to matched controls (n = 25 923).

RESULTS

Cancer was associated with increased risk of suicide [adjusted odds ratio (AOR) 1.40, 95% confidence interval (CI) 1.03-1.91, p < 0.05] even after adjusting for all mental disorders. The risk of suicide with cancer was particularly high in the first 90 days after initial diagnosis (AOR 4.10, 95% CI 1.71-9.82, p < 0.01) and decreased to non-significance after 1 year. Women with respiratory diseases had elevated risk of suicide whereas men did not. COPD, hypertension and diabetes were each associated with increased odds of suicide attempts in adjusted models (AORs ranged from 1.20 to 1.73).

CONCLUSIONS

People diagnosed with cancer are at increased risk of suicide, especially in the 3 months following initial diagnosis. Increased support and psychiatric involvement should be considered for the first year after cancer diagnosis.

Estimating the excess costs for patients with incident fractures, prevalent fractures, and nonfracture osteoporosis

SUMMARY

Based on a population age 50+, significant excess costs relative to matched controls exist for patients with incident fractures that are similar in relative magnitude to other chronic diseases such as stroke or heart disease. Prevalent fractures also have significant excess costs that are similar in relative magnitude to asthma/chronic obstructive pulmonary disease.

INTRODUCTION

Cost of illness studies for osteoporosis that only include incident fractures may ignore the long-term cost of prevalent fractures and primary preventive care. We estimated the excess costs for patients with incident fractures, prevalent fractures, and nonfracture osteoporosis relative to matched controls.

METHODS

Men and women age 50+ were selected from administrative records in the province of Manitoba, Canada for the fiscal year 2007-2008. Three types of cases were identified: (1) patients with incident fractures in the current year (2007-2008), (2) patients with prevalent fractures in previous years (1995-2007), and (3) nonfracture osteoporosis patients identified by specific pharmacotherapy or low bone mineral density. Excess resource utilization and costs were estimated by subtracting control means from case means.

RESULTS

Seventy-three percent of provincial population age 50+ (52 % of all men and 91 % of all women) were included (121,937 cases, 162,171 controls). There were 3,776 cases with incident fracture (1,273 men and 2,503 women), 43,406 cases with prevalent fractures (15,784 men and 27,622 women) and 74,755 nonfracture osteoporosis cases (7,705 men and 67,050 women). All incident fractures had significant excess costs. Incident hip fractures had the highest excess cost: men $44,963 (95 % CI: $38,498-51,428) and women $45,715 (95 % CI: $36,998-54,433). Prevalent fractures (other than miscellaneous or wrist fractures) also had significant excess costs. No significant excess costs existed for nonfracture osteoporosis.

CONCLUSION

Significant excess costs exist for patients with incident fractures and with prevalent hip, vertebral, humerus, multiple, and traumatic fractures. Ignoring prevalent fractures underestimate the true cost of osteoporosis.

The role of taste and appetite regulation in the understanding of overweight and obesity. Proceedings of the 16th Aschauer Soiree, 26th April 2008

Overweight and obesity have developed into major illnesses in most Western societies and significantly contribute to the financial burden of modern public health systems. Almost daily, new therapeutic proposals are published in the lay press, and also the scientific literature has increased dramatically in recent years. E.g., when searching MEDLINE (1966 - May 2008 (1)), the key word "obesity" meanwhile appears in more than 108,000 articles. Primary focus however, is put upon aspects of treatment, neglecting the role of taste and appetite regulation. Combining keywords like "obesity + treatment" results in over 50.000 citations, "obesity + diet" in over 23.000, "obesity + energy + expenditure" in over 13.000 citations (even "obesity + gastric + bypass" still evoke 2.600 citations), whereas "obesity + appetite + regulation" result in some 3.000, "obesity + NPY" - neuropeptid Y being one of the major chemical stimulators of appetite - evoke some 500 and "obesity + Arc + nucleus" - the arcuate nucleus being the anatomical centre of appetite regulation - no more than 370 scientific publications. The apparent scarcity of literature about taste and appetite regulation and the amazing lack of interest in neuronal information processing in overweight and obesity, has prompted the authors to brainstorm new aspects of the world-wide derailment of weight control.