Endoscopic treatment of chronic pancreatitis: a multicenter study of 1000 patients with long-term follow-up

BACKGROUND AND STUDY AIMS

Endoscopic ductal decompression therapy has become an established method of treating patients with painful obstructive chronic pancreatitis. Smaller series, mostly with a medium-term follow-up period, have reported encouraging results. The present analysis presents long-term follow-up data from a large multicenter patient cohort.

PATIENTS AND METHODS

Patients with painful chronic pancreatitis and with ductal obstruction due to either strictures and/or stones treated endoscopically at eight different centers underwent follow-up after 2 - 12 years (mean 4.9 years). The patients' clinical data, the rate of technical success, and complications were recorded from the charts. Follow-up data were prospectively obtained using structured questionnaires; the main parameter for evaluating treatment success was a significant reduction in pain (no pain or only weak pain).

RESULTS

Follow-up data were obtained from 1018 of 1211 patients treated (84%) with mainly strictures (47%), stones (18%), or strictures plus stones (32%). At the long-term follow-up, 60% of the patients had their endotherapy completed, 16% were still receiving some form of endoscopic treatment, and 24% had undergone surgery. The long-term success of endotherapy was 86% in the entire group, but only 65% in an intention-to-treat analysis. There were no significant differences between the patient groups with regard to either strictures, stones, or both. Pancreatic function was not positively affected by endoscopic therapy.

CONCLUSIONS

Endoscopic ductal decompression therapy offers relief of pain in two-thirds of the patients when it is used as the only form of treatment. One-quarter of the patients have to undergo surgery.

Association of clinical factors and recent anticancer therapy with COVID-19 severity among patients with cancer: a report from the COVID-19 and Cancer Consortium

BACKGROUND

Patients with cancer may be at high risk of adverse outcomes from severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. We analyzed a cohort of patients with cancer and coronavirus 2019 (COVID-19) reported to the COVID-19 and Cancer Consortium (CCC19) to identify prognostic clinical factors, including laboratory measurements and anticancer therapies.

PATIENTS AND METHODS

Patients with active or historical cancer and a laboratory-confirmed SARS-CoV-2 diagnosis recorded between 17 March and 18 November 2020 were included. The primary outcome was COVID-19 severity measured on an ordinal scale (uncomplicated, hospitalized, admitted to intensive care unit, mechanically ventilated, died within 30 days). Multivariable regression models included demographics, cancer status, anticancer therapy and timing, COVID-19-directed therapies, and laboratory measurements (among hospitalized patients).

RESULTS

A total of 4966 patients were included (median age 66 years, 51% female, 50% non-Hispanic white); 2872 (58%) were hospitalized and 695 (14%) died; 61% had cancer that was present, diagnosed, or treated within the year prior to COVID-19 diagnosis. Older age, male sex, obesity, cardiovascular and pulmonary comorbidities, renal disease, diabetes mellitus, non-Hispanic black race, Hispanic ethnicity, worse Eastern Cooperative Oncology Group performance status, recent cytotoxic chemotherapy, and hematologic malignancy were associated with higher COVID-19 severity. Among hospitalized patients, low or high absolute lymphocyte count; high absolute neutrophil count; low platelet count; abnormal creatinine; troponin; lactate dehydrogenase; and C-reactive protein were associated with higher COVID-19 severity. Patients diagnosed early in the COVID-19 pandemic (January-April 2020) had worse outcomes than those diagnosed later. Specific anticancer therapies (e.g. R-CHOP, platinum combined with etoposide, and DNA methyltransferase inhibitors) were associated with high 30-day all-cause mortality.

CONCLUSIONS

Clinical factors (e.g. older age, hematological malignancy, recent chemotherapy) and laboratory measurements were associated with poor outcomes among patients with cancer and COVID-19. Although further studies are needed, caution may be required in utilizing particular anticancer therapies.

CLINICAL TRIAL IDENTIFIER

NCT04354701.

Evidence of a molecular barrier limiting susceptibility of humans, cattle and sheep to chronic wasting disease

Chronic wasting disease (CWD) is a transmissible spongiform encephalopathy (TSE) of deer and elk, and little is known about its transmissibility to other species. An important factor controlling interspecies TSE susceptibility is prion protein (PrP) homology between the source and recipient species/genotypes. Furthermore, the efficiency with which the protease-resistant PrP (PrP-res) of one species induces the in vitro conversion of the normal PrP (PrP-sen) of another species to the protease-resistant state correlates with the cross-species transmissibility of TSE agents. Here we show that the CWD-associated PrP-res (PrP(CWD)) of cervids readily induces the conversion of recombinant cervid PrP-sen molecules to the protease-resistant state in accordance with the known transmissibility of CWD between cervids. In contrast, PrP(CWD)-induced conversions of human and bovine PrP-sen were much less efficient, and conversion of ovine PrP-sen was intermediate. These results demonstrate a barrier at the molecular level that should limit the susceptibility of these non-cervid species to CWD.

Glioma imaging in Europe: A survey of 220 centres and recommendations for best clinical practice

Objectives

At a European Society of Neuroradiology (ESNR) Annual Meeting 2015 workshop, commonalities in practice, current controversies and technical hurdles in glioma MRI were discussed. We aimed to formulate guidance on MRI of glioma and determine its feasibility, by seeking information on glioma imaging practices from the European Neuroradiology community.

Methods

Invitations to a structured survey were emailed to ESNR members (n=1,662) and associates (n=6,400), European national radiologists’ societies and distributed via social media.

Results

Responses were received from 220 institutions (59% academic). Conventional imaging protocols generally include T2w, T2-FLAIR, DWI, and pre- and post-contrast T1w. Perfusion MRI is used widely (85.5%), while spectroscopy seems reserved for specific indications. Reasons for omitting advanced imaging modalities include lack of facility/software, time constraints and no requests. Early postoperative MRI is routinely carried out by 74% within 24–72 h, but only 17% report a percent measure of resection. For follow-up, most sites (60%) issue qualitative reports, while 27% report an assessment according to the RANO criteria. A minority of sites use a reporting template (23%).

Conclusion

Clinical best practice recommendations for glioma imaging assessment are proposed and the current role of advanced MRI modalities in routine use is addressed.

Key Points

• We recommend the EORTC-NBTS protocol as the clinical standard glioma protocol.

• Perfusion MRI is recommended for diagnosis and follow-up of glioma.

• Use of advanced imaging could be promoted with increased education activities.

• Most response assessment is currently performed qualitatively.

• Reporting templates are not widely used, and could facilitate standardisation.

Electronic supplementary material

The online version of this article (10.1007/s00330-018-5314-5) contains supplementary material, which is available to authorized users.

Chromosome-sized DNA molecules of Plasmodium falciparum

At least seven chromosome-sized DNA molecules (750 to 2000 kilobases in length and one fraction of undetermined molecular weight) from cultured clones and isolates of Plasmodium falciparum have been separated by pulsed-field gradient gel electrophoresis. Whereas asexual blood stages and sexual stages of the same line have identical molecular karyotypes, the length of chromosome-sized DNA molecules among different geographical isolates and several clones derived from a single patient is different. These length alterations of chromosomes are the result of DNA rearrangements that must occur unrelated to sexual differentiation.

Melanoma-specific tumor-infiltrating lymphocytes but not circulating melanoma-specific T cells may predict survival in resected advanced-stage melanoma patients

PURPOSE

To study the effect of autologous tumor cell vaccinations on the presence and numbers of circulating CD8+ T cells specific for tumor-associated antigens (TAA) in metastatic melanoma patients. To investigate the correlation between the presence of tumor-infiltrating lymphocytes (TIL) and circulating TAA-specific CD8+ T cells before and after autologous tumor cell vaccination with overall survival.

EXPERIMENTAL DESIGN

Twenty-five stage III and resected stage IV metastatic melanoma patients were adjuvantly treated with a series of intracutaneously injected autologous tumor cell vaccinations, of which the first two contained BCG as an immunostimulatory adjuvant. Tumor samples and blood samples obtained before and after vaccination of these patients were studied for the presence of TAA-specific T cells using HLA-tetramers and results were correlated with survival.

RESULTS

In 5 of 17 (29%) melanoma patients, circulating TAA-specific T cells were detectable prior to immunizations. No significant changes in the frequency and specificity were found during the treatment period in all patients. Presence of circulating TAA-specific T cells was not correlated with survival (log rank, P=0.215). Inside melanoma tissue, TAA-specific TIL could be detected in 75% of 16 available tumor samples. In case of detectable TAA-specific TIL, median survival was 22.5 months compared to median survival of 4.5 months in case of absence of TAA-specific T cells (log rank, P=0.0094). In none of the patients, TAA-specific T cells were found both in tumor tissue and blood at the same time.

CONCLUSIONS

These data suggest that the presence of TAA-specific TILs forms a prognostic factor, predicting improved survival in advanced-stage melanoma patients. The absence of TAA-specific T cells in the circulation suggests that homing of the tumor-specific T cell population to the tumor site contributes to the effectiveness of antitumor immunity.

Assessing patient safety culture in hospitals across countries

OBJECTIVE

It is believed that in order to reduce the number of adverse events, hospitals have to stimulate a more open culture and reflective attitude towards errors and patient safety. The objective is to examine similarities and differences in hospital patient safety culture in three countries: the Netherlands, the USA and Taiwan.

DESIGN

This is a cross-sectional survey study across three countries. A questionnaire, the Hospital Survey on Patient Safety Culture (Hospital SOPS), was disseminated nationwide in the Netherlands, the USA and Taiwan.

SETTING

The study was conducted in 45 hospitals in the Netherlands, 622 in the USA and 74 in Taiwan.

PARTICIPANTS

A total of 3779 professionals from the participating hospitals in the Netherlands, 196 462 from the USA and 10 146 from Taiwan participated in the study.

MAIN OUTCOME MEASURES

The main outcome measures of the study were 12 dimensions of patient safety culture, e.g. Teamwork, Organizational learning, Communication openness.

RESULTS

Most hospitals in all three countries have high scores on teamwork within units. The area with a high potential for improvement in all three countries is Handoffs and transitions. Differences between countries exist on the following dimensions: Non-punitive response to error, Feedback and communication about error, Communication openness, Management support for patient safety and Organizational learning--continuous improvement. On the whole, US respondents were more positive about the safety culture in their hospitals than Dutch and Taiwanese respondents. Nevertheless, there are even larger differences between hospitals within a country.

CONCLUSIONS

Comparison of patient safety culture data has shown similarities and differences within and between countries. All three countries can improve areas of their patient safety culture. Countries can identify and share best practices and learn from each other.

Measuring patient safety culture: an assessment of the clustering of responses at unit level and hospital level

OBJECTIVES

To test the claim that the Hospital Survey on Patient Safety Culture (HSOPS) measures patient safety culture instead of mere individual attitudes and to determine the most appropriate level (individual, unit or hospital level) for interventions aimed at improving the culture of patient safety.

METHODS

National patient safety culture data were used from 1889 hospital staff working at 87 units in 19 hospitals across The Netherlands. The multilevel structure of the variation of responses to the 11 dimensions of the questionnaire was explored by fitting three-level random intercept models: individual, unit and hospital level.

RESULTS

The unit level was the dominating level for the clustering of responses to the 11 dimensions. Intraclass correlations (ICC) at unit level ranged from 4.3 to 31.7, representing considerable higher-level variation. For three dimensions of patient safety culture, there was significant clustering of responses at hospital level as well: (1) Feedback about and learning from error, (2) Teamwork across hospital units and (3) Non-punitive response to error.

CONCLUSIONS

At a conceptual level, the detection of clustering of responses within units and hospitals confirms the claim that the HSOPS measures group culture and not just individual attitudes. In addition, the results have implications for interventions on patient safety culture. Improvement efforts should be directed at their most relevant organisational level. In general, improvement efforts on patient safety culture should be addressed at the unit level, rather than the individual or hospital level.

Incorporating functional MR imaging into diffusion tensor tractography in the preoperative assessment of the corticospinal tract in patients with brain tumors

BACKGROUND AND PURPOSE

Our goal was to improve the preoperative assessment of the corticospinal tract (CST) in patients with brain tumors. We investigated whether the integration of functional MR imaging (fMRI) data and diffusion tensor (DT) tractography can be used to evaluate the spatial relationship between the hand and foot fibers of the CST and tumor borders.

MATERIALS AND METHODS

We imaged 10 subjects: 1 healthy volunteer and 9 patients. Imaging consisted of a 3D T1-weighted sequence, a gradient-echo echo-planar imaging (EPI) sequence for fMRI, and a diffusion-weighted EPI sequence for DT tractography. DT tractography was initiated from a seed region of interest in the white matter area subjacent to the maximal fMRI activity in the precentral cortex. The target region of interest was placed in the cerebral peduncle.

RESULTS

In the healthy volunteer, we successfully tracked hand, foot, and lip fibers bilaterally by using fMRI-based DT tractography. In all patients, we could track the hand fibers of the CST bilaterally. In 4 patients who also performed foot tapping, we could clearly distinguish hand and foot fibers. We were able to depict the displacement of hand and foot fibers by tumor and the course of fibers through areas of altered signal intensity.

CONCLUSION

Incorporating fMRI into DT tractography in the preoperative assessment of patients with brain tumors may provide additional information on the course of important white matter tracts and their relationship to the tumor. Only this approach allows a distinction between the CST components, while visualization of the CST is improved when fiber tracking is hampered by tumor (infiltration) or perifocal edema.

Inter-rater agreement in glioma segmentations on longitudinal MRI

Background

Tumor segmentation of glioma on MRI is a technique to monitor, quantify and report disease progression. Manual MRI segmentation is the gold standard but very labor intensive. At present the quality of this gold standard is not known for different stages of the disease, and prior work has mainly focused on treatment-naive glioblastoma. In this paper we studied the inter-rater agreement of manual MRI segmentation of glioblastoma and WHO grade II-III glioma for novices and experts at three stages of disease. We also studied the impact of inter-observer variation on extent of resection and growth rate.

Methods

In 20 patients with WHO grade IV glioblastoma and 20 patients with WHO grade II-III glioma (defined as non-glioblastoma) both the enhancing and non-enhancing tumor elements were segmented on MRI, using specialized software, by four novices and four experts before surgery, after surgery and at time of tumor progression. We used the generalized conformity index (GCI) and the intra-class correlation coefficient (ICC) of tumor volume as main outcome measures for inter-rater agreement.

Results

For glioblastoma, segmentations by experts and novices were comparable. The inter-rater agreement of enhancing tumor elements was excellent before surgery (GCI 0.79, ICC 0.99) poor after surgery (GCI 0.32, ICC 0.92), and good at progression (GCI 0.65, ICC 0.91). For non-glioblastoma, the inter-rater agreement was generally higher between experts than between novices. The inter-rater agreement was excellent between experts before surgery (GCI 0.77, ICC 0.92), was reasonable after surgery (GCI 0.48, ICC 0.84), and good at progression (GCI 0.60, ICC 0.80). The inter-rater agreement was good between novices before surgery (GCI 0.66, ICC 0.73), was poor after surgery (GCI 0.33, ICC 0.55), and poor at progression (GCI 0.36, ICC 0.73). Further analysis showed that the lower inter-rater agreement of segmentation on postoperative MRI could only partly be explained by the smaller volumes and fragmentation of residual tumor. The median interquartile range of extent of resection between raters was 8.3% and of growth rate was 0.22 mm/year.

Conclusion

Manual tumor segmentations on MRI have reasonable agreement for use in spatial and volumetric analysis. Agreement in spatial overlap is of concern with segmentation after surgery for glioblastoma and with segmentation of non-glioblastoma by non-experts.

•

Inter-rater agreement for longitudinal glioma segmentation was determined.

•

Agreement between 4 experts was higher than between 4 novices.

•

Three time-points of glioblastoma (WHO IV) and diffuse glioma (WHO II-III) are studied.

•

Impact on extent of resection and growth rate measurements was determined.

Osteopontin levels and increased disease activity in relapsing–remitting multiple sclerosis patients

Osteopontin (OPN) has been identified as the most prominent cytokine-encoding gene expressed within multiple sclerosis (MS) lesions. Recently, we demonstrated that OPN plasma levels were elevated in active relapsing-remitting (RR) MS patients. In this longitudinal study, a trend was observed for OPN serum levels in relation to clinical exacerbations. Moreover, OPN protein levels were significantly elevated 1 month prior to increase of gadolinium (Gd)-enhancing lesion number, whereas no relation was observed between OPN levels and increase in Gd-enhancing lesion volume. Although no robust relation between OPN and disease activity was observed, these data suggest that OPN levels are elevated prior to increased disease activity in RR MS patients.

Correlation between concentrations of melatonin in saliva and serum in patients with delayed sleep phase syndrome

Exogenous melatonin, which can be used to treat certain circadian rhythm disorders, maximally advances delayed rhythms when administered 5 hours before the endogenous melatonin starts to increase. The time of the start of the endogenously melatonin is defined as Dim Light Melatonin Onset (DLMO). The DLMO concentration has been defined in serum to be 10 pg/ml. Because of the greater practicability of frequent saliva sampling over blood sampling, we have validated radioimmunoassay (RIA) measurements of melatonin in saliva in patients diagnosed as suffering from a typical circadian rhythm disorder: Delayed Sleep Phase Syndrome (DSPS). Based on these results we have defined the equivalent salivary DLMO concentration to be 4 pg/ml.

Outcome after complicated minor head injury

BACKGROUND AND PURPOSE

Functional outcome in patients with minor head injury with neurocranial traumatic findings on CT is largely unknown. We hypothesized that certain CT findings may be predictive of poor functional outcome.

MATERIALS AND METHODS

All patients from the CT in Head Injury Patients (CHIP) study with neurocranial traumatic CT findings were included. The CHIP study is a prospective, multicenter study of consecutive patients, > or =16 years of age, presenting within 24 hours of blunt head injury, with a Glasgow Coma Scale (GCS) score of 13-14 or a GCS score of 15 and a risk factor. Primary outcome was functional outcome according to the Glasgow Outcome Scale (GOS). Other outcome measures were the modified Rankin Scale (mRS), the Barthel Index (BI), and number and severity of postconcussive symptoms. The association between CT findings and outcome was assessed by using univariable and multivariable regression analysis.

RESULTS

GOS was assessed in 237/312 patients (76%) at an average of 15 months after injury. There was full recovery in 150 patients (63%), moderate disability in 70 (30%), severe disability in 7 (3.0%), and death in 10 (4.2%). Outcome according to the mRS and BI was also favorable in most patients, but 82% of patients had postconcussive symptoms. Evidence of parenchymal damage was the only independent predictor of poor functional outcome (odds ratio = 1.89, P = .022).

CONCLUSION

Patients with neurocranial complications after minor head injury generally make a good functional recovery, but postconcussive symptoms may persist. Evidence of parenchymal damage on CT was predictive of poor functional outcome.

Immunomodulatory effects of orally administered cannabinoids in multiple sclerosis

Cannabinoids can modulate the function of immune cells. We here present the first human in vivo study measuring immune function in 16 MS patients treated with oral cannabinoids. A modest increase of TNF-alpha in LPS-stimulated whole blood was found during cannabis plant-extract treatment (p=0.037), with no change in other cytokines. In the subgroup of patients with high adverse event scores, we found an increase in plasma IL-12p40 (p=0.002). The results suggest pro-inflammatory disease-modifying potential of cannabinoids in MS.

Dementia imaging in clinical practice: a European-wide survey of 193 centres and conclusions by the ESNR working group

PURPOSE

Through a European-wide survey, we assessed the current clinical practice of imaging in the primary evaluation of dementia, with respect to standardised imaging, evaluation and reporting.

METHODS

An online questionnaire was emailed to all European Society of Neuroradiology (ESNR) members (n = 1662) and non-members who had expressed their interest in ESNR activities in the past (n = 6400). The questionnaire featured 42 individual items, divided into multiple choice, single best choice and free text answers. Information was gathered on the context of the practices, available and preferred imaging modalities, applied imaging protocols and standards for interpretation, reporting and communication.

RESULTS

A total of 193 unique (non-duplicate) entries from the European academic and non-academic institutions were received from a total of 28 countries. Of these, 75% were neuroradiologists, 12% general radiologists and 11% (neuro) radiologists in training. Of responding centres, 38% performed more than five scans/week for suspected dementia. MRI was primarily used in 72% of centres. Over 90% of centres acquired a combination of T2w, FLAIR, T1w, DWI and T2*w sequences. Visual rating scales were used in 75% of centres, most often the Fazekas and medial temporal atrophy scale; 32% of respondents lacked full confidence in their use. Only 23% of centres performed volumetric analysis. A minority of centres (28%) used structured reports.

CONCLUSIONS

Current practice in dementia imaging is fairly homogeneous across Europe, in terms of image acquisition and image interpretation. Hurdles identified include training on the use of visual rating scales, implementation of volumetric assessment and structured reporting.

Biodiversity of mannose-specific adhesion in Lactobacillus plantarum revisited: strain-specific domain composition of the mannose-adhesin

Recently, we have identified the mannose-specific adhesin encoding gene (msa) of Lactobacillus plantarum. In the current study, structure and function of this potentially probiotic effector gene were further investigated, exploring genetic diversity of msa in L. plantarum in relation to mannose adhesion capacity. The results demonstrate that there is considerable variation in quantitative in vitro mannose adhesion capacity, which is paralleled by msa gene sequence variation. The msa genes of different L. plantarum strains encode proteins with variable domain composition. Construction of L. plantarum 299v mutant strains revealed that the msa gene product is the key-protein for mannose adhesion, also in a strain with high mannose adhering capacity. However, no straightforward correlation between adhesion capacity and domain composition of Msa in L. plantarum could be identified. Nevertheless, differences in Msa sequences in combination with variable genetic background of specific bacterial strains appears to determine mannose adhesion capacity and potentially affects probiotic properties. These findings exemplify the strain-specificity of probiotic characteristics and illustrate the need for careful and molecular selection of new candidate probiotics.

Molecular characterization of two lipoxygenases from barley

Two full-length lipoxygenase cDNA sequences (LoxB and LoxC) from barley (Hordeum distichum cv. L. Triumph) are described. The cDNAs share high homology with the barley LoxA cDNA. Southern blotting experiments indicate single copy numbers of the three lipoxygenase genes. RFLP mapping revealed the presence of single lipoxygenase loci. LoxA and LoxB map on chromosome 4 and LoxC on chromosome 7. Two isoenzymes, LOX1 and LOX2, have been purified previously from germinating barley and characterized. LOX1 is encoded by LoxA, while LOX2 is encoded by LoxC. The product related to the third cDNA (loxB) has not been identified so far, suggesting a low protein abundance for the corresponding isoform in barley. Transcripts corresponding with these LOX genes are predominantly observed in grain and in seedling, whereas transcripts corresponding to LoxB and LoxC are also observed in mature vegetative tissue. No lipoxygenase mRNA could be detected in aleurone layer of germinating grain. No significant differences in lipoxygenase mRNA levels were observed in developing grains grown under dormant or non-dormant conditions, suggesting that LOX is not directly involved in induction of grain dormancy.

First contact incidence of psychotic disorders among native Dutch and Moroccan immigrants in the Netherlands: influence of diagnostic bias

BACKGROUND

Several studies have reported increased incidence rates of psychotic disorders among immigrant groups. Surprisingly, the cross-cultural validity of the diagnostic instruments that were used was never tested.

AIMS

To examine whether the incidence rates of psychotic disorders including schizophrenia among Moroccan immigrants to the Netherlands remain increased when a cultural sensitive diagnostic interview is used.

METHOD

We compared first contact incidence with a standard and a cultural sensitive version of a diagnostic interview.

RESULTS

Age and gender adjusted relative risk for psychotic disorders and schizophrenia among Moroccans compared to native Dutch was 7.9 (95% CI 4.7-13.5) and 7.8 (95% CI 4.0-15.2) respectively based on the standard diagnostic interview and 4.2 (95% CI 2.3-7.9) and 1.5 (0.5-4.3) respectively based on the cultural sensitive version the diagnostic interview.

CONCLUSION

First contact incidence of schizophrenia among Moroccans was no longer significantly higher than among ethnic Dutch people when a cultural sensitive diagnostic procedure was applied.

Primary structure of a lipoxygenase from barley grain as deduced from its cDNA sequence

A full length cDNA sequence for a barley grain lipoxygenase was obtained. It includes a 5' untranslated region of 69 nucleotides, an open reading frame of 2586 nucleotides encoding a protein of 862 amino acid residues and a 3' untranslated region of 142 nucleotides. The molecular mass of the encoded polypeptide was calculated to be 96.392. Its amino acid sequence shows a high homology with that of other plant lipoxygenases identified to date.

Nature, causes and consequences of unintended events in surgical units

Background

Several studies have shown that the rate of unintended harm is higher in surgical than in non-surgical care. To improve patient safety in surgery, information about the underlying causes is needed. This observational study examined the nature, causes and consequences of unintended events in surgical units, and the completeness of event reporting.

Methods

Ten surgical units in the Netherlands participated. The study period per unit was 8–14 weeks, during which healthcare providers reported unintended events. Event reports were analysed with a root cause analysis tool (PRISMA). In addition, an independent surgeon reviewed about 40 patient records of patients in each surgical unit to examine whether an unintended event had occurred.

Results

A total of 881 unintended events were reported and analysed, of which 33·0 per cent were categorized as medication events. Most root causes were human (72·3 per cent), followed by organizational (16·1 per cent) and technical (5·7 per cent). More than half of the events had consequences for the patient. Sixty-four unintended events were identified in a review of 320 patient records. Only one of these events was also reported by a healthcare provider.

Conclusion

Event reporting and patient record review provide insight into diverse types of unintended events and complement each other. The information on unintended events from both sources may help target research and interventions to increase patient safety.

The effects of glyphosate and AMPA on the mediterranean mussel Mytilus galloprovincialis and its microbiota

Glyphosate, the most widely used herbicide worldwide, targets the 5-enolpyruvylshikimate-3-phosphate synthase (EPSPS) enzyme in the shikimate pathway found in plants and some microorganisms. While the potential for glyphosate to induce a broad range of biological effects in exposed organisms has been demonstrated, the global molecular mechanisms of toxicity and potential effects in bacterial symbionts remain unclear, in particular for ecologically important marine species such as bivalve molluscs. Here, the effects of glyphosate (GLY), its degradation product aminomethylphosphonic acid (AMPA), and a mixture of both (MIX) on the mussel M. galloprovincialis were assessed in a controlled experiment. For the first time, next generation sequencing (RNA-seq and 16S rRNA amplicon sequencing) was used to evaluate such effects at the molecular level in both the host and its respective microbiota. The results suggest that the variable capacity of bacterial species to proliferate in the presence of these compounds and the impairment of host physiological homeostasis due to AMPA and GLY toxicity may cause significant perturbations to the digestive gland microbiota, as well as elicit the spread of potential opportunistic pathogens such as Vibrio spp.. The consequent host-immune system activation identified at the molecular and cellular level could be aimed at controlling changes occurring in the composition of symbiotic microbial communities. Overall, our data raise further concerns about the potential adverse effects of glyphosate and AMPA in marine species, suggesting that both the effects of direct toxicity and the ensuing changes occurring in the host-microbial community must be taken into consideration to determine the overall ecotoxicological hazard of these compounds.

CYP1A2 polymorphisms in slow melatonin metabolisers: a possible relationship with autism spectrum disorder?

BACKGROUND

In some of our patients with intellectual disabilities (ID) and sleep problems, the initial good response to melatonin disappeared within a few weeks after starting treatment. In these patients melatonin levels at noon were extremely high (>50 pg/ml). We hypothesise that the disappearing effectiveness is associated with slow metabolisation of melatonin because of a single nucleotide polymorphism (SNP) of CYP1A2.

METHOD

In this pilot study we analysed DNA extracted from saliva samples of 15 consecutive patients with disappearing effectiveness of melatonin. Saliva was collected at noon and 4 pm for measuring melatonin levels.

RESULTS

In all patients' salivary melatonin levels at noon were >50 or melatonin half time was > 5 h. A SNP was found in eight of 15 patients. The allele 1C was found in two patients and in six patients the 1F allele was found.

CONCLUSIONS

Of 15 patients with disappearing effectiveness of melatonin, seven were diagnosed with autism spectrum disorder, and in four of them a SNP was found. The other eight patients were known with a genetic syndrome. In six of them behaviour was considered to be autistic-type and in three of them a SNP was found. This finding may give a new direction for research into the genetic background of autism.

Melatonin treatment in individuals with intellectual disability and chronic insomnia: a randomized placebo-controlled study

BACKGROUND

While several small-number or open-label studies suggest that melatonin improves sleep in individuals with intellectual disabilities (ID) with chronic sleep disturbance, a larger randomized control trial is necessary to validate these promising results.

METHODS

The effectiveness of melatonin for the treatment of chronic sleep disturbance was assessed in a randomized double-blind placebo-controlled trial with 51 individuals with ID. All of these individuals presented with chronic ideopatic sleep disturbance for more than 1 year. The study consisted of a 1-week baseline, followed by 4 weeks of treatment. Parents or other caregivers recorded lights off time, sleep onset time, night waking, wake up time and epileptic seizures. Endogenous melatonin cycle was measured in saliva before and after treatment.

RESULTS

Compared with placebo, melatonin significantly advanced mean sleep onset time by 34 min, decreased mean sleep latency by 29 min, increased mean total sleep time by 48 min, reduced the mean number of times the person awoke during the night by 0.4, decreased the mean duration of these night waking periods by 17 min and advanced endogenous melatonin onset at night by an average of 2.01 h. Lights off time, sleep offset time and the number of nights per week with night waking did not change. Only few minor or temporary adverse reactions and no changes in seizure frequency were reported.

CONCLUSIONS

Melatonin treatment improves some aspects of chronic sleep disturbance in individuals with ID.