Barriers and enablers of vigorous intermittent lifestyle physical activity (VILPA) in physically inactive adults: a focus group study

BACKGROUND

Vigorous Intermittent Lifestyle Physical Activity (VILPA) refers to brief bouts of vigorous intensity physical activity performed as part of daily living. VILPA has been proposed as a novel concept to expand physical activity options among the least active. As a nascent area of research, factors which impede or encourage VILPA in physically inactive adults are yet to be explored. Such information is pertinent in the design of future interventions. We examined the barriers and enablers of VILPA among physically inactive adults using the Capability, Opportunity, Motivation, Behavior (COM-B) model as a conceptual framework.

METHODS

We recruited a sample of self-identified physically inactive middle-aged and older adults (N = 78) based in Australia to take part in 19 online focus groups across three age groups: young-middle (age 35-44), middle (age 45-59) and old (age 60-76). We analyzed interviews using a critical realist approach to thematic analysis. Identified barriers and enablers were subsequently mapped onto the COM-B model components.

RESULTS

The data generated 6 barriers and 10 enablers of VILPA that corresponded to COM-B concepts. Barriers included physical limitations (physical capability), perceptions of aging, need for knowledge (psychological capability), environmental constraints (physical opportunity), perceptions of effort and energy, and fear (automatic motivation). Enablers included convenience, reframing physical activity as purposeful movement, use of prompts and reminders (physical opportunity), normalization of taking the active option, gamification (social opportunity), sense of achievement, health improvements, personally salient rewards (reflective motivation), identity fit, and changing from effortful deliberation to habitual action (automatic motivation).

CONCLUSION

The barriers and enablers of VILPA span capability, opportunity, and motivation beliefs. Promoting the time-efficient nature and simplicity of VILPA requiring no equipment or special gym sessions, the use of prompts and reminders at opportune times, and habit formation strategies could capitalize on the enablers. Addressing the suitability of the small bouts, the development of specific guidelines, addressing safety concerns, and explicating the potential benefits of, and opportunities to do, VILPA could ameliorate some of the barriers identified. Future VILPA interventions may require limited age customization, speaking to the potential for such interventions to be delivered at scale.

Accelerometer-derived physical activity and sedentary time and cardiac biomarkers: The Maastricht Study

Background

Cardiac troponins and NT-proBNP are biomarkers of cardiac injury that are used clinically in the diagnosis of myocardial infarction and heart failure. It is not known whether the amount, types and patterns of physical activity (PA) and sedentary behaviour are associated with levels of cardiac biomarkers.

Methods

In the population-based Maastricht Study (n = 2,370, 51.3% male, 28.3% T2D) we determined cardiac biomarkers hs-cTnI, hs-cTnT, and NT-proBNP. PA and sedentary time were measured by activPAL and divided into quartiles [quartile 1 (Q1) served as reference]. The weekly pattern of moderate-to-vigorous PA (insufficiently active; regularly actives; weekend warriors) and coefficient of variation (CV) was calculated. Linear regression analyses were conducted with adjustment for demographic, lifestyle, and cardiovascular risk factors.

Results

There was no consistent pattern between physical activity (different intensities: total, light, moderate-to-vigorous and vigorous) and sedentary time on the one hand and hs-cTnI and hs-cTnT on the other. Those with the highest levels of vigorous intensity PA had significantly lower levels of NT-proBNP. With regard to PA patterns, weekend warriors and regularly actives had lower levels of NT-proBNP but not with hs-cTnI and hs-cTnT (reference:insufficiently actives). A higher weekly moderate-to-vigorous PA CV (indicating more irregular activity) was associated with lower levels of hs-cTnI and higher levels of NT-proBNP, but not with hs-cTnT.

Conclusions

In general, there was no consistent association between PA and sedentary time and cardiac troponins. In contrast, vigorous and possibly moderate-to-vigorous intensity PA, especially if done regularly, were associated with lower levels of NT-proBNP.

ScipionTomo: Towards cryo-electron tomography software integration, reproducibility, and validation

Image processing in cryogenic electron tomography (cryoET) is currently at a similar state as Single Particle Analysis (SPA) in cryogenic electron microscopy (cryoEM) was a few years ago. Its data processing workflows are far from being well defined and the user experience is still not smooth. Moreover, file formats of different software packages and their associated metadata are not standardized, mainly since different packages are developed by different groups, focusing on different steps of the data processing pipeline.

The Scipion framework, originally developed for SPA (de la Rosa-Trevín et al., 2016), has a generic python workflow engine that gives it the versatility to be extended to other fields, as demonstrated for model building (Martínez et al., 2020). In this article, we provide an extension of Scipion based on a set of tomography plugins (referred to as ScipionTomo hereafter), with a similar purpose: to allow users to be focused on the data processing and analysis instead of having to deal with multiple software installation issues and the inconvenience of switching from one to another, converting metadata files, managing possible incompatibilities, scripting (writing a simple program in a language that the computer must convert to machine language each time the program is run), etcetera. Additionally, having all the software available in an integrated platform allows comparing the results of different algorithms trying to solve the same problem. In this way, the commonalities and differences between estimated parameters shed light on which results can be more trusted than others. ScipionTomo is developed by a collaborative multidisciplinary team composed of Scipion team engineers, structural biologists, and in some cases, the developers whose software packages have been integrated. It is open to anyone in the field willing to contribute to this project.

The result is a framework extension that combines the acquired knowledge of Scipion developers in close collaboration with third-party developers, and the on-demand design of functionalities requested by beta testers applying this solution to actual biological problems.

Cross-sectional associations of device-measured sedentary behaviour and physical activity with cardio-metabolic health in the 1970 British Cohort Study

AIMS

This study aimed to examine the cross-sectional associations of thigh accelerometry-assessed sedentary behaviour and moderate-to-vigorous physical activity (MVPA) with cardio-metabolic health markers and prevalent diabetes in a population sample of middle-aged British adults.

METHODS

Participants (n = 4892) from the age-46-to-48 wave of the 1970 British Cohort Study were fitted with a waterproofed activPAL3 micro device. Total/prolonged sedentary time, breaks and MVPA were the main exposures. We dichotomized prolonged sedentary time and MVPA based on the corresponding median, generating four combinations as categorical exposures. Outcomes comprised of diabetes and seven cardio-metabolic health markers. We used logistic regression and generalized linear models to examine independent/joint associations, conducting a minimally adjusted model including demographics and contextual covariates, and further adjusted for total sedentary time and/or MVPA as applicable.

RESULTS

Each set of 10 sedentary breaks and 1 h of prolonged sedentary time were associated with HbA_1c (mmol/mol) [B = -0.18 (-0.33, -0.03) and 2.35 (1.01, 3.69), respectively]. Each set of 10 sedentary breaks and 1 h of MVPA were favourably associated with diabetes [adjusted odds ratio (AOR): 0.80 (0.71, 0.99) and 0.42 (0.26, 0.67), respectively]. Joint analyses showed that only the low MVPA × long sedentary time combination had significantly higher odds for diabetes than the referent high MVPA × short sedentary time combination [AOR: 1.89 (1.17, 3.03)].

CONCLUSIONS

Each set of additional 10 sedentary breaks per day was associated with 20% lower odds for diabetes. A low physical activity level combined with long sedentary time might synergistically deteriorate cardio-metabolic health.

Association of physical activity and sedentary time with structural brain networks-The Maastricht Study

We assessed whether objectively measured low- and high-intensity physical activity (LPA and HPA) and sedentary time (ST) were associated with white matter connectivity, both throughout the whole brain and in brain regions involved in motor function. In the large population-based Maastricht Study (n = 1715, age 59.6 ± 8.1 (mean ± standard deviation) years, and 48% women), the amounts of LPA, HPA, and ST were objectively measured during 7 days by an activPAL accelerometer. In addition, using 3T structural and diffusion MRI, we calculated whole brain node degree and node degree of the basal ganglia and primary motor cortex. Multivariable linear regression analysis was performed, and we report standardized regression coefficients (stβ) adjusted for age, sex, education level, wake time, diabetes status, BMI, office systolic blood pressure, antihypertensive medication, total-cholesterol-to-HDL-cholesterol ratio, lipid-modifying medication, alcohol use, smoking status, and history of cardiovascular disease. Lower HPA was associated with lower whole brain node degree after full adjustment (stβ [95%CI] = - 0.062 [- 0.101, - 0.013]; p = 0.014), whereas lower LPA (stβ [95%CI] = - 0.013 [- 0.061, 0.034]; p = 0.580) and higher ST (stβ [95%CI] = - 0.030 [- 0.081, 0.021]; p = 0.250) was not. In addition, lower HPA was associated with lower node degree of the basal ganglia after full adjustment (stβ [95%CI] = - 0.070 [- 0.121, - 0.018]; p = 0.009). Objectively measured lower HPA, but not lower LPA and higher ST, was associated with lower whole brain node degree and node degree in specific brain regions highly specialized in motor function. Further research is needed to establish whether more HPA may preserve structural brain connectivity.

Burden of disease of type 2 diabetes mellitus: cost of illness and quality of life estimated using the Maastricht Study

AIMS

To estimate the societal costs and quality of life of people with type 2 diabetes and to compare these results with those of people with normal glucose tolerance or prediabetes.

METHODS

Data from 2915 individuals from the population-based Maastricht Study were included. Costs were assessed through a resource-use questionnaire completed by the participants; cost prices were based on Dutch costing guidelines. Quality of life was expressed in utilities using the Dutch EuroQol 5D-3L questionnaire and the SF-36 health survey. Based on normal fasting glucose and 2-h plasma glucose values, participants were classified into three groups: normal glucose tolerance (n = 1701); prediabetes (n = 446); or type 2 diabetes (n = 768).

RESULTS

Participants with type 2 diabetes had on average 2.2 times higher societal costs than those with normal glucose tolerance (€3,006 and €1,377 per 6 months, respectively) and had lower utilities (0.77 and 0.81, respectively). No significant differences were found between participants with normal glucose tolerance and those with prediabetes. Subgroup analyses showed that higher age, being female and having two or more diabetes-related complications resulted in higher costs (P < 0.05) and lower utilities.

CONCLUSIONS

This study showed that people with type 2 diabetes have substantially higher societal costs and lower quality of life than people with normal glucose tolerance. The results provide important input for future model-based economic evaluations and for policy decision-making.

Social network characteristics are associated with depressive symptoms: The Maastricht Study

Background

Previous studies suggested that social network characteristics are associated with depression. However, most of the previous studies investigated social network characteristics in isolation. We assessed the association of both structural and functional social network characteristics with prevalent and incident depressive symptoms over 5 years of follow-up.

Methods

We used data from 2,465 participants (49.1% women, mean age 59.8± 8.1 years) of The Maastricht Study, a population-based prospective cohort study. Social network characteristics were assessed through a name generator questionnaire. Depressive symptoms (9-item Patient Health Questionnaire score ≥10) were assessed at baseline and annually over 5 years. We used multivariate logistic regression and Cox regression analyses adjusted for socio-demographic characteristics, lifestyle and cardiovascular risk factors.

Results

Less emotional (odds ratio (OR) (95% confidence interval (CI)):1.19; 1.01-1.40) and informational support (OR (95%CI): 1.20 (1.04-1.39), and every fewer 10% of family members (OR(95%CI) 1.11 (1.01-1.23) were associated with prevalent clinically relevant depressive symptoms. Less emotional support (hazard ratio: 1.13; 95%CI: 1.03-1.25) was associated with incident clinically relevant depressive symptoms.

Conclusions

This study observed associations between poor social network characteristics with higher odds of depressive symptoms. In particular, less emotional support was associated with both prevalent and incident depressive symptoms.

Key messages

Poor social network characteristics were associated prevalent depressive symptoms. Less social support was associated with a higher risk of depressive symptoms.

A European consensus statement on the use of four-factor prothrombin complex concentrate for cardiac and non-cardiac surgical patients

Modern four-factor prothrombin complex concentrate was designed originally for rapid targeted replacement of the coagulation factors II, VII, IX and X. Dosing strategies for the approved indication of vitamin K antagonist-related bleeding vary greatly. They include INR and bodyweight-related protocols as well as fixed dose regimens. Particularly in the massively bleeding trauma and cardiac surgery patient, four-factor prothrombin complex concentrate is used increasingly for haemostatic resuscitation. Members of the Transfusion and Haemostasis Subcommittee of the European Association of Cardiothoracic Anaesthesiology performed a systematic literature review on four-factor prothrombin complex concentrate. The available evidence has been summarised for dosing, efficacy, drug safety and monitoring strategies in different scenarios. Whereas there is evidence for the efficacy of four-factor prothrombin concentrate for a variety of bleeding scenarios, convincing safety data are clearly missing. In the massively bleeding patient with coagulopathy, our group recommends the administration of an initial bolus of 25 IU.kg^-1 . This applies for: the acute reversal of vitamin K antagonist therapy; haemostatic resuscitation, particularly in trauma; and the reversal of direct oral anticoagulants when no specific antidote is available. In patients with a high risk for thromboembolic complications, e.g. cardiac surgery, the administration of an initial half-dose bolus (12.5 IU.kg^-1 ) should be considered. A second bolus may be indicated if coagulopathy and microvascular bleeding persists and other reasons for bleeding are largely ruled out. Tissue-factor-activated, factor VII-dependent and heparin insensitive point-of-care tests may be used for peri-operative monitoring and guiding of prothrombin complex concentrate therapy.

The association between diabetes status, HbA1c, diabetes duration, microvascular disease, and bone quality of the distal radius and tibia as measured with high-resolution peripheral quantitative computed tomography-The Maastricht Study

In this small cross-sectional study of predominantly well-treated participants with relatively short-term type 2 diabetes duration, HbA1c > 7% (53 mmol/mol) was associated with lower cortical density and thickness and higher cortical porosity at the distal radius, lower trabecular thickness at the distal tibia, and higher trabecular number at both sites.

INTRODUCTION

To examine the association between diabetes status and volumetric bone mineral density (vBMD), bone microarchitecture and strength of the distal radius and tibia as assessed with HR-pQCT. Additionally-in participants with type 2 diabetes (T2DM), to examine the association between HbA1c, diabetes duration, and microvascular disease (MVD) and bone parameters.

METHODS

Cross-sectional data from 410 (radius) and 198 (tibia) participants of The Maastricht Study (mean age 58 year, 51% female). Diabetes status (normal glucose metabolism, prediabetes, or T2DM) was based on an oral glucose tolerance test and medication history.

RESULTS

After full adjustment, prediabetes and T2DM were not associated with vBMD, bone microarchitecture, and strength of the radius and tibia, except for lower trabecular number (Tb.N) of the tibia (- 4%) in prediabetes and smaller cross-sectional area of the tibia (- 7%) in T2DM. In T2DM, HbA1c > 7% was associated with lower cortical vBMD (- 5%), cortical thickness (- 16%), higher cortical porosity (+ 20%) and Tb.N (+ 9%) of the radius, and higher Tb.N (+ 9%) and lower trabecular thickness (- 13%) of the tibia. Diabetes duration > 5 years was associated with higher Tb.N (+ 6%) of the radius. The presence of MVD was not associated with any bone parameters.

CONCLUSIONS

In this study with predominantly well-treated T2DM participants with relatively short-term diabetes duration, inadequate blood glucose control was negatively associated with cortical bone measures of the radius. In contrast, trabecular number was increased at both sites. Studies of larger sample size are warranted for more detailed investigations of bone density and bone quality in patients with T2DM.

The association between insulin use and volumetric bone mineral density, bone micro-architecture and bone strength of the distal radius in patients with type 2 diabetes - The Maastricht study

Type 2 diabetes mellitus (T2DM) has been associated with an increased risk of fractures, despite normal to increased bone mineral density (BMD). Insulin use is one of the factors linked to this increased fracture risk. However, direct negative effects of insulin on bone quality are not expected since insulin is thought to be anabolic to bone. In this cross-sectional study the association between insulin use and volumetric BMD (vBMD), bone micro-architecture and bone strength of the distal radius, as measured with HR-pQCT, was examined. Data from 50 participants with T2DM of The Maastricht Study (mean age 62±7.5years, 44% women) was used. Participants were classified as insulin user (n=13) or non-insulin user (n=37) based on prescription data. Linear regression analysis was used to estimate the association between current insulin use and HR-pQCT derived parameters. After adjustment for age, sex, body mass index, glycated hemoglobin A1c and T2DM duration, insulin use was associated with lower total vBMD (standardized beta (β):-0.56 (95% CI:-0.89 to -0.24)), trabecular vBMD (β:-0.58 (95% CI:-0.87 to -0.30)), trabecular thickness (β:-0.55 (95% CI:-0.87 to -0.23)), cortical thickness (β:-0.41 (95% CI:-0.74 to -0.08)), log cortical pore volume (β:-0.43 (95% CI:-0.73 to -0.13)), bone stiffness (β:-0.39 (95% CI:-0.62 to -0.17)) and failure load (β:-0.39 (95% CI:-0.60 to -0.17)) when compared to the non-insulin users. Insulin use was not associated with cortical vBMD, trabecular number, trabecular separation, cortical porosity and cortical pore diameter. This study indicates that insulin use is negatively associated with bone density, bone micro-architectural and bone strength parameters. These findings may partly explain the previously observed increased fracture risk in insulin users, although there may be residual confounding by other factors related to disease severity in insulin users.

[Heparin-induced thrombocytopenia type II (HIT II) : A medical-economic view]

BACKGROUND

In the context of inpatient and increasingly ambulatory thrombosis prophylaxis, heparins have been recognised as standard therapy for decades. In addition to the therapeutic benefit, therapy with heparins also entails the risk of undesirable side effects, such as bleeding and thrombocytopenia. Heparin-induced thrombocytopenia (HIT II) is deemed a serious side effect.

AIM

In the following work, HIT II is subjected to a medico-economic consideration (treatment, pharmaceuticals, subsequent costs due to possible complications) and, with regard to a possible HIT II prophylaxis, aspects of increasingly respected patient safety are also considered.

METHODS

In the context of a literature search the active ingredients argatroban and danaparoid, which are approved for HIT II treatment, were evaluated.

RESULTS

HIT II - especially in combination with thromboembolic complications - represents a medical-economic burden for the hospital. Although this is only an orientation guide, it shows that HIT II syndrome is not adequately cost-covered by the G‑DRG system. An early thrombosis prophylaxis with argatroban/danaparoid for HIT II risk patients should therefore be taken into account for medical-related as well as patient safety-relevant aspects. According to experience, the pharmaceutical supply for these medically needed products (anticoagulants) should be ensured for reasons of patient safety.

CONCLUSION

The risk of an immunological response to heparin therapy is known. Within the context of increased patient safety, thrombosis prophylaxis should be issued with a risk-adjusted prophylaxis.

The association between glucose metabolism status, diabetes severity and a history of fractures and recent falls in participants of 50 years and older-the Maastricht Study

In this cohort of relatively young and well-treated participants with type 2 diabetes, we found no association between diabetes status and a history of previous fractures and recent falls. Furthermore, no association between diabetes severity and previous fractures or recent falls was found.

INTRODUCTION

In this study, we examined the association between glucose metabolism status and historical fractures or recent falls and the effect of diabetes severity (glucose control, insulin use, and diabetes duration) on falls and fractures in the participants with type 2 diabetes.

METHODS

Cross-sectional data from 2005 participants of the Maastricht Study. Falls in the past 6 months and fractures ≥age 50 were assessed by questionnaire. Glucose metabolism status (normal glucose metabolism, impaired glucose metabolism, or type 2 diabetes) was based on the oral glucose tolerance test and medication use.

RESULTS

In the completely adjusted model, the odds for a fall were not significantly higher in those with impaired glucose metabolism status (OR (95%CI) 1.28 (0.93-1.77)) or with type 2 diabetes (OR (95%CI) 1.21 (0.80-1.81)) compared with the group with normal glucose metabolism. Within the group with type 2 diabetes, there were no significant differences with regard to reported falls between participants with HbA1c >7 % (53 mmol/mol) versus HbA1c ≤7 % (OR (95%CI) 1.05 (0.58-1.90)), insulin users versus non-insulin users (OR (95%CI) 1.51 (0.79-2.89)), and with a diabetes duration >5 versus ≤5 years (OR (95%CI) 0.52 (0.46-1.47)). Similarly, neither glucose metabolism status nor diabetes severity was associated with prior fractures.

CONCLUSIONS

Glucose metabolism status was not significantly associated with previous fractures and recent falls. In addition, in this cohort of relatively young and well-treated participants with type 2 diabetes, diabetes severity was not associated with previous fractures and recent falls.

Daily physical activity patterns from hip- and wrist-worn accelerometers

Accelerometer wear location may influence physical activity estimates. This study investigates this relationship through the examination of activity patterns throughout the day. Participants from the aging research evaluating accelerometry (AREA) study (n men  =  37, n women  =  47, mean age (SD)  =  78.9 (5.5) years) were asked to wear accelerometers in a free-living environment for 7 d at three different wear locations; one on each wrist and one on the right hip. During waking hours, wrist-worn accelerometers consistently produced higher median activity counts, about 5  ×  higher, as well as wider variability compared to hip-worn monitors. However, the shape of the accrual pattern curve over the course of the day for the hip and wrist are similar; there is a spike in activity in the morning, with a prolonged tapering of activity level as the day progresses. The similar patterns of hip and wrist activity accrual provide support that each location is capable of estimating total physical activity volume. The examination of activity patterns over time may provide a more detailed way to examine differences in wear location and different subpopulations.

Report of a Patient With Heparin-induced Thrombocytopenia Type II Associated With IgA Antibodies Only

Heparin-induced thrombocytopenia type II (HIT II) is usually mediated by immunoglobulin G (IgG) antibodies that lead to platelet activation via the FcγIIA-receptor. Here we describe a patient who developed HIT II after aortocoronary bypass surgery. His serum contained an antibody that was detectable by the heparin-induced platelet activation assay (HIPA) and by the ID-HPF4 particle agglutination assay. The flow cytometric analysis showed that the antibody was of the IgA class.

Associations of advanced glycation end-products with cognitive functions in individuals with and without type 2 diabetes: the maastricht study

CONTEXT

Advanced glycation end-products (AGEs) are thought to be involved in the pathogenesis of Alzheimer's disease. AGEs are products resulting from nonenzymatic chemical reactions between reduced sugars and proteins, which accumulate during natural aging, and their accumulation is accelerated in hyperglycemic conditions such as type 2 diabetes mellitus.

OBJECTIVE

The objective of the study was to examine associations between AGEs and cognitive functions.

DESIGN, SETTING, AND PARTICIPANTS

This study was performed as part of the Maastricht Study, a population-based cohort study in which, by design, 215 participants (28.1%) had type 2 diabetes mellitus.

MAIN OUTCOME MEASURES

We examined associations of skin autofluorescence (SAF) (n = 764), an overall estimate of skin AGEs, and specific plasma protein-bound AGEs (n = 781) with performance on tests for global cognitive functioning, information processing speed, verbal memory (immediate and delayed word recall), and response inhibition.

RESULTS

After adjustment for demographics, diabetes, smoking, alcohol, waist circumference, total cholesterol/high-density lipoprotein cholesterol ratio, triglycerides, and lipid-lowering medication use, higher SAF was significantly associated with worse delayed word recall (regression coefficient, b = -0.44; P = .04), and response inhibition (b = 0.03; P = .04). After further adjustment for systolic blood pressure, cardiovascular disease, estimated glomerular filtration rate, and depression, associations were attenuated (delayed word recall, b = -0.38, P = .07; response inhibition, b = 0.02, P = .07). Higher pentosidine levels were associated with worse global cognitive functioning (b = -0.61; P = .04) after full adjustment, but other plasma AGEs were not. Associations did not differ between individuals with and without diabetes.

CONCLUSION

We found inverse associations of SAF (a noninvasive marker for tissue AGEs) with cognitive performance, which were attenuated after adjustment for vascular risk factors and depression.

Diagnosing attention-deficit hyperactivity disorder (ADHD) in children involved with child protection services: are current diagnostic guidelines acceptable for vulnerable populations?

Children involved with child protection services (CPS) are diagnosed and treated for attention-deficit hyperactivity disorder (ADHD) at higher rates than the general population. Children with maltreatment histories are much more likely to have other factors contributing to behavioural and attentional regulation difficulties that may overlap with or mimic ADHD-like symptoms, including language and learning problems, post-traumatic stress disorder, attachment difficulties, mood disorders and anxiety disorders. A higher number of children in the child welfare system are diagnosed with ADHD and provided with psychotropic medications under a group care setting compared with family-based, foster care and kinship care settings. However, children's behavioural trajectories change over time while in care. A reassessment in the approach to ADHD-like symptoms in children exposed to confirmed (or suspected) maltreatment (e.g. neglect, abuse) is required. Diagnosis should be conducted within a multidisciplinary team and practice guidelines regarding ADHD diagnostic and management practices for children in CPS care are warranted both in the USA and in Canada. Increased education for caregivers, teachers and child welfare staff on the effects of maltreatment and often perplexing relationship with ADHD-like symptoms and co-morbid disorders is also necessary. Increased partnerships are needed to ensure the mental well-being of children with child protection involvement.

Can manic switches be predicted in pediatric major depression? A systematic literature review

BACKGROUND

The rate of switching from major depression to bipolar disorder is high in children. Predicting who is at risk for switching poses unique challenges and is of high clinical relevance. Our aim was to examine the existing scientific literature elucidating if certain clinical correlates predict ultimate bipolar switches in children initially presenting with a depressive episode.

METHODS

We conducted a systematic literature search of studies assessing the risk factors for bipolar switching in youth. In all, seven studies fit our a priori criteria and were thus included in our qualitative review.

RESULTS

Together, these papers found that manic switches in pediatric depression can be predicted by several risk factors, including positive family history of mood disorders, emotional and behavioral dysregulation, subthreshold mania, and psychosis.

LIMITATIONS

We identified only seven prospective informative studies for our review. The majority of subjects included in these studies were referred and Caucasian. Thus, the results may not generalize to other community samples and other ethnicities.

CONCLUSIONS

These findings can help alert clinicians of the risk of manic switches.

Moderate dosage of tranexamic acid during cardiac surgery with cardiopulmonary bypass and convulsive seizures: incidence and clinical outcome

BACKGROUND

Convulsive seizures (CS) occur in ∼1% of the patients after cardiac surgery with cardiopulmonary bypass. Recent investigations indicate an up to seven-fold increase in CS in cardiac surgical patients receiving high doses (≥60 mg kg(-1) body weight) of tranexamic acid (TA).

METHODS

In a retrospective data analysis of 4883 cardiac surgical patients, we investigated the incidence of CS in patients receiving a moderate dose of TA (24 mg kg(-1) body weight) compared with a reference group not receiving TA as a primary endpoint. Secondary endpoints were intensive care unit stay and in-hospital mortality. We performed propensity score (PS)-adjusted logistic regression analysis to test the association between TA use/non-use and clinical outcomes.

RESULTS

Compared with the reference group, the PS-adjusted odds ratio (OR) for CS in the TA group was 1.703 [95% confidence interval (CI): 1.01-2.87; P=0.045; incidence 2.5% vs 1.2%]. Log-ICU-stay was significantly longer (P=0.004) and PS-adjusted relative in-hospital mortality risk was significantly higher for the TA group compared with the reference group (OR=1.89; 95% CI: 1.21-2.96; P=0.005). Both the TA-associated CS incidence and the in-hospital mortality risk were only significant in patients undergoing open-heart surgery (OR=2.034, 95% CI: 1.07-3.87; P=0.034 and OR=2.20, 95% CI: 1.32-3.69; P=0.003, respectively) but not in patients undergoing coronary artery bypass grafting (OR=1.21, 95% CI: 0.49-3.03; P=0.678 and OR=1.13, 95% CI: 0.42-3.02; P=0.809, respectively).

CONCLUSIONS

In open-heart surgery, even moderate TA doses are associated with a doubled rate of CS and in-hospital mortality. Prospective trials are needed to further evaluate the safety profile of TA in cardiac surgery.

Lifelong physical activity in maintaining bone strength in older men and women of the Age, Gene/Environment Susceptibility-Reykjavik Study

We examined if lifelong physical activity is important for maintaining bone strength in the elderly. Associations of quantitative computerized tomography-acquired bone measures (vertebral and femoral) and self-reported physical activity in mid-life (mean age, 50 years), in old age (≥65 years), and throughout life (recalled during old age) were investigated in 2,110 men and 2,682 women in the AGES-Reykjavik Study. Results conclude lifelong physical activity with continuation into old age (≥65 years) best maintains better bone health later in life.

INTRODUCTION

Skeletal loading is thought to modulate the loss of bone in later life, and physical activity is a chief means of affecting bone strength by skeletal loading. Despite much discussion regarding lifelong versus early adulthood physical activity for preventing bone loss later in life, inconsistency still exists regarding how to maintain bone mass later in life (≥65 years).

METHODS

We examined if lifelong physical activity is important for maintaining bone strength in the elderly.

RESULTS

The associations of quantitative computerized tomography-acquired vertebral and femoral bone measures and self-reported physical activity in mid-life (mean age, 50 years), in old age (≥65 years), and throughout life (recalled during old age) were investigated in 2,110 men and 2,682 women in the AGES-Reykjavik Study.

CONCLUSION

Our findings conclude that lifelong physical activity with continuation into old age (≥65 years) best maintains better bone health in the elderly.

Argatroban anticoagulation for heparin induced thrombocytopenia in patients with ventricular assist devices

BACKGROUND

Patients receiving implantation of ventricular assist devices (VAD) suffer a high incidence of heparin induced thrombocytopenia (HIT); the occurrence of this condition is associated with increased complications and worse outcomes. We report our experience in the management of patients who were diagnosed with HIT either before (HITpre) or after (HITpost) implantation of VAD with argatroban, a direct thrombin inhibitor.

METHODS

This retrospective analysis assessed data of VAD patients diagnosed with HIT at Deutsches Herzzentrum Berlin between November 2005 and April 2009. Argatroban dose requirements, anticoagulation efficacy and adverse events (death, thromboembolism, bleeding) were recorded. Procedural success (discharge from the hospital, heart transplantation, or recovery of the failing heart) was also assessed.

RESULTS

Twenty-seven patients were identified (11 HITpre, 16 HITpost). Argatroban was effective in obtaining adequate anticoagulation with a reduced dose regimen (0.02-0.42 mcg/Kg/min starting dose; 0.02-1.5 mcg/Kg/min maintenance dose). We noted 5 thromboembolic complications (18%), 6 cases of major bleeding (22%) and 5 deaths (18%), all cause composite adverse end point occurring in 40% of patients. Procedural success was obtained in 81% of patients (92% HITpre, 69% HITpost). As compared to historical controls of patients treated with lepirudin in the period 2000-2005, results were significantly improved.

CONCLUSION

Argatroban anticoagulation is feasible in patients with HIT after VAD implantation, without increasing bleeding risk. Its impact in terms of survival should be reviewed also in the light of the technological improvements of assist devices.

[Analysis of quality in cardiac anesthesia]

In Anesthesia, especially in Cardiac Anesthesia in germany exist a lots of standards, that define good quality. For external quality assurance and analysis there is a core data set defined with an extension for cardiac anesthesia for a survey of patient risk factors und complications. Because there is no obligation only a minority of hospitals take an active part and only few data exists. No external structures exist to initiate quality improvements in the participating hospitals. Furthermore there is no external quality assurance to address patient satisfaction. The German Association for Anaesthesiology and Intensive Care has established the requirements for external quality analysis. The hospitals should use these possibilities to prevent external specifications. Structures to fulfil the last step of the Demming Cycle (ACT) should be added.

Bioline heparin-coated ECMO with bivalirudin anticoagulation in a patient with acute heparin-induced thrombocytopenia: the immune reaction appeared to continue unabated

Heparin-induced thrombocytopenia (HIT) is a serious, antibody-mediated complication of heparin which significantly confers risks of thrombosis and devastating outcomes. Once diagnosed, it requires immediate cessation of heparin and therapy with an alternative anticoagulant. No data are available in the literature on the pathophysiology and clinical implications of performing prolonged extracorporeal membrane oxygenation with a heparin-coated system in a patient with acute HIT treated with bivalirudin.

Follicular Non-Hodgkin's Lymphoma with Refractory Paraneoplastic Pemphigus: Case Report with Review of Novel Treatment Modalities

In this paper a patient with a non-Hodgkin's lymphoma (NHL) and paraneoplastic pemphigus (PNP) is described. PNP is a very rare, painful mucocutaneous intraepithelial blistering disease associated with occult or confirmed malignancy. Patients with PNP show severe, progressive mucocutaneous disease with a high mortality rate, because of drug-induced infectious complications. The patients sometimes benefit from high doses of oral corticosteroids. However, pulse therapy with high doses of prednisolone (or dexamethasone) in combination with other immunosuppressants induces variable and inconstant results. Intravenous immunoglobulin (IVIg) has been applied in different cases of PNP with encouraging results. Plasmapheresis or plasma exchange (PE) in combination with corticosteroids and/or cyclophosphamide or azathioprine showed similar rapid and beneficial results in association with decreasing auto-antibody levels in this group of refractory pemphigus. Another interesting therapeutic option is rituximab, a chimeric monoclonal antibody directed against the CD20 antigen, which is found on the surface of normal and malignant B-lymphocytes. Administration of rituximab for patients with PNP in combination with follicular NHL is not always successful regarding oral lesions as we report in this case. PE leading to prompt depletion of autoreactive antibodies combined with immunosuppressants or synchronisation of PE with IVIg seems the best treatment modality for this refractory group, but the therapeutic value and appropriate timing of rituximab obviously deserve further evaluation in patients with low grade NHL and PNP.

Bivalirudin anticoagulation during cardiac surgery: a single-center experience in 141 patients

The feasibility of bivalirudin for anticoagulation during cardiac surgery has been confirmed in four multicenter clinical trials. Here, we report our single-center experience with bivalirudin anticoagulation in “on-pump” and “off-pump” cardiac surgery in a large number of patients with and without heparin antibodies. Data of patients who underwent cardiac surgery with bivalirudin anticoagulation between 06/2003 and 12/2007 at our institution were reviewed. Assessment included procedural success, blood loss, transfusion requirements, re-exploration rates and drug-related complications during the procedures. There were 141 patients treated with bivalirudin, of whom 40 had heparin antibodies. In 26 patients, “off-pump” coronary artery bypass grafting was performed and the remaining 115 patients had surgery with cardiopulmonary bypass (CPB). The procedural success rate after 7 days and after 30 days was 99.4%. The mean blood loss after “off-pump” surgery was 833 ± 310 ml, with a transfusion rate of 30%. The mean blood loss after “on-pump” surgery was 750 ± 494 ml, with a transfusion rate of 56%. Two patients needed re-exploration due to persistent hemorrhage. Overall transfusion rates were increased in patients with heparin antibodies. The current investigation demonstrates that, in experienced hands, bivalirudin anticoagulation can be performed with excellent procedural success and low complication rates during “on-pump” and “off-pump” cardiac surgery. Recent problems associated with the production of heparin have emphasized the urgent need for an alternative for use beyond the limited indication of heparin-induced thrombocytopenia.

Successful use of bivalirudin for cardiopulmonary bypass in a patient with heparin allergy

Heparin-induced IgE-mediated hypersensitivity and anaphylactoid reactions, although rare, can pose a serious clinical problem for patients requiring cardiopulmonary bypass (CPB). Bivalirudin is a bivalent reversible direct thrombin inhibitor, with a half-life of 25 min, eliminated mostly by proteolytic cleavage. There are some reports on the use of bivalirudin for cardiac surgery, particularly for heparin-induced thrombocytopenia (HIT), but none on cases of heparin allergy. We report a case of heparin allergy successfully managed for CPB with bivalirudin anticoagulation.

Intake of polyunsaturated fatty acids and vitamin E reduces the risk of developing amyotrophic lateral sclerosis

BACKGROUND

To assess whether the premorbid dietary intake of fatty acids, cholesterol, glutamate or antioxidants was associated with the risk of developing amyotrophic lateral sclerosis (ALS).

METHODS

Patients referred to our clinic during 2001-2002, who had definite, probable or possible ALS according to El Escorial criteria, without a familial history of ALS, were asked to participate in a case-control study (132 patients and 220 healthy controls). A food-frequency questionnaire was used to assess dietary intake for the nutrients of interest. Multivariate logistic regression analysis was performed with adjustment for confounding factors (sex, age, level of education, energy intake, body mass index and smoking).

RESULTS

A high intake of polyunsaturated fatty acid (PUFA) and vitamin E was significantly associated with a reduced risk of developing ALS (PUFA: odds ratio (OR) = 0.4, 95% confidence interval (CI) = 0.2 to 0.7, p = 0.001; vitamin E: OR = 0.4, 95% CI = 0.2 to 0.7, p = 0.001). PUFA and vitamin E appeared to act synergistically, because in a combined analysis the trend OR for vitamin E was further reduced from 0.67 to 0.37 (p = 0.02), and that for PUFA from 0.60 to 0.26 (p = 0.005), with a significant interaction term (p = 0.03). The intake of flavonols, lycopene, vitamin C, vitamin B2, glutamate, calcium or phytoestrogens was not associated with the risk of developing ALS.

CONCLUSION

A high intake of PUFAs and vitamin E is associated with a 50-60% decreased risk of developing ALS, and these nutrients appear to act synergistically.