Guideline on multimodal rehabilitation for patients with post-intensive care syndrome.

BACKGROUND: Intensive Care Unit (ICU) survivors often experience several impairments in their physical, cognitive, and psychological health status, which are labeled as post-intensive care syndrome (PICS). The aim of this work is to develop a multidisciplinary and -professional guideline for the rehabilitative therapy of PICS. METHODS: A multidisciplinary/-professional task force of 15 healthcare professionals applied a structured, evidence-based approach to address 10 scientific questions. For each PICO-question (Population, Intervention, Comparison, and Outcome), best available evidence was identified. Recommendations were rated as "strong recommendation", "recommendation" or "therapy option", based on Grading of Recommendations, Assessment, Development and Evaluation principles. In addition, evidence gaps were identified. RESULTS: The evidence resulted in 12 recommendations, 4 therapy options, and one statement for the prevention or treatment of PICS. RECOMMENDATIONS: early mobilization, motor training, and nutrition/dysphagia management should be performed. Delirium prophylaxis focuses on behavioral interventions. ICU diaries can prevent/treat psychological health issues like anxiety and post-traumatic stress disorders. Early rehabilitation approaches as well as long-term access to specialized rehabilitation centers are recommended. Therapy options include additional physical rehabilitation interventions. Statement: A prerequisite for the treatment of PICS are the regular and repeated assessments of the physical, cognitive and psychological health in patients at risk for or having PICS. CONCLUSIONS: PICS is a variable and complex syndrome that requires an individual multidisciplinary, and multiprofessional approach. Rehabilitation of PICS should include an assessment and therapy of motor-, cognitive-, and psychological health impairments.

Antibacterial Effects of X-ray and MRI Contrast Media: An In Vitro Pilot Study.

Some radiological contrast agents have been shown to have effects on bacterial growth. In this study, the antibacterial effect and mechanism of action of iodinated X-ray contrast agents (Ultravist 370, Iopamiro 300, Telebrix Gastro 300 and Visipaque) and complexed lanthanide MRI contrast solutions (MultiHance and Dotarem) were tested against six different microorganisms. Bacteria with high and low concentrations were exposed to media containing different contrast media for various lengths of time and at pH 7.0 and 5.5. The antibacterial effect of the media was examined in further tests using agar disk diffusion analysis and the microdilution inhibition method. Bactericidal effects were found for microorganisms at low concentrations and low pH. Reductions were confirmed for Staphylococcus aureus and Escherichia coli.

Detecting Incident Delirium within Routinely Collected Inpatient Rehabilitation Data: Validation of a Chart-Based Method.

BACKGROUND: Delirium is a brain condition associated with poor outcomes in rehabilitation. It is therefore important to assess delirium incidence in rehabilitation. PURPOSE: To develop and validate a chart-based method to identify incident delirium episodes within the electronic database of a Swiss rehabilitation clinic, and to identify a study population of validated incident delirium episodes for further research purposes. DESIGN: Retrospective validation study. SETTINGS: Routinely collected inpatient clinical data from ZURZACH Care. PARTICIPANTS: All patients undergoing rehabilitation at ZURZACH Care, Rehaklinik Bad Zurzach between 2015 and 2018 were included. METHODS: Within the study population, we identified all rehabilitation stays for which ≥2 delirium-predictive key words (common terms used to describe delirious patients) were recorded in the medical charts. We excluded all prevalent delirium episodes and defined the remaining episodes to be potentially incident. At least two physicians independently confirmed or refuted each potential incident delirium episode by reviewing the patient charts. We calculated the positive predictive value (PPV) with 95% confidence interval (95% CI) for all potential incident delirium episodes and for specific subgroups. RESULTS: Within 10,515 rehabilitation stays we identified 554 potential incident delirium episodes. Overall, 125 potential incident delirium episodes were confirmed by expert review. The PPV of the chart-based method varied from 0.23 (95% CI 0.19-0.26) overall to 0.69 (95% CI 0.56-0.79) in specific subgroups. CONCLUSIONS: Our chart-based method was able to capture incident delirium episodes with low to moderate accuracy. By conducting an additional expert review of the medical charts, we identified a study population of validated incident delirium episodes. Our chart-based method contributes towards an automated detection of potential incident delirium episodes that, supplemented with expert review, efficiently yields a validated population of incident delirium episodes for research purposes.

The Hitchhiker's Guide to Hydrogen Peroxide Fumigation, Part 2: Verifying and Validating Hydrogen Peroxide Fumigation Cycles.

Introduction: Part 1 of this two-part series describes the use of hydrogen peroxide as a fumigant and compares it with other fumigants on the market. Technical requirements are outlined while considering physical and biological limitations of the system. This second part focuses primarily on the use of process controls to verify and validate hydrogen peroxide fumigations. Finally, a model encompassing the entire fumigation process is presented. Methods: Part 2 of the series focuses on the authors' long-time personal experiences in room and filter fumigation using various fumigation systems and is supplemented with relevant literature searches. Results: The reader is introduced to the planning and implementation of fumigation process validations. Biological indicators help users develop safe and efficient processes. Chemical indicators can be used as process controls, while measuring physical parameters will help avoid condensation of hydrogen peroxide. How many biological and chemical indicators and what type should be applied for cycle development are additionally explained. Discussion: It is important to consider numerous technical requirements when planning to implement hydrogen peroxide fumigation at an institution. Also, considerable thought needs to go into the verification and validation of the fumigation process. Conclusions: Part 1 of this series presents an overview of different fumigation systems based on hydrogen peroxide on the market and their technical requirements. Part 2 focuses on validation and verification of hydrogen peroxide fumigation while considering the entire fumigation process. The two parts together will serve users as a guide to establishing hydrogen peroxide fumigations at their facilities.

The Hitchhiker's Guide to Hydrogen Peroxide Fumigation, Part 1: Introduction to Hydrogen Peroxide Fumigation.

Introduction: When working with pathogens in laboratories, animal or production facilities, and even hospitals, the potential need for room fumigation for decontamination purposes must be taken into consideration. Questions regarding the choice of fumigant, technical aspects of the room, its ventilation, the fumigation system to be used, and other issues will arise and will have to be addressed. Methods: This article is based on literature searches and was compiled using the authors' long-time personal experience in room and filter fumigation using various fumigation systems. Results: The article can be used as a guide to establish an effective fumigation system in a laboratory or an animal facility setting and may be adapted for use in hospitals. Different systems for hydrogen peroxide fumigation on the market are presented. Also, technical aspects are discussed. Discussion: Hydrogen peroxide is used in various forms for fumigation of rooms, equipment, and filters. Regardless of the individual limitations of these forms, hydrogen peroxide is a versatile fumigation method. However, it is important to consider numerous technical requirements when planning to implement hydrogen peroxide fumigation at an institution. Conclusions: Subsequent to the present overview of different fumigation systems based on hydrogen peroxide on the market and their technical requirements, part 2 of this article will focus on validation and verification of hydrogen peroxide fumigation while considering the entire fumigation process. The two parts together will serve users as a guide to establishing hydrogen peroxide fumigations at their facilities.

Case Study: Room Fumigation Using Aerosolized Hydrogen Peroxide-A Versatile and Economic Fumigation Method.

Introduction: Formaldehyde is still the method of choice for fumigation of rooms and HEPA filters at high- and maximum-containment facilities because of its proven track record and low cost. However, formaldehyde has been shown to be carcinogenic and should ideally be replaced by other, less hazardous methods. This change has in part been hampered by the relatively high cost of alternative methods. Methods: Here, we provide examples of room fumigations using aerosolized hydrogen peroxide showing not only that it can be used economically but also that it is a versatile method and may be used under circumstances not normally suited for fumigation. Results and Discussion: Four examples of fumigation setups are presented that illustrate the versatility, ease of use, and adaptability of aerosolized hydrogen peroxide as a fumigant. In addition, we demonstrate that aerosolized hydrogen peroxide passes through HEPA filters in biological safety cabinets and individually ventilated cage racks. Conclusions: Considering that the fumigation method presented here is simple and highly effective, we expect it to serve as a relatively cost-effective alternative to formaldehyde fumigation for disinfecting potentially contaminated rooms and surfaces.

Synaptic pathology in the cerebellar dentate nucleus in chronic multiple sclerosis.

In multiple sclerosis, cerebellar symptoms are associated with clinical impairment and an increased likelihood of progressive course. Cortical atrophy and synaptic dysfunction play a prominent role in cerebellar pathology and although the dentate nucleus is a predilection site for lesion development, structural synaptic changes in this region remain largely unexplored. Moreover, the mechanisms leading to synaptic dysfunction have not yet been investigated at an ultrastructural level in multiple sclerosis. Here, we report on synaptic changes of dentate nuclei in post-mortem cerebella of 16 multiple sclerosis patients and eight controls at the histological level as well as an electron microscopy evaluation of afferent synapses of the cerebellar dentate and pontine nuclei of one multiple sclerosis patient and one control. We found a significant reduction of afferent dentate synapses in multiple sclerosis, irrespective of the presence of demyelination, and a close relationship between glial processes and dentate synapses. Ultrastructurally, we show autophagosomes containing degradation products of synaptic vesicles within dendrites, residual bodies within intact-appearing axons and free postsynaptic densities opposed to astrocytic appendages. Our study demonstrates loss of dentate afferent synapses and provides, for the first time, ultrastructural evidence pointing towards neuron-autonomous and neuroglia-mediated mechanisms of synaptic degradation in chronic multiple sclerosis.

Autoantigen conformation influences both B- and T-cell responses and encephalitogenicity.

It has become increasingly clear that only antibodies recognizing conformation-dependent epitopes of myelin oligodendrocyte glycoprotein (MOG) have a demyelinating potential in the animal model of multiple sclerosis, experimental autoimmune encephalomyelitis (EAE). Nevertheless, for the induction of EAE, most studies to date have used MOG peptides or bacterially expressed MOG, neither of which contain the tertiary structure of the native antigen. Non-refolded recombinant human MOG does not induce EAE in DA rats. Therefore, we refolded this protein in order to assess the influence of MOG conformation on its pathogenicity in DA rats. DA rats immunized with refolded human MOG developed severe acute EAE. As expected, rats immunized with the refolded protein had a higher amount of conformational MOG antibodies present in serum. But in addition, a striking effect of MOG refolding on the generation of T-cell responses was found. Indeed, T-cell responses against the encephalitogenic MOG 91-108 epitope were greatly enhanced after refolding. Therefore, we conclude that refolding of MOG increases its pathogenicity both by generating conformation-dependent MOG antibodies and by enhancing its processing or/and presentation on MHC molecules. These data are important in regard to investigations of the pathogenic potential of many (auto)antigens.

Substantial early, but nonprogressive neuronal loss in multiple sclerosis (MS) spinal cord.

Research in multiple sclerosis (MS) has recently been focusing on the extent of neuroaxonal damage and its contribution to disease outcome. In the present study, we examined spinal cord tissue from 30 clinically well-characterized MS patients. MS, amyotrophic lateral sclerosis (ALS), and control spinal cord tissue were subjected to morphometric analysis and immunohistochemistry for markers of cell damage and regeneration. Data were related to disease duration and age at death. Here, we present evidence for substantial, nonprogressive neuronal loss on the cervical and lumbar levels early in the disease course of MS. Chromatolytic neurons and immunoreactivity for c-Jun and GAP43 were observed in the ventral gray matter in and adjacent to actively demyelinating lesions, pointing toward neuronal damage and regeneration as an early response to lesion formation.

SONU20176289, a compound combining partial dopamine D(2) receptor agonism with specific serotonin reuptake inhibitor activity, affects neuroplasticity in an animal model for depression.

We investigated the efficacy of SONU20176289, a member of a group of novel phenylpiperazine derivatives with a mixed dopamine D(2) receptor partial agonist and specific serotonin reuptake inhibitor (SSRI) activity, in a chronic stress model of depression in male tree shrews. Animals were subjected to a 7-day period of psychosocial stress before treatment for 28 days with SONU20176289 (6 mg/kg/day, p.o.), during which stress was maintained. Stress reduced the in vivo brain concentrations of N-acetyl-aspartate, total creatine, and choline-containing compounds, as measured by localized proton magnetic resonance spectroscopy. Post mortem analyses revealed a reduced adult dentate cell proliferation and a decreased GluR2 expression in the prefrontal cortex. All these alterations were prevented by concomitant administration of SONU20176289. The results provide further support to the concept that antidepressant treatments may act by normalizing disturbed neuroplasticity, and indicate that combining dopamine D(2) receptor agonism with SSRI activity may serve as an effective tool in the treatment of depressive/anxiety syndromes.

Cortical pathology in multiple sclerosis.

PURPOSE OF REVIEW: Multiple sclerosis is the most common chronic, disabling central nervous system disease in young adults, characterized by inflammatory demyelinating white matter lesions with glial scar formation and axonal loss. Lately, evidence has accumulated that large areas of grey matter are affected in multiple sclerosis patients. RECENT FINDINGS: Findings in post-mortem brain tissue support the notion that cortical demyelination is frequent and extensive, especially in patients with chronic multiple sclerosis. Cortical lesions differ from white matter lesions with respect to inflammatory cell infiltration, gliosis, and remyelination. Thus, differences in cortical and white matter lesion pathogenesis have been proposed. Experimental models suggest a decisive role for antimyelin antibodies in cortical demyelination. Topical studies focus on damage to neurons, dendrites, and synapses in cortical multiple sclerosis lesions. Improved imaging techniques for the detection of cortical lesions are currently developed and will provide the basis for future clinicopathological correlative studies. SUMMARY: In summary, recent years have opened our eyes to the extensive grey matter involvement in multiple sclerosis. Studies on the pathogenesis of cortical demyelination, cortical damage, and repair will elucidate basic principles of multiple sclerosis lesion formation. However, more sensitive imaging tools are required to study the impact of cortical lesions on clinical symptoms, disability, and disease progression.

Extensive cortical remyelination in patients with chronic multiple sclerosis.

Recent studies revealed prominent cortical demyelination in patients with chronic multiple sclerosis (MS). Demyelination in white matter lesions is frequently accompanied by remyelination. This repair process, however, often remains incomplete and restricted to the lesion border. In the present study, we examined the frequency and extent of remyelination in cortical and white matter lesions in autopsy brain tissue of 33 patients with chronic MS. The majority of patients (29 of 33) harbored cortical demyelination. Remyelination of cortical lesions was identified light microscopically by the presence of thin and irregularly arranged myelin sheaths, and confirmed by electron microscopy. Extensive remyelination was found in 18%, remyelination restricted to the lesion border in 54%, and no remyelination in 28% of cortical lesions. A direct comparison of the extent of remyelination in white matter and cortical lesions of the same patients revealed that remyelination of cortical lesions was consistently more extensive. In addition, g-ratios of fibers in areas of "normal appearing cortex" yielded values consistent with remyelination. Our data confirm the high prevalence of cortical demyelination in chronic MS and imply that the propensity to remyelinate is high in cortical MS lesions.

Temporal and spatial coding of periodicity information in the inferior colliculus of awake chinchilla (Chinchilla laniger).

Amplitude modulation responses and onset latencies of multi-unit recordings and evoked potentials were investigated in the central nucleus of inferior colliculus (ICC) in the awake chinchilla. Nine hundred and one recording sites with best frequencies between 60 and 30 kHz showed either phasic (18%), tonic (25%), or phasic-tonic (57%) responses. Of 554 sites tested for responses to modulation frequencies 73% were responsive and 57% showed clear preference for a narrow range of modulation frequencies. Well defined bandpass characteristics were found for 32% of rate modulation transfer functions (rate-MTFs) and 36% of synchronization MTFs (sync-MTFs). The highest best modulation frequency (BMF) of a bandpass rate-MTF was 600 Hz. Neurons with phasic responses to best-frequency tones showed strong phase coupling to modulation frequencies and were dominated by bandpass rate-MTFs and sync-MTFs. Most neurons with tonic responses showed bandpass tuning only for sync-MTFs. Both BMFs and onset latencies changed systematically across frequency-band laminae of the ICC. Low BMFs and long latencies were located medially and high BMFs and short latencies laterally. Latency distributions obtained with evoked potentials to clicks showed a similar gradient to the multi-unit data. These findings are in line with previous findings in different animals including humans and support the hypothesis that temporal processing results in a topographic arrangement orthogonal to the spectral processing axis, thus forming a second neural axis of the auditory system.