The role of larvae of black soldier fly and house fly and of feed substrate microbes in biotransformation of aflatoxin B1.

Over the past few years, there has been growing interest in the ability of insect larvae to convert various organic side-streams containing mycotoxins into insect biomass that can be used as animal feed. Various studies have examined the effects of exposure to aflatoxin B1 (AFB1) on a variety of insect species, including the larvae of the black soldier fly (BSFL; Hermetia illucens L.; Diptera: Stratiomyidae) and the housefly (HFL; Musca domestica L.; Diptera: Muscidae). Most of these studies demonstrated that AFB1 degradation takes place, either enzymatic and/or non-enzymatic. The possible role of feed substrate microorganisms (MOs) in this process has thus far not been investigated. The main objective of this study was therefore to investigate whether biotransformation of AFB1 occurred and whether it is caused by insect-enzymes and/or by microbial enzymes of MOs in the feed substrate. In order to investigate this, sterile and non-sterile feed substrates were spiked with AFB1 and incubated either with or without insect larvae (BSFL or HFL). The AFB1 concentration was determined via LC-MS/MS analyses and recorded over time. Approximately 50% of the initially present AFB1 was recovered in the treatment involving BSFL, which was comparable to the treatment without BSFL (60%). Similar patterns were observed for HFL. The molar mass balance of AFB1 for the sterile feed substrates with BSFL and HFL was 73% and 78%, respectively. We could not establish whether non-enzymatic degradation of AFB1 in the feed substrates occurred. The results showed that both BSFL and substrate-specific MOs play a role in the biotransformation of AFB1 as well as in conversion of AFB1 into aflatoxin P1 and aflatoxicol, respectively. In contrast, HFL did not seem to contribute to AFB1 degradation. The obtained results contribute to our understanding of aflatoxin metabolism by different insect species. This information is crucial for assessing the safety of feeding fly larvae with feed substrates contaminated with AFB1 with the purpose of subsequent use as animal feed.

Desmoplakin cardiomyopathy-an inherited cardiomyopathy presenting with recurrent episodes of acute myocardial injury.

We present two female patients with recurrent episodes of myocardial injury, consisting of acute chest pain and elevated cardiac markers without coronary artery disease. Cardiovascular magnetic resonance imaging identified extensive late gadolinium enhancement suggestive of an inherited cardiomyopathy. Genetic testing showed heterozygous pathogenic variants in the desmoplakin (DSP) gene, the gene coding for the desmoplakin protein, a structural protein found in the cardiac desmosome. Pathogenic variants in the DSP gene are associated with dilated and arrhythmogenic cardiomyopathy. DSP cardiomyopathies may cause recurring myocardial injury mimicking an acute coronary syndrome or myocarditis. Cardiac magnetic resonance imaging is key in its diagnosis due to its specifying imaging features. Genetic testing is essential for the evaluation and confirmation of the diagnosis.

Ceramic-on-ceramic articulation in press-fit total hip arthroplasty as a potential reason for early failure, what about the survivors: a ten year follow-up.

PURPOSE: In press-fit total hip arthroplasty (THA), primary stability is needed to avoid micromotion and hereby aseptic loosening, the main reason for early revision. High aseptic loosening revision rates of the seleXys TH+ cup (Mathys Medical) with Ceramys ceramic-on-ceramic (CoC) bearing are seen in literature. Since CoC is presumed to overcome long-term wear-related revisions, the reason for early failure of this cup is important to clarify. The aim is to investigate its ten year outcomes and differentiate between potential causes and identify risk factors for aseptic loosening. METHODS: Retrospective screening of a prospectively documented series of 315 THAs was performed. Primary outcome was cumulative incidence of cup revision due to aseptic loosening. Secondary outcomes were component revision and reoperation. Additionally, potential predictive factors for aseptic loosening were evaluated. RESULTS: At the median follow-up of 9.7 years [IQR 4.4; 10.3], 48 TH+ (15.2%) were revised due to aseptic loosening. Competing risk analysis showed a ten year cumulative incidence of cup revision due to aseptic loosening of 15.6% (95% CI 12.0-20.2). Stabilization of early revision rates was observed, following a high rate of respectively 81.3% (n = 39) and 95.8% (n = 46) within the first two and three years. No significant predictive factors for aseptic loosening were found. CONCLUSION: The ten year results of seleXys TH+ cup with Ceramys CoC bearing showed an unacceptable high aseptic loosening rate, which stabilized over time after a high early failure incidence. This could be attributed to a problem with osseointegration during the transition of primary to definitive stability.

Wave Turbulence on the Surface of a Fluid in a High-Gravity Environment.

We report on the observation of gravity-capillary wave turbulence on the surface of a fluid in a high-gravity environment. By using a large-diameter centrifuge, the effective gravity acceleration is tuned up to 20 times Earth's gravity. The transition frequency between the gravity and capillary regimes is thus increased up to one decade as predicted theoretically. A frequency power-law wave spectrum is observed in each regime and is found to be independent of the gravity level and of the wave steepness. While the timescale separation required by weak turbulence is well verified experimentally regardless of the gravity level, the nonlinear and dissipation timescales are found to be independent of the scale, as a result of the finite size effects of the system (large-scale container modes) that are not taken currently into account theoretically.

Not All Patients with Critical Limb Ischaemia Require Revascularisation.

OBJECTIVES: International guidelines recommend revascularisation as the preferred treatment for patients with critical limb ischaemia (CLI). Most contemporary research focuses on the outcome of invasive procedures for CLI, but little is known about the outcome of conservative management. Amputation free survival (AFS) and overall survival (OS) was investigated in patients with CLI who did or did not receive revascularisation, and characteristics associated with clinical outcomes were explored. METHODS: This was a retrospective cohort study of consecutive patients with chronic CLI between 2010 and 2014 in a Dutch university hospital. CLI was defined as the presence of ischaemic rest pain or tissue loss in conjunction with an absolute systolic ankle pressure < 50 mmHg or a toe pressure < 30 mmHg. Patients were divided into invasive (revascularisation within 6 weeks), deferred invasive (revascularisation after 6 weeks), or permanently conservative treatment groups. Univariable and multivariable survival analyses were used to identify factors associated with AFS and OS. RESULTS: The majority (66.7%; N = 96) of the identified 144 patients with CLI (mean age 71.2 years; median follow-up 99 weeks) underwent revascularisation within 6 weeks of diagnosis. Deferred invasive treatment was provided in 18.1% (N = 26) patients and 22 patients (15.3%) were treated permanently conservatively. AFS and OS did not differ significantly between the three groups (Breslow-Wilcoxon p = .16 for AFS and p = .09 for OS). Age, chronic obstructive pulmonary disease (COPD), and heart disease were significant independent predictors of AFS. Age, COPD, and hypertension were significant independent predictors of OS. Treatment was not a significant predictor of either AFS or OS. CONCLUSIONS: Not all patients with CLI require revascularisation to achieve an AFS that is similar to patients undergoing revascularisation, although the efficacy of conservative versus invasive treatment in CLI patients is still unclear. Further prospective studies should determine subgroups of patients in whom revascularisation may be omitted.

Outcome of transoral robotic surgery for stage I-II oropharyngeal cancer.

Traditionally T1-2N0 oropharyngeal carcinoma is treated with a single treatment modality, being either radiotherapy or surgery. Currently, minimally invasive surgery, such as transoral robotic surgery (TORS), is gaining popularity. The aim of this study is to assess whether T1-2N0 oropharyngeal cancer can be safely and effectively resected with TORS, and to determine the oncologic and functional outcomes. In addition, the long-term quality-of-life outcomes are reported. Between 2007 and 2012, 18 patients with early stage oropharyngeal cancers underwent transoral resection with the da Vinci robot system in the Netherlands Cancer Institute. All surviving patients filled out the self-report assessments of quality-of-life questionnaires. Median robot-assisted operating time was 115 min (range 43-186 min), while median estimated blood loss was 5 ml (range 0-125 ml). In three cases the exposure was insufficient to obtain clear tumor margins because of tumor extension and local anatomy. Fourteen patients had clear surgical margins. Four patients received adjuvant radiotherapy. Nine patients underwent an elective unilateral neck dissection. The oropharyngeal cancer recurred in two patients. Regarding the quality of life, patients who needed postoperative radiotherapy had a worse outcome and patients treated with transoral resection only did quite well. TORS seems to be an oncologically safe surgical treatment for early stage T1-2N0 oropharyngeal cancer based on this relatively small group of patients. Selecting patients in whom sufficient surgical exposure can be obtained, should be performed with the greatest care to avoid the need for adjuvant radiotherapy. Comparing radiotherapy and TORS or CO2 laser should be the next step in finding the optimal treatment for patients with T1-2N0 oropharyngeal carcinoma.

Assessing the efficacy of candidate mosquito repellents against the background of an attractive source that mimics a human host.

Mosquito repellents are used around the globe to protect against nuisance biting and disease-transmitting mosquitoes. Recently, there has been renewed interest in the development of repellents as tools to control the transmission of mosquito-borne diseases. We present a new bioassay for the accurate assessment of candidate repellent compounds, using a synthetic odour that mimics the odour blend released by human skin. Using DEET (N,N-diethyl-meta-toluamide) and PMD (p-menthane-3,8-diol) as reference compounds, nine candidate repellents were tested, of which five showed significant repellency to the malaria mosquito Anopheles gambiae sensu stricto (Diptera: Culicidae). These included: 2-nonanone; 6-methyl-5-hepten-2-one; linalool; δ-decalactone, and δ-undecalactone. The lactones were also tested on the yellow fever mosquito Aedes aegypti (Stegomyia aegypti) (Diptera: Culicidae), against which they showed similar degrees of repellency. We conclude that the lactones are highly promising repellents, particularly because these compounds are pleasant-smelling, natural products that are also present in human food sources.

Composite reliability of a workplace-based assessment toolbox for postgraduate medical education.

In recent years, postgraduate assessment programmes around the world have embraced workplace-based assessment (WBA) and its related tools. Despite their widespread use, results of studies on the validity and reliability of these tools have been variable. Although in many countries decisions about residents' continuation of training and certification as a specialist are based on the composite results of different WBAs collected in a portfolio, to our knowledge, the reliability of such a WBA toolbox has never been investigated. Using generalisability theory, we analysed the separate and composite reliability of three WBA tools [mini-Clinical Evaluation Exercise (mini-CEX), direct observation of procedural skills (DOPS), and multisource feedback (MSF)] included in a resident portfolio. G-studies and D-studies of 12,779 WBAs from a total of 953 residents showed that a reliability coefficient of 0.80 was obtained for eight mini-CEXs, nine DOPS, and nine MSF rounds, whilst the same reliability was found for seven mini-CEXs, eight DOPS, and one MSF when combined in a portfolio. At the end of the first year of residency a portfolio with five mini-CEXs, six DOPS, and one MSF afforded reliable judgement. The results support the conclusion that several WBA tools combined in a portfolio can be a feasible and reliable method for high-stakes judgements.

Training charter in epilepsy surgery added competence.

The present Training Charter in Epilepsy Surgery Added Competence constitutes the third stage of a program initiated by the European Society for Stereotactic and Functional Neurosurgery (ESSFN) and substantiated in close collaboration with the Union Européennedes Médecins Spécialists (UEMS) and the European Association of Neurosurgical Societies (EANS). This program aims to raise the standards of clinical practice by guiding education and quality control concepts. The particular sections of this Charter include: definitions and standards of added competence training, relations of the Epilepsy Unit with the Neurosurgical Department, duration of epilepsy surgery fellowship, institution and training program director requirements, operative totals for epilepsy surgery, educational program, individual requirements, and evaluation and qualification of the trainees. The specification of all these requirements is expected to improve harmonisation and quality of epilepsy surgery practice across Europe, and enhance the clinical activity and the scientific productivity of existing neurosurgical centres.

Cost-effectiveness of proton radiotherapy versus photon radiotherapy for non-small cell lung cancer patients: Exploring the model-based approach.

INTRODUCTION: Proton radiotherapy (PT) is a promising but more expensive strategy than photon radiotherapy (XRT) for the treatment of non-small cell lung cancer (NSCLC). PT is probably not cost-effective for all patients. Therefore, patients can be selected using normal tissue complication probability (NTCP) models with predefined criteria. This study aimed to explore the cost-effectiveness of three treatment strategies for patients with stage III NSCLC: 1. photon radiotherapy for all patients (XRTAll); 2. PT for all patients (PTAll); 3. PT for selected patients (PTIndividualized). METHODS: A decision-analytical model was constructed to estimate and compare costs and QALYs of all strategies. Three radiation-related toxicities were included: dyspnea, dysphagia and cardiotoxicity. Costs and QALY's were incorporated for grade 2 and ≥ 3 toxicities separately. Incremental Cost-Effectiven Ratios (ICERs) were calculated and compared to a threshold value of €80,000. Additionally, scenario, sensitivity and value of information analyses were performed. RESULTS: PTAll yielded most QALYs, but was also most expensive. XRTAll was the least effective and least expensive strategy, and the most cost-effective strategy. For thresholds higher than €163,467 per QALY gained, PTIndividualized was cost-effective. When assuming equal minutes per fraction (15 minutes) for PT and XRT, PTIndividualized was considered the most cost-effective strategy (ICER: €76,299). CONCLUSION: Currently, PT is not cost-effective for all patients, nor for patient selected on the current NTCP models used in the Dutch indication protocol. However, with improved clinical experience, personnel and treatment costs of PT can decrease over time, which potentially leads to PTIndividualized, with optimal patient selection, will becoming a cost-effective strategy.

Behavioural responses of Anopheles gambiae sensu stricto to components of human breath, sweat and urine depend on mixture composition and concentration.

Host-seeking behaviour of the anthropophilic malaria vector Anopheles gambiae sensu stricto (Diptera: Culicidae) is mediated predominantly by olfactory cues. Several hundreds of odour components have been identified from human emanations, but only a few have been proven to act as attractants or synergists in the host-seeking behaviour of female An. gambiae. In previous work, aromatics, alcohols and ketones in human odours were found to elicit electrophysiological activity in antennal olfactory neurons of female An. gambiae. However, the behavioural effects of these compounds have not been investigated. In this study, behavioural responses of female An. gambiae to components of human breath, urine and sweat at a series of concentrations, or a single concentration in the case of acetone, were examined in combination with ammonia and L-lactic acid in a dual-choice olfactometer. The results showed that at specific concentrations 4-ethylphenol, indole, 3-methyl-1-butanol and two ketones inhibited the attractive effect of a mixture of ammonia and lactic acid. Acetone on its own was not attractive; however, when combined with lactic acid, the binary mixture was attractive. When combined with ammonia, acetone inhibited the attractiveness exerted by ammonia alone. Dodecanol and dimethyldisulphide did not affect the attraction exerted by ammonia and lactic acid at any of the concentrations tested. By contrast, a human-specific armpit odour, 7-octenoic acid, augmented the attraction exerted by the combination of ammonia and lactic acid at a specific dosage.

Pain recognition and treatment in the horse: a survey of equine veterinarians in The Netherlands and Belgium.

This survey investigated the attitudes of equine veterinarians in The Netherlands and the Flemish region of Belgium towards pain management in the horse. Questionnaires were sent out to 771 equine veterinarians, all members of the Dutch or Flemish equine practitioners society. The return rate of completed questionnaires was 16.6%. The survey provided information about the use of analgesic drugs, factors influencing their prescription, pain scoring, analgesic therapy for specific clinical conditions, use of epidural analgesia, and appraisal of personal knowledge of pain management. The pain scores attributed to specific clinical conditions showed considerable variation. Non-steroidal anti-inflammatory drugs (NSAIDS) were the most-often prescribed analgesic drugs, with older drugs still having an important role in pain management. Butorphanol was the main opioid used. A substantial proportion of the respondents considered their knowledge of pain recognition and analgesic therapy to be insufficient or moderate.

A systematic literature review on the effects of mycotoxin exposure on insects and on mycotoxin accumulation and biotransformation.

Novel protein sources for animal feed are needed, and the use of insects as feed ingredient is explored. The insect production sector offers opportunities for a circular and sustainable approach to feed production by upgrading waste or side streams into high-quality proteins. However, potential food or feed safety issues should be studied in advance. Mycotoxins, such as aflatoxin B1, are natural contaminants commonly found in agricultural crops and have proven to be detrimental to the agricultural industry, livestock, and human health. This systematic review aims to provide a comprehensive overview of the published evidence on effects of mycotoxin exposure on insect growth and survival, mycotoxin accumulation within the insect body, and metabolization of various mycotoxins by insects. The review includes 54 scientific articles published in the past 55 years, in total covering 32 insect species. The main findings are the following: (1) Insects of the order Coleoptera show lower mortality after exposure to aflatoxin B1 when compared to Lepidoptera and Diptera; (2) effects of mycotoxins on larval growth and survival are less detrimental in later larval stages; (3) accumulation of mycotoxins was low in most insect species; (4) mycotoxins are metabolized within the insect body, the degree of which depends on the particular mycotoxin and insect species; (5) cytochrome P450s are the main family of enzymes involved in biotransformation of mycotoxins in some insect species. Results of this review support an optimistic outlook for the use of mycotoxin-contaminated waste streams as substrate for insect rearing.

LEDs Make It Resilient: Effects on Plant Growth and Defense.

Light spectral composition influences plant growth and metabolism, and has important consequences for interactions with plant-feeding arthropods and their natural enemies. In greenhouse horticulture, light spectral composition can be precisely manipulated by light-emitting diodes (LEDs), and LEDs are already used to optimize crop production and quality. However, because light quality also modulates plant secondary metabolism and defense, it is important to understand the underlying mechanisms in the context of the growth-defense trade-off. We review the effects of the spectral composition of supplemental light currently used, or potentially used, in greenhouse horticulture on the mechanisms underlying plant growth and defense. This information is important for exploring opportunities to optimize crop performance and pest management, and thus for developing resilient crop-production systems.

Impaired Geriatric 8 Score is Associated with Worse Survival after Radiotherapy in Older Patients with Cancer.

AIMS: To investigate whether the Geriatric 8 (G8) score and the Timed Get Up and Go Test (TGUGT), together with clinical and demographic patient characteristics, are associated with survival and late toxicity after (chemo)radiation therapy, administered with curative intent in older patients with cancer. MATERIALS AND METHODS: Four hundred and two patients aged ≥65 years (median age 72 years, range 65-96 years), diagnosed with either breast, non-small cell lung, prostate, head and neck, rectal or oesophageal cancer, and referred for curative (chemo)radiation therapy, took part in a multicentre prospective cohort study in eight radiotherapy centres in the Netherlands. The G8 and TGUGT scores were assessed before starting treatment. Other potential predictors and late toxicity were also recorded. Survival status and date of death, if applicable, were ascertained at the Dutch national death registry. RESULTS: After 2.5 years, the overall survival was 83%. Survival was 87% for patients with high G8 scores and 55% for patients with low G8 scores (Log-rank P value < 0.0001). Survival was 77% for patients with good TGUGT results and 50% for patients with poor TGUGT results (Log-rank P value < 0.001). In multivariable analysis, in addition to age and type of primary tumour, the association of the G8 score with overall survival remained, with a hazard ratio of 2.1 (95% confidence interval 1.2-3.8) for low versus high scores. CONCLUSIONS: G8 was associated with overall survival in older patients with cancer irradiated with curative intent. This association was independent of the predictive value of age and primary tumour.

Lumbosacral spinal cord somatosensory evoked potentials for quantification of nociception in horses.

REASONS FOR PERFORMING STUDY: There is a need for objective evaluation and quantification of the efficacy of analgesic drugs and analgesic techniques in horses. OBJECTIVES: To determine whether lumbosacral spinal cord somatosensory evoked potentials (SSEP) can be a useful and reliable tool to assess nociception in equines. METHODS: SSEPs and electromyograms (EMG) from the epaxial muscles were recorded simultaneously, following electrical stimulation applied to the distal hindlimb in lightly anaesthetised Shetland ponies (n=7). In order to validate the model, the effect of increasing stimulus intensity was documented and the conduction velocities (CV) of the stimulated nerves were calculated. The effect of epidurally applied methadone (0.4 mg/kg bwt) in a randomised, crossover design was investigated. RESULTS: Two distinct complexes (N1P1 and N2P2) were identified in the SSEP waveform. Based on their latency and conduction velocity and the depressant effect of epidurally applied methadone, the SSEP N2P2 was ascribed to nociceptive Adelta-afferent stimulation. The SSEP N1P1 originated from non-nociceptive Abeta-afferent stimulation and was not influenced by epidurally applied methadone. CONCLUSIONS AND POTENTIAL RELEVANCE: The nociceptive Adelta component of the SSEP, the N2P2 complex, is presented as a valid and quantitative parameter of spinal nociceptive processing in the horse. Validation of the equine SSEP model enables the analgesic effects of new analgesics/analgesic techniques to be quantified and analgesia protocols for caudal epidural analgesia in equidae improved.

Intra-articular opioid analgesia is effective in reducing pain and inflammation in an equine LPS induced synovitis model.

REASONS FOR PERFORMING STUDY: Intra-articular administration of morphine as a local analgesic and anti-inflammatory drug is widely used in human medicine. In equids, little is known about its clinical analgesic and anti-inflammatory efficacy. OBJECTIVES: To use an inflammatory orthopaedic pain model to investigate the analgesic and anti-inflammatory effects of intra-articularly administered morphine as a new treatment modality in horses with acute arthritis. METHODS: In a crossover study design, synovitis was induced in the left or right talocrural joint by means of intra-articular injection of 0.5 ng lipopolyssacharide (LPS). The effect of 120 mg morphine, intra-articularly administered at 1 h after induction of synovitis, was evaluated using both physiological and behavioural pain variables. Synovial fluid was sampled at 0, 4, 8, 28 and 52 h after induction of synovitis and analysed for total protein concentration, leucocyte count and for prostaglandin E(2), bradykinin and substance P concentrations by ELISA. Ranges of motion of metatarsophalangeal and talocrural joints were measured as kinematic variables with the horses walking and trotting on a treadmill under sound and lame conditions. Clinical lameness scores and several behavioural variables related to the perception of pain were obtained. RESULTS: LPS injection caused marked transient synovitis, resulting in increased concentrations of inflammatory synovial fluid markers, clinical lameness, joint effusion and several behavioural changes, such as increased time spent recumbent, decreased limb loading at rest and decreased time spent eating silage. Intra-articular morphine resulted in a significant decrease in synovial white blood cell count, prostaglandin E(2) and bradykinin levels and improvement in clinical lameness, kinematic and behavioural parameters, compared to placebo treatment. CONCLUSIONS: Intra-articular morphine offers potent analgesic and anti-inflammatory effects in horses suffering from acute synovitis. POTENTIAL RELEVANCE: Local administration of opioids may be useful for horses with acute inflammatory joint pain and offers possibilities for multimodal analgesic therapies without opioid-related systemic side effects.

Post-anaesthetic myelopathy in a 3-year-old Friesian gelding.

A 3-year-old Friesian stallion was referred to the Department of Equine Sciences at Utrecht University with signs of colic. Laparotomy was performed and the stallion was castrated bilaterally because of an incarcerated inguinal hernia. Intestinal resection was not performed. Eight days postoperatively, the horse showed signs of severe colic and was admitted for re-laparotomy. After resection of 1.5 m of strangulated jejunum and severe intraoperative hypotension, bradycardia, and electrolyte disorders, the horse showed problems during recovery with signs of hindquarter paralysis. There was no pain perception in the hind limbs and there were no patellar or anal reflexes. The muscles of the hindquarters and the long extensor muscles of the back were soft and not painful on palpation. No improvement was seen 60 minutes after intravenous injection of corticosteroids. Because of the tentative diagnosis of post-anaesthetic myelopathy and its poor prognosis, and the fact that the horse was restless and did not accept being lifted with a sling system, the horse was euthanized with the owner's consent. Post-anaesthetic myelopathy is a rare neuropathological condition in the horse. Because of its low incidence, knowledge about its aetiology and contributing factors is rather limited. This case report presents the clinical observations and the anaesthetic protocol and compares this case with previously reported cases in the literature.

Community-acquired bacterial meningitis in adults: emergency department management protocol.

Acute bacterial meningitis (ABM) is a rare but disabling infectious condition that requires a performant multidisciplinary management approach. Between 70 and 90 adult patients are diagnosed with community-acquired ABM in Belgium annually, and reported case fatality rates range from 17 to 40%. The currently available guidelines provide evidence-based guidance on how to manage this disease. However, these guidelines do not translate the evidence to the daily practice at the emergency department in a Belgian healthcare context. We created a taskforce in University Hospitals Leuven consisting of experts with complementary expertise in managing this disease: neurology, neurosurgery, intensive care medicine, microbiology and infectious diseases. The taskforce agreed upon a flowchart containing seven management steps encompassing all relevant phases in emergency ABM management. In addition to the focus on timely and adequate initiation of antimicrobial treatment, the flowchart and protocol also provide guidance on practical hurdles such as how to assess the safety of performing a lumbar puncture and when to refer patients to the intensive care department. This protocol was implemented in University Hospitals Leuven and fosters inter-disciplinary coordination of ABM care.