Task Termination Triggers Spontaneous Removal of Information From Visual Working Memory.

Working memory (WM) is a goal-directed memory system that actively maintains a limited amount of task-relevant information to serve the current goal. By this definition, WM maintenance should be terminated after the goal is accomplished, spontaneously removing no-longer-relevant information from WM. Past studies have failed to provide direct evidence of spontaneous removal of WM content by allowing participants to engage in a strategic reallocation of WM resources to competing information within WM. By contrast, we provide direct neural and behavioral evidence that visual WM content can be largely removed less than 1 s after it becomes obsolete, in the absence of a strategic allocation of resources (total N = 442 adults). These results demonstrate that visual WM is intrinsically a goal-directed system, and spontaneous removal provides a means for capacity-limited WM to keep up with ever-changing demands in a dynamic environment.

Accurate prediction of histological grading of intraductal papillary mucinous neoplasia using deep learning.

BACKGROUND: Risk stratification and recommendation for surgery for intraductal papillary mucinous neoplasm (IPMN) are currently based on consensus guidelines. Risk stratification from presurgery histology is only potentially decisive owing to the low sensitivity of fine-needle aspiration. In this study, we developed and validated a deep learning-based method to distinguish between IPMN with low grade dysplasia and IPMN with high grade dysplasia/invasive carcinoma using endoscopic ultrasound (EUS) images. METHODS: For model training, we acquired a total of 3355 EUS images from 43 patients who underwent pancreatectomy from March 2015 to August 2021. All patients had histologically proven IPMN. We used transfer learning to fine-tune a convolutional neural network and to classify "low grade IPMN" from "high grade IPMN/invasive carcinoma." Our test set consisted of 1823 images from 27 patients, recruiting 11 patients retrospectively, 7 patients prospectively, and 9 patients externally. We compared our results with the prediction based on international consensus guidelines. RESULTS: Our approach could classify low grade from high grade/invasive carcinoma in the test set with an accuracy of 99.6 % (95 %CI 99.5 %-99.9 %). Our deep learning model achieved superior accuracy in prediction of the histological outcome compared with any individual guideline, which have accuracies between 51.8 % (95 %CI 31.9 %-71.3 %) and 70.4 % (95 %CI 49.8-86.2). CONCLUSION: This pilot study demonstrated that deep learning in IPMN-EUS images can predict the histological outcome with high accuracy.

Transjugular intrahepatic portosystemic shunt creation (TIPS) in the angio-CT-a hybrid intervention with image fusion.

OBJECTIVE: For transjugular intrahepatic portosystemic shunt (TIPS) creation, ultrasound guidance for portal vein puncture is strongly recommended. However, outside regular hours of service, a skilled sonographer might be lacking. Hybrid intervention suites combine CT imaging with conventional angiography allowing to project 3D information into the conventional 2D imaging and further CT-fluoroscopic puncture of the portal vein. The purpose of this study was to assess whether TIPS using angio-CT facilitates the procedure for a single interventional radiologist. METHODS: All TIPS procedures from 2021 and 2022 which took place outside regular working hours were included (n = 20). Ten TIPS procedures were performed with just fluoroscopy guidance and ten procedures using angio-CT. For the angio-CT TIPS, a contrast-enhanced CT was performed on the angiography table. From the CT, a 3D volume was created using virtual rendering technique (VRT). The VRT was blended with the conventional angiography image onto the live monitor and used as guidance for the TIPS needle. Fluoroscopy time, area dose product, and interventional time were assessed. RESULTS: Hybrid intervention with angio-CT did lead to a significantly shorter fluoroscopy time and interventional time (p = 0.034 for both). Mean radiation exposure was significantly reduced, too (p = 0.04). Furthermore, the mortality rate was lower in patients who underwent the hybrid TIPS (0% vs 33%). CONCLUSION: TIPS procedure in angio-CT performed by only one interventional radiologist is quicker and reduces radiation exposure for the interventionalist compared to mere fluoroscopy guidance. The results further indicate increased safety using angio-CT. CLINICAL RELEVANCE STATEMENT: This study aimed to evaluate the feasibility of using angio-CT in TIPS procedures during non-standard working hours. Results indicated that the use of angio-CT significantly reduced fluoroscopy time, interventional time, and radiation exposure, while also leading to improved patient outcomes. KEY POINTS: • Image guiding such as ultrasound is recommended for transjugular intrahepatic portosystemic shunt creation but might be not available for emergency cases outside of regular working hours. • Transjugular intrahepatic portosystemic shunt creation using an angio-CT with image fusion is feasible for only one physician under emergency settings and results in lower radiation exposure and faster procedures. • Transjugular intrahepatic portosystemic shunt creation using an angio-CT with image fusion seems to be safer than using mere fluoroscopy guidance.

What's so hard about hierarchical control? Pinpointing processing constraints within cue-based and serial-order control structures.

Most task spaces require a hierarchical structure, where decisions on one level are contingent on previous decisions made on one or more higher levels. While it is a truism that increasing the number of hierarchical levels makes it harder to solve a given task, the exact nature of this "number-of-levels" effect is not clear. On the one hand, processing costs might be strictly "local," incurred only when higher-level settings need to be updated, while otherwise lower-level decisions are insulated from the presence of higher-level settings (local updating costs with ballistic control). On the other hand, maintaining and integrating more complex hierarchical structures could require overall greater representational resources, negatively affecting each individual decision within the represented task space (global integration/maintenance costs). Further, navigation through hierarchical structures can be guided either through prompts in the environment (cue-based), or through sequential plans (serial-order based), with potentially distinct maintenance and updating demands. In two experiments, we assessed performance as a function of hierarchical level and format (serial-order vs. cue-based). Model comparisons showed that the pattern of costs in the serial-order format was consistent with a global maintenance/integration account. In contrast, in the cue-based format, costs arose at updating points and when one additional relevant level beyond the current decision was relevant, while additional levels produced no further costs. This overall constellation of costs can be explained by assuming that each decision requires checking the immediately relevant higher-level context for that decision. For cue-based control, this context involves the "next-level-up" rule, whereas in the serial-order format, each trial requires updating of the current position within the sequence, which in turn requires integration across all relevant hierarchical levels.

Adjunctive Hydrocortisone Improves Hemodynamics in Critically Ill Patients with Septic Shock: An Observational Study Using Transpulmonary Thermodilution.

Introduction: Septic shock is associated with high mortality and hemodynamic impairment. The use of corticoids is a common therapeutic tool in critically ill patients. However, data on the mechanisms and prognostic ability of hemodynamic improvement by adjunctive steroids are rare. This study primarily aimed to evaluate short-term effects of hydrocortisone therapy on catecholamine requirement and hemodynamics derived from transpulmonary thermodilution (TPTD) in 30 critically ill patients with septic shock and a 28 days mortality rate of 50%. Methods: Hydrocortisone was administered with an intravenous bolus of 200 mg, followed by a continuous infusion of 200 mg per 24 h. Hemodynamic assessment was performed immediately before as well as 2, 8, 16, and 24 h after the initiation of corticoids. For primary endpoint analysis, we evaluated the impact of hydrocortisone on vasopressor dependency index (VDI) and cardiac power index (CPI). Results: Adjunctive hydrocortisone induced significant decreases of VDI from 0.41 (0.29-0.49) mmHg-1 at baseline to 0.35 (0.25-0.46) after 2 h (P < .001), 0.24 (0.12-0.35) after 8 h (P < .001), 0.18 (0.09-0.24) after 16 h (P < .001) and 0.11 (0.06-0.20) mmHg-1 after 24 h (P < .001). In parallel, we found an improvement in CPI from 0.63 (0.50-0.83) W/m2 at baseline to 0.68 (0.54-0.85) after 2 h (P = .208), 0.71 (0.60-0.90) after 8 h (P = .033), 0.82 (0.6-0.98) after 16 h (P = .004) and 0.90 (0.67-1.07) W/m2 after 24 h (P < .001). Our analyses revealed a significant reduction in noradrenaline requirement in parallel with a moderate increase in mean arterial pressure, systemic vascular resistance index, and cardiac index. As a secondary endpoint, our results showed a significant decrease in lung water parameters. Moreover, changes in CPI (ΔCPI) and VDI (ΔVDI) after 24 h of hydrocortisone therapy revealed accurate prognostic ability to predict 28 days mortality (AUC = 0.802 vs 0.769). Conclusion: Adjunctive hydrocortisone leads to a rapid decrease in catecholamine requirement and a substantial circulatory improvement in critically ill patients with septic shock.

Efficacy and Safety of Cold Snare Polypectomy of Colorectal Polyps 10-15 mm with a Hybrid Snare: A Prospective Observational Pilot Study.

INTRODUCTION: Cold snare polypectomy (CSP) is a safe and effective procedure for small colorectal polyps ≤9 mm. There are only limited data regarding CSP of larger neoplastic lesions. This study evaluated the efficacy and safety of CSP for polyps between 10 and 15 mm in size. METHODS: In this prospective single-arm observational pilot study, patients with a least one polyp 10-15 mm were included. These polyps were preferably removed by CSP using a dedicated hybrid snare. The primary outcome was the histological complete resection rate (CRR) determined by pathologically negative margins of the specimen and no neoplastic tissue obtained from biopsies of the resection site margin. Secondary outcomes were en bloc resection rate, failure of CSP, and incidence of adverse events. RESULTS: A total of 61 neoplastic polyps were removed from 39 patients. Overall CRR was 80.3% (49/61). CSP was feasible in 78.7% (48/61) of polyps and the CRR in this group was 85.4% (41/48). When CSP failed (13/61; 21.3%), lesions were successfully resected by immediate HSP using the same snare with a CRR of 61.5% (8/13) in this group. One patient presented delayed hemorrhage after HSP of a polyp but successful hemostasis was achieved with two hemoclips. No other adverse events occurred. No recurrence was seen on follow-up colonoscopy in cases with incomplete resected polyps. CONCLUSION: CSP seems to be efficient and safe in removing colorectal polyps up to 15 mm. A hybrid snare seems to be particularly advantageous for these polyps as it allows immediate conversion to HSP if CSP might fail in larger polyps. This trial is registered at ClinicalTrials.gov (NCT04464837).

Conjunctive representations that integrate stimuli, responses, and rules are critical for action selection.

People can use abstract rules to flexibly configure and select actions for specific situations, yet how exactly rules shape actions toward specific sensory and/or motor requirements remains unclear. Both research from animal models and human-level theories of action control point to the role of highly integrated, conjunctive representations, sometimes referred to as event files. These representations are thought to combine rules with other, goal-relevant sensory and motor features in a nonlinear manner and represent a necessary condition for action selection. However, so far, no methods exist to track such representations in humans during action selection with adequate temporal resolution. Here, we applied time-resolved representational similarity analysis to the spectral-temporal profiles of electroencephalography signals while participants performed a cued, rule-based action selection task. In two experiments, we found that conjunctive representations were active throughout the entire selection period and were functionally dissociable from the representation of constituent features. Specifically, the strength of conjunctions was a highly robust predictor of trial-by-trial variability in response times and was selectively related to an important behavioral indicator of conjunctive representations, the so-called partial-overlap priming pattern. These results provide direct evidence for conjunctive representations as critical precursors of action selection in humans.

The Role of Conjunctive Representations in Stopping Actions.

Action selection appears to rely on conjunctive representations that nonlinearly integrate task-relevant features. Here, we tested a corollary of this hypothesis: that such representations are also intricately involved during attempts to stop an action-a key aspect of action regulation. We tracked both conjunctive representations and those of constituent rule, stimulus, or response features through trial-by-trial representational similarity analysis of the electroencephalogram signal in a combined rule-selection and stop-signal paradigm. Across two experiments with student participants (N = 57), we found (a) that the strength of decoded conjunctive representations prior to the stop signal uniquely predicted trial-by-trial stopping success (Experiment 1) and (b) that these representations were selectively suppressed following the onset of the stop signal (Experiments 1 and 2). We conclude that conjunctive representations are key to successful action execution and therefore need to be suppressed when an intended action is no longer appropriate.

B-Lines Scores Derived From Lung Ultrasound Provide Accurate Prediction of Extravascular Lung Water Index: An Observational Study in Critically Ill Patients.

INTRODUCTION: Visualization of B-lines via lung ultrasound provides a non-invasive estimation of pulmonary hydration. Extravascular lung water index (EVLWI) and pulmonary vascular permeability index (PVPI) assessed by transpulmonary thermodilution (TPTD) represent the most validated parameters of lung water and alveolocapillary permeability, but measurement is invasive and expensive. This study aimed to compare the correlations of B-lines scores from extensive 28-sector and simplified 4-sector chest scan with EVLWI and PVPI derived from TPTD in the setting of intensive care unit (primary endpoint). METHODS: We performed scoring of 28-sector and 4-sector B-Lines in 50 critically ill patients. TPTD was carried out with the PiCCO-2-device (Pulsion Medical Systems SE, Maquet Getinge Group). Median time exposure for ultrasound procedure was 12 minutes for 28-sector and 4 minutes for 4-sector scan. RESULTS: Primarily, we found close correlations of 28-sector as well as 4-sector B-Lines scores with EVLWI (R2 = 0.895 vs. R2 = 0.880) and PVPI (R2 = 0.760 vs. R2 = 0.742). Both B-lines scores showed high accuracy to identify patients with specific levels of EVLWI and PVPI. The extensive 28-sector B-lines score revealed a moderate advantage compared to simplified 4-sector scan in detecting a normal EVLWI ≤ 7 (28-sector scan: sensitivity = 81.8%, specificity = 94.9%, AUC = 0.939 versus 4-sector scan: sensitivity = 81.8%, specificity = 82.1%, AUC = 0.902). Both protocols were approximately equivalent in prediction of lung edema with EVLWI ≥ 10 (28-sector scan: sensitivity = 88.9%, specificity = 95.7%, AUC = 0.977 versus 4-sector scan: sensitivity = 81.5%, specificity = 91.3%, AUC = 0.958) or severe pulmonary edema with EVLWI ≥ 15 (28-sector scan: sensitivity = 91.7%, specificity = 97.4%, AUC = 0.995 versus 4-sector scan: sensitivity = 91.7%, specificity = 92.1%, AUC = 0.978). As secondary endpoints, our evaluations resulted in significant associations of 28-sector as well as simplified 4-sector B-Lines score with parameters of respiratory function. CONCLUSION: Both B-line protocols provide accurate non-invasive evaluation of lung water in critically ill patients. The 28-sector scan offers a marginal advantage in prediction of pulmonary edema, but needs substantially more time than 4-sector scan.

Prediction of Outcome in Acute Pancreatitis by the qSOFA and the New ERAP Score.

BACKGROUND: Early identification of patients with acute severe pancreatitis is important for prompt and adequate treatment. Existing scores for pancreatitis are often laborious or require serial patient evaluation, whereas the qSOFA score, that was established to predict outcome in patients with suspected infection, is simple to perform. AIMS AND METHODS: In this cohort study, we analyse the potential of the qSOFA score to predict outcome of patients with acute pancreatitis and refine the qSOFA score by rapid available laboratory parameters to the emergency room assessment of acute pancreatitis (ERAP) score. Validation was performed in a separate patient cohort. RESULTS: In total 203 patients with acute pancreatitis were recruited. The qSOFA score has the potential to predict ICU admission (AUC = 0.730, p = 0.002) and organ failure (AUC = 0.799, p = 0.013) in acute pancreatitis. Respiratory rate, mental status, blood urea nitrogen and C-reactive protein are the rapid available parameters with the highest individual impact in binary logistic regression analyses. Their combination to the ERAP score can predict severity of acute pancreatitis according to the revised Atlanta classification (AUC = 0.689 ± 0.041, p < 0.001), ICU admission (AUC = 0.789 ± 0.067, p < 0.001), multi-organ dysfunction syndrome (AUC = 0.963 ± 0.024, p < 0.001) and mortality (AUC = 0.952 ± 0.028, p = 0.001). The performance and prognostic validity for organ failure and mortality were validated in an independent patient cohort. CONCLUSION: The qSOFA is a rapidly available prognostic score in acute pancreatitis with limited prognostic validity. A combination with the laboratory parameters BUN and CRP results in the new ERAP score with outstanding prognostic validity for multi-organ dysfunction syndrome and mortality.

Isavuconazole and Liposomal Amphotericin B as Successful Combination Therapy of Refractory Invasive Candidiasis in a Liver Transplant Recipient: A Case Report and Literature Review.

Invasive fungal infections in liver transplant recipients are associated with elevated morbidity and mortality and pose a challenge to the treating physicians. Despite of lacking clinical data, the use of antifungal combination therapy is often considered to improve response rates in an immunocompromised patient population. We herein report a case of refractory invasive candidiasis in a liver transplant recipient treated successfully with a combination of isavuconazole und high-dose liposomal amphotericin B. The antimycotic combination treatment was able to clear a bloodstream infection with C. glabrata and led to regression of bilomas among tolerable side effects. The use of the above-mentioned antifungal combination therapy in a liver transplant recipient has not been reported previously. This case highlights the efficacy and safety of antifungal combination therapy in immunocompromised patients with refractory invasive candidiasis.

SARS-CoV-2 serology increases diagnostic accuracy in CT-suspected, PCR-negative COVID-19 patients during pandemic.

BACKGROUND: In the absence of PCR detection of SARS-CoV-2 RNA, accurate diagnosis of COVID-19 is challenging. Low-dose computed tomography (CT) detects pulmonary infiltrates with high sensitivity, but findings may be non-specific. This study assesses the diagnostic value of SARS-CoV-2 serology for patients with distinct CT features but negative PCR. METHODS: IgM/IgG chemiluminescent immunoassay was performed for 107 patients with confirmed (group A: PCR + ; CT ±) and 46 patients with suspected (group B: repetitive PCR-; CT +) COVID-19, admitted to a German university hospital during the pandemic's first wave. A standardized, in-house CT classification of radiological signs of a viral pneumonia was used to assess the probability of COVID-19. RESULTS: Seroconversion rates (SR) determined on day 5, 10, 15, 20 and 25 after symptom onset (SO) were 8%, 25%, 65%, 76% and 91% for group A, and 0%, 10%, 19%, 37% and 46% for group B, respectively; (p < 0.01). Compared to hospitalized patients with a non-complicated course (non-ICU patients), seroconversion tended to occur at lower frequency and delayed in patients on intensive care units. SR of patients with CT findings classified as high certainty for COVID-19 were 8%, 22%, 68%, 79% and 93% in group A, compared with 0%, 15%, 28%, 50% and 50% in group B (p < 0.01). SARS-CoV-2 serology established a definite diagnosis in 12/46 group B patients. In 88% (8/9) of patients with negative serology > 14 days after symptom onset (group B), clinico-radiological consensus reassessment revealed probable diagnoses other than COVID-19. Sensitivity of SARS-CoV-2 serology was superior to PCR > 17d after symptom onset. CONCLUSIONS: Approximately one-third of patients with distinct COVID-19 CT findings are tested negative for SARS-CoV-2 RNA by PCR rendering correct diagnosis difficult. Implementation of SARS-CoV-2 serology testing alongside current CT/PCR-based diagnostic algorithms improves discrimination between COVID-19-related and non-related pulmonary infiltrates in PCR negative patients. However, sensitivity of SARS-CoV-2 serology strongly depends on the time of testing and becomes superior to PCR after the 2nd week following symptom onset.

Vitamin D Deficiency Is Highly Prevalent in Critically Ill Patients and a Risk Factor for Mortality: A Prospective Observational Study Comparing Noncirrhotic Patients and Patients With Cirrhosis.

INTRODUCTION: A 25-hydroxyvitamin D, 25(OH)D, deficiency is common among critically ill patients and correlated with increased mortality. Furthermore, deficiency is associated with advanced liver disease. However, there are no studies available comparing the dimensions and consequences of a 25(OH)D deficiency between patients with and without liver cirrhosis in the setting of intensive care units (ICUs). This study focuses on differences in 25(OH)D status between critically ill noncirrhosis patients and patients with cirrhosis (primary end point), hypothesizing that deficiency and its impact on mortality risk are even more pronounced in patients with cirrhosis. METHODS: We performed a prospective observational study of 176 patients (noncirrhosis patients, N = 114; patients with cirrhosis, N = 62) with a laboratory assessment of 25(OH)D on ICU admission and survival analyses after 180 days. RESULTS: On admission, 55% of patients showed a severe deficiency, 25(OH)D <10 ng/mL, and a further 23% moderate deficiency (10-19 ng/mL). The overall median level of 25(OH)D was 8.0 (5.0-18.0) ng/mL (10.5 [6.0-21.3] in noncirrhosis patients vs 7.0 [4.8-10.0] in patients with cirrhosis; P < .001). We found extremely low levels particularly in patients without prior vitamin D supplementation (6.0 [4.0-7.5] in patients with cirrhosis vs 8.0 [5.0-12.0] ng/mL in noncirrhosis patients; P = .004). Vitamin D status correlated inversely with the sequential organ failure assessment, acute and physiology chronic health evaluation, model of end-stage liver disease, and Child-Pugh scores. Survival analyses categorized 25(OH)D levels <10 ng/mL as a high-risk factor for mortality 180 days after admission (hazard ratio [HR]: 2.45, 95% confidence interval [CI] = 1.60-3.70; P < .001). In patients with cirrhosis, a severe deficiency (<10 ng/mL) involved a significantly higher mortality risk than in noncirrhosis patients (HR: 2.30, 95% CI = 1.39-3.82; P = .001). In cases of admission levels ≥10 ng/mL, however, mortality risk was similar between patients with cirrhosis and noncirrhosis patients (HR: 1.08, 95% CI = 0.43-2.73; P = .873). CONCLUSIONS: Hypovitaminosis D is a highly frequent disorder in critically ill patients admitted to ICU. A severe deficiency with levels <10 ng/mL is a high risk factor for increased mortality, especially in patients with cirrhosis.

Transpulmonary thermodilution before and during veno-venous extra-corporeal membrane oxygenation ECMO: an observational study on a potential loss of indicator into the extra-corporeal circuit.

Haemodynamic monitoring before extra-corporeal membrane oxygenation (ECMO) might help to optimize the effectiveness of ECMO. However, there are concerns that pulmonary arterial and trans-pulmonary thermodilution (TPTD) might be confounded by a loss of indicator into the ECMO-circuit, resulting in an overestimation of volumetric parameters. Since there is a lack of data on indicator dilution techniques during ECMO, we compared TPTD-measurements before and during ECMO. TPTD-derived parameters before and after initiation of ECMO were compared in 14 intensive care unit-patients with veno-venous ECMO and TPTD-monitoring (PiCCO®). Eight patients had a jugular and six patients a femoral central venous catheter (CVC). Cardiac index, global end-diastolic volume index (GEDVI) and extra-vascular lung water index (EVLWI) before ECMO as well as the ECMO-flow were comparable in patients with jugular and femoral CVC. Pre-ECMO, cardiac index (CI) was not significantly different compared to values during ECMO (4.5 ± 1.7 vs. 4.4 ± 2.1 L/min/m2; p = 0.43). By contrast, GEDVI (791 ± 179 vs. 974 ± 384 mL/m2; p = 0.04) and EVLWI (21 ± 9 vs. 28 ± 11 mL/kg; p < 0.01) were higher during ECMO than before. Increases in GEDVI (36 ± 210 vs. 378 ± 247 mL/m2; p = 0.02) and EVLWI (3 ± 2 vs. 11 ± 8 mL/kg; p = 0.06) were substantially more pronounced in patients with femoral compared to jugular indicator injection. In multivariate analysis, femoral indicator injection was independently associated with larger increases in GEDVI (p < 0.01) and EVLWI (p = 0.04) during ECMO. However, CI and haemodynamic parameters not derived from TPTD, but from pulse contour analysis (systolic and diastolic arterial pressure, stroke volume variation and pulse pressure variation) were not affected by the start of ECMO. Our study demonstrates marked increases in GEDVI and EVLWI after the onset of ECMO. These increases were more pronounced for femoral compared to jugular indicator injection. CI and haemodynamic parameters not derived from TPTD were not affected by the extra-corporeal circuit.

Influence of Sustained Low-Efficiency Dialysis Treatment on Isavuconazole Plasma Levels in Critically Ill Patients.

Isavuconazole plasma concentrations were measured before and after sustained low-efficiency dialysis (SLED) treatment in 22 critically ill adult patients with probable invasive aspergillosis and underlying hematological malignancies. Isavuconazole levels were significantly lower after SLED treatment (5.73 versus 3.36 µg/ml; P < 0.001). However, even after SLED treatment, isavuconazole concentrations exceeded the in vivo MICs for several relevant Aspergillus species.

Increased risk of candidemia in patients with necrotising pancreatitis infected with candida species.

BACKGROUND AND OBJECTIVES: Candida infections are frequent in necrotising pancreatitis. Candidemia is associated with very high mortality and its risk due to infected pancreatic necrosis is unknown. So we aimed to assess potential risk factors and the risk of candidemia in necrotising pancreatitis. METHODS: We retrospectively searched our clinical database for the diagnosis necrotising pancreatitis from 2007 till March 2017 and entered relevant information in a database for statistical analysis. RESULTS: in total, 136 patients met the inclusion criteria. Candida infected pancreatic necrosis were found in 54 patients and 7 patients developed candidemia. Patients with Candida infected necrosis had a significantly higher in hospital mortality (35.2% versus 13.4%, p = 0.003). The highest mortality was observed in patients with candidemia (57.1% versus 20.2%, p = 0.042). Male gender (OR 0.32, CI 0.13-0.78, p = 0.013) and post-ERCP pancreatitis (OR 4.32, CI 1.01-18.36, p = 0.048) had a significant impact on the risk of Candida infections of pancreatic necrosis. Candidemia was significantly more frequent in patients with Candida infected necrosis (11.1% versus 1.2%, p = 0.016). Candida albicans was the most common species followed by Candida glabrata. CONCLUSION: Candidemia is a relevant complication of necrotising pancreatitis and associated with high mortality. If patients do not respond to antibiotic therapy empiric antifungal therapy should be discussed.

The Nature of Task Set Representations in Working Memory.

Selection and preparation of action plans (task sets) is often assumed to occur in working memory (WM). Yet, the absence of consistent evidence that WM capacity and task selection efficiency is correlated raises questions about the functional relationship between these two aspects of executive control. We used the EEG-derived contralateral delay activity (CDA) to index the WM load of task sets. In Experiment 1, we found a CDA set size effect (2 vs. 4 stimulus-response [S-R] rules) for high-WM, but not for low-WM, individuals when S-R sets were novel. In contrast, when only four task sets were presented throughout the experiment, we observed a sustained yet set size-independent use of WM for high-WM participants. Moreover, Experiment 2 showed an increase of the CDA in situations with task conflict, and this effect was larger the more that participants experienced RT conflict effects. Combined, these results indicate that even highly familiar S-R settings are maintained in WM, albeit in a compressed manner, presumably through cues to long-term memory representations. Finally, participants with low-WM capacity represented even familiar tasks in a load-dependent manner, suggesting that the establishment of effective retrieval structures itself is a capacity-limited process.

In-parallel connected intermittent hemodialysis through ECMO does not affect hemodynamic parameters derived from transpulmonary thermodilution.

INTRODUCTION: We report a case of renal replacement therapy (RRT) during extracorporeal membrane oxygenation (ECMO) via a single venous access and analyze the feasibility of transpulmonary thermodilution (TPTD) for hemodynamic monitoring. CASE REPORT: ECMO and RRT connected into the ECMO-extracorporeal circuit were performed via a single venous access because of multiple venous thromboses. An indicator for TPTD and pulse contour analysis (PCA) was applied into the central venous catheter (CVC) placed in the right vena jugularis. TPTD and PCA demonstrated comparable cardiac index. DISCUSSION: Congruent data for TPTD and PCA could be observed during TPTD and PCA measurements before ECMO, after ECMO and during ECMO and RRT. This might be explained by high blood flow having the lowest impact on TPTD by venous drainage in the femoral vein/distal vena cava and the TPTD indicator injection using the jugular CVC, as reported in our case. CONCLUSION: Hemodynamic monitoring using TPTD and PCA during ECMO/RRT is feasible and provides reliable results.

Applicability of stroke volume variation in patients of a general intensive care unit: a longitudinal observational study.

Sinus rhythm (SR) and controlled mechanical ventilation (CV) are mandatory for the applicability of respiratory changes of the arterial curve such as stroke volume variation (SVV) to predict fluid-responsiveness. Furthermore, several secondary limitations including tidal volumes <8 mL/kg and SVV-values within the "gray zone" of 9-13% impair prediction of fluid-responsiveness by SVV. Therefore, we investigated the prevalence of these four conditions in general ICU-patients. This longitudinal observational study analyzed a prospectively maintained haemodynamic database including 4801 transpulmonary thermodilution and pulse contour analysis measurements of 278 patients (APACHE-II 21.0 ± 7.4). The main underlying diseases were cirrhosis (32%), sepsis (28%), and ARDS (17%). The prevalence of SR and CV was only 19.4% (54/278) in the first measurements (primary endpoint), 18.8% (902/4801) in all measurements and 26.5% (9/34) in measurements with MAP < 65 mmHg and CI < 2.5 L/min/m2 and vasopressor therapy. In 69.1% (192/278) of the first measurements and in 65.9% (3165/4801) of all measurements the patients had SR but did not have CV. In 1.8% (5/278) of the first measurements and in 2.5% (119/4801) of all measurements the patients had CV but lacked SR. In 9.7% (27/278) of the first measurements and in 12.8% (615/4801) of all measurements the patients did neither have SR nor CV. Only 20 of 278 (7.2%) of the first measurements and 8.2% of all measurements fulfilled both major criteria (CV, SR) and both minor criteria for the applicability of SVV. The applicability of SVV in ICU-patients is limited due to the absence of mandatory criteria during the majority of measurements.

Switching between filter settings reduces the efficient utilization of visual working memory.

The capacity limitation of working memory requires that only relevant information gains access to the workspace, while irrelevant information is kept out. Thus, the ability to use attention to filter out irrelevant information is an important factor in how efficiently the limited storage space is used. Here, we examined to what degree the requirement to flexibly change filter settings affects filtering efficiency. Participants were presented with visual objects in different colors, and a cue presented in advance indicated which objects had to be stored. The contralateral delay activity, an event-related brain potential that reflects working-memory load was used to assess filtering efficiency during the retention interval. The data of two experiments showed that when filter settings had to be adjusted on a trial-by-trial basis, more irrelevant information passed the gate to working memory. Moreover, this switching-induced filtering deficit was restricted to those items that matched the previous, but currently irrelevant, filter settings. Thus, lingering effects of the selection history seem to counteract goal-directed encoding, and thus constitute an important attentional limitation for the efficient utilization of our limited workspace.