Algorithmic surveillance of ICU patients with acute respiratory distress syndrome (ASIC): protocol for a multicentre stepped-wedge cluster randomised quality improvement strategy.

INTRODUCTION: The acute respiratory distress syndrome (ARDS) is a highly relevant entity in critical care with mortality rates of 40%. Despite extensive scientific efforts, outcome-relevant therapeutic measures are still insufficiently practised at the bedside. Thus, there is a clear need to adhere to early diagnosis and sufficient therapy in ARDS, assuring lower mortality and multiple organ failure. METHODS AND ANALYSIS: In this quality improvement strategy (QIS), a decision support system as a mobile application (ASIC app), which uses available clinical real-time data, is implemented to support physicians in timely diagnosis and improvement of adherence to established guidelines in the treatment of ARDS. ASIC is conducted on 31 intensive care units (ICUs) at 8 German university hospitals. It is designed as a multicentre stepped-wedge cluster randomised QIS. ICUs are combined into 12 clusters which are randomised in 12 steps. After preparation (18 months) and a control phase of 8 months for all clusters, the first cluster enters a roll-in phase (3 months) that is followed by the actual QIS phase. The remaining clusters follow in month wise steps. The coprimary key performance indicators (KPIs) consist of the ARDS diagnostic rate and guideline adherence regarding lung-protective ventilation. Secondary KPIs include the prevalence of organ dysfunction within 28 days after diagnosis or ICU discharge, the treatment duration on ICU and the hospital mortality. Furthermore, the user acceptance and usability of new technologies in medicine are examined. To show improvements in healthcare of patients with ARDS, differences in primary and secondary KPIs between control phase and QIS will be tested. ETHICS AND DISSEMINATION: Ethical approval was obtained from the independent Ethics Committee (EC) at the RWTH Aachen Faculty of Medicine (local EC reference number: EK 102/19) and the respective data protection officer in March 2019. The results of the ASIC QIS will be presented at conferences and published in peer-reviewed journals. TRIAL REGISTRATION NUMBER: DRKS00014330.

Diagnostic Value of Positron Emission Tomography Combined with Computed Tomography for Evaluating Critically Ill Neurological Patients.

PURPOSE: 18F-fluorodeoxyglucose positron emission tomography combined with computed tomography (FDG-PET/CT) is a promising new tool for the identification of inflammatory, infectious, and neoplastic foci. The aim of our work was to evaluate the diagnostic value of FDG-PET/CT in patients treated on a neurological/neurosurgical ICU or stroke unit. METHODS: We performed a single-center, 10-year, retrospective evaluation of the value of FDG-PET/CT in critically ill adult patients with severe neurological disease. RESULTS: 42 patients underwent FDG-PET/CT. Of these, 15 were ventilated and 10 were under vasopressor support. We identified four indications for performing FDG-PET/CT: (1) excluding a paraneoplastic etiology in an otherwise unexplained encephalitis, encephalopathy or neuropathy, (2) detecting a large-vessel vasculitis in patients with ischemic stroke, (3) detecting an infectious focus in sepsis, and less frequently (4) evaluating cerebral metabolism. In 22 patients who were evaluated for an unknown malignancy, 5 scans revealed either a previously unknown tumor or unknown metastases of a previously treated malignancy. Of 11 patients investigated for large-vessel vasculitis, 2 showed an inflammation of arteries supplying the brain. Of six sepsis cases, FDG-PET/CT identified an infectious focus in four. SUMMARY: We found FDG-PET/CT to be a helpful tool in critically ill neurological patients. The results of the FDG-PET/CT had direct therapeutic consequences in the 12 true-positive cases. In 24 of the 29 negative cases, FDG-PET/CT helped exclude alternative diagnoses and/or influenced therapy. Our findings demonstrate the feasibility and diagnostic benefit of FDG-PET/CT in this group of patients.

Pharmacokinetic properties of different formulations of botulinum neurotoxin type A.

Although the relative potency measured by the number of units per nanogram of the toxin is different for the three preparations (BOTOX = 20 U/ng; Dysport = 40 U/ng, and CS-BOT = 15.2 U/ng), the effective dose for CS-BOT is similar to that of BOTOX (Allergan, Irvine, CA). Despite the twofold difference in potency per nanogram, it appears that the clinically observable activity of 1 U of BOTOX is roughly equivalent to 3 U of the Dysport (Inamed, Santa Barbara, CA) product. Using quantitative analysis of regional paralysis produced by local injections into the gastrocnemius muscles of mice, prior studies estimated the potency ratio between Dysport and BOTOX to be 4.2 to 1. In a single-blind, randomized comparison study of Dysport and BOTOX in 91 patients with blepharospasm or hemifacial spasm, it was found that 4:1 dose ratio produced similar benefits. A similar 4:1 Dysport:BOTOX ratio was found to produce equivalent beneficial effects in a double-blind study in patients with blepharospasm, but the frequency of side effects, particularly of ptosis, was lower in the BOTOX group. In a study of 73 patients with cervical dystonia treated either with Dysport or BOTOX, it was concluded that a 3:1 ratio provides equivalent results. But a recent study concluded that the appropriate conversion factor between BOTOX and Dysport is less than 3. Therefore, there is some controversy about the relative potencies of the two preparations, with one study proposing that 1 unit of BOTOX corresponds to 1 unit of Dysport.

Becoming a pianist. An fMRI study of musical literacy acquisition.

Musically naïve subjects were scanned using functional magnetic resonance imaging (fMRI) before and after they had been taught to read music and play keyboard. When subjects played melodies from musical notation after training, activation was seen in a cluster of voxels within the right superior parietal cortex consistent with the view that music reading involves spatial sensorimotor mapping.

Brain changes after learning to read and play music.

Musically naive participants were scanned before and after a period of 15 weeks during which they were taught to read music and play the keyboard. When participants played melodies from musical notation after training, activation was seen in a cluster of voxels within the bilateral superior parietal cortex. A subset of these voxels were activated in a second experiment in which musical notation was present, but irrelevant for task performance. These activations suggest that music reading involves the automatic sensorimotor translation of a spatial code (written music) into a series of motor responses (keypresses).

"Hey John": signals conveying communicative intention toward the self activate brain regions associated with "mentalizing," regardless of modality.

Successful communication between two people depends first on the recognition of the intention to communicate. Such intentions may be conveyed by signals directed at the self, such as calling a person's name or making eye contact. In this study we use functional magnetic resonance imaging to show that the perception of these two signals, which differ in modality and sensory channel, activate common brain regions: the paracingulate cortex and temporal poles bilaterally. These regions are part of a network that has been consistently activated when people are asked to think about the mental states of others. Activation of this network is independent of arousal as measured by changes in pupil diameter.