The utility of an RDoC motor domain to understand psychomotor symptoms in depression.

Despite the clinical impact of motor symptoms such as agitation or retardation on the course of depression, these symptoms are poorly understood. Novel developments in the field of instrumentation and mobile devices allow for dimensional and continuous recording of motor behavior in various settings, particularly outside the laboratory. Likewise, the use of novel assessments enables to combine multimodal neuroimaging with behavioral measures in order to investigate the neural correlates of motor dysfunction in depression. The research domain criteria (RDoC) framework will soon include a motor domain that will provide a framework for studying motor dysfunction in mood disorders. In addition, new studies within this framework will allow investigators to study motor symptoms across different stages of depression as well as other psychiatric diagnoses. Finally, the introduction of the RDoC motor domain will help test how motor symptoms integrate with the original five RDoC domains (negative valence, positive valence, cognitive, social processes, and arousal/regulation).

Resting state perfusion in the language network is linked to formal thought disorder and poor functional outcome in schizophrenia.

OBJECTIVE: Formal thought disorder (FTD) is a core symptom in schizophrenia. Here, we focus on resting state cerebral blood flow (rCBF) linked to dimensions of FTD. METHODS: We included 47 schizophrenia spectrum patients and 30 age- and gender-matched healthy controls. We assessed FTD with the assessment of thought, language, and communication (TLC) and imaging on a 3T MRI scanner. Within patients, we tested the association of FTD dimensions and in a subgroup (n = 27) the association of functional outcome after 6 months with whole brain rCBF. RESULTS: Negative FTD was most prominently associated with perfusion within the superior temporal gyrus, while positive FTD was associated with perfusion within the supplementary motor area, and inferior frontal gyrus. Perfusion within the left supramarginal gyrus was associated with social functioning after 6 months. CONCLUSIONS: Distinguishable associations of rCBF with FTD dimensions point to distinct underlying pathophysiology. The location of aberrant perfusion patterns suggests that negative FTD might reflect defective access to semantic memory while positive FTD likely reflects defective suppression of irrelevant information during increased speech production. Finally, the neural correlates of thought block were also predictive of poor functional outcome. Thus, functional outcome and distinct FTD dimensions may share some pathophysiology.

Severe sepsis in the ICU is often missing in hospital discharge codes.

BACKGROUND: Different International Classification of Diseases (ICD)-based code abstraction strategies have been used when studying the epidemiology of severe sepsis. The aim of this study was to compare three previously used ICD code abstraction strategies to the American College of Chest Physicians/Society of Critical Care Medicine (ACCP/SCCM) consensus criteria for severe sepsis, in a setting of intensive care patients. METHODS: All patients (≥ 18 years of age) with severe sepsis according to the ACCP/SCCM criteria registered in the Swedish Intensive Care Registry (2005-2009) were included in the study. Using the Swedish National Patient Register, we investigated whether these patients fulfilled an ICD code compilation for severe sepsis at hospital discharge. RESULTS: Overall, 9271 patients with severe sepsis were registered in the Swedish Intensive Care Registry. A majority of these patients (55.4%) were discharged from the hospital with ICD codes that did not correspond to any of the ICD code compilations. A minority of patients (10.3%) were discharged with ICD codes corresponding to all three code abstraction strategies applied. Overall, the proportion of patients discharged with ICD codes corresponding to the criteria of Angus et al. was 15.1%, to the criteria of Flaatten was 39.8%, and to the criteria of Martin et al. was 16.0%. CONCLUSIONS: A majority of patients with severe sepsis according to the ACCP/SCCM criteria were not discharged with ICD codes corresponding to the ICD code abstraction strategies; thus, the abstraction strategies did not identify the correct patients.

Identifying opportunities to increase organ donation after brain death. An observational study in Sweden 2009-2014.

BACKGROUND: There is a wide gap between the number of organ donors and patients on waiting lists for transplantation. The purpose of this Swedish nationwide study of the critical pathway for organ donation after brain death (DBD) was to identify missed opportunities for organ donation. METHODS: We performed a prospective, observational study of all ICU deaths in Sweden from Jan 1, 2009 to Dec 31, 2014. The protocol structure followed the critical pathway for organ donation, which was developed and tested during 2008. We analysed differences in donation incidences between healthcare providers (counties) and patient characteristics using descriptive statistics and logistic regression. RESULTS: The number of DBD per million population (pmp) was 14.9, varying almost 10-fold from 4.3 to 40.6 DBD pmp between counties. Regional variation in DBD decreased when we assigned the donor to the place of residence (from 6.9 to 27.7 DBD pmp). Women were more likely to become donors compared to men [crude odds ratio (OR) 1.60, 95% confidence interval (CI) 1.38-1.85, P < 0.001]. The increased likelihood remained after adjusting for age, comorbidity, and main diagnostic categories (OR 1.49, 95% CI 1.25-1.77, P < 0.001). An end-of-life decision was found in 50.9% of possible organ donors. CONCLUSIONS: Regional differences in DBD were considerable, and women were more likely to become donors than men. There is a need for increased awareness of the potential for organ donation as an integral part of end-of-life clinical care. In-depth analysis of these differences may reveal opportunities for action that could lead to increased DBD.

Distinct resting-state perfusion patterns underlie psychomotor retardation in unipolar vs. bipolar depression.

OBJECTIVE: Psychomotor abnormalities characterize both unipolar (UP) depression and bipolar (BP) depression. We aimed to assess their neurobiological correlates in terms of motor activity (AL) and resting-state cerebral blood flow (rCBF) and investigate their association in BP, UP, and healthy controls (HC). METHOD: We enrolled 42 depressed patients (22 BP, 20 UP) and 19 HC matched for age, gender, education, income. AL and rCBF were objectively assessed with the use of wrist actigraphy and arterial spin labeling. Group differences and the association of AL and rCBF were computed. RESULTS: Activity level was significantly reduced in patients, but no difference was found between BP and UP. Increased perfusion was found in BP compared with UP and HC, in multiple brain areas. We found positive correlations of rCBF and AL in BP and UP, in different parts of the insula and frontal regions. Only BP showed a cluster in the left precentral gyrus. In HC, only inverse correlations of AL and rCBF were found. CONCLUSION: The differences in rCBF and in the localization of the clusters of positive AL/rCBF correlations between BP and UP suggest that different neural impairments may underlie motor symptoms in the two disorders, but finally converge in phenotypically similar manifestations.

EEG marker of inhibitory brain activity correlates with resting-state cerebral blood flow in the reward system in major depression.

Frontal alpha band asymmetry (FAA) is a marker of altered reward processing in major depressive disorder (MDD), associated with reduced approach behavior and withdrawal. However, its association with brain metabolism remains unclear. The aim of this study was to investigate FAA and its correlation with resting-state cerebral blood flow (rCBF). We hypothesized an association of FAA with regional rCBF in brain regions relevant to reward processing and motivated behavior, such as the striatum. We enrolled 20 patients and 19 healthy subjects. FAA scores and rCBF were quantified with the use of EEG and arterial spin labeling. Correlations of the two were evaluated, as well as the association with FAA and psychometric assessments of motivated behavior and anhedonia. Patients showed a left-lateralized pattern of frontal alpha activity and a correlation of FAA lateralization with subscores of Hamilton Depression Rating Scale linked to motivated behavior. An association of rCBF and FAA scores was found in clusters in the dorsolateral prefrontal cortex bilaterally (patients), in the left medial frontal gyrus, in the right caudate head and in the right inferior parietal lobule (whole group). No correlations were found in healthy controls. Higher inhibitory right-lateralized alpha power was associated with lower rCBF values in prefrontal and striatal regions, predominantly in the right hemisphere, which are involved in the processing of motivated behavior and reward. Inhibitory brain activity in the reward system may contribute to some of the motivational problems observed in MDD.

Subtyping schizophrenia: A comparison of positive/negative and system-specific approaches.

BACKGROUND: Schizophrenia is a heterogeneous disorder. Over the years, different approaches have been proposed to approach this heterogeneity by categorizing symptom patterns. The study aimed to compare positive/negative and system-specific approaches to subtyping. METHODS: We used the Positive and Negative Syndrome Scale (PANSS) and Bern Psychopathology Scale (BPS), which consists of subscales for three domains (language, affect and motor behavior) that are hypothesized to be related to specific brain circuits, to assess cross-sectional psychopathological characteristics in a sample of 100 inpatients with schizophrenia spectrum disorders. We then categorized participants into positive/negative and system-specific subgroups to allow comparisons of the two approaches. RESULTS: The analyses revealed correlations between the PANSS positive subscore and the BPS affective subscore (r=.446, p<.001) and between the PANSS negative subscore and the BPS motor behavior subscore (r=.227, p=.023). As regards the positive and negative subtype, more participants were classified as positive in the language-dominant subtype (30.3%) and affect-dominant subtype (30.3%), whereas more were classified as negative in the motor behavior-dominant subtype (44.4%). However, most patients met the criteria for the mixed subtype. CONCLUSIONS: The results suggest that the positive/negative and system-specific approaches can be regarded as complementary. Future studies should examine both approaches in a longitudinal assessment of psychopathological symptoms and link them with qualitative-phenomenological approaches.

In-hospital vs. 30-day mortality in the critically ill - a 2-year Swedish intensive care cohort analysis.

BACKGROUND: Standardised mortality ratio (SMR) is a common quality indicator in critical care and is the ratio between observed mortality and expected mortality. Typically, in-hospital mortality is used to derive SMR, but the use of a time-fixed, more objective, end-point has been advocated. This study aimed to determine the relationship between in-hospital mortality and 30-day mortality on a comprehensive Swedish intensive care cohort. METHODS: A retrospective study on patients >15 years old, from the Swedish Intensive Care Register (SIR), where intensive care unit (ICU) admissions in 2009-2010 were matched with the corresponding hospital admissions in the Swedish Hospital Discharge Register. Recalibrated SAPS (Simplified Acute Physiology Score) 3 models were developed to predict and compare in-hospital and 30-day mortality. SMR based on in-hospital mortality and on 30-day mortality were compared between ICUs and between groups with different case-mixes, discharge destinations and length of hospital stays. RESULTS: Sixty-five ICUs with 48861 patients, of which 35610 were SAPS 3 scored, were included. Thirty-day mortality (17%) was higher than in-hospital mortality (14%). The SMR based on 30-day mortality and that based on in-hospital mortality differed significantly in 7/53 ICUs, for patients with sepsis, for elective surgery-admissions and in groups categorised according to discharge destination and hospital length of stay. CONCLUSION: Choice of mortality end-point influences SMR. The extent of the influence depends on hospital-, ICU- and patient cohort characteristics as well as inter-hospital transfer rates, as all these factors influence the difference between SMR based on 30-day mortality and SMR based on in-hospital mortality.

[Schizophrenic Psychoses with Motor-Dominant Symptoms: Considerations for a System-Specific Approach]. / Schizophrene Psychosen mit motordominanter Symptomatik: Überlegungen zu einem systemspezifischen Ansatz.

In order to reduce heterogeneity in schizophrenia, a system-specific approach consisting of the domains "language", "affect" and "motor behavior" has been proposed. We examined this system-specific approach for its applicability to clinical practice in the motor behavior domain, using the methodological approach of case studies, and discuss here the differences to the positive/negative concept. We analyzed eight cases with stable motor-dominant symptoms, and also quantitatively assessed motor behavior by using the Bern Psychopathology Scale (BPS), a standardized psychopathological assessment instrument, as well as actigraphic data. Characterization of cases using the positive/negative approach was not helpful. We found an overlap of the motor behavior domain with the other two domains. This complicates the application of the system-specific approach in the sense of a typology. Furthermore, we found both relapsing courses with full remission and chronic courses with deterioration within the motor-dominant subtype. Nevertheless, the system-specific approach has heuristic utility for the future.

Prenatal diagnosis in haemophilia A: experience of the genetic diagnostic laboratory.

The paper describes the experience of the Genetic Diagnostic Laboratory in prenatal testing for haemophilia A, an X-linked recessive disease caused by mutations in the F8 gene. Knowledge of a familial mutation prior to pregnancy can benefit prenatal diagnosis and decrease wait time for molecular testing during pregnancy. This is a retrospective review of a series of pregnant women who pursued F8 gene testing from December 1997 through May 2012, highlighting three cases, which demonstrate the technical complexities of analysis and the implications of not knowing carrier status prior to pregnancy. Mutations of the F8 gene were detected in affected males, obligate female carriers and suspected female carriers by DNA sequencing, inverse-PCR, qRT-PCR, Southern blot and exonic dosage analysis. The same methods were used to analyse prenatal samples from obligate or suspected female carriers upon request. Maternal cell contamination studies were performed for all prenatal samples analysed. Ninety-nine women pursued F8 testing during pregnancy, either for carrier status alone or carrier status and prenatal diagnosis. Ninety-one women (91%) requested carrier testing because they did not know their F8 mutation carrier status prior to pregnancy. Eight women requested prenatal diagnosis only, and only 4 of these were aware of their mutation status. Thirty-seven individuals were found to be mutation carriers. Forty-two prenatal samples were received for prenatal diagnosis. In total 21 foetuses were identified as mutation carriers. Mutation detection was complex and increased the turnaround time in some cases. Only four of 99 women who submitted samples for F8 testing were aware of their F8 mutation status prior to pregnancy. Knowledge of F8 mutation status prior to pregnancy allows for efficient prenatal diagnosis, when desired. Thus, preconception genetic counselling is required to inform patients of the available options and the complex and time-consuming nature of F8 testing.

EuroSCORE II and N-terminal pro-B-type natriuretic peptide for risk evaluation: an observational longitudinal study in patients undergoing coronary artery bypass graft surgery.

BACKGROUND: Postoperative heart failure remains the major cause of death after cardiac surgery. As N-terminal pro-B-type natriuretic peptide (NT-proBNP) is a predictor for postoperative heart failure, the aim was to evaluate if preoperative NT-proBNP could provide additional prognostic information to the recently launched EuroSCORE II. METHODS: A total of 365 patients with acute coronary syndrome (ACS) undergoing isolated coronary artery bypass graft (CABG) surgery were studied prospectively. Preoperative NT-proBNP and EuroSCORE II were evaluated with regard to severe circulatory failure after operation according to prespecified criteria. To assess what clinical outcomes are indicated by NT-proBNP levels in different risk categories, the patients were stratified according to EuroSCORE II. Based on receiver operating characteristics analysis, these cohorts were assessed with regard to preoperative NT-proBNP below or above 1028 ng litre(-1). The follow-up time averaged 4.4 (0.7) yr. RESULTS: Preoperative NT-proBNP≥1028 ng litre(-1) [odds ratio (OR) 9.9, 95% confidence interval (CI) 1.01-98.9; P=0.049] and EuroSCORE II (OR 1.24, 95% CI 1.06-1.46; P=0.008) independently predicted severe circulatory failure after operation. In intermediate-risk patients (EuroSCORE II 2.0-10.0), NT-proBNP≥1028 ng litre(-1) was associated with a higher incidence of severe circulatory failure (6.6% vs 0%; P=0.007), renal failure (14.8% vs 5.4%; P=0.03), stroke (6.6% vs 0.7%; P=0.03), longer intensive care unit stay [37 (35) vs 27 (38) h; P=0.002], and worse long-term survival. CONCLUSIONS: Combining EuroSCORE II and preoperative NT-proBNP appears to improve risk prediction with regard to severe circulatory failure after isolated CABG for ACS. NT-proBNP may be particularly useful in patients at intermediate risk according to EuroSCORE II. CLINICAL TRIAL REGISTRATION: NCT00489827.

What determines immediate use of invasive ventilation in patients with COPD?

BACKGROUND: The choice between non-invasive ventilation (NIV) and invasive ventilation in patients with an acute exacerbation of chronic obstructive pulmonary disease (AECOPD) may be irrational. The aim of this study was to examine those patient characteristics, and circumstances deemed important in the choice made between NIV and invasive ventilation in the intensive care unit (ICU). METHODS: We first examined 95 admissions of AECOPD patients on nine ICUs and identified variables associated with invasive ventilation. Thereafter, a questionnaire was sent to ICU personnel to study the relative importance of different factors with a possible influence on the decision to use invasive ventilation at once. RESULTS: Univariable analysis showed that increasing age [odds ratio (OR) 1.06 per year] and increasing body mass index (BMI) (OR 1.11 per kg/m(2) ) were associated with immediate invasive ventilation, while there was no such association with arterial blood gases or breath rate. BMI was the only factor that remained associated with immediate invasive ventilation in the multivariable analysis [OR 1.12 (95% confidence interval 1.03-1.23) kg/m(2) ]. Ranking of responses to the questionnaire showed that consciousness, respiratory symptoms and blood gases were powerful factors determining invasive ventilation, whereas high BMI and age were ranked low. Non-patient-related factors were also deemed important (physician in charge, presence of guidelines, ICU workload). CONCLUSION: Factors other than those deemed most important in guidelines appear to have an inappropriate influence on the choice between NIV and immediate intubation in AECOPD in the ICU. These factors must be identified to further increase the appropriate use of NIV.

A generic simulation model for planning critical care resource requirements.

Intensive care capacity planning based on factual or forecasted mean admission numbers and mean length of stay without taking non-linearity and variability into account is fraught with error. Simulation modelling may allow for a more accurate assessment of capacity needs. We developed a generic intensive care simulation model using data generated from anonymised patient records of all admissions to four different hospital intensive care units. The model was modified and calibrated stepwise to identify important parameters and their values to obtain a match between model predictions and actual data. The most important characteristic of the final model was the dependency of admission rate on actual occupancy. Occupancy, coverage and transfers of the final model were found to be within 2% of the actual data for all four simulated intensive care units. We have shown that this model could provide accurate decision support for planning critical care resource requirements.

Hypogammaglobulinemia: A contributing factor to multiple sclerosis fatigue?

OBJECTIVE: Fatigue is one of the most disabling and difficult to treat symptoms of autoimmune diseases and frequently presents in people with multiple sclerosis (PwMS). Hypogammaglobulinemia for immunoglobulin G (IgG) affects approximately 8-25% of PwMS. We performed a retrospective analysis to investigate the association of MS-fatigue and IgG hypogammaglobulinemia. METHODS: PwMS, treated at Eginition University Hospital Athens or at the University Hospital Bern, were included (n = 134 patients (Bern n = 99; Athens n = 35)). Mann Whitney U-test (MWT), ANOVA test, Chi2 test and multivariable linear regression models were run. RESULTS: 97/134 (72.4%) PwMS reported fatigue. In the multivariable linear regression analysis, IgG serum concentration (-1.6, 95%CI -2.7 - -0.5, p = 0.006), daytime sleepiness (0.8, 95%CI 0.2-1.4, p = 0.009), and a depressive mood (1.1, 95%CI 0.8-1.4, p < 0.001) were significantly associated with fatigue. The impact of IgG serum concentration (-2.9 95%CI -4.7 - -1.1, p = 0.002) remained significant also in the subcohort of PwMS without depressive symptoms or daytime sleepiness. CONCLUSIONS: We found an association between IgG hypogammaglobulinemia and fatigue in PwMS (Level of Evidence IV), which might be translated to other autoimmune diseases. It bears a potential therapeutic consequence considering IgG supplementation strategies, if our finding can be validated prospectively.

Need for improved antimicrobial and infection control stewardship in Vietnamese intensive care units.

OBJECTIVE: Survey of antibiotic consumption, microbial resistance and hygiene precautions in the intensive care units of three hospitals in northern Vietnam. METHODS: Observational study. Data were collected from the microbiological laboratories. Antibiotic consumption was determined based on quantities of drugs delivered from the pharmacy. A protocol to observe the application of hygiene precautions was developed and used. Bacteria were typed and tested for drug susceptibility using the disc-diffusion method. RESULTS: The mean antibiotic consumption was 811 defined daily doses per 1000 occupied bed days. The most commonly used antibiotics were third-generation cephalosporins, followed by carbapenems, amoxicillin and ampicillin. Eighty per cent of bacterial isolates were Gram-negative. The most common pathogens found in blood cultures were Escherichia coli and Klebsiella spp., Pseudomonas spp., Acinetobacter spp., Staphylococcus aureus and Enterococcus faecalis. Acinetobacter and Pseudomonas spp. were the two most frequently isolated bacteria from the respiratory tract and all other sources together. Seventy per cent of Acinetobacter species showed reduced susceptibility to imipenem, 80% to ciprofloxacin and 89% to ceftazidime. Forty-four per cent of Pseudomonas spp. showed reduced susceptibility to imipenem, 49% to ciprofloxacin and 49% to ceftazidime. Escherichia coli was fully susceptible to imipenem, but 57% of samples were resistant to both ciprofloxacin and cefotaxime. Hygiene precautions were poor, and fewer than 50% of patient contacts incorporated appropriate hand hygiene. CONCLUSION: Low antibiotic consumption, poor hygiene precautions and the high level of antibiotic resistance indicate that there is room for improvement regarding antibiotic use and infection control.

Detection of prostate cancer with complexed PSA and complexed/total PSA ratio - is there any advantage?

OBJECTIVE: To evaluate the performance of total PSA (tPSA), the free/total PSA ratio (f/tPSA), complexed PSA (cPSA) and the complexed/total PSA ratio (c/tPSA) in prostate cancer detection. METHODS: Frozen sera of 442 patients have been analysed for tPSA, free PSA (fPSA) and cPSA. 131 patients had prostate cancer and 311 patients benign prostatic hyperplasia. RESULTS: Differences in the distribution of the biomarkers were seen as follows: tPSA, cPSA and c/tPSA were significantly higher in the PC group, and f/tPSA was significantly higher in the BPH group. In the tPSA-range of 0-4 ng/ml none of the biomarkers showed a significant difference in the distribution between both groups. In the tPSA-ranges of 0-10 ng/ml, 2-10 ng/ml, 4-10 ng/ml and <10 ng/ml, f/tPSA showed the highest specificity at high sensitivtities, followed by c/tPSA, cPSA, and tPSA, respectively. In tPSA-ranges greater than 10 ng/ml, cPSA offered the best discriminatory ability. CPSA compared to tPSA offered better specificity at high sensitivities in all tPSA-ranges. CONCLUSION: F/tPSA offers the best ability to distinguish between both groups in lower tPSA-ranges, followed by c/tPSA. CPSA compared to tPSA offers a better ability to discriminate between both groups in all PSA-ranges and could be used as an initial test for PC.

Efficacy of retrograde ureteropyeloscopic holmium laser lithotripsy for intrarenal calculi >2 cm.

The objectives of this study are to assess the efficacy and safety of retrograde ureteroscopic holmium laser lithotripsy for intrarenal calculi greater than 2 cm in diameter. A total of 24 patients with a stone burden >2 cm were treated with retrograde ureteroscopic laser lithotripsy. Primary study endpoints were number of treatments until the patient was stone free and perioperative complications with a follow-up of at least 3 months after intervention. In 24 patients (11 women and 13 men, 20-78 years of age), a total of 40 intrarenal calculi were treated with retrograde endoscopic procedures. At the time of the initial procedure, calculi had an average total linear diameter of 29.75 ± 1.57 mm and an average stone volume of 739.52 ± 82.12 mm(3). The mean number of procedures per patient was 1.7 ± 0.8 (range 1-3 procedures). The overall stone-free rate was 92%. After 1, 2 and 3 procedures 54, 79 and 92% of patients were stone free, respectively. There were no major complications. Minor postoperative complications included pyelonephritis in three cases (7.5%), of whom all responded immediately to parenteral antibiotics. In one patient the development of steinstrasse in the distal ureter required ureteroscopic fragment disruption and basketing. Ureteroscopy with holmium laser lithotripsy represents an efficient treatment option and allows the treatment of large intrarenal calculi of all compositions and throughout the whole collecting system even for patients with a stone burden of more than 2 cm size.

Long-term effect of the ICU-diary concept on quality of life after critical illness.

BACKGROUND: Critically ill patients often spend time in the intensive care unit (ICU) either unconscious or sedated. On recovery, they are often in a state of confusion with memory loss that may be associated with a longstanding reduction in health-related quality of life (QoL). We hypothesised that the ICU-diary concept could improve their QoL by filling in their memory gaps. METHODS: A non-randomised, prospective study in a non-academic eight-bedded general ICU. A group of patients (n=38) were selected to receive the ICU-diary concept (keeping a diary with photos while on the ICU plus a follow-up meeting) when a long and complicated course was expected. Health-related QoL at 6, 12, 24 and 36 months was compared with a group that did not receive the ICU-diary (n=224). The Medical Outcomes Study 36-Item Short-Form (SF-36) was used to measure health-related QoL. Multiple regression models adjusted for age, sex, illness severity, pre-existing disease and diagnostic category was used to analyse the effects of the ICU-diary concept at 6 months, and changes over time were analysed using repeated measures MANOVA. RESULTS: Crude and adjusted scores for two dimensions of SF-36 (general health and vitality) and the physical component summary score were significantly higher at 6 months in the ICU-diary group (P<0.05) and some of the effects remained during the 3-year follow-up period (P<0.05). CONCLUSION: The ICU-diary concept was associated with improved health-related QoL during the 3-year follow-up period after a critical illness. The effect of this intervention needs to be confirmed in a larger randomised study.

Effects of 21 days of intensified training on markers of overtraining.

The purpose of this study was to impose a period of quantifiable intensified training to determine if commonly used diagnostic markers of overtraining parallel changes in physical performance and thus overtraining status. Eight trained male cyclists (24 ± 1 years, 71 ± 3 kg, VO2peak = 4.5 ± 0.1·L·min⁻¹) performed 21 days (3,211 km) of intensified training in the field where volume and intensity were increased over normal training. Salivary IgA, testosterone, and cortisol, 1-hour time trial performance, heart rate response, and profile of mood states (POMS) were collected and analyzed throughout the 21-day training period. The POMS category vigor declined from day 1 to day 4 and remained lower throughout (p < 0.05). There were no other statistical changes in overtraining parameters. However, individuals who demonstrated 2 or more symptoms of overtraining at any point throughout the 21 days were considered symptomatic and had a lower (p < 0.05) VO2peak (4.2 ± 0.1·vs. 4.7 ± 0.1 L·min⁻¹) and lower (p < 0.05) average workload during the initial 1-hour time trial (253 ± 5 vs. 288 ± 14 W). Interestingly, the 1-hour time trial power in these individuals with symptoms of overtraining did not decline (p > 0.05). These data demonstrate that markers of overtraining do not parallel a decrease in performance and should be interpreted with caution.