An Innovative Telemedical Network to Improve Infectious Disease Management in Critically Ill Patients and Outpatients (TELnet@NRW): Stepped-Wedge Cluster Randomized Controlled Trial.

BACKGROUND: Evidence-based infectious disease and intensive care management is more relevant than ever. Medical expertise in the two disciplines is often geographically limited to university institutions. In addition, the interconnection between inpatient and outpatient care is often insufficient (eg, no shared electronic health record and no digital transfer of patient findings). OBJECTIVE: This study aims to establish and evaluate a telemedical inpatient-outpatient network based on expert teleconsultations to increase treatment quality in intensive care medicine and infectious diseases. METHODS: We performed a multicenter, stepped-wedge cluster randomized trial (February 2017 to January 2020) to establish a telemedicine inpatient-outpatient network among university hospitals, hospitals, and outpatient physicians in North Rhine-Westphalia, Germany. Patients aged ≥18 years in the intensive care unit or consulting with a physician in the outpatient setting were eligible. We provided expert knowledge from intensivists and infectious disease specialists through advanced training courses and expert teleconsultations with 24/7/365 availability on demand respectively once per week to enhance treatment quality. The primary outcome was adherence to the 10 Choosing Wisely recommendations for infectious disease management. Guideline adherence was analyzed using binary logistic regression models. RESULTS: Overall, 159,424 patients (10,585 inpatients and 148,839 outpatients) from 17 hospitals and 103 outpatient physicians were included. There was a significant increase in guideline adherence in the management of Staphylococcus aureus infections (odds ratio [OR] 4.00, 95% CI 1.83-9.20; P<.001) and in sepsis management in critically ill patients (OR 6.82, 95% CI 1.27-56.61; P=.04). There was a statistically nonsignificant decrease in sepsis-related mortality from 29% (19/66) in the control group to 23.8% (50/210) in the intervention group. Furthermore, the extension of treatment with prophylactic antibiotics after surgery was significantly less likely (OR 9.37, 95% CI 1.52-111.47; P=.04). Patients treated by outpatient physicians, who were regularly participating in expert teleconsultations, were also more likely to be treated according to guideline recommendations regarding antibiotic therapy for uncomplicated upper respiratory tract infections (OR 1.34, 95% CI 1.16-1.56; P<.001) and asymptomatic bacteriuria (OR 9.31, 95% CI 3.79-25.94; P<.001). For the other recommendations, we found no significant effects, or we had too few observations to generate models. The key limitations of our study include selection effects due to the applied on-site triage of patients as well as the limited possibilities to control for secular effects. CONCLUSIONS: Telemedicine facilitates a direct round-the-clock interaction over broad distances between intensivists or infectious disease experts and physicians who care for patients in hospitals without ready access to these experts. Expert teleconsultations increase guideline adherence and treatment quality in infectious disease and intensive care management, creating added value for critically ill patients. TRIAL REGISTRATION: ClinicalTrials.gov NCT03137589; https://clinicaltrials.gov/ct2/show/NCT03137589.

[Evaluation of the project for the introduction of bystander resuscitation in schools in North Rhine-Westphalia]. / Evaluation des Projekts zur Einführung von Laienreanimation an Schulen in Nordrhein-Westfalen.

BACKGROUND: Teaching of resuscitation measures is not mandatory in all schools in Germany. It is currently limited to individual, partly mandatory projects despite a low bystander resuscitation rate. For this reason, the Ministry for Schools and Education of North Rhine-Westphalia initiated the project "Bystander resuscitation at schools in NRW" in March 2017. OBJECTIVE: The aim of this work was to evaluate this project. MATERIAL AND METHODS: All secondary schools in North Rhine-Westphalia were invited to participate in the project. Medical partners from each administrative district took part, who carried out resuscitation training with existing concepts for teacher or student training. After a 3-year period, the evaluation was carried out using standardized questionnaires for school headmasters, teachers and students. RESULTS: In total, more than 40,000 pupils from 249 schools in NRW could be trained in resuscitation within the project with 6 different concepts. Of the students 85% answered the questions regarding resuscitation correctly and overall felt safe in resuscitation measures. The one-off investment requirement for all schools is roughly 4-6.5 million € and around 340,000 € in each budget year. CONCLUSION: A legal constitution and funding are necessary for a nationwide introduction of resuscitation in schools. All established concepts are effective, therefore each school can use them exactly according to their needs, optimally in a stepped form. Training for teachers should focus on resuscitation.

ECCO2R therapy in the ICU: consensus of a European round table meeting.

BACKGROUND: With recent advances in technology, patients with acute respiratory distress syndrome (ARDS) and severe acute exacerbations of chronic obstructive pulmonary disease (ae-COPD) could benefit from extracorporeal CO2 removal (ECCO2R). However, current evidence in these indications is limited. A European ECCO2R Expert Round Table Meeting was convened to further explore the potential for this treatment approach. METHODS: A modified Delphi-based method was used to collate European experts' views to better understand how ECCO2R therapy is applied, identify how patients are selected and how treatment decisions are made, as well as to identify any points of consensus. RESULTS: Fourteen participants were selected based on known clinical expertise in critical care and in providing respiratory support with ECCO2R or extracorporeal membrane oxygenation. ARDS was considered the primary indication for ECCO2R therapy (n = 7), while 3 participants considered ae-COPD the primary indication. The group agreed that the primary treatment goal of ECCO2R therapy in patients with ARDS was to apply ultra-protective lung ventilation via managing CO2 levels. Driving pressure (≥ 14 cmH2O) followed by plateau pressure (Pplat; ≥ 25 cmH2O) was considered the most important criteria for ECCO2R initiation. Key treatment targets for patients with ARDS undergoing ECCO2R included pH (> 7.30), respiratory rate (< 25 or < 20 breaths/min), driving pressure (< 14 cmH2O) and Pplat (< 25 cmH2O). In ae-COPD, there was consensus that, in patients at risk of non-invasive ventilation (NIV) failure, no decrease in PaCO2 and no decrease in respiratory rate were key criteria for initiating ECCO2R therapy. Key treatment targets in ae-COPD were patient comfort, pH (> 7.30-7.35), respiratory rate (< 20-25 breaths/min), decrease of PaCO2 (by 10-20%), weaning from NIV, decrease in HCO3- and maintaining haemodynamic stability. Consensus was reached on weaning protocols for both indications. Anticoagulation with intravenous unfractionated heparin was the strategy preferred by the group. CONCLUSIONS: Insights from this group of experienced physicians suggest that ECCO2R therapy may be an effective supportive treatment for adults with ARDS or ae-COPD. Further evidence from randomised clinical trials and/or high-quality prospective studies is needed to better guide decision making.

[Diagnostics of posttraumatic stress disorder according to DSM-5 and ICD-11]. / Diagnostik der PTBS im Spannungsfeld von DSM-5 und ICD-11.

BACKGROUND: The Diagnostic and Statistical Manual of Mental Disorders (DSM-5) and the International Statistical Classification of Diseases and Related Health Problems (ICD-11, Version 2018) differ with respect to the diagnostic criteria of posttraumatic stress disorder (PTSD). The present study investigated the implications of these differences for the classification of PTSD within a sample of German survivors of various traumatic events. PATIENTS AND METHODS: A total of 341 trauma survivors who participated in a multicenter study were classified according to DSM-5 and ICD-11 and the results were compared. The PTSD checklist for DSM-5 (PCL-5) was used to diagnose PTSD. The ICD-11 PTSD cases were identified using a "restrictive" and a "wide" operationalization of re-experiencing symptoms (i. e. with and without intrusive memories). Depression and the level of trauma-related impairment were also assessed. RESULTS: The diagnosis rate using ICD-11 was significantly lower than under DSM-5 (DSM-5 64.5%, ICD-11 54.0%, p < 0.001) using a restrictive operationalization of re-experiencing symptoms but differences disappeared when using a wide operationalization. Rates of comorbidity with depression were reduced under ICD-11. Individuals with high and low levels of trauma-related impairment were equally likely to receive a PTSD diagnosis under ICD-11. DISCUSSION: Differences in the diagnosis rates between ICD-11 and DSM-5 depend on the operationalization of the specific ICD-11 re-experiencing requirements. Precise diagnostic guidelines are necessary to avoid inconsistent diagnoses.

The German version of the Posttraumatic Stress Disorder Checklist for DSM-5 (PCL-5): psychometric properties and diagnostic utility.

BACKGROUND: The Posttraumatic Stress Disorder (PTSD) Checklist (PCL, now PCL-5) has recently been revised to reflect the new diagnostic criteria of the disorder. METHODS: A clinical sample of trauma-exposed individuals (N = 352) was assessed with the Clinician Administered PTSD Scale for DSM-5 (CAPS-5) and the PCL-5. Internal consistencies and test-retest reliability were computed. To investigate diagnostic accuracy, we calculated receiver operating curves. Confirmatory factor analyses (CFA) were performed to analyze the structural validity. RESULTS: Results showed high internal consistency (α = .95), high test-retest reliability (r = .91) and a high correlation with the total severity score of the CAPS-5, r = .77. In addition, the recommended cutoff of 33 on the PCL-5 showed high diagnostic accuracy when compared to the diagnosis established by the CAPS-5. CFAs comparing the DSM-5 model with alternative models (the three-factor solution, the dysphoria, anhedonia, externalizing behavior and hybrid model) to account for the structural validity of the PCL-5 remained inconclusive. CONCLUSIONS: Overall, the findings show that the German PCL-5 is a reliable instrument with good diagnostic accuracy. However, more research evaluating the underlying factor structure is needed.

Clinical significance and risk factors for new onset and recurring atrial fibrillation following cardiac surgery - a retrospective data analysis.

BACKGROUND: Although mortality after cardiac surgery has significantly decreased in the last decade, patients still experience clinically relevant postoperative complications. Among others, atrial fibrillation (AF) is a common consequence of cardiac surgery, which is associated with prolonged hospitalization and increased mortality. METHODS: We retrospectively analyzed data from patients who underwent coronary artery bypass grafting, valve surgery or a combination of both at the University Hospital Muenster between April 2014 and July 2015. We evaluated the incidence of new onset and intermittent/permanent AF (patients with pre- and postoperative AF). Furthermore, we investigated the impact of postoperative AF on clinical outcomes and evaluated potential risk factors. RESULTS: In total, 999 patients were included in the analysis. New onset AF occurred in 24.9% of the patients and the incidence of intermittent/permanent AF was 59.5%. Both types of postoperative AF were associated with prolonged ICU length of stay (median increase approx. 2 days) and duration of mechanical ventilation (median increase 1 h). Additionally, new onset AF patients had a higher rate of dialysis and hospital mortality and more positive fluid balance on the day of surgery and postoperative days 1 and 2. In a multiple logistic regression model, advanced age (odds ratio (OR) = 1.448 per decade increase, p < 0.0001), a combination of CABG and valve surgery (OR = 1.711, p = 0.047), higher C-reactive protein (OR = 1.06 per unit increase, p < 0.0001) and creatinine plasma concentration (OR = 1.287 per unit increase, p = 0.032) significantly predicted new onset AF. Higher Horowitz index values were associated with a reduced risk (OR = 0.996 per unit increase, p = 0.012). In a separate model, higher plasma creatinine concentration (OR = 2.125 per unit increase, p = 0.022) was a significant risk factor for intermittent/permanent AF whereas higher plasma phosphate concentration (OR = 0.522 per unit increase, p = 0.003) indicated reduced occurrence of this arrhythmia. CONCLUSIONS: New onset and intermittent/permanent AF are associated with adverse clinical outcomes of elective cardiac surgery patients. Different risk factors implicated in postoperative AF suggest different mechanisms might be involved in its pathogenesis. Customized clinical management protocols seem to be warranted for a higher success rate of prevention and treatment of postoperative AF.

Feasibility, efficacy, and safety of ultrasound-guided axillary plexus blockade in pediatric patients with epidermolysis bullosa dystrophica.

BACKGROUND: In patients suffering from epidermolysis bullosa dystrophica (DEB), the most severe form of epidermolysis bullosa, trauma or friction cause separation of the skin from underlying tissue with consecutive painful blisters, scarifications, contractures, and pseudosyndactyly. To retain functionality of the hands surgical procedures are necessary. Anesthesia is challenging as difficult airways make general anesthesia risky. Regional anesthesia is considered controversial in patients with EB as accidental subcutaneous injections can cause severe blisters. As ultrasound-guided procedures became standard of care this might have changed however. AIM: In this case series, we describe feasibility, efficacy, and safety of ultrasound-guided plexus axillaris block in DEB patients undergoing hand surgery. METHOD: We performed a retrospective analysis of the charts of all children with DEB undergoing hand surgery under plexus axillaris block and sedation between 2009 and 2013 in our institution. RESULTS: Nineteen procedures in nine children were performed. Induction of anesthesia (securing monitoring, sedation, plexus block) took a mean time of 34 min. Perioperative analgesia was adequate in all procedures. No complications such as airway incidents, conversion to general anesthesia, movement during surgery, incomplete block, or formation of new blisters were seen. CONCLUSION: Ultrasound-guided plexus axillaris block in DEB patients undergoing hand surgery in our institution has been feasible, effective, and safe.

Does general anesthesia have a clinical impact on intraocular pressure in children?

BACKGROUND: Reliable measurement of intraocular pressure (IOP) is crucial in pediatric patients with suspected glaucoma. General anesthesia (GA) is usually needed in infants to allow a thorough examination. However, anesthesia itself may influence IOP, depending on the type used and the depth of sedation. The purpose of this study was to evaluate the normal distribution of IOP during GA in healthy children and to analyze differences in IOP relative to the anesthetics used and the measurement time point. METHODS: Approval for this observational study was received from the local institutional review boards and written informed consent was obtained from the children's parents. A total of 100 pediatric patients with no history of glaucoma scheduled for nonintraocular surgery underwent general anesthesia, induced with sevoflurane (s) or propofol (p) and maintained with either sevoflurane with remifentanil (S) or propofol with remifentanil (P). The patients were grouped to one of four subgroups (sS, sP, pP, pS) depending on the anesthetics used during induction and maintenance. Hemodynamic parameters and IOP were measured in both eyes at four defined time points: before anesthesia induction (M1); in apnea immediately after induction and before insertion of a laryngeal mask airway (M2); in deep anesthesia during mechanical ventilation (M3); and after extubation (M4), using a handheld Perkins applanation tonometer. Differences in IOP in both eyes during the measurement periods were analyzed using multivariate repeated-measures analysis of variance and Tukey-HSD as a posthoc test with statistical significance set at P < 0.05. Pearson correlation coefficient was used to investigate further relationships between heart rate, systolic blood pressure, and IOP. RESULTS: General anesthesia reduced IOP significantly. The mean IOP was normally distributed, with a mean of 7.4 ± 2.89 mmHg at M1. It decreased significantly to a minimum of 5.6 ± 3.04 mmHg (P < 0.01) at M2 and increased significantly to 7.2 ± 2.51 mmHg (P < 0.01) at M3 and again to 8.4 ± 3.72 mmHg (P = 0.03) at M4. All four subgroups (sS, sP, pP, pS) showed comparable decreases in IOP between M1 and M2. During deep anesthesia (M3) and during reversal (M4), the IOP increased again in all groups. During reversal (M4), however, the sS group had a significantly lower IOP than the pP group (P = 0.001) and sP group (P = 0.02). There were no correlations between changes in IOP and gender, age, or type of surgery. CONCLUSIONS: Sevoflurane and propofol, both in combination with remifentanil, significantly lower IOP in children. Individual IOP levels rise and fall during anesthesia, depending on the time point of measurement. The lowest IOP can be measured immediately after induction of anesthesia. This needs to be taken into account when measuring IOP in children.

A two-step multidisciplinary approach to treat recurrent esophageal strictures in children with epidermolysis bullosa dystrophica.

In children with severe generalized recessive dystrophic epidermolysis bullosa (RDEB), esophageal scarring leads to esophageal strictures with dysphagia, followed by malnutrition and delayed development. We describe a two-step multidisciplinary therapeutic approach to overcome malnutrition and growth retardation. In Step 1, under general anesthesia, orthograde balloon dilation of the esophagus is followed by gastrostomy creation using a direct puncture technique. In Step 2, further esophageal strictures are treated by retrograde dilation via the established gastrostomy; this step requires only a short sedation period. A total of 12 patients (median age 7.8 years, range 6 weeks to 17 years) underwent successful orthograde balloon dilation of esophageal strictures combined with direct puncture gastrostomy. After 12 and 24 months in 11 children, a substantial improvement of growth and nutrition was achieved (body mass index [BMI] standard deviation score [SDS] + 0.59 and + 0.61, respectively). In one child, gastrostomy was removed because of skin ulcerations after 10 days. Recurrent esophageal strictures were treated successfully in five children. The combined approach of balloon dilation and gastrostomy is technically safe in children with RDEB, and helps to promote catch-up growth and body weight. In addition, recurrent esophageal strictures can be treated successfully without general anesthesia in a retrograde manner via the established gastrostomy.

[Epidural analgesia in combination with general anesthesia]. / Epiduralanästhesie - Epiduralanästhesie in Kombination mit Allgemeinanästhesie.

Epidural anaesthesia is a widely used and accepted technique for perioperative analgesia in different kinds of surgery. Apart from analgetic effect and due to wide positve effects on patients outcome epidural analgesia is often used with general anaesthesia. It represents a reliable and reversible neural deafferentation technique that effectively contributes to a reduction of the surgical stress response with subsequent positive effects on cardiopulmonary, gastrointestinal, and immune function. Animal studies suggest that the use of epidural anaesthesia may be beneficial for cancer surgery because of less tumour recurrence. Further, a benefit is expected in patient's mortality. This article summarizes and critically discusses the current knowledge on the effects of epidural anaesthesia on pain management, cardiopulmonary as well as gastrointestinal functions and patient's outcome.

Repeated neurological complications during dialysis - a case for echo?

A 65-year old woman presented with acute or chronic renal failure and signs of right heart failure. Renal replacement therapy­using a surgically placed dialysis catheter via the left jugular vein­was repeatedly complicated by altered flows of the dialysis unit, impaired consciousness, new onset of seizures and left-sided hemiparesis. The tip of the dialysis catheter was detected on transesophageal echocardiography within the lumen of the ascending aorta. Further imaging of the neck vessels demonstrated a primary placement of the catheter in the left common carotid artery. This incident underscores the value of ultrasound guidance for placement of intravascular catheters.

Sudden gains in routine clinical care: application of a permutation test for trauma-focused cognitive behavioural therapy.

Background: Sudden gains, defined as large and stable improvements of psychopathological symptoms, are a ubiquitous phenomenon in psychotherapy. They have been shown to occur across several clinical contexts and to be associated with better short-term and long-term treatment outcome. However, the approach of sudden gains has been criticized for its tautological character: sudden gains are included in the computation of treatment outcomes, ultimately resulting in a circular conclusion. Furthermore, some authors criticize sudden gains as merely being random fluctuations.Objective: Use of efficient methods to evaluate whether the amount of sudden gains in a given sample lies above chance level.Method: We used permutation tests in a sample of 85 patients with posttraumatic stress disorder (PTSD) treated with trauma-focused cognitive behaviour therapy in routine clinical care. Scores of self-reported PTSD symptom severity were permuted 10.000 times within sessions and between participants to receive a random distribution.Results: Altogether, 18 participants showed a total of 24 sudden gains within the first 20 sessions. The permutation test yielded that the frequency of sudden gains was not beyond chance level. No significant predictors of sudden gains were identified and sudden gains in general were not predictive of treatment outcome. However, subjects with early sudden gains had a significantly lower symptom severity after treatment.Conclusions: Our data suggest that a significant proportion of sudden gains are due to chance. Further research is needed on the differential effects of early and late sudden gains.

Treatment-related sudden gains exhibit clinical significance when their manifestation is above chance level.We used permutation tests to examine their occurrence in trauma-focused cognitive behaviour therapy as applied in a naturalistic treatment setting.The occurrence of sudden gains in general was not significantly higher than chance, yet early sudden gains were associated with improved treatment outcome.

Risk factors associated with vasospasm after non-traumatic subarachnoid hemorrhage: a retrospective analysis of 456 patients.

BACKGROUND: The pathophysiology of vasospasm (VS) after non-traumatic subarachnoid hemorrhage is not completely understood. Several risk factors associated with VS were previously reported, partially with conflicting results. The aim of this study was to identify patients at increased risk for VS. METHODS: Retrospective analysis of data from all patients treated in our institutional intensive care unit (ICU) between 2010 and 2016 after non-traumatic subarachnoid hemorrhage. Possible contributing factors for VS studied were: age, sex, aneurysm-localization, treatment option, ICU-stay, ICU mortality, pre-existing condition, medication history, World Federation of Neurosurgical Societies (WFNS) grading system, modified Fisher scale. RESULTS: We obtained data from 456 patients. 184 were male and 272 female patients, respectively. Mean age was 57.7±13.9 and was not different between sexes. In 119 patients, VS was diagnosed after subarachnoid hemorrhage. Incidence of VS was not different between sexes (male: 22.3%, female: 28.7%, P=0.127). Patients with VS were significantly younger (mean age 52.2 vs. 59.7, P<0.001), meanwhile patients aged 36-40 yrs. had the highest incidence of VS. Most VS were found after rupture of middle cerebral artery-aneurysms. Higher incidence of VS was found after aneurysm clipping compared to coiling. VS developed more often in patients with more severe WFNS grade and Fisher scale. In multivariate analysis, age, previous drug abuse and history of anticoagulants were associated with the incidence of VS. CONCLUSIONS: Younger age, middle cerebral artery-aneurysms, aneurysm clipping, previous drug abuse and history of anticoagulants were associated with a higher incidence of VS after non-traumatic subarachnoid hemorrhage. No gender difference was found.

Do changes in dysfunctional posttraumatic cognitions differentially predict PTSD symptom clusters?

OBJECTIVE: In recent years, it has been suggested that the modification of dysfunctional posttraumatic cognitions plays a central role as a mechanism of change in cognitive behavioral therapy (CBT) for posttraumatic stress disorder (PTSD). Indeed, several studies have shown that changes in dysfunctional posttraumatic cognitions precede and predict symptom change. However, these studies have investigated the influence on overall symptom severity-despite the well-known multidimensionality of PTSD. The present study therefore aimed to explore differential associations between change in dysfunctional conditions and change in PTSD symptom clusters. METHOD: As part of a naturalistic effectiveness study evaluating trauma-focused cognitive behavioral therapy for PTSD in routine clinical care, 61 patients with PTSD filled out measures of dysfunctional posttraumatic cognitions and PTSD symptom severity every five sessions during the course of treatment. Lagged associations between dysfunctional cognitions and symptom severity at the following timepoint were examined using linear mixed models. RESULTS: Over the course of therapy, both dysfunctional cognitions and PTSD symptoms decreased. Posttraumatic cognitions predicted subsequent total PTSD symptom severity, although this effect was at least partly explained by the time factor. Moreover, dysfunctional cognitions predicted three out of four symptom clusters as expected. However, these effects were no longer statistically significant when the general effect for time was controlled for. CONCLUSION: The present study provides preliminary evidence that dysfunctional posttraumatic cognitions predict PTSD symptom clusters differentially. However, different findings when employing a traditional versus a more rigorous statistical approach make interpretation of findings difficult. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Development and validation of an interpretable 3 day intensive care unit readmission prediction model using explainable boosting machines.

Background: Intensive care unit (ICU) readmissions are associated with mortality and poor outcomes. To improve discharge decisions, machine learning (ML) could help to identify patients at risk of ICU readmission. However, as many models are black boxes, dangerous properties may remain unnoticed. Widely used post hoc explanation methods also have inherent limitations. Few studies are evaluating inherently interpretable ML models for health care and involve clinicians in inspecting the trained model. Methods: An inherently interpretable model for the prediction of 3 day ICU readmission was developed. We used explainable boosting machines that learn modular risk functions and which have already been shown to be suitable for the health care domain. We created a retrospective cohort of 15,589 ICU stays and 169 variables collected between 2006 and 2019 from the University Hospital Münster. A team of physicians inspected the model, checked the plausibility of each risk function, and removed problematic ones. We collected qualitative feedback during this process and analyzed the reasons for removing risk functions. The performance of the final explainable boosting machine was compared with a validated clinical score and three commonly used ML models. External validation was performed on the widely used Medical Information Mart for Intensive Care version IV database. Results: The developed explainable boosting machine used 67 features and showed an area under the precision-recall curve of 0.119 ± 0.020 and an area under the receiver operating characteristic curve of 0.680 ± 0.025. It performed on par with state-of-the-art gradient boosting machines (0.123 ± 0.016, 0.665 ± 0.036) and outperformed the Simplified Acute Physiology Score II (0.084 ± 0.025, 0.607 ± 0.019), logistic regression (0.092 ± 0.026, 0.587 ± 0.016), and recurrent neural networks (0.095 ± 0.008, 0.594 ± 0.027). External validation confirmed that explainable boosting machines (0.221 ± 0.023, 0.760 ± 0.010) performed similarly to gradient boosting machines (0.232 ± 0.029, 0.772 ± 0.018). Evaluation of the model inspection showed that explainable boosting machines can be useful to detect and remove problematic risk functions. Conclusions: We developed an inherently interpretable ML model for 3 day ICU readmission prediction that reached the state-of-the-art performance of black box models. Our results suggest that for low- to medium-dimensional datasets that are common in health care, it is feasible to develop ML models that allow a high level of human control without sacrificing performance.

The dissociative subtype of PTSD in trauma-exposed individuals: a latent class analysis and examination of clinical covariates.

Background: A dissociative subtype of posttraumatic stress disorder (D-PTSD) was introduced into the 5th edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) but latent profiles and clinical correlates of D-PTSD remain controversial. Objective: The aims of our study were to identify subgroups of individuals with distinct patterns of PTSD symptoms, including dissociative symptoms, by means of latent class analyses (LCA), to compare these results with the categorization of D-PTSD vs. PTSD without dissociative features according to the CAPS-5 interview, and to explore whether D-PTSD is associated with higher PTSD severity, difficulties in emotion regulation, and depressive symptoms. Method: A German sample of treatment-seeking individuals was investigated (N = 352). We conducted an LCA on the basis of symptoms of PTSD and dissociation as assessed by the CAPS-5. Moreover, severity of PTSD (PCL-5), difficulties in emotion regulation (DERS), and depressive symptoms (BDI-II) were compared between patients with D-PTSD according to the CAPS-5 interview and patients without dissociative symptoms. Results: LCA results suggested a 5-class model with one subgroup showing the highest probability to fulfill criteria for the dissociative subtype and high scores on both BDI and DERS. Significantly higher scores on the DERS, BDI and PCL-5 were found in the D-PTSD group diagnosed with the CAPS-5 (n = 75; 35.7%). Sexual trauma was also reported more often by this subgroup. When comparing the dissociative subtype to the LCA results, only a partial overlap could be found. Conclusions: Our findings suggest that patients with D-PTSD have significantly more problems with emotion regulation, more depressive symptoms, and more severe PTSD-symptoms. Given the results of our LCA, we conclude that the dissociative subtype seems to be more complex than D-PTSD as diagnosed by means of the CAPS-5.

Antecedentes: Un subtipo disociativo del trastorno de estrés postraumático (TEPT-D) fue introducido en la 5ª edición del Manual Diagnóstico y Estadístico de los Trastornos Mentales (DSM-5), pero los perfiles latentes y los correlatos clínicos del TEPT-D siguen siendo controversiales. Objetivo Los objetivos de nuestro estudio fueron identificar subgrupos de individuos con distintos patrones de síntomas de TEPT, incluyendo síntomas disociativos, mediante análisis de clases latentes (LCA, por sus siglas en inglés), comparar estos resultados con la categorización de TEPT-D vs. TEPT sin rasgos disociativos según la entrevista CAPS-5, y explorar si el TEPT-D se asocia con una mayor gravedad del TEPT, dificultades en la regulación de las emociones y síntomas depresivos.Método: Se investigó una muestra alemana de individuos que buscaban tratamiento (N = 352). Se realizó un LCA sobre la base de los síntomas de TEPT y disociación evaluados por el CAPS-5. Además, se comparó la gravedad del TEPT (PCL-5), las dificultades en la regulación de las emociones (DERS) y los síntomas depresivos (BDI-II) entre los pacientes con TEPT según la entrevista CAPS-5 y los pacientes sin síntomas disociativos.Resultados: Los resultados del LCA sugirieron un modelo de 5 clases con un subgrupo que mostraba la mayor probabilidad de cumplir los criterios del subtipo disociativo y altas puntuaciones tanto en el BDI como en el DERS. Se encontraron puntuaciones significativamente más altas en el DERS, el BDI y el PCL-5 en el grupo de TEPT-D diagnosticado con el CAPS-5 (n = 75; 35,7%). Este subgrupo también informó con más frecuencia de traumas sexuales. Al comparar el subtipo disociativo con los resultados del LCA, sólo se pudo encontrar una superposición parcial. Conclusiones Nuestros resultados sugieren que los pacientes con TEPT-D tienen significativamente más problemas con la regulación emocional, más síntomas depresivos y síntomas de TEPT más graves. Dados los resultados de nuestro LCA, concluimos que el subtipo disociativo parece ser más complejo que el TEPT-D diagnosticado mediante el CAPS-5.

Mechanisms of Change in Trauma-Focused Treatment for PTSD: The Role of Rumination.

OBJECTIVE: Cognitive behavioral therapy (CBT) has been well established in the treatment of posttraumatic stress disorder (PTSD). In recent years, researchers have begun to investigate its underlying mechanisms of change. Dysfunctional cognitive content, i.e. excessively negative appraisals of the trauma or its consequences, has been shown to predict changes in PTSD symptoms over the course of treatment. However, the role of change in cognitive processes, such as trauma-related rumination, needs to be addressed. The present study investigates whether changes in rumination intensity precede and predict changes in symptom severity. We also explored the extent to which symptom severity predicts rumination. METHOD: As part of a naturalistic effectiveness study evaluating CBT for PTSD in routine clinical care, eighty-eight patients with PTSD completed weekly measures of rumination and symptom severity. Lagged associations between rumination and symptoms in the following week were examined using linear mixed models. RESULTS: Over the course of therapy, both ruminative thinking and PTSD symptoms decreased. Rumination was a significant predictor of PTSD symptoms in the following week, although this effect was at least partly explained by the time factor (e.g., natural recovery or inseparable treatment effects). Symptom severity predicted ruminative thinking in the following week even with time as an additional predictor. CONCLUSIONS: The present study provides preliminary evidence that rumination in PTSD is reduced by CBT for PTSD but does not give conclusive evidence that rumination is a mechanism of change in trauma-focused treatment for PTSD.

Confirmatory factor analysis of the Clinician-Administered PTSD Scale (CAPS-5) based on DSM-5 vs. ICD-11 criteria.

Introduction: Many studies have investigated the latent structure of the DSM-5 criteria for posttraumatic stress disorder (PTSD). However, most research on this topic was based on self-report data. We aimed to investigate the latent structure of PTSD based on a clinical interview, the Clinician-Administered PTSD Scale (CAPS-5). Method: A clinical sample of 345 participants took part in this multi-centre study. Participants were assessed with the CAPS-5 and the Posttraumatic Stress Disorder Checklist (PCL-5). We evaluated eight competing models of DSM-5 PTSD symptoms and three competing models of ICD-11 PTSD symptoms. Results: The internal consistency of the CAPS-5 was replicated. In CFAs, the Anhedonia model emerged as the best fitting model within all tested DSM-5 models. However, when compared with the Anhedonia model, the non-nested ICD-11 model as a less complex three-factor solution showed better model fit indices. Discussion: We discuss the findings in the context of earlier empirical findings as well as theoretical models of PTSD.

Introducción: Muchos estudios han investigado la estructura latente de los criterios DSM-5 para el trastorno de estrés postraumático (TEPT). Sin embargo, la mayoría de la investigación en este tema estuvo basada en datos de auto-reporte. Nuestro objetivo fue investigar la estructura latente del TEPT basado en una entrevista clínica, la Escala de TEPT administrada por el Clínico (CAPS-5 por su sigla en inglés).Método: En este estudio multicéntrico participó una muestra clínica de 345 personas. Los participantes fueron evaluados con la CAPS-5 y la Lista de Chequeo de Trastorno de Estrés Postraumático (PCL-5, por su sigla en inglés). Evaluamos ocho modelos competitivos de síntomas de TEPT del DSM-5 y tres modelos competitivos de síntomas de TEPT de la CIE-11.Resultados: La consistencia interna de la CAPS-5 fue replicada. En los AFC el modelo de anhedonia emergió como el de mejor ajuste entre todos los modelos del DSM-5 evaluados. Sin embargo, cuando se comparó con el modelo de anhedonia, el modelo no anidado de CIE-11 como una solución menos compleja de tres factores mostró mejores índices de ajuste de modelo.Discusión: Discutimos los hallazgos en el contexto de los resultados empíricos previos y de los modelos teóricos del TEPT.

Comparing PTSD symptom networks in type I vs. type II trauma survivors.

Background: Network analysis has gained increasing attention as a new framework to study complex associations between symptoms of post-traumatic stress disorder (PTSD). A number of studies have been published to investigate symptom networks on different sets of symptoms in different populations, and the findings have been inconsistent. Objective: We aimed to extend previous research by testing whether differences in PTSD symptom networks can be found in survivors of type I (single event; sudden and unexpected, high levels of acute threat) vs. type II (repeated and/or protracted; anticipated) trauma (with regard to their index trauma). Method: Participants were trauma-exposed individuals with elevated levels of PTSD symptomatology, most of whom (94%) were undergoing assessment in preparation for PTSD treatment in several treatment centres in Germany and Switzerland (n = 286 with type I and n = 187 with type II trauma). We estimated Bayesian Gaussian graphical models for each trauma group and explored group differences in the symptom network. Results: First, for both trauma types, our analyses identified the edges that were repeatedly reported in previous network studies. Second, there was decisive evidence that the two networks were generated from different multivariate normal distributions, i.e. the networks differed on a global level. Third, explorative edge-wise comparisons showed moderate or strong evidence for specific 12 edges. Edges which emerged as especially important in distinguishing the networks were between intrusions and flashbacks, highlighting the stronger positive association in the group of type II trauma survivors compared to type I survivors. Flashbacks showed a similar pattern of results in the associations with detachment and sleep problems (type II > type I). Conclusion: Our findings suggest that trauma type contributes to the heterogeneity in the symptom network. Future research on PTSD symptom networks should include this variable in the analyses to reduce heterogeneity.

Antecedentes: El análisis de redes ha ganado cada vez más atención como un nuevo marco para estudiar asociaciones complejas entre síntomas del Trastorno de Estrés Postraumático (TEPT). Se han publicado una cantidad de estudios para investigar las redes de síntomas en diferentes conjuntos de síntomas en distintas poblaciones, y los hallazgos han sido inconsistentes.Objetivos: Nuestro objetivo fue ampliar la investigación previa probando si se pueden encontrar diferencias entre las redes de síntomas del TEPT en sobrevivientes de trauma de tipo 1 (evento único; súbito e inesperado, niveles elevados de amenaza aguda) versus los de tipo 2 (eventos repetidos y/o prolongados; anticipados) (con respecto a su trauma índice).Métodos: Los participantes eran individuos expuestos al trauma con niveles elevados de sintomatología de TEPT, la mayoría de los cuales (94%) se sometían a una evaluación en preparación para el tratamiento del TEPT en varios centros de Alemania y Suiza (n = 286 con tipo 1 y n = 187 con tipo 2 de trauma). Estimamos modelos gráficos Bayesianos Gaussianos para cada tipo de grupo de trauma y exploramos las diferencias entre los grupos en la red de síntomas.Resultados: En primer lugar, para ambos tipos de trauma, nuestros análisis identificaron los bordes que se reportaron repetidamente en estudios de redes anteriores. En segundo lugar, hubo evidencia decisiva que las dos redes fueron generadas de diferentes distribuciones normales multivariadas, es decir, las redes diferían a nivel global. En tercer lugar, las comparaciones exploratorias de los bordes mostraron una evidencia de moderada a fuerte para 12 bordes específicos. Los bordes que surgieron como especialmente importantes para distinguir las redes fueron las intrusiones y flashbacks, destacando la asociación fuertemente positiva entre los grupos de tipo 2 en comparación con los sobrevivientes de trauma del grupo de tipo 1. Los flashbacks mostraron un patrón similar de resultados en las asociaciones con desapego y problemas de sueño (tipo 2 > tipo 1).Conclusiones: Nuestros resultados sugieren que el tipo de trauma contribuye a la heterogeneidad en los síntomas de red. La investigación futura sobre las redes de los síntomas de TEPT debería incluir esta variable en los análisis para reducir la heterogeneidad.