Time-dependent complexity characterisation of activity patterns in patients with Chronic Fatigue Syndrome.

BACKGROUND: Chronic Fatigue Syndrome patients suffer from symptoms that cannot be explained by a single underlying biological cause. It is sometimes claimed that these symptoms are a manifestation of a disrupted autonomic nervous system. Prior works studying this claim from the complex adaptive systems perspective, have observed a lower average complexity of physical activity patterns in chronic fatigue syndrome patients compared to healthy controls. To further study the robustness of such methods, we investigate the within-patient changes in complexity of activity over time. Furthermore, we explore how these changes might be related to changes in patient functioning. METHODS: We propose an extension of the allometric aggregation method, which characterises the complexity of a physiological signal by quantifying the evolution of its fractal dimension. We use it to investigate the temporal variations in within-patient complexity. To this end, physical activity patterns of 7 patients diagnosed with chronic fatigue syndrome were recorded over a period of 3 weeks. These recordings are accompanied by physicians' judgements in terms of the patients' weekly functioning. RESULTS: We report significant within-patient variations in complexity over time. The obtained metrics are shown to depend on the range of timescales for which these are evaluated. We were unable to establish a consistent link between complexity and functioning on a week-by-week basis for the majority of the patients. CONCLUSIONS: The considerable within-patient variations of the fractal dimension across scales and time force us to question the utility of previous studies that characterise long-term activity signals using a single static complexity metric. The complexity of a Chronic Fatigue Syndrome patient's physical activity signal does not suffice to characterise their high-level functioning over time and has limited potential as an objective monitoring metric by itself.

Epidemiology and risk factors for mortality in critically ill patients with pancreatic infection.

Background: The AbSeS-classification defines specific phenotypes of patients with intra-abdominal infection based on the (1) setting of infection onset (community-acquired, early onset, or late-onset hospital-acquired), (2) presence or absence of either localized or diffuse peritonitis, and (3) severity of disease expression (infection, sepsis, or septic shock). This classification system demonstrated reliable risk stratification in intensive care unit (ICU) patients with intra-abdominal infection. This study aimed to describe the epidemiology of ICU patients with pancreatic infection and assess the relationship between the components of the AbSeS-classification and mortality. Methods: This was a secondary analysis of an international observational study ("AbSeS") investigating ICU patients with intra-abdominal infection. Only patients with pancreatic infection were included in this analysis (n=165). Mortality was defined as ICU mortality within 28 days of observation for patients discharged earlier from the ICU. Relationships with mortality were assessed using logistic regression analysis and reported as odds ratio (OR) and 95% confidence interval (CI). Results: The overall mortality was 35.2% (n=58). The independent risk factors for mortality included older age (OR=1.03, 95% CI: 1.0 to 1.1 P=0.023), localized peritonitis (OR=4.4, 95% CI: 1.4 to 13.9 P=0.011), and persistent signs of inflammation at day 7 (OR=9.5, 95% CI: 3.8 to 23.9, P<0.001) or after the implementation of additional source control interventions within the first week (OR=4.0, 95% CI: 1.3 to 12.2, P=0.013). Gram-negative bacteria were most frequently isolated (n=58, 49.2%) without clinically relevant differences in microbial etiology between survivors and non-survivors. Conclusions: In pancreatic infection, a challenging source/damage control and ongoing pancreatic inflammation appear to be the strongest contributors to an unfavorable short-term outcome. In this limited series, essentials of the AbSeS-classification, such as the setting of infection onset, diffuse peritonitis, and severity of disease expression, were not associated with an increased mortality risk.ClinicalTrials.gov number: NCT03270345.

Is the insomnia phenotype the common denominator in LUTS during transition periods? An expert NOPIA research group review.

AIMS: As people age, sleep stages and characteristics transition over time, but sleep deficits can profoundly impact health and cognitive functioning. Chronic sleep deprivation is linked to impaired attention and productivity, weakened immunity, increased risk of cardiovascular disease, obesity, and mental health disorders. Insomnia, obstructive sleep apnea syndrome, hormonal changes, nocturia, neurological disorders, and life events interfere with sleep patterns and some are linked to lower urinary tract symptoms (LUTS). This NOPIA symposium on Lifelong LUTS aimed to analyze the literature on associations between sleep and LUTS, generate ideas for future research, and explore whether there is support for the concept of lifelong LUTS in relation to changes in sleep throughout the lifespan. METHODS: An international panel of experts took part in an online meeting addressing the role of lifelong LUTS in relationship to sleep and the brain organized by the NOPIA research group. The manuscript summarizes existing literature, hypotheses, future research ideas, and clinical recommendations. RESULTS: Insomnia, sleep fragmentation, hyperarousal, and sensory processing disorders emerged as potential factors in the relationship between sleep and LUTS. Insomnia is often a persistent factor and may have been the initial symptom; however, it is often unrecognized and/or unaddressed in healthcare settings. By recognizing insomnia as a primary driver of various health issues, including nocturia, transitional care aims to address root causes and underlying problems earlier to initiate appropriate treatment. CONCLUSIONS: A multidisciplinary approach with collaboration between healthcare professionals from various disciplines, such as urology, sleep medicine, gynecology, pediatrics, and geriatrics, is needed and should include validated measurements such as the insomnia severity index and sleep and voiding diaries. Ensuring ongoing follow-up and monitoring through transitional care is crucial for individuals with persistent sleep problems and LUTS, allowing issues that arise or fluctuate over the lifespan to be addressed.

Retrospective evaluation of an intervention bundle on OPAT implementation in a large non-university hospital.

OBJECTIVES: Optimization of outpatient parenteral antimicrobial therapy (OPAT) requires interdisciplinarity and an operational algorithm. This report retrospectively assesses the impact of a multimodal quality-enhancement intervention bundle on the implementation rate, efficacy, and safety of a home OPAT program in a Belgian large community-based hospital. METHODS: OPAT recipients between 1 March 2019 and 30 June 2022 were included. The OPAT trajectories were divided into pre-intervention (from 1 March 2019 to 31 October 2020) and post-intervention (from 1 November 2020 to 30 June 2022) groups. The quality-enhancement intervention bundle consisted of the involvement of an infectious disease specialist, revision and implementation of a state-of-the-art prosthetic joint infection diagnosis and treatment protocol, weekly multidisciplinary discussion of all prosthetic joint infections, revision of the OPAT algorithm, and the introduction of teicoplanin as an OPAT-convenient antimicrobial. RESULTS: Eighty-five patients were included in a total of 96 OPAT trajectories (n = 33 pre-intervention; n = 63 post-intervention). After the intervention, the number of OPAT trajectories nearly doubled. The number of patients with a recurrent infection within 6 months after OPAT completion decreased 15%. The overall 6-month mortality and readmission rates during OPAT treatment decreased 8% and 10%, respectively. Mortality during OPAT treatment did not change. These differences between pre- and post-intervention did not achieve statistical significance, despite the higher risk for complications in the post-intervention group because of increased infection complexity and required treatment duration. CONCLUSION: Within a Belgian, single, large community-based hospital, a multimodal intervention bundle resulted in increases in OPAT implementation, infection complexity, and required treatment durations without statistically significant differences in outcomes.

Screening for multidrug-resistant organisms in high-risk hospitalized patients with hematologic diseases.

OBJECTIVES: Patients treated for hematologic malignancies are at higher risk for blood stream infections (BSI) and multidrug-resistant organisms (MDRO) are increasingly involved. Studies showed a significant association between rectal colonization status and a higher risk of subsequent MDRO BSI. The objective of our study was to probe the practice of surveillance cultures in Belgian hematology centers. METHODS: A questionnaire was sent to the 13 hematology centers participating in the acute leukemia board of the Belgian Hematology Society. 21 questions probed for the method of surveillance cultures, MDRO screened, antimicrobial prophylaxis, and empirical therapy and their relationship with colonization status. RESULTS: All centers completed the questionnaire in full. Routine gastrointestinal surveillance cultures in hematologic patients are taken in 10 hospitals. Organisms tested for included mostly ESBL (n = 9) and carbapenem-resistant (n = 8) Enterobacterales. All centers with a screening strategy adapt empiric antibiotic therapy based on MDRO colonization. Prophylaxis strategies are variable, only two centers adapt prophylaxis upon documentation of fluoroquinolone resistance. CONCLUSIONS: The majority of the Belgian centers perform routine surveillance cultures and adapt empiric therapy for neutropenic fever accordingly. Other reasons for testing include to gain insight into local epidemiology and to prevent in-hospital transmission. In general, there was significant variability in surveillance dimensions.

From nocturnal awakenings to nocturnal voiding: the relationship between insomnia and nocturia - a systematic review.

INTRODUCTION: The aim of this study was to systematically evaluate relevant literature regarding 1) the prevalence of nocturia in patients with insomnia; 2) sleep characteristics of insomniacs with and without nocturia; 3) interventions for the treatment of insomnia and their effect on nocturia. EVIDENCE ACQUISITION: A systematic review of literature was performed through EMBASE, MEDLINE, CLINICALTRIALS.GOV and CENTRAL databases up until November 2022 according to the Preferred Reporting Items for Systematic Review and Meta-analysis (PRISMA) statement. From the identified reports, 11 studies were retained, of which 7 were eligible for meta-analysis. Bias assessment was performed using the ROBINS tools as per the Cochrane collaboration guidelines. EVIDENCE SYNTHESIS: A total of 5396 older adults were included in the meta-analysis. The pooled estimate of the OR was 1.958 (95% CI: 1.609-2.384) for nocturia in patients with insomnia based on 7 studies in a random effects model with nonsignificant heterogeneity (I2=50.83%, P=0.06). Wake after sleep onset (WASO) was longer in people with insomnia and nocturia compared to those without and sleep efficiency (SE) declined. Interventions with melatonin, diet and behavioral therapy were beneficial on nocturia frequency in insomniacs. A limiting factor of our analysis was the scarcity of available data, potentially causing an important selection bias. CONCLUSIONS: The overall odds for nocturia in older adults is higher in patients with insomnia than those without and is associated with worse sleep outcomes. Interventions for treating insomnia such as melatonin, behavioral therapy and diet show beneficial results on nocturnal voiding frequency. We advocate for further research in which uniform definitions and questionnaires are used. Routine screening for nocturia in patients with insomnia could be beneficial to maximize sleep quality improvement.

Education on medically unexplained symptoms: a systematic review with a focus on cultural diversity and migrants.

BACKGROUND: Health care providers often struggle with the management of patients with medically unexplained symptoms (MUS), especially in case of a different ethnicity and/or cultural background. These challenges are insufficiently addressed in their training. OBJECTIVES: A systematic review on education in the field of MUS in a diverse context to improve MUS healthcare provider-patient interaction focused on intercultural communication. METHODS: Screening of PubMed, Web of Science, Cinahl and Cochrane Library on the keywords 'Medical unexplained (physical) symptoms (MUS)', 'Somatoform disorder', 'Functional syndrome', 'Diversity', 'Migrants', 'Ethnicity', 'Care models', 'Medical education', 'Communication skills', 'Health literacy'. RESULTS: MUS patients, especially with a different ethnic background, often feel not understood or neglected. Health care providers experience feelings of helplessness, which may provoke medical shopping and resource consumption. Attitudes and perceptions from undergraduate trainees to senior physicians tend to be negative, impacting on the quality of the patient/health care provider relationship and subsequently on health outcomes, patient satisfaction and therapeutic adherence. Current undergraduate, graduate and postgraduate education and training does not prepare health care providers for diagnosing and managing MUS patients in a diverse context. A continuum of training is necessary to achieve a long term and lasting change in attitudes towards these patients and trainers play a key role in this process. Hence, education should pay attention to MUS, requiring a specific competency profile and training, taken into account the variety in patients' cultural backgrounds. CONCLUSIONS: This systematic review identified significant gaps and shortcomings in education on MUS in a diverse context. These need to be addressed to improve outcomes.

Poor timing and failure of source control are risk factors for mortality in critically ill patients with secondary peritonitis.

PURPOSE: To describe data on epidemiology, microbiology, clinical characteristics and outcome of adult patients admitted in the intensive care unit (ICU) with secondary peritonitis, with special emphasis on antimicrobial therapy and source control. METHODS: Post hoc analysis of a multicenter observational study (Abdominal Sepsis Study, AbSeS) including 2621 adult ICU patients with intra-abdominal infection in 306 ICUs from 42 countries. Time-till-source control intervention was calculated as from time of diagnosis and classified into 'emergency' (< 2 h), 'urgent' (2-6 h), and 'delayed' (> 6 h). Relationships were assessed by logistic regression analysis and reported as odds ratios (OR) and 95% confidence interval (CI). RESULTS: The cohort included 1077 cases of microbiologically confirmed secondary peritonitis. Mortality was 29.7%. The rate of appropriate empiric therapy showed no difference between survivors and non-survivors (66.4% vs. 61.3%, p = 0.1). A stepwise increase in mortality was observed with increasing Sequential Organ Failure Assessment (SOFA) scores (19.6% for a value ≤ 4-55.4% for a value > 12, p < 0.001). The highest odds of death were associated with septic shock (OR 3.08 [1.42-7.00]), late-onset hospital-acquired peritonitis (OR 1.71 [1.16-2.52]) and failed source control evidenced by persistent inflammation at day 7 (OR 5.71 [3.99-8.18]). Compared with 'emergency' source control intervention (< 2 h of diagnosis), 'urgent' source control was the only modifiable covariate associated with lower odds of mortality (OR 0.50 [0.34-0.73]). CONCLUSION: 'Urgent' and successful source control was associated with improved odds of survival. Appropriateness of empirical antimicrobial treatment did not significantly affect survival suggesting that source control is more determinative for outcome.

Epidemiology and age-related mortality in critically ill patients with intra-abdominal infection or sepsis: an international cohort study.

OBJECTIVE: To describe epidemiology and age-related mortality in critically ill older adults with intra-abdominal infection. METHODS: A secondary analysis was undertaken of a prospective, multi-national, observational study (Abdominal Sepsis Study, ClinicalTrials.gov #NCT03270345) including patients with intra-abdominal infection from 309 intensive care units (ICUs) in 42 countries between January and December 2016. Mortality was considered as ICU mortality, with a minimum of 28 days of observation when patients were discharged earlier. Relationships with mortality were assessed by logistic regression analysis. RESULTS: The cohort included 2337 patients. Four age groups were defined: middle-aged patients [reference category; 40-59 years; n=659 (28.2%)], young-old patients [60-69 years; n=622 (26.6%)], middle-old patients [70-79 years; n=667 (28.5%)] and very old patients [≥80 years; n=389 (16.6%)]. Secondary peritonitis was the predominant infection (68.7%) and was equally prevalent across age groups. Mortality increased with age: 20.9% in middle-aged patients, 30.5% in young-old patients, 31.2% in middle-old patients, and 44.7% in very old patients (P<0.001). Compared with middle-aged patients, young-old age [odds ratio (OR) 1.62, 95% confidence interval (CI) 1.21-2.17], middle-old age (OR 1.80, 95% CI 1.35-2.41) and very old age (OR 3.69, 95% CI 2.66-5.12) were independently associated with mortality. Other independent risk factors for mortality included late-onset hospital-acquired intra-abdominal infection, diffuse peritonitis, sepsis/septic shock, source control failure, liver disease, congestive heart failure, diabetes and malnutrition. CONCLUSIONS: For ICU patients with intra-abdominal infection, age >60 years was associated with mortality; patients aged ≥80 years had the worst prognosis. Comorbidities and overall disease severity further compromised survival. As all of these factors are non-modifiable, it remains unclear how to improve outcomes.

Gram-negative central line-associated bloodstream infection incidence peak during the summer: a national seasonality cohort study.

Central line-associated bloodstream infections (CLABSI) cause increased morbidity, mortality, and hospital costs that are partially preventable. The phenomenon of seasonality among CLABSI rates has not been fully elucidated, but has implications for accurate surveillance and infection prevention trials. Longitudinal dynamic cohort of hospitals participating in hospital-wide and intensive care unit bloodstream infection surveillance for at least one full year over 2000 to 2014. Mixed-effects negative binomial regression analysis calculated the peak-to-low ratio between months as an adjusted CLABSI incidence rate ratio (IRR) with 95% confidence intervals (CI). Multivariate regression models examined the associations between CLABSI pathogens and ambient temperature and relative humidity. The study population included 104 hospital sites comprising 11,239 CLABSI. Regression analysis identified a hospital-wide increase in total CLABSI during July-August, with a higher gram-negative peak-to-low incidence rate ratio (IRR 2.52 [95% CI 1.92-3.30], p < 0.001) compared to gram-positive bacteria (IRR 1.29 [95% CI 1.11-1.48], p < 0.001). Subgroup analysis replicated this trend for CLABSI diagnosed in the intensive care unit. Only gram-negative CLABSI rates were associated with increased temperature (IRR + 30.3% per 5 °C increase [95% CI 17.3-43.6], p < 0.001) and humidity (IRR + 22.9% per 10% increase [95% CI 7.7-38.3), p < 0.001). The incidence and proportion of gram-negative CLABSI approximately doubled during the summer periods. Ambient temperature and humidity were associated with increases of hospital-acquired gram-negative infections. CLABSI surveillance, preventive intervention trials and epidemiological studies should consider seasonal variation and climatological factors when preparing study designs or interpreting their results.

Effects of cascade reporting of susceptibility profiles for Enterobacterales on broad-spectrum antibiotics use and resistance.

OBJECTIVE: To reduce the inappropriate use of broad-spectrum antibiotics in a 1000+ bed acute tertiary care hospital by the introduction of cascade antimicrobial susceptibility reporting for Enterobacterales. METHODS: Over a 1-year period, we selectively suppressed reporting of susceptibility to the broad-spectrum antibiotics piperacillin-tazobactam (TZP) and meropenem (MEM) for Enterobacterales strains susceptible to amoxicillin-clavulanic acid (AMC) and negative for extended-spectrum ß-lactamase (ESBL). We measured the effects on hospital-wide antibiotic consumption (defined daily doses/1000 admissions) and resistance of Escherichia coli and Klebsiella pneumoniae on two levels. First, we compared resistance and antibiotic use for the antibiotics impacted by the intervention (AMC, TZP and MEM) with control antibiotics that were consistently reported (fluoroquinolones, trimethoprim-sulfamethoxazole and third-generation cephalosporins). Second, we compared the resistance for TZP and MEM with a control pathogen (Pseudomonas aeruginosa) and studied the impact on rate of Clostridioides difficile-associated diarrhoea in our hospital. RESULTS: We observed an overall increased use of AMC relative to overall antibiotic consumption (20.0%, p<0.0001) together with a decreased use of TZP (-11.9%, p=0.049) and unchanged use of MEM (p=0.68) relative to overall antibiotic consumption. As for resistance, the number of ESBL-positive K. pneumoniae strains diminished by 5.9% (p<0.0001). When focusing on intensive care units, the carbapenemase-producing Enterobacterales (CPE) rate also decreased by 4.5% (p=0.0091). For E. coli, no significant difference in ESBL (p=0.33) and CPE (p=0.48) rates were observed. No significant difference in the rate of C. difficile infections was observed (p=0.40). CONCLUSIONS: Restricted susceptibility reporting of TZP and MEM was associated with a significant increased use of AMC and decreased use of TZP relative to overall antibiotic consumption and significant reduction in ESBL- and CPE-positive K. pneumoniae strains.

Patient-reported outcomes among people living with HIV on single- versus multi-tablet regimens: Data from a real-life setting.

BACKGROUND: The use of single-tablet regimens (STRs) in HIV treatment is ubiquitous. However, reintroducing the (generic) components as multi-tablet regimens (MTRs) could be an interesting cost-reducing strategy. It is essential to involve patient-reported outcome measures (PROs) to examine the effects of such an approach. Hence, this study compared PROs of people living with HIV taking an STR versus a MTR in a real world setting. MATERIALS AND METHODS: This longitudinal study included 188 people living with HIV. 132 remained on a MTR and 56 switched to an STR. At baseline, months 1-3-6-12-18 and 24, participants filled in questionnaires on health-related quality of life (HRQoL), depressive symptoms, HIV symptoms, neurocognitive complaints (NCC), treatment satisfaction and adherence. Generalized linear mixed models and generalized estimation equations mixed models were built. RESULTS: Clinical parameters and PROs of the two groups were comparable at baseline. Neurocognitive complaints and treatment satisfaction did differ over time among the groups. In the STR-group, the odds of having NCC increased monthly by 4,1% as compared to the MTR-group (p = 0.035). Moreover, people taking an STR were more satisfied with their treatment after 6 months: the median change score was high: 24 (IQR 7,5-29). Further, treatment satisfaction showed a contrary evolution in the groups: the estimated state score of the STR-group increased by 3,3 while it decreased by 0,2 in the MTR-group (p = 0.003). No differences over time between the groups were observed with regard to HRQoL, HIV symptoms, depressive symptoms and adherence. CONCLUSIONS: Neurocognitive complaints were more frequently reported among people on an STR versus MTR. This finding contrasts with the higher treatment satisfaction in the STR-group over time. The long-term effects of both PROs should guide the decision-making on STRs vs. (generic) MTRs.

Slow Wave Sleep of Elite and Nonelite Gymnasts Is Influenced by Weekly Training Hours, Not by Fitness Level.

PURPOSE: This study aimed to determine the influencing factors of potential differences in sleep architecture between elite (EG) and nonelite (NEG) female artistic gymnasts. METHODS: Twelve EG (15.1 [1.5] y old) and 10 NEG (15.3 [1.8] y old) underwent a nocturnal polysomnography after a regular training day (5.8 [0.8] h vs 2.6 [0.7] h), and, on a separate test day, they performed an incremental treadmill test after a rest day in order to determine physical fitness status. A multiple linear regression assessed the predictive value of training and fitness parameters toward the different sleep phases. Total sleep time and sleep efficiency (proportion of time effectively asleep to time in bed), as well as percentage of nonrapid eye movement sleep phase 1 (NREM1) and 2 (NREM2), slow wave sleep (SWS), and rapid eye movement sleep (REM), during a single night were compared between EG and NEG using an independent-samples t test. RESULTS: Peak oxygen uptake influenced NREM1 (ß = 1.035, P = .033), while amount of weekly training hours predicted SWS (ß = 1.897, P = .032). No differences were documented between EG and NEG in total sleep time and sleep efficiency. SWS was higher in EG (36.9% [11.4%]) compared with NEG (25.9% [8.3%], P = .020), compensated by a lower proportion of NREM2 (38.7% [10.2%] vs 48.4% [6.5%], P = .017), without differences in NREM1 and REM. CONCLUSIONS: The proportion of SWS was only predicted by weekly training hours and not by training hours the day of the polysomnography or physical fitness, while NREM1 was linked with fitness level. Sleep efficiency did not differ between EG and NEG, but in EG, more SWS and less NREM2 were identified.

Broad-spectrum azoles and flucloxacillin: a dangerous match.

Both invasive fungal infection with Aspergillus fumigatus and blood stream infection with methicillin-susceptible Staphylococcus aureus (MSSA) have a significant incidence in the critically ill. Voriconazole and, more recently, isavuconazole and high dose flucloxacillin are the standard first line treatments for these respective serious infections. However, an underestimated risk of a significant interaction needs to be taken into consideration, when both co-occur. We wish to highlight this important issue in the management of these patients through two case reports and to point to the inconsistency between different validated databases regarding this significant interaction as well the importance of a strict protocol for readily available therapeutic drug monitoring.

Seasonal variation of hospital-acquired bloodstream infections: A national cohort study.

BACKGROUND: Hospital-acquired bloodstream infections (HABSIs) cause increased morbidity, mortality, and hospital costs that are partially preventable. HABSI seasonality has been described for gram-negative bacteria but has not been stratified per infection origin. OBJECTIVE: To assess seasonality among all types of HABSIs and their associations with climate. METHODS: Hospitals performing surveillance for at least 1 full calendar year between 2000 and 2014 were included. Mixed-effects negative binomial regression analysis calculated the peak-to-low monthly ratio as an adjusted HABSI incidence rate ratio (IRR) with 95% confidence intervals (CIs). Another regression model examined associations between HABSI rates and climate variables. These analyses were stratified by microorganism and infectious origin. RESULTS: The study population included 104 hospitals comprising 44,111 HABSIs. Regression analysis identified an incidence rate ratio (IRR) peak in August for gram-negative HABSIs (IRR, 1.59; 95% CI, 1.49-1.71), CLABSIs (IRR, 1.49; 95% CI, 1.30-1.70), and urinary tract HABSI (IRR, 1.52; 95% CI, 1.34-1.74). The gram-negative incidence increased by 13.1% (95% CI, 9.9%-16.4%) for every 5°C increase in temperature. Seasonality was most present among E. coli, K. pneumoniae, E. cloacae, and the nonfermenters. Gram-positive and pulmonary HABSIs did not demonstrate seasonal variation. CONCLUSIONS: Seasonality with summer spikes occurred among gram-negative bacteria, CLABSIs, and urinary tract HABSIs. Higher ambient temperature was associated with gram-negative HABSI rates. The preventable causative factors for seasonality, such as the nurse-to-patient ratio, indoor room temperature or device-utilization, need to be examined to assess areas for improving patient safety.

Invasive pulmonary aspergillosis in solid-organ transplant patients in the intensive care unit.

INTRODUCTION: Solid-organ transplantation (SOT) is a well-known risk factor for invasive pulmonary aspergillosis (IPA). We report on the epidemiology and outcome of SOT patients with IPA in an intensive care unit (ICU) setting. METHODS: This is a secondary study based on a subset of SOT patients from a prospective observational multicenter cohort (the AspICU project) including ICU patients with at least one Aspergillus spp. positive culture. Cases were classified as proven, probable, or putative IPA, or as Aspergillus-colonized. Mortality was reported at 12 weeks. RESULTS: The study included 52 SOT patients (of which 18 lung, 17 liver, 12 kidney, and five heart transplants). Sixteen patients had proven IPA, 28 were categorized as putative IPA (of which only five reached a probable IPA diagnosis according to the European Organization for Research and Treatment of Cancer/Mycosis Study Group and Research Consortium criteria), and eight as Aspergillus-colonization. Among patients with IPA, 20 (45.5%) developed IPA during their ICU stay following transplantation whereas 24 patients (54.5%) had a medical ICU admission. Regarding medical imaging, nearly all IPA cases presented with non-specific findings as only nine demonstrated robust findings suggestive for invasive fungal disease. Overall, severity of the disease was reflected by a high prevalence of underlying conditions and acute organ derangements. Mortality among patients with IPA was 68%. Lung transplantation was associated with better survival (50%). CONCLUSION: IPA in SOT patients in the ICU develops in the presence of overall high severity of the disease. It rarely presents with suggestive medical imaging thereby hampering diagnosis. IPA in ICU patients with SOT carries a grim prognosis.

Epidemiology and organisation of care in medically unexplained symptoms: A systematic review with a focus on cultural diversity and migrants.

BACKGROUND: Since the pathophysiology of medically unexplained symptoms (MUS) remains unclear, healthcare providers often struggle with these patients, especially with a different ethnic and/or cultural background. These challenges are insufficiently addressed in their training and in the organisation of care. AIM: To improve healthcare provider-patient interaction focused on MUS patients in general and in ethnic minorities and refugees in particular through a systematic review of syndromal definitions and epidemiology and organisation of care of MUS patients. METHODS: Screening of PubMed, Web of Science, Cinahl and Cochrane Library on the keywords 'Medical unexplained (physical) symptoms (MUPS)', 'Somatoform disorder', 'Functional syndrome', 'Diversity', 'Migrants', 'Ethnicity', 'Care models', 'Medical education', 'Communication skills', 'Health literacy'. RESULTS: Different case definitions result in markedly different epidemiological estimates for MUS patients. Nevertheless, they are prevalent in a wide range of healthcare settings. Literature offers evidence of the effectiveness of structural frameworks in approaching MUS patients. Organisation of MUS care needs to transcend different levels of care: specialist tertiary and secondary care and primary care involving different qualifications of caregivers need to be aligned. CONCLUSION: The systematic review identified significant gaps and shortcomings in organisation of care. These need to be addressed in order to improve outcomes.

Antimicrobial Lessons From a Large Observational Cohort on Intra-abdominal Infections in Intensive Care Units.

Severe intra-abdominal infection commonly requires intensive care. Mortality is high and is mainly determined by disease-specific characteristics, i.e. setting of infection onset, anatomical barrier disruption, and severity of disease expression. Recent observations revealed that antimicrobial resistance appears equally common in community-acquired and late-onset hospital-acquired infection. This challenges basic principles in anti-infective therapy guidelines, including the paradigm that pathogens involved in community-acquired infection are covered by standard empiric antimicrobial regimens, and second, the concept of nosocomial acquisition as the main driver for resistance involvement. In this study, we report on resistance profiles of Escherichia coli, Klebsiella pneumoniae, Pseudomonas aeruginosa, Enterococcus faecalis and Enterococcus faecium in distinct European geographic regions based on an observational cohort study on intra-abdominal infections in intensive care unit (ICU) patients. Resistance against aminopenicillins, fluoroquinolones, and third-generation cephalosporins in E. coli, K. pneumoniae and P. aeruginosa is problematic, as is carbapenem-resistance in the latter pathogen. For E. coli and K. pneumoniae, resistance is mainly an issue in Central Europe, Eastern and South-East Europe, and Southern Europe, while resistance in P. aeruginosa is additionally problematic in Western Europe. Vancomycin-resistance in E. faecalis is of lesser concern but requires vigilance in E. faecium in Central and Eastern and South-East Europe. In the subcohort of patients with secondary peritonitis presenting with either sepsis or septic shock, the appropriateness of empiric antimicrobial therapy was not associated with mortality. In contrast, failure of source control was strongly associated with mortality. The relevance of these new insights for future recommendations regarding empiric antimicrobial therapy in intra-abdominal infections is discussed.

Hormone therapy as a possible solution for postmenopausal women with nocturia: results of a pilot trial.

OBJECTIVE: To observe the impact of different hormonal treatment options on nocturia, its causative factors and bother in postmenopausal women. METHODS: This prospective study recruited 245 postmenopausal women and divided them into four treatment groups based on patient's choice: Estrogen + Progesterone (E+P), Estrogen-only in patients with a prior hysterectomy, tissue-selective estrogen complex (TSEC) and no treatment. Nocturia and its causative factors were observed using two standardized questionnaires before and after treatment: the International Consultation on Incontinence Questionnaire Nocturia Module and the Targeting the individual's Aetiology of Nocturia to Guide Outcomes (TANGO). The results of the Targeting the individual's Aetiology of Nocturia to Guide Outcomes were divided in four influencing topics of which the sum score was calculated. RESULTS: A significant reduction in prevalence of nocturia ≥ twice per night was seen after treatment, as the prevalence decreased from 27.7% (59/213) to 16.4% (35/213). Specified per therapy, a significant reduction in nocturnal voiding frequency was observed in patients treated with E+P and TSEC (P = 0.018 and P = 0.018, respectively). This improvement could be explained by a significant reduction in SLEEP sum score in patients treated with E+P and TSEC (P < 0.001, P = 0.013, respectively). Estrogen-only led to a significant change in URINARY TRACT sum score, which is the result of a reduction in urgency prevalence (P = 0.039). CONCLUSIONS: E+P and TSEC treatment led to a significant reduction in nocturia prevalence and bother in women with ≥ 2 nocturnal voids. This effect is mainly the result of improvement in sleep disorders, however an improvement in bladder disorders can be suggested as well. More research is necessary to confirm these findings.

Video Summary:http://links.lww.com/MENO/A710 .