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Acute heart failure (AHF) is the most frequent cause of unplanned hospital admission in patients of >65 years of age and it is associated with significantly increased morbidity, mortality, and healthcare costs. Different AHF classification criteria have been proposed, mainly reflecting the clinical heterogeneity of the syndrome. Regardless of the underlying mechanism, peripheral and/or pulmonary congestion is present in the vast majority of cases. Furthermore, a marked reduction in cardiac output with peripheral hypoperfusion may occur in most severe cases. Diagnosis is made on the basis of signs and symptoms, laboratory, and non-invasive tests. After exclusion of reversible causes, AHF therapeutic interventions mainly consist of intravenous (IV) diuretics and/or vasodilators, tailored according to the initial hemodynamic status with the addition of inotropes/vasopressors and mechanical circulatory support if needed. The aim of this review is to discuss current concepts on the diagnosis and management of AHF in order to guide daily clinical practice and to underline the unmet needs. Preventive strategies are also discussed.

Supplemental material, sj-docx-1-ggm-10.1177_23337214231185664 for Caring for Dementia Caregivers: Understanding Caregiver Stress During the COVID-19 Pandemic by Lee Lancashire, Virginia Biggar, Meryl Comer, Terry Frangiosa, Allyson Gage, Russ Paulsen, Amber Roniger and Jessica Wolfe in Gerontology and Geriatric Medicine

Supplemental material, sj-docx-1-ggm-10.1177_23337214231185664 for Caring for Dementia Caregivers: Understanding Caregiver Stress During the COVID-19 Pandemic by Lee Lancashire, Virginia Biggar, Meryl Comer, Terry Frangiosa, Allyson Gage, Russ Paulsen, Amber Roniger and Jessica Wolfe in Gerontology and Geriatric Medicine

Objectives Chest trauma is associated with severe pain, which can hamper normal breathing. Serratus Anterior Plane block (SAPB) is a novel technique, which provides analgesia for chest wall surgery. We describe an interesting clinical case about the use of SAPB to improve pain and pulmonary function in a patient with severe chest trauma. Case presentation We report the pain management and the clinical evolution of a patient in ICU, with a severe chest trauma, after performing the SAPB. Following the SAPB, the patient had a reduction in pain intensity and an improvement in both respiratory mechanics and blood gas analysis allowing a weaning from mechanical ventilator. Conclusions Pain control greatly affects mortality and morbidity in patients with chest trauma. SAPB seems to be safer and equally effective in pain control compared to epidural analgesia in patients with chest trauma.

We aimed to evaluate the usefulness of C-reactive protein (CRP) and procalcitonin (PCT) as markers of infection, sepsis and as predictors of antibiotic response after non-emergency major abdominal surgery. We enrolled, from June 2015 to June 2019, all patients who underwent surgery due to abdominal infection (peritoneal abscess, peritonitis) or having sepsis episode after surgical procedures (i.e. hepatectomy, bowel perforation, pancreaticoduodenectomy (PD), segmental resection of the duodenum (SRD) or biliary reconstruction in a Tertiary Care Hospital. Serum CRP (cut-off value < 5 mg/L) and PCT (cut-off value < 0.1mcg/L) were measured in the day when fever was present or within 24 h after abdominal surgery. Both markers were assessed every 48 h to follow-up antibiotic response and disease evolution up to disease resolution. We enrolled a total of 260 patients underwent non-emergency major abdominal surgery and being infected or developing infection after surgical procedure with one or more microbes (55% mixed Gram-negative infection including Klebsiella KPC, 35% Gram-positive infection, 10% with Candida infection), 58% of patients had ICU admission for at least 96 h, 42% of patients had fast track ICU (48 h). In our group of patients, we found that PCT had a trend to increase after surgical procedure; particularly, those undergoing liver surgery had higher PCT than those underwent different abdominal surgery (U Mann-Whitney p < 0.05). CRP rapidly increase after surgery in those developing infection and showed a statistical significant decrease within 48 h in those subject being responsive to antibiotic treatment and having a clinical response within 10 days independently form the pathogens (bacterial or fungal). Further we found that those having CRP higher than 250 mg/L had a reduced percentage of success treatment at 10 days compared to those < 250 mg/mL (U Mann-Whitney p < 0.05). PCT did not show any variation according to treatment response. CRP in our cohort seems to be a useful marker to predict antibiotic response in those undergoing non-emergency abdominal surgery, while PCT seem to be increased in those having major liver surgery, probably due to hepatic production of cytokines.

This study describes the person-centered experience and impact of symptoms and the treatment needs of dementia-related psychosis (DRP) from a patient and care partner perspective.Qualitative interviews and a quantitative survey were used to collect patient experience data from persons with DRP or their care partners.Sixteen participants (1 person with DRP, 15 care partners) completed the qualitative interview; 212 participants (26 persons with DRP, 186 care partners) completed the quantitative survey. The most commonly reported symptoms were visual hallucinations, auditory hallucinations, persecutory delusions, and distortion of senses. The most common impacts were difficulty differentiating what is real from what is not real, increased anxiety, and effects on personal relationships. Current treatments were less than moderately helpful, and the ability to distinguish what is real from what is not real and overall symptom improvement were described as the most important benefits of an ideal treatment.Patient experience data provide insights into urgent therapeutic needs of patients by describing the nature, frequency, and severity of symptoms and the impacts they have on individuals' lives.Patient experience data demonstrate an unmet need for treatments to reduce the symptoms and impacts of DRP.

No robust evidence is provided by literature regarding the management of intracranial hypertension following severe traumatic brain injury (TBI). This is mostly due to the lack of prospective randomized controlled trials (RCTs), the presence of studies containing extreme heterogeneously collected populations and controversial considerations about chosen outcome. A scientific society should provide guidelines for care management and scientific support for those areas for which evidence-based medicine has not been identified. However, RCTs in severe TBI have failed to establish intervention effectiveness, arising the need to make greater use of tools such as Consensus Conferences between experts, which have the advantage of providing recommendations based on experience, on the analysis of updated literature data and on the direct comparison of different logistic realities. The Italian scientific societies should provide guidelines following the national laws ruling the best medical practice. However, many limitations do not allow the collection of data supporting high levels of evidence for intracranial pressure (ICP) monitoring and decompressive craniectomy (DC) in patients with severe TBI. This intersociety document proposes best practice guidelines for this subsetting of patients to be adopted on a national Italian level, along with joint statements from "TBI Section" of the Italian Society of Neurosurgery (SINch) endorsed by the Neuroanesthesia and Neurocritical Care Study Group of the Italian Society of Anesthesia, Analgesia, Resuscitation and Intensive Care (SIAARTI). Presented here is a recap of recommendations on management of ICP and DC supported a high level of available evidence and rate of agreement expressed by the assemblies during the more recent consensus conferences, where members of both groups have had a role of active participants and supporters. The listed recommendations have been sent to a panel of experts consisting of the 107 members of the "TBI Section" of the SINch and the 111 members of the Neuroanesthesia and Neurocritical Care Study Group of the SIAARTI. The aim of the survey was to test a preliminary evaluation of the grade of predictable future adherence of the recommendations following this intersociety proposal. The following recommendations are suggested as representing best clinical practice, nevertheless, adoption of local multidisciplinary protocols regarding thresholds of ICP values, drug therapies, hemostasis management and perioperative care of decompressed patients is strongly recommended to improve treatment efficiency, to increase the quality of data collection and to provide more powerful evidence with future studies. Thus, for this future perspective a rapid overview of the role of the multimodal neuromonitoring in the optimal severe TBI management is also provided in this document. It is reasonable to assume that the recommendations reported in this paper will in future be updated by new observations arising from future trials. They are not binding, and this document should be offered as a guidance for clinical practice through an intersociety agreement, taking in consideration the low level of evidence.

Background The most common hospital safety incidents are Hospital-Acquired-Infections (HAI) and among these Surgical Site Infections (SSIs). Our study proposes the use of a proactive system to manage risk combining the new Risk Identification Framework by WHO (IPCAF), the Lean method and the hospital’s Procedure Analysis. Each of the methods has pros and cons, and there is no existing literature that researches the concurrent use of all three methods. We focused on analysing patients’ surgical route to demonstrate that using an integrated system for preventing SSIs delivers enhanced results and significantly contibutes to a reduction in occurence of SSIs. Methods We conducted a retrospective observational study from 18 March 2019 to 20 April 2019 at Azienda Ospedaliera Universitaria Federico II di Napoli, Italia (Europa). The study is structured in 3 phases: Phase 1- application of proactive risk management tools (18 March- 15 April 2019); Phase 2-integration of results with the elaboration of a single system for proactive risk management (15-20 April 2019); Phase 3- collection of epidemiologic data concerning SSI. We used the incidence of surgical site as efficiency indicator (1-10 March 2022). The endpoints identified were: Primary Endpoint: a reduction of infection occurrence in surgical sites Secondary Endpoint: identification of critical points and control points within the surgical process with relevant corrective measures Results The rate of incidence of SSIs was selected as the efficacy indicator for the system. Our study recorded a 2.40% incidence rate for SSIs in 2020, compared to an incidence rate of 3.80% in 2018 and of 3.5% in 2017. Conclusions Considering the economic impact of the infections, along with the increased incidence of mortality and morbidity, employing all available tools to try and reduce SSIs incidence becomes paramount. A small reduction can produce significant cost savings that can be invested in other prevention programs. Key messages • Integrated system in proactively and promptly identifying risks related to patients’ surgical routes is effectiveness. • The system can be adapted to different healthcare settings, to prevent adverse incidents by employing a risk management strategy, and to further enhance existing strategies.

People with late-stage Alzheimer’s disease and related dementias (ADRD) who are assumed to have lost coherent cognitive capacity may exhibit unexpected episodes of lucidity (EL). Given the transient nature and lack of scientific explanation of the phenomenon, EL is under-investigated and poorly understood. To better understand this phenomenon, we set out to develop an operational definition of EL. Based on survey data from former and current family caregivers participating in UsAgainstAlzheimer’s A-LIST® (N = 480), we defined four EL typologies. We then interviewed 25 caregiver respondents about their experiences and used analyzed qualitative data to refine the preliminary typologies. Finally, we conducted a Delphi consensus panel with clinicians, researchers, and health care providers with medical, pharmacological, and clinical expertise to describe potential explanations for EL to help further refine the typologies. Next we will test the validity of these typologies in a prospective, demographically diverse sample of current family caregivers.

Sustainability is significantly important to the fashion business because of consumers' growing awareness of the environment. When a fashion company aims to promote sustainability, the main link is to develop a sustainable circular system. This chapter contributes understanding of how a historical fashion company has managed to evolve over time by implementing circular technology that can give it a competitive advantage in the market. The authors firstly describe the structure of H&M, the value it distributes in the market, and the future goals it has set for itself. Next, they introduce the methodology by which the company has managed to make its circular model impact on its performance, giving an overview of the relationship the company has with its stakeholders and consumers. Furthermore, based on secondary data and analysis, they learn how the Swedish fast fashion company has built its sustainable strength by developing eco-friendly materials, monitoring sustainable production, reducing carbon emissions in distribution, and promoting circular fashion.

Studies have shown that the pandemic has led to an increase in sick leave periods among healthcare workers (HCWs); however, this might have changed over time considering increase in vaccination coverage and change in COVID-19 variant predominance. Therefore, we conducted an observational study to evaluate whether the type of symptoms and the duration of sick leave period for healthcare workers working in a large university hospital in the South of Italy changed between January 2021 and January 2022; 398 cases of COVID-19 were identified for a total of 382 subjects involved. A total of 191 subjects answered the questionnaire about symptoms; of these, 79 had COVID-19 during the period from March 2020 until February 2022. The results showed a decrease of about 1.2 days in sick leave period for each quarter without finding significant differences in the perception of symptoms. It is possible to hypothesize a contribution from the Omicron variant to the decrease in sick leave period in the last quarter, from vaccination coverage, from optimization of COVID-19 management, and from change in the regulations for the assessment of positivity.

Background The What Matters Most (WMM) study was initiated to evaluate symptoms, AD-related impacts, treatment-related needs, preferences, and priorities among individuals with or at risk for Alzheimer’s disease (AD) and their care partners. The objective of this qualitative study phase was to identify a comprehensive set of concepts of interest that are meaningful to individuals across the AD continuum. Methods Interviews were conducted with 60 clinically referred individuals and care partners across 5 AD stages (n = 12 each): group 1 (non-clinically impaired individuals with AD pathology), group 2 (individuals with mild cognitive impairment and AD pathology), group 3 (individuals with mild AD), group 4 (individuals with moderate AD and their care partners), and group 5 (care partners of individuals with severe AD). Interviews were conducted by experienced interviewers, audio-recorded, and transcribed. Dominant trends were identified in each interview and compared across subsequent interviews to generate themes or patterns in descriptions of AD symptoms, impacts, and desired treatment outcomes. Results All participants endorsed current issues related to memory; nearly all participants (n = 55; 92%) across the five groups endorsed symptoms related to communication and language. Groups 1–3 reported an impact on mood/emotions (n = 23; 64%) and a decrease in social activities or outgoingness (n = 17; 47%). Current and future concerns reported by the overall sample included memory (n = 48; 80%), dependence (n = 40; 67%), and “other” concerns (n = 33; 55.0%) (e.g., uncertainty about the future, burdening others). The most desired AD treatment outcomes were improvement or restoration of memory (n = 40; 67%) and stopping AD progression (n = 35; 58.3%). Group-level differences were observed in the symptoms, impacts, and desired treatment outcomes among patients and care partners across the AD continuum. Conclusions Cognitive functioning issues—particularly in memory and communication—are present even in preclinical and early-stage AD, including among those without a formal AD diagnosis. While the impacts of AD vary across the disease-severity spectrum, improved memory and disease modification were treatment outcomes considered most important to participants across all 5 AD stages. Neuropsychological assessments traditionally used in AD clinical trials may not evaluate the often-subtle concepts that are important to patients and care partners. Results from this study will inform the second phase of the WMM project—a quantitative study to elicit the relative importance of these concepts of interest to people at risk for and living with AD and their care partners.

Corticosteroids use in severe and critical COVID-19 patients is recommended by international guidelines, as they reduce mortality. However, the use outside of these indications could be harmful and should be discouraged. The scope of this brief review is to examine the beneficial mechanisms of corticosteroids treatment in COVID-19 and when they should be adopted.

Little is known about how family caregivers who witness unexpected and spontaneous communication among people in late stages of Alzheimer's disease and related dementias (ADRD) appraise these episodes of lucidity (EL).In an electronic, cross-sectional survey for former and current caregivers who participate in UsAgainstAlzheimer's A-LISTCaregivers reported 72% of ELs to be quite a bit or very positive, 17% to be stressful, and 10% to be both stressful and positive. Twelve percent of caregivers changed care plans because of ELs and 13% sought out information about ELs.These exploratory data suggest caregiver reactions to EL vary. Caregivers may change or postpone care decisions due to EL, and few resources exist to address caregiver queries about EL.

Major adverse cardiac events, defined as death or myocardial infarction, are common causes of perioperative mortality and major morbidity in patients undergoing non-cardiac surgery. Reduction of perioperative cardiovascular risk in relation to non-cardiac surgery requires a stepwise patient evaluation that integrates clinical risk factors, functional status and the estimated stress of the planned surgical procedure. Major guidelines on preoperative cardiovascular risk assessment recommend to establish, firstly, the risk of surgery per se (low, moderate, high) and the related timing (elective vs. urgent/emergent), evaluate the presence of unstable cardiac conditions or a recent coronary revascularization (percutaneous coronary intervention or coronary artery bypass grafting), assess the functional capacity of the patient (usually expressed in metabolic equivalents), determine the value of non-invasive and/or invasive cardiovascular testing and then combine these data in estimating perioperative risk for major cardiac adverse events using validated scores (Revised Cardiac Risk Index (RCRI) or National Surgical Quality Improvement Program (NSQIP)). This stepwise approach has the potential to guide clinicians in determining which patients could benefit from cardiovascular therapy and/or coronary artery revascularization before non-cardiac surgery towards decreasing the incidence of perioperative morbidity and mortality. Finally, it should be highlighted that there is a need to implement specific strategies in the 2019 Coronavirus disease (COVID-19) pandemic to minimize the risk of transmission of COVID-19 infection during the preoperative risk assessment process.

Additional file 1. Supplemental Appendix

To develop an operational definition of and typologies for episodes of lucidity (EL), we conducted a cross-sectional study of former/current family caregivers from UsAgainstAlzheimer’s A_LIST (N = 538). More than 60% of caregivers (n = 294, 62%) reported witnessing EL with their care recipient over the course of their dementia. Most episodes happened in late stages of dementia (71%). Only 10% happened within 7 days before death. The majority of episodes (71%) lasted

People with late-stage Alzheimer’s disease and related dementias (ADRD) who are assumed to have lost coherent cognitive capacity may exhibit unexpected episodes of spontaneous, meaningful, and relevant communication or behavior. Most reports of paradoxical lucidity or “episodes of lucidity” (EL) are anecdotal or case studies. Given the transient nature and lack of scientific explanation of the phenomenon, EL is under-investigated and poorly understood.To develop an operational definition of and typologies for EL, we conducted a pilot study of former and current family caregivers from UsAgainstAlzheimer’s A-LIST® (N = 480). Over sixty percent of caregivers (n = 294, 61%) reported witnessing at least one EL with their care recipient over the course of dementia. Most episodes happened in late stages of dementia (71%). Only 10% happened within 7 days before death. The majority of episodes (71%) lasted M = 4.1; range = 1–5), but also expressed desire to know why/when EL occurs and how to respond to it.We plan to use these data to refine definitions and typologies to incorporate into a prospective, demographically diverse survey to family caregivers to assess predictors of EL and linking EL to caregiver well-being and bereavement response. Precise and robust operationalizations of EL will allow future research to assess if EL has different effects on ADRD prognosis or alters how family members understand, manage and adapt to a PLWD’s dementia progression.

Barriers to the early detection of mild cognitive impairment (MCI) and dementia can delay diagnosis and treatment. myMemCheck® was developed as a rapid free cognitive self-assessment tool that can be completed in the practice setting or at home to identify older adults that would benefit from a more comprehensive cognitive evaluation for MCI and dementia. Two prospective cross-sectional studies (N = 59; N = 357) were conducted to examine the psychometric properties and clinical utility of myMemCheck®. myMemCheck® evidenced adequate reliability (test-retest, r = 0.67) and strong construct validity (η2 = 0.29, discriminating normal, MCI, dementia). Receiver operating characteristic analysis evidenced an optional myMemCheck® cut score for identifying older adults with MCI or dementia (sensitivity = 0.80, specificity = 0.67, positive predictive value = 0.91, negative predictive value = 0.43). myMemCheck® explained 25% of cognitive status beyond basic patient information. We provide specific suggestions for integrating myMemCheck® into practice to optimize workflow. Study results are further interpreted in the context of two national online surveys (healthcare professionals, N = 181; consumers, N = 1740). Healthcare professionals widely agreed on the need (94%) and importance (86%) of cognitive self-assessments. Public demand for cognitive self-assessment was confirmed by consumers who trialed myMemCheck® as part of their survey participation—86% agreed on the need for a tool like myMemCheck®. Mixed methods findings suggest that myMemCheck® could fast- track the diagnostic process, facilitate appropriate referrals for cognitive and neuropsychological evaluation, reduce assessment burden in healthcare, and prevent negative outcomes associated with undetected cognitive impairment.

Purpose The aim of this study was to develop and validate case-finding algorithms for granulomatosis with polyangiitis (Wegener's, GPA), microscopic polyangiitis (MPA), and eosinophilic GPA (Churg–Strauss, EGPA). Methods Two hundred fifty patients per disease were randomly selected from two large healthcare systems using the International Classification of Diseases version 9 (ICD9) codes for GPA/EGPA (446.4) and MPA (446.0). Sixteen case-finding algorithms were constructed using a combination of ICD9 code, encounter type (inpatient or outpatient), physician specialty, use of immunosuppressive medications, and the anti-neutrophil cytoplasmic antibody type. Algorithms with the highest average positive predictive value (PPV) were validated in a third healthcare system. Results An algorithm excluding patients with eosinophilia or asthma and including the encounter type and physician specialty had the highest PPV for GPA (92.4%). An algorithm including patients with eosinophilia and asthma and the physician specialty had the highest PPV for EGPA (100%). An algorithm including patients with one of the diagnoses (alveolar hemorrhage, interstitial lung disease, glomerulonephritis, and acute or chronic kidney disease), encounter type, physician specialty, and immunosuppressive medications had the highest PPV for MPA (76.2%). When validated in a third healthcare system, these algorithms had high PPV (85.9% for GPA, 85.7% for EGPA, and 61.5% for MPA). Adding the anti-neutrophil cytoplasmic antibody type increased the PPV to 94.4%, 100%, and 81.2% for GPA, EGPA, and MPA, respectively. Conclusion Case-finding algorithms accurately identify patients with GPA, EGPA, and MPA in administrative databases. These algorithms can be used to assemble population-based cohorts and facilitate future research in epidemiology, drug safety, and comparative effectiveness. Copyright © 2016 John Wiley & Sons, Ltd.

Family caregiver engagement in clinical encounters can promote relationship-centered care and optimize outcomes for people with Alzheimer’s disease and related dementias (ADRD). Little is known, however, about effective ways for health care providers to engage family caregivers in clinical appointments to provide the highest quality care. We describe what caregivers of people with ADRD and people with mild cognitive impairment (MCI) consider potential best practices for engaging caregivers as partners in clinical appointments. Seven online focus groups were convened. Three groups included spousal caregivers ( n = 42), three included non-spousal caregivers ( n = 36), and one included people with MCI ( n = 15). Seven potential best practices were identified, including the following: “acknowledge caregivers’ role and assess unmet needs and capacity to care” and “communicate directly with person with ADRD yet provide opportunities for caregivers to have separate interactions with providers.” Participants outlined concrete steps for providers and health care systems to improve care delivery quality for people with ADRD.

Health care providers recognize that family can directly and indirectly affect adult patient health and reduce costs to healthcare systems. However, there is no consensus on the best practices for integrating caregivers into the healthcare experience. Research on how healthcare providers can integrate family abilities and values into patient plans of care for disease management, rehabilitation, or symptom control lags far behind the research on patient-centered care. Research on family engagement at critical points of patient care, such as hospital discharge or end-of-life decision making have been instrumental in highlighting opportunities to engage families to improve quality of care. Far less research has been done on integrating family values, capabilities, and capacity to care throughout a patient’s chronic disease continuum, leaving healthcare providers with few evidence-based, feasible or acceptable strategies they can offer to caregivers to improve patient outcomes and maintain their caregiver health. Using qualitative data from six focus groups with family caregivers of people with dementia and one focus group of people living with mild cognitive impairment, we identified potential “best practices” on engaging family caregivers in healthcare. Caregivers and patients reported clinical best practices would include coordination of services, personalized care, practices that enabled caregivers to provide optimal care (early identification of caregivers and routine assessment of caregiver health and capacity to care), and compassion and respect for the caregiver role and expertise. Data have been used to inform a new quantitative assessment to evaluate clinical best practices for engaging family caregivers.

Background:This study aimed to describe the person-centered experience of symptoms and impact of dementia-related psychosis (DRP) from a patient and care partner (CP) perspective.Methods:This observational, non-interventional, prospective study collected patient experience data to understand the impact of DRP in persons with various dementia subtypes. Qualitative interviews were conducted with persons or their CP who have a clinical diagnosis of all-cause dementia with psychotic symptoms, recruited through physician referrals. The quantitative online survey was completed by persons with self-reported DRP or their CP recruited by advocacy groups: UsAgainstAlzheimer’s and the Lewy Body Dementia Association. CP burden was beyond the scope of this study.Results:Sixteen individuals (1 patient, 15 CP) participated in the qualitative interview. The most commonly reported symptoms of DRP were visual hallucinations (88%), auditory hallucinations (69%), and persecutory delusions (56%). Participants described an impact of DRP on activities of daily living (75%), sleep (63%), family life (56%), and safety concerns (56%).The quantitative portion was completed by 212 participants (26 patients, 186 CP). DRP symptoms most frequently reported by patients were visual hallucinations (89%), auditory hallucinations (54%), and distortion of senses (54%); those reported by CP were paranoid delusions (76%), visual hallucinations (75%), and lack of trust for loved ones (52%). For patients with recent visual hallucinations, 61% of patients and 70% of CP reported experiencing this symptom on a weekly basis. When asked to rank the impact on the patient’s life, patients reported that visual hallucinations were the most impactful symptom whereas CP reported paranoid delusions/false beliefs as most impactful, followed by visual hallucinations. Difficulty differentiating what is real from what is not real, increased anxiety, and effects on personal relationships were the most common types of impacts reported by both patients and CP. Most patients (>40%) were not receiving medications for DRP.Conclusions:Persons with DRP experience hallucinations and delusions that have a substantial impact on their lives. Here, patient experience data demonstrate that there is a need for treatments to reduce the symptoms and impacts of DRP.Study Sponsored By: ACADIA Pharmaceuticals Inc.DisclosuresTF is a consultant with Frangiosa & Associates, LLC.VB and AT have no relevant financial relationships to disclose.TB, BK, and VA are employees of and may hold stock and/or stock options with ACADIA Pharmaceuticals Inc.

Background:We aimed to describe current treatment patterns and unmet needs of persons with DRP from a patient and care partner (CP) perspective.Methods:This observational, non-interventional, prospective study used a mixed-methods approach with qualitative interviews and a quantitative online survey. Persons with DRP and CP of persons with DRP reported the effectiveness of current treatments using a visual analog scale (VAS) of 0 (“not at all well”) to 5 (“extremely well”) and ranked benefits of an ideal treatment. CP burden was outside the scope of this study.Results:The qualitative interview was completed by 1 patient and 15 CP. Current treatments included atypical antipsychotics, antidepressants, anxiolytics, and benzodiazepines. Participants commonly indicated a need to improve patients’ ability to know what is real vs not real.The online survey was completed by 26 patients and 186 CP on behalf of patients under their care. Common treatments used included atypical antipsychotics (27% of patients, 41% of CP) and psychological/ behavioral therapy (23% of patients, 8% of CP). Many participants reported no current treatment (42% of patients, 42% of CP). Participants reported that current treatment methods were less than moderately helpful in treating patients’ most impactful symptoms with a median VAS score of 2.0/5 reported by patients and CP (mean VAS score [standard deviation] = 2.33 [1.0] for patients [n=15], mean [standard deviation] VAS score = 2.4 [1.3] for CP [n=104]). Discontinuation of a treatment was reported by 11 patients and 115 CP, most commonly due to a side effect (27% of patients, 31% of CP), doctor’s recommendation (27% of patients, 14% of CP), or lack of symptom improvement (9% of patients, 28% of CP). Participants ranked the ability to distinguish what is real vs not real (35% of patients, 49% of CP) and overall symptom improvement (42% of patients, 23% of CP) as the most important benefits of an ideal treatment.Conclusions:Patients and CPs reported either not taking any DRP treatments or that current treatments were associated with side effects along with limited efficacy. There is an unmet need for safe and effective treatments for DRP.Study Sponsored By:ACADIA Pharmaceuticals Inc.DisclosuresTF is a consultant with Frangiosa & Associates, LLC.VB and AT have no relevant financial relationships to disclose.TB, BK, and VA are employees of and may hold stock and/or stock options with ACADIA Pharmaceuticals Inc.

Este trabalho é direcionado ao estudo dos efeitos da radiação UV sobre amostras de poliestireno (PS) e de copolímeros de estireno com proporções variáveis de 2-trimetilsililóxi-1,3-butadieno (TSB, I), 2-metóxi-1,3-butadieno (MEB, II) e 2-etóxi-1,3-butadieno (ETB, III), em solução aerada, visando principalmente à amplificação da degradação ambiental do PS quando exposto a condições de intemperismo natural. (Ver no arquivo em PDF). Os polímeros foram sintetizados via polimerização radicalar em solução, resultando em uma massa molar ponderai média (Mw) de cerca de 30,0 kg/mol para o homo e copolímeros. Estes produtos, após serem submetidos a um processo de hidrólise na presença de fluoreto de tetrabutilamônio (série TSB) ou HCI aquoso (séries MEB e ETB), resultaram em PS contendo grupos carbonila na cadeia principal sendo, a seguir, isolados e caracterizados por meio de técnicas analíticas como espectroscopia de infravermelho (IR), análise elementar, cromatografia de exclusão por tamanho (SEC), espalhamento de luz estático dependente do tempo (TDSLS), análise térmica (TG e DSC) e microscopia eletrônica de varredura (MEV). As soluções poliméricas foram irradiadas com lâmpada de mercúrio de baixa pressão (99,5% de emissão a 254 nm), na presença de ar e à temperatura ambiente, por um período de dez horas. As alterações sofridas pelos polímeros foram acompanhadas por meio de medidas de IR, TDSLS e SEC. Os espectros no infravermelho mostraram um aumento contínuo da intensidade de algumas bandas: na região entre 3800 - 3000 cm-1, houve um alargamento das bandas que pode ser atribuído à formação de grupos hidroxila e/ou hidroperóxido; na região de 1900 - 1500 cm-1, observou-se o aparecimento de um ombro em 1712 cm-1, que pode ser atribuído à formação de grupos cetona e aldeído como funções terminais na cadeia do polímero e, na região entre 1500 - 1000 cm-1, o alargamento das bandas foi atribuído à formação de grupos anidrido. Os estudos realizados por TDSLS revelaram claramente que os copolímeros degradam com mais rapidez que o PS puro, e as taxas de degradação aumentam proporcionalmente ao aumento no teor de carbonilas incorporadas ao polímero. Tal observação tem suporte nas massas molares ponderais médias obtidas via SEC (Mw) dos fragmentos resultantes da fotólise, com valores cada vez menores com o aumento dos efeitos da fotodegradação, iniciando com cerca de 34,0 kg/mol (TSB5), por exemplo, e decrescendo a valores de Mw tão baixos quanto 4,8 kg/mol (TSB15). Para finalizar, tentou-se verificar o comportamento dos polímeros quando expostos a condições reais de utilização, submetendo-se corpos de prova a um envelhecimento acelerado em câmara de intemperismo artificial e avaliando seu comportamento mecânico. Os resultados mostraram que, para homo e copolímeros, houve uma redução na resistência à tração com o aumento do tempo de exposição (0 a 600 horas), sendo este efeito muito mais acentuado para os copolímeros. This work was directed to the study of the UV radiation effects upon samples of polystyrene (PS) and copolymers of styrene with different fractions of 2-trimethylsililoxy-1,3-butadiene (TSB, I), 2-methoxy-1 ,3-butadiene (MEB, II) and 2-ethoxy-1,3-butadiene (ETB, III), in normally aerated solution, aiming at the optimization of the PS degradation when exposed to weathering conditions. (See in the PDF file). The polymers were prepared by free-radical polymerization in solution, resulting in average molecular weight (Mw) of about 30.0 kg/mol for the homo and copolymers. The resulting polymers were submitted to hydrolysis in the presence of tetrabutylamonium fluoride (TSB series) or aqueous HCI (MEB and ETB series), resulting in PS containing carbonyls inserted in its backbone. The polymers were isolated and characterized by infrared spectroscopy (IR), elemental analysis, size exclusion chromatography (SEC), time dependent static light scattering (TDSLS), thermal analysis (TG and DSC) and scanning electron microscopy (SEM). The polymeric solutions were irradiated with a low pressure mercury lamp (99.5% emission at 254 nm), in the presence of air at room temperature, for a period of 10 hours. The polymer changes were followed by IR, TDSLS and SEC. The infrared spectra showed a continuous increase in the intensity of some bands: the broad band in the region of 3800 - 3000 cm-1 was assigned to the formation of hydroxides or hydroperoxides groups; the band at 1900 - 1500 cm-1 with a shoulder at 1712 cm-1 can be assigned to ketones or aldehydes, which appear as chain termination groups and the band at 1500 - 1000 cm-1 was attributed to the formation of anhydrides. The TDSLS studies clearly showed that the copolymers degradated much faster than the pure PS, and the degradation rates were directly related to the increase in the TSB, MEB and ETB contents of the polymer. This observation is supported by the decreasing molecular weight values obtained by SEC (Mw) for the resulting fragments from photolysis, when the carbonylic content of the polymer increased, starting at around 34.0 kg/mol (TSB5), for instance, decreasing to Mw values as low as 4.8 kg/mol (TSB15). Finally, we tried to found out the polymer behavior when exposed to the real outdoor conditions of use, by submitting samples to an accelerated aging process in a Weather-o-Meter chamber and evaluating its mechanical behavior afterwards. The results showed that for both, homo and copolymers, there was a reduction in the tensile strength with increasing in the exposition time (0 to 600 hours). This behavior is much stronger in the copolymers.

The objectives of this study were to perform bioelectrical impedance analysis before and after heart transplantation with comparison to healthy subjects. Eight patients (7 men, 1 woman) before (day 0) and after transplantation (day 3, 7, 12, 15, and 180) and 24 healthy controls, matched for sex, age, and body mass were studied. Data collection included bioelectrical impedance analysis (resistance, reactance, and estimates of body water), clinical, and laboratory measurements. Compared with controls, patients had at baseline significantly higher reactance, not significantly different resistance, body weight, total body water, and intra- to extracellular water ratio. After surgery, for reactance, there was an acute decrease followed by a slow, progressive increase up to normal level by day 15. Resistance and body weight did not significantly change; the intra- to extracellular water ratio significantly decreased with stable total body water. Changes in reactance are the main effects induced on bioelectrical impedance by heart transplantation. Acutely, there is a large decrease which likely reflects changes both in water distribution and in cell membrane function. The late changes more likely reflect the shift of body water from the extra- to the intracellular space with stable total body water.

This study investigates the impact of learning Standard Italian among Italian Australian dialect speakers. More specifically, it examines the Italian language learning experiences of bilingual Italian Australians who grew up speaking an Italian dialect at home and studied Italian in formal contexts. It also investigates the possible effect that formal Italian language instruction, and other influences, have had on their current language use. Despite the fact that in Australia the Italian language has been taught in various programs over many years and to a large number of learners who are Italian dialect speakers, little research has been conducted in this area. This study is informed by both social constructionist and phenomenological frameworks and draws on research in the areas of sociolinguistics and second language learning and instruction. The research was conducted in Adelaide, South Australia, on a sample of ten Italian Australians who were brought up in Australia speaking an Italian dialect, using a mixed method approach. Pre-interview questionnaires and semi structured interviews were used to obtain data which was analysed through a thematic approach. From this, themes emerged in the areas of language learning experiences and the participants’ perceived impact that such experiences, and other influences, have had on their language use.The findings show a range of learning experiences among participants. While a small number identify areas where their Italian instruction has had an impact, most do not believe in such an impact on their language use. All perceive that other influences, such as family networks, have had a more significant impact.

The aim of this study was to develop and validate case-finding algorithms for granulomatosis with polyangiitis (Wegener's, GPA), microscopic polyangiitis (MPA), and eosinophilic GPA (Churg-Strauss, EGPA).Two hundred fifty patients per disease were randomly selected from two large healthcare systems using the International Classification of Diseases version 9 (ICD9) codes for GPA/EGPA (446.4) and MPA (446.0). Sixteen case-finding algorithms were constructed using a combination of ICD9 code, encounter type (inpatient or outpatient), physician specialty, use of immunosuppressive medications, and the anti-neutrophil cytoplasmic antibody type. Algorithms with the highest average positive predictive value (PPV) were validated in a third healthcare system.An algorithm excluding patients with eosinophilia or asthma and including the encounter type and physician specialty had the highest PPV for GPA (92.4%). An algorithm including patients with eosinophilia and asthma and the physician specialty had the highest PPV for EGPA (100%). An algorithm including patients with one of the diagnoses (alveolar hemorrhage, interstitial lung disease, glomerulonephritis, and acute or chronic kidney disease), encounter type, physician specialty, and immunosuppressive medications had the highest PPV for MPA (76.2%). When validated in a third healthcare system, these algorithms had high PPV (85.9% for GPA, 85.7% for EGPA, and 61.5% for MPA). Adding the anti-neutrophil cytoplasmic antibody type increased the PPV to 94.4%, 100%, and 81.2% for GPA, EGPA, and MPA, respectively.Case-finding algorithms accurately identify patients with GPA, EGPA, and MPA in administrative databases. These algorithms can be used to assemble population-based cohorts and facilitate future research in epidemiology, drug safety, and comparative effectiveness. Copyright © 2016 John WileySons, Ltd.

The study examined whether indexing glomerular filtration rate (GFR) for body surface area is appropriate for people who are severely overweight. Twenty normotensive adult men who were severely overweight but without microalbuminuria were enrolled into this study. The control group consisted of 20 healthy subjects matched for age, sex, and height. GFR was determined by measuring insulin with the continuous-infusion method. The clearance of endogenous creatinine was also measured after two daily urine collections. Renal plasma flow (RPF) was measured by p-aminohippurate clearance using the continuous-infusion method. Lean body weight was measured by impedentiometry. Adjusting for body surface area (in 1.73 m(2)) caused a significant reduction in GFR (P0.0001) in overweight humans (84.1 +/- 2.32 versus 109.6 +/- 3.07 mL/min/1.73 m(2)). The difference disappeared when GFR/height criteria were adopted. No difference between obese and healthy controls occurred after adjusting for lean body weight. Data for creatinine clearance paralleled those with insulin clearance; a significant reduction (P0.001) occurred after indexing for basal surface area, which disappeared after correction for height, as well as for lean body weight.

Background: Sevelamer hydrochloride, a major phosphate binder for patients on maintenance hemodialysis (MHD) is associated with reduced serum bicarbonate concentration due to hydrochloric acid release in the gut and to the binding of short chain fatty acids in the large intestine. Since metabolic acidosis can be deleterious, a study was devised to compare the time course of serum bicarbonate concentration during treatment with sevelamer hydrochloride or calcium carbonate.Methods: Sixteen well nourished patients on MHD who were in excellent clinical conditions and achieving target levels for blood pressure (BP) and hemoglobin (Hb), while on a protein intake of 1.1g/kg body weight (bw), were enrolled in the study. After a 2-week washout period, the patients were divided into two groups, each consisting of eight patients, and randomized either to 24 weeks of sevelamer followed by 24 weeks of calcium carbonate (group A) or to 24 weeks of calcium carbonate followed by 24 weeks of sevelamer (group B). Protein intake, n-protein catabolic rate (nPCR), serum concentrations of calcium, phosphate, calcium x phosphate (Ca x P) product, bicarbonate, intact parathyroid hormone (iPTH) and albumin were monitored. Time course changes in serum bicarbonate concentrations in relation to short and long dialytic intervals (48 vs. 72 hr) were also investigated.Results: Both sevelamer and calcium carbonate effectively controlled serum phosphate and the Ca x P product. During calcium carbonate treatment plasma phosphate concentrations were significantly below those of patients on sevelamer. Plasma bicarbonate concentration fell within target DOQI values during calcium carbonate administration both in group A and in group B, a goal which was not achieved under sevelamer administration. After a long dialytic interval in patients on sevelamer, serum bicarbonate concentration averaged 17.3 +/- 1.1mEq/L, whereas it averaged 21.1 +/- 0.7mEq/L in patients on calcium carbonate (p < 0.01). Finally, a 24-week sevelamer administration caused a statistically significant (p < 0.05) reduction (0.8 g/dL) in serum albumin concentration, without affecting iPTH. Taken together, these results indicate that sevelamer worsens metabolic acidosis, which needs to be corrected.

This work was directed to the study of the UV radiation effects on samples of polystyrene (PS) and copolymers of styrene with different proportions of 2-substituted-1,3-butadienes, in the presence of air and in solution, aiming at the optimisation of the degradation of the PS when exposed to the natural environment. Polymers were prepared by free-radical polymerization in solution, using azo-bis-isobutyronitrile as initiator, resulting in an average molecular weight, M w of about 30.0 kg/mol for the homo- and copolymers. The polymers were separated and characterized by infrared spectroscopy, elemental analysis, light scattering and gel permeation chromatography. The degradation rates were directly related to the increase in the comonomer contents of the polymers.

BACKGROUND AND OBJECTIVE To evaluate the use of remifentanil-propofol administered as target-controlled infusion during awake fibreoptic intubation for anticipated difficult tracheal intubation in acromegalic patients. METHOD In all, 20 consecutive acromegalic patients underwent elective endonasal endoscopic transsphenoidal pituitary surgery. After premedication with midazolam 0.03 mg kg(-1), initially a target-controlled infusion of remifentanil 1.0 ng mL(-1) and propofol 1.5 microg mL(-1) was started. The fibreoptic intubation was performed by the same physician experienced with the fibreoptic technique. During the fibreoptic procedure the target concentrations of remifentanil and propofol ranged between 1.0 and 5.0 ng mL(-1), and between 1.5 and 3.5 microg mL(-1), respectively. Changes in heart rate and mean arterial pressure were recorded during airway manipulation, during tracheal intubation, and at 1 and 3 min after. On the first postoperative day, patient recall and level of discomfort during fibreoptic intubation were evaluated. RESULTS Endotracheal intubation was efficaciously and quickly secured in all patients. A significant increase in mean arterial pressure and heart rate was recorded only during tracheal intubation (P < 0.05). Oxygenation was sufficient and no bradypnea or apnoea was recorded. All patients later described their anaesthetic experience as satisfactory. During fibreoptic intubation, remifentanil (ng mL(-1)) and propofol (microg mL(-1)) mean effect-site concentrations were 3.2 +/- 0.3 and 2.0 +/- 1.0, respectively. CONCLUSION Remifentanil and propofol target-controlled infusion provided satisfactory conscious sedation allowing for successful oral fibreoptic intubation in acromegalic patients with no recall.

Renal dysfunction is a constant feature of congestive heart failure and is a stronger predictor of mortality than left ventricular ejection fraction or New York Heart Association classification. In heart failure, a reduction of glomerular filtration rate and renal plasma flow occurs, although the filtration fraction increases. There are many reason for this pattern. A reduction in effective circulating volume stimulates sympathetic activity and the renin-angiotensin-aldosterone system, and it is associated with increased concentrations of atrial natriuretic peptide, brain natriuretic peptide, and tumor necrosis factor α. Because in chronic kidney disease heart dysfunction commonly is present, an efficient cardiologist-nephrologist interaction should be promoted. © 2005 Elsevier Inc. All rights reserved.

Objectives: To analyse circulating concentrations of advanced glycation end products (AGEs) in patients with severe congestive heart failure (CHF) and after heart transplantation; to identify the potential contribution of kidney function to plasma AGE concentrations; and to determine whether AGE concentrations and parameters of oxidative stress are interrelated.Methods and results: Circulating N-epsilon-(carboxymethyl) lysine (CML) and AGE associated fluorescence (AGE-Fl), lipid peroxidation, and glomerular filtration rate (GFR) were measured in a cross sectional study of 22 patients with advanced CHF, 30 heart transplant recipients, and 20 healthy controls. Compared with the controls, the CHF patients had decreased CML (mean(SEM) 467.8 (20.0) ng/ml v 369.3 (22.3) ng/ml, p