Multi-ancestry genome-wide association study of 21,000 cases and 95,000 controls identifies new risk loci for atopic dermatitis

Genetic association studies have identified 21 loci associated with atopic dermatitis risk predominantly in populations of European ancestry. To identify further susceptibility loci for this common, complex skin disease, we performed a meta-analysis of >15 million genetic variants in 21,399 cases and 95,464 controls from populations of European, African, Japanese and Latino ancestry, followed by replication in 32,059 cases and 228,628 controls from 18 studies. We identified ten new risk loci, bringing the total number of known atopic dermatitis risk loci to 31 (with new secondary signals at four of these loci). Notably, the new loci include candidate genes with roles in the regulation of innate host defenses and T cell function, underscoring the important contribution of (auto)immune mechanisms to atopic dermatitis pathogenesis

Variation in Structure and Process of Care in Traumatic Brain Injury: Provider Profiles of European Neurotrauma Centers Participating in the CENTER-TBI Study.

INTRODUCTION: The strength of evidence underpinning care and treatment recommendations in traumatic brain injury (TBI) is low. Comparative effectiveness research (CER) has been proposed as a framework to provide evidence for optimal care for TBI patients. The first step in CER is to map the existing variation. The aim of current study is to quantify variation in general structural and process characteristics among centers participating in the Collaborative European NeuroTrauma Effectiveness Research in Traumatic Brain Injury (CENTER-TBI) study. METHODS: We designed a set of 11 provider profiling questionnaires with 321 questions about various aspects of TBI care, chosen based on literature and expert opinion. After pilot testing, questionnaires were disseminated to 71 centers from 20 countries participating in the CENTER-TBI study. Reliability of questionnaires was estimated by calculating a concordance rate among 5% duplicate questions. RESULTS: All 71 centers completed the questionnaires. Median concordance rate among duplicate questions was 0.85. The majority of centers were academic hospitals (n = 65, 92%), designated as a level I trauma center (n = 48, 68%) and situated in an urban location (n = 70, 99%). The availability of facilities for neuro-trauma care varied across centers; e.g. 40 (57%) had a dedicated neuro-intensive care unit (ICU), 36 (51%) had an in-hospital rehabilitation unit and the organization of the ICU was closed in 64% (n = 45) of the centers. In addition, we found wide variation in processes of care, such as the ICU admission policy and intracranial pressure monitoring policy among centers. CONCLUSION: Even among high-volume, specialized neurotrauma centers there is substantial variation in structures and processes of TBI care. This variation provides an opportunity to study effectiveness of specific aspects of TBI care and to identify best practices with CER approaches

Variation in general supportive and preventive intensive care management of traumatic brain injury: a survey in 66 neurotrauma centers participating in the Collaborative European NeuroTrauma Effectiveness Research in Traumatic Brain Injury (CENTER-TBI) study

Abstract Background General supportive and preventive measures in the intensive care management of traumatic brain injury (TBI) aim to prevent or limit secondary brain injury and optimize recovery. The aim of this survey was to assess and quantify variation in perceptions on intensive care unit (ICU) management of patients with TBI in European neurotrauma centers. Methods We performed a survey as part of the Collaborative European NeuroTrauma Effectiveness Research in Traumatic Brain Injury (CENTER-TBI) study. We analyzed 23 questions focused on: 1) circulatory and respiratory management; 2) fever control; 3) use of corticosteroids; 4) nutrition and glucose management; and 5) seizure prophylaxis and treatment. Results The survey was completed predominantly by intensivists (n = 33, 50%) and neurosurgeons (n = 23, 35%) from 66 centers (97% response rate). The most common cerebral perfusion pressure (CPP) target was > 60 mmHg (n = 39, 60%) and/or an individualized target (n = 25, 38%). To support CPP, crystalloid fluid loading (n = 60, 91%) was generally preferred over albumin (n = 15, 23%), and vasopressors (n = 63, 96%) over inotropes (n = 29, 44%). The most commonly reported target of partial pressure of carbon dioxide in arterial blood (PaCO2) was 36–40 mmHg (4.8–5.3 kPa) in case of controlled intracranial pressure (ICP) < 20 mmHg (n = 45, 69%) and PaCO2 target of 30–35 mmHg (4–4.7 kPa) in case of raised ICP (n = 40, 62%). Almost all respondents indicated to generally treat fever (n = 65, 98%) with paracetamol (n = 61, 92%) and/or external cooling (n = 49, 74%). Conventional glucose management (n = 43, 66%) was preferred over tight glycemic control (n = 18, 28%). More than half of the respondents indicated to aim for full caloric replacement within 7 days (n = 43, 66%) using enteral nutrition (n = 60, 92%). Indications for and duration of seizure prophylaxis varied, and levetiracetam was mostly reported as the agent of choice for both seizure prophylaxis (n = 32, 49%) and treatment (n = 40, 61%). Conclusions Practice preferences vary substantially regarding general supportive and preventive measures in TBI patients at ICUs of European neurotrauma centers. These results provide an opportunity for future comparative effectiveness research, since a more evidence-based uniformity in good practices in general ICU management could have a major impact on TBI outcome

Variation in neurosurgical management of traumatic brain injury

Background: Neurosurgical management of traumatic brain injury (TBI) is challenging, with only low-quality evidence. We aimed to explore differences in neurosurgical strategies for TBI across Europe. Methods: A survey was sent to 68 centers participating in the Collaborative European Neurotrauma Effectiveness Research in Traumatic Brain Injury (CENTER-TBI) study. The questionnaire contained 21 questions, including the decision when to operate (or not) on traumatic acute subdural hematoma (ASDH) and intracerebral hematoma (ICH), and when to perform a decompressive craniectomy (DC) in raised intracranial pressure (ICP). Results: The survey was completed by 68 centers (100%). On average, 10 neurosurgeons work in each trauma center. In all centers, a neurosurgeon was available within 30 min. Forty percent of responders reported a thickness or volume threshold for evacuation of an ASDH. Most responders (78%) decide on a primary DC in evacuating an ASDH during the operation, when swelling is present. For ICH, 3% would perform an evacuation directly to prevent secondary deterioration and 66% only in case of clinical deterioration. Most respondents (91%) reported to consider a DC for refractory high ICP. The reported cut-off ICP for DC in refractory high ICP, however, differed: 60% uses 25 mmHg, 18% 30 mmHg, and 17% 20 mmHg. Treatment strategies varied substantially between regions, specifically for the threshold for ASDH surgery and DC for refractory raised ICP. Also within center variation was present: 31% reported variation within the hospital for inserting an ICP monitor and 43% for evacuating mass lesions. Conclusion: Despite a homogeneous organization, considerable practice variation exists of neurosurgical strategies for TBI in Europe. These results provide an incentive for comparative effectiveness research to determine elements of effective neurosurgical care

Swiss recommendations for non-anaesthesiologist administered procedural sedation and analgesia in adults

Various specialists use sedation and analgesia for their interventions without the presence of an anaesthesiologist. Therefore, the need for professional recommendations is obvious. The Swiss recommendations were first published in 2016. In contrast to other guidelines, especially those published by the European Society of Anaesthesiology, the Swiss recommendations were developed in close cooperation with other relevant societies that practise procedural sedation and analgesia in adults. The Swiss recommendations were approved by the members of the Swiss Society of Anaesthesiology and Reanimation, the Swiss Society of Gastroenterology and Hepatology, the Swiss Society of Pulmonology, the Swiss Society of Cardiology and the Swiss Society of Vascular and Interventional Radiology. In this way, maximum acceptance and practicability were achieved. Unlike in other recommendations, for example the American Society of Anesthesiology guidelines, the most critical points such as how to deal with deep sedation and who is allowed to perform have been extensively discussed in the Swiss working group and are also addressed in the Swiss recommendations. The key points of the Swiss recommendations are multidisciplinary acceptance, advanced preoperative evaluation and selection of patients, clear safety recommendations and minimal requirements regarding monitoring, documentation and staff

Heritable responses to combined effects of heat stress and ivermectin in the yellow dung fly

In current times of global change, several sources of stress such as contaminants and high temperatures may act synergistically. The extent to which organisms persist in stressful conditions will depend on the fitness consequences of multiple simultaneously acting stressors and the genetic basis of compensatory genetic responses. Ivermectin is an antiparasitic drug used in livestock that is excreted in dung of treated cattle, causing severe negative consequences on non-target fauna. We evaluated the effect of a combination of heat stress and exposure to ivermectin in the yellow dung fly, Scathophaga stercoraria (Diptera: Scathophagidae). In a first experiment we investigated the effects of high rearing temperature on susceptibility to ivermectin, and in a second experiment we assayed flies from a latitudinal gradient to assess potential effects of local thermal adaptation on ivermectin sensitivity. The combination of heat and ivermectin synergistically reduced offspring survival, revealing severe effects of the two stressors when combined. However, latitudinal populations did not systematically vary in how ivermectin affected offspring survival, body size, development time, cold and heat tolerance. We also found very low narrow-sense heritability of ivermectin sensitivity, suggesting evolutionary constraints for responses to the combination of these stressors beyond immediate maternal or plastic effects. If the revealed patterns hold also for other invertebrates, the combination of increasing climate warming and ivermectin stress may thus have severe consequences for biodiversity. More generally, our study underlines the need for quantitative genetic analyses in understanding wildlife responses to interacting stressors that act synergistically and threat biodiversity

Heritable responses to combined effects of heat stress and ivermectin in the yellow dung fly

In current times of global change, several sources of stress such as contaminants and high temperatures may act synergistically. The extent to which organisms persist in stressful conditions will depend on the fitness consequences of multiple simultaneously acting stressors and the genetic basis of compensatory genetic responses. Ivermectin is an antiparasitic drug used in livestock that is excreted in dung of treated cattle, causing severe negative consequences on non-target fauna. We evaluated the effect of a combination of heat stress and exposure to ivermectin in the yellow dung fly, Scathophaga stercoraria (Diptera: Scathophagidae). In a first experiment we investigated the effects of high rearing temperature on susceptibility to ivermectin, and in a second experiment we assayed flies from a latitudinal gradient to assess potential effects of local thermal adaptation on ivermectin sensitivity. The combination of heat and ivermectin synergistically reduced offspring survival, revealing severe effects of the two stressors when combined. However, latitudinal populations did not systematically vary in how ivermectin affected offspring survival, body size, development time, cold and heat tolerance. We also found very low narrow-sense heritability of ivermectin sensitivity, suggesting evolutionary constraints for responses to the combination of these stressors beyond immediate maternal or plastic effects. If the revealed patterns hold also for other invertebrates, the combination of increasing climate warming and ivermectin stress may thus have severe consequences for biodiversity. More generally, our study underlines the need for quantitative genetic analyses in understanding wildlife responses to interacting stressors that act synergistically and threat biodiversity