A Narrative Review about Autism Spectrum Disorders and Exclusion of Gluten and Casein from the Diet

This research received funding from CTS549 group of Psiquiatry and Neurosciences from the University of Granada.Objective: Autism spectrum disorders (ASDs) appear in the early stages of neurodevelopment, and they remain constant throughout life. Currently, due to limitations in ASDs treatment, alternative approaches, such as nutritional interventions, have frequently been implemented. The aim of this narrative review is to gather the most relevant and updated studies about dietary interventions related to ASDs etiopathogenesis. Results: Our literature search focused on the gluten- and casein-free (GFCF) diet. The literature found shows the inexistence of enough scientific evidence to support a general recommendation of dietary intervention in children with ASD. Protocols and procedures for assessing risk and safety are also needed. Future lines: Prospective and controlled research studies with larger sample sizes and longer follow-up times are scarce and needed. In addition, studies considering an assessment of intestinal permeability, bacterial population, enzymatic, and inflammatory gastrointestinal activity are interesting to identify possible responders. Besides brain imaging techniques, genetic tests can also contribute as markers to evaluate the comorbidity of gastrointestinal symptoms.University of Granada CTS54

Features Associated With Depressive Predominant Polarity and Early Illness Onset in Patients With Bipolar Disorder

Objective: The aim of this study is to determine the prevalence of three possible diagnostic specifiers, namely predominant polarity (PP) throughout illness, polarity of the first episode and early age at onset, in a sample of bipolar disorder (BD) patients and their association with important socio-demographic, clinical and course-of-illness variables. Methods: A retrospective and naturalistic study on 108 BD outpatients, who were classified according to the PP, polarity of the first episode and early age at onset ( 20 years) [vs. late (>20 years)] and were characterized by their demographics, clinical data, functionality and social support, among others features. After bivariate analyses, those variables showing certain association (P value < 0.25) with the three dependent variables were entered in logistic regression backward selection procedures to identify the variables independently associated with the PP, polarity of the first episode and early age at onset. Results: The sample consisted of 75 women ad 33 men, 74% with type I BD and 26% with type II. Around 70% had depressive PP, onset with a depressive episode and onset after age 20. Depressive PP was independently associated with depressive onset, higher score on the CGI severity scale and work disability. Onset with depressive episode was associated with type II BD, longer diagnostic delay and higher score on family disability. Early age at onset ( 20 years) was associate with younger age, longer diagnostic delay, presence of ever psychotic symptoms, current use of antipsychotic drugs and higher social support score. Conclusions: The results of this study show that BD patients with depressive PP, onset with depression and early age at onset may represent greater severity, because they are frequently associated with variables that worsen the prognosis. Our findings match up with the conclusions of two systematic reviews and we also include a disability factor (at family and work) that has not been previously reported. This work contributes to the use of polarity and age at onset in BD patients, as it can become a useful instrument in the prognostic and therapeutic applications

Epidemiology of social phobia in Andalusia.

Introducción: Los estudios poblacionales sobre trastorno de ansiedad social (TAS) son relativamente infrecuentes no habiendo información sobre prevalencia y correlatos del TAS en la población general andaluza. Material y métodos: Se estudió una muestra aleatoria y representativa de la población general andaluza identificada previamente por métodos estandarizados de estratificación. Así, se incluyeron un total de 4.507 participantes (tasa de respuesta el 83,7%) a los que se administró una batería de pruebas que incluyó: variables sociodemográficas, clínicas y psicosociales (acontecimientos vitales amenazantes, experiencia previa de abusos, presencia de trastorno de personalidad, rasgos de neuroticismo, impulsividad y paranoia, autonomía global, salud física, consumo de tóxicos). El diagnóstico de TAS se realizó con la MINI International Diagnostic Interview. Se identificaron prevalencias de TAS con un IC 95% y correlatos y comorbilidades con TAS testados mediante regresión logística binaria. Resultados: La prevalencia de TAS encontrada fue del 1,1% (IC 95% = 0,8-1,4). El diagnóstico de fobia social se asoció independiente y significativamente con una menor edad, menor nivel de autonomía global, presentar trastorno de personalidad, tener niveles más elevados de neuroticismo y de paranoia, haber sufrido maltrato en la infancia y haber tenido acontecimientos vitales amenazantes. Además, el TAS se asoció comórbidamente con depresión mayor, trastorno de pánico y abuso de alcohol. Conclusiones: La prevalencia y los factores asociados a TAS en la población andaluza son relativamente similares a los encontrados en estudios internacionales, aunque la asociación entre TAS y paranoia no había sido reportada anteriormente.Introduction: Population studies on social anxiety disorder (SAD) are relatively scarce and there is no previous reported evidence on prevalence or correlates of SAD in an Andalusian general population sample. Material and methods: We used a random representative sample previously identified via standard stratification procedures. Thus, a final sample of 4507 participants were included (response rate 83.7%). Interviewees were thoroughly assessed on sociodemographic, clinical and psychosocial factors, including: exposures to threatening life events (TLEs), childhood abuse, personality disorder and traits (neuroticism, impulsivity, paranoia), global functioning, physical health and toxics consumption. SAD diagnosis was ascertained using the Mini International Neuropsychiatric Interview. Both, pooled prevalences (with 95% confidence intervals) and risk correlates for SAD were estimated using binary logistic regression. Results: Estimated prevalence for SAD was 1.1% (95%CI=0.8-1.4). Having a SAD diagnosis was independently and significantly associated with younger age, poorer global functioning, higher neuroticism and paranoia personality traits, having suffered childhood abuse and exposure to previous TLEs. Furthermore, SAD was significantly associated with comorbid personality disorder, major depression, panic disorder and alcohol abuse. Conclusions: Among this large Andalusian population sample, prevalence of SAD and its associated factors are relatively similar to previously reported international studies, although no population study had reported earlier such a strong association with paranoia.Introduction: Population studies on social anxiety disorder (SAD) are relatively scarce and there is no previous reported evidence on prevalence or correlates of SAD in an Andalusian general population sample. Material and methods: We used a random representative sample previously identified via standard stratification procedures. Thus, a final sample of 4507 participants were included (response rate 83.7%). Interviewees were thoroughly assessed on sociodemographic, clinical and psychosocial factors, including: exposures to threatening life events (TLEs), childhood abuse, personality disorder and traits (neuroticism, impulsivity, paranoia), global functioning, physical health and toxics consumption. SAD diagnosis was ascertained using the Mini International Neuropsychiatric Interview. Both, pooled prevalences (with 95% confidence intervals) and risk correlates for SAD were estimated using binary logistic regression. Results: Estimated prevalence for SAD was 1.1% (95%CI=0.8-1.4). Having a SAD diagnosis was independently and significantly associated with younger age, poorer global functioning, higher neuroticism and paranoia personality traits, having suffered childhood abuse and exposure to previous TLEs. Furthermore, SAD was significantly associated with comorbid personality disorder, major depression, panic disorder and alcohol abuse. Conclusions: Among this large Andalusian population sample, prevalence of SAD and its associated factors are relatively similar to previously reported international studies, although no population study had reported earlier such a strong association with paranoia.El trabajo fue financiado, sin beneficio económico alguno para los autores, por las siguientes becas públicas de la Consejería de Innovación (Proyectos de Excelencia n.◦ 10- CTS-6682) y por el ministerio de ciencia e innovación ISCIII (Proyecto # ISCIII PI18/00467) y ISCIII, Proyectos de Investigación en Salud (Ref. PI18/00467) FEDER/Junta de Andalucía-Consejería de Economía y Conocimiento/ Proyecto B-CTS-361-UGR18. La financiación para open access corrió a cargo de Universidad de Granada / CBUA

Predicting sudden cardiac death in adults with congenital heart disease

[Objectives] To develop, calibrate, test and validate a logistic regression model for accurate risk prediction of sudden cardiac death (SCD) and non-fatal sudden cardiac arrest (SCA) in adults with congenital heart disease (ACHD), based on baseline lesion-specific risk stratification and individual’s characteristics, to guide primary prevention strategies.[Methods] We combined data from a single-centre cohort of 3311 consecutive ACHD patients (50% male) at 25-year follow-up with 71 events (53 SCD and 18 non-fatal SCA) and a multicentre case–control group with 207 cases (110 SCD and 97 non-fatal SCA) and 2287 consecutive controls (50% males). Cumulative incidences of events up to 20 years for specific lesions were determined in the prospective cohort. Risk model and its 5-year risk predictions were derived by logistic regression modelling, using separate development (18 centres: 144 cases and 1501 controls) and validation (two centres: 63 cases and 786 controls) datasets.[Results] According to the combined SCD/SCA cumulative 20 years incidence, a lesion-specific stratification into four clusters—very-low (12%)—was built. Multivariable predictors were lesion-specific cluster, young age, male sex, unexplained syncope, ischaemic heart disease, non-life threatening ventricular arrhythmias, QRS duration and ventricular systolic dysfunction or hypertrophy. The model very accurately discriminated (C-index 0.91; 95% CI 0.88 to 0.94) and calibrated (p=0.3 for observed vs expected proportions) in the validation dataset. Compared with current guidelines approach, sensitivity increases 29% with less than 1% change in specificity.[Conclusions] Predicting the risk of SCD/SCA in ACHD can be significantly improved using a baseline lesion-specific stratification and simple clinical variables.Peer reviewe

Efficacy of clozapine versus standard treatment in adult individuals with intellectual disability and treatment-resistant psychosis (CLOZAID): study protocol of a multicenter randomized clinical trial

BackgroundIntellectual disability (ID) affects approximately 1% of the worldwide population and individuals with ID have a higher comorbidity with mental illness, and specifically psychotic disorders. Unfortunately, among individuals with ID, limited research has been conducted since ID individuals are usually excluded from mental illness epidemiological studies and clinical trials. Here we perform a clinical trial to investigate the effectiveness of clozapine in the treatment of resistant psychosis in individuals with ID. The article highlights the complexity of diagnosing and treating psychopathological alterations associated with ID and advocates for more rigorous research in this field.MethodsA Phase IIB, open-label, randomized, multicenter clinical trial (NCT04529226) is currently ongoing to assess the efficacy of oral clozapine in individuals diagnosed with ID and suffering from treatment-resistant psychosis. We aim to recruit one-hundred and fourteen individuals (N=114) with ID and resistant psychosis, who will be randomized to TAU (treatment as usual) and treatment-with-clozapine conditions. As secondary outcomes, changes in other clinical scales (PANSS and SANS) and the improvement in functionality, assessed through changes in the Euro-QoL-5D-5L were assessed. The main outcome variables will be analyzed using generalized linear mixed models (GLMM), assessing the effects of status variable (TAU vs. Clozapine), time, and the interaction between them.DiscussionThe treatment of resistant psychosis among ID individuals must be directed by empirically supported research. CLOZAID clinical trial may provide relevant information about clinical guidelines to optimally treat adults with ID and treatment-resistant psychosis and the benefits and risks of an early use of clozapine in this underrepresented population in clinical trials.Trial registrationClinicaltrials.gov: NCT04529226. EudraCT: 2020-000091-37

Prevalence, associated factors and outcomes of pressure injuries in adult intensive care unit patients: the DecubICUs study

Funder: European Society of Intensive Care Medicine; doi: http://dx.doi.org/10.13039/501100013347Funder: Flemish Society for Critical Care NursesAbstract: Purpose: Intensive care unit (ICU) patients are particularly susceptible to developing pressure injuries. Epidemiologic data is however unavailable. We aimed to provide an international picture of the extent of pressure injuries and factors associated with ICU-acquired pressure injuries in adult ICU patients. Methods: International 1-day point-prevalence study; follow-up for outcome assessment until hospital discharge (maximum 12 weeks). Factors associated with ICU-acquired pressure injury and hospital mortality were assessed by generalised linear mixed-effects regression analysis. Results: Data from 13,254 patients in 1117 ICUs (90 countries) revealed 6747 pressure injuries; 3997 (59.2%) were ICU-acquired. Overall prevalence was 26.6% (95% confidence interval [CI] 25.9–27.3). ICU-acquired prevalence was 16.2% (95% CI 15.6–16.8). Sacrum (37%) and heels (19.5%) were most affected. Factors independently associated with ICU-acquired pressure injuries were older age, male sex, being underweight, emergency surgery, higher Simplified Acute Physiology Score II, Braden score 3 days, comorbidities (chronic obstructive pulmonary disease, immunodeficiency), organ support (renal replacement, mechanical ventilation on ICU admission), and being in a low or lower-middle income-economy. Gradually increasing associations with mortality were identified for increasing severity of pressure injury: stage I (odds ratio [OR] 1.5; 95% CI 1.2–1.8), stage II (OR 1.6; 95% CI 1.4–1.9), and stage III or worse (OR 2.8; 95% CI 2.3–3.3). Conclusion: Pressure injuries are common in adult ICU patients. ICU-acquired pressure injuries are associated with mainly intrinsic factors and mortality. Optimal care standards, increased awareness, appropriate resource allocation, and further research into optimal prevention are pivotal to tackle this important patient safety threat

Correction to: Prevalence, associated factors and outcomes of pressure injuries in adult intensive care unit patients: the DecubICUs study

The original version of this article unfortunately contained a mistake

Prevalence, associated factors and outcomes of pressure injuries in adult intensive care unit patients: the DecubICUs study

Funder: European Society of Intensive Care Medicine; doi: http://dx.doi.org/10.13039/501100013347Funder: Flemish Society for Critical Care NursesAbstract: Purpose: Intensive care unit (ICU) patients are particularly susceptible to developing pressure injuries. Epidemiologic data is however unavailable. We aimed to provide an international picture of the extent of pressure injuries and factors associated with ICU-acquired pressure injuries in adult ICU patients. Methods: International 1-day point-prevalence study; follow-up for outcome assessment until hospital discharge (maximum 12 weeks). Factors associated with ICU-acquired pressure injury and hospital mortality were assessed by generalised linear mixed-effects regression analysis. Results: Data from 13,254 patients in 1117 ICUs (90 countries) revealed 6747 pressure injuries; 3997 (59.2%) were ICU-acquired. Overall prevalence was 26.6% (95% confidence interval [CI] 25.9–27.3). ICU-acquired prevalence was 16.2% (95% CI 15.6–16.8). Sacrum (37%) and heels (19.5%) were most affected. Factors independently associated with ICU-acquired pressure injuries were older age, male sex, being underweight, emergency surgery, higher Simplified Acute Physiology Score II, Braden score 3 days, comorbidities (chronic obstructive pulmonary disease, immunodeficiency), organ support (renal replacement, mechanical ventilation on ICU admission), and being in a low or lower-middle income-economy. Gradually increasing associations with mortality were identified for increasing severity of pressure injury: stage I (odds ratio [OR] 1.5; 95% CI 1.2–1.8), stage II (OR 1.6; 95% CI 1.4–1.9), and stage III or worse (OR 2.8; 95% CI 2.3–3.3). Conclusion: Pressure injuries are common in adult ICU patients. ICU-acquired pressure injuries are associated with mainly intrinsic factors and mortality. Optimal care standards, increased awareness, appropriate resource allocation, and further research into optimal prevention are pivotal to tackle this important patient safety threat

Reducing the environmental impact of surgery on a global scale: systematic review and co-prioritization with healthcare workers in 132 countries

Abstract Background Healthcare cannot achieve net-zero carbon without addressing operating theatres. The aim of this study was to prioritize feasible interventions to reduce the environmental impact of operating theatres. Methods This study adopted a four-phase Delphi consensus co-prioritization methodology. In phase 1, a systematic review of published interventions and global consultation of perioperative healthcare professionals were used to longlist interventions. In phase 2, iterative thematic analysis consolidated comparable interventions into a shortlist. In phase 3, the shortlist was co-prioritized based on patient and clinician views on acceptability, feasibility, and safety. In phase 4, ranked lists of interventions were presented by their relevance to high-income countries and low–middle-income countries. Results In phase 1, 43 interventions were identified, which had low uptake in practice according to 3042 professionals globally. In phase 2, a shortlist of 15 intervention domains was generated. In phase 3, interventions were deemed acceptable for more than 90 per cent of patients except for reducing general anaesthesia (84 per cent) and re-sterilization of ‘single-use’ consumables (86 per cent). In phase 4, the top three shortlisted interventions for high-income countries were: introducing recycling; reducing use of anaesthetic gases; and appropriate clinical waste processing. In phase 4, the top three shortlisted interventions for low–middle-income countries were: introducing reusable surgical devices; reducing use of consumables; and reducing the use of general anaesthesia. Conclusion This is a step toward environmentally sustainable operating environments with actionable interventions applicable to both high– and low–middle–income countries

Influencia de una dieta libre de gluten y caseína sobre las alteraciones del comportamiento en niños y adolescentes diagnosticados de trastorno del espectro autista

Introducción y objetivos. Dadas las limitaciones en el tratamiento de los Trastornos del Espectro Autista (TEA), muchas familias recurren al uso de intervenciones alternativas. La dieta libre de gluten y caseína (DLGC) como enfoque etiopatogénico y terapéutico de los TEA ha recibido abundante atención bibliográfica y sigue siendo actualmente objeto de interés y controversia. La beta-casomorfina es un péptido derivado de las proteínas de la leche de vaca, llamada así por su procedencia (caseína) y por su actividad opioide similar a la morfina. Se ha postulado que los sujetos con TEA podrían tener altas concentraciones de estos biopéptidos que influirían en el origen y en el curso de los síntomas nucleares y periféricos del autismo. Los objetivos de esta investigación son: 1) Determinar la influencia de una DLGC sobre las alteraciones del comportamiento de niños y adolescentes diagnosticados de TEA y 2) Estudiar la relación entre los posibles cambios conductuales y los niveles urinarios de beta-casomorfina. Material y método. Se realizaron dos estudios de similares características pero con periodos de seguimiento diferentes, en diferentes momentos de tiempo y utilizando muestras distintas. Primero se realizó un estudio a 3 + 3 meses de seguimiento y años más tarde se replicó la metodología para un segundo estudio en el que se amplió la intervención a 6 + 6 meses. El tipo de diseño escogido para ambos estudios fue un ensayo clínico aleatorizado cruzado a simple ciego. El periodo de seguimiento se dividió en dos fases de la misma duración cada una (tres meses para el primer estudio y seis meses para el segundo). Cada participante recibió durante una fase dieta normal (con gluten y caseína) y durante la otra fase DLGC. Se asignó aleatoriamente el orden de intervención (empezar con dieta normal o DLGC) y se realizaron tres evaluaciones a lo largo del seguimiento (al inicio de cada estudio, tras la dieta normal y tras la DLGC). En cada evaluación se cumplimentaron cuestionarios de conducta y autismo, de seguimiento de la dieta y se determinaron los niveles de beta-casomorfina en orina. Resultados. En ninguno de los dos estudios (3 + 3 meses y 6 + 6 meses) se encontraron cambios significativos en las escalas de conducta ni en los niveles urinarios de beta-casomorfina tras la DLGC. Conclusiones. Una DLGC no produce cambios significativos en los síntomas comportamentales del autismo ni en los niveles urinarios de beta-casomorfina. Son necesarios futuros estudios que, además de eliminar el gluten y la caseína durante un periodo de tiempo suficiente (al menos 6 meses), incluyan elementos de placebo y doble ciego, así como otros marcadores biológicos para definir mejor a los sujetos que puedan beneficiarse de estas dietas.Tesis Univ. Granada