Modalita' di sedoanalgesia e di analgosedazione e disturbi cognitivi

Questo studio fa parte del “Progetto Van Gogh” , nato per individuare e comprendere i fattori che favoriscono l'insorgenza di Delirio e Disturbo Post traumatico da Stress(PTSD)nei pazienti ricoverati in terapia intensiva, così da ridurne l'incidenza, migliorarne il decorso clinico e favorirne un migliore recupero e reinserimento nella società. È stato selezionato un gruppo di 122 pazienti con un’età media di 64,71 + o – 2,82 anni (40 donne con un’età media di 64,71 +o- 14,27 anni e 82 uomini con un’età media di 64,97 +o- 13,32 anni) ricoverati dall’ottobre 2009 al gennaio 2010 presso il reparto di terapia intensiva dell’ospedale Santa Chiara di Pisa. I criteri di esclusione prevedevano un’età inferiore ai 18 anni, ricovero in seguito a trauma cranico, interventi di neurochirurgia, anamnesi positiva per malattie psichiatriche. Di tali pazienti sono stati considerati:sesso ed età,presenza di sepsi,tipo di trattamento subito (chirurgico o meno),tipo di ventilazione e durata di questa, presenza di alterazioni emodinamiche e dell’equilibrio acido base e il tipo di trattamento analgesico. Per la valutazione della presenza del delirio è stata utilizzata la Confusion Assessment Method for the ICU (CAM-ICU), facendo due misurazioni al giorno: una fra le ore 8 e le 9 e la seconda fra le 14 e le 15. Inoltre in tali orari venivano appuntati i valori di pressione arteriosa, saturazione di ossigeno e tipo di ventilazione, i valori dell’emogas analisi e la presenza o meno di dolore. A distanza di circa un mese i pazienti sono stati poi intervistati telefonicamente per la valutazione della presenza di PTSD. Per la valutazione abbiamo utilizzato la Davidson Trauma Scale, considerando come probabile PTSD i punteggi uguali o superiori a 20. Da questa grande quantità di dati ottenuti, il mio studio è andato ad analizzare nello specifico se tra analgosedazione e sedoanalgesia sussiste una differenza significativa nello sviluppo di Delirio e PTSD

The perception of the affective expressions of anger and fear: evidence for fast and slow processing of threatening faces

Ein Gesichtsausdruck von Ärger wird leichter erkannt und löst eine stärkere affektive Reaktion in einem Betrachter aus, wenn Blickkontakt vorliegt. Ein angstvoller Ausdruck hat hingegen eine stärkere Wirkung, wenn der Blick der betrachteten Person auf die Umgebung gerichtet ist. Eine Interpretation dieses Befundes zielt auf die Bedrohlichkeit der betrachteten Gesichter ab: Ärger legt bei direktem Blick eine unmittelbare Bedrohung nahe, Angst weist bei abgewandtem Blick auf eine mögliche Bedrohung in einer geteilten Umwelt hin. Die Verarbeitung von Bedrohungsinformationen aus Gesichtern könnte durch ein spezialisiertes mentales und hirnphysiologisches Organ, ein sogenanntes „Modul“ erfolgen, das unabhängig von Bewusstsein operiert und in dem die Amygdala eine zentrale Rolle einnimmt. Die Amygdala ist eine Hirnstruktur, die mit schneller Gefahrenerkennung und unwillkürlichen Schutzreaktionen in Verbindung gebracht wird. Unklar war bislang, ob sich die genannten Reize tatsächlich durch eine vergleichsweise stärkere Bedrohlichkeit auszeichnen, und ob der obige Interaktionsbefund – hinsichtlich der Aktivierung der Amygdala und des Verhalten von Versuchspersonen – auch in Abwesenheit voll ausgeprägten Reizbewusstseins vorliegt. Das Projekt hat diese Fragen untersucht. Zunächst konnte gezeigt werden, dass die Stärke der Schreckreaktion, die während der Betrachtung von Bildern ausgelöst wird, die Bedrohlichkeit widerspiegelt, die Versuchspersonen subjektiv durch sie empfinden. Anhand der Schreckreaktion als einem objektiven Bedrohungsmaß konnte anschließend bestätigt werden, dass Ärgerausdrücke mit direktem Blick (Blickkontakt) und Angstausdrücke mit abgewandtem Blick eine stärkere Bedrohung hervorrufen als die beiden komplementären Reizbedingungen. In einem dritten Experiment wurden diese Reize schließlich so präsentiert, dass sie keinen voll ausgeprägten Bewusstheitseindruck hervorrufen konnten. Dies geschah durch ihre sehr kurze Darbietung einschließlich eines unmittelbar darauf folgenden zweiten Reizes, der den Eindruck des ersten zeitlich überlagerte. Trotz dieser erschwerten Sehbedingungen zeigten Versuchspersonen im Erkennen der Reizkategorien Unterschiede, die mit der bevorzugten Verarbeitung besonders bedrohlicher Gesichter – Ärgerausdrücke mit direktem und Angstausdrücke mit abgewandtem Blick – kompatibel sind. Zusätzlich wurde in diesem dritten Experiment die Beteiligung verschiedener Hirnstrukturen untersucht. Für die Amygdala zeigte sich ein uneinheitlicher Befund: Während Ärgerausdrücke die Amygdala unabhängig von einem bewussten Seheindruck zu aktivieren schienen, waren Angstausdrücke offenbar auf einen solchen angewiesen. Dieses zweite Ergebnis passt zu Befunden anderer Forscher, die eine Aktivierung der Amygdala durch beobachtete Angst (im Gegensatz zu Ärger) mit der aufmerksamkeitsbasierten Lokalisation möglicher Gefahren in Verbindung bringen. Somit legt diese Arbeit nahe, dass zumindest für Ärgerausdrücke der Einfluss der Blickrichtung auf ihre Verarbeitung auf der Funktionsweise eines spezialisierten Moduls zur Bedrohungsermittlung beruht. Blickrichtungseinflüsse auf die Angstwahrnehmung hingegen scheinen anteilig auf bewusster Reizverarbeitung zu beruhen, auch wenn diese ebenfalls zu gesteigerter Bedrohlichkeit führen kann. Für die funktionale Rolle der Amygdala muss dies kein Widerspruch sein, da sie eine komplexe Struktur ist und daher an unterschiedlichen Hirnfunktionen beteiligt sein kann.The literature reports an interaction effect of facial expression (anger/fear) and gaze direction (direct/averted) on perceptual (detection scores), affective (ratings), and neurophysiological (BOLD response of the amygdala) measures: direct-gaze angry and averted fearful faces are particularly salient. The purpose of this work was to assess, to what extent this effect is mediated by threat. This was done by examining startle potentiation by the overt (experiment 1/2), as well as signal detection and brain activation by the covert (backward masked) presentation of affective faces with varying in gaze direction. The results suggest the advantage of direct-gaze anger (vs. averted) to be mediated by threat. Regarding fear the situation is twofold: fast perceptual effects (detection despite masking) seem to have occurred, but they are not mediated by activation of the amygdala. The latter was observed, but only after perceptual learning had taken place. This finding relates amygdalar activation by fearful faces to the processing of the more general self-relevance of these stimuli. Therefore the data suggest the amygdala to be involved in both: the specific detection of threat as well as the more general processing of biological or social significance

Emily Hunter McGowin, Quivering Families. The Quiverfull Movement and Evangelical Theology of the Family

Die Theologin Emily Hunter McGowin setzt 2018 mit Quivering Families. The Quiverfull Movement and Evangelical Theology of the Family auf Grundlage ihrer Dissertation die 2009 für eine breitere Öffentlichkeit begonnene Forschung von Journalistin Kathryn Joyce zur Quiverfull-Bewegung fort. Die stark patriarchalisch geprägte Quiverfull-Bewegung (abgeleitet von Psalm 127, 3–5) lehnt Familienplanung in jeglicher Form strikt ab. Kinder werden als eine Strategie angesehen, um den eigenen christlich..

S1 guidelines for the diagnosis and treatment of ichthyoses – update

Ichthyoses are a group of rare genetic skin disorders that pose numerous clinical challenges, in particular with respect to the correct diagnosis and appropriate management. The present update of the German ichthyosis guidelines addresses recent diagnostic advances that have resulted in the Sorèze consensus classification. In this context, we provide an updated diagnostic algorithm, taking into account clinical features as well as the molecular genetic basis of these disorders. Moreover, we highlight current therapeutic approaches such as psychosocial support, balneotherapy, mechanical scale removal, topical therapy, and systemic retinoid therapy. General aspects such as the indication for physical therapy, ergotherapy, or genetic counseling are also discussed. The present update was consented by an interdisciplinary consensus conference that included dermatologists, pediatricians, human geneticists, and natural scientists as well as representatives of the German patient support organization Selbsthilfe Ichthyose e. V

Oversizing and Restenosis with Self-Expanding Stents in Iliofemoral Arteries

Purpose: Uncoated self-expanding nitinol stents (NS) are commonly oversized in peripheral arteries. In current practice, 1-mm oversizing is recommended. Yet, oversizing of NS may be associated with increased restenosis. To provide further evidence, NS were implanted in porcine iliofemoral arteries with a stent-to-artery-ratio between 1.0 and 2.3. Besides conventional uncoated NS, a novel self-expanding NS with an antiproliferative titanium-nitride-oxide (TiNOX) coating was tested for safety and efficacy. Methods: Ten uncoated NS and six TiNOX-coated NS (5-6mm) were implanted randomly in the iliofemoral artery of six mini-pigs. After implantation, quantitative angiography (QA) was performed for calculation of artery and minimal luminal diameter. Follow-up was performed by QA and histomorphometry after 5months. Results: Stent migration, stent fracture, or thrombus formation were not observed. All stents were patent at follow-up. Based on the location of the stent (iliac/femoral) and the stent-to-artery-ratio, stent segments were divided into "normal-sized” (stent-to-artery-ratio<1.4, n=12) and "oversized” (stent-to-artery-ratio≥1.4, n=9). All stent segments expanded to their near nominal diameter during follow-up. Normal-sized stent segments increased their diameter by 6% and oversized segments by 29%. A significant correlation between oversizing and restenosis by both angiography and histomorphometry was observed. Restenosis rates were similar for uncoated NS and TiNOX-coated NS. Conclusions: TiNOX-coated NS are as safe and effective as uncoated NS in the porcine iliofemoral artery. All stents further expand to near their nominal diameter during follow-up. Oversizing is linearly and positively correlated with neointimal proliferation and restenosis, which may not be reduced by TiNOX-coatin

Instantaneous coronary collateral function during supine bicycle exercise

Aims The instantaneous response of the collateral circulation to isometric physical exercise in patients with non-occlusive coronary artery disease (CAD) is not known. Methods and results Thirty patients (age 59 ± 9 years) undergoing percutaneous coronary intervention because of stable CAD were included in the study. Collateral function was determined before and during the last minute of a 6 min protocol of supine bicycle exercise during radial artery access coronary angiography. Collateral flow index (CFI, no unit) was determined as the ratio of mean distal coronary occlusive to mean aortic pressure both subtracted by central venous pressure. To avoid confounding due to recruitment of coronary collaterals by repetitive balloon occlusions, patients were randomly assigned to a group ‘rest first' with CFI measurement during rest followed by CFI during exercise, and to a group ‘exercise first' with antecedent CFI measurement during exercise before CFI at rest. Simultaneously, coronary collateral conductance (occlusive myocardial blood flow per aorto-coronary pressure drop) was determined by myocardial contrast echocardiography in the last 10 consecutive patients. Overall, CFI increased from 0.168 ± 0.118 at rest to 0.262 ± 0.166 during exercise (P = 0.0002). The exercise-induced change in CFI did not differ statistically in the two study groups. Exercise-induced CFI reserve (CFI during exercise divided by CFI at rest) was 2.2 ± 1.8. Overall, rest to peak bicycle exercise change of coronary collateral conductance was from 0.010 ± 0.010 to 1.109 ± 0.139 mL/min/100 mmHg (P < 0.0001); the respective change was similar in both groups. Conclusion In patients with non-occlusive CAD, collateral flow instantaneously doubles during supine bicycle exercise as compared with the resting state. ClinicalTrials.gov Identifier: NCT0094705

Quality of life and clinical characteristics of self-improving congenital ichthyosis within the disease spectrum of autosomal recessive congenital ichthyosis

Background Autosomal-recessive congenital ichthyosis (ARCI) is a heterogeneous group of ichthyoses presenting at birth. Self-improving congenital ichthyosis (SICI) is a subtype of ARCI and is diagnosed when skin condition improves remarkably (within years) after birth. So far, there are sparse data on SICI and quality of life (QoL) in this ARCI subtype. This study aims to further delineate the clinical spectrum of SICI as a rather unique subtype of ARCI. Objectives This prospective study included 78 patients (median age: 15 years) with ARCI who were subdivided in SICI (n = 18) and non-SICI patients (nSICI, n = 60) by their ARCI phenotype. Methods Quality of life (QoL) was assessed using the (Children's) Dermatology Life Quality Index. Statistical analysis was performed with chi-squared and t-Tests. Results The genetically confirmed SICI patients presented causative mutations in the following genes: ALOXE3 (8/16; 50.0%), ALOX12B (6/16; 37.5%), PNPLA1 (1/16; 6.3%) and CYP4F22 (1/16; 6.3%). Hypo-/anhidrosis and insufficient vitamin D levels (<30 ng/mL) were often seen in SICI patients. Brachydactyly (a shortening of the 4th and 5th fingers) was statistically more frequent in SICI (P = 0.023) than in nSICI patients. A kink of the ear's helix was seen in half of the SICI patients and tends to occur more frequently in patients with ALOX12B mutations (P = 0.005). QoL was less impaired in patients under the age of 16, regardless of ARCI type. Conclusions SICI is an underestimated, milder clinical variant of ARCI including distinct features such as brachydactyly and kinking of the ears. Clinical experts should be aware of these features when seeing neonates with a collodion membrane. SICI patients should be regularly checked for clinical parameters such as hypo-/anhidrosis or vitamin D levels and monitored for changes in quality of life