Brain Pro-TCT:Quality improvement of delirium detection on a cardiothoracic surgical ward

1) Please declare any conflicts of interest below: The authors declare a potential conflict of interest but not a personal conflict of interest. Part of the costs for this study are covered by Heartcentre Twente Foundation. Prolira provided training and the DeltaScans during the study period free of charge and applied a discount to the disposable patch costs. 2) Ethics Approval: Ethical approval was waived by the Advisory committee Medisch Spectrum Twente at Enschede. The Institutional Review Board of Medisch Spectrum Twente has concluded that this study does not fall under the remit of the Medical Research Involving Human Subjects. 3) Context: The study was done on the cardiothoracic surgery ward at Thoraxcentrum Twente (Medisch Spectrum Twente, Enschede, the Netherlands), a tertiary teaching hospital. Patients 70 years or older who underwent cardiac surgery were included. The quality improvement team included nurse practitioners in cardiac surgery and psychiatry, a cardiac surgeon, nurses, a technical physician, and an epidemiologist. 4) Problem: Delirium is a common syndrome of acute brain failure, which often occurs in hospitalized older patients following cardiac surgery. Delirium after cardiac surgery is related to adverse long-term outcomes, more readmissions to hospital, and decreased cognitive and functional outcomes. Early detection of delirium allows early treatment of underlying causes. In standard care, we use a delirium observation scale score (DOSS). Recently, a single-channel electroencephalography (EEG) medical device was developed to screen delirium based on detection of delta waves (DeltaScan). Using DeltaScan in routine care may improve delirium detection and clinical outcomes. 5) Assessment of problem and analysis of its causes: Previous delirium studies in Thoraxcentrum Twente using DOSS as standard care reported an incidence of delirium of 13 to 17% in elective patients aged ≥45 years. Published and unpublished research data for cardiothoracic surgery wards show an increase of delirium detection by &gt;15% (absolute percentage growth), when DeltaScan was used in clinical studies. Nurses, nurse practitioners, and medical doctors were informed  about the aims of the study and importance of delirium screening. A nurse improvement project, including a workgroup, was started, where the importance of screening was emphasized. Before the implementation of the DeltaScan, nurses on the surgical ward received education and training. Medical doctors, residents, and nurse practitioners were trained on how to interpret the DeltaScan scores. 6) Intervention: First, we continued the DOSS as regular care for delirium screening; three measurements a day for the first three postoperative days. Second, DeltaScan was implemented as new regular care. DeltaScan measurements took place twice a day for at least three consecutive days. 7) Strategy for change: In February 2021 additional training of the DOSS for delirium screening began, and from April 2021 onwards, prospective data collection of the first group continued till May 2022. Training with DeltaScan started in March/April 2022. The DeltaScan data collection started in May 2022, and is still ongoing. 8) Measurement of improvement: The primary endpoints to measure improvement were incidence of delirium, and length of hospital stay. Secondary endpoints included delirium duration, adherence to delirium protocol, and costs related to the innovation. The innovation was deemed successful with an incidence increase from 15 to 30%, and a length of stay reduction with at least 1.5 days. This abstract is based on preliminary data until October 2022. 9) Effects of changes: In total 612 patients were included, with 450 patients in the DOSS group and 162 patients (interim results) in the DeltaScan group. Incidence of finding delirium increased from 15% to 25% (p = 0.008). Median length of hospital stay for delirium patients was reduced from 9 hospital nights to 5.5 nights (p = 0.002). Median duration of delirium decreased (not significantly) from 77 hours to 65 hours (p = 0.12). 10) Lessons learned: Involving all stakeholders early in the project helped to gain commitment to the innovation. The change was measured in a scientific study, as no formal results on effectivity are known at the moment. Introducing a new device for delirium screening arouses resistance. Reducing or removing this resistance remains difficult. 11) Messages for others: Involving all stakeholders in a working group for delirium screening helped to start an innovation, monitor benefits, and motivated colleagues to actually commit to the innovation. Screening for delirium with DeltaScan in our study leads to an increase of finding delirium, and reduced hospital stay (interim results) for patients after cardiothoracic surgery. It is unknown yet, whether this is cost-effective. We hypothesize that these results are expected to be similar for other patient groups such as geriatric or general surgical patients. 12) Please describe how you have involved patients, carers, or family members in the project: Patients and their relatives are informed about the risk of delirium and the impact of delirium before hospital admission. Relatives and patients are often informed during measurements on the importance of adequate delirium screening, where positive responses are often heard. No formal co-creation by patients was done, but informal feedback will be collected in the near future. </p

Intracellular and Extracellular Roles of Granzyme K.

Granzymes are a family of serine proteases stored in granules inside cytotoxic cells of the immune system. Granzyme K (GrK) has been only limitedly characterized and knowledge on its molecular functions is emerging. Traditionally GrK is described as a granule-secreted, pro-apoptotic serine protease. However, accumulating evidence is redefining the functions of GrK by the discovery of novel intracellular (e.g. cytotoxicity, inhibition of viral replication) and extracellular roles (e.g. endothelial activation and modulation of a pro-inflammatory immune cytokine response). Moreover, elevated GrK levels are associated with disease, including viral and bacterial infections, airway inflammation and thermal injury. This review aims to summarize and discuss the current knowledge of i) intracellular and extracellular GrK activity, ii) cytotoxic and non-cytotoxic GrK functioning, iii) the role of GrK in disease, and iv) GrK as a potential therapeutic target

Landbouwschade door ander waterbeheer beter te bepalen

Er is een belangrijke basis gelegd voor een nieuwe (klimaatrobuuste) methode om te voorspellen welke gevolgen veranderingen in het waterbeheer hebben voor de landbouwopbrengsten

Immunotherapy in Medulloblastoma: Current State of Research, Challenges, and Future Perspectives.

Medulloblastoma (MB), a primary tumor of the central nervous system, is among the most prevalent pediatric neoplasms. The median age of diagnosis is six. Conventional therapies include surgical resection of the tumor with subsequent radiation and chemotherapy. However, these therapies often cause severe brain damage, and still, approximately 75% of pediatric patients relapse within a few years. Because the conventional therapies cause such severe damage, especially in the pediatric developing brain, there is an urgent need for better treatment strategies such as immunotherapy, which over the years has gained accumulating interest. Cancer immunotherapy aims to enhance the body's own immune response to tumors and is already widely used in the clinic, e.g., in the treatment of melanoma and lung cancer. However, little is known about the possible application of immunotherapy in brain cancer. In this review, we will provide an overview of the current consensus on MB classification and the state of in vitro, in vivo, and clinical research concerning immunotherapy in MB. Based on existing evidence, we will especially focus on immune checkpoint inhibition and CAR T-cell therapy. Additionally, we will discuss challenges associated with these immunotherapies and relevant strategies to overcome those

Emissions of transboundary air pollutants in the Netherlands 1990-2012 : Informative Inventory Report 2014

Emissies Nederland blijven in 2012 onder nationale plafonds De uitstoot van stikstofoxiden (NOx), ammoniak, zwaveldioxide en niet-methaan vluchtige organische stoffen (NMVOS) is in 2012 in Nederland licht gedaald. Daarmee bleef de uitstoot onder de maxima die de Europese Unie daaraan sinds 2010 stelt. Nederland voldoet daardoor, net als in 2011, aan de vier 'nationale emissieplafonds' (NEC) voor deze stoffen. Dit blijkt uit de Nederlandse emissiecijfers van grootschalige luchtverontreinigende stoffen. Het RIVM verzamelt en analyseert deze cijfers. Behalve bovengenoemde stoffen gaat het om de uitstoot van koolmonoxide, fijn stof (PM10), zware metalen en persistente organische stoffen (POP's). De uitstoot van al deze stoffen is tussen 1990 en 2012 gedaald. Dit komt vooral door schonere auto's en brandstoffen en door emissiebeperkende maatregelen van industriële sectoren. Meer kilometers door bromfietsen Door de jaren heen zijn de methoden om de emissies te berekenen verbeterd, wat nu resulteert in nauwkeurigere cijfers. De emissies van bromfietsen en motorfietsen zijn afhankelijk van het aantal gereden kilometers per jaar en daar is nu beter inzicht in. Het totale aantal gereden kilometers door bromfietsen blijkt in de afgelopen jaren bijna twee keer zo hoog is als werd gedacht. Daarmee is de uitstoot van schadelijke stoffen navenant hoger. Ten opzichte van andere typ voertuigen blijven bromfietsen echter een relatief kleine emissiebron en dragen ze beperkt bij aan de totale nationale emissies. In steden zijn ze wel een relevante bron. Het aantal gereden kilometers door motorfietsen, en daarmee de uitstoot, blijft in lijn met eerdere inzichten. Vrachtauto's zwaarder beladen De uitstoot van schadelijke stoffen door vrachtauto's is voor het eerst berekend op basis van recente inzichten in het gewicht van vrachtauto's. Trekker-opleggers blijken zwaarder beladen dan tot nu toe werd verondersteld. Ook rijden vrachtauto's vaker met een aanhanger dan tot nu toe werd aangenomen, waardoor ze zwaarder zijn. Een hoger gewicht betekent een hoger brandstofverbruik, en veelal ook een hogere uitstoot per gereden kilometer. De uitstoot van PM10 door vrachtauto's is hierdoor circa 5 procent hoger dan in de vorige IIR-rapportage. Hogere emissies ammoniak De uitstoot van ammoniak blijkt hoger dan eerder werd verondersteld vanwege enkele nieuwe inzichten; de cijfers zijn hierdoor vanaf 1997 bijgesteld. Zo worden luchtwassers, die voornamelijk op varkensstallen zitten, niet altijd gebruikt. Ook is vanaf 2002 in melkveestallen het leefoppervlak per dier toegenomen. Door het grotere contactoppervlak van mest met lucht wordt meer ammoniak uitgestoten. Door de aangepaste aannames is het nationale totaal met 6,6 kiloton verhoogd ten opzichte van 2011.Emissions the Netherlands in 2012 remain under national ceilings Emissions of nitrogen oxides (NOx), ammonia, sulphur dioxide and non-methane volatile organic compounds (NMVOC) in the Netherlands have slightly decreased in 2012. Consequently, the emissions stayed below the caps the European Union has set from 2010. Herewith, the Netherlands comply with all four so-called emission ceilings (NEC). This has become apparent from the emission data on air pollutants from the Netherlands. RIVM collects and reports these data. Besides above-mentioned substances, emissions of carbon monoxide, particulate matter (PM10), heavy metals and persistent organic pollutants (POPs) have been reported. The emissions of all substances have decreased in the 1990 - 2012 period. The downward trend may in particular be attributed to cleaner fuels, cleaner car engines and to emission reductions in the industrial sectors. More kilometres by mopeds Over the years emission calculation methods have been improved, resulting in higher data accuracy. In 2012, the emissions from mopeds and motorcycles have been calculated, based on improved knowledge of the mileages. The total number of kilometres driven by mopeds appears to have been nearly twice as high in recent years. As a result, the emissions of pollutants are proportionally higher. In relation to the total number of vehicles, the number of mopeds however remains relatively low and their contribution to the total national emissions is limited. In cities, they are a relevant source. The mileages by motorcycles, and consequently their emissions remain in line with previous insights. Heavy-duty vehicles carry heavier loads Emissions of pollutants by heavy-duty trucks have for the first time been calculated on the basis of recent insights in truck loads. Tractor-trailer combinations appear to carry heavier loads and the fraction of trailers behind rigid trucks is larger than previously assumed. A heavier load means a higher fuel use and for most substances a higher emission per kilometre driven. PM10 emissions by heavy-duty trucks are about 5 percent higher than in the previous IIR report. Higher agricultural ammonia emissions Agricultural ammonia emissions appear to be higher than previously assumed because of new insights. Air scrubbers on animal housing (predominantly pigs) were not always in use or even employed. Since 2002, the living space per animal has increased for dairy cattle housing. This resulted in a higher contact surface manure-air and thus more ammonia emitted. The new insights have raised the national total of ammonia emissions by about 6 percent compared to 2011

Waterwijzers Landbouw en Natuur : Kwantificering effecten waterbeheer en klimaat

Landbouw en natuur stellen specifieke eisen aan de waterhuishouding, vooral aan beschikbaar water in de wortelzone. Bestaande beoordelingssystemen houden echter geen rekening met de gevolgen van klimaatverandering voor respectievelijk landbouwopbrengsten en natuurdoelen. Daarom zijn er nu twee systemen in ontwikkeling die dat, zo goed mogelijk, wel doen: de Waterwijzer Landbouw en de Waterwijzer Natuur. Beide kunnen worden gebruikt voor het vaststellen van schade aan landbouw en natuur, maar ook voor het optimaliseren van de waterhuishouding

The complexity of screening PMS2 in DNA isolated from formalin-fixed paraffin-embedded material

Germline variants in the DNA mismatch repair (MMR) gene PMS2 cause 1-14% of all Lynch Syndrome cancers. Correct variant analysis of PMS2 is complex due to the presence of multiple pseudogenes and the occurrence of gene conversion. The analysis complexity increases in highly fragmented DNA from formalin-fixed paraffin-embedded (FFPE) tissue. Here we describe a reliable approach to detect true PMS2 variants in fragmented DNA. A custom NGS panel designed for FFPE tissue was used targeting four MMR genes, POLE and POLD1. Amplicon design for PMS2 was based on the position of paralogous sequence variants (PSVs) that distinguish PMS2 from its pseudogenes. PMS2 variants in exons 1-11 can be correctly curated based on this information. For exons 12-15 this is less reliable as these undergo gene conversion. Using this method, we screened PMS2 variants in 125 MMR-deficient tumors. Of the 125 tumors tested, six were unexplained MMR-deficient tumors with solitary PMS2 protein expression loss. In these six tumors two unclassified variants (class 3) and five variants likely affecting function (class 4/5) were detected in PMS2. One microsatellite unstable tumor with positive staining for all MMR proteins was found to carry a frameshift PMS2 variant (class 5). No class 4 or class 5 PMS2 variants were detected in tumors with other patterns of MMR protein expression loss.Molecular tumour pathology - and tumour geneticsMTG2 - Moleculaire genetica van gastrointestinale tumore

Serum methylarginines and spirometry-measured lung function in older adults

Rationale: Methylarginines are endogenous nitric oxide synthase inhibitors that have been implicated in animal models of lung disease but have not previously been examined for their association with spirometric measures of lung function in humans. Objectives: This study measured serum concentrations of asymmetric and symmetric dimethylarginine in a representative sample of older community-dwelling adults and determined their association with spirometric lung function measures. Methods: Data on clinical, lifestyle, and demographic characteristics, methylated arginines, and L-arginine (measured using LC-MS/MS) were collected from a population-based sample of older Australian adults from the Hunter Community Study. The five key lung function measures included as outcomes were Forced Expiratory Volume in 1 second, Forced Vital Capacity, Forced Expiratory Volume in 1 second to Forced Vital Capacity ratio, Percent Predicted Forced Expiratory Volume in 1 second, and Percent Predicted Forced Vital Capacity. Measurements and Main Results: In adjusted analyses there were statistically significant independent associations between a) higher asymmetric dimethylarginine, lower Forced Expiratory Volume in 1 second and lower Forced Vital Capacity; and b) lower L-arginine/asymmetric dimethylarginine ratio, lower Forced Expiratory Volume in 1 second, lower Percent Predicted Forced Expiratory Volume in 1 second and lower Percent Predicted Forced Vital Capacity. By contrast, no significant associations were observed between symmetric dimethylarginine and lung function. Conclusions: After adjusting for clinical, demographic, biochemical, and pharmacological confounders, higher serum asymmetric dimethylarginine was independently associated with a reduction in key measures of lung function. Further research is needed to determine if methylarginines predict the decline in lung function

Novel chimerized IgA CD20 antibodies : Improving neutrophil activation against CD20-positive malignancies

ABSTRACT Current combination therapies elicit high response rates in B cell malignancies, often using CD20 antibodies as the backbone of therapy. However, many patients eventually relapse or develop progressive disease. Therefore, novel CD20 antibodies combining multiple effector mechanisms were generated. To study whether neutrophil-mediated destruction of B cell malignancies can be added to the arsenal of effector mechanisms, we chimerized a panel of five previously described murine CD20 antibodies to the human IgG1, IgA1 and IgA2 isotype. Of this panel, we assessed in vitro antibody-dependent cell-mediated cytotoxicity (ADCC), complement-dependent cytotoxicity (CDC) and direct cell death induction capacity and studied the efficacy in two different in vivo mouse models. IgA antibodies outperformed IgG1 antibodies in neutrophil-mediated killing in vitro, both against CD20-expressing cell lines and primary patient material. In these assays, we observed loss of CD19 with both IgA and IgG antibodies. Therefore, we established a novel method to improve the assessment of B-cell depletion by CD20 antibodies by including CD24 as a stable cell marker. Subsequently, we demonstrated that only IgA antibodies were able to reduce B cell numbers in this context. Additionally, IgA antibodies showed efficacy in both an intraperitoneal tumor model with EL4 cells expressing huCD20 and in an adoptive transfer model with huCD20-expressing B cells. Taken together, we show that IgA, like IgG, can induce ADCC and CDC, but additionally triggers neutrophils to kill (malignant) B cells. We conclude that antibodies of the IgA isotype offer an attractive repertoire of effector mechanisms for the treatment of CD20-expressing malignancies.Peer reviewe

Methicillin Resistance Transfer from Staphylocccus epidermidis to Methicillin-Susceptible Staphylococcus aureus in a Patient during Antibiotic Therapy

BACKGROUND: The mecA gene, encoding methicillin resistance in staphylococci, is located on a mobile genetic element called Staphylococcal Cassette Chromosome mec (SCCmec). Horizontal, interspecies transfer of this element could be an important factor in the dissemination of methicillin-resistant S. aureus (MRSA). Previously, we reported the isolation of a closely related methicillin-susceptible Staphylococcus aureus (MSSA), MRSA and potential SCCmec donor Staphylococcus epidermidis isolate from the same patient. Based on fingerprint techniques we hypothesized that the S. epidermidis had transferred SCCmec to the MSSA to become MRSA. The aim of this study was to show that these isolates form an isogenic pair and that interspecies horizontal SCCmec transfer occurred. METHODOLOGY/RESULTS: Whole genome sequencing of both isolates was performed and for the MSSA gaps were closed by conventional sequencing. The SCCmec of the S. epidermidis was also sequenced by conventional methods. The results show no difference in nucleotide sequence between the two isolates except for the presence of SCCmec in the MRSA. The SCCmec of the S. epidermidis and the MRSA are identical except for a single nucleotide in the ccrB gene, which results in a valine to alanine substitution. The main difference with the closely related EMRSA-16 is the presence of SaPI2 encoding toxic shock syndrome toxin and exfoliative toxin A in the MSSA-MRSA pair. No transfer of SCCmec from the S. epidermidis to the MSSA could be demonstrated in vitro. CONCLUSION: The MSSA and MRSA form an isogenic pair except for SCCmec. This strongly supports our hypothesis that the MRSA was derived from the MSSA by interspecies horizontal transfer of SCCmec from S. epidermidis O7.1