Quantitative brain volumetric data has shown promise in predicting cognitive decline however, due to labor-intensive manual segmentation methods required, this technique has had limited clinical applicability. Our aim was to assess the diagnostic efficacy of using NeuroreaderTM(NR), a FDA cleared automated segmentation software, in patients with mild cognitive impairment (MCI) to supplement neuropsychological testing. 349 MCI patients with 3 year follow up were included of which 155 progressed to AD within 3-years. Clinical data was obtained through the Alzheimer's Disease Neuroimaging Initiative, a publically available North American database. Baseline and 1 year differences in 12 regions of interest (ROI) were analyzed using NeuroreaderTM. Receiver Operating Characteristic (ROC) curves were generated using 1 year changes in Mini Mental Status Exam (MMSE) scores with and without NR metrics. Results were compared using the DeLong method to assess the diagnostic efficacy of NR. Adjusting for age, gender, and education level, combining 1-year changes in NR metrics with MMSE scores outperformed MMSE scores alone. AUC 86.4% (CI 82.7 – 90.2) vs AUC 79.9% (CI 75.2 – 84.6). AUC difference(DeLong), p < .05. Tracking 1 yr. brain volumetry with Neuroreader can improve the prediction of 3 year AD conversion in patients with MCI . Comparing model using 1-year MMSE changes alone (Red) vs. 1-year MMSE changes with 1-year NR changes (Blue). Model combining MMSE and NR out-performed model using MMSE alone (AUC 86.4% vs. AUC 79.9%).
BACKGROUND: Consensus guidelines for postoperative nausea and vomiting (PONV) prophylaxis recommend a risk-based approach in which the number of antiemetics administered is based on a preoperative estimate of PONV risk. These guidelines have been adapted by the Multicenter Perioperative Outcomes Group (MPOG) to serve as measures of clinician and hospital compliance with guideline-recommended care. However, the impact of this approach on clinical outcomes is not known. METHODS: We performed a single-center, retrospective study of adult patients undergoing general anesthesia from 2018 to 2021. Risk factors for PONV were defined using MPOG definitions: female sex, history of PONV or motion sickness, nonsmoker, inhaled anesthesia >60 minutes, high-risk procedure (cholecystectomy, laparoscopic, gynecologic), and age <50 years. Adequate prophylaxis was defined using the MPOG PONV-05 metric: at least 2 agents for patients with 1 to 2 risk factors and at least 3 agents for patients with 3+ risk factors. PONV was defined as documented PONV or receipt of rescue antiemetics. To estimate the association between adequate prophylaxis and PONV, we used Bayesian binomial models with overlap propensity score weighting. RESULTS: We included 76,703 cases (43% receiving adequate prophylaxis) with PONV occurring in 19%. In unadjusted and unweighted comparison, adequate prophylaxis was associated with increased incidence of PONV: median odds ratio 1.21 (95% credible interval [1.16–1.25]). However, after propensity score weighting and multivariable adjustment, adequate prophylaxis was associated with reduced relative and absolute risk for PONV: weighted marginal median odds ratio 0.90 [0.84–0.98] and absolute risk reduction (ARR) 1.6% [0.6%–2.6%]. There was evidence for a differential effect of adequate prophylaxis across the guideline-defined risk spectrum, with benefit seen in patients with 1 to 5 risk factors (conditional probabilities of benefit >0.81), but not in those at high predicted risk. Patient-specific, covariate-adjusted ARR was heterogeneous, with a median patient-specific conditional probability of benefit of 0.84 (95% credible interval, 0.73–0.90). CONCLUSIONS: Guideline-directed PONV prophylaxis is associated with a modest reduction in PONV, although this effect is small and heterogeneous on the absolute scale. We found evidence for a differential association between adequate prophylaxis and PONV across the guideline-defined risk spectrum, with diminution in patients at very high predicted preoperative risk. While patient-specific benefit was heterogenous, most patients had reasonably high predicted probabilities of absolute benefit from a guideline-directed strategy. Further assessment of these associations in a multicenter setting, with more robust investigation of risk prediction methods will allow for better understanding of the optimal approach to PONV prophylaxis.
Background: The Society of Critical Care Medicine (SCCM) and American Society for Parenteral and Enteral Nutrition (ASPEN) recommend that obese, critically ill patients receive 11–14 kcal/kg/d using actual body weight (ABW) or 22–25 kcal/kg/d using ideal body weight (IBW), because feeding these patients 50%‐70% maintenance needs while administering high protein may improve outcomes. It is unknown whether these equations achieve this target when validated against indirect calorimetry, perform equally across all degrees of obesity, or compare well with other equations. Methods : Measured resting energy expenditure (MREE) was determined in obese (body mass index [BMI] ≥30 kg/m 2 ), critically ill patients. Resting energy expenditure was predicted (PREE) using several equations: 12.5 kcal/kg ABW (ASPEN‐Actual BW), 23.5 kcal/kg IBW (ASPEN‐Ideal BW), Harris‐Benedict (adjusted‐weight and 1.5 stress‐factor), and Ireton‐Jones for obesity. Correlation of PREE to 65% MREE, predictive accuracy, precision, bias, and large error incidence were calculated. Results : All equations were significantly correlated with 65% MREE but had poor predictive accuracy, had excessive large error incidence, were imprecise, and were biased in the entire cohort (N = 31). In the obesity cohort (n = 20, BMI 30–50 kg/m 2 ), ASPEN‐Actual BW had acceptable predictive accuracy and large error incidence, was unbiased, and was nearly precise. In super obesity (n = 11, BMI >50 kg/m 2 ), ASPEN‐Ideal BW had acceptable predictive accuracy and large error incidence and was precise and unbiased. Conclusions : SCCM/ASPEN‐recommended body weight equations are reasonable predictors of 65% MREE depending on the equation and degree of obesity. Assuming that feeding 65% MREE is appropriate, this study suggests that patients with a BMI 30–50 kg/m 2 should receive 11–14 kcal/kg/d using ABW and those with a BMI >50 kg/m 2 should receive 22–25 kcal/kg/d using IBW.
Current approaches to the management of severe mental illness have four major limitations: 1) symptom reporting is intermittent and subject to problems with reliability; 2) service users report feelings of disengagement from their care planning; 3) late detection of symptoms delay interventions and increase the risk of relapse; and 4) care systems are held back by the costs of unscheduled hospital admissions that could have been avoided with earlier detection and intervention. The ClinTouch system was developed to close the loop between service users and health professionals. ClinTouch is an end-to-end secure platform, providing a validated mobile assessment technology, a web interface to view symptom data and a clinical algorithm to detect risk of relapse. ClinTouch integrates high-resolution, continuous longitudinal symptom data into mental health care services and presents it in a form that is easy to use for targeting care where it is needed. The architecture and methodology can be easily extended to other clinical domains, where the paradigm of targeted clinical interventions, triggered by the early detection of decline, can improve health outcomes.
Acute kidney injury (AKI) remains a frequent and serious complication of surgical procedures and critical illness that is consistently associated with worse outcomes and increased long-term morbidity and mortality. Much work has gone into finding kidney protective measures with disappointingly few therapeutic options available to prevent or to treat AKI. Research has defined some effective kidney protective practices and the purpose of this chapter is to help the clinician to differentiate better clinical practices that are either ineffective, detrimental, or protective to the kidney. The chapter will first provide an introduction to kidney physiology with particular focus on areas that make it vulnerable to injury. The chapter will then shift focus to diagnosis of kidney injury including definitions and early biomarkers that can help risk stratify patients. Then, specific mechanisms of postoperative and critical illness-associated kidney injury will be outlined. The rest of the chapter will review evidence from renal-protective research studies pertinent to the preoperative, intraoperative, and postoperative periods. After reading this chapter, the clinician should have a more robust framework for adoption (mostly avoidance) of renal protective practices (stratified based on level of evidence available) to guide their clinical practice.
# 1.1.01 Supraspinal modulation of gait abnormalities associated with noncompressive radiculopathy may be mediated by altered neurotransmitter sensitivity {#article-title-2} Radiculopathy resulting from intervertebral disc herniation involves mechanical compression and biochemical inflammation of
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