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- Cost-effectiveness (2)
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- Delirium prevention (2)
- Dementia (2)
- Elective surgery (2)
- Older patients (2)
- Postoperative cognitive dysfunction (2)
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- Alps (1)
Background
Postoperative delirium is a common disorder in older adults that is associated with higher morbidity and mortality, prolonged cognitive impairment, development of dementia, higher institutionalization rates, and rising healthcare costs. The probability of delirium after surgery increases with patients’ age, with pre-existing cognitive impairment, and with comorbidities, and its diagnosis and treatment is dependent on the knowledge of diagnostic criteria, risk factors, and treatment options of the medical staff. In this study, we will investigate whether a cross-sectoral and multimodal intervention for preventing delirium can reduce the prevalence of delirium and postoperative cognitive decline (POCD) in patients older than 70 years undergoing elective surgery. Additionally, we will analyze whether the intervention is cost-effective.
Methods
The study will be conducted at five medical centers (with two or three surgical departments each) in the southwest of Germany. The study employs a stepped-wedge design with cluster randomization of the medical centers. Measurements are performed at six consecutive points: preadmission, preoperative, and postoperative with daily delirium screening up to day 7 and POCD evaluations at 2, 6, and 12 months after surgery. Recruitment goals are to enroll 1500 patients older than 70 years undergoing elective operative procedures (cardiac, thoracic, vascular, proximal big joints and spine, genitourinary, gastrointestinal, and general elective surgery procedures.
Discussion
Results of the trial should form the basis of future standards for preventing delirium and POCD in surgical wards. Key aims are the improvement of patient safety and quality of life, as well as the reduction of the long-term risk of conversion to dementia. Furthermore, from an economic perspective, we expect benefits and decreased costs for hospitals, patients, and healthcare insurances.
Trial registration
German Clinical Trials Register, DRKS00013311. Registered on 10 November 2017.
Background
Postoperative delirium is a common disorder in older adults that is associated with higher morbidity and mortality, prolonged cognitive impairment, development of dementia, higher institutionalization rates, and rising healthcare costs. The probability of delirium after surgery increases with patients’ age, with pre-existing cognitive impairment, and with comorbidities, and its diagnosis and treatment is dependent on the knowledge of diagnostic criteria, risk factors, and treatment options of the medical staff. In this study, we will investigate whether a cross-sectoral and multimodal intervention for preventing delirium can reduce the prevalence of delirium and postoperative cognitive decline (POCD) in patients older than 70 years undergoing elective surgery. Additionally, we will analyze whether the intervention is cost-effective.
Methods
The study will be conducted at five medical centers (with two or three surgical departments each) in the southwest of Germany. The study employs a stepped-wedge design with cluster randomization of the medical centers. Measurements are performed at six consecutive points: preadmission, preoperative, and postoperative with daily delirium screening up to day 7 and POCD evaluations at 2, 6, and 12 months after surgery. Recruitment goals are to enroll 1500 patients older than 70 years undergoing elective operative procedures (cardiac, thoracic, vascular, proximal big joints and spine, genitourinary, gastrointestinal, and general elective surgery procedures.
Discussion
Results of the trial should form the basis of future standards for preventing delirium and POCD in surgical wards. Key aims are the improvement of patient safety and quality of life, as well as the reduction of the long-term risk of conversion to dementia. Furthermore, from an economic perspective, we expect benefits and decreased costs for hospitals, patients, and healthcare insurances.
Trial registration
German Clinical Trials Register, DRKS00013311. Registered on 10 November 2017.
Receiver function approaches have proven to be valuable for the investigation of crustal and upper mantle discontinuities whose sharp changes in seismic velocities cause wave conversions. While the crustal and mantle transition zone discontinuities are largely understood, the X-discontinuity at 250-350 km depth is still an object of controversial debate. The origin and global distribution of this structure with a velocity jump of 1.5-4.8% for compressional and shear waves is still unexplained. Although the crustal and mantle transition zone discontinuities beneath SW Morocco and surroundings have been investigated, only a few studies observed the X-discontinuity and place the depth at 260-370 km beneath the region of western Morocco. In order to better locate and characterize the X-discontinuity beneath southwest Morocco, we create P-wave receiver functions using data recorded by the Morocco-Munster array and detect the X-discontinuity at apparent depths of 285-350 km. In the western part of our study region we find apparent depths of similar to 310-340 km. The eastern part of the study area appears more complex: we locate two velocity jumps at apparent depths of around 285-295 km and 330-350 km in the northeast, and in the southeast we find a discontinuity at apparent depths of 340-350 km. Due to the large depth range and the twofold appearance of the X-discontinuity, we suggest that two different phase transitions cause the X-discontinuity beneath SW Morocco. The velocity contrasts at larger depths likely point to the coesite-stishovite phase transition occurring in deep eclogitic pools. The shallower depths can be explained by the transition from orthoenstatite to high-pressure clinoenstatite which requires the reaction between eclogite and peridotite to form orthopyroxene-rich peridotite. This reaction is likely related to previously proposed small-scale mantle upwellings beneath SW Morocco. Since both phase transitions require eclogite occurrence, the location of the X-discontinuity in this region can be used to indicate the location of recycled oceanic crust.
The AlpArray seismic network
(2018)
The AlpArray programme is a multinational, European consortium to advance our understanding of orogenesis and its relationship to mantle dynamics, plate reorganizations, surface processes and seismic hazard in the Alps-Apennines-Carpathians-Dinarides orogenic system. The AlpArray Seismic Network has been deployed with contributions from 36 institutions from 11 countries to map physical properties of the lithosphere and asthenosphere in 3D and thus to obtain new, high-resolution geophysical images of structures from the surface down to the base of the mantle transition zone. With over 600 broadband stations operated for 2 years, this seismic experiment is one of the largest simultaneously operated seismological networks in the academic domain, employing hexagonal coverage with station spacing at less than 52 km. This dense and regularly spaced experiment is made possible by the coordinated coeval deployment of temporary stations from numerous national pools, including ocean-bottom seismometers, which were funded by different national agencies. They combine with permanent networks, which also required the cooperation of many different operators. Together these stations ultimately fill coverage gaps. Following a short overview of previous large-scale seismological experiments in the Alpine region, we here present the goals, construction, deployment, characteristics and data management of the AlpArray Seismic Network, which will provide data that is expected to be unprecedented in quality to image the complex Alpine mountains at depth.
IntroductionPostoperative delirium (POD) is a common and serious adverse event of surgery in older people. Because of its great impact on patients' safety and quality of life, identification of modifiable risk factors could be useful. Although preoperative medication intake is assumed to be an important modifiable risk factor, the impact of anticholinergic drugs on the occurrence of POD seems underestimated in elective surgery. The aim of this study was to investigate the association between preoperative anticholinergic burden and POD. We hypothesized that a high preoperative anticholinergic burden is an independent, potentially modifiable predisposing and precipitating factor of POD in older people. MethodsBetween November 2017 and April 2019, 1,470 patients of 70 years and older undergoing elective orthopedic, general, cardiac, or vascular surgery were recruited in the randomized, prospective, multicenter PAWEL trial. Anticholinergic burden of a sub-cohort of 899 patients, who did not receive a multimodal intervention for preventing POD, was assessed by two different tools at hospital admission: The established Anticholinergic Risk Scale (ARS) and the recently developed Anticholinergic Burden Score (ABS). POD was detected by confusion assessment method (CAM) and a validated post discharge medical record review. Logistic regression analyses were performed to evaluate the association between anticholinergic burden and POD. ResultsPOD was observed in 210 of 899 patients (23.4%). Both ARS and ABS were independently associated with POD. The association persisted after adjustment for relevant confounding factors such as age, sex, comorbidities, preoperative cognitive and physical status, number of prescribed drugs, surgery time, type of surgery and anesthesia, usage of heart-lung-machine, and treatment in intensive care unit. If a patient was taking one of the 56 drugs listed in the ABS, risk for POD was 2.7-fold higher (OR = 2.74, 95% CI = 1.55-4.94) and 1.5-fold higher per additional point on the ARS (OR = 1.54, 95% CI = 1.15-2.02). ConclusionPreoperative anticholinergic drug exposure measured by ARS or ABS was independently associated with POD in older patients undergoing elective surgery. Therefore, identification, discontinuation or substitution of anticholinergic medication prior to surgery may be a promising approach to reduce the risk of POD in older patients.
Probing the core-mantle boundary beneath Europe and Western Eurasia: A detailed study using PcP
(2015)
We use PcP (the core reflected P phase) recordings of deep earthquakes and nuclear explosions from the Grafenberg (Germany) and NORSAR (Norway) arrays to investigate the core-mantle boundary region beneath Europe and western Eurasia. We find evidence for a previously unknown ultra-low velocity zone 600 km south-east of Moscow, located at the edge of a middle-size low shear- velocity region imaged in seismic tomography that is located beneath the Volga river region. The observed amplitude variations of PcP can be modelled by velocity reductions of P and S-waves of -5% and -15%, respectively, with a density increase of +15%. Travel time delays of pre-and postcursors are indicating a thickness of about 13 km for this ultra-low velocity region (ULVZ). However, our modelling also reveals highly ambiguous amplitude variations of PcP and a reflection off the top of the anomaly for various ULVZs and topography models. Accordingly, large velocity contrasts of up to -10% in V-P and -20% in Vs cannot be excluded. In general, the whole Volga river region shows a complex pattern of PcP amplitudes caused most likely by CMB undulations. Further PcP probes beneath Paris, Kiev and northern Italy indicate likely normal CMB conditions, whereas the samples below Finland and the Hungary-Slovakia border yield strongly amplified PcP signals suggesting strong CMB topography effects.
We evaluate the amplitude behaviour of PcP as a function of distance and several ULVZ models using the 1D reflectivity and the 2D Gauss beam method. The influence of the velocity and density perturbations is analysed as well as the anomaly thickness, the dominant period of the source wavelet and interface topographies. Strong variation of the PcP amplitude are obtained as a function of distance and of the impedance contrast. We also consider two types of topographies: undulations atop the CMB in the presence of flat ULVZs and vice versa. Where a broad range of CMB topography dimensions lead to large PcP amplitude variations, only large ULVZ undulations generate significant amplitude scattering. Consequently, this indicates that topography effects of anomalies may mask the true medium parameters as well as the ULVZ thickness. Moreover, there might be a possibility of misinterpreting the precursor as PcP, in particular for thin ULVZs. (C) 2015 Elsevier B.V. All rights reserved.