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During the COVID-19 pandemic, the bidirectional relationship between policy and data reliability has been a challenge for researchers of the local municipal health services. Policy decisions on population specific test locations and selective registration of negative test results led to population differences in data quality. This hampered the calculation of reliable population specific infection rates needed to develop proper data driven public health policy.

The use of pre-workout supplements has become increasingly popular, including the use of supplements containing synephrine. Synephrine might stimulate weight loss and improve sports performance by its proposed adrenergic properties. However, with its increasing popularity, numerous cases of adverse events related to synephrine use have been reported. This study provides a comprehensive overview and analysis of current case reports related to the supplemental use of synephrine. The scientific literature on cases of adverse events related to synephrine intake was collected through August 2021 using Pubmed and Google Scholar and subsequently reviewed and analysed. We obtained 30 case reports describing a total of 35 patients who suffered from medical complaints following use of synephrine-containing supplements. The patients most often presented with chest pain, palpitations, syncope and dizziness. Commonly raised diagnoses were ischaemic heart disease, cardiac arrhythmias and cerebrovascular disease. Five patients were left disabled or remained on medication at last follow-up. We here show an association between the use of pre-workout supplements containing synephrine and adverse events, mainly related to the cardiovascular system. However, we cannot exclude a role of possible confounding factors such as caffeine. Thus, the use of pre-workout supplements containing synephrine may lead to serious adverse health events, and therefore, caution is needed.

SamenvattingDe complexe interactie tussen het beleid en de kwaliteit van registratiedata vormde tijdens de COVID-19-pandemie een uitdaging voor GGD-onderzoekers. Beleidskeuzen gericht op populatiespecifieke testlocaties en de selectieve registratieplicht van negatieve testresultaten leidden tot populatieverschillen in datakwaliteit. Populatieverschillen in de besmettingsgraad konden daardoor niet betrouwbaar worden vastgesteld. Dit belemmerde de ontwikkeling van relevante sturingsinformatie voor beleidsmakers in de publieke gezondheidssector.

Background: Patterns of longitudinal adherence may predict advanced neoplasia (AN) detection in subsequent rounds of colorectal cancer (CRC) screening. However, after more than five rounds, it is important to obtain a simplified measure. The aim was to determine the best simplified measure of longitudinal adherence to predict AN detection in CRC screening. Methods: Individuals with four invitations from a Dutch Fecal immunochemical testing (FIT-)based pilot study and two Italian FIT-based CRC screening programs were included. We calculated AN detection in the fourth round, stratified by prior adherence. Five simplified measures were compared to full information (permutations) using chi-squared goodness-of-fit: adherence previous invitation, consistency, frequency, frequency + adherence previous invitation, and proportion of invitations covered. Results: AN detection in the fourth round was highly dependent on prior adherence behavior. For inconsistent adherence, detection in the fourth round was strongly dependent on frequency and time since last participation. The performance of the simplified measures to capture this variation differed considerably. ‘Adherence previous invitation’ scored worst in predicting AN detection. ‘Frequency+adherence previous invitation’ had lowest chi-squared goodness-of-fit. Discussion: The simplified measure ‘frequency+adherence previous invitation’ is the best measure to reflect patterns of longitudinal adherence and could be used to emphasize to individuals the importance of CRC screening.

Background: Pulmonary complications of blood transfusion, including transfusion-related acute lung injury (TRALI), transfusion-associated circulatory overload (TACO), and transfusion-associated dyspnea, are generally underdiagnosed and under-reported. The international TRALI and TACO definitions have recently been updated. Currently, no standardized pulmonary transfusion reaction reporting form exists and most of the hemovigilance forms have not yet incorporated the updated definitions. We developed a harmonized reporting form, aimed at improved data collection on pulmonary transfusion reactions for hemovigilance and research purposes by developing a standardized model reporting form and flowchart. Materials and Methods: Using a modified Delphi method among an international, multidisciplinary panel of 24 hemovigilance experts, detailed recommendations were developed for a standardized model reporting form for pulmonary complications of blood transfusion. Two Delphi rounds, including scoring systems, took place and several subsequent meetings were held to discuss issues and obtain consensus. Additionally, a flowchart was developed incorporating recently published redefinitions of pulmonary transfusion reactions. Results: In total, 17 participants completed the first questionnaire (70.8% response rate) and 14 participants completed the second questionnaire (58.3% response rate). According to the results from the questionnaires, the standardized model reporting form was divided into various subcategories: general information, patient history and transfusion characteristics, reaction details, investigations, treatment and supportive care, narrative, and transfused product. Conclusion: In this article, we present the recommendations from a global group of experts in the hemovigilance field. The standardized model reporting form and flowchart provide an initiative that may improve data collected to address pulmonary transfusion reactions.

Background Many breast, cervical, and colorectal cancer screening programmes were disrupted due to the COVID-19 pandemic. This study aimed to estimate the effects of five restart strategies after the disruption on required screening capacity and cancer burden. Methods Microsimulation models simulated five restart strategies for breast, cervical, and colorectal cancer screening. The models estimated required screening capacity, cancer incidence, and cancer-specific mortality after a disruption of 6 months. The restart strategies varied in whether screens were caught up or not and, if so, immediately or delayed, and whether the upper age limit was increased. Results The disruption in screening programmes without catch-up of missed screens led to an increase of 2.0, 0.3, and 2.5 cancer deaths per 100 000 individuals in 10 years in breast, cervical, and colorectal cancer, respectively. Immediately catching-up missed screens minimised the impact of the disruption but required a surge in screening capacity. Delaying screening, but still offering all screening rounds gave the best balance between required capacity, incidence, and mortality. Conclusions Strategies with the smallest loss in health effects were also the most burdensome for the screening organisations. Which strategy is preferred depends on the organisation and available capacity in a country.

During the COVID-19 pandemic, the bidirectional relationship between policy and data reliability has been a challenge for researchers of the local municipal health services. Policy decisions on population specific test locations and selective registration of negative test results led to population differences in data quality. This hampered the calculation of reliable population specific infection rates needed to develop proper data driven public health policy.

Haemovigilance is the systematic surveillance of adverse events in the transfusion chain, and encompasses activities that contribute to the safety and quality in the process of blood donation and transfusion. From the start in the early 1990s, haemovigilance has put emphasis on different adverse reactions and incidents in recipients and subsequently in donors, pointing to vulnerabilities in the transfusion chain and areas for prevention. More recently, the monitoring of efficacy and efficiency of transfusion practice has been introduced in the concept of haemovigilance. The purpose of this review is to present an overview of the current status and future developments of haemovigilance. Haemovigilance is part of the quality systems of the blood collection establishments, transfusion laboratories and the transfusion institutions. The monitoring, investigation and analysis of adverse events generates relevant data for the quality cycle of these systems, driving continuous improvement in transfusion practice. Recommendations based on haemovigilance findings have led to changes in clinical guidelines and policies. Despite the progress haemovigilance has made, further developments are needed. Current challenges lie in the field of the establishment of haemovigilance systems in low resource settings, the international harmonisation of definitions and the prevention of underreporting. In addition, the causal relationship between the transfusion and the reaction is often unclear. Biomarkers may aid in the imputability assessment and their role in the diagnosis of transfusion reactions needs to be further investigated. Future developments are expected in automated reporting, the use of big data and increased shareability of international data, contributing to a better understanding of the causal mechanisms and risk factors, and to prevention of adverse events. Haemovigilance is an evolving discipline and will continue to contribute to improving the safety of blood donation and transfusion.

Samenvatting Inleiding Bij lokale overheden groeit het bewustzijn dat armoede samenhangt met stress en een verminderde gezondheid. Vitaliteit is een aspect van gezondheid waar beleidsmakers graag op zouden willen sturen, maar dat niet in alle Nederlandse gemeenten gemeten wordt. We hebben de relatie tussen moeite met rondkomen en vitaliteit in de regio Zuid-Holland Zuid kwantitatief onderzocht, met extra aandacht voor mediatie door angst en depressie. Methode Voor dit dwarsdoorsnedeonderzoek is gebruikgemaakt van de Gezondheidsmonitor volwassenen en ouderen uit 2016. Deze vragenlijst is ingevuld door een aselecte steekproef van 10.650 volwassen inwoners van Zuid-Holland Zuid. De relatie tussen moeite met rondkomen en vitaliteit is bepaald op basis van lineaire regressiemodellen, gecorrigeerd voor potentiële confounders of verklarende variabelen. Verschillen tussen gemeenten zijn onderzocht met behulp van multilevel-analyses. Resultaten Inwoners die moeite ervaren met rondkomen waren minder vitaal dan inwoners die geen moeite ervaren met rondkomen, en dit verschil was groter naarmate moeite met rondkomen ernstiger was. Ten opzichte van de groep inwoners die geen moeite ervaart met rondkomen was de vitaliteitsscore 0,23 (95%-betrouwbaarheidsinterval 0,18–0,29) punten lager bij weinig moeite, 0,49 (95%-BI 0,40–0,57) punten bij een beetje moeite en 0,92 (95%-BI 0,77–1,07) punten lager bij veel moeite met rondkomen, op een schaal van maximaal 7 punten, na correctie voor confounders. De geobserveerde relatie werd grotendeels verklaard door verschillen in angst en depressie. Conclusie Inwoners die moeite ervaren met rondkomen zijn minder vitaal. Hun verhoogde risico op angst en depressie ligt hier mogelijk aan ten grondslag. Vervolgonderzoek is nodig om oorzaak en gevolg verder te ontrafelen. Deze resultaten zijn een reden om de samenwerking tussen verschillende beleidsdomeinen, zoals het sociaal domein en volksgezondheid te versterken.

Ein 70-jahriger Patient stellt sich mit multipel metastasiertem Nierenzellkarzinom (NZK) 25 Jahre nach Erstdiagnose in unserer Klinik mit Makrohamaturie und tastsuspektem rechten Hoden vor. Bei der ureterorenoskopischen Probenentnahme aus dem linken Harnleiter und nach der Orchiektomie rechts zeigen sich Metastasen eines klarzelligen Nierenzellkarzinoms. Trotz seltener Metastasen in unterschiedlichsten Organsystemen fuhrte eine individuelle multimodale Therapie zu einem langjahrigen Uberleben im metastasierten Stadium. Dieser Fall zeigt, dass Jahrzehnte nach Erstdiagnose die Metastasierung eines NZK moglich ist und dass daran gedacht werden sollte.

Aims A second wave of the COVID-19 pandemic may force many health care providers to downscale their services again,including colonoscopies which may impact capacity for colorectal cancer (CRC) screening. This study aimed to determinethe optimal measure to handle these temporary shortages in colonoscopy capacity in the Dutch national CRC screeningprogram to retain as much of the preventive effect of the screening program as possible. Methods We used the MISCAN-Colon model to simulate the Dutch national CRC screening program, providing biennial FITto individuals aged 55-75, under three different scenarios to temporarily reduce required colonoscopy capacity in thesecond half of 2020 and 2021: increase in FIT cut-off value exclusion of specific age-groups, and extension of the screening interval For each scenario, we estimated the impact on required colonoscopy capacity in 2020-2021, long-term CRC incidence,mortality and life years (LYs) lost. Outcomes were compared to a reference scenario without colonoscopy restrictions. Results In 2020 and 2021, the required colonoscopy capacity without any restrictions was 100,300 colonoscopies.Increasing the cut-off, excluding age-groups and extending the screening interval resulted in a reduction of 11,600-27,000,10,800-17,500, and 16,100-49,500 colonoscopies, respectively (Table 1). Increasing the cut-off resulted in 400-900 excessCRC cases and 200-500 excess CRC-related deaths from 2020-2050, while excluding age-groups resulted in 200-600excess CRC cases and 200-500 excess CRC-related deaths. Unexpectedly, extending the screening interval up to 34 months prevented 200-300 more CRC cases and 200-600 more CRC-related deaths, because screening occurred until slightlyhigher ages due to the initial delay. All measures resulted in LYs lost, but extending the screening interval up to 34 monthshad the smallest impact. Abbreviations: CRC, colorectal cancer;LYs, Life Years;μg Hb/g feces, microgram Hemoglobin per gram feces.∗Number between brackets are negative numbers. Conclusions A temporary extension of the screening interval to accommodate reduction in available colonoscopy capacityresults in the smallest impact on the CRC incidence, mortality and LYs lost. (Table Presented).

A 70-year-old man with multiple metastasized renal cell carcinoma (RCC) presented himself in our clinic 25 years after initial diagnosis with newly developed hematuria and conspicuous right testis. The biopsy of the left ureter taken by ureterorenoscopy and the right orchiectomy show metastases of a clear cell RCC. This special case shows rare metastases in different organ systems. The individualized multimodal treatment led to a long-term survival with this metastasized disease. The presented case shows that late recurrences of RCC can occur years after initial diagnosis and should be considered at any time.

Aims Colorectal cancer (CRC) screening programs worldwide have been disrupted during the COVID-19 pandemic. Thisstudy aimed to estimate the impact of hypothetical disruptions to organized FIT-based CRC screening programs on short-and long-term CRC incidence and mortality in three countries using microsimulation modelling. Methods Using CRC microsimulation models for Australia (Policy1-Bowel), Canada (OncoSim) and the Netherlands (ASCCAand MISCAN-Colon) participating in the COVID-19 and Cancer Global Modelling Consortium (CCGMC), we simulated a rangeof scenarios to assess the potential impact of disruptions to screening on CRC incidence and mortality. Modelled scenariosvaried by disruption duration (3-, 6-and 12-months), post-disruption participation reduction, and catch-up screeningstrategy (no catch-up, immediate and 6-month delayed catch-up). Results Without catch-up screening, CRC incidence increased by 0.1-0.3 %, 0.2-0.6 %, and 0.4-1.2 % over 2020-2050among individuals aged 50 years and older in the three modelled countries after 3-, 6-, and 12-month disruptions,respectively, compared to undisrupted screening and CRC mortality increased by 0.2-0.5 %, 0.4-1.0 %, and 0.8-2.0 % over2020-2050 among individuals aged 50 years and older compared to undisrupted screening. A 6-month disruption withoutcatch-up resulted in an estimated 3,552, 2,844 and 803-1,803 additional CRC diagnoses and 1,961, 1,319, and 678-881 additional CRC-related deaths in Australia, Canada and the Netherlands, respectively. A post-disruption reduction inparticipation increased CRC diagnoses by 0.2-0.9 % and CRC-related deaths by 0.5-1.6 % compared to undisruptedscreening. Providing catch-up screening minimized this impact to 0.0-0.2 %. Conclusions Although the relative impact of the modelled CRC screening disruptions due to the COVID-19 pandemicappears modest, given a high burden of CRC, there is a substantial impact on CRC diagnoses and deaths across allcountries considered. It is crucial that, if disrupted, screening programs ensure participation rates return to previouslyobserved rates and provide catch-up screening wherever possible, as the impact of any disruption could be considerablylarger otherwise.

Aims A second wave of the COVID-19 pandemic may force many health care providers to downscale their services again,including colonoscopies which may impact capacity for colorectal cancer (CRC) screening. This study aimed to determinethe optimal measure to handle these temporary shortages in colonoscopy capacity in the Dutch national CRC screeningprogram to retain as much of the preventive effect of the screening program as possible. Methods We used the MISCAN-Colon model to simulate the Dutch national CRC screening program, providing biennial FITto individuals aged 55-75, under three different scenarios to temporarily reduce required colonoscopy capacity in thesecond half of 2020 and 2021: increase in FIT cut-off value exclusion of specific age-groups, and extension of the screening interval For each scenario, we estimated the impact on required colonoscopy capacity in 2020-2021, long-term CRC incidence,mortality and life years (LYs) lost. Outcomes were compared to a reference scenario without colonoscopy restrictions. Results In 2020 and 2021, the required colonoscopy capacity without any restrictions was 100,300 colonoscopies.Increasing the cut-off, excluding age-groups and extending the screening interval resulted in a reduction of 11,600-27,000,10,800-17,500, and 16,100-49,500 colonoscopies, respectively (Table 1). Increasing the cut-off resulted in 400-900 excessCRC cases and 200-500 excess CRC-related deaths from 2020-2050, while excluding age-groups resulted in 200-600excess CRC cases and 200-500 excess CRC-related deaths. Unexpectedly, extending the screening interval up to 34 months prevented 200-300 more CRC cases and 200-600 more CRC-related deaths, because screening occurred until slightlyhigher ages due to the initial delay. All measures resulted in LYs lost, but extending the screening interval up to 34 monthshad the smallest impact. Abbreviations: CRC, colorectal cancer;LYs, Life Years;μg Hb/g feces, microgram Hemoglobin per gram feces.∗Number between brackets are negative numbers. Conclusions A temporary extension of the screening interval to accommodate reduction in available colonoscopy capacityresults in the smallest impact on the CRC incidence, mortality and LYs lost. (Table Presented).

OBJECTIVE Low birth weight is associated with cardiovascular disease. We examined the effects of fetal and infant growth patterns on cardiovascular outcomes in children. METHODS In a population-based prospective cohort study among 6239 children, we estimated fetal-femur length and weight by 20 and 30 weeks ultrasound, and child length and weight at birth, 0.5, 1, 2 and 6 years. We measured blood pressure (BP), carotid-femoral pulse wave velocity, aortic root diameter, left ventricular mass and fractional shortening at 6 years. We used regression analyses to identify longitudinal growth patterns associated with height-standardized vascular outcomes and body-surface-area-standardized cardiac outcomes. RESULTS Younger gestational age and lower birth weight were associated with higher BP, smaller aortic root diameter and lower left ventricular mass in childhood (all P values

BACKGROUND Associations between dairy intake and body mass index (BMI) have been inconsistently observed in epidemiological studies, and the causal relationship remains ill defined. METHODS We performed Mendelian randomization (MR) analysis using an established dairy intake-associated genetic polymorphism located upstream of the lactase gene (LCT-13910 C/T, rs4988235) as an instrumental variable (IV). Linear regression models were fitted to analyze associations between (a) dairy intake and BMI, (b) rs4988235 and dairy intake, and (c) rs4988235 and BMI in each study. The causal effect of dairy intake on BMI was quantified by IV estimators among 184802 participants from 25 studies. RESULTS Higher dairy intake was associated with higher BMI (β = 0.03 kg/m2 per serving/day; 95% CI, 0.00–0.06; P = 0.04), whereas the LCT genotype with 1 or 2 T allele was significantly associated with 0.20 (95% CI, 0.14–0.25) serving/day higher dairy intake (P = 3.15 × 10−12) and 0.12 (95% CI, 0.06–0.17) kg/m2 higher BMI (P = 2.11 × 10−5). MR analysis showed that the genetically determined higher dairy intake was significantly associated with higher BMI (β = 0.60 kg/m2 per serving/day; 95% CI, 0.27–0.92; P = 3.0 × 10−4). CONCLUSIONS The present study provides strong evidence to support a causal effect of higher dairy intake on increased BMI among adults.

Indoor carbon dioxide (CO2) concentrations have been used for decades to characterize building ventilation and indoor air quality. Many of these applications require rates of CO2 generation from the building occupants, which are currently based on approaches and data that are several decades old. However, CO2 generation rates can be derived from well-established concepts within the fields of human metabolism and exercise physiology, which relate these rates to body size and composition, diet, and level of physical activity. This paper reviews how CO2 generation rates have been estimated in the past and discusses how they can be characterized more accurately. Based on this information, a new approach to estimating CO2 generation rates is presented, which is based on the described concepts from the fields of human metabolism and exercise physiology. Using this approach and more recent data on body mass and physical activity, values of CO2 generation rates from building occupants are presented along with the variability that may occur based on body mass and activity data.

Objective: Low birth weight is associated with cardiovascular disease in adulthood. Hemodynamic adaptations related to fetal growth restriction may underlie these associations, through persistent influences on cardiovascular development. We examined the associations of third trimester fetal hemodynamics with cardiovascular outcomes in childhood. Methods: In a prospective cohort study among 917 pregnant women and their children, we measured fetal growth, and fetal arterial and cardiac hemodynamic variables with ultrasound and Doppler examinations at a gestational age of 30.3 (95% range 28.8-32.3) weeks. At the age of 6 years, we measured blood pressure, carotid-femoral pulse wave velocity, and left cardiac structures and function. Results: We observed that fetal hemodynamics were not associated with childhood blood pressure and carotid-femoral pulse wave velocity the fetal aorta ascendens diameter and left cardiac output were positively associated with childhood aortic root diameter [0.14 standard deviation score (SDS), 95% confidence interval (CI) 0.07-0.22 and 0.08 SDS, 95% CI 0.01-0.15 per SDS change in diameter and output, respectively]. Fetal left ventricular diastolic filling pattern was inversely associated with aortic root diameter (-0.07 SDS, 95% CI-0.13 to 0.00 per SDS change in E/A ratio) at 6 years. Analyses adjusted and stratified for estimated fetal weight showed no differences in results. Conclusion: Our results suggest that third trimester fetal vascular resistance parameters do not affect blood pressure or arterial stiffness in childhood. Fetal cardiac functional and structural measures are associated with cardiac outcomes in childhood. Whether these early adaptations lead to greater risks of cardiovascular disease should be further studied.

textabstractbackground In adults, low level of education was shown to be associated with higher blood pressure levels and alterations in cardiac structures and function. It is currently unknown whether socioeconomic inequalities in arterial and cardiac alterations originate in childhood. Therefore, we investigated the association of maternal education with blood pressure levels, arterial stiffness, and cardiac structures and function at the age of 6 years and potential underlying factors. methods The study included 5,843 children participating in a prospective cohort study in the Netherlands. Maternal education was assessed at enrollment. Blood pressure, carotid-femoral pulse wave velocity, left atrial diameter, aortic root diameter, left ventricular mass, and fractional shortening were measured at the age of 6 years. results Children with low educated (category 1) mothers had higher systolic (2.80 mm Hg; 95% confidence interval (CI) = 1.62-2.94) and diastolic (1.80 mm Hg; 95% CI = 1.25-2.35) blood pressure levels compared with children with high educated (category 4) mothers. The main explanatory factors were the child's body mass index (BMI), maternal BMI, and physical activity. Maternal education was negatively associated with fractional shortening (Ptrend = 0.008), to which blood pressure and child's BMI contributed the most. No socioeconomic gradient was observed in other arterial and cardiac measurements. conclusions Socioeconomic inequalities in blood pressure are already present in childhood. Higher fractional shortening among children from low socioeconomic families might be a first cardiac adaptation to higher blood pressure and higher BMI. Interventions should be aimed at lowering child BMI and increasing physical activity among children from low socioeconomic families.

Suboptimal maternal dietary intake during pregnancy might lead to fetal cardiovascular adaptations and higher blood pressure in the offspring. The aim of the present study was to investigate the associations of maternal first-trimester dietary intake with blood pressure in children at the age of 6 years. We assessed first-trimester maternal daily dietary intake by a FFQ and measured folate, homocysteine and vitamin B12 concentrations in the blood, in a population-based prospective cohort study among 2863 mothers and children. Childhood systolic and diastolic blood pressure was measured using a validated automatic sphygmomanometer. First-trimester maternal daily intake of energy, fat, protein and carbohydrate was not associated with childhood blood pressure. Furthermore, maternal intake of micronutrients was not associated with childhood blood pressure. Also, higher maternal vitamin B12 concentrations were associated with a higher diastolic blood pressure (0·31 mmHg per standard deviation increase in vitamin B12 (95 % CI 0·06, 0·56)). After taking into account multiple testing, none of the associations was statistically significant. Maternal first-trimester folate and homocysteine concentrations were not associated with childhood blood pressure. The results from the present study suggest that maternal Fe intake and vitamin B12 concentrations during the first trimester of pregnancy might affect childhood blood pressure, although the effect estimates were small and were not significant after correction for multiple testing. Further studies are needed to replicate these findings, to elucidate the underlying mechanisms and to assess whether these differences in blood pressure persist in later life.

IntroductionDepression and hypercholesterolemia are two of the most commonly treated conditions in the developed countries, while the lipid–lowering agents and antidepressants are among the most widely prescribed drugs in the world. There is a common concern that selective serotonin reuptake inhibitors (SSRIs) can trigger statin adverse effects, especially myopathy. However, the supporting evidence originates from studies in-vitro and big epidemiological studies. Recent pharmacokinetic insights indicate that the magnitude of pharmacokinetic interaction between SSRIs and statins is likely to be below the threshold for clinical significance.Objectives and aimsExplorative study on pharmacokinetic effects of SSRIs on statin drugs.MethodsWe performed a detailed literature review through PubMed, EMBASE and Cochran's Library to assess the clinical relevance of combined SSRIs and statin use. To address pharmacokinetic interactions between two drug groups, we focused on:– cytochrome P450 enzyme metabolism of statins;– CYP enzyme inhibition by SSRIs;– SSRIs–statin drug interactions;– non-CYP pharmacokinetic pathways.ResultsWith regard to pharmacokinetic drug interactions and the risk of statin related myopathy, escitalopram, citalopram, and paroxetine are to be safe in co-therapy with all statins. Rosuvastatin and pravastatin are almost certain to be safe in co-therapy with all SSRIs. Fluoxetine and sertraline are also likely to be safe, even when combined with atorvastatin, simvastatin, and lovastatin.ConclusionThough the absolute risk of concomitant use of SSRIs with statins seems to be negligible, even this risk can be minimized by using lower statin doses and monitoring the patient.Disclosure of interestThe authors have not supplied their declaration of competing interest.

IntroductionSelective serotonin reuptake inhibitors (SSRIs) are the most prescribed antidepressants worldwide. In older adults, citalopram is generally well tolerated and safe in the therapeutic dose range of 20 to 40 mg/day. In literature, there are cases of SSRI-induced psychosis, but mainly with fluoxetine. There are only three reported cases of citalopram-induced delusions, however, these case-reports did not involve an older adult.Objectives and aimsTo provide a case of citalopram–induced psychosis in an older adult, followed by the review of available literature.MethodsA case report is presented and discussed followed by a literature review.ResultsA 64-year-old woman without somatic illnesses was referred by a general practitioner with depressive symptoms. One week after initiation of citalopram 10 mg/day she suddenly developed delusions, predominantly in the early morning. No other medical evidence was found that could explain her delusions. After discontinuation of citalopram her delusions quickly resolved.ConclusionThis is the first case report of a SSRI-induced delusion in an older adult. Citalopram has been reported to be one of the safest SSRIs. Although most SSRI's have a mild side-effect profile, care should be taken when initiating SSRIs since unpredictable adverse effects may occur.Disclosure of interestThe authors have not supplied their declaration of competing interest.

IntroductionQuetiapine, a short-acting atypical anti-psychotic drug for the treatment of bipolar I disorder and schizophrenia, is increasingly used off-label for the treatment of sleep disturbances or insomnia. However, data supporting this off-label prescription of quetiapine are limited.Objectives and aimsTo report and discuss the effects of “off-label” use of quetiapine for the treatment of sleep disturbances.MethodsAn English-language literature search was conducted using Pubmed, EMBASE and Cochrane library (December 1980–December 2015) using the search terms quetiapine, insomnia, sleep disorders, sleep disturbances, and sleeplessness.ResultsDuring the last decade, there is an enormous increase in prescribing quetiapine. This anti-psychotic drug is among the best selling drugs worldwide. For the approved indications, the usual therapeutic dose range is 400–800 mg/day. However, off-label use of quetiapine was most evident for the 25 mg/day to 100 mg/day. In some countries, off-label uses are promoted to non-psychiatrists for the treatment of insomnia, dementia, agitation, and aggression. Inappropriate anti-psychotic use may lead to serious health problems, including metabolic effects, increased sudden cardiac death, and age-related side effects with increased risk for orthostatic hypotension, fractures, pneumonia, cognitive impairment, and stroke.ConclusionThere is growing concern regarding the potential harm from off-label prescription of anti-psychotics, particularly quetiapine. There is little evidence supporting the enormous off-label uses of quetiapine. In addition, prescribing quetiapine for indications that are not evidence based has ethical, financial, and safety implications, especially in the older population.Disclosure of interestThe authors have not supplied their declaration of competing interest.

IntroductionMorbid obesity (BMI ≥ 35) has been associated with mood and anxiety disorders. Regular use of antidepressants is common among patients who are candidate for bariatric surgery. The Roux-en-Y gastric bypass (RYGB) is one of the most common techniques used in bariatric surgery for reducing nutrient absorption. This type of surgery may however result in major changes in drug absorption.Objectives and aimsTo report and discuss the consequences of bariatric surgery on changes in antidepressant drug absorption.MethodsWe present all published in vitro and in vivo studies on antidepressant drug absorption after bariatric surgery.ResultsIn vitro studies showed that only bupropion had a significantly increased dissolution in a post-RYGB environment; venlafaxine and citalopram showed no alteration of dissolution; fluoxetine, paroxetine, sertraline, and amitryptiline had an significantly decreased dissolution in a post RYGB environment. Some in-vivo studies reported that only citalopram and escitalopram had an increased dissolution.ConclusionAfter bariatric surgery, special caution is required in patients using antidepressant medication because of the expected changes in drug absorption, nutritional status, and electrolyte balance.Disclosure of interestThe authors have not supplied their declaration of competing interest.