Perioperative Risk Factors for Postoperative Delirium in Patients Undergoing Esophagectomy

Background Postoperative delirium affects up to 50% of patients undergoing esophagectomy and is associated with negative outcomes. The perioperative risk factors for delirium in this population are not well understood. We conducted this study to assess perioperative risk factors for postoperative delirium among esophagectomy patients. Methods We performed a secondary data analysis of patients enrolled in a randomized controlled trial evaluating the efficacy of haloperidol prophylaxis postoperatively in reducing delirium among esophagectomy patients. Postoperative delirium was assessed twice daily using the Confusion Assessment Method for the ICU. Univariate and logistic regression analyses were performed to examine the association between perioperative variables and development of postoperative delirium. Results Of 84 consecutive esophagectomy patients, 27 (32%) developed postoperative delirium. Patients who developed postoperative delirium had higher APACHE II scores [22.1 (6.5) versus 17.4 (6.8); p=0.003], longer mechanical ventilation days [1.7 (1.4) versus 1.0 (1.1); p=0.001], and longer ICU days [5.1 (2.6) versus 2.6 (1.6); p<0.001]. In a logistic regression model, only ICU length of stay was found to have significant association with postoperative delirium [OR 1.65; 95% CI 1.21-2.25]. Conclusions ICU length of stay was significantly associated with postoperative delirium. Other perioperative factors including duration of surgery, blood loss, and hemoglobin levels were not significantly associated with postoperative delirium

Comments on Percrocuta carnifex (Carnivora, Percrocutidae) based on new fossil material from the Nagri Formation (Middle Siwaliks) of Hasnot, Pakistan

New dentary material of Percrocuta carnifex (Pilgrim, 1913) from the Nagri Formation ofHasnot, Pakistan, is described. Specimens of this species from the Siwalik continental deposits described by previous authors are discussed in detail. In addition to the taxonomic description of the new material, the occurrence and stratigraphic position of this species within the Siwalik Hills are re-evaluated. Except for the holotype, the specimens assigned to this species are very fragmentary. The newly discovered material, a right mandibular ramus containing teeth, is the best preserved specimen found to date. The comparative analysis, based on tooth morphology and dimensions of previously reported specimens and of the specimen studied here, suggests that this species is restricted to the Chinji and Nagri formations. Finally, the dental morphological features of the studied specimen and those of other species of Percrocuta are compared, and then the phylogenetic relationship between these species is discussed. The described specimen is thus important for the taxonomic, stratigraphic and phylogenetic knowledge of P. carnifex from the Siwaliks

Risk factors for the progression of mild cognitive impairment to dementia

The increasing prevalence of cognitive impairment among the older adult population warrants attention to the identification of practices that may minimize the progression of early forms of cognitive impairment, including the transitional stage of mild cognitive impairment (MCI), to permanent stages of dementia. This article identifies both markers of disease progress and risk factors linked to the progression of MCI to dementia. Potentially modifiable risk factors may offer researchers a point of intervention to modify the effect of the risk factor and to minimize the future burden of dementia

The Healthy Aging Brain Care (HABC) Monitor: validation of the Patient Self-Report Version of the clinical tool designed to measure and monitor cognitive, functional, and psychological health

BACKGROUND: Primary care providers need an inexpensive, simple, user-friendly, easily standardized, sensitive to change, and widely available multidomain instrument to measure the cognitive, functional, and psychological symptoms of patients suffering from multiple chronic conditions. We previously validated the Caregiver Report Version of the Healthy Aging Brain Care Monitor (HABC Monitor) for measuring and monitoring the severity of symptoms through caregiver reports. The purpose of this study was to assess the reliability and validity of the Patient Self-Report Version of the HABC Monitor (Self-Report HABC Monitor). DESIGN: Cross-sectional study. SETTING: Primary care clinics affiliated with a safety net urban health care system in Indianapolis, Indiana, USA. SUBJECTS: A total of 291 subjects aged ≥65 years with a mean age of 72.7 (standard deviation 6.2) years, 76% female, and 56% African Americans. ANALYSIS: Psychometric validity and reliability of the Self-Report HABC Monitor. RESULTS: Among 291 patients analyzed, the Self-Report HABC Monitor demonstrated excellent fit for the confirmatory factor analysis model (root mean square error of approximation =0.030, comparative fit index =0.974, weighted root mean square residual =0.837) and good internal consistency (0.78-0.92). Adequate convergent-divergent validity (differences between the Telephone Interview for Cognitive Status test-based cognitive function impairment versus nonimpairment groups) was demonstrated only when patients were removed from analysis if they had both cognitive function test impairment and suspiciously perfect self-report HABC Monitor cognitive floor scores of 0. CONCLUSION: The Self-Report HABC Monitor demonstrates good reliability and validity as a clinically practical multidimensional tool for measuring symptoms. The tool can be used along with its caregiver version to provide useful feedback (via monitoring of symptoms) for modifying care plans. Determining the validity of HABC Monitor scores from patients who self-report a perfect cognitive score of 0 requires cognitive function test results (eg, Telephone Interview for Cognitive Status or Mini Mental State Examination) or Caregiver Report HABC Monitor scores or further clinical examination to rule out the possibility that the patient is denying or unaware of their cognitive symptoms

Evaluation of the genetic structure of the urban dwelling species of Bank Myna (Acridotheres ginginisnus) using random amplified polymorphic DNA (RAPD) analysis

We used the random amplified polymorphic DNA (RAPD) technique to decipher the genetic structure of the Bank Myna (Acridotheres ginginisnus) in Pakistan. The samples were collected from four cities namely: Dera Ghazi Khan, Jahanian, Khanewal and Gujranwala. The analysis showed a high genetic diversity at species level (H = 0.318, S = 0.467) but low levels at population levels (H = 0.047, S = 0.069 to H = 0.195, S = 0.283). The four populations analyzed were genetically distant from each other and hinted the effect of urbanization role in isolating the urban dwelling species. The genetic distances between populations ranged from D = 0.2403 to D = 0.3419 and the similarity coefficient showed low range from 0.66 to 0.70. This study will help in future conservation plans and also help the understanding of the role of urbanization on fragmentation of species’ natural distribution and dispersal mechanism.Key words: Acridotheres ginginisnus, Bank Myna, random amplified polymorphic DNA (RAPD), genetic structure

Burden of Substance Abuse-Related Admissions to the Medical ICU

Background Admissions to the ICU related to alcohol, prescription drugs, and illicit drugs are shown to be widespread and costly. In 1993, a study revealed 28% of ICU admissions at Johns Hopkins Hospital were related to substance abuse and accrued 39% of costs. Since then, health-care expenditures have increased, and substance abuse treatment admissions have risen. We conducted a study to provide updated data on ICU utilization and costs related to licit and illicit abuse at a large county hospital in Indianapolis, Indiana. Methods All admissions to the medical ICU at Eskenazi Hospital from March to October 2017 were reviewed. Demographics, reason for admission, relation to substance abuse and specific substance, ICU and hospital length of stay, Acute Physiology and Chronic Health Evaluation II (APACHE II) scores, mortality, insurance status, and hospital charges were collected based on chart review. Results A total of 611 admissions generated $74,587,280.35 in charges. A total of 25.7% of admissions related to substance abuse accounted for 23.1% of total charges. Illicit drugs were 13% of total admissions, generating 11% of charges. Alcohol-related admissions were 9.5% of total admissions, generating 7.6% of charges. Prescription drugs were 2.9% of admissions, generating 4.2% of charges. Of the substance abuse admissions, patients were generally men and 40 to 64 years of age, with longer ICU stay, higher APACHE II scores, and higher mortality. Conclusions Substance abuse admissions make up almost a one-quarter of resources used by our ICU. Patients tend to be younger and sicker with a higher risk of death. Identifying and accurately describing the landscape of this current health crisis will help us take appropriate action in the future

Impact Assessment of Orography on the Extreme Precipitation Event of July 2010 over Pakistan: A Numerical Study

The topography influences monsoon precipitation and gives rise to significant rainfall events in South Asia. The physical mechanism involved in such events includes mechanical uplifting, thermodynamics, small scale cloud processes, and large scale atmospheric circulations. The investigation into orographic precipitation is pursued by synoptic and model analysis. Deep convection occurs as warm moist airflow is channeling over steep mountains. WRF model coupled with Morrison double moment scheme is used to assess the relative impact of topography on extreme rainfall event of 26–30 July 2010 in Pakistan. Two sensitivity tests with full topography (CTL) and reduced topography by 50% (LOW) are carried out. Two distinct precipitation zones over Hindukush and Himalaya mountains are identified. The topographic changes significantly affect moisture divergence and spatial and temporal distribution of precipitation. A low level jet is created on windward side of big mountains, yielding enhanced moisture flux and instability. Eddy kinetic energy significantly changes with orographic height. Energy flux created further unstabilized atmosphere and deep convection, producing wide spread heavy rainfall in the area in Himalaya foothills. Under the set synoptic conditions, orographic orientation enhanced the moisture accumulation and deep convection, resulting in occurrence of this extreme event

The confusion assessment method for the intensive care unit in patients with cirrhosis

In the intensive care unit (ICU), delirium is routinely measured with the widely-used, validated Confusion Assessment Method for the ICU (CAM-ICU), but CAM-ICU has not been studied in patients with cirrhosis. We studied a group of patients with cirrhosis to determine the relationship between delirium measured by CAM-ICU and clinical outcomes. Consecutive patients with cirrhosis admitted to the ICU from 2009 to 2012 were included in a retrospective cohort study. Patients were screened twice daily for coma and delirium during their ICU stay using the Richmond Agitation Sedation Scale (RASS) and CAM-ICU. The association between delirium/coma and mortality was determined using multiple logistic regression. RASS and CAM-ICU were also compared to a retrospective assessment of hepatic encephalopathy (HE). Of 91 patients with cirrhosis, 26 (28.6 %) developed delirium/coma. RASS/CAM-ICU had fair agreement with the HE assessment (κ 0.38). Patients with delirium/coma had numerically greater mortality in-hospital (23.1 vs. 7.7 %, p = 0.07) and at 90 days (30.8 vs. 18.5 %, p = 0.26), and they also had longer hospital length of stay (median 19.5 vs. 6 days, p < 0.001). Delirium/coma was associated with increased inpatient mortality, independent of disease severity (unadjusted OR 3.6; 95 % CI, 0.99-13.1; MELD-adjusted OR 5.4; 95 % CI, 1.3-23.8; acute physiology score-adjusted OR 2.2; 95 % CI, 0.53-8.9). Delirium/coma was also associated with longer length of stay after adjusting for disease severity. In critically ill patients with cirrhosis, delirium/coma as measured by the RASS and CAM-ICU is associated with increased mortality and hospital length of stay. For these patients, these measures provide valuable information and may be useful tools for clinical care. RASS and CAM-ICU need to be compared to HE-specific measures in future studies

Deprescribing in the Pharmacologic Management of Delirium (de-PMD): A Randomized Trial in the Intensive Care Unit

OBJECTIVE: Benzodiazepines and anticholinergics are risk factors for delirium in the intensive care unit (ICU). We tested the impact of a deprescribing intervention on short-term delirium outcomes. DESIGN: Multi-site randomized clinical trial SETTING: ICU’s of three large hospitals PARTICIPANTS: Two hundred adults aged ≥ 18 years admitted to an ICU with delirium according to the Richmond Agitation Severity Scale and the Confusion Assessment Method for the ICU (CAM-ICU). Participants had a contraindication to haloperidol (seizure disorder or prolonged QT interval) or preference against haloperidol as a treatment for delirium, and were excluded for serious mental illness, stroke, pregnancy or alcohol withdrawal. Participants were randomized to a deprescribing intervention or usual care. The intervention included electronic alerts combined with pharmacist support to deprescribe anticholinergics and benzodiazepines. MEASUREMENTS: Primary outcomes were delirium duration measured by the CAM-ICU, and severity measured by the Delirium Rating Scale Revised-98 (DRS-R-98) and the CAM-ICU-7; secondary outcomes included adverse events and mortality. RESULTS: Participants had a mean age of 61.8 (standard deviation: 14.3) years, 59% female, and 52% African American with no significant differences in baseline characteristics between groups. No differences between groups were identified in the number exposed to anticholinergics (p=0.219) or benzodiazepines (p=0.566), the median total anticholinergic score (p=0.282), or the median total benzodiazepine dose in lorazepam equivalents (p=0.501). Neither median delirium/coma-free days (p=0.361) nor median change in delirium severity scores (p=0.582 for DRS-R-98; p=0.333 for CAM-ICU-7) were different between groups. No differences in adverse events or mortality were identified. CONCLUSIONS: When added to state-of-the-art clinical services, this deprescribing intervention had no impact on medication use in ICU participants. Given the age of the population, results of clinical outcomes may not be easily extrapolated to older adults. Nonetheless, improved approaches for deprescribing or preventing anticholinergics and benzodiazepines should be developed to determine the impact on delirium outcomes