Using Simulated Family Presence to Decrease Agitation in Older Hospitalized Delirious Patients: A Randomized Controlled Trial

Background: Simulated family presence has been shown to be an effective nonpharmacological intervention to reduce agitation in persons with dementia in nursing homes. Hyperactive or mixed delirium is a common and serious complication experienced by hospitalized patients, a key feature of which is agitation. Effective nonpharmacological interventions to manage delirium are needed. Objectives: To examine the effect of simulated family presence through pre-recorded video messages on the agitation level of hospitalized, delirious, acutely agitated patients. Design: Single site randomized control trial, 3 groups x 4 time points mixed factorial design conducted from July 2015 to March 2016. Setting: Acute care level one trauma center in an inner city of the state of Connecticut, USA. Participants: Hospitalized patients experiencing hyperactive or mixed delirium and receiving continuous observation were consecutively enrolled (n = 126), with 111 participants completing the study. Most were older, male, Caucasian, spouseless, with a pre-existing dementia. Methods: Participants were randomized to one of the following study arms: view a one minute family video message, view a one minute nature video, or usual care. Participants in experimental groups also received usual care. The Agitated Behavior Scale was used to measure the level of agitation prior to, during, immediately following, and 30 minutes following the intervention. Results: Both the family video and nature video groups displayed a significant change in median agitation scores over the four time periods (p \u3c .001), whereas the control group did not. The family video group had significantly lower median agitation scores during the intervention period (p \u3c .001) and a significantly greater proportion (94%) of participants experiencing a reduction in agitation from the pre-intervention to during intervention (p \u3c .001) than those viewing the nature video (70%) or those in usual care only (30%). The median agitation scores for the three groups were not significantly different at either of the post intervention time measurements. When comparing the proportion of participants experiencing a reduction in agitation from baseline to post intervention, there remained a statistically significant difference (p = .001) between family video(60%) and usual care (35.1%) immediately following the intervention Conclusion: This work provides preliminary support for the use of family video messaging as a nonpharmacological intervention that may decrease agitation in selected hospitalized delirious patients. Further studies are necessary to determine the efficacy of the intervention as part of a multi-component intervention as well as among younger delirious patients without baseline dementia

Peripheral leukocyte counts and outcomes after intracerebral hemorrhage

<p>Abstract</p> <p>Background</p> <p>Intracerebral hemorrhage (ICH) is a devastating disease that carries a 30 day mortality of approximately 45%. Only 20% of survivors return to independent function at 6 months. The role of inflammation in the pathophysiology of ICH is increasingly recognized. Several clinical studies have demonstrated an association between inflammatory markers and outcomes after ICH; however the relationship between serum biomarkers and functional outcomes amongst survivors has not been previously evaluated. Activation of the inflammatory response as measured by change in peripheral leukocyte count was examined and assessment of mortality and functional outcomes after ICH was determined.</p> <p>Findings</p> <p>Patients with spontaneous ICH admitted to a tertiary care center between January 2005 and April 2010 were included. The change in leukocyte count was measured as the difference between the maximum leukocyte count in the first 72 hours and the leukocyte count on admission. Mortality was the primary outcome. Secondary outcomes were mortality at 1 year, discharge disposition and the modified Barthel index (MBI) at 3 months compared to pre-admission MBI. 423 cases were included. The in-hospital mortality was 30.4%. The change in leukocyte count predicted worse discharge disposition (OR = 1.258, p = 0.009). The change in leukocyte count was also significantly correlated with a decline in the MBI at 3 months. These relationships remained even after removal of all patients with evidence of infection.</p> <p>Conclusions</p> <p>Greater changes in leukocyte count over the first 72 hours after admission predicted both worse short term and long term functional outcomes after ICH.</p

Family History is a Predictor for Appendicitis in Adults Presenting to the Emergency Department

Introduction: A family history of appendicitis has been reported to increase the likelihood of thediagnosis in children and in a retrospective study of adults. We compare positive family history with thediagnosis of acute appendicitis in a prospective sample of adults.Methods: We conducted a prospective observational study of a convenience sample of 428 patients.We compared patients with surgically proven appendicitis to a group without appendicitis. The latterwere further grouped by their presenting symptoms: those presenting with a chief complaint ofabdominal pain and those with other chief complaints. Participants answered questions regarding theirfamily history of appendicitis. Family history was then compared for the appendicitis group versus thenonappendicitis group as a whole, and then versus the subgroup of patients without appendicitis butwith abdominal pain. The primary analysis was a v2 test of proportions and the calculation of odds ratio(OR) for the relationship between final diagnosis of appendicitis and family history.Results: Of 428 patients enrolled, 116 had appendicitis. Of those with other diagnoses, 158 hadabdominal pain and 154 had other complaints. Of all patients with appendicitis, 37.9% (confidence interval [CI]=29.1–46.8) had positive family history. Of those without appendicitis, 23.7% (CI=19.0–28.4) had positive family history. In the subgroup without appendicitis but with abdominal pain, 25.9%(CI=19.1–32.8) had positive family history. Both comparisons were significant (P=0.003; OR=1.97;95% CI=1.2–3.1; and P=0.034; OR=1.74; 95% CI=1.04–2.9, respectively). By multivariate logisticregression analysis across the full sample, family history was a significant independent predictor (P=0.011; OR = 1.883) of appendicitis.Conclusion: Adults presenting to the emergency department with a known family history ofappendicitis are more likely to have this disease than those without. [West J Emerg Med.2012;13(6):468–471.

Family History is a Predictor for Appendicitis in Adults Presenting to the Emergency Department

Introduction: A family history of appendicitis has been reported to increase the likelihood of the diagnosis in children and in a retrospective study of adults. We compare positive family history with the diagnosis of acute appendicitis in a prospective sample of adults.Methods: We conducted a prospective observational study of a convenience sample of 428 patients.We compared patients with surgically proven appendicitis to a group without appendicitis. The latter were further grouped by their presenting symptoms: those presenting with a chief complaint of abdominal pain and those with other chief complaints. Participants answered questions regarding their family history of appendicitis. Family history was then compared for the appendicitis group versus then on appendicitis group as a whole, and then versus the subgroup of patients without appendicitis but with abdominal pain. The primary analysis was a v2 test of proportions and the calculation of odds ratio(OR) for the relationship between final diagnosis of appendicitis and family history.Results: Of 428 patients enrolled, 116 had appendicitis. Of those with other diagnoses, 158 had abdominal pain and 154 had other complaints. Of all patients with appendicitis, 37.9% (confidence interval [CI]=29.1–46.8) had positive family history. Of those without appendicitis, 23.7% (CI=19.0–28.4) had positive family history. In the subgroup without appendicitis but with abdominal pain, 25.9%(CI=19.1–32.8) had positive family history. Both comparisons were significant (P=0.003; OR=1.97;95% CI=1.2–3.1; and P=0.034; OR=1.74; 95% CI=1.04–2.9, respectively). By multivariate logistic regression analysis across the full sample, family history was a significant independent predictor (P=0.011; OR = 1.883) of appendicitis.Conclusion: Adults presenting to the emergency department with a known family history of appendicitis are more likely to have this disease than those without

Are Preexisting Retinal and Central Nervous System-Related Comorbidities Risk Factors for Complications Following Robotic-Assisted Laparoscopic Prostatectomy?

ABSTRACTPurpose:To assess whether retinal and central nervous system (CNS) comorbidities are risk factors for complications following robotic assisted laparoscopic prostatectomy (RALP).Materials and Methods:A retrospective review of our RALP database identified 1868 patients who underwent RALP by a single surgeon between December 10, 2003-March 14, 2014. We hypothesized that patients with preexisting retinal or CNS comorbidities were at a greater risk of suffering retinal and CNS complications following RALP. Perioperative complications and risk of recurrence were graded using the Clavien and D'Amico systems, respectively.Results:40 (2.1%) patients had retinal or CNS-related comorbidities, of which 15 had a history of retinal surgery and 24 had a history of cerebrovascular accident, aneurysm and/or neurosurgery. One additional patient had a history of both retinal and CNS events.Patients with retinal or CNS comorbidities were significantly older, had elevated PSA levels and CCI (Charlson Comorbidity Index) scores than the control group. Blood loss, length of stay, surgical duration, BMI, diagnostic Gleason score and T-stage were not statistically different between groups.No retinal or CNS complications occurred in either group. The distribution of patients between D'Amico risk categories was not statistically different between the groups. There was also no difference in the incidence of total complications between the groups.Conclusions:RALP-associated retinal and CNS complications are rare. While our RALP database is large, the cohort of patients with retinal or CNS-related comorbidities was relatively small. Our dataset suggests retinal and CNS pathology presents no greater risk of suffering from perioperative complications following RALP

Postoperative day one: a high risk period for respiratory events

In 2001, the Joint Commission on Accreditation of Healthcare Organizations released Pain Management Standards that has led to an increased focus on pain control. Since then the Institute for Safe Medication Practices has noted that overaggressive pain management has led to increases in oversedation and fatal respiratory depression. One of our previous studies found that postoperative patients may be reaching dangerously high levels of sedation as a result of pain management. Our hypothesis is that postoperative patients who have a respiratory event caused by analgesic use are more likely to have that event in the first postoperative day. We performed a retrospective case-control analysis identifying 62 postoperative patients who had a respiratory event. A respiratory event was defined as respiratory depression caused by narcotic use in the postoperative period that was reversed by naloxone. Sixty-two postoperative patients with no such event were chosen randomly and frequency matched based on surgical procedure and diagnosis-related group. Risk factors for an event were identified. Of the cases, 77.4% had a respiratory event in the first 24 hours postoperatively. Significant risk factors for an event were as follows: 65 years of age or older, having chronic obstructive pulmonary disease, having 1 or more comorbidities, and being placed on hydromorphone. The first 24 hours after surgery represents a high-risk period for a respiratory event as a result of narcotic use. The realization of this risk can lead to the implementation of standards to increase patient safety in the first postoperative day