Developing and implementing an integrated delirium prevention system of care:a theory driven, participatory research study

Background: Delirium is a common complication for older people in hospital. Evidence suggests that delirium incidence in hospital may be reduced by about a third through a multi-component intervention targeted at known modifiable risk factors. We describe the research design and conceptual framework underpinning it that informed the development of a novel delirium prevention system of care for acute hospital wards. Particular focus of the study was on developing an implementation process aimed at embedding practice change within routine care delivery. Methods: We adopted a participatory action research approach involving staff, volunteers, and patient and carer representatives in three northern NHS Trusts in England. We employed Normalization Process Theory to explore knowledge and ward practices on delirium and delirium prevention. We established a Development Team in each Trust comprising senior and frontline staff from selected wards, and others with a potential role or interest in delirium prevention. Data collection included facilitated workshops, relevant documents/records, qualitative one-to-one interviews and focus groups with multiple stakeholders and observation of ward practices. We used grounded theory strategies in analysing and synthesising data. Results: Awareness of delirium was variable among staff with no attention on delirium prevention at any level; delirium prevention was typically neither understood nor perceived as meaningful. The busy, chaotic and challenging ward life rhythm focused primarily on diagnostics, clinical observations and treatment. Ward practices pertinent to delirium prevention were undertaken inconsistently. Staff welcomed the possibility of volunteers being engaged in delirium prevention work, but existing systems for volunteer support were viewed as a barrier. Our evolving conception of an integrated model of delirium prevention presented major implementation challenges flowing from minimal understanding of delirium prevention and securing engagement of volunteers alongside practice change. The resulting Prevention of Delirium (POD) Programme combines a multi-component delirium prevention and implementation process, incorporating systems and mechanisms to introduce and embed delirium prevention into routine ward practices. Conclusions: Although our substantive interest was in delirium prevention, the conceptual and methodological strategies pursued have implications for implementing and sustaining practice and service improvements more broadly

Does using a femoral nerve block for total knee replacement decrease postoperative delirium?

<p>Abstract</p> <p>Background</p> <p>The effect of peripheral nerve blocks on postoperative delirium in older patients has not been studied. Peripheral nerve blocks may reduce the incidence of postoperative opioid use and its side effects such as delirium via opioid-sparing effect.</p> <p>Methods</p> <p>A prospective cohort study was conducted in patients who underwent total knee replacement. Baseline cognitive function was assessed using the Telephone Interview for Cognitive Status. Postoperative delirium was measured using the Confusion Assessment Method postoperatively. Incidence of postoperative delirium was compared in two postoperative management groups: femoral nerve block ± patient-controlled analgesia and patient-controlled analgesia only. In addition, pain levels (using numeric rating scales) and opioid use were compared in two groups.</p> <p>Results</p> <p>85 patients were studied. The overall incidence of postoperative delirium either on postoperative day one or day two was 48.1%. Incidence of postoperative delirium in the femoral nerve block group was lower than patient controlled analgesia only group (25% vs. 61%, <it>P </it>= 0.002). However, there was no significant difference between the groups with respect to postoperative pain level or the amount of intravenous opioid use.</p> <p>Conclusions</p> <p>Femoral nerve block reduces the incidence of postoperative delirium. These results suggest that a larger randomized control trial is necessary to confirm these preliminary findings.</p

The influence of tethered epidermal growth factor on connective tissue progenitor colony formation

Strategies to combine aspirated marrow cells with scaffolds to treat connective tissue defects are gaining increasing clinical attention and use. In situations such as large defects where initial survival and proliferation of transplanted connective tissue progenitors (CTPs) are limiting, therapeutic outcomes might be improved by using the scaffold to deliver growth factors that promote the early stages of cell function in the graft. Signaling by the epidermal growth factor receptor (EGFR) plays a role in cell survival and has been implicated in bone development and homeostasis. Providing epidermal growth factor (EGF) in a scaffold-tethered format may sustain local delivery and shift EGFR signaling to pro-survival modes compared to soluble ligand. We therefore examined the effect of tethered EGF on osteogenic colony formation from human bone marrow aspirates in the context of three different adhesion environments using a total of 39 donors. We found that tethered EGF, but not soluble EGF, increased the numbers of colonies formed regardless of adhesion background, and that tethered EGF did not impair early stages of osteogenic differentiation.National Institute of General Medical Sciences (U.S.) (Grant NIH RO1 AR42997)National Institute of General Medical Sciences (U.S.) (Grant NIH RO1 AG024980)National Institute of General Medical Sciences (U.S.) (Grant NIH RO1 GM59870)National Institute of General Medical Sciences (U.S.) (Grant NIH DE019523

Intentional replantation for the management of maxillary sinusitis

Aim. To present a case that emphasizes the importance of the use of intentional replantation as a technique to successfully treat a periapical lesion and an odontogenic maxillary sinusitis through the alveolus at the same time. Summary. This case report presents a patient with odontogenic maxillary sinusitis secondary to periapical disease of a maxillary molar that had previously received root canal treatment. The molar was extracted, with drainage and rinsing of the maxillary sinus. The apices were resected extra-orally, and the retrograde cavity was prepared with ultrasound and retrograde filling using silver amalgam. The tooth was then replanted. After 2 years, the patient was asymptomatic, periapical radiography showed no evidence of root resorption and computed tomography scanning demonstrated the resolution of maxillary sinusitis

Delirium Incidence, Duration and Severity in Critically Ill Patients with COVID-19

Background: Delirium incidence, duration and severity in patients admitted to the intensive care unit (ICU) due to COVID-19 is not known. Methods: We conducted an observational study at two large urban academic Level 1 trauma centers. Consecutive patients admitted to the ICU with a positive SARS-CoV-2 nasopharyngeal swab polymerase chain reaction test from March 1st, 2020 to April 27, 2020, were included. Individuals younger than 18 years of age, without any documented delirium assessments (CAM-ICU), or without a discharge disposition were excluded. The primary outcomes were delirium rates and delirium duration and the secondary outcome was delirium severity. Outcomes were assessed for up to the first 14 days of ICU stay. Results: Of 243 consecutive patients with confirmed COVID-19 admitted to the ICU, 144 met eligibility criteria and were included in the analysis. Delirium occurred in 73.6% (106/144) and delirium or coma occurred in 76.4% (110/144). Sixty-three percent of patients were positive for delirium on the first CAM-ICU assessment. The median duration of delirium and coma was 7 days (IQR: 3-10), and the median delirium duration was 5 days (IQR: 2-7). The median CAM-ICU-7 score was 6 (IQR: 4-7) representing severe delirium. Mechanical ventilation was associated with greater odds of developing delirium (OR: 42.1, 95%CI: 13.0-137.1). Mortality was 26.4% in patients with delirium compared to 15.8% in patients without delirium. Conclusions: 73.6% of patients admitted to the ICU with COVID-19 experience delirium that persists for approximately 1 week. Invasive mechanical ventilation is significantly associated with odds of delirium. Clinical attention to prevent and manage delirium and reduce delirium duration and severity is urgently needed for patients with COVID-19.Babar Khan, Sujuan Gao, and Anthony Perkins are supported through NIA R01 AG 055391, R01 AG 052493 and NHLBI R01 HL131730. Anthony Perkins is also supported by NIA grants 1K23AG062555-01 and R01AG056325. Roberto Machado is supported by 1R01HL111656, 1R01HL127342 and 1R01HL133951. Sophia Wang is supported by K23AG062555-01. Edward Marcantonio is supported by grants R01AG044518 and K24AG035075 from the NIA. Malaz Boustani received funding from NIA R01AG034205 and disclosed that he has ownership equity in two for profit companies, Preferred Population Health Management and RestUp. The products and services of the two companies are not related to the research activities of the paper

Automatic model-based telluric correction for the ESPRESSO data reduction software. Model description and application to radial velocity computation

Ground-based high-resolution spectrographs are key instruments for several astrophysical domains. Unfortunately, the observed spectra are contaminated by the Earth's atmosphere. While different techniques exist to correct for telluric lines in exoplanet atmospheric studies, in radial velocity (RV) studies, telluric lines with an absorption depth of >2% are generally masked, which poses a problem for faint targets and M dwarfs as most of their RV content is present where telluric contamination is important. We propose a simple telluric model to be embedded in the ESPRESSO DRS. The goal is to provide telluric-free spectra and enable RV measurements, including spectral ranges where telluric lines fall. The model is a line-by-line radiative transfer code that assumes a single atmospheric layer. We use the sky conditions and the physical properties of the lines from HITRAN to create the telluric spectrum. A subset of selected telluric lines is used to robustly fit the spectrum through a Levenberg-Marquardt minimization algorithm. When applied to stellar spectra from A0- to M5-type stars, the residuals of the strongest H2O lines are below 2% for all spectral types, with the exception of M dwarfs, which are within the pseudo-continuum. We then determined the RVs from the telluric-corrected ESPRESSO spectra of Tau Ceti and Proxima. We created telluric-free masks and compared the obtained RVs with the DRS RVs. In the case of Tau Ceti, we identified that micro-telluric lines introduce systematics up to an amplitude of 58 cm/s and with a period of one year. For Proxima, the gain in spectral content at redder wavelengths is equivalent to a gain of 25% in photon noise. This leads to better constraints on the semi-amplitude and eccentricity of Proxima d. We showcase that our model can be applied to other molecules, and thus to other wavelength regions observed by other spectrographs, such as NIRPS.Comment: 18 pages, 18 figures, accepted to A&