The protocol of the Oslo Study of Clonidine in Elderly Patients with Delirium; LUCID:a randomised placebo-controlled trial

Background Delirium affects 15% of hospitalised patients and is linked with poor outcomes, yet few pharmacological treatment options exist. One hypothesis is that delirium may in part result from exaggerated and/or prolonged stress responses. Dexmedetomidine, a parenterally-administered alpha2-adrenergic receptor agonist which attenuates sympathetic nervous system activity, shows promise as treatment in ICU delirium. Clonidine exhibits similar pharmacodynamic properties and can be administered orally. We therefore wish to explore possible effects of clonidine upon the duration and severity of delirium in general medical inpatients. Methods/Design The Oslo Study of Clonidine in Elderly Patients with Delirium (LUCID) is a randomised, placebo-controlled, double-blinded, parallel group study with 4-month prospective follow-up. We will recruit 100 older medical inpatients with delirium or subsyndromal delirium in the acute geriatric ward. Participants will be randomised to oral clonidine or placebo until delirium free for 2 days (Diagnostic and Statistical Manual of Mental Disorders (DSM-5) criteria), or after a maximum of 7 days treatment. Assessment of haemodynamics (blood pressure, heart rate and electrocardiogram) and delirium will be performed daily until discharge or a maximum of 7 days after end of treatment. The primary endpoint is the trajectory of delirium over time (measured by Memorial Delirium Assessment Scale). Secondary endpoints include the duration of delirium, use of rescue medication for delirium, pharmacokinetics and pharmacodynamics of clonidine, cognitive function after 4 months, length of hospital stay and need for institutionalisation. Discussion LUCID will explore the efficacy and safety of clonidine for delirium in older medical inpatients. Trial registration ClinicalTrials.gov NCT01956604 . EudraCT Number: 2013-000815-2

Occurrence and Seasonality of Cyclic Volatile Methyl Siloxanes in Arctic Air

Cyclic volatile methyl siloxanes (cVMS) are present in technical applications and personal care products. They are predicted to undergo long-range atmospheric transport, but measurements of cVMS in remote areas remain scarce. An active air sampling method for decamethylcyclopentasiloxane (D5) was further evaluated to include hexamethylcyclotrisiloxane (D3), octamethylcyclotetrasiloxane (D4), and dodecamethylcyclohexasiloxane (D6). Air samples were collected at the Zeppelin observatory in the remote Arctic (79° N, 12° E) with an average sampling time of 81 ± 23 h in late summer (August−October) and 25 ± 10 h in early winter (November−December) 2011. The average concentrations of D5 and D6 in late summer were 0.73 ± 0.31 and 0.23 ± 0.17 ng/m3, respectively, and 2.94 ± 0.46 and 0.45 ± 0.18 ng/m3 in early winter, respectively. Detection of D5 and D6 in the Arctic atmosphere confirms their long-range atmospheric transport. The D5 measurements agreed well with predictions from a Eulerian atmospheric chemistry−transport model, and seasonal variability was explained by the seasonality in the OH radical concentrations. These results extend our understanding of the atmospheric fate of D5 to high latitudes, but question the levels of D3 and D4 that have previously been measured at Zeppelin with passive air samplers.acceptedVersio

Occurrence and seasonality of cyclic volatile methyl siloxanes in Arctic air

Cyclic volatile methyl siloxanes (cVMS) are present in technical applications and personal care products. They are predicted to undergo long-range atmospheric transport, but measurements of cVMS in remote areas remain scarce. An active air sampling method for decamethylcyclopentasiloxane (D5) was further evaluated to include hexamethylcyclotrisiloxane (D3), octamethylcyclotetrasiloxane (D4), and dodecamethylcyclohexasiloxane (D6). Air samples were collected at the Zeppelin observatory in the remote Arctic (79° N, 12° E) with an average sampling time of 81 ± 23 h in late summer (August−October) and 25 ± 10 h in early winter (November−December) 2011. The average concentrations of D5 and D6 in late summer were 0.73 ± 0.31 and 0.23 ± 0.17 ng/m3, respectively, and 2.94 ± 0.46 and 0.45 ± 0.18 ng/m3 in early winter, respectively. Detection of D5 and D6 in the Arctic atmosphere confirms their long-range atmospheric transport. The D5 measurements agreed well with predictions from a Eulerian atmospheric chemistry−transport model, and seasonal variability was explained by the seasonality in the OH radical concentrations. These results extend our understanding of the atmospheric fate of D5 to high latitudes, but question the levels of D3 and D4 that have previously been measured at Zeppelin with passive air samplers

Undiagnosed delirium is frequent and difficult to predict: Results from a prevalence survey of a tertiary hospital

AIMS AND OBJECTIVES: To study the prevalence and determinants of undiagnosed delirium in a tertiary hospital. BACKGROUND: Delirium is a common inpatient condition. It is frequently undiagnosed in a variety of settings, but determinants of undiagnosed delirium are largely unknown, and the frequency of undiagnosed delirium across all inpatient units is uncertain. The utility of hospital-wide screening then is also uncertain. METHODS: Hospital-wide prevalence study conducted over 4 months, using a chart-based method. Gender, age, admitting unit, history of dementia and comorbidity were used in univariate and multivariate analyses to search for differences in patients with no delirium, with undiagnosed delirium and with diagnosed delirium. Sensitivity, specificity and number needed to screen were calculated from proportions in each group. Study was conducted in concordance with STROBE guidelines. RESULTS: Delirium was prevalent in 12.5% of all patients and undiagnosed in 24.1% of patients. Only age ≥65 years and a history of dementia predicted delirium, and undiagnosed delirium in both univariate and multivariate analyses. Age ≥65 years accounts for 92.3% sensitivity and 50.8% specificity for undiagnosed delirium in this group. History of dementia had a 23.0% sensitivity and 97.0% specificity. Twenty-eight patients would need to be screened to detect a case of undiagnosed delirium. DISCUSSION: There was a high rate of delirium and undiagnosed delirium in this cohort. Known risk factors for delirium also independently predict undiagnosed delirium; other factors were not found. CONCLUSION: Undiagnosed delirium is common and difficult to predict from patient baseline characteristics other than age. RELEVANCE TO CLINICAL PRACTICE: Assessment of all inpatients for delirium is recommended

Atrial fibrillation in cryptogenic stroke and TIA patients in the nordic atrial fibrillation and stroke The Nordic Atrial Fibrillation and Stroke (NOR-FIB) Study : Main results

Introduction: Secondary stroke prevention depends on proper identification of the underlying etiology and initiation of optimal treatment after the index event. The aim of the NOR-FIB study was to detect and quantify underlying atrial fibrillation (AF) in patients with cryptogenic stroke (CS) or transient ischaemic attack (TIA) using insertable cardiac monitor (ICM), to optimise secondary prevention, and to test the feasibility of ICM usage for stroke physicians. Patients and methods: Prospective observational international multicenter real-life study of CS and TIA patients monitored for 12 months with ICM (Reveal LINQ) for AF detection. Results: ICM insertion was performed in 91.5% by stroke physicians, within median 9 days after index event. Paroxysmal AF was diagnosed in 74 out of 259 patients (28.6%), detected early after ICM insertion (mean 48 ± 52 days) in 86.5% of patients. AF patients were older (72.6 vs 62.2; p < 0.001), had higher pre-stroke CHA₂DS₂-VASc score (median 3 vs 2; p < 0.001) and admission NIHSS (median 2 vs 1; p = 0.001); and more often hypertension (p = 0.045) and dyslipidaemia (p = 0.005) than non-AF patients. The arrhythmia was recurrent in 91.9% and asymptomatic in 93.2%. At 12-month follow-up anticoagulants usage was 97.3%. Discussion and conclusions: ICM was an effective tool for diagnosing underlying AF, capturing AF in 29% of the CS and TIA patients. AF was asymptomatic in most cases and would mainly have gone undiagnosed without ICM. The insertion and use of ICM was feasible for stroke physicians in stroke units