Down Syndrome Reduces the Sedative Effect of Midazolam in Pediatric Cardiovascular Surgical Patients

Down syndrome (DS) is frequently comorbid with congenital heart disease and has recently been shown to reduce the sedative effect of benzodiazepine (BDZ)-class anesthesia but this effect in a clinical setting has not been studied. Therefore, this study compared midazolam sedation after heart surgery in DS and normal children. We retrospectively reviewed patient records in our pediatric intensive care unit (PICU) of pediatric cardiovascular operations between March 2015 and March 2018. We selected five days of continuous post-operative data just after termination of muscle relaxants. Midazolam sedation was estimated by Bayesian inference for generalized linear mixed models. We enrolled 104 patients (average age 26 weeks) of which 16 (15%) had DS. DS patients had a high probability of receiving a higher midazolam dosage and dexmedetomidine dosage over the study period (probability = 0.99, probability = 0.97) while depth of sedation was not different in DS patients (probability = 0.35). Multi regression modeling included severity scores and demographic data showed DS decreases midazolam sedation compared with controls (posterior OR = 1.32, 95% CrI = 1.01–1.75). In conclusion, midazolam dosages should be carefully adjusted as DS significantly decreases midazolam sedative effect in pediatric heart surgery patients

Type D personality is a predictor of prolonged acute brain dysfunction (delirium/coma) after cardiovascular surgery

BackgroundPrevious studies have shown a relationship between delirium and depressive symptoms after cardiac surgery with distress personalities linking to negative surgical outcomes. The aim of the present study is to further investigate the association between patients with Type D (distressed) personality with regards to delirium after cardiac surgery.MethodsWe conducted a consecutive-sample observational cohort pilot study with an estimated 142 patients needed. Enrollment criteria included patients aged ≥18 years who were undergoing planned cardiovascular, thoracic and abdominal artery surgery between October 2015 to August 2016 at the University of Tsukuba Hospital, Japan. All patients were screened by Type-D Personality Scale-14 (DS14) as well as the Hospital Anxiety and Depression Scale (HADS) the day before surgery. Following surgery, daily data was collected during recovery and included severity of organ dysfunction, sedative/analgesic exposure and other relevant information. We then evaluated the association between Type D personality and delirium/coma days (DCDs) during the 7-day study period. We applied regression and mediation modeling for this study.ResultsA total of 142 patients were enrolled in the present study and the total prevalence of delirium was found to be 34% and 26% of the patients were Type D. Non-Type D personality patients experienced an average of 1.3 DCDs during the week after surgery while Type D patients experienced 2.1 days over the week after surgery. Multivariate analysis showed that Type D personality was significantly associated with increased DCDs (OR:2.8, 95%CI:1.3–6.1) after adjustment for depressive symptoms and clinical variables. Additionally, there was a significant Type D x depression interaction effect (OR:1.7, 95% CI:1.2–2.2), and depressive symptoms were associated with DCDs in Type D patients, but not in non-Type D patients. Mediation modeling showed that depressive symptoms partially mediated the association of Type D personality with DCDs (Aroian test =0.04).ConclusionsType D personality is a prognostic predictor for prolonged acute brain dysfunction (delirium/coma) in cardiovascular patients independent from depressive symptoms and Type D personality-associated depressive symptoms increase the magnitude of acute brain dysfunction.Research articl

Post-intensive care syndrome: its pathophysiology, prevention, and future directions

Expanding elderly populations are a major social challenge in advanced countries worldwide and have led to a rapid increase in the number of elderly patients in intensive care units (ICUs). Innovative advances in medical technology have enabled lifesaving of patients in ICUs, but there remain various problems to improve their long-term prognoses. Post-intensive care syndrome (PICS) refers to physical, cognition, and mental impairments that occur during ICU stay, after ICU discharge or hospital discharge, as well as the long-term prognosis of ICU patients. Its concept also applies to pediatric patients (PICS-p) and the mental status of their family (PICS-F). Intensive care unit-acquired weakness, a syndrome characterized by acute symmetrical limb muscle weakness after ICU admission, belongs to physical impairments in three domains of PICS. Prevention of PICS requires performance of the ABCDEFGH bundle, which incorporates the prevention of delirium, early rehabilitation, family intervention, and follow-up from the time of ICU admission to the time of discharge. Diary, nutrition, nursing care, and environmental management for healing are also important in the prevention of PICS. This review outlines the pathophysiology, prevention, and future directions of PICS

New data on Uranium-series ages of hermatypic corals from the Pleistocene limestone on Kikai, Ryukyu Islands

Twenty-one Pleistocene corals newly collected at fourteen localities on the island of Kikai were dated by the uranium-series 230Th/234U method. One of the most salient observations is that a part of the Pleistocene limestone on the island was dated to be Middle Pleistocene in age, which may be correlative with two stages of the high sea stand. The one is corresponding to the stage 7 of the marine oxygen isotopic record (Emiliani and Shackleton, 1974), approximately 200, 000 years B.P., and the other may be correlative to the stage 9 (or older one), 250, 000 years or more B.P. From the distribution of corals assigned to more than 250, 000 years and the lithology of limestone including those corals, the very shallow environment where hermatypic corals could grow up is inferred to have spread at that time over the area having a diameter of at least 6.5 km. Namely, the initial coral reef settled directly onto the Pliocene basement (Somachi Formation; Nakagawa, 1969) might be a fairly extensive table reef and the limestone deposited as such a reef is nowadays composed the basal part of Late Pleistocene limestone. The other new uranium-series dates also are shown in the present paper. We point out, based on these new 230Th/234U dates, that the geologic history itemized by Konishi et al. (1970) should be modified, although it is not necessarily required to change principally the articles concerning the history since the past 130, 000 years. 琉球列島喜界島に分布する更新統石灰岩(Hanzawa, 1935, のRiukiu Limestone)から, 新しく230Th/234U法によって放射年代を求めた。ここで報告する年代値は, ほとんどが, これまで放射年代が知られていない地点で採集した7属(Favia, Goniastrea, Porites, Montipora, Favites, Galaxea, Montastrea)・合計21個の礁性サンゴ化石から得たものである。その結果として, 喜界島の更新統の一部は, 更新世中期における2回の高海水準期に形成されたことが明らかになった。一つは, おおよそ20万年前のEmiliani and Shackleton (1974)のoxygen isotopic stage 7にあたり, 他の一つは, 25万年以上前のstage9(あるいは, より以前の温暖期)に相当する。後者の年代値は, 島の各所で採集した試料から得られたが, それら採集地点の広がりとそれらサンゴ化石を含む石灰岩の岩相などから, 当時, 礁性サンゴの生育が可能な極浅海環境が, 一つの直径が少なくとも6.5kmある範囲に広がっていたと思われる。すなわち, 基盤(上部鮮新統早町層;中川, 1969)上に, はじめて形成されたサンゴ礁は, かなりの広がりをもった卓礁であった可能性もあり, 当時の礁を形成していた石灰岩は, 現在, Konishi et al.(1974)ほかの琉球石灰岩古・中および新期部層の基底部を構成していると考えられる。今回新たに得られた230Th/234Uサンゴ年代から, 以前Konishi et al.(1970)によって箇条書きにして述べられた本島の地史を, 過去13万年間の部分は基本的に変更の必要はないものの, 一部修正しなければならないことを指摘する