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

Effects of music intervention on inflammatory markers in critically ill and post-operative patients: A systematic review of the literature

BACKGROUND: Music listening has been shown to reduce anxiety, stress, and patient tolerance of procedures. Music may also have beneficial effects on inflammatory biomarkers in intensive care and post-operative patients, but the quality of evidence is not clear. OBJECTIVES: We conducted a systematic review to evaluate the effects of music on inflammatory biomarkers in intensive care, and post-operative patients. METHODS: A comprehensive search of the literature was performed. After screening 1570 references, full text review of 26 studies was performed. Fourteen studies were selected for inclusion. RESULTS: Seven studies showed a significant decrease in cortisol levels, but the level of evidence was low. Three studies had low risk of methodological bias, while 11 studies had high risk of bias. CONCLUSIONS: Music intervention may decrease cortisol levels, but other biomarkers remain unchanged. Given the low level of evidence, further research on music effects on inflammatory biomarkers is needed

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

Psychiatric symptoms and their association with sleep disturbances in intensive care unit survivors

Background: Sleep disturbances in critically ill patients are associated with poorer long-term clinical outcomes and quality of life. Studies are needed to better characterize associations and risk factors for persistent sleep disturbances after intensive care unit (ICU) discharge. Psychiatric disorders are frequently associated with sleep disturbances, but the role of psychiatric symptoms in sleep disturbances in ICU survivors has not been well-studied. Objective: To examine the association between psychiatric symptoms and sleep disturbances in ICU survivors. Methods: 112 adult ICU survivors seen from July 2011 to August 2016 in the Critical Care Recovery Center, an ICU survivor clinic at the Eskenazi Hospital in Indianapolis, IN, USA, were assessed for sleep disturbances (insomnia, hypersomnia, difficulty with sleep onset, difficulty with sleep maintenance, and excessive daytime sleepiness) and psychiatric symptoms (trauma-related symptoms and moderate to severe depressive symptoms) 3 months after ICU discharge. A multivariate logistic regression model was performed to examine the association between psychiatric symptoms and sleep disturbances. Analyses were controlled for age, hypertension, history of depression, and respiratory failure. Results: ICU survivors with both trauma-related and depression symptoms (OR 16.66, 95% CI 2.89-96.00) and trauma-related symptoms alone (OR 4.59, 95% CI 1.11-18.88) had a higher likelihood of sleep disturbances. Depression symptoms alone were no longer significantly associated with sleep disturbances when analysis was controlled for trauma-related symptoms. Conclusion: Trauma-related symptoms and trauma-related plus moderate to severe depressive symptoms were associated with a higher likelihood of sleep disturbances. Future studies are needed to determine whether psychiatric symptoms are associated with objective changes on polysomnography and actigraphy and whether adequate treatment of psychiatric symptoms can improve sleep disturbances

Resolving IRAS 09111-1007 at 350 microns - a different path to ULIRG formation?

We have resolved the ultraluminous infrared galaxy (ULIRG), IRAS 09111-1007, with the new 350 micron-optimised Second Generation Submillimeter High Angular Resolution Camera (SHARC II) and present the first submillimetre fluxes and images for the system. IRAS 09111-1007 comprises two interacting luminous infrared galaxies (LIRGs) with a projected nuclear separation of 39 kpc. The Western galaxy is roughly four times more luminous in the submillimetre than its Eastern counterpart. It is an extremely bright LIRG with an AGN. The classification of the Eastern source is uncertain: it could be a Seyfert 2 galaxy or a LINER. We highlight IRAS 09111-1007 as a system that necessitates further study: a double AGN ULIRG whose molecular gas content differs from other widely separated pairs and whose ULIRG phase might not be explained by current multiple merger and/or final stage ULIRG scenarios.Comment: 6 pages, 4 figures. Accepted for publication in MNRAS Letter

Submillimetre surveys: The prospects for Herschel

Using the observed submillimetre source counts, from 250-1200 microns (including the most recent 250, 350 and 500 micron counts from BLAST), we present a model capable of reproducing these results, which is used as a basis to make predictions for upcoming surveys with the SPIRE instrument aboard the Herschel Space Observatory. The model successfully fits both the integral and differential source counts of submillimetre galaxies in all wavebands, predicting that while ultra-luminous infrared galaxies dominate at the brightest flux densities, the bulk of the infrared background is due to the less luminous infrared galaxy population. The model also predicts confusion limits and contributions to the cosmic infrared background that are consistent with the BLAST results. Applying this to SPIRE gives predicted source confusion limits of 19.4, 20.5 and 16.1mJy in the 250, 350 and 500 micron bands respectively. This means the SPIRE surveys should achieve sensitivities 1.5 times deeper than BLAST, revealing a fainter population of infrared-luminous galaxies, and detecting approximately 2600, 1300, and 700 sources per square degree in the SPIRE bands (with one in three sources expected to be a high redshift ultra-luminous source at 500 microns). The model number redshift distributions predict a bimodal distribution of local quiescent galaxies and a high redshift peak corresponding to strongly evolving star-forming galaxies. It suggests the very deepest surveys with Herschel-SPIRE ought to sample the source population responsible for the bulk of the infrared background.Comment: 5 pages, 4 figures, accepted for publication in MNRAS Letter

Effect of Delirium on Physical Function in Noncardiac Thoracic Surgery Patients

Background: The effect of delirium on physical function in patients undergoing noncardiac thoracic surgery has not been well described and may differ from that in other surgical populations. Objective: To determine the effects of delirium on muscle strength and functional independence. The primary end point was change in Medical Research Council sum score (MRC-SS) by delirium status. Methods: A secondary analysis of data from a clinical trial involving English-speaking adults aged 18 years or older who were undergoing major noncardiac thoracic surgery. Exclusion criteria were history of schizophrenia, Parkinson disease, dementia, alcohol abuse, or neuroleptic malignant syndrome; haloperidol allergy; being pregnant or nursing; QT prolongation; and taking levodopa or cholinesterase inhibitors. Delirium was assessed twice daily using the Confusion Assessment Method for the Intensive Care Unit. Preoperatively and postoperatively, muscle strength was assessed using the modified MRC-SS and functional independence was assessed using the Katz scale of activities of daily living. Changes in MRC-SS and Katz score by delirium status were analyzed using the Fisher exact test. Results: Seventy-three patients were included in the analysis. Median (interquartile range) MRC-SS and Katz score before surgery did not differ significantly between patients without and with delirium (MRC-SS: 30 [30-30] vs 30 [30-30], P > .99; Katz score: 6 [6-6] vs 6 [6-6], P = .63). The percentage of patients with a change in MRC-SS was similar in patients without and with delirium (17% vs 13%, respectively; P > .99). More patients in the delirium group had a change in Katz score (13% vs 0%, P = .04). Conclusions: Postoperative delirium was not associated with change in muscle strength. Follow-up studies using other muscle measures may be needed

Investigation of Biofuel as a Potential Renewable Energy Source

An accelerating global energy demand, paired with the harmful environmental effects of fossil fuels, has triggered the search for alternative, renewable energy sources. Biofuels are arguably a potential renewable energy source in the transportation industry as they can be used within current infrastructures and require less technological advances than other renewable alternatives, such as electric vehicles and nuclear power. The literature suggests biofuels can negatively impact food security and production; however, this is dependent on the type of feedstock used in biofuel production. Advanced biofuels, derived from inedible biomass, are heavily favoured but require further research and development to reach their full commercial potential. Replacing fossil fuels by biofuels can substantially reduce particulate matter (PM), carbon monoxide (CO) emissions, but simultaneously increase emissions of nitrogen oxides (NOx), acetaldehyde (CH3CHO) and peroxyacetyl nitrate (PAN), resulting in debates concerning the way biofuels should be implemented. The potential biofuel blends (FT-SPK, HEFA-SPK, ATJ-SPK and HFS-SIP) and their use as an alternative to kerosene-type fuels in the aviation industry have also been assessed. Although these fuels are currently more costly than conventional aviation fuels, possible reduction in production costs has been reported as a potential solution. A preliminary study shows that i-butanol emissions (1.8 Tg/year) as a biofuel can increase ozone levels by up to 6% in the upper troposphere, highlighting a potential climate impact. However, a larger number of studies will be needed to assess the practicalities and associated cost of using the biofuel in existing vehicles, particularly in terms of identifying any modifications to existing engine infrastructure, the impact of biofuel emissions, and their chemistry on the climate and human health, to fully determine their suitability as a potential renewable energy source

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

First Constraints on Source Counts at 350 Microns

We have imaged a $\sim$6 arcminute$^2$ region in the Bo\"otes Deep Field using the 350 $\mu$m-optimised second generation Submillimeter High Angular Resolution Camera (SHARC II), achieving a peak 1$\sigma$ sensitivity of $\sim$5 mJy. We detect three sources above 3$\sigma$, and determine a spurious source detection rate of 1.09 in our maps. In the absence of $5\sigma$ detections, we rely on deep 24 $\mu$m and 20 cm imaging to deduce which sources are most likely to be genuine, giving two real sources. From this we derive an integral source count of 0.84$^{+1.39}_{-0.61}$ sources arcmin$^{-2}$ at $S>13$ mJy, which is consistent with 350 $\mu$m source count models that have an IR-luminous galaxy population evolving with redshift. We use these constraints to consider the future for ground-based short-submillimetre surveys.Comment: accepted for publication in The Astrophysical Journa