Preoperative cerebrospinal fluid cytokine levels and the risk of postoperative delirium in elderly hip fracture patients

Aging and neurodegenerative disease predispose to delirium and are both associated with increased activity of the innate immune system resulting in an imbalance between pro- and anti-inflammatory mediators in the brain. We examined whether hip fracture patients who develop postoperative delirium have altered levels of inflammatory mediators in cerebrospinal fluid (CSF) prior to surgery. Patients were 75 years and older and admitted for surgical repair of an acute hip fracture. CSF samples were collected preoperatively. In an exploratory study, we measured 42 cytokines and chemokines by multiplex analysis. We compared CSF levels between patients with and without postoperative delirium and examined the association between CSF cytokine levels and delirium severity. Delirium was diagnosed with the Confusion Assessment Method; severity of delirium was measured with the Delirium Rating Scale Revised-98. Mann-Whitney U tests or Student t-tests were used for between-group comparisons and the Spearman correlation coefficient was used for correlation analyses. Sixty-one patients were included, of whom 23 patients (37.7%) developed postsurgical delirium. Concentrations of Fms-like tyrosine kinase-3 (P=0.021), Interleukin-1 receptor antagonist (P=0.032) and Interleukin-6 (P=0.005) were significantly lower in patients who developed delirium postoperatively. Our findings fit the hypothesis that delirium after surgery results from a dysfunctional neuroinflammatory response: stressing the role of reduced levels of anti-inflammatory mediators in this process. The Effect of Taurine on Morbidity and Mortality in the Elderly Hip Fracture Patient.Registration number: NCT00497978. Local ethical protocol number: NL16222.094.0

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Stress-Induced Hyperglycemia in Healthy Bungee Jumpers Without Diabetes Due to Decreased Pancreatic beta-Cell Function and Increased Insulin Resistance

Background: Acute diseases are associated with increased stress and immune responses. Both of these responses are associated with disturbances of glucose metabolism, and it is therefore difficult to ascertain whether these disturbances are related to increased stress alone or a result of the systemic inflammatory response. We investigated the effects that acute stress has on glucose metabolism in an acute stress model that is not accompanied by an increased immune response. Subjects and Methods: Glucose levels as well as pancreatic beta-cell function, insulin resistance, and parameters of stress and immune responses were assessed in healthy bungee jumpers 2 h before, immediately before, and after the jump. Results: Glucose levels and stress hormones were increased, right before and after the jump, whereas the immune response was decreased. Pancreatic beta-cell function was decreased right before the jump, and insulin resistance was increased right after the jump. Higher levels of cortisol correlated with increased insulin resistance after the jump. Furthermore, larger increments of cortisol before and of epinephrine after the jump were associated with decreased pancreatic beta-cell function. Conclusions: Acute stress in healthy bungee jumpers induces acute disturbances of glucose metabolism that are independent from a systemic inflammatory respons

POCUS series: The use of velocity time integral in assessing cardiac output and fluid responsiveness

In the last decade ultrasound has found its place in the intensive care unit. Initially ultrasound was used primarily to increase safety and efficacy of line insertion but now many intensivists use point-of-care ultrasound (POCUS) to aid in diagnosis, assessment of therapy and therapeutic interventions. In this series we aim to highlight one specific POCUS technique at a time, which we believe will prove to be useful in your clinical practice. Our aim is to provide you with a short and practical description of the technique as well as its merits and pitfalls. In this issue we describe the use of the left ventricular outflow tract velocity time integral to ascertain cardiac output and fluid responsiveness

Self-expanding metal stents in benign biliary strictures due to chronic pancreatitis

Background and Study Aims: In selected patients with chronic pancreatitis in whom conventional plastic stenting fails and in whom surgery is contraindicated or declined, insertion of a biliary self-expanding metal stent (SEMS) may be a valuable treatment option. Patients and Methods: Between 1994 and 1999, 13 patients with chronic pancreatitis received SEMS for benign biliary strictures (four women and nine men; mean age 56). The indications for SEMS placement were: contraindication to surgery (n = 10), presumed inoperable pancreatic carcinoma (n = 1), concomitant unresectable lung cancer (n = 1), and declined surgery (n = 1). The success of treatment was defined as adequate biliary drainage due to SEMS therapy. Results: The mean follow-up period was 50 months (range 6 days - 86 months). Nine patients (69%) were successfully treated with SEMS therapy: a patent first SEMS (n = 5); a patent second SEMS inserted through the first SEMS (n = 3); and one patent SEMS after balloon cleaning. SEMS treatment was not successful in four patients (due to stent migration in one case and occlusion in three). The mean patency period of the SEMS was 60 months (95% Cl, 43 months - 77 months). At 33 months, the probability of adequate biliary drainage with SEMS therapy was 75%. Conclusions: SEMS therapy was safe and provided successful and prolonged biliary drainage in a selected group of patients with benign biliary strictures due to chronic pancreatitis in whom surgical intervention was not possible or desirabl