Delirium

Delirium is a common neuropsychiatric syndrome and can occur in various clinical settings. It has a multi-factorial aetiology. It is associated with increased morbidity and mortality. Tools and strategies to screen and assess the severity of delirium can be used for an early intervention. Proactive screening for delirium has the potential to allow more optimal management, and thereby reduce morbidity and mortality significantly. Appropriate drug therapy may form part of multi-component interventions in the prevention and treatment of delirium. Further research is warranted in the systematic identification of high-risk patients undergoing major procedures as well as in the prophylactic or pre-emptive use of appropriate drugs and dosages

Liaison psychiatry services in Wales

Aims and method: Recent funding from Welsh Government for mental health has helped to develop liaison psychiatry services in Wales. Systematic data collection was undertaken to map the liaison psychiatry services in Wales in collaboration with the Royal College of Psychiatrists in Wales and Public Health Wales 1000 Lives Improvement. A questionnaire was designed and circulated to all the health boards in Wales to gather information to map liaison psychiatry services in Wales. Up-to-date information was confirmed in January 2018, via email. Results: Over the past 2 years, liaison psychiatry services have been set up in six out of seven health boards in Wales. Staffing levels have increased and the remit of services has broadened. Clinical implications: Mapping has highlighted that liaison psychiatry services in Wales continue to evolve. It will be important to continue to monitor these developments and their effects. Comparison with services in England will provide a useful comparison of service provision. A particular challenge will be to establish and monitor liaison psychiatry standards in Wales. Declaration of interest: None

A Review on Anticancer Potential of Nitric Oxide

Nitrous oxide (NO) is a free radical gas which performs various physiological and pathological processes in body. NO is produced by different enzymatic pathways and plays role in homeostasis. Over past years, NO has emerged as a molecule of interest in many ailments including cancer. But its role in cancer is still controversy. It can display dose-dependant anticancer therapy on one hand and induce procancer properties on the other hand. But as compared to conventional treatments, NO proved better tumor cell resistance. This review mentions dichotomous nature of NO that may encourage future research assessing the role of NO in cancer prevention and treatment either as a single agent or in combination with other antineoplastic compounds

A randomized controlled trial of quetiapine versus placebo in the treatment of delirium

Background Delirium is a commonly occurring complex neuropsychiatric disorder. Evidence for its treatment based on randomized controlled trials (RCTs) is poor. Aims To determine the efficacy and acceptability of quetiapine in the treatment of delirium. Method A double-blind, RCT was conducted. A total of 42 patients were randomized to quetiapine or a placebo group. The primary outcome measure was the Delirium Rating Scale Revised 98. Other scales used were the Brief Psychiatric Rating Scale, Mini-Mental State Examination and Clinical Global Improvement. In order to account for missing data, a nonlinear mixed-effects model was used to estimate the difference between the two groups. Results The quetiapine group improved more rapidly than the placebo group. Specifically, the quetiapine group recovered 82.7% faster (S.E. 37.1%, P=.026) than the placebo group in terms of DRS-R-98 severity score. In terms of the DRS-R-98 noncognitive subscale, the quetiapine group improved 57.7% faster (S.E. 29.2%, P=.048) than the placebo group. Conclusions Quetiapine has the potential to more quickly reduce the severity of noncognitive aspects of delirium. This study was underpowered for treatment comparisons at specific points in time but nonetheless detected significant differences when analyzing the whole study period. While it is not possible to draw definitive conclusions, further larger studies exploring the use of quetiapine in other delirium populations seem justified. Larger increments in the dose of quetiapine may yield even stronger results

Clozapine is associated with secondary antibody deficiency

Background: Schizophrenia affects 1% of the population. Clozapine is the only medication licensed for treatment-resistant schizophrenia and is intensively monitored to prevent harm from neutropenia. Clozapine is also associated with increased risk of pneumonia although the mechanism is poorly understood.AimsTo investigate the potential association between clozapine and antibody deficiency. Methods: Patients taking clozapine and patients who were clozapine-naive and receiving alternative antipsychotics were recruited and completed a lifestyle, medication and infection-burden questionnaire. Serum total immunoglobulins (immunoglobulin (Ig)G, IgA, IgM) and specific IgG antibodies to haemophilus influenzae type B, tetanus and IgG, IgA and IgM to pneumococcus were measured. Results: Immunoglobulins were all significantly reduced in the clozapine-treated group (n = 123) compared with the clozapine-naive group (n = 111). Odds ratios (ORs) for a reduction in clozapine:control immunoglobulin values below the fifth percentile were IgG, OR = 6.00 (95% CI 1.31-27.44); IgA, OR = 16.75 (95% CI 2.18-128.60); and IgM, OR = 3.26 (95% CI 1.75-6.08). These findings remained significant despite exclusion of other potential causes of hypogammaglobulinaemia. In addition, duration on clozapine was associated with decline in IgG. A higher proportion of the clozapine-treated group reported taking more than five courses of antibiotics in the preceding year (5.3% (n = 5) versus 1% (n = 1). Conclusions: Clozapine use was associated with significantly reduced immunoglobulin levels and an increased proportion of patients using more than five antibiotic courses in a year. Antibody testing is not included in existing clozapine monitoring programmes but may represent a mechanistic explanation and modifiable risk factor for the increased rates of pneumonia and sepsis-related mortality previously reported in this vulnerable cohort.Declaration of interestS.J. has received support from CSL Behring, Shire, LFB, Biotest, Binding Site, Sanofi, GSK, UCB Pharma, Grifols, BPL SOBI, Weatherden, Zarodex and Octapharma for projects, advisory boards, meetings, studies, speaker and clinical trials

Ultra-Low-Power, High-Accuracy 434 MHz Indoor Positioning System for Smart Homes Leveraging Machine Learning Models

Global navigation satellite systems have been used for reliable location-based services in outdoor environments. However, satellite-based systems are not suitable for indoor positioning due to low signal power inside buildings and low accuracy of 5 m. Future smart homes demand low-cost, high-accuracy and low-power indoor positioning systems that can provide accuracy of less than 5 m and enable battery operation for mobility and long-term use. We propose and implement an intelligent, highly accurate and low-power indoor positioning system for smart homes leveraging Gaussian Process Regression (GPR) model using information-theoretic gain based on reduction in differential entropy. The system is based on Time Difference of Arrival (TDOA) and uses ultra-low-power radio transceivers working at 434 MHz. The system has been deployed and tested using indoor measurements for two-dimensional (2D) positioning. In addition, the proposed system provides dual functionality with the same wireless links used for receiving telemetry data, with configurable data rates of up to 600 Kbauds. The implemented system integrates the time difference pulses obtained from the differential circuitry to determine the radio frequency (RF) transmitter node positions. The implemented system provides a high positioning accuracy of 0.68 m and 1.08 m for outdoor and indoor localization, respectively, when using GPR machine learning models, and provides telemetry data reception of 250 Kbauds. The system enables low-power battery operation with consumption of <200 mW power with ultra-low-power CC1101 radio transceivers and additional circuits with a differential amplifier. The proposed system provides low-cost, low-power and high-accuracy indoor localization and is an essential element of public well-being in future smart homes

Clozapine is associated with secondary antibody deficiency

Background Schizophrenia affects 1% of the population. Clozapine is the only medication licensed for treatment-resistant schizophrenia and is intensively monitored to prevent harm from neutropenia. Clozapine is also associated with increased risk of pneumonia although the mechanism is poorly understood. Aims To investigate the potential association between clozapine and antibody deficiency. Methods Patients taking clozapine and patients who were clozapine-naive and receiving alternative antipsychotics were recruited and completed a lifestyle, medication and infection-burden questionnaire. Serum total immunoglobulins (immunoglobulin (Ig)G, IgA, IgM) and specific IgG antibodies to haemophilus influenzae type B, tetanus and IgG, IgA and IgM to pneumococcus were measured. Results Immunoglobulins were all significantly reduced in the clozapine-treated group (n = 123) compared with the clozapine-naive group (n = 111). Odds ratios (ORs) for a reduction in clozapine:control immunoglobulin values below the fifth percentile were IgG, OR = 6.00 (95% CI 1.31–27.44); IgA, OR = 16.75 (95% CI 2.18–128.60); and IgM, OR = 3.26 (95% CI 1.75–6.08). These findings remained significant despite exclusion of other potential causes of hypogammaglobulinaemia. In addition, duration on clozapine was associated with decline in IgG. A higher proportion of the clozapine-treated group reported taking more than five courses of antibiotics in the preceding year (5.3% (n = 5) versus 1% (n = 1). Conclusions Clozapine use was associated with significantly reduced immunoglobulin levels and an increased proportion of patients using more than five antibiotic courses in a year. Antibody testing is not included in existing clozapine monitoring programmes but may represent a mechanistic explanation and modifiable risk factor for the increased rates of pneumonia and sepsis-related mortality previously reported in this vulnerable cohort

The Mini-Mental State Examination (MMSE) as a diagnostic and screening test for delirium: Systematic review and meta-analysis

Objective: To analyse the evidence concerning the accuracy of the Mini-Mental State Examination (MMSE) as a diagnostic and screening test for the presence of delirium in adults. Method: Two authors searched MEDLINE, PsychINFO and EMBASE from inception till 3/2014. Articles were included that investigated the diagnostic validity of the MMSE to detect delirium against standardised criteria. A diagnostic validity meta-analysis was conducted. Results: Thirteen studies were included representing 2017 patients in medical settings of whom 29.4% had delirium. The meta-analysis revealed the MMSE had an overall sensitivity and specificity estimate of 84.1% and 73.0%, but this was 81.1% and 82.8% in a subgroup analysis involving robust high quality studies. Sensitivity was unchanged but specificity was 68.4% (95% CI = 50.9% to 83.5%) in studies using a predefined cut-off of < 24 to signify a case. In high-risk samples where delirium was present in 25% of patients, then the Positive predictive value and Negative predictive value would be 50.9% (48.3% - 66.2%) and 93.2% (90.0% - 96.5%). Conclusion: The MMSE cannot be recommended as a case-finding confirmatory test of delirium, but may be used as an initial screen to rule out high scorers who are unlikely to have delirium with approximately 93% accuracy

Delirium

Delirium is a common neuropsychiatric syndrome and can occur in various clinical settings. It has a multi-factorial aetiology. It is associated with increased morbidity and mortality. Tools and strategies to screen and assess the severity of delirium can be used for an early intervention. Proactive screening for delirium has the potential to allow more optimal management, and thereby reduce morbidity and mortality significantly. Appropriate drug therapy may form part of multi-component interventions in the prevention and treatment of delirium. Further research is warranted in the systematic identification of high-risk patients undergoing major procedures as well as in the prophylactic or pre-emptive use of appropriate drugs and dosages

Use of Antipsychotic Medications in Non-Substance-Related Delirium—the Gap Between Research Findings and Clinical Practices

Purpose of the review Gaps exist between the research knowledge base and clinical practices pertaining to the use of antipsychotics in delirium. We reviewed 19 major randomized studies on the use of antipsychotics in non-substance-related delirium to understand factors contributing to this gap. Recent findings Based on limited literature, antipsychotics are not effective in treating delirium in patients who are mechanically ventilated intensive care unit patients and those in palliative care, but they may be effective in preventing delirium in high-risk patients after elective surgery. The literature on the use of antipsychotics for delirium in general hospital patients is less clear. Summary Delirium is a complex and heterogeneous syndrome and is influenced by several individual and clinical factors, which make researching its pharmacological treatment very difficult. Furthermore, heterogeneity of the studies is a barrier to reliable meta-analyses. Until methodologically sound literature pertinent to specific patient populations and clinical scenarios accumulates, we should use both the research literature and clinical expertise to formulate practice guidelines