Antipsychotics for delirium in the general hospital setting in consecutive 2453 inpatients: a prospective observational study

OBJECTIVE

Attention to risk of antipsychotics for older patients with delirium has been paid. A clinical question was whether risk of antipsychotics for older patients with delirium would exceed efficacy of those even in the general hospital setting.

METHODS

A prospective observational study proceeded over a 1-year period at 33 general hospitals, where at least one psychiatrist worked full time. Subjects were patients who developed delirium during their admission due to acute somatic diseases or surgery, and who received antipsychotics for delirium. The primary outcome was rates and kinds of serious adverse events.

RESULTS

Among 2834 patients who developed delirium, 2453 patients received antipsychotics, such as risperidone (34%), quetiapine (32%), and parenteral haloperidol (20%), for delirium. Out of 2453 patients, 22 serious adverse events (0.9%) were reported. Aspiration pneumonia was the most frequent (17 patients, 0.7%), followed by cardiovascular events (4 patients, 0.2%) and venous thromboembolism (1 patient, 0.0%). There was no patient with a fracture or intracranial injury due to a fall. No one died because of antipsychotic side effects. The mean Clinical Global Impressions-Improvement Scale score was 2.02 (SD 1.09). Delirium was resolved within 1 week in more than half of the patients (54%).

CONCLUSIONS

In the general hospital setting under management including fine dosage adjustment and early detection of side effects, risk of antipsychotics for older patients with delirium might be low, in contrast to antipsychotics for dementia in the nursing home or outpatient settings. A point may be not how to avoid using antipsychotics but how to monitor their risk.

The predictive value of a change in natural killer cell activity for delirium

PURPOSE

Few studies looking for an effective biomarker to predict delirium have been performed. This study was designed to investigate whether a change in inflammatory status, indicated by blood natural killer (NK) cell activity, predicts delirium.

METHODS

This prospective study, performed in 4 university and 1 general hospital from September, 2011 to October, 2012, included 29 patients. Eligible patients were 65-89years old, newly and emergently admitted. Patients were assessed daily, up to 7days, for occurrence of DSM-IV-defined delirium. The main outcome measure was change in blood NK cell activity between the first and second mornings after admission.

RESULTS

The mean change in blood NK cell activity on the second morning, compared to the first morning, in patients developing delirium (n=9) was significantly greater than that in patients without delirium (n=20) (6.0% [SD 8.4] vs. -1.4% [9.0], respectively, t=2.10, P=0.045). Significant difference between the groups was still found after adjusting for age, the history of previous delirium, and the Clinical Dementia Rating score (F=6.63, P=0.017). Of note is that 8 of 9 (89%) patients developing delirium had increased blood NK cell activity, as did only 8 of 20 (40%) patients without delirium, giving measurement of this parameter, for distinguishing the two groups, a sensitivity of 89%, specificity 60%, positive predictive value 50%, negative predictive value 92%, positive likelihood ratio 2.22, and negative likelihood ratio 0.19. When combining this predictor with another predictor, a Delirium Rating Scale-Revised-98 severity score of 5 or more at baseline, positive and negative likelihood ratios were 7.80 and 0.24, respectively.

CONCLUSION

Increase in blood NK cell activity may be associated with developing delirium. Further studies including larger numbers of patients are needed to justify the preventive use of drugs for patients meeting criteria for both predictors.

One-year outcomes of unipolar depression patients with manic or hypomanic switch during acute antidepressant treatment

OBJECTIVE

The aim of the study was to investigate one-year outcomes of unipolar depression patients with manic or hypomanic switch during acute antidepressant treatment.

METHODS

A review of medical records revealed 37 consecutive patients admitted from 1997 to 2002 who underwent an antidepressant-induced manic or hypomanic switch fulfilling DSM-IV criteria. Their clinical courses were retrospectively investigated after discharge.

RESULTS

Of the 37 patients, 33 (89.2%) were followed up for 1 year after discharge. None developed a manic episode, while seven developed a hypomanic episode, including 1 patient who was lost after emerging from a hypomanic episode within 6 months after discharge. Only one of those seven patients developed hypomania during acute antidepressant treatment for a recurrent depressive episode under maintenance mood stabilizer treatment. Furthermore, bipolar conversion occurred in four patients within the first 6 months and in another two patients, including 1 with rapid cycling, over the subsequent 6 months after discharge. Of these 33 patients, 28 received continuous maintenance treatment with mood stabilizers for the one-year period after discharge.

CONCLUSIONS

The subjects were considered to have a bipolar nature according to the prevalence rate of bipolar conversion over a one-year period. Longer follow-up studies appear warranted determine the diagnostic issues of antidepressant-induced switch in unipolar depression.

Local bandgap control of germanium by silicon nitride stressor

We have proposed a new approach to tune the operation wavelength of Franz-Keldysh Ge electro-absorption modulation in Si photonics by controlling the local strain environment to cover the whole range of C + L bands (1.53 - 1.62 μm). The present paper shows a proof of strain-tuning modulator concept by the shift of the Ge absorption edge using SiN(x) stressor films and Franz-Keldysh effect in strain-controlled Ge.

Remission in patients with active rheumatoid arthritis by tocilizumab treatment in routine clinical practice: results from 3 years of prospectively registered data

OBJECTIVES: This study aimed to evaluate the remission in rheumatoid arthritis (RA) patients treated with tocilizumab (TCZ), based on prospectively registered data in clinical practice. METHODS: We studied 114 consecutive RA patients treated with TCZ for an average of 3.5 years. Remission was evaluated by using the EULAR criteria and the new ACR/EULAR Boolean-based criteria. RESULTS: Among 114 patients (average age 52.2 years; average disease duration 10.6 years), 76 (67 %) had previously received anti-TNF biologics. Mean baseline DAS28-ESR of 5.4 and improved to 2.4 at 36 months. Overall, DAS28-ESR <2.6 was attained by 66.7 %, while ACR/EULAR remission was attained by 35.1 %. ACR/EULAR remission rate was significantly higher in the patients who were biologics-naïve and had good response at the first month. Among 23 patients who completed the treatment for 3 years and had ACR/EULAR remission at 1 year, 15 (65 %) remained in the remission and 16 (70 %) had a DAS28-ESR <2.6 at the final follow-up. The retention rate at 36 months was 68.2 %. CONCLUSIONS: In patients with RA, TCZ is highly effective for both biologics-naïve patients and patients previously exposed to biologics, achieving a high remission rate and drug continuation rate (68.2 %) in clinical practice.

The valproate serum level in maintenance therapy for bipolar disorder in Japan

The appropriate therapeutic serum valproate level in maintenance therapy for bipolar disorder is not well known. We studied the serum valproate levels in seventeen bipolar I and twenty-four bipolar II disorder outpatients who had been treated with stable doses of valproate successfully for at least 12 months as prophylactic therapy. The trough serum valproate levels were 52.2 +/- 20.4 microg/ml in bipolar I, and 41.0 +/- 18.3 microg/ml in bipolar II disorder patients, respectively. A greater trend towards a higher trough level (p = 0.07) was indicated in the bipolar I disorder group. We speculate that these valproate levels may be an approximation to the appropriate valproate levels in maintenance therapy and that there may be a correlation between the level of valproate required for stabilization and the subtype of the bipolar disorder. However, when interpreting these findings, certain limitations to this study? Need to be taken into account as follows. The sample size was small. We could not look at a group on valproate that had relapsed and a group that had dropped out of maintenance therapy. Further studies are needed.

The octadecaneuropeptide stimulates somatolactin release from cultured goldfish pituitary cells

The present study aimed to investigate the distribution of the octadecaneuropeptide (ODN) in the goldfish brain and to look for a possible effect of ODN on somatolactin (SL) release from pituitary cells. A discrete population of ODN-immunoreactive neurones was localised in the lateral part of the nucleus lateralis tuberis. These neurones sent projections through the neurohypophyseal tract towards the neurohypophysis, and nerve fibres were seen in the close vicinity of SL-producing cells in the pars intermedia. Incubation of cultured goldfish pituitary cells with graded concentrations of ODN (10(-9) -10(-5 ) m) induced a dose-dependent stimulation of SL-β, but not SL-α, release. ODN-evoked SL release was blocked by the metabotrophic endozepine receptor antagonist cyclo(1-8) [DLeu(5) ]OP but was not affected by the central-type benzodiazepine receptor antagonist flumazenil. ODN-induced SL release was suppressed by treatment with the phospholipase C (PLC) inhibitor U-73122 but not with the protein kinase A (PKA) inhibitor H-89. These results indicate that, in fish, ODN produced by hypothalamic neurones acts as a hypophysiotrophic neuropeptide stimulating SL release. The effect of ODN is mediated through a metabotrophic endozepine receptor positively coupled to the PLC/inositol 1,4,5-trisphosphate/protein kinase C-signalling pathway.

[Mood stabilizers]

Mood stabilizers available in Japan include lithium, valproate, carbamazepine, and lamotrigine. These are prescribed for manic or hypomanic episodes of bipolar disorder, organic mania, and drug-induced mania. Careful dose titration is needed in consideration for serum drug level and clinical symptoms. Lithium frequently develops neurological toxicity because of its narrow therapeutic serum level. Valproate has the most favorable adverse effect profile among mood stabilizers, but gastrointestinal symptoms and weight gain can appear with a dose dependent fashion. Hyperammonemia is occasionally induced early after initiation of valproate and tends to be overlooked. Carbamazepine sometimes develops liver dysfunction and skin disorders associated with allergic mechanisms. Lamotrigine should be slowly titrated to avoid severe skin disorders such as Stevens-Johnson syndrome.