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Ding Z, Yu Z, Sun Z, Liu X, Chen R. Potential mechanism of Taohong Siwu Decoction in preventing and treating postoperative delirium in intertrochanteric fracture patients based on retrospective analysis and network pharmacology. J Orthop Surg Res 2024; 19:369. [PMID: 38902693 PMCID: PMC11191233 DOI: 10.1186/s13018-024-04854-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2024] [Accepted: 06/14/2024] [Indexed: 06/22/2024] Open
Abstract
OBJECTIVE Elderly patients with hip fractures are at a greater risk of developing postoperative delirium (POD), which significantly impacts their recovery and overall quality of life. Neuroinflammation is a pathogenic mechanism of POD. Taohong Siwu Decoction (THSWD), known for its ability to promote blood circulation and remove blood stasis, can effectively reduce inflammation in the nervous system. Therefore, the objective of this article is to provide a comprehensive summary of the clinical efficacy of THSWD in the prevention of POD. Additionally, it aims to investigate the underlying mechanism of THSWD in the prevention and treatment of POD using network pharmacology and molecular docking. METHODS We conducted a retrospective analysis of patients with intertrochanteric fractures between January 2016 and October 2021. The patients were divided into two groups: the control and THSWD group. We performed a comparative analysis of hemoglobin (HB), albumin (ALB), C-reactive protein (CRP), blood urea nitrogen (BUN), and the blood urea nitrogen to creatinine ratio (BCR) on two different time points: the day before surgery (D0) and the third day after surgery (D3). Furthermore, we examined the incidence and duration of delirium, as well as the Harris Hip Score (HHS) at 3 months and 12 months post-surgery. Network pharmacology was employed to identify the primary targets and mechanisms of THSWD in the management of delirium. Molecular docking was employed to confirm the interaction between active ingredients and COX-2. Inflammatory cytokines, including cyclooxygenase-2 (COX-2), interleukin-1β (IL-1β), interleukin-6 (IL-6), and tumor necrosis factor- (TNF-α), were measured using the enzyme-linked immunosorbent assay (ELISA). The cognitive status of the patients was assessed using the Mini-Mental State Examination (MMSE) scoring system. RESULTS Regardless of whether it is in D0 or D3, THSWD treatment can increase HB levels while decreasing BCR. In D3, the THSWD group demonstrated a significant reduction in the expression of CRP and BUN when compared to the control group. However, there were no significant differences in ABL levels, surgery duration, and blood loss between the two groups. Additionally, THSWD treatment requires fewer blood transfusions and can reduce the incidence and duration of POD. The results of the logistic analysis suggest that both CRP levels and BCR independently contribute to the risk of POD. Network pharmacology analysis indicates that THSWD has the potential to prevent and treat POD possibly through inflammatory pathways such as IL-17 signaling pathways and NF-kappa B signaling pathways. Molecular docking validated the interaction between the active ingredient of THSWD and COX-2. Furthermore, THSWD treatment can reduce the levels of COX-2, IL-1β, IL-6, TNF-α, BUN and CRP in the blood of patients with POD, increase HB levels, and enhance MMSE scores. The expression of COX-2 is positively associated with other inflammatory markers (IL-1β, IL-6, TNF-α, and CRP), and inversely associated with MMSE. CONCLUSION THSWD has been found to have a preventive and therapeutic effect on POD in intertrochanteric fracture patients possibly through inflammatory pathways. This effect may be attributed to its ability to increase hemoglobin levels and reduce the levels of certain detrimental factors, such as blood urea nitrogen and inflammatory factors.
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Affiliation(s)
- Zhihong Ding
- Department of traumatic orthopedics, Xiangyang Hospital of Traditional Chinese Medicine [Xiangyang Institute of Traditional Chinese Medicine], Xiangyang, 441000, Hubei, China
| | - Zhiyong Yu
- Department of traumatic orthopedics, Xiangyang Hospital of Traditional Chinese Medicine [Xiangyang Institute of Traditional Chinese Medicine], Xiangyang, 441000, Hubei, China
| | - Zhibo Sun
- Department of traumatic orthopedics, Xiangyang Hospital of Traditional Chinese Medicine [Xiangyang Institute of Traditional Chinese Medicine], Xiangyang, 441000, Hubei, China
| | - Xinghui Liu
- School of Basic Medical Sciences, Hubei University of Arts and Science, No. 296 Longzhong Road, Xiangcheng District, Xiangyang, 441000, Hubei, China.
| | - Rong Chen
- Department of traumatic orthopedics, Xiangyang Hospital of Traditional Chinese Medicine [Xiangyang Institute of Traditional Chinese Medicine], Xiangyang, 441000, Hubei, China.
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Zhang H, Zhang A, Lin Y, Li C, Yang Y, Dong R, Lin X, Wang B, Bi Y. COVID-19 vaccination may prevent postoperative delirium in elderly patients undergoing elective non-cardiac surgery: The PNDRFAP and PNDABLE studies. Heliyon 2024; 10:e30414. [PMID: 38818170 PMCID: PMC11137356 DOI: 10.1016/j.heliyon.2024.e30414] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2023] [Revised: 04/22/2024] [Accepted: 04/25/2024] [Indexed: 06/01/2024] Open
Abstract
Background Postoperative delirium (POD) often occurs in elderly patients after surgery. We conducted two clinical studies to determine whether COVID-19 vaccination has a protective effect on POD and to explore the role of CSF biomarkers in this process. Methods We conducted two clinical studies, Perioperative Neurocognitive Disorder Risk Factor and Prognosis (PNDRFAP) and Perioperative Neurocognitive Disorder and Biomarker Lifestyle (PNDABLE), in which patients more than or equal to 65 years old who have had elective non-cardiac surgery were enrolled. The preoperative cognitive status of patients were evaluated by Mini-Mental State Examination (MMSE) one day preoperatively. Confusion Assessment Method (CAM) was used to diagnose POD. We used the mediation model to analyze the relationship between CSF biomarkers, COVID-19 vaccination and POD, as well as Dynamic Nomogram to calculate the incidence of Non-Postoperative Delirium (NPOD). The main outcome of these studies was the incidence of POD during seven days postoperatively or before discharge, which was assessed by CAM. Results In the final, 705 participants were enrolled in the PNDRFAP study, and 638 patients in the PNDABLE. In both studies, we found that the occurrence of POD was lower in patients who had injected COVID-19 vaccination before surgery compared with those without vaccination (PNDRFAP: 10.20 % [21/205] vs 25.80 % [129/500], P < 0.001; PNDABLE: 2.40 % [4/164] vs 34.60 % [164/474], P < 0.001). Mediation analysis showed that the protective effect of preoperative COVID-19 vaccine on POD was significantly mediated by CSF Aβ42 (proportion = 17.56 %), T-tau (proportion = 19.64 %), Aβ42/T-tau (proportion = 29.67 %), and Aβ42/P-tau (proportion = 12.26 %). Conclusions COVID-19 vaccine is a protective factor for POD in old patients, which is associated with CSF biomarkers.
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Affiliation(s)
- Haoran Zhang
- Department of Anesthesiology, Qingdao Municipal Hospital, Qingdao, Shandong, China
| | - Aihua Zhang
- Department of Anesthesiology, Qingdao Municipal Hospital, Qingdao, Shandong, China
| | - Yanan Lin
- Department of Anesthesiology, Qingdao Municipal Hospital, Qingdao, Shandong, China
| | - Chuan Li
- Department of Anesthesiology, Qingdao Municipal Hospital, Qingdao, Shandong, China
| | - Yunchao Yang
- Department of Anesthesiology, Qingdao University Medical College, Qingdao, Shandong, China
| | - Rui Dong
- Department of Anesthesiology, Qingdao Municipal Hospital, Qingdao, Shandong, China
| | - Xu Lin
- Department of Anesthesiology, Qingdao Municipal Hospital, Qingdao, Shandong, China
| | - Bin Wang
- Department of Anesthesiology, Qingdao Municipal Hospital, Qingdao, Shandong, China
| | - Yanlin Bi
- Department of Anesthesiology, Qingdao Municipal Hospital, Qingdao, Shandong, China
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Fan Y, Yang T, Liu Y, Gan H, Li X, Luo Y, Yang X, Pang Q. Nomogram for predicting the risk of postoperative delirium in elderly patients undergoing orthopedic surgery. Perioper Med (Lond) 2024; 13:34. [PMID: 38702728 PMCID: PMC11069318 DOI: 10.1186/s13741-024-00393-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2023] [Accepted: 04/26/2024] [Indexed: 05/06/2024] Open
Abstract
OBJECTIVE To retrospectively analyze the risk factors for postoperative delirium (POD) after orthopedic surgery in elderly patients and establish an individualized nomogram to predict the risk of POD. METHODS The data of 1011 patients who underwent orthopedic surgery from January 2019 to January 2022 were retrospectively analyzed. Univariate and multivariate logistic analyses were used to screen for independent risk factors. Stepwise regression was conducted to screen risk factors to construct a nomogram to predict the risk of POD after orthopedic surgery in elderly individuals, and nomogram validation analyses were performed. RESULTS The logistic regression results showed that age (≥ 75 years old vs. < 75 years old; odds ratio (OR) = 2.889; 95% confidence interval (CI), 1.149, 7.264), sex (male vs. female, OR = 2.368; 95% CI, 1.066, 5.261), and preoperative cognitive impairment (yes vs. no, OR = 13.587; 95% CI, 4.360, 42.338) were independent risk factors for POD in elderly patients who underwent orthopedic surgery (P < 0.05). A nomogram was constructed using 7 risk factors, i.e., age, American Society of Anesthesiologists (ASA) classification, sex, preoperative hemoglobin (Hb), preoperative pulmonary disease, cognitive impairment, and intraoperative infusion volume. The area under the curve (AUC) showed good discrimination (0.867), the slope of the calibration curve was 1.0, and the optimal net benefit of the nomogram from the decision curve analysis (DCA) was 0.01-0.58. CONCLUSION This study used 7 risk factors to construct a nomogram to predict the risk of POD after major orthopedic surgery in elderly individuals, and the nomogram had good discrimination ability, accuracy, and clinical practicability.
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Affiliation(s)
- Yunping Fan
- Department of Anesthesiology, Shizhu Tujia Autonomous County People's Hospital, Chongqing, 409100, China
| | - Tingjun Yang
- Department of Anesthesiology, Shizhu Tujia Autonomous County People's Hospital, Chongqing, 409100, China
| | - Yuhan Liu
- Department of Anesthesiology, Shizhu Tujia Autonomous County People's Hospital, Chongqing, 409100, China
| | - Haibin Gan
- Department of Anesthesiology, Shizhu Tujia Autonomous County People's Hospital, Chongqing, 409100, China
| | - Xiaohua Li
- Department of Anesthesiology, Shizhu Tujia Autonomous County People's Hospital, Chongqing, 409100, China
| | - Yanrong Luo
- Department of Anesthesiology, Shizhu Tujia Autonomous County People's Hospital, Chongqing, 409100, China
| | - Xuping Yang
- Department of Anesthesiology, Shizhu Tujia Autonomous County People's Hospital, Chongqing, 409100, China
| | - Qianyun Pang
- Department of Anesthesiology, Chongqing University Cancer Hospital, Hanyu Road No. 181, Shapingba District, Chongqing, 400030, China.
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Benovic S, Ajlani AH, Leinert C, Fotteler M, Wolf D, Steger F, Kestler H, Dallmeier D, Denkinger M, Eschweiler GW, Thomas C, Kocar TD. Introducing a machine learning algorithm for delirium prediction-the Supporting SURgery with GEriatric Co-Management and AI project (SURGE-Ahead). Age Ageing 2024; 53:afae101. [PMID: 38776213 PMCID: PMC11110913 DOI: 10.1093/ageing/afae101] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2023] [Indexed: 05/24/2024] Open
Abstract
INTRODUCTION Post-operative delirium (POD) is a common complication in older patients, with an incidence of 14-56%. To implement preventative procedures, it is necessary to identify patients at risk for POD. In the present study, we aimed to develop a machine learning (ML) model for POD prediction in older patients, in close cooperation with the PAWEL (patient safety, cost-effectiveness and quality of life in elective surgery) project. METHODS The model was trained on the PAWEL study's dataset of 878 patients (no intervention, age ≥ 70, 209 with POD). Presence of POD was determined by the Confusion Assessment Method and a chart review. We selected 15 features based on domain knowledge, ethical considerations and a recursive feature elimination. A logistic regression and a linear support vector machine (SVM) were trained, and evaluated using receiver operator characteristics (ROC). RESULTS The selected features were American Society of Anesthesiologists score, multimorbidity, cut-to-suture time, estimated glomerular filtration rate, polypharmacy, use of cardio-pulmonary bypass, the Montreal cognitive assessment subscores 'memory', 'orientation' and 'verbal fluency', pre-existing dementia, clinical frailty scale, age, recent falls, post-operative isolation and pre-operative benzodiazepines. The linear SVM performed best, with an ROC area under the curve of 0.82 [95% CI 0.78-0.85] in the training set, 0.81 [95% CI 0.71-0.88] in the test set and 0.76 [95% CI 0.71-0.79] in a cross-centre validation. CONCLUSION We present a clinically useful and explainable ML model for POD prediction. The model will be deployed in the Supporting SURgery with GEriatric Co-Management and AI project.
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Affiliation(s)
- Samuel Benovic
- Institute of Geriatric Research, Ulm University Medical Center, Ulm, Germany
- Agaplesion Bethesda Clinic Ulm, Ulm, Germany
| | - Anna H Ajlani
- Institute of the History, Philosophy and Ethics of Medicine, Ulm University, Ulm, Germany
- Department of Sociology with a Focus on Innovation and Digitalization, Institute of Sociology, Johannes Kepler University Linz, Linz, Austria
| | - Christoph Leinert
- Institute of Geriatric Research, Ulm University Medical Center, Ulm, Germany
- Agaplesion Bethesda Clinic Ulm, Ulm, Germany
| | - Marina Fotteler
- Agaplesion Bethesda Clinic Ulm, Ulm, Germany
- DigiHealth Institute, Neu-Ulm University of Applied Sciences, Neu-Ulm, Germany
| | - Dennis Wolf
- Institute of Medical Systems Biology, Ulm University, Ulm, Germany
| | - Florian Steger
- Institute of the History, Philosophy and Ethics of Medicine, Ulm University, Ulm, Germany
| | - Hans Kestler
- Institute of Medical Systems Biology, Ulm University, Ulm, Germany
| | - Dhayana Dallmeier
- Institute of Geriatric Research, Ulm University Medical Center, Ulm, Germany
- Department of Epidemiology, Boston University School of Public Health, Boston, USA
| | - Michael Denkinger
- Institute of Geriatric Research, Ulm University Medical Center, Ulm, Germany
- Agaplesion Bethesda Clinic Ulm, Ulm, Germany
| | - Gerhard W Eschweiler
- Geriatric Center, University Hospital Tübingen, Tubingen, Germany
- Department of Psychiatry and Psychotherapy, Tübingen University Hospital, Tübingen, Germany
| | - Christine Thomas
- Department of Psychiatry and Psychotherapy, Tübingen University Hospital, Tübingen, Germany
- Department of Geriatric Psychiatry and Psychotherapy, Klinikum Stuttgart, Stuttgart, Germany
| | - Thomas D Kocar
- Institute of Geriatric Research, Ulm University Medical Center, Ulm, Germany
- Agaplesion Bethesda Clinic Ulm, Ulm, Germany
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Zhu HY, Yan JL, Zhang M, Xu TY, Chen C, Wu ZL. Anesthesia, Anesthetics, and Postoperative Cognitive Dysfunction in Elderly Patients. Curr Med Sci 2024; 44:291-297. [PMID: 38517674 DOI: 10.1007/s11596-024-2836-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2023] [Accepted: 12/20/2023] [Indexed: 03/24/2024]
Abstract
Postoperative cognitive dysfunction (POCD) remains a major issue that worsens the prognosis of elderly surgery patients. This article reviews the current research on the effect of different anesthesia methods and commonly utilized anesthetics on the incidence of POCD in elderly patients, aiming to provide an understanding of the underlying mechanisms contributing to this condition and facilitate the development of more reasonable anesthesia protocols, ultimately reducing the incidence of POCD in elderly surgery patients.
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Affiliation(s)
- Hong-Yu Zhu
- Department of Anesthesiology, Linhe District People's Hospital, Bayannur, 015000, China
| | - Jian-Li Yan
- Department of Neurosurgery, Xinzhou District People's Hospital, Wuhan, 430408, China
| | - Min Zhang
- Department of Anesthesiology, Linhe District People's Hospital, Bayannur, 015000, China
| | - Tian-Yun Xu
- Department of Anesthesiology, Linhe District People's Hospital, Bayannur, 015000, China
| | - Chen Chen
- Department of Anesthesiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China.
| | - Zhi-Lin Wu
- Department of Anesthesiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China.
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Almodibeg B, Forget P. Challenges of acute pain management in older patients. Age Ageing 2024; 53:afae061. [PMID: 38557666 DOI: 10.1093/ageing/afae061] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2024] [Indexed: 04/04/2024] Open
Abstract
Adequate management of acute pain in the older population is crucial. However, it is inherently complex because of multiple physiological changes that significantly impact both the pharmacokinetics and pharmacodynamics of medications. Current guidelines promote paracetamol as the first-line analgesic for acute pain in older adults, whereas opioids are advised cautiously for moderate to severe acute pain. However, opioids come with a significant array of side effects, which can be more pronounced in older individuals. Ketamine administered via intranasal (IN) and nebulised inhalation in the emergency department for managing acute pain in older patients shows promising potential for improving pain management and reducing opioid reliance Kampan, Thong-on, Sri-on (2024, Age Ageing, 53, afad255). Nebulised ketamine appears superior in terms of adverse event incidence. However, the adoption of IN or nebulised ketamine in older adult acute pain management remains unclear because of the lack of definitive conclusions and clear guidelines. Nevertheless, these modalities can be valuable options for patients where opioid analgesics are contraindicated or when intravenous morphine titration is impractical or contraindicated. Here, we review these concepts, the latest evidence and propose avenues for research.
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Affiliation(s)
- Bader Almodibeg
- Anaesthesia Technology Department, King Khalid University-College of Applied Medical Sciences, Khamis Mushait, Asir, Saudi Arabia
- Epidemiology Group-Institute of Applied Health Sciences, University of Aberdeen-School of Medicine, Medical Sciences and Nutrition, Foresterhill Health Campus, Aberdeen AB25 2ZD, UK
- Pain AND Opioids after Surgery (PANDOS) Research Group, European Society of Anaesthesiology and Intensive Care, Brussels, Belgium
| | - Patrice Forget
- Epidemiology Group-Institute of Applied Health Sciences, University of Aberdeen-School of Medicine, Medical Sciences and Nutrition, Foresterhill Health Campus, Aberdeen AB25 2ZD, UK
- Pain AND Opioids after Surgery (PANDOS) Research Group, European Society of Anaesthesiology and Intensive Care, Brussels, Belgium
- Department of Anaesthesia, NHS Grampian, Aberdeen, UK
- IMAGINE UR UM 103, Anesthesia Critical Care, Emergency and Pain Medicine Division, Nîmes University Hospital, Montpellier University, 30900 Nîmes, France
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Thisayakorn P, Thipakorn Y, Tantavisut S, Sirivichayakul S, Vojdani A, Maes M. Increased IgA-mediated responses to the gut paracellular pathway and blood-brain barrier proteins predict delirium due to hip fracture in older adults. Front Neurol 2024; 15:1294689. [PMID: 38379706 PMCID: PMC10876854 DOI: 10.3389/fneur.2024.1294689] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2023] [Accepted: 01/25/2024] [Indexed: 02/22/2024] Open
Abstract
Introduction Delirium is accompanied by immune response system activation, which may, in theory, cause a breakdown of the gut barrier and blood-brain barrier (BBB). Some results suggest that the BBB is compromised in delirium, but there is no data regarding the gut barrier. This study investigates whether delirium is associated with impaired BBB and gut barriers in elderly adults undergoing hip fracture surgery. Methods We recruited 59 older adults and measured peak Delirium Rating Scale (DRS) scores 2-3 days after surgery, and assessed plasma IgG/IgA levels (using ELISA techniques) for zonulin, occludin, claudin-6, β-catenin, actin (indicating damage to the gut paracellular pathway), claudin-5 and S100B (reflecting BBB damage), bacterial cytolethal distending toxin (CDT), LPS-binding protein (LBP), lipopolysaccharides (LPS), Porphyromonas gingivalis, and Helicobacter pylori. Results Results from univariate analyses showed that delirium is linked to increased IgA responses to all the self-epitopes and antigens listed above, except for LPS. Part of the variance (between 45-48.3%) in the peak DRS score measured 2-3 days post-surgery was explained by independent effects of IgA directed to LPS and LBP (or bacterial CDT), baseline DRS scores, and previous mild stroke. Increased IgA reactivity to the paracellular pathway and BBB proteins and bacterial antigens is significantly associated with the activation of M1 macrophage, T helper-1, and 17 cytokine profiles. Conclusion Heightened bacterial translocation, disruption of the tight and adherens junctions of the gut and BBB barriers, elevated CDT and LPS load in the bloodstream, and aberrations in cell-cell interactions may be risk factors for delirium.
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Affiliation(s)
- Paul Thisayakorn
- Department of Psychiatry, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Yanin Thipakorn
- Department of Psychiatry, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Saran Tantavisut
- Department of Orthopedics, Hip Fracture Research Unit, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Sunee Sirivichayakul
- Department of Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Aristo Vojdani
- Immunosciences Lab Inc., Los Angeles, CA, United States
- Cyrex Labs LLC, Phoenix, AZ, United States
| | - Michael Maes
- Sichuan Provincial Center for Mental Health, Sichuan Provincial People’s Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
- Key Laboratory of Psychosomatic Medicine, Chinese Academy of Medical Sciences, Chengdu, China
- Department of Psychiatry, Medical University of Plovdiv, Plovdiv, Bulgaria
- Research Institute, Medical University of Plovdiv, Plovdiv, Bulgaria
- Kyung Hee University, Seoul, Republic of Korea
- Cognitive Impairment and Dementia Research Unit, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
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Liu S, Patanwala AE, Naylor JM, Stevens JA, Bugeja B, Begley D, Khor KE, Lau E, Adie S, Penm J. Tapentadol Versus Oxycodone for Opioid-Related Adverse Drug Events and Clinical Outcomes After Inpatient Surgery. THE JOURNAL OF PAIN 2024; 25:466-475. [PMID: 37741523 DOI: 10.1016/j.jpain.2023.09.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/27/2023] [Revised: 08/25/2023] [Accepted: 09/11/2023] [Indexed: 09/25/2023]
Abstract
Oxycodone is a commonly prescribed opioid for postoperative pain. However, there has been a marked increase in the use of tapentadol over the previous decade due to a perceived superior safety profile of tapentadol compared to oxycodone. There is limited real-world evidence on the safety of tapentadol compared to oxycodone after surgery. The primary objective was to examine the impact of tapentadol compared to oxycodone use on the incidence of opioid-related adverse drug events after surgery. Data for adult surgical patients receiving tapentadol or oxycodone during hospitalization between January 1, 2018, and December 31, 2021, were collected from electronic medical records of 3 tertiary metropolitan hospitals in Australia. The primary outcome was the incidence of opioid-related adverse events. Patients receiving tapentadol or oxycodone were matched using nearest-neighbour propensity score matching. In the matched cohorts (n = 1,530 vs n = 2,775; mean [standard deviation] age 62.3 [17.0] years vs 61.9 [standard deviation 17.9] years; 43% vs 45% male for the tapentadol vs oxycodone groups, respectively), patients given tapentadol experienced a similar incidence of adverse events overall (14.4%, 220/1,530 vs 12.6%, 349/2,775; P = .100; 95% CI -.35% to 3.95%). Secondary outcomes included an increased risk of delirium (2.7%, 41/1,530 vs 1.3%, 37/2,775), arrhythmias (3.4%, 52/1,530 vs 2.2%, 62/2,775), and length of hospital stay (5 [range 1-201] vs 4 [range 1-226] days) compared with oxycodone use. Further real-world studies are warranted to determine the impact of tapentadol use on a broad range of patient outcomes. PERSPECTIVE: This study provides an early signal that tapentadol use may be associated with an increased risk of some adverse events and a longer length of stay. Further research is needed to examine the impact of tapentadol use on a broad range of patient outcomes in clinical practice settings.
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Affiliation(s)
- Shania Liu
- The University of Sydney, Faculty of Medicine and Health, School of Pharmacy, Sydney, Australia; Department of Pharmacy, Prince of Wales Hospital, Sydney, Australia
| | - Asad E Patanwala
- The University of Sydney, Faculty of Medicine and Health, School of Pharmacy, Sydney, Australia; Department of Pharmacy, Royal Prince Alfred Hospital, Sydney, Australia
| | - Justine M Naylor
- Whitlam Orthopaedic Research Centre, Ingham Institute, Sydney, Australia; South Western Sydney School of Clinical Medicine, UNSW Medicine and Health, UNSW Sydney, Sydney, New South Wales, Australia
| | - Jennifer A Stevens
- School of Clinical Medicine, University of New South Wales Medicine and Health, St Vincent's Clinical School, UNSW Medicine and Health, UNSW Sydney, Sydney, Australia; School of Medicine, University of Notre Dame, Sydney, Australia
| | - Bernadette Bugeja
- Department of Pain Management, Prince of Wales Hospital, Sydney, Australia
| | - David Begley
- Department of Pain Management, Prince of Wales Hospital, Sydney, Australia
| | - Kok E Khor
- Department of Pain Management, Prince of Wales Hospital, Sydney, Australia; Prince of Wales Clinical School, School of Clinical Medicine, UNSW Medicine and Health, UNSW Sydney, Sydney, Australia
| | - Eric Lau
- Department of Pharmacy, St George Hospital, Sydney, Australia
| | - Sam Adie
- St George and Sutherland Clinical School, School of Clinical Medicine, UNSW Medicine and Health, UNSW Sydney, Sydney, Australia
| | - Jonathan Penm
- The University of Sydney, Faculty of Medicine and Health, School of Pharmacy, Sydney, Australia; Department of Pharmacy, Prince of Wales Hospital, Sydney, Australia
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Luo S, Deng L, Chen Y, Zhou W, Canavese F, Li L. Does enhanced cognitive performance reduce fracture risk? a Mendelian randomization study. Aging (Albany NY) 2023; 15:14985-14995. [PMID: 38112588 PMCID: PMC10781472 DOI: 10.18632/aging.205325] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2023] [Accepted: 11/03/2023] [Indexed: 12/21/2023]
Abstract
OBJECTIVE While observational studies have suggested a link between cognitive performance and fracture risk, the causality and site-specific nature are unclear. We applied Mendelian randomization (MR) to elucidate these associations. METHODS 147 single-nucleotide polymorphisms (SNPs) tied strongly to cognitive performance (p< 5e-8) were selected. We performed MR analysis to investigate the causal relationship between cognitive performance and fractures at specific sites, including the wrist, upper arm, shoulder, ribs, sternum, thoracic spine, lumbar spine, pelvis, femur, leg, and ankle. The primary estimate was determined using the inverse variance-weighted method. Additionally, we examined heterogeneity using the MR Pleiotropy RESidual Sum Outlier test and Cochran Q, and employed MR-Egger regression to identify horizontal pleiotropy. RESULTS MR analysis identified a causal association between cognitive performance and fractures at the lumbar-spine-pelvis (odds ratio [OR] = 0.727, 95% CI = 0.552-0.956, p = 0.023), and ribs-sternum-thoracic spine sites (OR = 0.774, 95% CI = 0.615-0.974, p = 0.029). However, no causal association was found for fractures at other sites. CONCLUSIONS This study provided evidence of a causal connection between cognitive performance and fracture risk at certain locations. These findings underline the potential of cognitive enhancement strategies as innovative and effective methods for fracture prevention.
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Affiliation(s)
- Shaoting Luo
- Department of Pediatric Orthopedics, Shengjing Hospital of China Medical University, Shenyang 110004, Liaoning, P.R. China
| | - Linfang Deng
- Department of Nursing, Jinzhou Medical University, Jinzhou 121001, Liaoning, P.R. China
| | - Yufan Chen
- Department of Pediatric Orthopedics, Shengjing Hospital of China Medical University, Shenyang 110004, Liaoning, P.R. China
| | - Weizheng Zhou
- Department of Pediatric Orthopedics, Shengjing Hospital of China Medical University, Shenyang 110004, Liaoning, P.R. China
| | - Federico Canavese
- Department of Pediatric Orthopedic Surgery, Lille University Centre, Jeanne de Flandre Hospital, Lille 59000, Nord Department, France
| | - Lianyong Li
- Department of Pediatric Orthopedics, Shengjing Hospital of China Medical University, Shenyang 110004, Liaoning, P.R. China
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10
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Ali MIM, Kalkman GA, Wijers CHW, Fleuren HWHA, Kramers C, de Wit HAJM. External validity of an automated delirium prediction model (DEMO) and comparison to the manual VMS-questions: a retrospective cohort study. Int J Clin Pharm 2023; 45:1128-1135. [PMID: 37713029 DOI: 10.1007/s11096-023-01641-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2023] [Accepted: 08/23/2023] [Indexed: 09/16/2023]
Abstract
BACKGROUND It is estimated that one-third of delirium cases in hospitals could be prevented with appropriate interventions. In Dutch hospitals a manual instrument (VMS-questions) is used to identify patients at-risk for delirium. Delirium Model (DEMO) is an automated model which could support delirium prevention more efficiently. However, it has not been validated beyond the hospital it was developed in. AIM To externally validate the DEMO and compare its performance to the VMS-questions. METHOD A retrospective cohort study between July and December 2018 was conducted. Delirium cases were identified through a chart review, and the VMS-questions were extracted from the electronic health records. The DEMO was validated in patients ≥ 60 years, and a comparison with the VMS-questions was made in patients ≥ 70 years. RESULTS In total 1,345 admissions were included. The DEMO predicted 59 out of 75 delirium cases (sensitivity 0.79, 95% CI = 0.68-0.87; specificity 0.75, 95% CI = 0.72-0.77). Compared to the VMS-questions, the DEMO showed a lower specificity (0.64 vs. 0.72; p < 0.001) and a comparable sensitivity (0.83 vs. 0.80; p = 0.56). The VMS-questions were missing in 20% of admissions, in which the DEMO correctly predicted 10 of 12 delirium cases. CONCLUSION The DEMO showed acceptable performance for delirium prediction. Overall the DEMO predicted more delirium cases because the VMS-questions were missing in 20% of admissions. This study shows that automated instruments such as DEMO could play a key role in the efficient and timely deployment of measures to prevent delirium.
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Affiliation(s)
- Ma Ida Mohmaed Ali
- Department of Clinical Pharmacy, Canisius Wilhelmina Hospital, Nijmegen, The Netherlands
| | - Gerard A Kalkman
- Department of Clinical Pharmacy, Canisius Wilhelmina Hospital, Nijmegen, The Netherlands.
| | | | - Hanneke W H A Fleuren
- Department of Clinical Pharmacy, Canisius Wilhelmina Hospital, Nijmegen, The Netherlands
| | - Cornelis Kramers
- Department of Clinical Pharmacy, Canisius Wilhelmina Hospital, Nijmegen, The Netherlands
- Department of Pharmacology-Toxicology, Radboud University Hospital, Nijmegen, The Netherlands
| | - Hugo A J M de Wit
- Department of Clinical Pharmacy, Canisius Wilhelmina Hospital, Nijmegen, The Netherlands
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Teunissen AJW, Koning MV, Liefers WJ, Stap DV, Roukema G, de Bruijn B, Teunissen CE, Koopman SA. A double-blind, randomised, placebo-controlled trial comparing intrathecal bupivacaine with bupivacaine plus morphine to reduce delirium in patients with hip fractures-Salmon-Mind trial study protocol. BJA OPEN 2023; 7:100216. [PMID: 37638088 PMCID: PMC10457486 DOI: 10.1016/j.bjao.2023.100216] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/05/2023] [Accepted: 06/20/2023] [Indexed: 08/29/2023]
Abstract
Background Surgical treatment of proximal femur fractures is complicated by postoperative delirium in about one-third of patients. Pain and opioid consumption are modifiable factors that may influence the incidence of delirium.1 An intrathecal injection of morphine may lead to a reduction in postoperative pain and reduced systemic opioid consumption. In current practice, the addition of morphine to intrathecal anaesthesia is commonly used but depends on the anaesthesiologist's preference. Recently, a retrospective study found that intrathecal morphine was independently associated with a lower incidence of delirium. However, this has to be confirmed in a prospective, randomised study. We hypothesise that using intrathecal morphine reduces postoperative pain and opioid consumption during the first 48 h after surgery and reduces the incidence of delirium during hospital admission. We also seek additional evidence of the association between neuronal injury (delirium) and neurofilament light in serum of patients with proximal femur fractures. Objective The primary objective is to compare the incidence of delirium. The secondary objectives are to compare pain scores, systemic opioid consumption, and (opioid-related) side-effects. The tertiary objective is to test the association between intrathecal morphine and neurofilament light as a marker of neuronal injury. Study design A double-blind, randomised, placebo-controlled intervention study is proposed. Study population All patients with a proximal femur fracture who are scheduled for surgery under spinal anaesthesia. Intervention The intervention is the addition of morphine 100 μg to the intrathecal injection for spinal anaesthesia. The intervention group will receive a mixture of bupivacaine 10 mg and morphine 100 μg. The control group will receive bupivacaine 10 mg. Clinical trial registration EU Clinical Trials Register: EudraCT number 2020-002143-27.
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Affiliation(s)
| | - Mark V. Koning
- Anaesthesiology, Rijnstate Hospital, Arnhem, the Netherlands
| | | | - Dawi v.d. Stap
- Geriatrics, Maasstad Hospital, Rotterdam, the Netherlands
| | - Gert Roukema
- Surgery, Maasstad Hospital, Rotterdam, the Netherlands
| | - Bart de Bruijn
- Anaesthesiology, Maasstad Hospital, Rotterdam, the Netherlands
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12
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Ma Z, Wang J, He T, Zhu S, Sheng C, Ge Y, Yuan L. Correlation between preoperative frailty and postoperative delirium in elderly patients undergoing hip arthroplasty. Medicine (Baltimore) 2023; 102:e34785. [PMID: 37653780 PMCID: PMC10470691 DOI: 10.1097/md.0000000000034785] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2023] [Revised: 07/25/2023] [Accepted: 07/26/2023] [Indexed: 09/02/2023] Open
Abstract
BACKGROUND Postoperative delirium (POD) refers to acute brain dysfunction occurring within 7 days after operation or before discharge. Frailty refers to the state that the body's physiological reserve is insufficient, so that the compensative capacity to endogenous and exogenous stress stimuli decreases. The purpose of this study is to explore the association of preoperative frailty (PF) with POD in elderly patients undergoing hip arthroplasty. METHODS Totally 228 elderly patients (age ≥ 65 years) who received elective hip arthroplasty in the Ningbo No. 6 Hospital between December 2021 and June 2022 were enrolled. One day before surgery, the frailty phenotype scale was adopted for evaluation of patients' frailty. On the 1st-3rd day after operation, the confusion assessment method was adopted for evaluation of delirium, and the patients were grouped into a POD group and non-POD group. Logistic regression was conducted to analyze the correlation between PF and POD. RESULTS Among the patients, the incidence of PF was 30.70% (70/228), and the incidence of delirium within 3 days after operation was 25.88% (59/228). According to binary logistic regression analysis, PF, age, hypertension, diabetes mellitus, and preoperative sleep disorder were independent risk factors for POD in elderly patients undergoing hip arthroplasty (all P < .05). CONCLUSION PF is a crucial risk factor for POD in elderly patients undergoing hip arthroplasty.
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Affiliation(s)
- Zihan Ma
- Health Science Center, Ningbo University, Ningbo, Zhejiang, China
| | - Jianlin Wang
- Department of Anesthesiology, Ningbo No. 6 Hospital, Ningbo, Zhejiang, China
| | - Tianyi He
- Health Science Center, Ningbo University, Ningbo, Zhejiang, China
| | - Shaoxiong Zhu
- Health Science Center, Ningbo University, Ningbo, Zhejiang, China
| | - Chaoxu Sheng
- Department of Anesthesiology, Ningbo No. 6 Hospital, Ningbo, Zhejiang, China
| | - Yeying Ge
- Department of Anesthesiology, Ningbo No. 6 Hospital, Ningbo, Zhejiang, China
| | - Liyong Yuan
- Department of Anesthesiology, Ningbo No. 6 Hospital, Ningbo, Zhejiang, China
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13
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Labaste F, Delort F, Ferré F, Bounes F, Reina N, Valet P, Dray C, Minville V. Postoperative delirium is a risk factor of institutionalization after hip fracture: an observational cohort study. Front Med (Lausanne) 2023; 10:1165734. [PMID: 37649978 PMCID: PMC10464946 DOI: 10.3389/fmed.2023.1165734] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2023] [Accepted: 07/10/2023] [Indexed: 09/01/2023] Open
Abstract
Introduction Hip fracture is a common clinical problem in geriatric patients often associated with poor postoperative outcomes. Postoperative delirium (POD) and postoperative neurocognitive disorders (NCDs) are particularly frequent. The consequences of these disorders on postoperative recovery and autonomy are not fully described. The aim of this study was to determine the role of POD and NCDs on the need for institutionalization at 3 months after hip fracture surgery. Method A population-based prospective cohort study was conducted on hip fracture patients between March 2016 and March 2018. The baseline interview, which included a Mini-Mental State Examination (MMSE), was conducted in the hospital after admission for hip fracture. NCDs were appreciated by MMSE scoring evolution (difference between preoperative MMSE and MMSE at day 5 >2 points). POD was evaluated using the Confusion Assessment Method. The primary endpoint was the rate of new institutionalization at 3 months. We used a multivariate analysis to assess the risk of new institutionalization. Results A total of 63 patients were included. Thirteen patients (20.6%) were newly institutionalized at 3 months. Two factors were significantly associated with the risk of postoperative institutionalization at 3 months: POD (OR = 5.23; 95% CI 1.1-27.04; p = 0.04) and IADL evolution (OR = 1.8; 95% CI 1.23-2.74; p = 0.003). Conclusion Only POD but not NCDs was associated with the risk of dependency and institutionalization after hip fracture surgery. The prevention of POD appears to be essential for improving patient outcomes and optimizing the potential for returning home.
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Affiliation(s)
- François Labaste
- Anesthesiology and Intensive Care Department CHU Toulouse, Toulouse, France
- Institut RESTORE UMR 1301-Inserm 5070-CNRS EFS Univ. P. Sabatier, Toulouse, France
| | - François Delort
- Anesthesiology and Intensive Care Department CHU Toulouse, Toulouse, France
| | - Fabrice Ferré
- Anesthesiology and Intensive Care Department CHU Toulouse, Toulouse, France
| | - Fanny Bounes
- Anesthesiology and Intensive Care Department CHU Toulouse, Toulouse, France
| | - Nicolas Reina
- Orthopedic Surgery Department, CHU Toulouse, Toulouse, France
| | - Philippe Valet
- Institut RESTORE UMR 1301-Inserm 5070-CNRS EFS Univ. P. Sabatier, Toulouse, France
| | - Cédric Dray
- Institut RESTORE UMR 1301-Inserm 5070-CNRS EFS Univ. P. Sabatier, Toulouse, France
| | - Vincent Minville
- Anesthesiology and Intensive Care Department CHU Toulouse, Toulouse, France
- Institut RESTORE UMR 1301-Inserm 5070-CNRS EFS Univ. P. Sabatier, Toulouse, France
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14
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Deng H, Wu Y, Gao P, Kong D, Pan C, Xu S, Tang D, Jiao Y, Wen D, Yu W. Preoperative Pain Facilitates Postoperative Cognitive Dysfunction via Periaqueductal Gray Matter-Dorsal Raphe Circuit. Neuroscience 2023; 524:209-219. [PMID: 36958595 DOI: 10.1016/j.neuroscience.2023.03.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2022] [Revised: 03/09/2023] [Accepted: 03/15/2023] [Indexed: 03/25/2023]
Abstract
Postoperative cognitive dysfunction (POCD) is a medically induced, rapidly occurring postoperative disease, which is hard to recover and seriously threatens the quality of life, especially for elderly patients, so it is important to identify the risk factors for POCD and apply early intervention to prevent POCD. As we have known, pain can impair cognition, and many surgery patients experience different preoperative pain, but it is still unknown whether these patients are vulnerable for POCD. Here we found that chronic pain (7 days, but not 1 day acute pain) induced by Complete Freund's Adjuvant (CFA) injected in the hind paw of rats could easily induce spatial cognition and memory impairment after being exposed to sevoflurane anesthesia. Next, for the mechanisms, we focused on the Periaqueductal Gray Matter (PAG), a well-known pivotal nucleus in pain process. It was detected the existence of neural projection from ventrolateral PAG (vlPAG) to adjacent nucleus Dorsal Raphe (DR), the origin of serotonergic projection for the whole cerebrum, through virus tracing and patch clamp recordings. The Immunofluorescence staining and western blot results showed that Tryptophan Hydroxylase 2 (TPH2) for serotonin synthesis in the DR was increased significantly in the rats treated with CFA for 7 days and sevoflurane for 3 hours, while chemo-genetic inhibition of the vlPAG-DR projection induced obvious spatial learning and memory impairment. Our study suggests that preoperative chronic pain may facilitate cognitive function impairment after receiving anesthesia through the PAG-DR neural circuit, and preventative analgesia should be a considerable measure to reduce the incidence of POCD.
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Affiliation(s)
- Haoyue Deng
- Department of Anesthesiology, Renji Hospital, Shanghai Jiao Tong University School of Medicine, P.O. Box 200127, No. 160 Pujian Road, Shanghai, China; Key Laboratory of Anesthesiology (Shanghai Jiao Tong University), Ministry of Education, China
| | - Yi Wu
- Department of Anesthesiology, Renji Hospital, Shanghai Jiao Tong University School of Medicine, P.O. Box 200127, No. 160 Pujian Road, Shanghai, China; Key Laboratory of Anesthesiology (Shanghai Jiao Tong University), Ministry of Education, China
| | - Po Gao
- Department of Anesthesiology, Renji Hospital, Shanghai Jiao Tong University School of Medicine, P.O. Box 200127, No. 160 Pujian Road, Shanghai, China; Key Laboratory of Anesthesiology (Shanghai Jiao Tong University), Ministry of Education, China
| | - Dexu Kong
- Department of Anesthesiology, Renji Hospital, Shanghai Jiao Tong University School of Medicine, P.O. Box 200127, No. 160 Pujian Road, Shanghai, China; Key Laboratory of Anesthesiology (Shanghai Jiao Tong University), Ministry of Education, China
| | - Chao Pan
- Department of Anesthesiology, Renji Hospital, Shanghai Jiao Tong University School of Medicine, P.O. Box 200127, No. 160 Pujian Road, Shanghai, China; Key Laboratory of Anesthesiology (Shanghai Jiao Tong University), Ministry of Education, China
| | - Saihong Xu
- Department of Anesthesiology, Renji Hospital, Shanghai Jiao Tong University School of Medicine, P.O. Box 200127, No. 160 Pujian Road, Shanghai, China; Key Laboratory of Anesthesiology (Shanghai Jiao Tong University), Ministry of Education, China
| | - Dan Tang
- Department of Anesthesiology, Renji Hospital, Shanghai Jiao Tong University School of Medicine, P.O. Box 200127, No. 160 Pujian Road, Shanghai, China; Key Laboratory of Anesthesiology (Shanghai Jiao Tong University), Ministry of Education, China
| | - Yingfu Jiao
- Department of Anesthesiology, Renji Hospital, Shanghai Jiao Tong University School of Medicine, P.O. Box 200127, No. 160 Pujian Road, Shanghai, China; Key Laboratory of Anesthesiology (Shanghai Jiao Tong University), Ministry of Education, China.
| | - Daxiang Wen
- Department of Anesthesiology, Renji Hospital, Shanghai Jiao Tong University School of Medicine, P.O. Box 200127, No. 160 Pujian Road, Shanghai, China; Key Laboratory of Anesthesiology (Shanghai Jiao Tong University), Ministry of Education, China.
| | - Weifeng Yu
- Department of Anesthesiology, Renji Hospital, Shanghai Jiao Tong University School of Medicine, P.O. Box 200127, No. 160 Pujian Road, Shanghai, China; Key Laboratory of Anesthesiology (Shanghai Jiao Tong University), Ministry of Education, China.
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15
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Huang JW, Yang YF, Gao XS, Xu ZH. A single preoperative low-dose dexamethasone may reduce the incidence and severity of postoperative delirium in the geriatric intertrochanteric fracture patients with internal fixation surgery: an exploratory analysis of a randomized, placebo-controlled trial. J Orthop Surg Res 2023; 18:441. [PMID: 37337260 DOI: 10.1186/s13018-023-03930-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Accepted: 06/13/2023] [Indexed: 06/21/2023] Open
Abstract
OBJECTIVE Postoperative delirium (POD) is a common complication along with poor prognosis in geriatric intertrochanteric fracture (ITF) patients. However, the prevention and treatment of POD remain unclear. Previous studies have confirmed that POD is essentially a consequence of neuro-inflammatory responses. Dexamethasone is a glucocorticoid with comprehensive anti-inflammatory effects, while a high dose of dexamethasone correlates with many side effects or even adverse consequences. Thus, this prospective study aims to discuss whether a single preoperative low-dose dexamethasone can reduce the impact of POD on geriatric ITF patients with internal fixation surgery. METHODS Between June 2020 and October 2022, there were 219 consecutive ITF patients assessed in our department. Of the 219 ITF patients, 160 cases who met the inclusion and exclusion criteria were finally enrolled and randomly allocated to the dexamethasone group and the placebo group (80 geriatric ITF patients in each group) in this prospective study. The patients in the dexamethasone group received intravenous 10 mg (2 ml) dexamethasone while the patients in the placebo group received intravenous 2 ml saline in 30 min before being sent to the operating room, respectively. The baseline characteristics, surgical information, incidence and severity of POD as the efficacy-related outcomes, and infection events and hyperglycemia as safety-related outcomes (adverse events), were collected and analyzed between the two groups. The severity of POD was evaluated by Memorial Delirium Assessment Scale (MDAS) score. RESULTS There were no differences in baseline characteristics and surgical information between the dexamethasone group and the placebo group. The dexamethasone group had a lower incidence of POD than the placebo group within the first 5 days after surgery [(9/80, 11.3% vs. 21/80, 26.3%, RR = 0.83, 95% CI 0.71-0.97, P = 0.015]. The dexamethasone group had lower MDAS scores (Mean ± SD) than the placebo group [13.2 ± 1.0 (range 11 to 15) vs. 15.48 ± 2.9 (range 9 to 20), P = 0.011, effect size = 0.514]. There were no differences in infection events and hyperglycemia between the two groups. CONCLUSIONS A single preoperative low-dose dexamethasone may reduce the incidence and severity of POD in geriatric ITF patients with internal fixation surgery. TRIAL REGISTRATION ChiCTR2200055281.
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Affiliation(s)
- Jian-Wen Huang
- Department of Orthopaedic Surgery, Guangzhou First People's Hospital, The Second Affiliated Hospital, School of Medicine, South China University of Technology, 1 Panfu Road, Guangzhou, 510180, Guangdong, China
| | - Yun-Fa Yang
- Department of Orthopaedic Surgery, Guangzhou First People's Hospital, The Second Affiliated Hospital, School of Medicine, South China University of Technology, 1 Panfu Road, Guangzhou, 510180, Guangdong, China.
| | - Xiao-Sheng Gao
- Department of Orthopaedic Surgery, Guangzhou First People's Hospital, The Second Affiliated Hospital, School of Medicine, South China University of Technology, 1 Panfu Road, Guangzhou, 510180, Guangdong, China
| | - Zhong-He Xu
- Department of Orthopaedic Surgery, Guangzhou First People's Hospital, The Second Affiliated Hospital, School of Medicine, South China University of Technology, 1 Panfu Road, Guangzhou, 510180, Guangdong, China
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16
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Berk T, Thalmann M, Jensen KO, Schwarzenberg P, Jukema GN, Pape HC, Halvachizadeh S. Implementation of a novel nursing assessment tool in geriatric trauma patients with proximal femur fractures. PLoS One 2023; 18:e0284320. [PMID: 37294793 PMCID: PMC10256203 DOI: 10.1371/journal.pone.0284320] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2022] [Accepted: 03/29/2023] [Indexed: 06/11/2023] Open
Abstract
BACKGROUND Geriatric trauma patients represent a special challenge in postoperative care and are prone to specific complications. The goal of this study was to analyse the predictive potential of a novel nursing assessment tool, the outcome-oriented nursing assessment for acute care (ePA-AC), in geriatric trauma patients with proximal femur fractures (PFF). METHODS A retrospective cohort study of geriatric trauma patients aged ≥ 70 years with PFF was conducted at a level 1 trauma centre. The ePA-AC is a routinely used tool that evaluates pneumonia; confusion, delirium and dementia (CDD); decubitus (Braden Score); the risk of falls; the Fried Frailty index (FFI); and nutrition. Assessment of the novel tool included analysis of its ability to predict complications including delirium, pneumonia and decubitus. RESULTS The novel ePA-AC tool was investigated in 71 geriatric trauma patients. In total, 49 patients (67.7%) developed at least one complication. The most common complication was delirium (n = 22, 44.9%). The group with complications (Group C) had a significantly higher FFI compared with the group without complications (Group NC) (1.7 ± 0.5 vs 1.2 ± 0.4, p = 0.002). Group C had a significantly higher risk score for malnutrition compared with Group NC (6.3 ± 3.4 vs 3.9 ± 2.8, p = 0.004). A higher FFI score increased the risk of developing complications (odds ratio [OR] 9.8, 95% confidence interval [CI] 2.0 to 47.7, p = 0.005). A higher CDD score increased the risk of developing delirium (OR 9.3, 95% CI 2.9 to 29.4, p < 0.001). CONCLUSION The FFI, CDD, and nutritional assessment tools are associated with the development of complications in geriatric trauma patients with PFF. These tools can support the identification of geriatric patients at risk and might guide individualised treatment strategies and preventive measures.
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Affiliation(s)
- Till Berk
- Department of Trauma, University Hospital Zurich, Zurich, Switzerland
- Harald-Tscherne Laboratory for Orthopedic and Trauma Research, University of Zurich, Zurich, Switzerland
| | - Marion Thalmann
- Harald-Tscherne Laboratory for Orthopedic and Trauma Research, University of Zurich, Zurich, Switzerland
| | - Kai Oliver Jensen
- Department of Trauma, University Hospital Zurich, Zurich, Switzerland
| | | | | | - Hans-Christoph Pape
- Department of Trauma, University Hospital Zurich, Zurich, Switzerland
- Harald-Tscherne Laboratory for Orthopedic and Trauma Research, University of Zurich, Zurich, Switzerland
| | - Sascha Halvachizadeh
- Department of Trauma, University Hospital Zurich, Zurich, Switzerland
- Harald-Tscherne Laboratory for Orthopedic and Trauma Research, University of Zurich, Zurich, Switzerland
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Yager M, Clark BR, Gulley N, Denny DL. Position Statement: Delirium Among Orthopedic or Rehabilitative Patients. Rehabil Nurs 2023; 48:87-90. [PMID: 37133328 DOI: 10.1097/rnj.0000000000000413] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/04/2023]
Affiliation(s)
- Melissa Yager
- Department of Orthopedics, Sharp HealthCare, San Diego, CA, USA
| | - Betty R Clark
- Betty Clark Educational Services, Land O'Lakes, FL, USA
| | - Nichole Gulley
- VA Northeast Ohio Healthcare System, Louis Stokes VA Medical Center, Cleveland, OH, USA
| | - Dawn L Denny
- Department of Nursing, University of North Dakota, Grand Forks, ND, USA
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18
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Yager M, Clark BR, Gulley N, Denny DL. Delirium Position Statement. Orthop Nurs 2023; 42:147-150. [PMID: 37262372 DOI: 10.1097/nor.0000000000000940] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/03/2023] Open
Affiliation(s)
- Melissa Yager
- Melissa Yager, PhD, RN, CNS, ONC, Director of the Orthopedic Service Line, Department of Orthopedics, Sharp HealthCare, San Diego, CA
- Betty R. Clark, MEd, BSN, RN, CRRN, Educational Services, Land O'Lakes, FL
- Nichole Gulley, MSN, APRN, AGCNS, CRRN, CMSRN, Spinal Cord Injury/Disorders Clinical Nurse Specialist, VA Northeast Ohio Healthcare System, Louis Stokes VA Medical Center, Cleveland, OH
- Dawn L. Denny, PhD, RN, ONC, Associate Professor, College of Nursing & Professional Disciplines, University of North Dakota, Grand Forks, ND
| | - Betty R Clark
- Melissa Yager, PhD, RN, CNS, ONC, Director of the Orthopedic Service Line, Department of Orthopedics, Sharp HealthCare, San Diego, CA
- Betty R. Clark, MEd, BSN, RN, CRRN, Educational Services, Land O'Lakes, FL
- Nichole Gulley, MSN, APRN, AGCNS, CRRN, CMSRN, Spinal Cord Injury/Disorders Clinical Nurse Specialist, VA Northeast Ohio Healthcare System, Louis Stokes VA Medical Center, Cleveland, OH
- Dawn L. Denny, PhD, RN, ONC, Associate Professor, College of Nursing & Professional Disciplines, University of North Dakota, Grand Forks, ND
| | - Nichole Gulley
- Melissa Yager, PhD, RN, CNS, ONC, Director of the Orthopedic Service Line, Department of Orthopedics, Sharp HealthCare, San Diego, CA
- Betty R. Clark, MEd, BSN, RN, CRRN, Educational Services, Land O'Lakes, FL
- Nichole Gulley, MSN, APRN, AGCNS, CRRN, CMSRN, Spinal Cord Injury/Disorders Clinical Nurse Specialist, VA Northeast Ohio Healthcare System, Louis Stokes VA Medical Center, Cleveland, OH
- Dawn L. Denny, PhD, RN, ONC, Associate Professor, College of Nursing & Professional Disciplines, University of North Dakota, Grand Forks, ND
| | - Dawn L Denny
- Melissa Yager, PhD, RN, CNS, ONC, Director of the Orthopedic Service Line, Department of Orthopedics, Sharp HealthCare, San Diego, CA
- Betty R. Clark, MEd, BSN, RN, CRRN, Educational Services, Land O'Lakes, FL
- Nichole Gulley, MSN, APRN, AGCNS, CRRN, CMSRN, Spinal Cord Injury/Disorders Clinical Nurse Specialist, VA Northeast Ohio Healthcare System, Louis Stokes VA Medical Center, Cleveland, OH
- Dawn L. Denny, PhD, RN, ONC, Associate Professor, College of Nursing & Professional Disciplines, University of North Dakota, Grand Forks, ND
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Khan AA, AbuAlrob H, Al-Alwani H, Ali DS, Almonaei K, Alsarraf F, Bogoch E, Dandurand K, Gazendam A, Juby AG, Mansoor W, Marr S, Morgante E, Myslik F, Schemitsch E, Schneider P, Thain J, Papaioannou A, Zalzal P. Post hip fracture orthogeriatric care-a Canadian position paper addressing challenges in care and strategies to meet quality indicators. Osteoporos Int 2023; 34:1011-1035. [PMID: 37014390 DOI: 10.1007/s00198-022-06640-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2022] [Accepted: 12/12/2022] [Indexed: 04/05/2023]
Abstract
INTRODUCTION Osteoporosis is a major disease state associated with significant morbidity, mortality, and health care costs. Less than half of the individuals sustaining a low energy hip fracture are diagnosed and treated for the underlying osteoporosis. OBJECTIVE A multidisciplinary Canadian hip fracture working group has developed practical recommendations to meet Canadian quality indicators in post hip fracture care. METHODS A comprehensive narrative review was conducted to identify and synthesize key articles on post hip fracture orthogeriatric care for each of the individual sections and develop recommendations. These recommendations are based on the best evidence available today. CONCLUSION Recommendations are anticipated to reduce recurrent fractures, improve mobility and healthcare outcomes post hip fracture, and reduce healthcare costs. Key messages to enhance postoperative care are also provided.
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Affiliation(s)
- Aliya A Khan
- Department of Medicine, Division of Endocrinology and Metabolism and Geriatrics, McMaster University, Hamilton, ON, Canada.
| | - Hajar AbuAlrob
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
- Department of Medicine, Division of Geriatric Medicine, McMaster University, Hamilton, ON, Canada
| | - Hatim Al-Alwani
- Department of Medicine, Division of Endocrinology and Metabolism and Geriatrics, McMaster University, Hamilton, ON, Canada
| | - Dalal S Ali
- Department of Medicine, Division of Endocrinology and Metabolism and Geriatrics, McMaster University, Hamilton, ON, Canada
| | - Khulod Almonaei
- Department of Medicine, Division of Endocrinology and Metabolism and Geriatrics, McMaster University, Hamilton, ON, Canada
| | - Farah Alsarraf
- Department of Medicine, Division of Endocrinology and Metabolism and Geriatrics, McMaster University, Hamilton, ON, Canada
| | - Earl Bogoch
- Department of Surgery, Division of Orthopaedic Surgery, University of Toronto, Toronto, ON, Canada
| | - Karel Dandurand
- Department of Medicine, Division of Endocrinology and Metabolism and Geriatrics, McMaster University, Hamilton, ON, Canada
| | - Aaron Gazendam
- Department of Surgery, Division of Orthopaedic Surgery, McMaster University, Hamilton, ON, Canada
| | - Angela G Juby
- Department of Medicine, Division of Geriatric Medicine, University of Alberta, Edmonton, AB, Canada
| | - Wasim Mansoor
- Trillium Health Partners, University of Toronto, Toronto, ON, Canada
| | - Sharon Marr
- Department of Medicine, Division of Geriatric Medicine, McMaster University, Hamilton, ON, Canada
| | - Emmett Morgante
- Bone Research and Education Center Patient Support Program and Education Coordinator, Oakville, ON, Canada
| | - Frank Myslik
- Division of Emergency Medicine, Western University, London, ON, Canada
| | - Emil Schemitsch
- Department of Surgery, Division of Orthopaedic Surgery, Western University, London, ON, Canada
| | - Prism Schneider
- Department of Surgery, Division of Orthopaedic Surgery, University of Calgary, Calgary, AB, Canada
| | - Jenny Thain
- Department of Medicine, Division of Geriatric Medicine, Western University, London, ON, Canada
| | - Alexandra Papaioannou
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
- Department of Medicine, Division of Geriatric Medicine, McMaster University, Hamilton, ON, Canada
| | - Paul Zalzal
- Department of Surgery, Division of Orthopaedic Surgery, McMaster University, Hamilton, ON, Canada
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20
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Lee DH, Chang CH, Chang CW, Chen YC, Tai TW. Postoperative Delirium in Patients Receiving Hip Bipolar Hemiarthroplasty for Displaced Femoral Neck Fractures: The Risk Factors and Further Clinical Outcomes. J Arthroplasty 2023; 38:737-742. [PMID: 36273712 DOI: 10.1016/j.arth.2022.10.022] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2022] [Revised: 10/13/2022] [Accepted: 10/14/2022] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND Postoperative delirium in patients who have hip fractures may lead to poor outcomes. This study aimed to determine perioperative risk factors and clinical outcomes of postoperative delirium in patients undergoing hip bipolar hemiarthroplasty for displaced femoral neck fractures. METHODS Among 1,353 patients who underwent hemiarthroplasty at our institution during 2013-2021, we identified 78 patients with postoperative delirium diagnosed with the confusion assessment method. The mean delirium duration was 28 hours (range: 15-520). We also included 1:2 sex- and age-matched patients who did not have postoperative delirium after the same surgery as a matching cohort for comparison. Patient comorbidities, perioperative data, delirium occurrence, and outcomes were collected for analyses. RESULTS A Charlson Comorbidity Index (CCI) score ≥6 (odds ratio (OR): 2.08, P = .017), nighttime surgery (OR: 3.47, p =<.001), surgical delays (OR: 1.01, P = .012), preoperative anemia (OR: 2.1, P = .012), and blood transfusions (OR: 2.47, P = .01) may increase the risk of postoperative delirium. The presentation of delirium was associated with sepsis (OR: 3.77, P = .04), longer hospital stays (P < .001), higher 1-year mortality (OR: 3.97, P = .002), and overall mortality (OR: 2.1, P = .02). CONCLUSION Postoperative delirium predicted poor outcomes. Our results emphasized the importance of early identification of patients at risk and optimization of the medical conditions before and after surgery.
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Affiliation(s)
- Deng Horng Lee
- Departments of Orthopedics, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Chih-Hsun Chang
- Departments of Orthopedics, National Cheng Kung University Hospital Dou-Liou Branch, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Chih-Wei Chang
- Departments of Orthopedics, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Yi-Chen Chen
- Departments of Nursing, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Ta-Wei Tai
- Departments of Orthopedics, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan; Skeleton Materials and Bio-compatibility Core Lab, Research Center of Clinical Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
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21
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Hawley S, Inman D, Gregson CL, Whitehouse M, Johansen A, Judge A. Risk Factors and 120-day Functional Outcomes of Delirium After Hip Fracture Surgery: A Prospective Cohort Study Using the UK National Hip Fracture Database (NHFD). J Am Med Dir Assoc 2023; 24:694-701.e7. [PMID: 36933569 DOI: 10.1016/j.jamda.2023.02.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2022] [Revised: 02/07/2023] [Accepted: 02/08/2023] [Indexed: 03/17/2023]
Abstract
OBJECTIVES To identify risk factors of postoperative delirium among patients with hip fracture with normal preoperative cognition, and examine associations with returning home or recovery of mobility. DESIGN Prospective cohort study. SETTING AND PARTICIPANTS We used the National Hip Fracture Database (NHFD) to identify patients presenting with hip fracture in England (2018-2019), but excluded those with abnormal cognition (abbreviated mental test score [AMTS] < 8) on presentation. METHODS We examined the results of routine delirium screening performed using the 4 A's Test (4AT), to assess alertness, attention, acute change, and orientation in a 4-item mental test. Associations between 4AT score and return home or to outdoor mobility at 120 days were estimated, and risk factors identified for abnormal 4AT scores: (1) 4AT ≥4 suggesting delirium and (2) 4AT = 1-3 being an intermediate score not excluding delirium. RESULTS Overall, 63,502 patients (63%) had a preoperative AMTS ≥8, in whom a postoperative 4AT score ≥4 suggestive of delirium was seen in 4454 (7%). These patients were less likely to return home (odds ratio [OR], 0.46; 95% CI, 0.38-0.55) or regain outdoor mobility (OR, 0.63; 95% CI, 0.53-0.75) by 120 days. Multiple factors including any deficit in preoperative AMTS and malnutrition were associated with higher risk of 4AT ≥4, while use of preoperative nerve blocks was associated with lower risk (OR, 0.88; 95% CI, 0.81-0.95). Poorer outcomes were also seen in 12,042 (19%) patients with 4AT = 1-3; additional risk factors associated with this score included socioeconomic deprivation and surgical procedure types that were not compliant with National Institute of Health and Care Excellence guidance. CONCLUSION AND IMPLICATIONS Delirium after hip fracture surgery significantly reduces the likelihood of returning home or to outdoor mobility. Our findings underline the importance of measures to prevent postoperative delirium, and aid the identification of high-risk patients for whom delirium prevention might potentially improve outcomes.
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Affiliation(s)
- Samuel Hawley
- Musculoskeletal Research Unit, Translational Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK.
| | - Dominic Inman
- Department of Orthopaedics, Northumbria Healthcare NHS Foundation Trust, Northumberland, UK; Care Quality Improvement Department, Royal College of Physicians, London, UK
| | - Celia L Gregson
- Musculoskeletal Research Unit, Translational Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Michael Whitehouse
- Musculoskeletal Research Unit, Translational Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK; National Institute for Health Research Bristol Biomedical Research Centre, University Hospitals Bristol and Weston NHS Foundation Trust and University of Bristol, Bristol, UK
| | - Antony Johansen
- Care Quality Improvement Department, Royal College of Physicians, London, UK; University Hospital of Wales and School of Medicine, Cardiff University, UK
| | - Andrew Judge
- Musculoskeletal Research Unit, Translational Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK; National Institute for Health Research Bristol Biomedical Research Centre, University Hospitals Bristol and Weston NHS Foundation Trust and University of Bristol, Bristol, UK
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22
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Phing AH, Makpol S, Nasaruddin ML, Wan Zaidi WA, Ahmad NS, Embong H. Altered Tryptophan-Kynurenine Pathway in Delirium: A Review of the Current Literature. Int J Mol Sci 2023; 24:5580. [PMID: 36982655 PMCID: PMC10056900 DOI: 10.3390/ijms24065580] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2023] [Revised: 03/09/2023] [Accepted: 03/11/2023] [Indexed: 03/17/2023] Open
Abstract
Delirium, a common form of acute brain dysfunction, is associated with increased morbidity and mortality, especially in older patients. The underlying pathophysiology of delirium is not clearly understood, but acute systemic inflammation is known to drive delirium in cases of acute illnesses, such as sepsis, trauma, and surgery. Based on psychomotor presentations, delirium has three main subtypes, such as hypoactive, hyperactive, and mixed subtype. There are similarities in the initial presentation of delirium with depression and dementia, especially in the hypoactive subtype. Hence, patients with hypoactive delirium are frequently misdiagnosed. The altered kynurenine pathway (KP) is a promising molecular pathway implicated in the pathogenesis of delirium. The KP is highly regulated in the immune system and influences neurological functions. The activation of indoleamine 2,3-dioxygenase, and specific KP neuroactive metabolites, such as quinolinic acid and kynurenic acid, could play a role in the event of delirium. Here, we collectively describe the roles of the KP and speculate on its relevance in delirium.
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Affiliation(s)
- Ang Hui Phing
- Department of Emergency Medicine, Faculty of Medicine, Universiti Kebangsaan Malaysia, Jalan Yaacob Latif, Bandar Tun Razak, Cheras, Kuala Lumpur 56000, Malaysia
| | - Suzana Makpol
- Department of Biochemistry, Faculty of Medicine, Universiti Kebangsaan Malaysia, Jalan Yaacob Latif, Bandar Tun Razak, Cheras, Kuala Lumpur 56000, Malaysia; (S.M.)
| | - Muhammad Luqman Nasaruddin
- Department of Biochemistry, Faculty of Medicine, Universiti Kebangsaan Malaysia, Jalan Yaacob Latif, Bandar Tun Razak, Cheras, Kuala Lumpur 56000, Malaysia; (S.M.)
| | - Wan Asyraf Wan Zaidi
- Department of Medicine, Faculty of Medicine, Universiti Kebangsaan Malaysia, Jalan Yaacob Latif, Bandar Tun Razak, Cheras, Kuala Lumpur 56000, Malaysia
| | - Nurul Saadah Ahmad
- Department of Emergency Medicine, Faculty of Medicine, Universiti Kebangsaan Malaysia, Jalan Yaacob Latif, Bandar Tun Razak, Cheras, Kuala Lumpur 56000, Malaysia
| | - Hashim Embong
- Department of Emergency Medicine, Faculty of Medicine, Universiti Kebangsaan Malaysia, Jalan Yaacob Latif, Bandar Tun Razak, Cheras, Kuala Lumpur 56000, Malaysia
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Liposomal Bupivacaine Decreases Intravenous Opioid Use in Patients with Hip Fracture: A Modification to a Novel Pain Protocol. J Am Acad Orthop Surg 2023; 31:e246-e255. [PMID: 36821079 DOI: 10.5435/jaaos-d-22-00493] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2022] [Accepted: 10/23/2022] [Indexed: 02/24/2023] Open
Abstract
INTRODUCTION The aim of this study was to determine whether the administration of liposomal bupivacaine decreased opioid use and delirium in patients sustaining a hip fracture. METHODS A retrospective review of patients with hip fracture from September 2018 to October 2019 was performed through our institution's hip fracture registry. A liposomal bupivacaine cocktail was administered intraoperatively. Opioid requirement was determined for postoperative days 1, 2, and 3. Delirium was identified through chart review. Visual analog scale pain scores were averaged for postoperative days 1, 2, and 3. Four groups were analyzed: patients who received liposomal bupivacaine and IV acetaminophen, patients who only received IV acetaminophen, patients who only received liposomal bupivacaine, and control patients whose data were collected before this intervention. Continuous data were compared using a one-way analysis of variance or Student t-test, as applicable. Categorical data were compared using the Fisher exact test. Significance was set at P < 0.05. RESULTS One hundred nine patients met the inclusion criteria for the study with a mean age of 81.2 years. Eighty-two patients (75.2%) received intraoperative liposomal bupivacaine during the study year. Intravenous opioid requirement was markedly different among all four groups in all postoperative days. Oral opioid requirement and pain scores were not different between groups on any postoperative day. A notable decrease in IV opioid requirement in all postoperative days was seen in the Intervention groups (day 1 P < 0.001, day 2 P = 0.002, and day 3 P = 0.030). There existed a trend toward decreased delirium rates in the Intervention groups compared with the No Intervention group (23.9% vs. 32.8%, P = 0.272). CONCLUSION The inclusion of liposomal bupivacaine in our institution's novel pain protocol led to notable decreases in opioid requirement in all postoperative days studied with a trend toward decreased delirium rates as well.
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24
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de Haan E, van Rijckevorsel VAJIM, Bod P, Roukema GR, de Jong L. Delirium After Surgery for Proximal Femoral Fractures in the Frail Elderly Patient: Risk Factors and Clinical Outcomes. Clin Interv Aging 2023; 18:193-203. [PMID: 36818548 PMCID: PMC9936875 DOI: 10.2147/cia.s390906] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2022] [Accepted: 01/24/2023] [Indexed: 02/15/2023] Open
Abstract
Purpose The primary aim of this study was to identify risk factors for delirium after hip fracture surgery. The secondary purpose of this study was to verify peri-operative clinical outcomes, adverse events and mortality rates in delirium patients after hip fracture surgery. Patients and Methods A prospective hip fracture database was used to obtain data. In total, 2051 patients older than 70 years undergoing a hip fracture surgery between 01-01-2018 and 01-01-2021 were included. A delirium was diagnosed by a geriatrician based on the DSM-V criteria. Results The results showed that 16% developed a delirium during hospital admission. Multivariable analysis showed that male gender (OR: 1.99, p<0.001), age (OR: 1.06, p<0.001), dementia (OR: 1.66, p=0.001), Parkinson's disease (OR: 2.32, p=0.001), Δhaemoglobin loss (OR: 1.19, p=0.022), pneumonia (OR: 3.86, p<0.001), urinary tract infection (UTI) (OR: 1.97, p=0.001) and wound infection (OR: 3.02, p=0.007) were significant independent prognostic risk factors for the development of a delirium after hip surgery. The median length in-hospital stay was longer in patients with a delirium (9 days) vs patients without a delirium (6 days) (p<0.001). The 30-day mortality was 7% (with delirium 16% vs with no delirium 6% (p<0.001)). Conclusion Significant independent prognostic factors associated with delirium after hip surgery were male gender, age, dementia, Parkinson's disease, Δhaemoglobin loss, pneumonia, UTI and wound infection.
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Affiliation(s)
- Eveline de Haan
- Surgery Department, Maasstad Hospital, Rotterdam, the Netherlands,Surgery Department, Franciscus Hospital, Rotterdam, the Netherlands,Correspondence: Eveline de Haan, Tel +31654922535, Email
| | | | - Pepijn Bod
- Surgery Department, Maasstad Hospital, Rotterdam, the Netherlands
| | - Gert R Roukema
- Surgery Department, Maasstad Hospital, Rotterdam, the Netherlands
| | - Louis de Jong
- Surgery Department, Maasstad Hospital, Rotterdam, the Netherlands
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Yang Q, Fu J, Pan X, Shi D, Li K, Sun M, Ding J, Shi Z, Wang J. A retrospective analysis of the incidence of postoperative delirium and the importance of database selection for its definition. BMC Psychiatry 2023; 23:88. [PMID: 36747159 PMCID: PMC9900975 DOI: 10.1186/s12888-023-04576-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2022] [Accepted: 01/27/2023] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND Postoperative delirium (POD) is a common complication after major surgery, resulting in various adverse reactions. However, incidence and risk factors associated with POD after shoulder arthroplasty (SA) have not been well studied using a large-scale national database. METHODS A retrospective database analysis was performed based on the Nationwide Inpatient Sample (NIS) from 2005 to 2014, the largest fully paid hospital care database in the United States. Patients undergoing SA were included. The patient's demographics, comorbidities, length of stay (LOS), total costs, type of insurance, type of hospital, in-hospital mortality, and medical and surgical perioperative complications were assessed. RESULTS A total of 115,147 SA patients were obtained from the NIS database. The general incidence of delirium after SA was 0.89%, peaking in 2010. Patients with delirium after SA had more comorbidities, prolonged LOS, increased hospitalization costs, and higher in-hospital mortality (P < 0.0001). These patients were associated with medical complications during hospitalization, including acute renal failure, acute myocardial infarction, pneumonia, pulmonary embolism, stroke, urinary tract infection, sepsis, continuous invasive mechanical ventilation, blood transfusion, and overall perioperative complications. Risk factors associated with POD include advanced age, neurological disease, depression, psychosis, fluid and electrolyte disturbances, and renal failure. Protective factors include elective hospital admissions and private insurance. CONCLUSION The incidence of delirium after SA is relatively low. Delirium after SA was associated with increased comorbidities, LOS, overall costs, Medicare coverage, mortality, and perioperative complications. Studying risk factors for POD can help ensure appropriate management and mitigate its consequences. Meanwhile, we found some limitations of this type of research and the need to establish a country-based POD database, including further clearly defining the diagnostic criteria for POD, investigating risk factors and continuing to collect data after discharge (30 days or more), so as to further improve patient preoperative optimization and management.
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Affiliation(s)
- Qinfeng Yang
- grid.284723.80000 0000 8877 7471Division of Orthopaedic Surgery, Department of Orthopaedics, Nanfang Hospital, Southern Medical University, 1838 Guangzhou Avenue, Guangzhou, 510515 Guangdong China
| | - Jinlang Fu
- grid.284723.80000 0000 8877 7471Division of Orthopaedic Surgery, Department of Orthopaedics, Nanfang Hospital, Southern Medical University, 1838 Guangzhou Avenue, Guangzhou, 510515 Guangdong China
| | - Xin Pan
- grid.284723.80000 0000 8877 7471Division of Orthopaedic Surgery, Department of Orthopaedics, Nanfang Hospital, Southern Medical University, 1838 Guangzhou Avenue, Guangzhou, 510515 Guangdong China
| | - Danping Shi
- grid.284723.80000 0000 8877 7471Department of Neurosurgery, Nanfang Hospital, Southern Medical University, Guangzhou, 510515 Guangdong China
| | - Kunlian Li
- Beijing Goodwill Hessian Health Technology Co., Ltd, Gehua Tower, No.1 Qinglong Hutong, Dongcheng District, Beijing, 100007 China
| | - Min Sun
- Beijing Goodwill Hessian Health Technology Co., Ltd, Gehua Tower, No.1 Qinglong Hutong, Dongcheng District, Beijing, 100007 China
| | - Jie Ding
- Huiqiao Medical Center, Nanfang Hospital, Southern Medical University, 1838 Guangzhou Avenue, Guangzhou, 510515, Guangdong, China.
| | - Zhanjun Shi
- Division of Orthopaedic Surgery, Department of Orthopaedics, Nanfang Hospital, Southern Medical University, 1838 Guangzhou Avenue, Guangzhou, 510515, Guangdong, China.
| | - Jian Wang
- Division of Orthopaedic Surgery, Department of Orthopaedics, Nanfang Hospital, Southern Medical University, 1838 Guangzhou Avenue, Guangzhou, 510515, Guangdong, China.
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26
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Cook E, Laycock J, Acharya M, Backhouse MR, Corbacho B, Doherty L, Forward D, Hewitt C, Hilton C, Hull P, Kassam J, Maturana C, Mcdaid C, Roche J, Sivapathasuntharam D, Torgerson D, Bates P. Lateral compression type 1 fracture fixation in the elderly (L1FE): study protocol for a randomised controlled trial (with internal pilot) comparing the effects of INFIX surgery and non-surgical management for treating patients with lateral compression type 1 (LC-1) fragility fractures. Trials 2023; 24:78. [PMID: 36732808 PMCID: PMC9893645 DOI: 10.1186/s13063-022-07063-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2022] [Accepted: 12/30/2022] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND Lateral compression type1 (LC-1) fragility fractures are a common, painful injury in older adults resulting in reduced mobility. The incidence of these fractures is increasing with the growing older adult population. The current standard of care is non-surgical management; however, patients with this injury are at risk of long-term immobility and related complications. INFIX is a pelvic fixation device used in younger patients with high-energy fractures. The device is fitted via a percutaneous technique with no external pin sites and has good purchase even in osteoporotic bone. It therefore has the potential to be well tolerated in patients with LC-1 fragility fractures. INFIX could improve patients' ability to mobilise and reduce the risk of immobility-related complications. However, there is a risk of complications related to surgery, and robust evidence is required on patient outcomes. This study will investigate the clinical and cost-effectiveness of surgical fixation with INFIX compared to non-surgical management of LC-1 fragility fractures in older adults. METHODS A multi-centre randomised controlled trial of 600 patients allocated 1:1 to non-surgical management or INFIX surgery. The study will have a 12-month internal pilot to assess recruitment and trial feasibility. The primary outcome will be the patient quality of life over 6 months, measured by the patient-reported EQ-5D-5L. The secondary outcomes will include physical function, mental health, pain, delirium, imaging assessment, resource use, and complications. DISCUSSION The L1FE study aims to compare the clinical and cost-effectiveness of surgical and non-surgical management of people aged 60 years and older with LC-1 fragility fractures. The trial is sufficiently powered and rigorously designed to inform future clinical and patient decision-making and allocation of NHS resources. TRIAL REGISTRATION International Standard Randomised Controlled Trial Number Registry ISRCTN16478561. Registered on 8 April 2019.
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Affiliation(s)
- Elizabeth Cook
- grid.5685.e0000 0004 1936 9668York Trials Unit, Department of Health Sciences, University of York, Heslington, YO10 5DD UK
| | - Joanne Laycock
- grid.5685.e0000 0004 1936 9668York Trials Unit, Department of Health Sciences, University of York, Heslington, YO10 5DD UK
| | - Mehool Acharya
- grid.416201.00000 0004 0417 1173Pelvic and Acetabular Reconstruction Unit, Southmead Hospital, Bristol, BS10 5NB UK
| | - Michael Ross Backhouse
- grid.5685.e0000 0004 1936 9668York Trials Unit, Department of Health Sciences, University of York, Heslington, YO10 5DD UK ,grid.7372.10000 0000 8809 1613Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry, CV4 7AL UK
| | - Belen Corbacho
- grid.5685.e0000 0004 1936 9668York Trials Unit, Department of Health Sciences, University of York, Heslington, YO10 5DD UK
| | - Laura Doherty
- grid.5685.e0000 0004 1936 9668York Trials Unit, Department of Health Sciences, University of York, Heslington, YO10 5DD UK
| | - Daren Forward
- grid.240404.60000 0001 0440 1889Nottingham University Hospitals, Derby Road, Nottingham, NG7 2UH UK
| | - Catherine Hewitt
- grid.5685.e0000 0004 1936 9668York Trials Unit, Department of Health Sciences, University of York, Heslington, YO10 5DD UK
| | - Catherine Hilton
- grid.416041.60000 0001 0738 5466Bart’s Health NHS Trust, The Royal London Hospital, Whitechapel Road, Whitechapel, London, E1 1BB UK
| | - Peter Hull
- grid.24029.3d0000 0004 0383 8386Cambridge University Hospitals NHS Foundation Trust, Hills Road, Cambridge, CB2 0QQ UK
| | - Jamila Kassam
- grid.416041.60000 0001 0738 5466Bart’s Health NHS Trust, The Royal London Hospital, Whitechapel Road, Whitechapel, London, E1 1BB UK
| | - Camila Maturana
- grid.5685.e0000 0004 1936 9668York Trials Unit, Department of Health Sciences, University of York, Heslington, YO10 5DD UK
| | - Catriona Mcdaid
- grid.5685.e0000 0004 1936 9668York Trials Unit, Department of Health Sciences, University of York, Heslington, YO10 5DD UK
| | - Jenny Roche
- grid.5685.e0000 0004 1936 9668York Trials Unit, Department of Health Sciences, University of York, Heslington, YO10 5DD UK
| | - Dhanupriya Sivapathasuntharam
- grid.416041.60000 0001 0738 5466Bart’s Health NHS Trust, The Royal London Hospital, Whitechapel Road, Whitechapel, London, E1 1BB UK
| | - David Torgerson
- grid.5685.e0000 0004 1936 9668York Trials Unit, Department of Health Sciences, University of York, Heslington, YO10 5DD UK
| | - Peter Bates
- grid.416041.60000 0001 0738 5466Bart’s Health NHS Trust, The Royal London Hospital, Whitechapel Road, Whitechapel, London, E1 1BB UK
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Maes M, Thisayakorn P, Thipakorn Y, Tantavisut S, Sirivichayakul S, Vojdani A. Reactivity to neural tissue epitopes, aquaporin 4 and heat shock protein 60 is associated with activated immune-inflammatory pathways and the onset of delirium following hip fracture surgery. Eur Geriatr Med 2023; 14:99-112. [PMID: 36520371 DOI: 10.1007/s41999-022-00729-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2022] [Accepted: 12/04/2022] [Indexed: 12/23/2022]
Abstract
OBJECTIVES Activation of the immune-inflammatory response system (IRS) and a deficiency in the compensatory immunoregulatory system (CIRS), neuronal injuries, and alterations in the glutamate receptor (GlutaR), aquaporin-4 (AQP4) and heat shock protein 60 (HSP60) are involved in delirium. Increased serum levels of neurofilament protein (NFP), glial fibrillary acidic protein (GFAP) and myelin basic protein (MBP) are biomarkers of neuronal injury. This investigation delineates whether elevated IgA/IgG reactivity against those self-antigens is associated with delirium severity and IRS activation. METHODS We measured peak Delirium Rating Scale (DRS) scores on days 2 and 3 following surgery in 59 hip fractured older adults, and IgA and IgG antibody levels against MBP, NFP, GFAP and myelin oligodendrocyte glycoprotein (MOG), metabotropic glutamate receptors mGluRs 1 and 5, N-Methyl-D-Aspartate receptor (NMDAR) GLU1 (NR1) and GLU2 (NR2), APQ4 and HSP60. RESULTS The IgA antibody levels against those self-antigens, especially GFAP, MBP and HSP60, strongly predict peak DRS scores on days 2 and 3 post-surgery. IgA reactivity against NMDAR and baseline DRS scores explained 40.6% of the variance in peak DRS scores, while IgA against NMDAR, IgG against MBP and age explained 29.1% of the variance in the IRS/CIRS ratio. There was no correlation between DRS scores and IgG directed against other self-antigens. CONCLUSIONS Increased IgA levels against neuronal self-antigens, AQP4 and HSP60 are risk factors for delirium. Polyreactive antibody-associated breakdown of immune tolerance, IRS activation and injuries in the neuronal cytoskeleton, oligodendrocytes, astrocytes, glial cells, and myelin sheath are involved in the pathophysiology of delirium.
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Affiliation(s)
- Michael Maes
- Department of Psychiatry, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand.
- Department of Psychiatry, Medical University of Plovdiv, Plovdiv, Bulgaria.
- IMPACT Strategic Research Center, Deakin University, Geelong, Australia.
| | - Paul Thisayakorn
- Department of Psychiatry, Hip Fracture Research Unit, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand.
| | - Yanin Thipakorn
- Department of Psychiatry, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Saran Tantavisut
- Department of Orthopedics, Hip Fracture Research Unit, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Sunee Sirivichayakul
- Department of Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Aristo Vojdani
- Immunosciences Lab. Inc, Los Angeles, CA, USA
- Cyrex Labs LLC, Phoeniz, AZ, USA
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Papangelou A, Boorman DW, Sharifpour M, Patel HP, Cassim T, García PS. Associations of an eye-tracking task and pupillary metrics with age and ASA physical status score in a preoperative cohort. J Clin Monit Comput 2023; 37:795-803. [PMID: 36708440 PMCID: PMC9883606 DOI: 10.1007/s10877-023-00974-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2022] [Accepted: 11/26/2022] [Indexed: 01/29/2023]
Abstract
Advanced age, American Society of Anesthesiologists physical status (ASA) classification and the presence of cognitive impairment are associated with an elevated risk of postoperative morbidity and mortality. The visual paired comparison (VPC) task, which relies on recognition of novel images, examines declarative memory. VPC scores have demonstrated the ability to detect mild cognitive impairment and track progression of neurodegenerative disease. Quantitative pupillometry may have similar value. We evaluate for associations between these variables of interest and the feasibility of performing these tests in the preoperative clinic. Prospective data from 199 patients seen in the preoperative clinic at a tertiary academic center were analyzed. A 5 min VPC task (Neurotrack Technologies, Inc, Redwood City, CA) was administered during their scheduled preoperative clinic visit. Pupillary light reflexes were measured at the same visit (PLR-3000™, Neuroptics Corp, Irvine, California).Thirty-four percent of patients were categorized as ASA 2 and 58% as ASA 3. Median age was 57 (IQR: 44-69). Associations were demonstrated between age and ASA physical status (Mann-Whitney U Test, p < 0.0001), maximum pupil size (Spearman Rank Correlation, r = - 0.40, p < 0.0001), and maximum constriction velocity (Spearman Rank Correlation, r = - 0.39, p < 0.0001). Our data also revealed an association between VPC score and age (Spearman Rank Correlation, p = 0.0016, r = - 0.21) but not ASA score (Kruskal-Wallis Test, p = 0.14). When compared to a nonsurgical cohort with no history of memory impairment, our population scored worse on the VPC task (Mann-Whitney U Test, p = 0.0002). A preoperative 5 min VPC task and pupillometry are feasible tests in the preoperative setting and may provide a valuable window into an individual's cognition prior to elective surgery.
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Affiliation(s)
- Alexander Papangelou
- grid.189967.80000 0001 0941 6502Department of Anesthesiology, Emory University School of Medicine, Atlanta, GA USA
| | - David W. Boorman
- grid.189967.80000 0001 0941 6502Department of Anesthesiology, Emory University School of Medicine, Atlanta, GA USA
| | - Milad Sharifpour
- grid.50956.3f0000 0001 2152 9905Department of Anesthesiology, Cedars Sinai Medical Center, Los Angeles, CA USA
| | - Haresh P. Patel
- grid.415146.30000 0004 0455 0755Department of Internal Medicine, Wellstar Kennestone Regional Medical Center, Marietta, GA USA
| | - Tuan Cassim
- grid.21729.3f0000000419368729Department of Anesthesiology, Columbia University, New York, NY USA
| | - Paul S. García
- grid.21729.3f0000000419368729Department of Anesthesiology, Columbia University, New York, NY USA
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Chen Y, Liang S, Wu H, Deng S, Wang F, Lunzhu C, Li J. Postoperative delirium in geriatric patients with hip fractures. Front Aging Neurosci 2022; 14:1068278. [PMID: 36620772 PMCID: PMC9813601 DOI: 10.3389/fnagi.2022.1068278] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2022] [Accepted: 12/02/2022] [Indexed: 12/24/2022] Open
Abstract
Postoperative delirium (POD) is a frequent complication in geriatric patients with hip fractures, which is linked to poorer functional recovery, longer hospital stays, and higher short-and long-term mortality. Patients with increased age, preoperative cognitive impairment, comorbidities, perioperative polypharmacy, and delayed surgery are more prone to develop POD after hip fracture surgery. In this narrative review, we outlined the latest findings on postoperative delirium in geriatric patients with hip fractures, focusing on its pathophysiology, diagnosis, prevention, and treatment. Perioperative risk prediction, avoidance of certain medications, and orthogeriatric comprehensive care are all examples of effective interventions. Choices of anesthesia technique may not be associated with a significant difference in the incidence of postoperative delirium in geriatric patients with hip fractures. There are few pharmaceutical measures available for POD treatment. Dexmedetomidine and multimodal analgesia may be effective for managing postoperative delirium, and adverse complications should be considered when using antipsychotics. In conclusion, perioperative risk intervention based on orthogeriatric comprehensive care is the most effective strategy for preventing postoperative delirium in geriatric patients with hip fractures.
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Affiliation(s)
- Yang Chen
- Department of Orthopedics, The Second Hospital of Anhui Medical University, Hefei, China,Institute of Orthopedics, Research Center for Translational Medicine, The Second Hospital of Anhui Medical University, Hefei, China
| | - Shuai Liang
- Department of Orthopedics, The Second Hospital of Anhui Medical University, Hefei, China,Institute of Orthopedics, Research Center for Translational Medicine, The Second Hospital of Anhui Medical University, Hefei, China
| | - Huiwen Wu
- Department of Orthopedics, The Second Hospital of Anhui Medical University, Hefei, China,Institute of Orthopedics, Research Center for Translational Medicine, The Second Hospital of Anhui Medical University, Hefei, China
| | - Shihao Deng
- Department of Orthopedics, The Second Hospital of Anhui Medical University, Hefei, China,Institute of Orthopedics, Research Center for Translational Medicine, The Second Hospital of Anhui Medical University, Hefei, China
| | - Fangyuan Wang
- Department of Orthopedics, The Second Hospital of Anhui Medical University, Hefei, China,Institute of Orthopedics, Research Center for Translational Medicine, The Second Hospital of Anhui Medical University, Hefei, China
| | - Ciren Lunzhu
- Department of Orthopedics, Shannan City People’s Hospital, Shannan, China
| | - Jun Li
- Department of Orthopedics, The Second Hospital of Anhui Medical University, Hefei, China,Institute of Orthopedics, Research Center for Translational Medicine, The Second Hospital of Anhui Medical University, Hefei, China,*Correspondence: Jun Li,
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Kang N, Yang N, Zhao K, Li Z, Zhang W, Han Y, Liu K, Song Y, Chen L, Li Y, Hong J, Li Y, Guo X, Wang G, Yuan Y. Preoperative plasma visfatin may have a dual effect on the occurrence of postoperative delirium. Front Med (Lausanne) 2022; 9:1024942. [PMID: 36482916 PMCID: PMC9722954 DOI: 10.3389/fmed.2022.1024942] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2022] [Accepted: 10/05/2022] [Indexed: 03/04/2024] Open
Abstract
BACKGROUND Visfatin is considered to be a "novel pro-inflammatory cytokine." Neuroinflammatory response is one of the important mechanisms of postoperative delirium (POD). The relationship between preoperative plasma visfatin and POD is unclear. OBJECTIVE To investigate the relationship between preoperative plasma visfatin concentrations and POD (primary outcome) in older hip fracture patients and to explore whether it affects POD through inflammatory factors. MATERIALS AND METHODS This prospective cohort study enrolled 176 elderly patients who were scheduled for hip fracture surgery. Preoperative plasma was collected on the morning of surgery, and visfatin levels were measured. Interleukin (IL)-1 and IL-6 were measured using patients' plasma collected on the first day after surgery. We used the 3-min diagnostic interview for Confusion Assessment Method-defined delirium (3D-CAM) twice daily within the 2 days after surgery to assess whether POD had occurred. Restricted cubic splines and piecewise regression were used to explore the relationship between preoperative plasma visfatin concentrations and POD, and further mediation analysis was used to verify whether visfatin plays a role in POD through regulating inflammatory factors. RESULTS The incidence of POD was 18.2%. A J-shaped association was observed between preoperative plasma visfatin levels and POD. The risk of POD decreased within the lower visfatin concentration range up to 37.87 ng/ml, with a hazard ratio of 0.59 per 5 ng/ml [odds ratio (OR) = 0.59, 95% confidence interval (CI) = 0.37-0.95], but the risk increased above this concentration (P for non-linearity < 0.001, with a hazard ratio of 1.116 per 10 ng/ml; OR = 1.10, 95% CI = 1.02-1.23). Mediation effect analysis showed that when the plasma visfatin concentration was higher than 37.87 ng/ml, the effect of visfatin on POD was mediated by IL-6 (p < 0.01). A significant indirect association with postoperative plasma IL-6 was observed between preoperative plasma visfatin and POD (adjusted β = 0.1%; 95% CI = 4.8∼38.9%; p < 0.01). CONCLUSION Visfatin is the protective factor in POD when the preoperative plasma visfatin concentration is below 37.87 ng/ml, but when it exceeds 37.87 ng/ml, the visfatin concentration is a risk factor for POD, which is mediated by postoperative plasma IL-6. The results suggest that preoperative visfatin may have a dual effect on the POD occurrence. CLINICAL TRIAL REGISTRATION [www.ClinicalTrials.gov], identifier [ChiCTR21 00052674].
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Affiliation(s)
- Ning Kang
- Department of Anesthesiology, Peking University Third Hospital, Beijing, China
| | - Ning Yang
- Department of Anesthesiology, Peking University Third Hospital, Beijing, China
| | - Kaixuan Zhao
- Department of Anesthesiology, Peking University Third Hospital, Beijing, China
| | - Zhengqian Li
- Department of Anesthesiology, Peking University Third Hospital, Beijing, China
| | - Wenchao Zhang
- Department of Anesthesiology, Beijing Jishuitan Hospital, Beijing, China
| | - Yongzheng Han
- Department of Anesthesiology, Peking University Third Hospital, Beijing, China
| | - Kaixi Liu
- Department of Anesthesiology, Peking University Third Hospital, Beijing, China
| | - Yanan Song
- Department of Anesthesiology, Peking University Third Hospital, Beijing, China
| | - Lei Chen
- Department of Anesthesiology, Peking University Third Hospital, Beijing, China
| | - Yue Li
- Department of Anesthesiology, Peking University Third Hospital, Beijing, China
| | - Jingshu Hong
- Department of Anesthesiology, Peking University Third Hospital, Beijing, China
| | - Yitong Li
- Department of Anesthesiology, Peking University Third Hospital, Beijing, China
| | - Xiangyang Guo
- Department of Anesthesiology, Peking University Third Hospital, Beijing, China
- Beijing Center of Quality Control and Improvement on Clinical Anesthesia, Beijing, China
| | - Geng Wang
- Department of Anesthesiology, Beijing Jishuitan Hospital, Beijing, China
| | - Yi Yuan
- Department of Anesthesiology, Beijing Jishuitan Hospital, Beijing, China
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Zhao B, Ji HS, Xu CY, Li DJ, Xing ZQ, Liu B, Han Y, Xia WJ, Han LH. Incidence and risk factors of postoperative delirium after pancreatic cancer surgery: a retrospective study. Surg Today 2022; 53:736-742. [DOI: 10.1007/s00595-022-02614-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2022] [Accepted: 09/25/2022] [Indexed: 11/07/2022]
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A quality improvement project addressing the underreporting of delirium in hip fracture patients. Int J Orthop Trauma Nurs 2022; 47:100974. [PMID: 36399973 DOI: 10.1016/j.ijotn.2022.100974] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2022] [Revised: 09/28/2022] [Accepted: 09/30/2022] [Indexed: 11/17/2022]
Abstract
INTRODUCTION After discovering a low incidence of delirium for hip fracture patients at our institution, we evaluated if this was due to underreporting and, if so, where process errors occurred. METHODS Hip fracture patients aged ≥60 with a diagnosis of delirium were identified. Chart-Based Delirium Identification Instrument (CHART-DEL) identified missed diagnoses of delirium. Process maps were created based off staff interviews and observations. RESULTS The incidence of delirium was 15.3% (N = 176). Within a random sample (n = 98), 15 patients (15.5%) were diagnosed, while 20 (24.7%) went undiagnosed despite evidence of delirium. Including missed diagnoses, delirium prevalence was higher in the sample compared to all patients (35.7% vs 15.3%, p < 0.001). Most missed diagnoses were due to failure in identifying delirium (60%) or failure in documenting/coding diagnosis (20%). The prevalence of baseline cognitive impairment was higher in undiagnosed delirium patients versus correctly diagnosed patients (80% vs 20%, p = 0.001). CONCLUSIONS Our institution significantly underreports delirium among hip fracture patients mainly due to; (1) failure to identify delirium by the clinical staff, and (2) failure to document/code diagnosis despite correct identification. Baseline cognitive impairment can render delirium diagnosis challenging. These serve as targets for quality improvement and hip fracture care enhancement.
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Lin X, Guo Y, Dong R, Wang B, Bi Y. Potential value of cerebrospinal fluid α-synuclein in the identification of postoperative delirium undergoing knee/hip arthroplasty: The perioperative neurocognitive disorder and biomarker lifestyle study. Front Neurosci 2022; 16:935869. [PMID: 36353596 PMCID: PMC9637833 DOI: 10.3389/fnins.2022.935869] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2022] [Accepted: 10/04/2022] [Indexed: 11/26/2022] Open
Abstract
Objective Postoperative delirium (POD) is a common postoperative complication, which may be associated with α-synuclein (α-syn). The purpose of this study was to explore the association between the expression level of α-syn in cerebrospinal fluid (CSF) and POD. Methods We conducted a prospective observational cohort study, which involved in 740 participants (mean age of 61.86 years, range 40–90 years; 40% female) from the Perioperative Neurocognitive Disorder And Biomarker Lifestyle (PNDABLE) study in the final analysis. POD was diagnosed using the Confusion Assessment Scale (CAM), and its severity was measured using the Memorial Delirium Assessment Scale (MDAS). Enzyme-linked immune-sorbent assay (ELISA) was used to detect the concentrations of α-syn, Aβ40, Aβ42, T-tau, and P-tau in CSF. Results The incidence of POD was 11.22% (83/740). The logistic regression analysis showed that the increased concentrations of CSF α-syn (OR = 1.005, 95%CI 1.004–1.006, P < 0.001), P-tau (OR = 1.093, 95%CI 1.071–1.115, P < 0.001), and T-tau (OR = 1.008, 95%CI 1.006–1.009, P < 0.001) were risk factors of POD. Linear regression showed that CSF α-syn had positive correlations with P-tau (β = 0.480, P < 0.001), T-tau (β = 0.334, P < 0.001), while negative correlations with Aβ40 (β = –0.378 P < 0.001), Aβ42 (β = -0.800, P = 0.001) in POD patients. Mediation analyses showed the association between α-syn and POD was partially mediated by tau pathologies (proportion: 16–17%). Conclusion CSF α-syn is one of the preoperative risk factors for POD, which may be mediated through tau pathologies. Clinical trial registration [www.ClinicalTrials.gov], identifier [ChiCTR20 00033439].
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Affiliation(s)
- Xu Lin
- Department of Anesthesiology, Qingdao Municipal Hospital Affiliated to Qingdao University, Qingdao, China
| | - Yuwei Guo
- Department of Anesthesiology, Qingdao Municipal Hospital Affiliated to Qingdao University, Qingdao, China
| | - Rui Dong
- Department of Anesthesiology, Drum Tower Hospital Affiliated to Medical College of Nanjing University, Nanjing, China
| | - Bin Wang
- Department of Anesthesiology, Qingdao Municipal Hospital Affiliated to Qingdao University, Qingdao, China
- *Correspondence: Bin Wang,
| | - Yanlin Bi
- Department of Anesthesiology, Qingdao Municipal Hospital Affiliated to Qingdao University, Qingdao, China
- Yanlin Bi,
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Li B, Ju J, Zhao J, Qin Y, Zhang Y. A Nomogram to Predict Delirium after Hip Replacement in Elderly Patients with Femoral Neck Fractures. Orthop Surg 2022; 14:3195-3200. [PMID: 36253966 PMCID: PMC9732590 DOI: 10.1111/os.13541] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2021] [Revised: 08/20/2022] [Accepted: 08/24/2022] [Indexed: 12/14/2022] Open
Abstract
OBJECTIVE Postoperative delirium (POD) is a common complication, and clinical practitioners have taken measures to improve the quality of life after hip replacement surgery. We aim to establish a nomogram to predict POD in elderly patients with femoral neck fractures (FNFs) after hip replacement. METHODS A total of 384 elderly patients (267 females) with an average age of 75.8 years who underwent hip replacement from June 2010 to May 2020 were retrospectively reviewed. Patients were divided into delirium and non-delirium groups according to the confusion assessment method. The risk factors for POD were analyzed by multivariate logistic regression, and the nomogram was established based on the results. RESULTS The incidence of POD was 33.33% (128/384). Univariate analysis showed that advanced age, diabetes, lacunar cerebral infarction, surgery type, intraoperative blood loss, electrolyte imbalance, and anemia were risk factors for POD (p < 0.05). Multivariate logistic regression revealed that the independent risk factors for POD were age (OR = 1.332, 95% CI [1.224, 1.449], p < 0.01), surgery type (OR = 0.351, 95% CI [0.137, 0.900], p = 0.029), electrolyte imbalance (OR = 4.407, 95% CI [1.947, 9.977], p< 0.01), anemia (OR = 10.819, 95% CI [4.573, 25.598], p < 0.01). The prediction equation was established; logistic (p) = -25.469 + 0.277*X1(age[value = years of age]) + 1.293*X2(surgery[value = 0 for "total hip replacement" or value = 1 for "hemiarthroplasty"]) + 1.510*X3(electrolyte imbalance[value = 0 for "no" or value = 1 for "yes"]) + 2.157*X4(anemia[value = 1 for "hemoglobin with < 120g/L in male and < 110g/L in female patients" ]) or 2.975*X5(anemia[value = 1 for "hemoglobin with <90g/L"]). The area under the curve was 0.957 (95% CI [0.938, 0.976], p < 0.01). CONCLUSION The incidence of POD in elderly patients with FNF after hip replacement is high. The nomogram incorporating age, surgery type, electrolyte imbalance, and anemia could provide an individualized prediction for POD among FNF patients after hip replacement, which may help the physician determine appropriate perioperative management.
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Affiliation(s)
- Bingbing Li
- Department of Trauma & OrthopedicsPeking University People's HospitalBeijingChina,National Center for Trauma MedicineBeijingChina,Key Laboratory of Trauma and Neural RegenerationMinistry of EducationBeijingChina
| | - Jiabao Ju
- Department of Trauma & OrthopedicsPeking University People's HospitalBeijingChina,National Center for Trauma MedicineBeijingChina,Key Laboratory of Trauma and Neural RegenerationMinistry of EducationBeijingChina
| | - Jiaying Zhao
- Department of Trauma & OrthopedicsPeking University People's HospitalBeijingChina,National Center for Trauma MedicineBeijingChina,Key Laboratory of Trauma and Neural RegenerationMinistry of EducationBeijingChina
| | - Ying Qin
- Department of Trauma & OrthopedicsPeking University People's HospitalBeijingChina,National Center for Trauma MedicineBeijingChina,Key Laboratory of Trauma and Neural RegenerationMinistry of EducationBeijingChina
| | - Yan Zhang
- Department of Trauma & OrthopedicsPeking University People's HospitalBeijingChina,National Center for Trauma MedicineBeijingChina,Key Laboratory of Trauma and Neural RegenerationMinistry of EducationBeijingChina
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Lin X, Cao Y, Liu X, Yu K, Miao H, Li T. The hotspots and publication trends in postoperative delirium: A bibliometric analysis from 2000 to 2020. Front Aging Neurosci 2022; 14:982154. [PMID: 36225889 PMCID: PMC9549321 DOI: 10.3389/fnagi.2022.982154] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2022] [Accepted: 09/08/2022] [Indexed: 11/13/2022] Open
Abstract
Background Postoperative delirium (POD) is a common aging-associated postoperative complication that has received increasing attention in the context of the aging global population and the number of articles published on POD is gradually increasing. This study aimed to quantify the basic information of scholarly publications on POD and identify the most impactful literature, trends, and hotspots in POD research. Materials and methods We searched articles on POD through the Science Citation Index Expanded databases published from 2000 to 2020. Bibliographic information, including year, country, authorship, type, journal, funding, affiliations, subject areas, and hotspots, was collected for further analysis. Results A total of 2,114 articles on POD from 2000 to 2020 were identified. The highest number of studies (n = 748) were published in the United States, comprising the most total citations (13,928), followed by China (n = 278), and Germany (n = 209). Inouye, Sharon K. was the most productive author, with 66 publications on POD. The Journal of the American Geriatrics Society published the highest number of articles (n = 80), with the most total citations (4,561) and average (57.01), followed by Anesthesia and Analgesia (n = 52), and the British Journal of Anaesthesia (n = 43). Harvard University was the most productive institute, with the highest H-index (n = 46) and highest degree centrality (n = 191). The top hotspots in the field of POD during this period were “elderly,” “cardiac surgery,” “cognitive impairment,” “hip fracture,” and “intensive care unit.” Conclusion This study provides an overview of developments in the field of POD over the past 20 years using bibliometric analysis. Overall, research on POD has flourished worldwide. The United States (US) has a relatively high academic impact owing to its productive expertise and institutions in this field. Despite much research illustrating the diagnosis and management of POD in clinical practice, more basic research is needed.
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Xu L, Lyu W, Wei P, Zheng Q, Li C, Zhang Z, Li J. Lower preoperative serum uric acid level may be a risk factor for postoperative delirium in older patients undergoing hip fracture surgery: a matched retrospective case-control study. BMC Anesthesiol 2022; 22:282. [PMID: 36071379 PMCID: PMC9450341 DOI: 10.1186/s12871-022-01824-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2022] [Accepted: 08/26/2022] [Indexed: 11/11/2022] Open
Abstract
Background Postoperative delirium (POD) is a common complication after hip fracture surgery that is associated with various short- and long-term outcomes. The mechanism of POD may be associated with the oxidative stress process. Uric acid has been shown to provide a neuroprotective effect in various neurodegenerative diseases through its antioxidant properties. However, it is unclear whether lower preoperative serum uric acid levels are associated with the development of POD after hip fracture surgery. Therefore, this study assessed the association of lower preoperative uric acid levels in patients with POD during hospitalization. Methods This is a matched retrospective case-control study that included 96 older patients (≥65 y) who underwent hip fracture surgery. POD was diagnosed using the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. Patients diagnosed with POD (cases) were matched 1:1 with patients without POD (controls) on the basis of age, sex, and anesthesia type. The relationship between preoperative uric acid and POD was analyzed by multivariable analysis. Results The POD and non-POD groups each had 48 patients. In the univariate analysis, lower log preoperative serum uric acid value, higher neutrophil-to-lymphocyte ratio, and cerebrovascular disease were more likely in patients with POD than in those with no POD. Multivariable conditional logistic regression analysis showed that lower log preoperative serum uric acid (adjusted odds ratio [aOR], 0.028; confidence interval [CI], 0.001–0.844; p = 0.040), higher neutrophil-to-lymphocyte ratio (aOR, 1.314; 95% CI, 1.053–1.638; p = 0.015), and increased surgery duration (aOR, 1.034; 95% CI, 1.004–1.065; p = 0.024) were associated with increased risk of POD. Conclusions Lower preoperative serum uric acid levels may be an independent risk factor for POD after adjustment for possible confounding factors. However, large prospective studies are needed to confirm this finding.
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Affiliation(s)
- Lin Xu
- Department of Anesthesiology, Qilu Hospital (Qingdao), Cheeloo College of Medicine, Shandong University, Qingdao, 266035, P.R. China.,Department of Anesthesiology, Qilu Hospital of Shandong University, Jinan, 250000, P.R. China
| | - Wenyuan Lyu
- Department of Anesthesiology, Qilu Hospital (Qingdao), Cheeloo College of Medicine, Shandong University, Qingdao, 266035, P.R. China
| | - Penghui Wei
- Department of Anesthesiology, Qilu Hospital (Qingdao), Cheeloo College of Medicine, Shandong University, Qingdao, 266035, P.R. China
| | - Qiang Zheng
- Department of Anesthesiology, Qilu Hospital (Qingdao), Cheeloo College of Medicine, Shandong University, Qingdao, 266035, P.R. China
| | - Chengwei Li
- Department of Anesthesiology, Qilu Hospital (Qingdao), Cheeloo College of Medicine, Shandong University, Qingdao, 266035, P.R. China.,Department of Anesthesiology, Qilu Hospital of Shandong University, Jinan, 250000, P.R. China
| | - Zheng Zhang
- Department of Anesthesiology, Qilu Hospital (Qingdao), Cheeloo College of Medicine, Shandong University, Qingdao, 266035, P.R. China.,Department of Anesthesiology, Qilu Hospital of Shandong University, Jinan, 250000, P.R. China
| | - Jianjun Li
- Department of Anesthesiology, Qilu Hospital (Qingdao), Cheeloo College of Medicine, Shandong University, Qingdao, 266035, P.R. China. .,Department of Anesthesiology, Qilu Hospital of Shandong University, Jinan, 250000, P.R. China.
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Muzzana C, Mantovan F, Huber MK, Trevisani K, Niederbacher S, Kugler A, Ausserhofer D. Delirium in elderly postoperative patients: A prospective cohort study. Nurs Open 2022; 9:2461-2472. [PMID: 35716398 PMCID: PMC9374408 DOI: 10.1002/nop2.1263] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2021] [Revised: 04/11/2022] [Accepted: 05/06/2022] [Indexed: 11/06/2022] Open
Abstract
AIM To describe the incidence, time in days and risk factors for postoperative delirium in elderly patients. DESIGN Prospective cohort study. METHODS Patients over 65 years were daily screened with the 4A's Test and the Delirium Observation Screening Scale for postoperative delirium. A psychiatrist assessed according to the DSM-V. We performed descriptive and logistic regression analyses. RESULTS From 202 patients, 7.5% (N = 15) had a diagnosed postoperative delirium, whereby 73.3% (N = 11) developed the delirium during the first 48 hr after surgery. The median duration was 1 day. Patients over 80 years suffering from heart failure with surgical drains, bladder catheter, central venous catheter had higher odds for developing a postoperative delirium. The incidence of postoperative delirium in our sample was lower compared with other surgical and ortho-geriatric populations. Despite age, several modifiable postoperative factors were associated with the occurrence of postoperative delirium.
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Affiliation(s)
- Chiara Muzzana
- College of Healthcare Professions Claudiana, Bolzano-Bozen, Italy
| | - Franco Mantovan
- College of Healthcare Professions Claudiana, Bolzano-Bozen, Italy.,Hospital of Bruneck-Brunico, SABES-ASDAA, Bruneck-Brunico, Italy
| | | | - Katia Trevisani
- College of Healthcare Professions Claudiana, Bolzano-Bozen, Italy
| | | | - Alexander Kugler
- Hospital of Bruneck-Brunico, SABES-ASDAA, Bruneck-Brunico, Italy
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Bhushan S, Huang X, Duan Y, Xiao Z. The impact of regional versus general anesthesia on postoperative neurocognitive outcomes in elderly patients undergoing hip fracture surgery: A systematic review and meta-analysis. Int J Surg 2022; 105:106854. [PMID: 36031067 DOI: 10.1016/j.ijsu.2022.106854] [Citation(s) in RCA: 23] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2022] [Revised: 08/09/2022] [Accepted: 08/12/2022] [Indexed: 10/15/2022]
Abstract
BACKGROUND Randomized trials have shown conflicting results regarding differences in outcomes according to anesthesia type on the prevalence of postoperative delirium (POD) or postoperative cognitive dysfunction (POCD) in hip surgery patients. The aim of this Meta analysis is to compare the effect of general and regional anesthesia in older patients undergoing hip fracture surgery. METHODS A literature search for meta-analysis was performed using Pubmed, The Cochrane Library, Embase and Web of Science citation index for randomized controlled trials (RCTs) to compare the regional anesthesia (RA) to general anesthesia (GA) for postoperative outcomes in elderly undergoing hip fracture surgery till June 2022. The primary outcomes were the incidence of POD or POCD at 24 h, 3 days and 7 days postoperatively. The secondary outcomes were 30 days mortality rate and other adverse events. The risk of bias was assessed using the Cochrane methodology. RESULTS Eight studies including 3555 elderly patients over 65 years old showed that there was no significant difference in the prevalence of POD or POCD between RA and GA at 24 h [OR 0.73; 95% coincidence interval (CI) 0.19, 2.71, I2 = 53%; n = 452; P = 0.63], at 3 days [OR 1.03; 95% CI 0.79, 1.35, I2 = 0%; n = 1362; P = 0.82], at 7 days [OR 0.79; 95% CI 0.41, 1.52, I2 = 51%; n = 1336; P = 0.47], respectively. No significant differences were observed in the incidence of other adverse events. CONCLUSIONS No significant difference was found in the incidence of cognitive dysfunction after either general or regional anesthesia in elderly patients. Our finding of similar outcomes at 24 h, 3 days and 7 days postoperatively with either technique suggests that anesthesia choices for hip-fracture surgery may be based on the individual characteristics of each patient rather than on anticipated differences in clinical outcomes.
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Affiliation(s)
- Sandeep Bhushan
- Department of Cardio-Thoracic Surgery, Chengdu Second People's Hospital, Chengdu, Sichuan, 610017, China.
| | - Xin Huang
- Department of Anesthesiology, West China Hospital of Sichuan University, Sichuan, Chengdu, 610041, China.
| | - Yuanqiong Duan
- Department of Gynecology and Obstetrics, West China Second University Hospital, Sichuan University, Sichuan, 610041, China.
| | - Zongwei Xiao
- Department of Cardio-Thoracic Surgery, Chengdu Second People's Hospital, Chengdu, Sichuan, 610017, China.
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Rehabilitation interventions for persons with hip fracture and cognitive impairment: A scoping review. PLoS One 2022; 17:e0273038. [PMID: 35969624 PMCID: PMC9377630 DOI: 10.1371/journal.pone.0273038] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2022] [Accepted: 08/02/2022] [Indexed: 11/19/2022] Open
Abstract
Background
Hip fractures are common fall-related injuries, with rehabilitation and recovery often complicated by cognitive impairment. Understanding what interventions exist, and in what settings, for people with hip fracture and co-occurring cognitive impairment is important in order to provide more evidence on rehabilitation and related outcomes for this population.
Objective
To examine the extent, nature, and range of literature on rehabilitation interventions for adults with hip fracture and cognitive impairment.
Methods
Articles were required to: include an adult population with hip fracture and cognitive impairment, include a rehabilitation intervention, and be published between January 1, 2000 and November 19, 2021. Articles were excluded if they were opinion pieces, study protocols, conference abstracts, or if they did not describe the rehabilitation intervention. Relevant articles were searched on the following electronic databases: MEDLINE, EMBASE, CINAHL Plus, APA PsycINFO, Cochrane Library, Web of Science, and the Physiotherapy Evidence Database. All articles were double-screened by two reviewers and disagreements were resolved through consensus. Data were extracted and synthesized using descriptive approaches.
Results
Seventeen articles were included in this scoping review. We identified a variety of interventions targeting this population; about half were specific to physical rehabilitation, with the other half incorporating components that addressed multiple aspects of the care journey. Interventions had varying outcomes and no studies qualitatively explored patient or family experiences. All intervations were initiated in hospital, with less than half including cross-sectoral components. About half of the articles described modifying or tailoring the intervention to the participants’ needs, but there was limited information on how to adapt rehabilitation interventions for individuals with cognitive impairment.
Conclusions
More work is need to better understand patient, family, and provider experiences with rehabilitation interventions, how to tailor interventions for those with cognitive impairment, and how to successfully implement sustainable interventions across sectors.
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Qi YM, Li YJ, Zou JH, Qiu XD, Sun J, Rui YF. Risk factors for postoperative delirium in geriatric patients with hip fracture: A systematic review and meta-analysis. Front Aging Neurosci 2022; 14:960364. [PMID: 35992597 PMCID: PMC9382199 DOI: 10.3389/fnagi.2022.960364] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2022] [Accepted: 07/18/2022] [Indexed: 12/04/2022] Open
Abstract
Objectives This systematic review and meta-analysis was conducted to identify the potential risk factors for postoperative delirium in geriatric patients with hip fracture. Methods PubMed, EMBASE, and Cochrane Library were searched from inception until December 31st, 2021. A combined searching strategy of subject words and free words was adopted. Studies involving risk factors for postoperative delirium in elderly patients undergoing hip fracture surgeries were reviewed. Qualities of included studies were assessed using the Newcastle–Ottawa Scale. Data were pooled and a meta-analysis was performed using Review Manager 5.3. Results A total of 37 studies were included. The following risk factors were significant: advanced age (per year increase) (OR: 1.05, 95% CI 1.04–1.07), age>80 years (OR: 2.26, 95% CI 1.47–3.47), male (OR: 1.53, 95% CI 1.37–1.70), preoperative cognitive impairment (OR:3.20, 95% CI 2.12–4.83), preoperative dementia (OR: 2.74, 95% CI 2.18–3.45), preoperative delirium (OR: 9.23, 95% CI 8.26–10.32), diabetes (OR: 1.18, 95% CI 1.05–1.33), preoperative functional dependence (OR: 1.31, 95% CI 1.11–1.56), ASA level (per level increase) (OR: 1.63, 95% CI 1.04–2.57), ASA level≥3(OR: 1.76, 95% CI 1.39–2.24), low albumin (OR: 3.30, 95% CI 1.44–7.55), medical comorbidities (OR: 1.15, 95% CI 1.06–1.25), Parkinson's disease (OR: 4.17, 95% CI 1.68–10.31) and surgery delay>48 h (OR: 1.90, 95% CI 1.36–2.65). Conclusions Clinicians should be alert to patients with those risk factors. To identify the risk factors more precisely, more research studies with larger sample size and better design should be conducted.
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Affiliation(s)
- Yi-ming Qi
- Department of Orthopaedics, School of Medicine, Zhongda Hospital, Southeast University, Nanjing, China
- Multidisciplinary Team (MDT) for Geriatric Hip Fracture Comprehensive Management, School of Medicine, Zhongda Hospital, Southeast University, Nanjing, China
- Orthopaedic Trauma Institute, Southeast University, Nanjing, China
- School of Medicine, Southeast University, Nanjing, China
| | - Ying-juan Li
- Multidisciplinary Team (MDT) for Geriatric Hip Fracture Comprehensive Management, School of Medicine, Zhongda Hospital, Southeast University, Nanjing, China
- School of Medicine, Southeast University, Nanjing, China
- Department of Geriatrics, School of Medicine, Zhongda Hospital, Southeast University, Nanjing, China
| | - Ji-hong Zou
- Multidisciplinary Team (MDT) for Geriatric Hip Fracture Comprehensive Management, School of Medicine, Zhongda Hospital, Southeast University, Nanjing, China
- School of Medicine, Southeast University, Nanjing, China
- Department of Geriatrics, School of Medicine, Zhongda Hospital, Southeast University, Nanjing, China
| | - Xiao-dong Qiu
- Multidisciplinary Team (MDT) for Geriatric Hip Fracture Comprehensive Management, School of Medicine, Zhongda Hospital, Southeast University, Nanjing, China
- School of Medicine, Southeast University, Nanjing, China
- Department of Anesthesiology, School of Medicine, Zhongda Hospital, Southeast University, Nanjing, China
| | - Jie Sun
- Multidisciplinary Team (MDT) for Geriatric Hip Fracture Comprehensive Management, School of Medicine, Zhongda Hospital, Southeast University, Nanjing, China
- School of Medicine, Southeast University, Nanjing, China
- Department of Anesthesiology, School of Medicine, Zhongda Hospital, Southeast University, Nanjing, China
- Jie Sun
| | - Yun-feng Rui
- Department of Orthopaedics, School of Medicine, Zhongda Hospital, Southeast University, Nanjing, China
- Multidisciplinary Team (MDT) for Geriatric Hip Fracture Comprehensive Management, School of Medicine, Zhongda Hospital, Southeast University, Nanjing, China
- Orthopaedic Trauma Institute, Southeast University, Nanjing, China
- School of Medicine, Southeast University, Nanjing, China
- Trauma Center, Zhongda Hospital, Southeast University, Nanjing, China
- *Correspondence: Yun-feng Rui
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Deng Y, Qin Z, Wu Q, Liu L, Yang X, Ju X, Zhang Y, Liu L. Efficacy and Safety of Remimazolam Besylate versus Dexmedetomidine for Sedation in Non-Intubated Older Patients with Agitated Delirium After Orthopedic Surgery: A Randomized Controlled Trial. Drug Des Devel Ther 2022; 16:2439-2451. [PMID: 35937566 PMCID: PMC9354763 DOI: 10.2147/dddt.s373772] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2022] [Accepted: 07/23/2022] [Indexed: 12/26/2022] Open
Abstract
Purpose The purpose of the present study was to investigate the efficacy and safety of remimazolam besylate compared with dexmedetomidine for the relief of agitated delirium in non-intubated older patients after orthopedic surgery. Patients and methods Seventy-five patients were randomly divided into two groups. Patients assigned to the remimazolam group received a loading dose of 0.075 mg/kg remimazolam besylate over 1 minute, followed by a continuous infusion of 0.1 to 0.3 mg/kg/h. Subjects randomized to the dexmedetomidine group received a loading infusion of 0.5 μg/kg dexmedetomidine over 10 minutes, followed by a maintenance dose of 0.2 to 0.7 μg/kg/h. Meanwhile, RASS score-guided dose titration was followed. To assess the efficacy of the study drugs in terms of time to resolution of agitation, time to first achievement of target sedation, percentage of time within the target sedation range, and time to delirium resolution. Safety of the sedatives was evaluated by adverse events during hospitalization. Results Time to resolution of agitation did not differ between the two groups. The time to first achievement of target sedation was 19.0 (9.5 to 31.0) minutes for remimazolam besylate vs 43.5 (15.0 to 142.5) minutes for dexmedetomidine (P < 0.001). Percentage of time within the target sedation range was 77.8% for remimazolam besylate-treated patients and 67.4% for dexmedetomidine-treated patients (P = 0.001). Patients in the remimazolam group had longer time to delirium resolution (29.5 [21.3 to 32.5] hours) than those in the dexmedetomidine group (22.8 [18.9 to 28.5] hours) (P = 0.042). Patients sedated with remimazolam besylate had more oversedation (P = 0.036) but less hypotension (P = 0.007). Conclusion Compared with dexmedetomidine, remimazolam besylate was equally effective in relieving agitation, and resulted in earlier achievement of sedation goal and more controllable sedation. Remimazolam may be an ideal agent for obtaining rapid tranquillisation.
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Affiliation(s)
- Yang Deng
- Intensive Care Unit, Sichuan Provincial Orthopedic Hospital, Chengdu, 610041, People’s Republic of China
| | - Zhijun Qin
- Intensive Care Unit, Sichuan Provincial Orthopedic Hospital, Chengdu, 610041, People’s Republic of China
- Correspondence: Zhijun Qin, Intensive Care Unit, Sichuan Provincial Orthopedic Hospital, No. 132, West First Section, First Ring Road, Chengdu, 610041, People’s Republic of China, Tel +86-18708499493, Email
| | - Qianyun Wu
- Nursing Department, Sichuan Provincial Orthopedic Hospital, Chengdu, 610041, People’s Republic of China
| | - Linsong Liu
- Intensive Care Unit, Sichuan Provincial Orthopedic Hospital, Chengdu, 610041, People’s Republic of China
| | - Xi Yang
- Intensive Care Unit, Sichuan Provincial Orthopedic Hospital, Chengdu, 610041, People’s Republic of China
| | - Xuan Ju
- Intensive Care Unit, Sichuan Provincial Orthopedic Hospital, Chengdu, 610041, People’s Republic of China
| | - Ying Zhang
- Intensive Care Unit, Sichuan Provincial Orthopedic Hospital, Chengdu, 610041, People’s Republic of China
| | - Lei Liu
- Department of Infection Control, Sichuan Provincial Orthopedic Hospital, Chengdu, 610041, People’s Republic of China
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Stanley GHM, Barber ARJ, O'Brien AM, Hamill C, Boardman G, Frear CC, Edgar DW, Seymour H, Wood FM. Delirium in hospitalised adults with acute burns - A systematic review. Burns 2022; 48:1040-1054. [PMID: 35701326 DOI: 10.1016/j.burns.2022.05.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2022] [Revised: 04/09/2022] [Accepted: 05/24/2022] [Indexed: 12/15/2022]
Abstract
INTRODUCTION Delirium is a potentially modifiable, acutely altered mental state, commonly characterised as a hospital-acquired complication. Studies of adult inpatients with acute burns with and without delirium identify causative risks related to the injury or treatment and outcomes related to the patient and healthcare system. We compare patients with and without delirium, providing a high-level quantitative synthesis of delirium risks and outcomes to inform guidelines and future research. METHODS A systematic review, meta-analysis and GRADE evaluation of risks and outcomes associated with delirium in adults with acute burns was conducted using PRISMA guidelines and PROSPERO protocol CRD42021283055. The Newcastle-Ottawa Scale was used to assess quality. RESULTS Investigators reviewed ten studies. ASA score ≥ 3, Total Body Surface Area Percentage (TBSA)> 10%, surgery done, ICU admission, hospital and also Intensive Care Unit (ICU) lengths of stay all had statistically significant associations with delirium, with low-very low certainty on GRADE evaluation. Limitations were heterogeneous studies, review methodology and study bias. CONCLUSION Delirium represents a significant risk to comorbid patients with burns that are hospitalised, receive ICU care, and surgery. Further research is indicated to precisely categorise delirium along the clinical journey to identify modifiable factors, prevention, and proactive therapy.
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Affiliation(s)
- Guy H M Stanley
- Burn Injury Research Unit, University of Western Australia, Crawley, Western Australia, Australia; State Adult Burn Unit, Fiona Stanley Hospital, SMHS, Western Australia, Australia.
| | | | - Aoife M O'Brien
- State Adult Burn Unit, Fiona Stanley Hospital, SMHS, Western Australia, Australia
| | - Cheryl Hamill
- Library & Information Service, SMHS, Western Australia, Australia
| | - Glenn Boardman
- Research support & development, SMHS, Western Australia, Australia
| | - Cody C Frear
- Faculty of Medicine, University of Queensland, Herston, Queensland, Australia
| | - Dale W Edgar
- State Adult Burn Unit, Fiona Stanley Hospital, SMHS, Western Australia, Australia; The Institute for Health Research, The University of Notre Dame Australia, Fremantle, Western Australia, Australia
| | - Hannah Seymour
- Department of Geriatric Medicine, SMHS, Western Australia, Australia
| | - Fiona M Wood
- Burn Injury Research Unit, University of Western Australia, Crawley, Western Australia, Australia; State Adult Burn Unit, Fiona Stanley Hospital, SMHS, Western Australia, Australia
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Ng JPH, Tan TL, Pillai A, Ho SWL. Outcomes of ultra-old vs old patients after hip fracture surgery: a matched cohort analysis of 1524 patients. Arch Orthop Trauma Surg 2022; 143:3145-3154. [PMID: 35864337 DOI: 10.1007/s00402-022-04550-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2022] [Accepted: 07/08/2022] [Indexed: 11/02/2022]
Abstract
BACKGROUND Surgical management of geriatric hip fractures yields improved functional outcomes with decreased morbidity and mortality. Cohort studies have suggested that the older patients within the geriatric age group have worse outcomes with surgery, However, these studies inherently report inflated risks due to poor handling of confounders and have inadequately age-stratified their geriatric population. AIM This study aims to investigate the effect of age alone on the 1-year mortality and functional status of geriatric patients after hip fracture surgery. METHODS This is a retrospective single institution cohort study based on the prospectively-maintained registry of hip fracture patients. 2603 patients aged 60 years and above were treated surgically under a geriatric-orthopaedic hip fracture pathway from January 2014 to December 2018. Patients were split into two age groups: ultra-old (≥ 85 years) vs old (< 85 years). Baseline demographics and the ASA (American Society of Anaesthesiologists) status and the Modified Barthel's Index (MBI) were obtained at admission and 1 year after the fracture. Adverse outcomes from the fracture and surgery were recorded during a follow-up period of minimally 2 years. A 2:1 matching process based on the gender, fracture type, ASA status, CCI and MBI categories was conducted. RESULTS There were 1009 and 515 patients in the old and ultra-old age groups, respectively. 1-year mortality was similar for both age groups (4.0% ultra-old vs 3.6% old, p = 0.703). 30-day morbidity was similar except for higher rates of postoperative pneumonia in the ultra-old (14.0 vs 6.3%, p < 0.001). MBI scores at 1-year were lower in the ultra-old (severe dependence: 16.4 vs 10.0%; p = 0.001). Ultra-old patients were less likely to be community ambulant at 12 months (21.2 vs 36.0%) with the deterioration in ambulatory status significant after correction for baseline status (p < 0.001). CONCLUSION The 1-year mortality of surgically-managed geriatric hip fracture patients older than 85 years of age is not determined by age alone. Patients aged 85 years and above are at higher risk for pneumonia postoperatively. Ultra-old hip fracture patients with an intertrochanteric fracture are more likely to have poorer function at 1 year after hip fracture surgery.
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Affiliation(s)
- Julia Poh Hwee Ng
- Department of Orthopedic Surgery, Tan Tock Seng Hospital, 11 Jalan Tan Tock Seng, Singapore, 308433, Singapore
| | - Tong Leng Tan
- Department of Orthopedic Surgery, Tan Tock Seng Hospital, 11 Jalan Tan Tock Seng, Singapore, 308433, Singapore
| | - Anand Pillai
- Department of Orthopedic Surgery, Tan Tock Seng Hospital, 11 Jalan Tan Tock Seng, Singapore, 308433, Singapore
| | - Sean Wei Loong Ho
- Department of Orthopedic Surgery, Tan Tock Seng Hospital, 11 Jalan Tan Tock Seng, Singapore, 308433, Singapore.
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Shen Y, Wang C, Zhong X, Wu Y, He X. Observation of Anesthetic Effect of Dexmedetomidine Combined With Intraspinal Anesthesia in Hip Arthroplasty and its Effect on Postoperative Delirium and Stress Response. Front Surg 2022; 9:928922. [PMID: 35846975 PMCID: PMC9286240 DOI: 10.3389/fsurg.2022.928922] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2022] [Accepted: 05/27/2022] [Indexed: 11/25/2022] Open
Abstract
Objective To observe the anesthetic effect of dexmedetomidine combined with spinal anesthesia in hip arthroplasty, and to analyze the effects of dexmedetomidine on postoperative stress response, incidence of delirium, immune function and inflammatory indicators. Methods A total of 42 patients who underwent hip replacement in our hospital from March 2020 to June 2021 were selected as the research subjects and randomly divided into the control group and the observation group, 21 cases in each group. The control group was given intraspinal anesthesia, and the observation group was given dexmedetomidine on this basis. The onset time and maintenance time of sensory and motor nerve block were recorded. Stress response indexes [cortisol (Cor), blood glucose (Glu), adrenaline (E), noadrenaline (NE)], T lymphocyte subsets (CD3+, CD4+, CD8+, CD4+/CD8+), inflammatory indexes [tumor necrosis factor -α (TNF-α) and interleukin-6 (IL-6)] were detected before and after operation, and the incidence of postoperative delirium in both groups was recorded. Results The onset time of sensory nerve block and motor block in the observation group were lower than those in the control group, and the retention time of sensory nerve block and motor nerve block were higher than those in the control group (P < 0.05). After surgery, the levels of Cor, Glu, E and NE in the observation group were lower than those in the control group (P < 0.05). After surgery, the incidence of postoperative delirium in the observation group (4.79%) was lower than that in the control group (28.57%) (P < 0.05). After surgery, the levels of CD3+, CD4+, CD8+, and CD4+/CD8+ in the observation group were higher than those in the control group (P < 0.05). After surgery, the levels of TNF-α and IL-6 in the observation group were lower than those in the control group (P < 0.05). Conclusion The combined use of dexmedetomidine and intraspinal anesthesia has good anesthesia effect in hip joint replacement, which can greatly reduce the stress response of patients, reduce the incidence of postoperative delirium, and effectively restore the immune function of patients, reduce the level of inflammatory response, and has high clinical application value.
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Affiliation(s)
- Yading Shen
- Department of Anesthesiology, Yiwu Central Hospital, Yiwu, China
| | - Chenyu Wang
- Department of Anesthesiology, Yiwu Central Hospital, Yiwu, China
| | - Xiaoping Zhong
- Department of Anesthesiology, Yiwu Central Hospital, Yiwu, China
| | - Yandan Wu
- Department of Anesthesiology, Yiwu Central Hospital, Yiwu, China
| | - Xiaoxia He
- Department of Anesthesiology, Zhuji People's Hospital of Zhejiang Province, Zhuji, China
- Correspondence: Xiaoxia He
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Elnour AA, Babkir S, A AKK. The predictors of postoperative delirium at surgical units in Sudan: A multicenter, cross-sectional, prospective study. Pharm Pract (Granada) 2022; 20:2705. [PMID: 36733520 PMCID: PMC9851826 DOI: 10.18549/pharmpract.2022.3.2705] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2022] [Accepted: 08/02/2022] [Indexed: 02/05/2023] Open
Abstract
Background Knowledge of potential and amenable risk factors involved in the development of postoperative delirium (POD) is imperative for successful prevention and subsequent management. Objective The current study objective was to delineate the risk factors associated with the occurrence of POD among patients undergoing surgical procedures. Methods This multi-center (6 hospitals), cross-sectional prospective hospital-based study recruited 415 subjects aged ≥50 years who were scheduled to undergo different types of surgery. Delirium Observational Screening Scale used for the diagnosis of POD. Short Nutritional Assessment Questionnaire used for assessing the nutritional and the hydration status of patients. Pre and postoperative risk factors analyzed by univariate (chi square) and then multivariate analyses and the incidence rate of POD, was reported. Results The main outcome measure was the development of POD. Out of the 385, only 43 subjects (11.2%) developed POD. High American Society of Anesthesiologists score (OR: 10.76, 95% CI: 1.379-83.99, P =0.023), duration of surgery (OR: 5.426, 95% CI: [2.249-13.092]; P =0.0001), were the strongest independent risk factors for the development of POD. Katz Index of Independence in Activities of Daily Living score (OR: 3.227, 95% CI: [1.177-8.844], P =0.023), and age ≥ 70 years (OR: 1.174, 95% CI: [1.015-1.359]; P =0.027) were additional strongest independent risk factors for the development of POD. Conclusion Based on analysis or study, we found High American Society of Anesthesiologist sore, Katz-ADL, duration of surgery, and advanced age were predictors of POD. Our findings suggest preventive measures initiated in subjects identified at risk of developing POD. These results support the healthcare providers in the early prevention, diagnosis, and timely management of POD.
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Affiliation(s)
- Asim Ahmed Elnour
- PhD, MSc. Program of Clinical Pharmacy, College of Pharmacy, Al Ain University, Abu Dhabi campus, Abu Dhabi-United Arab Emirates. AAU Health and Biomedical Research Center, Al Ain University, Abu Dhabi, United Arab Emirates.
| | - Sara Babkir
- MSc, B-Pharm. Clinical Pharmacist, Clinical and Drug Supply Chain Management, MSc in Medical Health Professions Education - Alneelain University and MSc in Hospital Pharmacy - National University, Doctors Without Borders "Medicines Sans Frontiers-MSF": Supply Department Khartoum-Sudan, Sudan.
| | - Al-Kubaissi Khalid A
- PhD, MSc. Department of Pharmacy Practice & Pharmacotherapeutics, College of Pharmacy-University of Sharjah, Sharjah-United Arab Emirates.
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Rajeev A, Railton C, Devalia K. The crucial factors influencing the development and outcomes of postoperative delirium in proximal femur fractures. Aging Med (Milton) 2022; 5:94-100. [PMID: 35783117 PMCID: PMC9245175 DOI: 10.1002/agm2.12206] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2022] [Revised: 03/29/2022] [Accepted: 03/30/2022] [Indexed: 01/09/2023] Open
Abstract
Objective The aim of this study is to find the incidence, risks, and reasons for prolonged length of hospital stay, short, long‐term mortality, and the factors contributing to mortality of postoperative delirium in proximal femoral fractures. Methods The data for the study was obtained from National Hip Fracture Database (NHFD) and internal hospital computer systems (Medway, ICE, Clinic letters) between January 2018 and December 2019. One hundred seventy‐five patients were found have developed postoperative delirium. The outcomes measured were postoperative anemia, lower respiratory tract infection, urinary tract infection, acute kidney injury, urinary retention, cardiac event and stroke, alcohol or drug withdrawal, length of hospital stay, and 30 day and 1 year mortality. Results The patients who developed delirium were 68 (38.9%) with American Society of Anesthesiologists (ASA) grade 4 and 94 (22.3%) without delirium (p < 0.05). The average length of stay after developing postoperative delirium was 19.69 days compared to 17.4 days for patients without delirium. The mortality at 30 days and 1 year was 10.9% and 37% in patients who had postoperative delirium compared to 2.1% and 2.8% to those without delirium, respectively. Conclusion Postoperative delirium is three times more common in hip fractures. Early detection and timely management are crucial in the improvement of functional outcomes and mortality.
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Affiliation(s)
- Aysha Rajeev
- Department of Trauma and Orthopaedics Gateshead Health Foundation NHS Trust Tyne and Wear UK
| | - Catherine Railton
- Department of Trauma and Orthopaedics Gateshead Health Foundation NHS Trust Tyne and Wear UK
| | - Kailash Devalia
- Department of Trauma and Orthopaedics Gateshead Health Foundation NHS Trust Tyne and Wear UK
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Kong H, Xu LM, Wang DX. Perioperative neurocognitive disorders: A narrative review focusing on diagnosis, prevention, and treatment. CNS Neurosci Ther 2022; 28:1147-1167. [PMID: 35652170 PMCID: PMC9253756 DOI: 10.1111/cns.13873] [Citation(s) in RCA: 37] [Impact Index Per Article: 18.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2021] [Revised: 05/03/2022] [Accepted: 05/06/2022] [Indexed: 12/13/2022] Open
Abstract
Perioperative neurocognitive disorders (NCDs) refer to neurocognitive abnormalities detected during the perioperative periods, including preexisting cognitive impairment, preoperative delirium, delirium occurring up to 7 days after surgery, delayed neurocognitive recovery, and postoperative NCD. The Diagnostic and Statistical Manual of Mental Disorders‐5th edition (DSM‐5) is the golden standard for diagnosing perioperative NCDs. Given the impracticality of using the DSM‐5 by non‐psychiatric practitioners, many diagnostic tools have been developed and validated for different clinical scenarios. The etiology of perioperative NCDs is multifactorial and includes predisposing and precipitating factors. Identifying these risk factors is conducive to preoperative risk stratification and perioperative risk reduction. Prevention for perioperative NCDs should include avoiding possible contributors and implementing nonpharmacologic and pharmacological interventions. The former generally includes avoiding benzodiazepines, anticholinergics, prolonged liquid fasting, deep anesthesia, cerebral oxygen desaturation, and intraoperative hypothermia. Nonpharmacologic measures include preoperative cognitive prehabilitation, comprehensive geriatric assessment, implementing fast‐track surgery, combined use of regional block, and sleep promotion. Pharmacological measures including dexmedetomidine, nonsteroidal anti‐inflammatory drugs, and acetaminophen are found to have beneficial effects. Nonpharmacological treatments are the first‐line measures for established perioperative NCDs. Pharmacological treatments are still limited to severely agitated or distressed patients.
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Affiliation(s)
- Hao Kong
- Department of Anesthesiology and Critical Care Medicine, Peking University First Hospital, Beijing, China
| | - Long-Ming Xu
- Department of Anesthesiology and Critical Care Medicine, Peking University First Hospital, Beijing, China
| | - Dong-Xin Wang
- Department of Anesthesiology and Critical Care Medicine, Peking University First Hospital, Beijing, China.,Outcomes Research Consortium, Cleveland, Ohio, USA
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Thisayakorn P, Thipakorn Y, Tantavisut S, Sirivichayakul S, Maes M. Delirium due to hip fracture is associated with activated immune-inflammatory pathways and a reduction in negative immunoregulatory mechanisms. BMC Psychiatry 2022; 22:369. [PMID: 35641947 PMCID: PMC9158285 DOI: 10.1186/s12888-022-04021-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2022] [Accepted: 05/25/2022] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND The objectives of this study were to delineate whether delirium in older adults is associated with activation of the immune-inflammatory response system (IRS) as indicated by activation of M1, T helper (Th)1, and Th17 profiles, and/or by reduced activities of the compensatory immunoregulatory system (CIRS), including Th2 and T regulatory profiles. METHODS We recruited 65 older adult patients with a low energy impact hip fracture who underwent hip fracture operation. The CAM-ICU and the Delirium Rating Scale, Revised-98-Thai version (DRS-R-98) were assessed pre-operatively and 1, 2 and 3 days after surgery. Blood samples (day 1 and 2) post-surgery were assayed for cytokines/chemokines using a MultiPlex assay and the neutrophil/lymphocyte ratio. RESULTS We found that delirium and/or the DRS-R-98 score were associated with IRS activation as indicated by activated M1, Th1, Th17 and T cell growth profiles and by attenuated CIRS functions. The most important IRS biomarkers were CXCL8, interleukin (IL)-6, and tumor necrosis factor-α, and the most important CIRS biomarkers were IL-4 and soluble IL-1 receptor antagonist. We found that 42.5% of the variance in the actual changes in the DRS-R-98 score (averaged from day 1 to day 3) was explained by T cell growth factors, baseline DRS-R-98 scores and age. An increase in the NLR reflects overall IRS, M1, Th1, Th17, and Th2 activation. CONCLUSIONS Post-hip surgery delirium is associated with activated IRS pathways and appears especially in patients with lowered CIRS functions.
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Affiliation(s)
- Paul Thisayakorn
- Department of Psychiatry, Hip Fracture Research Unit, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand.
| | - Yanin Thipakorn
- grid.7922.e0000 0001 0244 7875Department of Psychiatry, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Saran Tantavisut
- grid.7922.e0000 0001 0244 7875Department of Orthopedics, Hip Fracture Research Unit, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Sunee Sirivichayakul
- grid.7922.e0000 0001 0244 7875Department of Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Michael Maes
- Department of Psychiatry, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand. .,Department of Psychiatry, Medical University of Plovdiv, Plovdiv, Bulgaria. .,IMPACT Strategic Research Center, Deakin University, Geelong, Australia.
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Yoshimura M, Shiramoto H, Koga M, Yoshimatsu A, Morimoto Y. Comparing the effects of peripheral nerve block and general anesthesia with general anesthesia alone on postoperative delirium and complications in elderly patients: a retrospective cohort study using a nationwide database. Reg Anesth Pain Med 2022; 47:rapm-2022-103566. [PMID: 35636781 DOI: 10.1136/rapm-2022-103566] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2022] [Accepted: 05/05/2022] [Indexed: 11/04/2022]
Abstract
INTRODUCTION The difference between the effects of peripheral nerve block (PNB) with general anesthesia (GA) and GA alone on the patients' postoperative clinical outcomes remains unknown. We assessed whether there is a difference in postoperative delirium and composite morbidity between patients receiving GA with PNB and GA alone using a national clinical database in Japan. METHODS We compared the outcomes of patients receiving GA with PNB and GA alone from April 2016 to October 2019. The primary outcome was postoperative delirium, defined as a status requiring newly prescribed antipsychotic drugs or that given the code of a reimbursable disease after the surgery date. The secondary outcome was morbidity incidence as the occurrence of at least one of any of the following life-threatening complications. We conducted propensity score-matched analyses using covariates for patients who underwent any surgical procedure. We used instrumental variables and restricted the definition of postoperative delirium and subgroup for sensitivity analyses. RESULTS Of 653,759 patients, 90,358 received GA-PNB and 563,401 received only GA. After 1:4 propensity score matching, 89,754 patients were included in the GA-PNB and 359,015 in the GA. The adjusted ORs for postoperative delirium and composite morbidity were 0.96 (95% CIs 0.94 to 0.99; p<0.01), 0.80 (95% CIs 0.76 to 0.83; p<0.001), respectively, for the GA-PNB concerning the GA. For sensitivity analyses, findings were also consistent with instrumental variables and subgroup analyses. DISCUSSION This retrospective, nationwide cohort study demonstrated that GA-PNB was associated with a small reduction in the likelihood of postoperative delirium and a moderate reduction in the likelihood of composite morbidity.
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Affiliation(s)
- Manabu Yoshimura
- Department of Anesthesiology, Ube Industries Central Hospital, Ube, Japan
| | - Hiroko Shiramoto
- Department of Anesthesiology, Ube Industries Central Hospital, Ube, Japan
| | - Mami Koga
- Department of Anesthesiology, Ube Industries Central Hospital, Ube, Japan
| | - Aya Yoshimatsu
- Department of Anesthesiology, Ube Industries Central Hospital, Ube, Japan
| | - Yasuhiro Morimoto
- Department of Anesthesiology, Ube Industries Central Hospital, Ube, Japan
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50
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Nobuhara C, Devinney M, Berger M. Regional vs General Anesthesia and Incidence of Postoperative Delirium in Older Patients Undergoing Hip Fracture Surgery. JAMA 2022; 327:1707-1708. [PMID: 35503352 DOI: 10.1001/jama.2022.3538] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Chloe Nobuhara
- Duke University School of Medicine, Durham, North Carolina
| | - Michael Devinney
- Department of Anesthesiology, Duke University School of Medicine, Durham, North Carolina
| | - Miles Berger
- Department of Anesthesiology, Duke University School of Medicine, Durham, North Carolina
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