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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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Kluger M, Skarin M, Collier J, Rice D, Merien F, Almeida K, Ross J, Hogan S, McNair P. The effect of dexamethasone on biomarkers of inflammation and neuronal damage in patients with hip fracture: A secondary analysis of a randomised controlled trial. Eur J Anaesthesiol 2023; 40:372-377. [PMID: 36809185 DOI: 10.1097/eja.0000000000001810] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/23/2023]
Affiliation(s)
- Michal Kluger
- From the Department of Anaesthesiology and Perioperative Medicine, Te Whatu Ora Waitemata (MK, MS, JC), Health and Rehabilitation Research Institute Auckland University of Technology (DR, PM), AUT-Roche Diagnostics Laboratory, Auckland University of Technology (FM, KA, JR, SH), Auckland, New Zealand
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Dai C, Das Gupta S, Wang Z, Jiang H, Velkov T, Shen J. T-2 toxin and its cardiotoxicity: New insights on the molecular mechanisms and therapeutic implications. Food Chem Toxicol 2022; 167:113262. [PMID: 35792220 DOI: 10.1016/j.fct.2022.113262] [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: 05/25/2022] [Revised: 06/15/2022] [Accepted: 06/24/2022] [Indexed: 10/17/2022]
Abstract
T-2 toxin is one of the most toxic and common trichothecene mycotoxins, and can cause various cardiovascular diseases. In this review, we summarized the current knowledge-base and challenges as it relates to T-2 toxin related cardiotoxicity. The molecular mechanisms and potential treatment approaches were also discussed. Pathologically, T-2 toxin-induced cardiac toxicity is characterized by cell injury and death in cardiomyocyte, increased capillary permeability, necrosis of cardiomyocyte, hemorrhage, and the infiltration of inflammatory cells in the heart. T-2 toxin exposure can cause cardiac fibrosis and finally lead to cardiac dysfunction. Mechanistically, T-2 toxin exposure-induced cardiac damage involves the production of ROS, mitochondrial dysfunction, peroxisome proliferator-activated receptor-gamma (PPAR-γ) signaling pathway, endoplasmic reticulum (ER stress), transforming growth factor beta 1 (TGF-β1)/smad family member 2/3 (Smad2/3) signaling pathway, and autophagy and inflammatory responses. Antioxidant supplementation (e.g., catalase, vitamin C, and selenium), induction of autophagy (e.g., rapamycin), blockade of inflammatory signaling (e.g., methylprednisolone) or treatment with PPAR-γ agonists (e.g., pioglitazone) may provide protective effects against these detrimental cardiac effects caused by T-2 toxin. We believe that our review provides new insights in understanding T-2 toxin exposure-induced cardiotoxicity and fuels effective prevention and treatment strategies against this important food-borne toxin-induced health problems.
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Affiliation(s)
- Chongshan Dai
- College of Veterinary Medicine, China Agricultural University, No.2 Yuanmingyuan West Road, Beijing, 100193, PR China; Beijing Key Laboratory of Detection Technology for Animal-Derived Food Safety, Beijing, 100193, PR China.
| | - Subhajit Das Gupta
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX, 75230, USA
| | - Zhanhui Wang
- College of Veterinary Medicine, China Agricultural University, No.2 Yuanmingyuan West Road, Beijing, 100193, PR China; Beijing Key Laboratory of Detection Technology for Animal-Derived Food Safety, Beijing, 100193, PR China
| | - Haiyang Jiang
- College of Veterinary Medicine, China Agricultural University, No.2 Yuanmingyuan West Road, Beijing, 100193, PR China; Beijing Key Laboratory of Detection Technology for Animal-Derived Food Safety, Beijing, 100193, PR China
| | - Tony Velkov
- Department of Pharmacology & Therapeutics, School of Biomedical Sciences, Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Parkville, Victoria, 3010, Australia
| | - Jianzhong Shen
- College of Veterinary Medicine, China Agricultural University, No.2 Yuanmingyuan West Road, Beijing, 100193, PR China; Beijing Key Laboratory of Detection Technology for Animal-Derived Food Safety, Beijing, 100193, PR China
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Kluger MT, Skarin M, Collier J, Rice DA, McNair PJ, Seow MY, Connolly MJ. Steroids to reduce the impact on delirium (STRIDE): a double-blind, randomised, placebo-controlled feasibility trial of pre-operative dexamethasone in people with hip fracture. Anaesthesia 2021; 76:1031-1041. [PMID: 33899214 DOI: 10.1111/anae.15465] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/05/2021] [Indexed: 01/18/2023]
Abstract
Neuro-inflammation may be important in the pathogenesis of postoperative delirium following hip fracture surgery. Studies have suggested a potential role for steroids in reducing postoperative delirium; however, the potential efficacy and safety of pre-operative high-dose dexamethasone in this specific population is largely unknown. Conducting such a study could be challenging, considering the multidisciplinary team involvement and the emergency nature of the surgery. The aim of this study was to assess feasibility and effectiveness of dexamethasone given as early as possible following hospital admission for hip fracture, to inform whether a full-scale trial is warranted. This single-centre, randomised, double-blind, placebo-controlled study randomly allocated 79 participants undergoing hip fracture surgery to dexamethasone 20 mg or placebo pre-operatively. Eligibility and recruitment rates, timing of the intervention and adverse events were recorded. Incidence and severity of postoperative delirium were assessed using the 4AT delirium screening tool and the Memorial Delirium Assessment Scale. Postoperative pain, length of stay and mortality were also assessed. The eligibility rate for inclusion was 178/527 (34%), and 57/178 (32%) of eligible patients presented to hospital when no researcher was available (e.g. after-hours, weekends, public holidays). Recruitment was limited mainly by ethical limitations (not including patients with impaired cognition) and lack of weekend staffing. Median (IQR [range]) time from emergency department admission to drug administration was 13.3 (5.9-17.6 [1.8-139.6]) hours. There was a significant difference in delirium severity scores, favouring the dexamethasone group: median (IQR [range]) 5 (3-6 [3-7]) vs. 9 (6-13 [5-14]) in the placebo group, with the probability of superiority effect size being 0.89, p = 0.010. Delirium incidence did not differ between groups: 6/40 (15%) in the dexamethasone group vs. 9/39 (23%) in the placebo group, relative risk (95%CI) 0.65 (0.22-1.65), p = 0.360). A larger randomised controlled trial is feasible and ideally this should include people with existing cognitive impairment, seven days-a-week cover and a multicentre design.
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Affiliation(s)
- M T Kluger
- Department of Anaesthesiology and Peri-operative Medicine, Waitematā DHB, Auckland, New Zealand.,Department of Anaesthesiology, University of Auckland, Auckland, New Zealand
| | - M Skarin
- Department of Anaesthesiology and Peri-operative Medicine, Waitematā DHB, Auckland, New Zealand
| | - J Collier
- Department of Anaesthesiology and Peri-operative Medicine, Waitematā DHB, Auckland, New Zealand
| | - D A Rice
- Health and Rehabilitation Research Institute, AUT University, Auckland, New Zealand
| | - P J McNair
- Health and Rehabilitation Research Institute, AUT University, Auckland, New Zealand
| | - M Y Seow
- Department of Orthopaedic Surgery, Waitematā DHB, Auckland, New Zealand
| | - M J Connolly
- Department of Geriatric Medicine, University of Auckland and Waitematā DHB, Auckland, New Zealand
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