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Nishizawa Y, Thompson KC, Yamanashi T, Wahba NE, Saito T, Marra PS, Nagao T, Nishiguchi T, Shibata K, Yamanishi K, Hughes CG, Pandharipande P, Cho H, Howard MA, Kawasaki H, Toda H, Kanazawa T, Iwata M, Shinozaki G. Epigenetic signals associated with delirium replicated across four independent cohorts. Transl Psychiatry 2024; 14:275. [PMID: 38965205 PMCID: PMC11224347 DOI: 10.1038/s41398-024-02986-w] [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: 01/03/2024] [Revised: 06/15/2024] [Accepted: 06/25/2024] [Indexed: 07/06/2024] Open
Abstract
Delirium is risky and indicates poor outcomes for patients. Therefore, it is crucial to create an effective delirium detection method. However, the epigenetic pathophysiology of delirium remains largely unknown. We aimed to discover reliable and replicable epigenetic (DNA methylation: DNAm) markers that are associated with delirium including post-operative delirium (POD) in blood obtained from patients among four independent cohorts. Blood DNA from four independent cohorts (two inpatient cohorts and two surgery cohorts; 16 to 88 patients each) were analyzed using the Illumina EPIC array platform for genome-wide DNAm analysis. We examined DNAm differences in blood between patients with and without delirium including POD. When we compared top CpG sites previously identified from the initial inpatient cohort with three additional cohorts (one inpatient and two surgery cohorts), 11 of the top 13 CpG sites showed statistically significant differences in DNAm values between the delirium group and non-delirium group in the same directions as found in the initial cohort. This study demonstrated the potential value of epigenetic biomarkers as future diagnostic tools. Furthermore, our findings provide additional evidence of the potential role of epigenetics in the pathophysiology of delirium including POD.
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Affiliation(s)
- Yoshitaka Nishizawa
- Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Palo Alto, CA, USA
- Department of Psychiatry, Osaka Medical and Pharmaceutical University School of Medicine, Osaka, Japan
| | - Kaitlyn C Thompson
- Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Palo Alto, CA, USA
- University of Nebraska Medical Center, Omaha, NE, USA
| | - Takehiko Yamanashi
- Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Palo Alto, CA, USA
- Department of Psychiatry, University of Iowa Carver College of Medicine, Iowa City, IA, USA
- Department of Neuropsychiatry, Tottori University Faculty of Medicine, Yonago-shi, Tottori, Japan
| | - Nadia E Wahba
- Department of Psychiatry, Oregon Health and Science University, School of Medicine, Portland, OR, USA
| | - Taku Saito
- Department of Psychiatry, National Defense Medical College School of Medicine, Tokorozawa, Saitama, Japan
| | - Pedro S Marra
- Department of Psychiatry, University of Iowa Carver College of Medicine, Iowa City, IA, USA
| | - Takaaki Nagao
- Department of Neurosurgery, University of Iowa Carver College of Medicine, Iowa City, IA, USA
- Department of Neurosurgery (Sakura), Toho University School of Medicine Faculty of Medicine, Sakura-shi, Chiba, Japan
| | - Tsuyoshi Nishiguchi
- Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Palo Alto, CA, USA
- Department of Neuropsychiatry, Tottori University Faculty of Medicine, Yonago-shi, Tottori, Japan
| | - Kazuki Shibata
- Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Palo Alto, CA, USA
- Sumitomo Pharma Co, Ltd, Osaka, Osaka, Japan
| | - Kyosuke Yamanishi
- Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Palo Alto, CA, USA
- Department of Neuropsychiatry, Hyogo Medical University, College of Medicine, Nishinomiya, Hyogo, Japan
| | - Christopher G Hughes
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Pratik Pandharipande
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Hyunkeun Cho
- University of Iowa, College of Public Health, Iowa City, IA, USA
| | - Matthew A Howard
- Department of Neurosurgery, University of Iowa Carver College of Medicine, Iowa City, IA, USA
| | - Hiroto Kawasaki
- Department of Neurosurgery, University of Iowa Carver College of Medicine, Iowa City, IA, USA
| | - Hiroyuki Toda
- Department of Psychiatry, National Defense Medical College School of Medicine, Tokorozawa, Saitama, Japan
| | - Tetsufumi Kanazawa
- Department of Psychiatry, Osaka Medical and Pharmaceutical University School of Medicine, Osaka, Japan
| | - Masaaki Iwata
- Department of Neuropsychiatry, Tottori University Faculty of Medicine, Yonago-shi, Tottori, Japan
| | - Gen Shinozaki
- Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Palo Alto, CA, USA.
- Department of Psychiatry, University of Iowa Carver College of Medicine, Iowa City, IA, USA.
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Yang Y, Zhang W, Liu Y, Liu X, Xie J, Xu R, Huang Y, Hao J, Sun Y, Gu X, Ma Z. Mitochondrial Dysfunction of Peripheral Platelets as a Predictive Biomarker for Postoperative Delirium in Elderly Patients. Ann Neurol 2024; 96:74-86. [PMID: 38501714 DOI: 10.1002/ana.26918] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2023] [Revised: 03/03/2024] [Accepted: 03/06/2024] [Indexed: 03/20/2024]
Abstract
OBJECTIVE To determine the association between the preoperative Bioenergetic Health Index (BHI) of platelets and the occurrence of postoperative delirium (POD) in elderly patients. METHODS Elderly patients scheduled for major abdominal surgery under general anesthesia were included. The presence of POD was assessed within the 3 days after surgery. Seahorse XF analysis and transmission electron microscopy were utilized to evaluate the mitochondrial metabolism and morphology of platelets. RESULTS A total of 20 out of 162 participants developed POD. Participants with POD showed lower preoperative Mini-Mental State Examination scores and total protein levels, fewer educational years, longer surgery duration, higher mean platelet volume, and lower platelet BHI compared with those without POD. Damaged mitochondria with swollen appearance and distorted cristae was detected in platelets from participants with POD. Preoperative platelet BHI was independently associated with the occurrence of POD after adjusting for age, education, preoperative Mini-Mental State Examination score, preoperative mean platelet volume and total protein levels, surgical type and duration, and lymphocyte counts on the first postoperative day (OR 0.11, 95% CI 0.03-0.37, p < 0.001). The areas under the receiver operating curves for predicting POD were 0.83 (95% CI 0.76-0.88) for platelet BHI. It showed a sensitivity of 85.00% and specificity of 73.24%, with an optimal cutoff value of 1.61. Using a serial combination (mean platelet volume followed by BHI) yielded a sensitivity of 80.00% and specificity of 82.39%. INTERPRETATION Preoperative platelet BHI was independently associated with the occurrence of POD in elderly patients and has the potential as a screening biomarker for POD risk. ANN NEUROL 2024;96:74-86.
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Affiliation(s)
- Yan Yang
- Department of Anesthesiology, Nanjing Drum Tower Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, China
| | - Wei Zhang
- Department of Anesthesiology, Nanjing Drum Tower Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, China
| | - Yue Liu
- Department of Anesthesiology, Nanjing Drum Tower Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, China
| | - Xin Liu
- Department of Anesthesiology, Nanjing Drum Tower Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, China
| | - Jun Xie
- Department of Anesthesiology, Nanjing Drum Tower Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, China
| | - Rui Xu
- Department of Anesthesiology, Nanjing Drum Tower Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, China
| | - Yulin Huang
- Department of Anesthesiology, Nanjing Drum Tower Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, China
| | - Jing Hao
- Department of Anesthesiology, Nanjing Drum Tower Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, China
| | - Yu'e Sun
- Department of Anesthesiology, Nanjing Drum Tower Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, China
| | - Xiaoping Gu
- Department of Anesthesiology, Nanjing Drum Tower Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, China
| | - Zhengliang Ma
- Department of Anesthesiology, Nanjing Drum Tower Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, China
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Kinoshita H, Saito J, Kushikata T, Oyama T, Takekawa D, Hashiba E, Sawa T, Hirota K. The Perioperative Frontal Relative Ratio of the Alpha Power of Electroencephalography for Predicting Postoperative Delirium After Highly Invasive Surgery: A Prospective Observational Study. Anesth Analg 2023; 137:1279-1288. [PMID: 36917508 DOI: 10.1213/ane.0000000000006424] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/15/2023]
Abstract
BACKGROUND We investigated the associations between postoperative delirium (POD) and both the relative ratio of the alpha (α)-power of electroencephalography (EEG) and inflammatory markers in a prospective, single-center observational study. METHODS We enrolled 84 patients who underwent radical cancer surgeries with reconstruction for esophageal cancer, oral floor cancer, or pharyngeal cancer under total intravenous anesthesia. We collected the perioperative EEG data and the perioperative data of the inflammatory markers, including neutrophil gelatinase-associated lipocalin, presepsin, procalcitonin, C-reactive protein, and the neutrophil-lymphocyte ratio (NLR). The existence of POD was evaluated based on the Intensive Care Delirium Screening Checklist. We compared the time-dependent changes in the relative ratio of the EEG α-power and inflammatory markers between the patients with and without POD. RESULTS Four of the 84 patients were excluded from the analysis. Of the remaining 80 patients, 25 developed POD and the other 55 did not. The relative ratio of the α-power at baseline was significantly lower in the POD group than the non-POD group (0.18 ± 0.08 vs 0.28 ± 0.11, P < .001). A time-dependent decline in the relative ratio of α-power in the EEG during surgery was observed in both groups. There were significant differences between the POD and non-POD groups in the baseline, 3-h, 6-h, and 9-h values of the relative ratio of α-power. The preoperative NLR of the POD group was significantly higher than that of the non-POD group (2.88 ± 1.04 vs 2.22 ± 1.00, P < .001), but other intraoperative inflammatory markers were comparable between the groups. Two multivariable logistic regression models demonstrated that the relative ratio of the α-power at baseline was significantly associated with POD. CONCLUSIONS Intraoperative frontal relative ratios of the α-power of EEG were associated with POD in patients who underwent radical cancer surgery. Intraoperative EEG monitoring could be a simple and more useful tool for predicting the development of postoperative delirium than measuring perioperative acute inflammatory markers. A lower relative ratio of α-power might be an effective marker for vulnerability of brain and ultimately for the development of POD.
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Affiliation(s)
- Hirotaka Kinoshita
- From the Department of Anesthesiology, Hirosaki University Graduate School of Medicine, Hirosaki, Japan
| | - Junichi Saito
- From the Department of Anesthesiology, Hirosaki University Graduate School of Medicine, Hirosaki, Japan
| | - Tetsuya Kushikata
- From the Department of Anesthesiology, Hirosaki University Graduate School of Medicine, Hirosaki, Japan
| | - Tasuku Oyama
- From the Department of Anesthesiology, Hirosaki University Graduate School of Medicine, Hirosaki, Japan
| | - Daiki Takekawa
- From the Department of Anesthesiology, Hirosaki University Graduate School of Medicine, Hirosaki, Japan
| | - Eiji Hashiba
- Division of Intensive Care, Hirosaki University Medical Hospital, Hirosaki, Japan
| | - Teiji Sawa
- Department of Anesthesiology, School of Medicine, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Kazuyoshi Hirota
- From the Department of Anesthesiology, Hirosaki University Graduate School of Medicine, Hirosaki, Japan
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Liu XH, Zhang QF, Liu Y, Lu QW, Wu JH, Gao XH, Chen ZY. Risk factors associated with postoperative delirium in elderly patients undergoing hip surgery. Front Psychiatry 2023; 14:1288117. [PMID: 37928911 PMCID: PMC10620517 DOI: 10.3389/fpsyt.2023.1288117] [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: 09/05/2023] [Accepted: 10/09/2023] [Indexed: 11/07/2023] Open
Abstract
Objective We retrospectively analyzed the occurrence of postoperative delirium following hip surgery and the associated risk factors. The aim was to establish a clinical foundation for preventing postoperative delirium after hip surgery. Methods We retrospectively selected elderly patients who had hip surgery at our hospital between January 2022 and August 2022. We included patients who experienced delirium in the observation group and those who did not encounter delirium in the control group. We then proceeded to compare various indicators among these two groups of patients. Results We analyzed a total of 97 cases of hip surgery, and among them, 32 cases experienced postoperative delirium, resulting in an incidence rate of 32.9%. Various factors were found to be linked to the development of postoperative delirium, including age, height, gender (male), preoperative erythrocyte sedimentation rate (ESR), postoperative ESR, preoperative lactate levels, pain scores on the first day after surgery, type of surgical procedure, and the occurrence of delirium in the post-anesthesia care unit (PACU delirium). Additionally, it was observed that 75% of patients who had PACU delirium also experienced postoperative delirium. Conclusion Postoperative delirium in patients who have hip surgery had an incidence rate of 32.9%. This phenomenon is linked to various factors that pose a risk, such as the patient age, height, gender, preoperative ESR levels, postoperative ESR levels, preoperative lactate levels, pain scores on the day following surgery, and the specific surgical procedure performed. The likelihood of experiencing delirium increases by 12% for every additional 10 years in patient age. Additionally, the occurrence of delirium in the PACU is a strong indicator of the likelihood of experiencing postoperative delirium.
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Affiliation(s)
- Xiao-Hong Liu
- Department of Anesthesiology, the Second Affiliated Hospital of Fujian Medical University, Quanzhou, China
- Department of Anesthesiology, Jinjiang Municipal Hospital (Shanghai Sixth People's Hospital Fujian Campus), Jinjiang, China
| | - Qing-Fu Zhang
- Department of Anesthesiology, Shanghai Jiaotong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Ying Liu
- Department of Anesthesiology, the Second Affiliated Hospital of Fujian Medical University, Quanzhou, China
| | - Qing-Wang Lu
- Department of Anesthesiology, Jinjiang Municipal Hospital (Shanghai Sixth People's Hospital Fujian Campus), Jinjiang, China
| | - Jian-Hua Wu
- Department of Anesthesiology, the Second Affiliated Hospital of Fujian Medical University, Quanzhou, China
| | - Xiao-Hua Gao
- Department of Anesthesiology, the Second Affiliated Hospital of Fujian Medical University, Quanzhou, China
| | - Zhi-Yuan Chen
- Department of Anesthesiology, the Second Affiliated Hospital of Fujian Medical University, Quanzhou, China
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Gonçalves M, Khera T, Otu HH, Narayanan S, Dillon ST, Shanker A, Gu X, Jung Y, Ngo LH, Marcantonio ER, Libermann TA, Subramaniam B. Multivariable model of postoperative delirium in cardiac surgery patients: proteomic and demographic contributions. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2023:2023.05.30.23289741. [PMID: 37333093 PMCID: PMC10274980 DOI: 10.1101/2023.05.30.23289741] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/20/2023]
Abstract
Background Delirium following cardiac surgery is common, morbid, and costly, but may be prevented with risk stratification and targeted intervention. Preoperative protein signatures may identify patients at increased risk for worse postoperative outcomes, including delirium. In this study, we aimed to identify plasma protein biomarkers and develop a predictive model for postoperative delirium in older patients undergoing cardiac surgery, while also uncovering possible pathophysiological mechanisms. Methods SOMAscan analysis of 1,305 proteins in the plasma from 57 older adults undergoing cardiac surgery requiring cardiopulmonary bypass was conducted to define delirium-specific protein signatures at baseline (PREOP) and postoperative day 2 (POD2). Selected proteins were validated in 115 patients using the ELLA multiplex immunoassay platform. Proteins were combined with clinical and demographic variables to build multivariable models that estimate the risk of postoperative delirium and bring light to the underlying pathophysiology. Results A total of 115 and 85 proteins from SOMAscan analyses were found altered in delirious patients at PREOP and POD2, respectively (p<0.05). Using four criteria including associations with surgery, delirium, and biological plausibility, 12 biomarker candidates (Tukey's fold change (|tFC|)>1.4, Benjamini-Hochberg (BH)-p<0.01) were selected for ELLA multiplex validation. Eight proteins were significantly altered at PREOP, and seven proteins at POD2 (p<0.05), in patients who developed postoperative delirium compared to non-delirious patients. Statistical analyses of model fit resulted in the selection of a combination of age, sex, and three proteins (angiopoietin-2 (ANGPT2); C-C motif chemokine 5 (CCL5); and metalloproteinase inhibitor 1 (TIMP1); AUC=0.829) as the best performing predictive model for delirium at PREOP. The delirium-associated proteins identified as biomarker candidates are involved with inflammation, glial dysfunction, vascularization, and hemostasis, highlighting the multifactorial pathophysiology of delirium. Conclusion Our study proposes a model of postoperative delirium that includes a combination of older age, female sex, and altered levels of three proteins. Our results support the identification of patients at higher risk of developing postoperative delirium after cardiac surgery and provide insights on the underlying pathophysiology. ClinicalTrials.gov ( NCT02546765 ).
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Ren Y, Zhang Y, Zhan J, Sun J, Luo J, Liao W, Cheng X. Machine learning for prediction of delirium in patients with extensive burns after surgery. CNS Neurosci Ther 2023; 29:2986-2997. [PMID: 37122154 PMCID: PMC10493655 DOI: 10.1111/cns.14237] [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: 01/03/2023] [Revised: 02/23/2023] [Accepted: 04/15/2023] [Indexed: 05/02/2023] Open
Abstract
AIMS Machine learning-based identification of key variables and prediction of postoperative delirium in patients with extensive burns. METHODS Five hundred and eighteen patients with extensive burns who underwent surgery were included and randomly divided into a training set, a validation set, and a testing set. Multifactorial logistic regression analysis was used to screen for significant variables. Nine prediction models were constructed in the training and validation sets (80% of dataset). The testing set (20% of dataset) was used to further evaluate the model. The area under the receiver operating curve (AUROC) was used to compare model performance. SHapley Additive exPlanations (SHAP) was used to interpret the best one and to externally validate it in another large tertiary hospital. RESULTS Seven variables were used in the development of nine prediction models: physical restraint, diabetes, sex, preoperative hemoglobin, acute physiological and chronic health assessment, time in the Burn Intensive Care Unit and total body surface area. Random Forest (RF) outperformed the other eight models in terms of predictive performance (ROC:84.00%) When external validation was performed, RF performed well (accuracy: 77.12%, sensitivity: 67.74% and specificity: 80.46%). CONCLUSION The first machine learning-based delirium prediction model for patients with extensive burns was successfully developed and validated. High-risk patients for delirium can be effectively identified and targeted interventions can be made to reduce the incidence of delirium.
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Affiliation(s)
- Yujie Ren
- Medical Center of Burn Plastic and Wound RepairThe First Affiliated Hospital of Nanchang UniversityNanchangChina
| | - Yu Zhang
- Medical Innovation CenterThe First Affiliated Hospital of Nanchang UniversityNanchangChina
| | - Jianhua Zhan
- Medical Center of Burn Plastic and Wound RepairThe First Affiliated Hospital of Nanchang UniversityNanchangChina
| | - Junfeng Sun
- Medical Center of Burns and PlasticGanzhou People's HospitalGanzhouChina
| | - Jinhua Luo
- Medical Center of Burn Plastic and Wound RepairThe First Affiliated Hospital of Nanchang UniversityNanchangChina
| | - Wenqiang Liao
- Medical Center of Burn Plastic and Wound RepairThe First Affiliated Hospital of Nanchang UniversityNanchangChina
| | - Xing Cheng
- Medical Center of Burn Plastic and Wound RepairThe First Affiliated Hospital of Nanchang UniversityNanchangChina
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Liu W, Wang Y, Chen K, Ye M, Lu W, Chen K, Shen X. Effect of Intraoperative Dexmedetomidine Use on Postoperative Delirium in the Elderly After Laryngectomy: A Randomized Controlled Clinical Trial. Drug Des Devel Ther 2023; 17:2933-2941. [PMID: 37766822 PMCID: PMC10521928 DOI: 10.2147/dddt.s424526] [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: 07/02/2023] [Accepted: 09/15/2023] [Indexed: 09/29/2023] Open
Abstract
Purpose To examine whether intraoperative dexmedetomidine reduces postoperative delirium (POD) in elderly patients who underwent a laryngectomy. Methods Patients were randomly assigned to receive dexmedetomidine or a saline placebo infused during surgery. The study period was July 2020 to January 2022. Participants were elderly individuals (≥65 years) who underwent a laryngectomy. Immediately after induction of anesthesia, a 0.5 μg.kg-1 bolus of study solution was administered for 10 min, followed by a maintenance infusion of 0.2 μg.kg-1.hr-1 until the end of surgery. Patients were assessed daily for POD (primary outcome). Plasma inflammatory factors were measured at baseline, on the first postoperative day, and on the third postoperative day. Results In total, 304 male patients were randomized; 299 patients [median (interquartile range) age, 69.0 (67.0-73.0) years] completed in-hospital delirium assessments. There was no difference in the incidence of POD between the dexmedetomidine and control groups (21.3% [32 of 150] vs 24.2% [36 of 149], P=0.560). However, dexmedetomidine reduced POD in patients with laryngeal cancer and a higher tumor stage (21.6% vs 38.5%; OR, 0.441; 95% CI, 0.209-0.979; P=0.039). Dexmedetomidine reduced levels of C-reactive protein (CRP) (P=0.0056) and interleukin 6 (IL-6) (P<0.001) on the first and third postoperative days, respectively. More patients had intraoperative hypotension in the dexmedetomidine group (29.3% [44 of 150] vs 17.4% [26 of 149], P=0.015). Conclusion Intraoperative dexmedetomidine administration did not prevent POD in patients with laryngeal cancer. Dexmedetomidine reduced serum CRP and IL-6 levels postoperatively but caused a higher occurrence of intraoperative hypotension in elderly patients after a laryngectomy.
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Affiliation(s)
- Weiwei Liu
- Department of Anesthesiology, Eye & ENT Hospital, Fudan University, Shanghai, 200031, People’s Republic of China
| | - Yiru Wang
- Department of Anesthesiology, Eye & ENT Hospital, Fudan University, Shanghai, 200031, People’s Republic of China
| | - Kaizheng Chen
- Department of Anesthesiology, Eye & ENT Hospital, Fudan University, Shanghai, 200031, People’s Republic of China
| | - Min Ye
- Department of Anesthesiology, Eye & ENT Hospital, Fudan University, Shanghai, 200031, People’s Republic of China
| | - Weisha Lu
- Department of Anesthesiology, Eye & ENT Hospital, Fudan University, Shanghai, 200031, People’s Republic of China
| | - Keyu Chen
- Department of Anesthesiology, Eye & ENT Hospital, Fudan University, Shanghai, 200031, People’s Republic of China
| | - Xia Shen
- Department of Anesthesiology, Eye & ENT Hospital, Fudan University, Shanghai, 200031, People’s Republic of China
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Vasunilashorn SM, Dillon ST, Marcantonio ER, Libermann TA. Application of Multiple Omics to Understand Postoperative Delirium Pathophysiology in Humans. Gerontology 2023; 69:1369-1384. [PMID: 37722373 PMCID: PMC10711777 DOI: 10.1159/000533789] [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: 01/24/2023] [Accepted: 08/23/2023] [Indexed: 09/20/2023] Open
Abstract
Delirium, an acute change in cognition, is common, morbid, and costly, particularly among hospitalized older adults. Despite growing knowledge of its epidemiology, far less is known about delirium pathophysiology. Initial work understanding delirium pathogenesis has focused on assaying single or a limited subset of molecules or genetic loci. Recent technological advances at the forefront of biomarker and drug target discovery have facilitated application of multiple "omics" approaches aimed to provide a more complete understanding of complex disease processes such as delirium. At its basic level, "omics" involves comparison of genes (genomics, epigenomics), transcripts (transcriptomics), proteins (proteomics), metabolites (metabolomics), or lipids (lipidomics) in biological fluids or tissues obtained from patients who have a certain condition (i.e., delirium) and those who do not. Multi-omics analyses of these various types of molecules combined with machine learning and systems biology enable the discovery of biomarkers, biological pathways, and predictors of delirium, thus elucidating its pathophysiology. This review provides an overview of the most recent omics techniques, their current impact on identifying delirium biomarkers, and future potential in enhancing our understanding of delirium pathogenesis. We summarize challenges in identification of specific biomarkers of delirium and, more importantly, in discovering the mechanisms underlying delirium pathophysiology. Based on mounting evidence, we highlight a heightened inflammatory response as one common pathway in delirium risk and progression, and we suggest other promising biological mechanisms that have recently emerged. Advanced multiple omics approaches coupled with bioinformatics methodologies have great promise to yield important discoveries that will advance delirium research.
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Affiliation(s)
- Sarinnapha M. Vasunilashorn
- Division of General Medicine, Department of Medicine, Beth Israel Deaconess Medical Center (BIDMC), Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
- Department of Epidemiology, Harvard T. H. Chan School of Public Health, Boston, MA, USA
| | - Simon T. Dillon
- Harvard Medical School, Boston, MA, USA
- Division of Interdisciplinary Medicine and Biotechnology, Department of Medicine, BIDMC, Boston, MA, USA
- Genomics, Proteomics, Bioinformatics and Systems Biology Center, BIDMC, Boston, MA, USA
| | - Edward R. Marcantonio
- Division of General Medicine, Department of Medicine, Beth Israel Deaconess Medical Center (BIDMC), Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
- Division of Gerontology, Department of Medicine, BIDMC, Boston, MA, USA
| | - Towia A. Libermann
- Harvard Medical School, Boston, MA, USA
- Division of Interdisciplinary Medicine and Biotechnology, Department of Medicine, BIDMC, Boston, MA, USA
- Genomics, Proteomics, Bioinformatics and Systems Biology Center, BIDMC, Boston, MA, USA
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Wiredu K, O’Connor S, Naseem H, Brauer BL, Kettenbach AN, Frost HR, Shaefi S, Gerber SA. Intraoperative plasma proteomic changes in cardiac surgery: In search of biomarkers of post-operative delirium. Proteomics Clin Appl 2023; 17:e2200066. [PMID: 36567636 PMCID: PMC10290728 DOI: 10.1002/prca.202200066] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2022] [Revised: 12/02/2022] [Accepted: 12/21/2022] [Indexed: 12/27/2022]
Abstract
PURPOSE Delirium presents a significant healthcare burden. It complicates post-operative care in up to 50% of cardiac surgical patients with worse outcomes, longer hospital stays and higher cost of care. Moreover, the nature of delirium following cardiac surgery with cardiopulmonary bypass (CPB) remains unclear, the underlying pathobiology is poorly understood, status quo diagnostic methods are subjective, and diagnostic biomarkers are currently lacking. OBJECTIVE To identify diagnostic biomarkers of delirium and for insights into possible neuronal pathomechanisms. EXPERIMENTAL DESIGN Comparative proteomic analyses were performed on plasma samples from a nested matched cohort of patients who underwent cardiac surgery. Validation by targeted proteomics was performed in an independent set of samples. Biomarkers were assessed for biological functions and diagnostic accuracy. RESULTS Forty-seven percent of subjects demonstrated delirium. Of 3803 proteins identified from patient samples by multiplexed quantitative proteomics, 16 were identified as signatures of exposure to CPB, and 11 biomarkers distinguished delirium cases from non-cases (AuROC = 93%). Notable among these biomarkers are C-reactive protein, serum amyloid A-1 and cathepsin-B. CONCLUSIONS AND CLINICAL RELEVANCE The interplay of systemic and central inflammatory markers sheds new light on delirium pathogenesis. This work suggests that accurate identification of cases may be achievable using panels of biomarkers.
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Affiliation(s)
- Kwame Wiredu
- Department of Molecular and Systems Biology, Geisel School of Medicine at Dartmouth, Lebanon, NH
- Department of Anesthesia, Critical Care and Pain Medicine, Mass General Hospital, Boston MA
- Department of Anaesthesia, Harvard Medical School, Boston MA
| | - Sean O’Connor
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Boston MA
| | - Heba Naseem
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Boston MA
| | - Brooke L. Brauer
- Department of Biochemistry and Cell Biology, Geisel School of Medicine at Dartmouth, Lebanon, NH
| | - Arminja N. Kettenbach
- Department of Biochemistry and Cell Biology, Geisel School of Medicine at Dartmouth, Lebanon, NH
- Dartmouth Cancer Center, Geisel School of Medicine at Dartmouth, Lebanon, NH
| | - Hildreth R. Frost
- Dartmouth Cancer Center, Geisel School of Medicine at Dartmouth, Lebanon, NH
- Department of Biomedical Data Science, Geisel School of Medicine at Dartmouth, Lebanon, NH
| | - Shahzad Shaefi
- Department of Anaesthesia, Harvard Medical School, Boston MA
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Boston MA
| | - Scott A. Gerber
- Department of Molecular and Systems Biology, Geisel School of Medicine at Dartmouth, Lebanon, NH
- Department of Biochemistry and Cell Biology, Geisel School of Medicine at Dartmouth, Lebanon, NH
- Dartmouth Cancer Center, Geisel School of Medicine at Dartmouth, Lebanon, NH
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10
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Lozano-Vicario L, García-Hermoso A, Cedeno-Veloz BA, Fernández-Irigoyen J, Santamaría E, Romero-Ortuno R, Zambom-Ferraresi F, Sáez de Asteasu ML, Muñoz-Vázquez ÁJ, Izquierdo M, Martínez-Velilla N. Biomarkers of delirium risk in older adults: a systematic review and meta-analysis. Front Aging Neurosci 2023; 15:1174644. [PMID: 37251808 PMCID: PMC10213257 DOI: 10.3389/fnagi.2023.1174644] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2023] [Accepted: 04/26/2023] [Indexed: 05/31/2023] Open
Abstract
Delirium is a neuropsychiatric syndrome associated with increased morbidity and mortality in older patients. The aim of this study was to review predictive biomarkers of delirium in older patients to gain insights into the pathophysiology of this syndrome and provide guidance for future studies. Two authors independently and systematically searched MEDLINE, Embase, Cochrane Library, Web of Science and Scopus databases up to August 2021. A total of 32 studies were included. Only 6 studies were eligible for the meta-analysis, pooled results showed a significant increase in some serum biomarkers (C-reactive protein [CRP], tumour necrosis factor alpha [TNF-α] and interleukin-6 [IL-6]) among patients with delirium (odds ratio = 1.88, 95% CI 1.01 to 1.637; I2 = 76.75%). Although current evidence does not favour the use of any particular biomarker, serum CRP, TNF-α, and IL-6 were the most consistent biomarkers of delirium in older patients.
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Affiliation(s)
| | - Antonio García-Hermoso
- Navarrabiomed, Hospital Universitario de Navarra (HUN), Universidad Pública de Navarra (UPNA), Instituto de Investigación Sanitaria de Navarra (IdiSNA), Pamplona, Spain
| | | | - Joaquín Fernández-Irigoyen
- Proteomics Unit, Navarrabiomed, Hospital Universitario de Navarra (HUN), Universidad Pública de Navarra (UPNA), Instituto de Investigación Sanitaria de Navarra (IDISNA), Pamplona, Spain
| | - Enrique Santamaría
- Proteomics Unit, Navarrabiomed, Hospital Universitario de Navarra (HUN), Universidad Pública de Navarra (UPNA), Instituto de Investigación Sanitaria de Navarra (IDISNA), Pamplona, Spain
| | | | - Fabricio Zambom-Ferraresi
- Navarrabiomed, Hospital Universitario de Navarra (HUN), Universidad Pública de Navarra (UPNA), Instituto de Investigación Sanitaria de Navarra (IdiSNA), Pamplona, Spain
- CIBER of Frailty and Healthy Aging (CIBERFES), Instituto de Salud Carlos III, Madrid, Spain
| | - Mikel L. Sáez de Asteasu
- Navarrabiomed, Hospital Universitario de Navarra (HUN), Universidad Pública de Navarra (UPNA), Instituto de Investigación Sanitaria de Navarra (IdiSNA), Pamplona, Spain
| | | | - Mikel Izquierdo
- Navarrabiomed, Hospital Universitario de Navarra (HUN), Universidad Pública de Navarra (UPNA), Instituto de Investigación Sanitaria de Navarra (IdiSNA), Pamplona, Spain
- CIBER of Frailty and Healthy Aging (CIBERFES), Instituto de Salud Carlos III, Madrid, Spain
| | - Nicolás Martínez-Velilla
- Geriatric Unit, Hospital Universitario de Navarra (HUN), Pamplona, Spain
- Navarrabiomed, Hospital Universitario de Navarra (HUN), Universidad Pública de Navarra (UPNA), Instituto de Investigación Sanitaria de Navarra (IdiSNA), Pamplona, Spain
- CIBER of Frailty and Healthy Aging (CIBERFES), Instituto de Salud Carlos III, Madrid, Spain
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11
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Sun Y, Peng HP, Wu TT. Postoperative C-Reactive Protein Predicts Postoperative Delirium in Colorectal Cancer Following Surgery. Clin Interv Aging 2023; 18:559-570. [PMID: 37038607 PMCID: PMC10082577 DOI: 10.2147/cia.s387117] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2022] [Accepted: 03/30/2023] [Indexed: 04/07/2023] Open
Abstract
Background Postoperative delirium (POD) is a common complication in operative patients. Neuroinflammation has been reported to be a potential mechanism associated with the development of POD. Identifying available inflammatory markers such as C-reactive protein (CRP) would aid clinicians in early detection of POD. Previous studies have demonstrated that CRP may be a promising predictive marker for POD. Thus, this study aimed to explore the association between CRP and POD among those elderly colorectal cancer (CRC) patients. Methods 643 patients with CRC were included in this study. CRP levels were measured before operation and on postoperative day 1. The univariate and multivariate regression analyses were used to identify risk factors for POD. Results Of 643 patients with CRC, 112 cases (17.4%) had POD. CRC patients with POD showed older age, higher CRP level on postoperative day 1, and higher percentage of smoking, diabetes mellitus, and chronic obstructive pulmonary disease (COPD) than CRC patients without POD. Preoperative CRP level was not associated with the POD. Univariate and multivariate regression analyses showed that older age (> 70 years), diabetes mellitus, COPD, and higher CRP level on postoperative day 1 (> 48 mg/L) were risk factors for POD in CRC patients. Conclusion Postoperative CRP level is an independent indicator for POD among CRC patients, suggesting the predictive role of postoperative CRP levels for POD in elderly CRC patients undergoing surgery.
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Affiliation(s)
- Yan Sun
- Department of Anesthesiology, First Affiliated Hospital of Soochow University, Suzhou, Jiangsu, People’s Republic of China
| | - Hui-Ping Peng
- Department of Anesthesiology, First Affiliated Hospital of Soochow University, Suzhou, Jiangsu, People’s Republic of China
| | - Ting-Ting Wu
- Department of Anesthesiology, First Affiliated Hospital of Soochow University, Suzhou, Jiangsu, People’s Republic of China
- Correspondence: Ting-Ting Wu; Hui-Ping Peng, Email ;
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12
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Wiredu K, Aduse-Poku E, Shaefi S, Gerber SA. Proteomics for the Discovery of Clinical Delirium Biomarkers: A Systematic Review of Major Studies. Anesth Analg 2023; 136:422-432. [PMID: 36580411 DOI: 10.1213/ane.0000000000006246] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Delirium represents a significant health care burden, diagnosed in more than 2 million elderly Americans each year. In the surgical population, delirium remains the most common complication among elderly patients, and is associated with longer hospital stays, higher costs of care, increased mortality, and functional impairment. The pathomechanism of disease is poorly understood, with current diagnostic approaches somewhat subjective and arbitrary, and definitive diagnostic biomarkers are currently lacking. Despite the recent interest in delirium research, biomarker discovery for it remains new. Most attempts to discover biomarkers are targeted studies that seek to assess the involvement of one or more members of a focused panel of candidates in delirium. For a more unbiased, system-biology view, we searched literature from Medical Literature Analysis and Retrieval System Online (MEDLINE), Cochrane Central, Web of Science, SCOPUS, and Dimensions between 2016 and 2021 for untargeted proteomic discovery studies for biomarkers of delirium conducted on human geriatric subjects. Two reviewers conducted an independent review of all search results and resolved discordance by consensus. From an overall search of 1172 publications, 8 peer-reviewed studies met our defined inclusion criteria. The 370 unique perioperative biomarkers identified in these reports are enriched in pathways involving activation of the immune system, inflammatory response, and the coagulation cascade. The most frequently identified biomarker was interleukin-6 (IL-6). By reviewing the distribution of protein biomarker candidates from these studies, we conclude that a panel of proteins, rather than a single biomarker, would allow for discriminating delirium cases from noncases. The paucity of hypothesis-generating studies in the peer-reviewed literature also suggests that a system-biology view of delirium pathomechanisms has yet to fully emerge.
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Affiliation(s)
- Kwame Wiredu
- From the Department of Molecular and Systems Biology, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire.,Program in Quantitative Biomedical Science, Dartmouth College, Hanover, New Hampshire
| | | | - Shahzad Shaefi
- Department of Anesthesiology, Critical Care and Pain Medicine, Harvard Medical School/Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Scott A Gerber
- From the Department of Molecular and Systems Biology, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire.,Program in Quantitative Biomedical Science, Dartmouth College, Hanover, New Hampshire.,Dartmouth Cancer Center, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire
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13
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Su LJ, Chen MJ, Yang R, Zou H, Chen TT, Li SL, Guo Y, Hu RF. Plasma biomarkers and delirium in critically ill patients after cardiac surgery: A prospective observational cohort study. Heart Lung 2023; 59:139-145. [PMID: 36801548 DOI: 10.1016/j.hrtlng.2023.02.010] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2022] [Revised: 02/06/2023] [Accepted: 02/08/2023] [Indexed: 02/18/2023]
Abstract
BACKGROUND Delirium is common in postoperative critically ill patients and may affect by intraoperative events. Biomarkers are vital indicators in the development and prediction of delirium. OBJECTIVES This study aimed to investigate the associations between various plasma biomarkers and delirium. METHODS We performed a prospective cohort study on cardiac surgery patients. Delirium assessment was performed twice daily using the confusion assessment method for the intensive care unit (ICU), and the Richmond Agitation Sedation Scale was used to assess the depth of sedation and agitation. Blood samples were collected on the day after ICU admission, and the concentrations of cortisol, interleukin (IL)-1β, IL-6, tumor necrosis factor α, soluble tumor necrosis factor receptor-1 (sTNFR-1), and sTNFR-2 were measured. RESULTS Delirium in the ICU was noted in 93 (29.2%, 95% CI 24.2-34.3) out of 318 patients (mean age 52 years, SD 12.0). The longer duration of cardiopulmonary bypass, aortic clamping and surgery, and higher plasma, erythrocytes, and platelet transfusion requirements were among the significant differences in intraoperative events between patients with and without delirium. Median levels of IL-6 (p = 0.017), TNF-α (p = 0.048), sTNFR-1 (p < 0.001), and sTNFR-2 (p = 0.001) were significantly higher in patients with delirium than in those without it. After adjusting for demographic variables and intraoperative events, only sTNFR-1 (odds ratio 6.83, 95% CI: 1.14-40.90) was associated with delirium. CONCLUSIONS Plasma IL-6, TNF-α, sTNFR-1, and sTNFR-2 levels were higher in ICU-acquired delirium patients after cardiac surgery. sTNFR-1 was a potential indicator of the disorder.
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Affiliation(s)
- Li-Jing Su
- School of Nursing, Fujian Medical University, Fuzhou 350122, China
| | - Mei-Jing Chen
- School of Nursing, Fujian Medical University, Fuzhou 350122, China
| | - Rong Yang
- Follow-up Center, Fujian Medical University Union Hospital, Fuzhou, China
| | - Hong Zou
- Department of Clinical Laboratory, Fujian Medical University Union Hospital, Fuzhou, China
| | - Ting-Ting Chen
- School of Nursing, Fujian Medical University, Fuzhou 350122, China
| | - Sai-Lan Li
- Department of Cardiac Surgery, Fujian Medical University Union Hospital, Fuzhou, China
| | - Yuan Guo
- Department of Cardiac Surgery, Fujian Medical University Union Hospital, Fuzhou, China
| | - Rong-Fang Hu
- School of Nursing, Fujian Medical University, Fuzhou 350122, China.
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14
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Ormseth CH, LaHue SC, Oldham MA, Josephson SA, Whitaker E, Douglas VC. Predisposing and Precipitating Factors Associated With Delirium: A Systematic Review. JAMA Netw Open 2023; 6:e2249950. [PMID: 36607634 PMCID: PMC9856673 DOI: 10.1001/jamanetworkopen.2022.49950] [Citation(s) in RCA: 41] [Impact Index Per Article: 41.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
IMPORTANCE Despite discrete etiologies leading to delirium, it is treated as a common end point in hospital and in clinical trials, and delirium research may be hampered by the attempt to treat all instances of delirium similarly, leaving delirium management as an unmet need. An individualized approach based on unique patterns of delirium pathophysiology, as reflected in predisposing factors and precipitants, may be necessary, but there exists no accepted method of grouping delirium into distinct etiologic subgroups. OBJECTIVE To conduct a systematic review to identify potential predisposing and precipitating factors associated with delirium in adult patients agnostic to setting. EVIDENCE REVIEW A literature search was performed of PubMed, Embase, Web of Science, and PsycINFO from database inception to December 2021 using search Medical Subject Headings (MeSH) terms consciousness disorders, confusion, causality, and disease susceptibility, with constraints of cohort or case-control studies. Two reviewers selected studies that met the following criteria for inclusion: published in English, prospective cohort or case-control study, at least 50 participants, delirium assessment in person by a physician or trained research personnel using a reference standard, and results including a multivariable model to identify independent factors associated with delirium. FINDINGS A total of 315 studies were included with a mean (SD) Newcastle-Ottawa Scale score of 8.3 (0.8) out of 9. Across 101 144 patients (50 006 [50.0%] male and 49 766 [49.1%] female patients) represented (24 015 with delirium), studies reported 33 predisposing and 112 precipitating factors associated with delirium. There was a diversity of factors associated with delirium, with substantial physiological heterogeneity. CONCLUSIONS AND RELEVANCE In this systematic review, a comprehensive list of potential predisposing and precipitating factors associated with delirium was found across all clinical settings. These findings may be used to inform more precise study of delirium's heterogeneous pathophysiology and treatment.
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Affiliation(s)
- Cora H. Ormseth
- Department of Emergency Medicine, University of California, San Francisco
| | - Sara C. LaHue
- Department of Neurology, University of California, San Francisco
| | - Mark A. Oldham
- Department of Psychiatry, University of Rochester Medical Center, Rochester, New York
| | | | - Evans Whitaker
- University of California, San Francisco, School of Medicine
| | - Vanja C. Douglas
- Department of Neurology, University of California, San Francisco
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15
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Hshieh TT, Schmitt EM, Fong TG, Arnold S, Cavallari M, Dickerson BC, Dillon ST, Jones RN, Libermann TA, Marcantonio ER, Pascual-Leone A, Shafi MM, Touroutoglou A, Travison TG, Gou RY, Tommet D, Abdeen A, Earp B, Kunze L, Lange J, Vlassakov K, Inouye SK. Successful aging after elective surgery II: Study design and methods. J Am Geriatr Soc 2023; 71:46-61. [PMID: 36214228 PMCID: PMC9870853 DOI: 10.1111/jgs.18065] [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: 06/09/2022] [Revised: 08/30/2022] [Accepted: 09/04/2022] [Indexed: 01/26/2023]
Abstract
BACKGROUND The Successful Aging after Elective Surgery (SAGES) II study was designed to increase knowledge of the pathophysiology and linkages between delirium and dementia. We examine novel biomarkers potentially associated with delirium, including inflammation, Alzheimer's disease (AD) pathology and neurodegeneration, neuroimaging markers, and neurophysiologic markers. The goal of this paper is to describe the study design and methods for the SAGES II study. METHODS The SAGES II study is a 5-year prospective observational study of 400-420 community dwelling persons, aged 65 years and older, assessed prior to scheduled surgery and followed daily throughout hospitalization to observe for development of delirium and other clinical outcomes. Delirium is measured with the Confusion Assessment Method (CAM), long form, after cognitive testing. Cognitive function is measured with a detailed neuropsychologic test battery, summarized as a weighted composite, the General Cognitive Performance (GCP) score. Other key measures include magnetic resonance imaging (MRI), transcranial magnetic stimulation (TMS)/electroencephalography (EEG), and Amyloid positron emission tomography (PET) imaging. We describe the eligibility criteria, enrollment flow, timing of assessments, and variables collected at baseline and during repeated assessments at 1, 2, 6, 12, and 18 months. RESULTS This study describes the hospital and surgery-related variables, delirium, long-term cognitive decline, clinical outcomes, and novel biomarkers. In inter-rater reliability assessments, the CAM ratings (weighted kappa = 0.91, 95% confidence interval, CI = 0.74-1.0) in 50 paired assessments and GCP ratings (weighted kappa = 0.99, 95% CI 0.94-1.0) in 25 paired assessments. We describe procedures for data quality assurance and Covid-19 adaptations. CONCLUSIONS This complex study presents an innovative effort to advance our understanding of the inter-relationship between delirium and dementia via novel biomarkers, collected in the context of major surgery in older adults. Strengths include the integration of MRI, TMS/EEG, PET modalities, and high-quality longitudinal data.
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Affiliation(s)
- Tammy T. Hshieh
- Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts, USA
- Division of Aging, Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts, USA
| | - Eva M. Schmitt
- Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts, USA
| | - Tamara G. Fong
- Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts, USA
- Department of Neurology, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Steve Arnold
- Department of Neurology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Michele Cavallari
- Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts, USA
- Department of Radiology, Brigham and Women’s Hospital, Boston, Massachusetts, USA
| | | | - Simon T. Dillon
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Richard N. Jones
- Department of Psychiatry and Human Behavior, Department of Neurology, Warren Alpert Medical School, Brown University, Providence, Rhode Island, USA
| | - Towia A. Libermann
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Edward R. Marcantonio
- Division of General Medicine, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
- Division of Gerontology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Alvaro Pascual-Leone
- Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts, USA
- Deanna and Sidney Wolk Center for Memory Health, HebrewSeniorLife, Boston, Massachusetts, USA
- Department of Neurology, Harvard Medical School, Boston, Massachusetts, USA
| | - Mouhsin M. Shafi
- Department of Neurology, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | | | - Thomas G. Travison
- Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts, USA
| | - Ray Yun Gou
- Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts, USA
| | - Douglas Tommet
- Department of Psychiatry and Human Behavior, Department of Neurology, Warren Alpert Medical School, Brown University, Providence, Rhode Island, USA
| | - Ayesha Abdeen
- Department of Orthopedic Surgery, Boston Medical Center, Boston, Massachusetts, USA
| | - Brandon Earp
- Department of Orthopedic Surgery, Brigham and Women’s Faulkner Hospital, Boston, Massachusetts, USA
| | - Lisa Kunze
- Department of Anesthesia, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Jeffrey Lange
- Department of Orthopedic Surgery, Brigham and Women’s Hospital, Boston, Massachusetts, USA
| | - Kamen Vlassakov
- Department of Anesthesia, Brigham and Women’s Hospital, Boston, Massachusetts, USA
| | - Sharon K. Inouye
- Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts, USA
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16
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Wilke S, Steiger E, Bärwolff TL, Kleine JF, Müller-Werdan U, Rosada A. Delirium in older hospitalized patients-A prospective analysis of the detailed course of delirium in geriatric inpatients. PLoS One 2023; 18:e0279763. [PMID: 36928887 PMCID: PMC10019648 DOI: 10.1371/journal.pone.0279763] [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: 07/08/2022] [Accepted: 12/14/2022] [Indexed: 03/18/2023] Open
Abstract
BACKGROUND Delirium in older hospitalized patients (> 65) is a common clinical syndrome, which is frequently unrecognized. AIMS We aimed to describe the detailed clinical course of delirium and related cognitive functioning in geriatric patients in a mainly non-postoperative setting in association with demographic and clinical parameters and additionally to identify risk factors for delirium in this common setting. METHODS Inpatients of a geriatric ward were screened for delirium and in the case of presence of delirium included into the study. Patients received three assessments including Mini-Mental-Status-Examination (MMSE) and the Delirium Rating Scale Revised 98 (DRS-R-98). We conducted correlation and linear mixed-effects model analyses to detect associations. RESULTS Overall 31 patients (82 years (mean)) met the criteria for delirium and were included in the prospective observational study. Within one week of treatment, mean delirium symptom severity fell below the predefined cut-off. While overall cognitive functioning improved over time, short- and long-term memory deficits remained. Neuroradiological conspicuities were associated with cognitive deficits, but not with delirium severity. DISCUSSION The temporal stability of some delirium symptoms (short-/long-term memory, language) on the one hand and on the other hand decrease in others (hallucinations, orientation) shown in our study visualizes the heterogeneity of symptoms attributed to delirium and their different courses, which complicates the differentiation between delirium and a preexisting cognitive decline. The recovery from delirium seems to be independent of preclinical cognitive status. CONCLUSION Treatment of the acute medical condition is associated with a fast decrease in delirium severity. Given the high incidence and prevalence of delirium in hospitalized older patients and its detrimental impact on cognition, abilities and personal independence further research needs to be done.
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Affiliation(s)
- Skadi Wilke
- Department of Geriatrics, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Edgar Steiger
- Central Research Institute of Ambulatory Health Care in Germany (Zi), Berlin, Germany
| | - Tanja L. Bärwolff
- Department of Geriatrics, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Justus F. Kleine
- Department of Neuroradiology, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | | | - Adrian Rosada
- Department of Geriatrics, Charité-Universitätsmedizin Berlin, Berlin, Germany
- * E-mail:
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17
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Yamanashi T, Crutchley KJ, Wahba NE, Nagao T, Marra PS, Akers CC, Sullivan EJ, Iwata M, Howard MA, Cho HR, Kawasaki H, Hughes CG, Pandharipande PP, Hefti MM, Shinozaki G. The genome-wide DNA methylation profiles among neurosurgery patients with and without post-operative delirium. Psychiatry Clin Neurosci 2023; 77:48-55. [PMID: 36266784 PMCID: PMC9812874 DOI: 10.1111/pcn.13495] [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: 05/14/2022] [Revised: 10/11/2022] [Accepted: 10/16/2022] [Indexed: 01/07/2023]
Abstract
AIMS There is no previous study demonstrating the differences of genome-wide DNA methylation (DNAm) profiles between patients with and without postoperative delirium (POD). We aimed to discover epigenetic (DNAm) markers that are associated with POD in blood obtained from patients before and after neurosurgery. METHODS Pre- and post-surgical blood DNA samples from 37 patients, including 10 POD cases, were analyzed using the Illumina EPIC array genome-wide platform. We examined DNAm differences in blood from patients with and without POD. Enrichment analysis with Gene Ontology and Kyoto Encyclopedia of Genes and Genomes terms were also conducted. RESULTS When POD cases were tested for DNAm change before and after surgery, enrichment analyses showed many relevant signals with statistical significance in immune response related-pathways and inflammatory cytokine related-pathways such as "cellular response to cytokine stimulus", "regulation of immune system process", "regulation of cell activation", and "regulation of cytokine production". Furthermore, after excluding the potential effect of common factors related to surgery and anesthesia between POD cases and non-POD controls, the enrichment analyses showed significant signals such as "immune response" and "T cell activation", which are same pathways previously identified from an independent non-surgical inpatient cohort. CONCLUSIONS Our first genome-wide DNAm investigation of POD showed promising signals related to immune response, inflammatory response and other relevant signals considered to be associated with delirium pathophysiology. Our data supports the hypothesis that epigenetics play an important role in the pathophysiological mechanism of delirium and suggest the potential usefulness of an epigenetics-based biomarker of POD.
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Affiliation(s)
- Takehiko Yamanashi
- Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Palo Alto, California, USA.,Department of Psychiatry, University of Iowa Carver College of Medicine, Iowa City, Iowa, USA.,Department of Neuropsychiatry, Tottori University Faculty of Medicine, Tottori, Japan
| | - Kaitlyn J Crutchley
- Department of Psychiatry, University of Iowa Carver College of Medicine, Iowa City, Iowa, USA.,University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Nadia E Wahba
- Department of Psychiatry, University of Iowa Carver College of Medicine, Iowa City, Iowa, USA
| | - Takaaki Nagao
- Department of Neurosurgery, University of Iowa Carver College of Medicine, Iowa City, Iowa, USA.,Department of Neurosurgery (Sakura), Toho University School of Medicine Faculty of Medicine, Chiba, Japan
| | - Pedro S Marra
- Department of Psychiatry, University of Iowa Carver College of Medicine, Iowa City, Iowa, USA
| | - Cade C Akers
- Department of Psychiatry, University of Iowa Carver College of Medicine, Iowa City, Iowa, USA
| | - Eleanor J Sullivan
- Department of Psychiatry, University of Iowa Carver College of Medicine, Iowa City, Iowa, USA
| | - Masaaki Iwata
- Department of Neuropsychiatry, Tottori University Faculty of Medicine, Tottori, Japan
| | - Mathew A Howard
- Department of Neurosurgery, University of Iowa Carver College of Medicine, Iowa City, Iowa, USA
| | - Hyunkeun R Cho
- College of Public Health, University of Iowa, Iowa City, Iowa, USA
| | - Hiroto Kawasaki
- Department of Neurosurgery, University of Iowa Carver College of Medicine, Iowa City, Iowa, USA
| | - Christopher G Hughes
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Pratik P Pandharipande
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Marco M Hefti
- Department of Pathology, University of Iowa Carver College of Medicine, Iowa City, Iowa, USA
| | - Gen Shinozaki
- Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Palo Alto, California, USA.,Department of Psychiatry, University of Iowa Carver College of Medicine, Iowa City, Iowa, USA
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18
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Zhang Y, Hu J, Zuo W, He P, Xue Q, Feng X, Zhang Y, Maze M. Longitudinal Profiling of Plasma Cytokines and Its Association With Postoperative Delirium in Elderly Patients Undergoing Major Lower Limb Surgery: A Prospective Observational Study. Anesth Analg 2023; 136:34-42. [PMID: 36534715 DOI: 10.1213/ane.0000000000006250] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND Surgery is accompanied by a systemic inflammatory response that may presage delirium in susceptible individuals. Little is known about the trajectory of plasma proinflammatory cytokines and their potential associations with postoperative delirium (POD). The current study longitudinally assessed both pro and anti-inflammatory plasma cytokine response and development of POD in older surgical patients to investigate associations with individual and/or clusters of cytokines that may indicate pathogenic mechanisms. METHODS A prospective longitudinal study sought to enroll patients >60 years old who were scheduled for major lower limb surgery under general anesthesia. Blood was obtained preoperatively and postoperatively from day 1 through postoperative day 4 for measurement of plasma interleukin-1β (IL-1β), IL-2, IL-4, IL-6, soluble IL-6 receptor (sIL-6R), IL-10, and tumor necrosis factor-α (TNF-α). Participants were assessed for POD twice daily for 4 days using the confusion assessment method. Trajectory of postoperative changes in plasma cytokines was determined by a group-based trajectory modeling analysis that was informed by distinct cytokines identified by time-dependent Cox regression model. RESULTS One hundred eighty-eight patients were assessed for eligibility of whom 129 underwent major surgery and 126 had complete datasets for final analysis. POD was diagnosed in 31 of 126 patients (24.6%). Time-dependent Cox regression model identified that higher IL-6 and sIL-6R levels were associated with higher risk of developing POD. A two-cluster model (stable lower and fluctuating higher levels) was considered to be the most statistically appropriate model for IL-6 and sIL-6R trajectory. More participants with fluctuating higher IL-6 were delirious (73.3% vs 18.0%, P = .001) as were those with fluctuating higher sIL-6R (81.3% vs 16.4%, P = .001). CONCLUSIONS As higher IL-6 and sIL-6R levels were significantly associated with higher risk of POD and the combination is required for IL-6 trans-signaling, it is possible that activation of this pathway may be associated with POD. Furthermore, it will be important to determine whether high levels of the combination of IL-6 and sIL-6R can be an early biomarker for the subsequent development of POD.
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Affiliation(s)
- Yu Zhang
- From the Department of Anesthesiology, The Second Hospital of Anhui Medical University, Hefei, China.,Key Laboratory of Anesthesiology and Perioperative Medicine of Anhui Higher Education Institutes, Anhui Medical University, Hefei, China
| | - Jun Hu
- From the Department of Anesthesiology, The Second Hospital of Anhui Medical University, Hefei, China.,Key Laboratory of Anesthesiology and Perioperative Medicine of Anhui Higher Education Institutes, Anhui Medical University, Hefei, China
| | - Weiguang Zuo
- Department of Clinical Laboratory, The Second Hospital of Anhui Medical University, Hefei, China
| | - Pei He
- Key Laboratory of Anesthesiology and Perioperative Medicine of Anhui Higher Education Institutes, Anhui Medical University, Hefei, China
| | - Qi Xue
- From the Department of Anesthesiology, The Second Hospital of Anhui Medical University, Hefei, China.,Key Laboratory of Anesthesiology and Perioperative Medicine of Anhui Higher Education Institutes, Anhui Medical University, Hefei, China
| | - Xiaomei Feng
- Department of Anesthesiology, University of Utah, Salt Lake City, Utah
| | - Ye Zhang
- From the Department of Anesthesiology, The Second Hospital of Anhui Medical University, Hefei, China.,Key Laboratory of Anesthesiology and Perioperative Medicine of Anhui Higher Education Institutes, Anhui Medical University, Hefei, China
| | - Mervyn Maze
- Department of Anesthesia and Perioperative Care and Centre for Cerebrovascular Research, University of California, San Francisco, San Francisco, California
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Hydrogen Gas Treatment Improves Postoperative Delirium and Cognitive Dysfunction in Elderly Noncardiac Patients. J Pers Med 2022; 13:jpm13010067. [PMID: 36675728 PMCID: PMC9867387 DOI: 10.3390/jpm13010067] [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: 10/26/2022] [Revised: 12/03/2022] [Accepted: 12/08/2022] [Indexed: 12/29/2022] Open
Abstract
Purpose: Postoperative delirium is a state of acute brain dysfunction characterized by fluctuating mental status that affects millions of patients each year. We used prophylactic inhalation of hydrogen gas in elderly patients undergoing elective surgery to compare their occurrence of postoperative delirium with that of controls. Methods: A total of 184 patients aged ≥ 65 years were enrolled and randomized into either a control group or a hydrogen inhalation group. The quality of sleep was assessed 1 day before and 1, 3, and 7 days after surgery at 8 A.M. The Confusion Assessment Method (CAM) was used as a screening tool for delirium and assessed the patients’ state of consciousness 1−7 days after surgery. Results: Postoperative delirium occurred in 17 (24%) of 70 patients without hydrogen inhalation and in 10 (12%) of 83 patients after hydrogen inhalation. The incidence of delirium was decreased in the hydrogen group. No significant differences were found between length of stay in hospital after surgery and sleep quality at 1, 3, and 7 days postoperatively between the two groups. The numerical rating scale (NRS) pain scores were higher in the hydrogen group (4.08 ± 1.77) than the control group (3.54 ± 1.77) on day 1 (p < 0.05); however, the mean difference between the two groups was small (1 to 1.6). There were no significant differences on day 3 and 7. The postoperative C-reactive protein level was significantly lower in the hydrogen group than the control group. Conclusions: This study suggests that hydrogen inhalation can prevent postoperative delirium in elderly noncardiac patients by reducing the inflammatory response.
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20
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Ma X, Mei X, Tang T, Wang M, Wei X, Zheng H, Cao J, Zheng H, Cody K, Xiong L, Marcantonio ER, Xie Z, Shen Y. Preoperative homocysteine modifies the association between postoperative C-reactive protein and postoperative delirium. Front Aging Neurosci 2022; 14:963421. [PMID: 36212043 PMCID: PMC9532549 DOI: 10.3389/fnagi.2022.963421] [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: 06/08/2022] [Accepted: 09/02/2022] [Indexed: 01/08/2023] Open
Abstract
Background Homocysteine and C-reactive protein (CRP) may serve as biomarkers of postoperative delirium. We set out to compare the role of blood concentration of homocysteine versus CRP in predicting postoperative delirium in patients. Materials and methods In this prospective observational cohort study, the plasma concentration of preoperative homocysteine and postoperative CRP was measured. Delirium incidence and severity within 3 days postoperatively were determined using the Confusion Assessment Method and Confusion Assessment Method-Severity algorithm. Results Of 143 participants [69% female, median (interquartile range, 25th–75th) age of 71 (67–76) years] who had knee or hip surgery under general anesthesia, 44 (31%) participants developed postoperative delirium. Postoperative plasma concentration of CRP was associated with postoperative delirium incidence [adjusted odds ratio (OR) per one standard deviation change in CRP: 1.51; 95% Confidence Interval (CI): 1.05, 2.16; P = 0.026], and severity [in which each one standard deviation increase in postoperative CRP was associated with a 0.47 point (95% CI: 0.18–0.76) increase in the severity of delirium, P = 0.002] after adjusting age, sex, preoperative Mini-Mental State Examination score and the days when postoperative CRP was measured. A statistically significant interaction (adjusted P = 0.044) was also observed, in which the association between postoperative plasma concentration of CRP and postoperative delirium incidence was stronger in the participants with lower preoperative plasma concentrations of homocysteine compared to those with higher preoperative levels. Conclusion Pending validation studies, these data suggest that preoperative plasma concentration of homocysteine modifies the established association between postoperative plasma concentration of CRP and postoperative delirium incidence.
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Affiliation(s)
- Xin Ma
- Department of Psychiatry, Shanghai Tenth People’s Hospital, Tongji University School of Medicine, Shanghai, China
- Anesthesia and Brain Research Institute, Tongji University School of Medicine, Shanghai, China
| | - Xinchun Mei
- Department of Psychiatry, Shanghai Tenth People’s Hospital, Tongji University School of Medicine, Shanghai, China
- Anesthesia and Brain Research Institute, Tongji University School of Medicine, Shanghai, China
| | - Tianyi Tang
- Department of Psychiatry, Shanghai Tenth People’s Hospital, Tongji University School of Medicine, Shanghai, China
- Anesthesia and Brain Research Institute, Tongji University School of Medicine, Shanghai, China
| | - Meijuan Wang
- Department of Psychiatry, Shanghai Tenth People’s Hospital, Tongji University School of Medicine, Shanghai, China
| | - Xiaoyi Wei
- Department of Psychiatry, Shanghai Tenth People’s Hospital, Tongji University School of Medicine, Shanghai, China
- Anesthesia and Brain Research Institute, Tongji University School of Medicine, Shanghai, China
| | - Hailin Zheng
- Department of Psychiatry, Shanghai Tenth People’s Hospital, Tongji University School of Medicine, Shanghai, China
- Anesthesia and Brain Research Institute, Tongji University School of Medicine, Shanghai, China
| | - Jing Cao
- Anesthesia and Brain Research Institute, Tongji University School of Medicine, Shanghai, China
| | - Hui Zheng
- Massachusetts General Hospital Biostatistics Center, Massachusetts General Hospital and Harvard Medical School, Boston, MA, United States
| | - Kathryn Cody
- Anesthesia Research Center, Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA, United States
| | - Lize Xiong
- Department of Anesthesiology and Translational Research Institute of Brain and Brain-Like Intelligence, Shanghai Fourth People’s Hospital of Tongji University School of Medicine, Shanghai, China
| | - Edward R. Marcantonio
- Divisions of General Medicine and Gerontology, Department of Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, United States
| | - Zhongcong Xie
- Geriatric Anesthesia Research Unit, Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital and Harvard Medical School, Charlestown, MA, United States
- *Correspondence: Zhongcong Xie,
| | - Yuan Shen
- Anesthesia and Brain Research Institute, Tongji University School of Medicine, Shanghai, China
- Shanghai Mental Health Center of Shanghai Jiao Tong University, Shanghai, China
- Yuan Shen,
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21
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Zhao Y, Zang C, Ren S, Fu J, Liu N, Zhou Z, Lang B. Effects of different levels of controlled hypotension on regional cerebral oxygen saturation and postoperative cognitive function in patients undergoing total knee arthroplasty. Front Med (Lausanne) 2022; 9:989341. [PMID: 36186818 PMCID: PMC9515465 DOI: 10.3389/fmed.2022.989341] [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: 07/12/2022] [Accepted: 08/26/2022] [Indexed: 11/13/2022] Open
Abstract
Background Controlled hypotension technique was usually used to reduce intraoperative bleeding, and it could improve visualization of the surgical field during total knee arthroplasty (TKA). However, inappropriate controlled hypotension, through reducing cerebral blood flow or cerebral perfusion pressure, may cause postoperative cognitive dysfunction (POCD), so it is important to identify the appropriate level of controlled hypotension. Objective: To investigate the effects of different levels of controlled hypotension on regional cerebral oxygen saturation and postoperative cognitive function in patients undergoing TKA. Methods Patients meeting inclusion criteria were enrolled through preoperative visits and basic information was obtained. The patients were randomly divided into three groups: Group A, MAP was maintained at 90–100% of the baseline; Group B, MAP was maintained at 80–90% of the baseline; Group C, MAP was maintained at 70–80% of the baseline. The MAP, HR, and rSO2 were observed and recorded during the operation. The C-reactive protein (CRP), hemoglobin (Hb) and MMSE score at 1, 3, and 7 days after operation were recorded. SPSS25.0 was used for data analysis. Result When the MAP had a decrease among the three groups, rSO2 did not decrease significantly, and none of the patients experienced POCD which was measured by MMSE. And there was no correlation between the decline in rSO2 and that in MAP. Conclusion No POCD was experienced in the three groups, and we recommend that the controlled hypotensive target indicated by MAP was maintained at 70–80% of the baseline which not only decreases intraoperative bleeding and improve the quality of the surgical field, but also is still within safe levels.
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Affiliation(s)
- Yajuan Zhao
- Department of Anesthesiology, Weifang People’s Hospital, Weifang, China
| | - Chuanbo Zang
- School of Anesthesiology, Weifang Medical University, Weifang, China
| | - Shengjie Ren
- School of Anesthesiology, Weifang Medical University, Weifang, China
| | - Jianbin Fu
- The 80th Group Army Hospital of the Chinese People’s Liberation Army, Weifang, China
| | - Ning Liu
- Department of Anesthesiology, Weifang People’s Hospital, Weifang, China
| | - Ziyu Zhou
- The 80th Group Army Hospital of the Chinese People’s Liberation Army, Weifang, China
| | - Bao Lang
- Department of Anesthesiology, Weifang People’s Hospital, Weifang, China
- *Correspondence: Bao Lang,
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22
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Fong TG, Inouye SK. The inter-relationship between delirium and dementia: the importance of delirium prevention. Nat Rev Neurol 2022; 18:579-596. [PMID: 36028563 PMCID: PMC9415264 DOI: 10.1038/s41582-022-00698-7] [Citation(s) in RCA: 76] [Impact Index Per Article: 38.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/07/2022] [Indexed: 12/30/2022]
Abstract
Delirium and dementia are two frequent causes of cognitive impairment among older adults and have a distinct, complex and interconnected relationship. Delirium is an acute confusional state characterized by inattention, cognitive dysfunction and an altered level of consciousness, whereas dementia is an insidious, chronic and progressive loss of a previously acquired cognitive ability. People with dementia have a higher risk of developing delirium than the general population, and the occurrence of delirium is an independent risk factor for subsequent development of dementia. Furthermore, delirium in individuals with dementia can accelerate the trajectory of the underlying cognitive decline. Delirium prevention strategies can reduce the incidence of delirium and associated adverse outcomes, including falls and functional decline. Therefore, delirium might represent a modifiable risk factor for dementia, and interventions that prevent or minimize delirium might also reduce or prevent long-term cognitive impairment. Additionally, understanding the pathophysiology of delirium and the connection between delirium and dementia might ultimately lead to additional treatments for both conditions. In this Review, we explore mechanisms that might be common to both delirium and dementia by reviewing evidence on shared biomarkers, and we discuss the importance of delirium recognition and prevention in people with dementia. In this Review, Fong and Inouye explore mechanisms that might be common to both delirium and dementia. They present delirium as a possible modifiable risk factor for dementia and discuss the importance of delirium prevention strategies in reducing this risk. Delirium and dementia are frequent causes of cognitive impairment among older adults and have a distinct, complex and interconnected relationship. Delirium prevention strategies have been shown to reduce not only the incidence of delirium but also the incidence of adverse outcomes associated with delirium such as falls and functional decline. Adverse outcomes associated with delirium, such as the onset of dementia symptoms in individuals with preclinical dementia, and/or the acceleration of cognitive decline in individuals with dementia might also be delayed by the implementation of delirium prevention strategies. Evidence regarding the association of systemic inflammatory and neuroinflammatory biomarkers with delirium is variable, possibly as a result of co-occurring dementia pathology or disruption of the blood–brain barrier. Alzheimer disease pathology, even prior to the onset of symptoms, might have an effect on delirium risk, with potential mechanisms including neuroinflammation and gene–protein interactions with the APOE ε4 allele. Novel strategies, including proteomics, multi-omics, neuroimaging, transcranial magnetic stimulation and EEG, are beginning to reveal how changes in cerebral blood flow, spectral power and connectivity can be associated with delirium; further work is needed to expand these findings to patients with delirium superimposed upon dementia.
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Affiliation(s)
- Tamara G Fong
- Aging Brain Center, Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, MA, USA. .,Department of Neurology, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, USA.
| | - Sharon K Inouye
- Aging Brain Center, Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, MA, USA.,Division of Gerontology, Department of Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, USA
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23
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Meulenbroek AL, van Mil SR, Faes MC, Mattace-Raso FUS, Fourneau I, van der Laan L. A systematic review of strategies for preventing delirium in patients undergoing vascular surgery. Ann Vasc Surg 2022; 85:433-443. [PMID: 35460860 DOI: 10.1016/j.avsg.2022.04.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2022] [Revised: 03/29/2022] [Accepted: 04/03/2022] [Indexed: 12/19/2022]
Abstract
OBJECTIVES Elderly patients undergoing vascular surgery are at risk of developing postoperative delirium, which is associated with a high mortality. Delirium prevention is difficult and is investigated in surgical patients from various specialisms, but little is known about delirium prevention in vascular surgery. For this reason we performed a systematic review on strategies for delirium prevention in patients undergoing elective surgery for peripheral arterial disease or for an aneurysm of the abdominal aorta. METHODS This systematic review included studies describing strategies for preventing delirium in patients undergoing elective surgery for peripheral arterial disease or for an aneurysm of the abdominal aorta. The search was conducted using the keywords 'vascular surgery', 'prevention' and 'delirium', and was last run on October 21st, 2021 in the electronic databases Pubmed, MEDLINE, Embase, Web of Science, the Cochrane library and Emcare. Risk of bias was assessed using the Cochrane Risk of Bias tool for randomized controlled trials and the ROBINS-1 tool for observational studies. RESULTS Four studies including 565 patients were included in the systematic review. A significant decrease in the incidence of delirium was reported by a study investigating the effect of comprehensive geriatric assessments within patients undergoing surgery for an aneurysm of the abdominal aorta or lower limb bypass surgery (24% in the control group versus 11% in the intervention group, p = 0.018), and in the total group of a study evaluating the effect of outpatient clinic multimodal prehabilitation for patients with an aneurysm of the abdominal aorta (11.7% in the control group versus 8.2% in the intervention group, p = 0.043, OR = 0.56). A non-significant decrease in delirium incidence was described for patients receiving a multidisciplinary quality improvement at the vascular surgical ward (21.4% in the control group versus 14.6% in the intervention group, p = 0.17). The study concerning the impact of the type of anaesthesia on delirium in eleven older vascular surgical patients, of which three developed delirium, did not differentiate between the different types of anaesthesia the patients received. CONCLUSION Despite the high and continuous increasing incidence of delirium in the growing elderly vascular population, little is known about effective preventive strategies. An approach to address multiple risk factors simultaneously seems to be promising in delirium prevention, whether through multimodal prehabilitation or comprehensive geriatric assessments. Several strategies including prehabilitation programs have been proven to be successful in other types of surgery and more research is required to evaluate effective preventive strategies and prehabilitation programs in vascular surgical patients.
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Affiliation(s)
| | | | - Miriam C Faes
- Department of Geriatrics, Amphia Hospital, Breda, the Netherlands
| | - Francesco U S Mattace-Raso
- Section of Geriatric Medicine, Department of Internal Medicine, Erasmus MC University Medical Centre, Rotterdam, the Netherlands
| | - Inge Fourneau
- Department of Cardiovascular science and Vascular Surgery, University Hospitals Leuven, Belgium
| | - Lijckle van der Laan
- Department of Surgery, Amphia Hospital, Breda, the Netherlands; Department of Cardiovascular science and Vascular Surgery, University Hospitals Leuven, Belgium
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24
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Vasunilashorn SM, Dillon ST, Chan NY, Fong TG, Joseph M, Tripp B, Xie Z, Ngo LH, Lee CG, Elias JA, Otu HH, Inouye SK, Marcantonio ER, Libermann TA. Proteome-Wide Analysis Using SOMAscan Identifies and Validates Chitinase-3-Like Protein 1 as a Risk and Disease Marker of Delirium Among Older Adults Undergoing Major Elective Surgery. J Gerontol A Biol Sci Med Sci 2022; 77:484-493. [PMID: 35239952 PMCID: PMC8893174 DOI: 10.1093/gerona/glaa326] [Citation(s) in RCA: 22] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2020] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Delirium (an acute change in cognition) is a common, morbid, and costly syndrome seen primarily in aging adults. Despite increasing knowledge of its epidemiology, delirium remains a clinical diagnosis with no established biomarkers to guide diagnosis or management. Advances in proteomics now provide opportunities to identify novel markers of risk and disease progression for postoperative delirium and its associated long-term consequences (eg, long-term cognitive decline and Alzheimer's disease [AD]). METHODS In a nested matched case-control study (18 delirium/no-delirium pairs) within the Successful Aging after Elective Surgery study (N = 556), we evaluated the association of 1305 plasma proteins preoperatively [PREOP] and on postoperative day 2 [POD2]) with delirium using SOMAscan. Generalized linear models were applied to enzyme-linked immunosorbant assay (ELISA) validation data of one protein across the full cohort. Multi-protein modeling included delirium biomarkers identified in prior work (C-reactive protein, interleukin-6 [IL6]). RESULTS We identified chitinase-3-like-protein-1 (CHI3L1/YKL-40) as the sole delirium-associated protein in both a PREOP and a POD2 predictor model, a finding confirmed by ELISA. Multi-protein modeling found high PREOP CHI3L1/YKL-40 and POD2 IL6 increased the risk of delirium (relative risk [95% confidence interval] Quartile [Q]4 vs Q1: 2.4[1.2-5.0] and 2.1[1.1-4.1], respectively). CONCLUSIONS Our identification of CHI3L1/YKL-40 in postoperative delirium parallels reports of CHI3L1/YKL-40 and its association with aging, mortality, and age-related conditions including AD onset and progression. This highlights the type 2 innate immune response, involving CHI3L1/YKL-40, as an underlying mechanism of postoperative delirium, a common, morbid, and costly syndrome that threatens the independence of older adults.
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Affiliation(s)
- Sarinnapha M Vasunilashorn
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - Simon T Dillon
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - Noel Y Chan
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Tamara G Fong
- Harvard Medical School, Boston, Massachusetts, USA
- Department of Neurology, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
- Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts, USA
| | - Marie Joseph
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Bridget Tripp
- Department of Electrical and Computer Engineering, University of Nebraska-Lincoln, Lincoln, Nebraska, USA
| | - Zhongcong Xie
- Harvard Medical School, Boston, Massachusetts, USA
- Department of Anesthesia, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Long H Ngo
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - Chun Geun Lee
- Department of Molecular Microbiology and Immunology, Warren Alpert School of Medicine, Brown University, Boston, Massachusetts, USA
| | - Jack A Elias
- Department of Molecular Microbiology and Immunology, Warren Alpert School of Medicine, Brown University, Boston, Massachusetts, USA
| | - Hasan H Otu
- Department of Electrical and Computer Engineering, University of Nebraska-Lincoln, Lincoln, Nebraska, USA
| | - Sharon K Inouye
- Harvard Medical School, Boston, Massachusetts, USA
- Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts, USA
| | - Edward R Marcantonio
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - Towia A Libermann
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
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25
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Khan SH, Lindroth H, Jawed Y, Wang S, Nasser J, Seyffert S, Naqvi K, Perkins AJ, Gao S, Kesler K, Khan B. Serum Biomarkers in Postoperative Delirium After Esophagectomy. Ann Thorac Surg 2022; 113:1000-1007. [PMID: 33774004 PMCID: PMC8582321 DOI: 10.1016/j.athoracsur.2021.03.035] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2020] [Revised: 02/09/2021] [Accepted: 03/17/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND Esophagectomy is associated with postoperative delirium, but its pathophysiology is not well defined. We conducted this study to measure the relationship among serum biomarkers of inflammation and neuronal injury and delirium incidence and severity in a cohort of esophagectomy patients. METHODS Blood samples were obtained from patients preoperatively and on postoperative days 1 and 3 and were analyzed for S100 calcium-binding protein B, C-reactive protein (CRP), interleukin (IL) 8 and IL-10, tumor necrosis factor-α, and insulin-like growth factor 1. Delirium was assessed twice daily using the Richmond Agitation Sedation Scale and Confusion Assessment Method for Intensive Care Unit. Delirium severity was assessed once daily with the Delirium Rating Scale-Revised-98. RESULTS Samples from 71 patients were included. Preoperative biomarker concentrations were not associated with postoperative delirium. Significant differences in change in concentrations from preoperatively to postoperative day 1 were seen in IL-8 (delirium, 38.6; interquartile range [IQR], 29.3-69.8; no delirium, 24.8; IQR, 16.0-41.7, P = .022), and IL-10 (delirium, 26.1; IQR, 13.9-36.7; no delirium, 12.4; IQR, 7.7-25.7; P = .025). Greater postoperative increase in S100 calcium-binding protein B (Spearman r = 0.289, P = .020) and lower levels of insulin-like growth factor 1 were correlated with greater delirium severity (Spearman r = -0.27, P = .040). Greater CRP change quartiles were associated with higher delirium incidence adjusting for severity of illness (odds ratio, 1.68; 95% confidence interval, 1.03-2.75; P = .037) or comorbidities (odds ratio, 1.70; 95% confidence interval, 1.05-2.76, P = .030). CONCLUSIONS Differences in change in serum CRP, IL-8, and IL-10 concentrations were associated with postoperative delirium, suggesting biomarker measurement early in the postoperative course is associated with delirium.
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Affiliation(s)
- Sikandar H Khan
- Division of Pulmonary, Critical Care, Sleep and Occupational Medicine, Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana; Center for Aging Research, Regenstrief Institute, Indiana University School of Medicine, Indianapolis, Indiana.
| | - Heidi Lindroth
- Division of Pulmonary, Critical Care, Sleep and Occupational Medicine, Department of Medicine, Indiana University School of Medicine, Indianapolis, IN,IU Center of Aging Research, Regenstrief Institute, Indianapolis, IN,Indiana University School of Nursing, Indianapolis, Indiana
| | - Yameena Jawed
- Division of Pulmonary, Critical Care, Sleep and Occupational Medicine, Department of Medicine, Indiana University School of Medicine, Indianapolis, IN
| | - Sophia Wang
- Department of Psychiatry, Indiana University School of Medicine, Indianapolis, IN
| | - Jason Nasser
- IU Center of Aging Research, Regenstrief Institute, Indianapolis, IN,Lebanese American University, School of Medicine, Byblos, Lebanon
| | - Sarah Seyffert
- Department of Internal Medicine, Indiana University School of Medicine
| | - Kiran Naqvi
- IU Center of Aging Research, Regenstrief Institute, Indianapolis, IN
| | - Anthony J. Perkins
- Department of Biostatistics, Indiana University School of Medicine, Indianapolis, IN
| | - Sujuan Gao
- Department of Biostatistics, Indiana University School of Medicine, Indianapolis, IN
| | - Kenneth Kesler
- Department of Cardiothoracic Surgery, Indiana University
| | - Babar Khan
- Division of Pulmonary, Critical Care, Sleep and Occupational Medicine, Department of Medicine, Indiana University School of Medicine, Indianapolis, IN,IU Center of Aging Research, Regenstrief Institute, Indianapolis, IN
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26
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Di Giorgio A, Mirijello A, De Gennaro C, Fontana A, Alboini PE, Florio L, Inchingolo V, Zarrelli M, Miscio G, Raggi P, Marciano C, Antonioni A, De Cosmo S, Aucella F, Greco A, Carella M, Copetti M, Leone MA. Factors Associated with Delirium in COVID-19 Patients and Their Outcome: A Single-Center Cohort Study. Diagnostics (Basel) 2022; 12:diagnostics12020544. [PMID: 35204633 PMCID: PMC8871116 DOI: 10.3390/diagnostics12020544] [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: 01/25/2022] [Revised: 02/10/2022] [Accepted: 02/16/2022] [Indexed: 11/16/2022] Open
Abstract
Background: A significant proportion of patients with coronavirus disease 2019 (COVID-19) suffer from delirium during hospitalization. This single-center observational study investigates the occurrence of delirium, the associated risk factors and its impact on in-hospital mortality in an Italian cohort of COVID 19 inpatients. Methods: Data were collected in the COVID units of a general medical hospital in the South of Italy. Socio-demographic, clinical and pharmacological features were collected. Diagnosis of delirium was based on a two-step approach according to 4AT criteria and DSM5 criteria. Outcomes were: dates of hospital discharge, Intensive Care Unit (ICU) admission, or death, whichever came first. Univariable and multivariable proportional hazards Cox regression models were estimated, and risks were reported as hazard ratios (HR) along with their 95% confidence intervals (95% CI). Results: A total of 47/214 patients (22%) were diagnosed with delirium (21 hypoactive, 15 hyperactive, and 11 mixed). In the multivariable model, four independent variables were independently associated with the presence of delirium: dementia, followed by age at admission, C-reactive protein (CRP), and Glasgow Coma Scale. In turn, delirium was the strongest independent predictor of death/admission to ICU (composite outcome), followed by Charlson Index (not including dementia), CRP, and neutrophil-to-lymphocyte ratio. The probability of reaching the composite outcome was higher for patients with the hypoactive subtype than for those with the hyperactive subtype. Conclusions: Delirium was the strongest predictor of poor outcome in COVID-19 patients, especially in the hypoactive subtype. Several clinical features and inflammatory markers were associated with the increased risk of its occurrence. The early recognition of these factors may help clinicians to select patients who would benefit from both non-pharmacological and pharmacological interventions in order to prevent delirium, and in turn, reduce the risk of admission to ICU or death.
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Affiliation(s)
- Annabella Di Giorgio
- Neurology Unit, Fondazione IRCCS Casa Sollievo della Sofferenza, 71013 San Giovanni Rotondo, Italy; (A.D.G.); (C.D.G.); (P.E.A.); (L.F.); (V.I.); (M.Z.)
| | - Antonio Mirijello
- Internal Medicine Unit, Fondazione IRCCS Casa Sollievo della Sofferenza, 71013 San Giovanni Rotondo, Italy; (A.M.); (S.D.C.)
| | - Clara De Gennaro
- Neurology Unit, Fondazione IRCCS Casa Sollievo della Sofferenza, 71013 San Giovanni Rotondo, Italy; (A.D.G.); (C.D.G.); (P.E.A.); (L.F.); (V.I.); (M.Z.)
| | - Andrea Fontana
- Biostatistics Unit, Fondazione IRCCS Casa Sollievo della Sofferenza, 71013 San Giovanni Rotondo, Italy; (A.F.); (M.C.)
| | - Paolo Emilio Alboini
- Neurology Unit, Fondazione IRCCS Casa Sollievo della Sofferenza, 71013 San Giovanni Rotondo, Italy; (A.D.G.); (C.D.G.); (P.E.A.); (L.F.); (V.I.); (M.Z.)
| | - Lucia Florio
- Neurology Unit, Fondazione IRCCS Casa Sollievo della Sofferenza, 71013 San Giovanni Rotondo, Italy; (A.D.G.); (C.D.G.); (P.E.A.); (L.F.); (V.I.); (M.Z.)
| | - Vincenzo Inchingolo
- Neurology Unit, Fondazione IRCCS Casa Sollievo della Sofferenza, 71013 San Giovanni Rotondo, Italy; (A.D.G.); (C.D.G.); (P.E.A.); (L.F.); (V.I.); (M.Z.)
| | - Michele Zarrelli
- Neurology Unit, Fondazione IRCCS Casa Sollievo della Sofferenza, 71013 San Giovanni Rotondo, Italy; (A.D.G.); (C.D.G.); (P.E.A.); (L.F.); (V.I.); (M.Z.)
| | - Giuseppe Miscio
- Laboratory Medicine Unit, Fondazione IRCCS Casa Sollievo della Sofferenza, 71013 San Giovanni Rotondo, Italy;
| | - Pamela Raggi
- Scientific Research Department, Fondazione IRCCS Casa Sollievo della Sofferenza, 71013 San Giovanni Rotondo, Italy; (P.R.); (C.M.); (M.C.)
| | - Carmen Marciano
- Scientific Research Department, Fondazione IRCCS Casa Sollievo della Sofferenza, 71013 San Giovanni Rotondo, Italy; (P.R.); (C.M.); (M.C.)
| | - Annibale Antonioni
- Unit of Clinical Neurology, Department of Neuroscience and Rehabilitation, AOU Sant’Anna, 44124 Ferrara, Italy;
| | - Salvatore De Cosmo
- Internal Medicine Unit, Fondazione IRCCS Casa Sollievo della Sofferenza, 71013 San Giovanni Rotondo, Italy; (A.M.); (S.D.C.)
| | - Filippo Aucella
- Nephrology Unit, Fondazione IRCCS Casa Sollievo della Sofferenza, 71013 San Giovanni Rotondo, Italy;
| | - Antonio Greco
- Geriatric Unit, Fondazione IRCCS Casa Sollievo della Sofferenza, 71013 San Giovanni Rotondo, Italy;
| | - Massimo Carella
- Scientific Research Department, Fondazione IRCCS Casa Sollievo della Sofferenza, 71013 San Giovanni Rotondo, Italy; (P.R.); (C.M.); (M.C.)
| | - Massimiliano Copetti
- Biostatistics Unit, Fondazione IRCCS Casa Sollievo della Sofferenza, 71013 San Giovanni Rotondo, Italy; (A.F.); (M.C.)
| | - Maurizio A. Leone
- Neurology Unit, Fondazione IRCCS Casa Sollievo della Sofferenza, 71013 San Giovanni Rotondo, Italy; (A.D.G.); (C.D.G.); (P.E.A.); (L.F.); (V.I.); (M.Z.)
- Correspondence: ; Tel.: +39-0882-410964
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Subramaniam A, Wengritzky R, Skinner S, Shekar K. Colorectal Surgery in Critically Unwell Patients: A Multidisciplinary Approach. Clin Colon Rectal Surg 2022; 35:244-260. [PMID: 35966378 PMCID: PMC9374534 DOI: 10.1055/s-0041-1740045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/11/2023]
Abstract
A proportion of patients require critical care support following elective or urgent colorectal procedures. Similarly, critically ill patients in intensive care units may also need colorectal surgery on occasions. This patient population is increasing in some jurisdictions given an aging population and increasing societal expectations. As such, this population often includes elderly, frail patients or patients with significant comorbidities. Careful stratification of operative risks including the need for prolonged intensive care support should be part of the consenting process. In high-risk patients, especially in setting of unplanned surgery, treatment goals should be clearly defined, and appropriate ceiling of care should be established to minimize care that is not in the best interest of the patient. In this article we describe approaches to critically unwell patients requiring colorectal surgery and how a multidisciplinary approach with proactive intensive care involvement can help achieve the best outcomes for these patients.
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Affiliation(s)
- Ashwin Subramaniam
- Department of Intensive Care Medicine, Peninsula Health, Frankston, Victoria, Australia,Faculty of Medicine, Nursing and Health Sciences, Monash University, Clayton, Victoria, Australia,Department of Intensive Care, The Bays Healthcare, Mornington, Victoria, Australia,Address for correspondence Ashwin Subramaniam, MBBS, MMed, FRACP, FCICM Intensive Care Specialist, Frankston HospitalVictoriaAustralia
| | - Robert Wengritzky
- Department of Anaesthesia, Peninsula Health, Frankston, Victoria, Australia
| | - Stewart Skinner
- Department of Surgery, Peninsula Health, Frankston, Victoria, Australia
| | - Kiran Shekar
- Adult Intensive Care Services, the Prince Charles Hospital, Brisbane, Queensland, Australia,Queensland University of Technology, University of Queensland, Brisbane, Queensland, Australia
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Wang S, Greene R, Song Y, Chan C, Lindroth H, Khan S, Rios G, Sanders RD, Khan B. Postoperative delirium and its relationship with biomarkers for dementia: a meta-analysis. Int Psychogeriatr 2022; 34:1-14. [PMID: 35034675 PMCID: PMC9288560 DOI: 10.1017/s104161022100274x] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
OBJECTIVES This study seeks to identify Alzheimer's and related dementias (ADRD) biomarkers associated with postoperative delirium (POD) via meta-analysis. DESIGN A comprehensive search was conducted. Studies met the following inclusion criteria: >18 years of age, identified POD with standardized assessment, and biomarker measured in the AT(N)-X (A = amyloid, T = tau, (N)=neurodegeneration, X-Other) framework. Exclusion criteria: focus on prediction of delirium, delirium superimposed on dementia, other neurologic or psychiatric disorders, or terminal delirium. Reviewers extracted and synthesized data for the meta-analysis. SETTING Meta-analysis. PARTICIPANTS Patients with POD. MEASUREMENTS Primary outcome: association between POD and ATN-X biomarkers. Secondary outcomes involved sample heterogeneity. RESULTS 28 studies were included in this meta-analysis. Studies focused on inflammatory and neuronal injury biomarkers; there were an insufficient number of studies for amyloid and tau biomarker analysis. Two inflammatory biomarkers (IL-6, and CRP) showed a significant relationship with POD (IL-6 n = 10, standardized mean difference (SMD): 0.53, 95% CI: 0.36-0.70; CRP n = 14, SMD: 0.53, 95% CI: 0.33-0.74). Two neuronal injury biomarkers (blood-based S100B and NfL) were positively associated with POD (S100B n = 5, SMD: 0.40, 95% CI: 0.11-0.69; NFL n = 2, SMD: 0.93, 95% CI: 0.28-1.57). Of note, many analyses were impacted by significant study heterogeneity. CONCLUSIONS This meta-analysis identified an association between certain inflammatory and neuronal injury biomarkers and POD. Future studies will need to corroborate these relationships and include amyloid and tau biomarkers in order to better understand the relationship between POD and ADRD.
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Affiliation(s)
- Sophia Wang
- Department of Psychiatry, Indiana University School of Medicine, Indianapolis, IN
- Indiana Alzheimer’s Disease Research Center, Indiana University School of Medicine, Indianapolis, IN
| | - Ryan Greene
- Department of Psychiatry, Indiana University School of Medicine, Indianapolis, IN
| | - Yiqing Song
- Fairbanks School of Public Health, Indiana University, Indianapolis, IN
| | - Carol Chan
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins School of Medicine, Baltimore, MD
| | - Heidi Lindroth
- Division of Nursing Research, Department of Nursing, Mayo Clinic, Rochester, MN
| | - Sikandar Khan
- Division of Pulmonary, Critical Care, Sleep and Occupational Medicine, Department of Medicine, Indiana University School of Medicine, Indianapolis, IN
- IU Center of Aging Research, Regenstrief Institute, Indianapolis, IN
- Center for Health Innovation and Implementation Science
| | - Gabriel Rios
- Ruth Lilly Medical Library, Indiana University School of Medicine, Indianapolis, IN
| | - Robert D. Sanders
- Specialty of Anaesthetics, University of Sydney, Sydney Medical School/Central Clinical School, Sydney, Australia; Department of Anaesthetics and Institute of Academic Surgery, Royal Prince Alfred Hospital
| | - Babar Khan
- Division of Pulmonary, Critical Care, Sleep and Occupational Medicine, Department of Medicine, Indiana University School of Medicine, Indianapolis, IN
- IU Center of Aging Research, Regenstrief Institute, Indianapolis, IN
- Center for Health Innovation and Implementation Science
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29
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Daisy CC, Varinos S, Howell DR, Kaplan K, Mannix R, Meehan WP, Wang F, Berkstresser B, Lee RS, Froehlich JW, Zurakowski D, Moses MA. Proteomic Discovery of Noninvasive Biomarkers Associated With Sport-Related Concussions. Neurology 2022; 98:e186-e198. [PMID: 34675105 PMCID: PMC8762586 DOI: 10.1212/wnl.0000000000013001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2021] [Accepted: 10/14/2021] [Indexed: 01/13/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Sport-related concussions affect millions of individuals across the United States each year, and current techniques to diagnose and monitor them rely largely on subjective measures. Our goal was to discover and validate objective, quantifiable noninvasive biomarkers with the potential to be used in sport-related concussion diagnosis. METHODS Urine samples from a convenience series of healthy control collegiate athletes who had not sustained a concussion and athletes who sustained a concussion as diagnosed by a sports medicine physician within 7 days were collected prospectively and studied. Participants also completed an instrumented single-task gait analysis as a functional measure. Participants were recruited from a single collegiate athletic program and were ≥18 years of age and were excluded if they had a concomitant injury, active psychiatric conditions, or preexisting neurologic disorders. Using Tandem Mass Tags (TMT) mass spectroscopy and ELISA, we identified and validated urinary biomarkers of concussion. RESULTS Forty-eight control and 47 age- and sex-matched athletes with concussion were included in the study (51.6% female, 48.4% male, average age 19.6 years). Participants represented both contact and noncontact sports. All but 1 of the postconcussion participants reported experiencing symptoms at the time of data collection. Insulin-like growth factor 1 (IGF-1) and IGF binding protein 5 (IGFBP5) were downregulated in the urine of athletes with concussions compared to healthy controls. Multivariable risk algorithms developed to predict the probability of sport-related concussion showed that IGF-1 multiplexed with single-task gait velocity predicts concussion risk across a range of postinjury time points (area under the curve [AUC] 0.786, 95% confidence interval [CI] 0.690-0.884). When IGF-1 and IGFBP5 are multiplexed with single-task gait velocity, they accurately distinguish between healthy controls and individuals with concussion at acute time points (AUC 0.835, 95% CI 0.701-0.968, p < 0.001). DISCUSSION These noninvasive biomarkers, discovered in an objective and validated manner, may be useful in diagnosing and monitoring sport-related concussions in both acute phases of injury and several days after injury. TRIAL REGISTRATION INFORMATION ClinicalTrials.gov Identifier: NCT02354469 (submitted February 2015, first patient enrolled August 2015). CLASSIFICATION OF EVIDENCE This study provides Class III evidence that urinary IGF-1 and IGFBP5 multiplexed with single-task gait velocity may be useful in diagnosing sport-related concussion.
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Affiliation(s)
- Cassandra C Daisy
- From the Vascular Biology Program (C.C.D., S.V., K.K., M.A.M.), Division of Sports Medicine (D.R.H., W.P.M.), Department of Orthopaedics, Brain Injury Center (D.R.H., R.M., W.P.M.), Sports Concussion Clinic (R.M.), Division of Sports Medicine, Division of Emergency Medicine (R.M.), Department of Urology (R.S.L., J.W.F.), Department of Anesthesia (D.Z.), and Department of Surgery (M.A.M.), Boston Children's Hospital; The Micheli Center for Sports Injury Prevention (D.R.H., R.M., W.P.M.), Waltham, MA; Sports Medicine Center (D.R.H.), Children's Hospital Colorado; Department of Orthopedics (D.R.H.), University of Colorado School of Medicine, Aurora; Departments of Pediatrics (W.P.M.), and Orthopaedic Surgery (W.P.M.), and Surgery (R.S.L., J.W.F., D.Z., M.A.M.), Harvard Medical School; and Harvard Sports Medicine (F.W., B.B.), Boston, MA
| | - Speros Varinos
- From the Vascular Biology Program (C.C.D., S.V., K.K., M.A.M.), Division of Sports Medicine (D.R.H., W.P.M.), Department of Orthopaedics, Brain Injury Center (D.R.H., R.M., W.P.M.), Sports Concussion Clinic (R.M.), Division of Sports Medicine, Division of Emergency Medicine (R.M.), Department of Urology (R.S.L., J.W.F.), Department of Anesthesia (D.Z.), and Department of Surgery (M.A.M.), Boston Children's Hospital; The Micheli Center for Sports Injury Prevention (D.R.H., R.M., W.P.M.), Waltham, MA; Sports Medicine Center (D.R.H.), Children's Hospital Colorado; Department of Orthopedics (D.R.H.), University of Colorado School of Medicine, Aurora; Departments of Pediatrics (W.P.M.), and Orthopaedic Surgery (W.P.M.), and Surgery (R.S.L., J.W.F., D.Z., M.A.M.), Harvard Medical School; and Harvard Sports Medicine (F.W., B.B.), Boston, MA
| | - David R Howell
- From the Vascular Biology Program (C.C.D., S.V., K.K., M.A.M.), Division of Sports Medicine (D.R.H., W.P.M.), Department of Orthopaedics, Brain Injury Center (D.R.H., R.M., W.P.M.), Sports Concussion Clinic (R.M.), Division of Sports Medicine, Division of Emergency Medicine (R.M.), Department of Urology (R.S.L., J.W.F.), Department of Anesthesia (D.Z.), and Department of Surgery (M.A.M.), Boston Children's Hospital; The Micheli Center for Sports Injury Prevention (D.R.H., R.M., W.P.M.), Waltham, MA; Sports Medicine Center (D.R.H.), Children's Hospital Colorado; Department of Orthopedics (D.R.H.), University of Colorado School of Medicine, Aurora; Departments of Pediatrics (W.P.M.), and Orthopaedic Surgery (W.P.M.), and Surgery (R.S.L., J.W.F., D.Z., M.A.M.), Harvard Medical School; and Harvard Sports Medicine (F.W., B.B.), Boston, MA
| | - Katherine Kaplan
- From the Vascular Biology Program (C.C.D., S.V., K.K., M.A.M.), Division of Sports Medicine (D.R.H., W.P.M.), Department of Orthopaedics, Brain Injury Center (D.R.H., R.M., W.P.M.), Sports Concussion Clinic (R.M.), Division of Sports Medicine, Division of Emergency Medicine (R.M.), Department of Urology (R.S.L., J.W.F.), Department of Anesthesia (D.Z.), and Department of Surgery (M.A.M.), Boston Children's Hospital; The Micheli Center for Sports Injury Prevention (D.R.H., R.M., W.P.M.), Waltham, MA; Sports Medicine Center (D.R.H.), Children's Hospital Colorado; Department of Orthopedics (D.R.H.), University of Colorado School of Medicine, Aurora; Departments of Pediatrics (W.P.M.), and Orthopaedic Surgery (W.P.M.), and Surgery (R.S.L., J.W.F., D.Z., M.A.M.), Harvard Medical School; and Harvard Sports Medicine (F.W., B.B.), Boston, MA
| | - Rebekah Mannix
- From the Vascular Biology Program (C.C.D., S.V., K.K., M.A.M.), Division of Sports Medicine (D.R.H., W.P.M.), Department of Orthopaedics, Brain Injury Center (D.R.H., R.M., W.P.M.), Sports Concussion Clinic (R.M.), Division of Sports Medicine, Division of Emergency Medicine (R.M.), Department of Urology (R.S.L., J.W.F.), Department of Anesthesia (D.Z.), and Department of Surgery (M.A.M.), Boston Children's Hospital; The Micheli Center for Sports Injury Prevention (D.R.H., R.M., W.P.M.), Waltham, MA; Sports Medicine Center (D.R.H.), Children's Hospital Colorado; Department of Orthopedics (D.R.H.), University of Colorado School of Medicine, Aurora; Departments of Pediatrics (W.P.M.), and Orthopaedic Surgery (W.P.M.), and Surgery (R.S.L., J.W.F., D.Z., M.A.M.), Harvard Medical School; and Harvard Sports Medicine (F.W., B.B.), Boston, MA
| | - William P Meehan
- From the Vascular Biology Program (C.C.D., S.V., K.K., M.A.M.), Division of Sports Medicine (D.R.H., W.P.M.), Department of Orthopaedics, Brain Injury Center (D.R.H., R.M., W.P.M.), Sports Concussion Clinic (R.M.), Division of Sports Medicine, Division of Emergency Medicine (R.M.), Department of Urology (R.S.L., J.W.F.), Department of Anesthesia (D.Z.), and Department of Surgery (M.A.M.), Boston Children's Hospital; The Micheli Center for Sports Injury Prevention (D.R.H., R.M., W.P.M.), Waltham, MA; Sports Medicine Center (D.R.H.), Children's Hospital Colorado; Department of Orthopedics (D.R.H.), University of Colorado School of Medicine, Aurora; Departments of Pediatrics (W.P.M.), and Orthopaedic Surgery (W.P.M.), and Surgery (R.S.L., J.W.F., D.Z., M.A.M.), Harvard Medical School; and Harvard Sports Medicine (F.W., B.B.), Boston, MA
| | - Francis Wang
- From the Vascular Biology Program (C.C.D., S.V., K.K., M.A.M.), Division of Sports Medicine (D.R.H., W.P.M.), Department of Orthopaedics, Brain Injury Center (D.R.H., R.M., W.P.M.), Sports Concussion Clinic (R.M.), Division of Sports Medicine, Division of Emergency Medicine (R.M.), Department of Urology (R.S.L., J.W.F.), Department of Anesthesia (D.Z.), and Department of Surgery (M.A.M.), Boston Children's Hospital; The Micheli Center for Sports Injury Prevention (D.R.H., R.M., W.P.M.), Waltham, MA; Sports Medicine Center (D.R.H.), Children's Hospital Colorado; Department of Orthopedics (D.R.H.), University of Colorado School of Medicine, Aurora; Departments of Pediatrics (W.P.M.), and Orthopaedic Surgery (W.P.M.), and Surgery (R.S.L., J.W.F., D.Z., M.A.M.), Harvard Medical School; and Harvard Sports Medicine (F.W., B.B.), Boston, MA
| | - Brant Berkstresser
- From the Vascular Biology Program (C.C.D., S.V., K.K., M.A.M.), Division of Sports Medicine (D.R.H., W.P.M.), Department of Orthopaedics, Brain Injury Center (D.R.H., R.M., W.P.M.), Sports Concussion Clinic (R.M.), Division of Sports Medicine, Division of Emergency Medicine (R.M.), Department of Urology (R.S.L., J.W.F.), Department of Anesthesia (D.Z.), and Department of Surgery (M.A.M.), Boston Children's Hospital; The Micheli Center for Sports Injury Prevention (D.R.H., R.M., W.P.M.), Waltham, MA; Sports Medicine Center (D.R.H.), Children's Hospital Colorado; Department of Orthopedics (D.R.H.), University of Colorado School of Medicine, Aurora; Departments of Pediatrics (W.P.M.), and Orthopaedic Surgery (W.P.M.), and Surgery (R.S.L., J.W.F., D.Z., M.A.M.), Harvard Medical School; and Harvard Sports Medicine (F.W., B.B.), Boston, MA
| | - Richard S Lee
- From the Vascular Biology Program (C.C.D., S.V., K.K., M.A.M.), Division of Sports Medicine (D.R.H., W.P.M.), Department of Orthopaedics, Brain Injury Center (D.R.H., R.M., W.P.M.), Sports Concussion Clinic (R.M.), Division of Sports Medicine, Division of Emergency Medicine (R.M.), Department of Urology (R.S.L., J.W.F.), Department of Anesthesia (D.Z.), and Department of Surgery (M.A.M.), Boston Children's Hospital; The Micheli Center for Sports Injury Prevention (D.R.H., R.M., W.P.M.), Waltham, MA; Sports Medicine Center (D.R.H.), Children's Hospital Colorado; Department of Orthopedics (D.R.H.), University of Colorado School of Medicine, Aurora; Departments of Pediatrics (W.P.M.), and Orthopaedic Surgery (W.P.M.), and Surgery (R.S.L., J.W.F., D.Z., M.A.M.), Harvard Medical School; and Harvard Sports Medicine (F.W., B.B.), Boston, MA
| | - John W Froehlich
- From the Vascular Biology Program (C.C.D., S.V., K.K., M.A.M.), Division of Sports Medicine (D.R.H., W.P.M.), Department of Orthopaedics, Brain Injury Center (D.R.H., R.M., W.P.M.), Sports Concussion Clinic (R.M.), Division of Sports Medicine, Division of Emergency Medicine (R.M.), Department of Urology (R.S.L., J.W.F.), Department of Anesthesia (D.Z.), and Department of Surgery (M.A.M.), Boston Children's Hospital; The Micheli Center for Sports Injury Prevention (D.R.H., R.M., W.P.M.), Waltham, MA; Sports Medicine Center (D.R.H.), Children's Hospital Colorado; Department of Orthopedics (D.R.H.), University of Colorado School of Medicine, Aurora; Departments of Pediatrics (W.P.M.), and Orthopaedic Surgery (W.P.M.), and Surgery (R.S.L., J.W.F., D.Z., M.A.M.), Harvard Medical School; and Harvard Sports Medicine (F.W., B.B.), Boston, MA
| | - David Zurakowski
- From the Vascular Biology Program (C.C.D., S.V., K.K., M.A.M.), Division of Sports Medicine (D.R.H., W.P.M.), Department of Orthopaedics, Brain Injury Center (D.R.H., R.M., W.P.M.), Sports Concussion Clinic (R.M.), Division of Sports Medicine, Division of Emergency Medicine (R.M.), Department of Urology (R.S.L., J.W.F.), Department of Anesthesia (D.Z.), and Department of Surgery (M.A.M.), Boston Children's Hospital; The Micheli Center for Sports Injury Prevention (D.R.H., R.M., W.P.M.), Waltham, MA; Sports Medicine Center (D.R.H.), Children's Hospital Colorado; Department of Orthopedics (D.R.H.), University of Colorado School of Medicine, Aurora; Departments of Pediatrics (W.P.M.), and Orthopaedic Surgery (W.P.M.), and Surgery (R.S.L., J.W.F., D.Z., M.A.M.), Harvard Medical School; and Harvard Sports Medicine (F.W., B.B.), Boston, MA
| | - Marsha A Moses
- From the Vascular Biology Program (C.C.D., S.V., K.K., M.A.M.), Division of Sports Medicine (D.R.H., W.P.M.), Department of Orthopaedics, Brain Injury Center (D.R.H., R.M., W.P.M.), Sports Concussion Clinic (R.M.), Division of Sports Medicine, Division of Emergency Medicine (R.M.), Department of Urology (R.S.L., J.W.F.), Department of Anesthesia (D.Z.), and Department of Surgery (M.A.M.), Boston Children's Hospital; The Micheli Center for Sports Injury Prevention (D.R.H., R.M., W.P.M.), Waltham, MA; Sports Medicine Center (D.R.H.), Children's Hospital Colorado; Department of Orthopedics (D.R.H.), University of Colorado School of Medicine, Aurora; Departments of Pediatrics (W.P.M.), and Orthopaedic Surgery (W.P.M.), and Surgery (R.S.L., J.W.F., D.Z., M.A.M.), Harvard Medical School; and Harvard Sports Medicine (F.W., B.B.), Boston, MA.
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Ren Y, Zhang Y, Luo J, Liao W, Cheng X, Zhan J. Research progress on risk factors of delirium in burn patients: A narrative review. Front Psychiatry 2022; 13:989218. [PMID: 36405924 PMCID: PMC9666388 DOI: 10.3389/fpsyt.2022.989218] [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: 07/08/2022] [Accepted: 10/17/2022] [Indexed: 11/06/2022] Open
Abstract
Delirium, an acute brain dysfunction, is a common and serious complication in burn patients. The occurrence of delirium increases the difficulty of patient treatment, is associated with various adverse outcomes, and increases the burden on the patient's family. Many scholars have studied the factors that cause delirium, but the causes, pathogenesis, and treatment of delirium in burn patients have not been fully revealed. There is no effective pharmacological treatment for delirium, but active preventive measures can effectively reduce the incidence of delirium in burn patients. Therefore, it is necessary to study the relevant factors affecting the occurrence of delirium in burn patients. This study was conducted on December 20, 2021 by searching the PubMed database for a narrative review of published studies. The search strategy included keywords related to "burns," "delirium," and "risk factors." We reviewed the characteristics of delirium occurrence in burn patients and various delirium assessment tools, and summarized the risk factors for the development of delirium in burn patients in terms of personal, clinical, and environmental factors, and we found that although many risk factors act on the development of delirium in burn patients, some of them, such as clinical and environmental factors, are modifiable, suggesting that we can estimate the exposure of burn patients to risk factors by assessing their likelihood of delirium occurring and to make targeted interventions that provide a theoretical basis for the prevention and treatment of burn delirium.
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Affiliation(s)
- Yujie Ren
- Medical Center of Burn Plastic and Wound Repair, The First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, China
| | - Yu Zhang
- Medical Innovation Center, The First Affiliated Hospital of Nanchang University, Nanchang, China
| | - Jinhua Luo
- Medical Center of Burn Plastic and Wound Repair, The First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, China
| | - Wenqiang Liao
- Medical Center of Burn Plastic and Wound Repair, The First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, China
| | - Xing Cheng
- Medical Center of Burn Plastic and Wound Repair, The First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, China
| | - Jianhua Zhan
- Medical Center of Burn Plastic and Wound Repair, The First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, China
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Fernández-Jiménez E, Muñoz-Sanjose A, Mediavilla R, Martínez-Alés G, Louzao II, Andreo J, Cebolla S, Bravo-Ortiz MF, Bayón C. Prospective Analysis Between Neutrophil-to-Lymphocyte Ratio on Admission and Development of Delirium Among Older Hospitalized Patients With COVID-19. Front Aging Neurosci 2021; 13:764334. [PMID: 34887744 PMCID: PMC8650500 DOI: 10.3389/fnagi.2021.764334] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2021] [Accepted: 11/01/2021] [Indexed: 12/23/2022] Open
Abstract
Objective: To examine any prospective association between neutrophil-to-lymphocyte ratio (NLR) at hospital admission and subsequent delirium in older COVID-19 hospitalized patients comparing by sex and age groups. Methods: The sample consisted of 1,785 COVID-19 adult inpatients (minimum sample size required of 635 participants) admitted to a public general hospital in Madrid (Spain) between March 16th and April 15th, 2020. Variables were obtained from electronic health records. Binary logistic regression models were performed between baseline NLR and delirium adjusting for age, sex, medical comorbidity, current illness severity, serious mental illness history and use of chloroquine and dexamethasone. An NLR cut-off was identified, and stratified analyses were performed by age and sex. Also, another biomarker was tested as an exposure (the systemic immune-inflammation index -SII). Results: 55.3% of the patients were men, with a mean age of 66.8 years. Roughly 13% of the patients had delirium during hospitalization. NLR on admission predicted subsequent delirium development (adjusted OR = 1.02, 95 percent CI: 1.00-1.04, p = 0.024). Patients between 69 and 80 years with NLR values > 6.3 presented a twofold increased risk for delirium (p = 0.004). There were no sex differences in the association between baseline NLR and delirium (p > 0.05) nor SII predicted delirium development (p = 0.341). Conclusion: NLR is a good predictor of delirium during hospitalization, especially among older adults, independently of medical comorbidity, illness severity, and other covariates. Routine blood tests on admission might provide valuable information to guide the decision-making process to be followed with these especially vulnerable patients.
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Affiliation(s)
- Eduardo Fernández-Jiménez
- Department of Psychiatry, Clinical Psychology and Mental Health, La Paz University Hospital, Madrid, Spain.,Hospital La Paz Institute for Health Research (IdiPAZ), Madrid, Spain
| | - Ainoa Muñoz-Sanjose
- Department of Psychiatry, Clinical Psychology and Mental Health, La Paz University Hospital, Madrid, Spain.,Hospital La Paz Institute for Health Research (IdiPAZ), Madrid, Spain
| | - Roberto Mediavilla
- Department of Psychiatry, Universidad Autónoma de Madrid (UAM), Madrid, Spain.,Centro de Investigación Biomédica en Red (CIBERSAM), Madrid, Spain
| | - Gonzalo Martínez-Alés
- Department of Psychiatry, Clinical Psychology and Mental Health, La Paz University Hospital, Madrid, Spain.,Centro de Investigación Biomédica en Red (CIBERSAM), Madrid, Spain.,Department of Epidemiology, Columbia University Mailman School of Public Health, New York, NY, United States
| | - Iker I Louzao
- Department of Psychiatry, Clinical Psychology and Mental Health, La Paz University Hospital, Madrid, Spain
| | - Jorge Andreo
- Hospital La Paz Institute for Health Research (IdiPAZ), Madrid, Spain
| | - Susana Cebolla
- Department of Psychiatry, Clinical Psychology and Mental Health, La Paz University Hospital, Madrid, Spain.,Hospital La Paz Institute for Health Research (IdiPAZ), Madrid, Spain
| | - María-Fe Bravo-Ortiz
- Department of Psychiatry, Clinical Psychology and Mental Health, La Paz University Hospital, Madrid, Spain.,Hospital La Paz Institute for Health Research (IdiPAZ), Madrid, Spain.,Department of Psychiatry, Universidad Autónoma de Madrid (UAM), Madrid, Spain.,Centro de Investigación Biomédica en Red (CIBERSAM), Madrid, Spain
| | - Carmen Bayón
- Department of Psychiatry, Clinical Psychology and Mental Health, La Paz University Hospital, Madrid, Spain.,Hospital La Paz Institute for Health Research (IdiPAZ), Madrid, Spain.,Department of Psychiatry, Universidad Autónoma de Madrid (UAM), Madrid, Spain
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Dunne SS, Coffey JC, Konje S, Gasior S, Clancy CC, Gulati G, Meagher D, Dunne CP. Biomarkers in delirium: A systematic review. J Psychosom Res 2021; 147:110530. [PMID: 34098376 DOI: 10.1016/j.jpsychores.2021.110530] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2021] [Revised: 05/19/2021] [Accepted: 05/19/2021] [Indexed: 12/20/2022]
Abstract
BACKGROUND Delirium is a common neuropsychiatric disorder associated with prolonged hospital stays, and increased morbidity and mortality. Diagnosis is frequently missed due to varying disease presentation and lack of standardized testing. We examined biomarkers as diagnostic or prognostic indicators of delirium, and provide a rational basis for future studies. METHOD Systematic review of literature published between Jan 2000 and June 2019. Searches included: PubMed; Web of Science; CINAHL; EMBASE; COCHRANE and Medline. Additional studies were identified by searching bibliographies of eligible articles. RESULTS 2082 relevant papers were identified from all sources. Seventy-three met the inclusion criteria, all of which were observational. These assessed a range of fourteen biomarkers. All papers included were in the English language. Assessment methods varied between studies, including: DSM criteria; Confusion Assessment Method (CAM) or CAM-Intensive Care Unit (ICU). Delirium severity was measured using the Delirium Rating Scale (DRS). Delirium was secondary to post-operative dysfunction or acute medical conditions. CONCLUSION Evidence does not currently support the use of any one biomarker. However, certain markers were associated with promising results and may warrant evaluation in future studies. Heterogeneity across study methods may have contributed to inconclusive results, and more clarity may arise from standardization of methods of clinical assessment. Adjusting for comorbidities may improve understanding of the pathophysiology of delirium, in particular the role of confounders such as inflammation, cognitive disorders and surgical trauma. Future research may also benefit from inclusion of other diagnostic modalities such as EEG as well as analysis of genetic or epigenetic factors.
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Affiliation(s)
- Suzanne S Dunne
- Centre for Interventions in Infection, Inflammation and Immunity (4i) and School of Medicine, University of Limerick, Limerick, Ireland
| | - J Calvin Coffey
- Centre for Interventions in Infection, Inflammation and Immunity (4i) and School of Medicine, University of Limerick, Limerick, Ireland
| | - Swiri Konje
- Centre for Interventions in Infection, Inflammation and Immunity (4i) and School of Medicine, University of Limerick, Limerick, Ireland
| | - Sara Gasior
- Centre for Interventions in Infection, Inflammation and Immunity (4i) and School of Medicine, University of Limerick, Limerick, Ireland
| | - Conor C Clancy
- Centre for Interventions in Infection, Inflammation and Immunity (4i) and School of Medicine, University of Limerick, Limerick, Ireland
| | - Gautam Gulati
- Centre for Interventions in Infection, Inflammation and Immunity (4i) and School of Medicine, University of Limerick, Limerick, Ireland
| | - David Meagher
- Centre for Interventions in Infection, Inflammation and Immunity (4i) and School of Medicine, University of Limerick, Limerick, Ireland; Cognitive Impairment Research Group, School of Medicine, University of Limerick, Limerick, Ireland
| | - Colum P Dunne
- Centre for Interventions in Infection, Inflammation and Immunity (4i) and School of Medicine, University of Limerick, Limerick, Ireland; Cognitive Impairment Research Group, School of Medicine, University of Limerick, Limerick, Ireland.
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Noah AM, Almghairbi D, Evley R, Moppett IK. Preoperative inflammatory mediators and postoperative delirium: systematic review and meta-analysis. Br J Anaesth 2021; 127:424-434. [PMID: 34218905 DOI: 10.1016/j.bja.2021.04.033] [Citation(s) in RCA: 38] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2020] [Revised: 03/23/2021] [Accepted: 04/12/2021] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND Postoperative delirium has eluded attempts to define its complex aetiology and describe specific risk factors. The role of neuroinflammation as a risk factor, determined by measuring blood levels of preoperative 'innate' inflammatory mediator levels, has been investigated. However, results have been conflicting. We conducted a systematic review and meta-analysis of the evidence on associations between preoperative blood levels of inflammatory mediators and postoperative delirium in the older person. Influence of type of surgery was also assessed. METHODS Original, low risk of bias studies, published in peer-reviewed journals, which fulfilled the eligibility criteria were included. Seventeen articles fulfilled study criteria. Data extraction, synthesis, and risk of bias analysis were guided by Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) and quality in prognostic studies guidelines. Meta-analyses used a random-effects model. Inflammatory mediators included C-reactive protein, interleukin-6, -8, and -10, tumour necrosis factor-α, insulin-like growth factor-1, cortisol, and neopterin. Surgical groups were cardiac, noncardiac, and hip fracture. RESULTS Higher preoperative interleukin-6 was associated with postoperative delirium with a standardised mean difference (95% confidence interval) of 0.33 (0.11-0.56) and P=0.003. Higher neopterin was also associated with postoperative delirium. CONCLUSIONS The association of preoperative blood levels of inflammatory mediators with postoperative delirium may be influenced by the type of surgery and the specific mediator. The potential modulating effect of type of surgery, intrinsic brain vulnerability, and the complex interactions between inflammatory mediators and binding proteins will need to be considered in future studies. CLINICAL TRIAL REGISTRATION CRD42019159471 (PROSPERO).
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Affiliation(s)
- Abiodun M Noah
- Anaesthesia and Critical Care, Academic Unit of Injury, Inflammation and Recovery Science, University of Nottingham, Nottingham, UK
| | - Dalal Almghairbi
- Anaesthesia and Critical Care, Academic Unit of Injury, Inflammation and Recovery Science, University of Nottingham, Nottingham, UK
| | - Rachel Evley
- Anaesthesia and Critical Care, Academic Unit of Injury, Inflammation and Recovery Science, University of Nottingham, Nottingham, UK
| | - Iain K Moppett
- Anaesthesia and Critical Care, Academic Unit of Injury, Inflammation and Recovery Science, University of Nottingham, Nottingham, UK.
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Forget MF, Del Degan S, Leblanc J, Tannous R, Desjardins M, Durand M, Vu TTM, Nguyen QD, Desmarais P. Delirium and Inflammation in Older Adults Hospitalized for COVID-19: A Cohort Study. Clin Interv Aging 2021; 16:1223-1230. [PMID: 34234422 PMCID: PMC8242147 DOI: 10.2147/cia.s315405] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Accepted: 06/10/2021] [Indexed: 01/08/2023] Open
Abstract
Purpose The occurrence and predictors of delirium in older adults hospitalized for coronavirus disease 2019 (COVID-19) have not been well described. Highlighting the association with inflammatory markers may be useful for identifying delirium. This study aimed to determine the prevalence and incidence of delirium and explore its association with the C-reactive protein (CRP). Patients and Methods This cohort study of adults aged 65 and older with a COVID-19 diagnosis took place at an academic healthcare institution between April and May 2020. COVID-19 was diagnosed by positive nasopharyngeal swab. Serum levels of CRP were collected as a marker of systemic inflammation. The primary outcome was the prevalence and incidence of delirium. Delirium was diagnosed primarily during a patient's stay in hospital based on the Diagnostic and Statistical Manual of Mental Disorders Fifth Edition (DSM-5). To ensure that no delirium diagnosis was missed during hospital stay, clinical records were reviewed by clinicians with geriatric medicine training for retrospective diagnoses. Results A total of 127 patients aged 65 and older were hospitalized with a diagnosis of COVID-19. The median age was 82 years (IQR: 74–88), with 54 (43%) females. Overall, delirium was present in 62 (49%) patients: manifestations of delirium were present on the first day of hospitalization in 53 of these cases (86%), while 9 cases (14%) developed delirium during hospitalization. After controlling for age and sex, the mean CRP value over the first 3 days since arrival was associated with a higher risk of delirium (OR 1.35; 95% CI: 1.01–1.85) for every 50 mg/L increase. Conclusion In this cohort of older adults hospitalized for COVID-19, delirium was highly prevalent. An early increase in CRP levels should raise suspicion about the occurrence of delirium and could improve its diagnosis.
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Affiliation(s)
- Marie-France Forget
- Department of Medicine, Division of Geriatrics, Centre Hospitalier de l'Université de Montréal, Montréal, Québec, Canada
| | - Sophie Del Degan
- Department of Medicine, Division of Geriatrics, Centre Hospitalier de l'Université de Montréal, Montréal, Québec, Canada
| | - Julie Leblanc
- Department of Medicine, Division of Geriatrics, Centre Hospitalier de l'Université de Montréal, Montréal, Québec, Canada
| | - Rita Tannous
- Department of Medicine, Division of Geriatrics, Centre Hospitalier de l'Université de Montréal, Montréal, Québec, Canada
| | - Michaël Desjardins
- Department of Medicine, Division of Infectious Disease, Centre Hospitalier de l'Université de Montréal, Montréal, Québec, Canada
| | - Madeleine Durand
- Department of Medicine, Division of Internal Medicine, Centre Hospitalier de l'Université de Montréal, Montréal, Québec, Canada.,Innovation Hub, Centre de Recherche du Centre Hospitalier de l'Université de Montréal, Montréal, Québec, Canada
| | - Thien Tuong Minh Vu
- Department of Medicine, Division of Geriatrics, Centre Hospitalier de l'Université de Montréal, Montréal, Québec, Canada.,Department of Neurosciences, Centre de Recherche du Centre Hospitalier de l'Université de Montréal, Montréal, Québec, Canada
| | - Quoc Dinh Nguyen
- Department of Medicine, Division of Geriatrics, Centre Hospitalier de l'Université de Montréal, Montréal, Québec, Canada.,Innovation Hub, Centre de Recherche du Centre Hospitalier de l'Université de Montréal, Montréal, Québec, Canada
| | - Philippe Desmarais
- Department of Medicine, Division of Geriatrics, Centre Hospitalier de l'Université de Montréal, Montréal, Québec, Canada.,Department of Neurosciences, Centre de Recherche du Centre Hospitalier de l'Université de Montréal, Montréal, Québec, Canada
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Zhao Y, Yue J, Lei P, Lin T, Peng X, Xie D, Gao L, Shu X, Wu C. Neutrophil-lymphocyte ratio as a predictor of delirium in older internal medicine patients: a prospective cohort study. BMC Geriatr 2021; 21:334. [PMID: 34034650 PMCID: PMC8147036 DOI: 10.1186/s12877-021-02284-w] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2020] [Accepted: 05/11/2021] [Indexed: 02/08/2023] Open
Abstract
BACKGROUNDS Delirium is a common neuropsychiatric syndrome in older hospitalized patients. Previous studies have suggested that inflammation and oxidative stress contribute to the pathophysiology of delirium. However, it remains unclear whether neutrophil-lymphocyte ratio (NLR), an indicator of systematic inflammation, is associated with delirium. This study aimed to investigate the value of NLR as an independent risk factor for delirium among older hospitalized patients. METHODS We conducted a prospective study of 740 hospitalized patients aged ≥ 70 years in the geriatric ward of West China Hospital of Sichuan University. Neutrophil and lymphocyte counts were collected within 24 h after hospital admission. Delirium was assessed on admission and every 48 h thereafter. We used the receiver operating characteristic analysis to assess the ability of the NLR for predicting delirium. The optimal cut-point value of the NLR was determined based on the highest Youden index (sensitivity + specificity - 1). Patients were categorized according to the cut-point value and quartiles of NLR, respectively. We then used logistic regression to identify the unadjusted and adjusted associations between NLR as a categorical variable and delirium. RESULTS The optimal cut-point value of NLR for predicting delirium was 3.626 (sensitivity: 75.2 %; specificity: 63.4 %; Youden index: 0.386). The incidence of delirium was significantly higher in patients with NLR > 3.626 than NLR ≤ 3.626 (24.5 % vs. 5.8 %; P < 0.001). Significantly fewer patients in the first quartile of NLR experienced delirium than in the third (4.3 % vs. 20.0 %; P < 0.001) and fourth quartiles of NLR (4.3 % vs. 24.9 %; P < 0.001). Results from the multivariable logistic regression models showed that NLR was independently associated with delirium. CONCLUSIONS NLR is a simple and practical marker that can predict the development of delirium in older internal medicine patients.
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Affiliation(s)
- Yanli Zhao
- Department of Geriatrics and National Clinical Research Center for Geriatrics, West China Hospital, Sichuan University, 610041, Chengdu, Sichuan Province, China
| | - Jirong Yue
- Department of Geriatrics and National Clinical Research Center for Geriatrics, West China Hospital, Sichuan University, 610041, Chengdu, Sichuan Province, China.
| | - Peng Lei
- Department of Neurology, State Key Laboratory of Biotherapy, West China Hospital, Sichuan University, 610041, Chengdu, Sichuan Province, China
| | - Taiping Lin
- Department of Geriatrics and National Clinical Research Center for Geriatrics, West China Hospital, Sichuan University, 610041, Chengdu, Sichuan Province, China
| | - Xuchao Peng
- Department of Geriatrics and National Clinical Research Center for Geriatrics, West China Hospital, Sichuan University, 610041, Chengdu, Sichuan Province, China
| | - Dongmei Xie
- Department of Geriatrics and National Clinical Research Center for Geriatrics, West China Hospital, Sichuan University, 610041, Chengdu, Sichuan Province, China
| | - Langli Gao
- Department of Geriatrics and National Clinical Research Center for Geriatrics, West China Hospital, Sichuan University, 610041, Chengdu, Sichuan Province, China
| | - Xiaoyu Shu
- Department of Geriatrics and National Clinical Research Center for Geriatrics, West China Hospital, Sichuan University, 610041, Chengdu, Sichuan Province, China
| | - Chenkai Wu
- Global Health Research Center, Duke Kunshan University, 215300, Kunshan, Jiangsu Province, China
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Vasunilashorn SM, Ngo LH, Dillon ST, Fong TG, Carlyle BC, Kivisäkk P, Trombetta BA, Vlassakov KV, Kunze LJ, Arnold SE, Xie Z, Inouye SK, Libermann TA, Marcantonio ER. Plasma and cerebrospinal fluid inflammation and the blood-brain barrier in older surgical patients: the Role of Inflammation after Surgery for Elders (RISE) study. J Neuroinflammation 2021; 18:103. [PMID: 33931093 PMCID: PMC8088047 DOI: 10.1186/s12974-021-02145-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2020] [Accepted: 03/30/2021] [Indexed: 11/17/2022] Open
Abstract
Background Our understanding of the relationship between plasma and cerebrospinal fluid (CSF) remains limited, which poses an obstacle to the identification of blood-based markers of neuroinflammatory disorders. To better understand the relationship between peripheral and central nervous system (CNS) markers of inflammation before and after surgery, we aimed to examine whether surgery compromises the blood-brain barrier (BBB), evaluate postoperative changes in inflammatory markers, and assess the correlations between plasma and CSF levels of inflammation. Methods We examined the Role of Inflammation after Surgery for Elders (RISE) study of adults aged ≥ 65 who underwent elective hip or knee surgery under spinal anesthesia who had plasma and CSF samples collected at baseline and postoperative 1 month (PO1MO) (n = 29). Plasma and CSF levels of three inflammatory markers previously identified as increasing after surgery were measured using enzyme-linked immunosorbent assay: interleukin-6 (IL-6), C-reactive protein (CRP), and chitinase 3-like protein (also known as YKL-40). The integrity of the BBB was computed as the ratio of CSF/plasma albumin levels (Qalb). Mean Qalb and levels of inflammation were compared between baseline and PO1MO. Spearman correlation coefficients were used to determine the correlation between biofluids. Results Mean Qalb did not change between baseline and PO1MO. Mean plasma and CSF levels of CRP and plasma levels of YKL-40 and IL-6 were higher on PO1MO relative to baseline, with a disproportionally higher increase in CRP CSF levels relative to plasma levels (CRP tripled in CSF vs. increased 10% in plasma). Significant plasma-CSF correlations for CRP (baseline r = 0.70 and PO1MO r = 0.89, p < .01 for both) and IL-6 (PO1MO r = 0.48, p < .01) were observed, with higher correlations on PO1MO compared with baseline. Conclusions In this elective surgical sample of older adults, BBB integrity was similar between baseline and PO1MO, plasma-CSF correlations were observed for CRP and IL-6, plasma levels of all three markers (CRP, IL-6, and YKL-40) increased from PREOP to PO1MO, and CSF levels of only CRP increased between the two time points. Our identification of potential promising plasma markers of inflammation in the CNS may facilitate the early identification of patients at greatest risk for neuroinflammation and its associated adverse cognitive outcomes.
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Affiliation(s)
- Sarinnapha M Vasunilashorn
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA. .,Harvard Medical School, Boston, MA, USA. .,Department of Epidemiology, Harvard T. H. Chan School of Public Health, Boston, MA, USA.
| | - Long H Ngo
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA.,Department of Biostatistics, Harvard T. H. Chan School of Public Health, Boston, MA, USA
| | - Simon T Dillon
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
| | - Tamara G Fong
- Harvard Medical School, Boston, MA, USA.,Department of Neurology, Beth Israel Deaconess Medical Center, Boston, MA, USA.,Marcus Institute for Aging Research, Boston, MA, USA
| | - Becky C Carlyle
- Harvard Medical School, Boston, MA, USA.,Department of Neurology, Massachusetts General Hospital, Boston, MA, USA
| | - Pia Kivisäkk
- Harvard Medical School, Boston, MA, USA.,Department of Neurology, Massachusetts General Hospital, Boston, MA, USA
| | - Bianca A Trombetta
- Department of Neurology, Massachusetts General Hospital, Boston, MA, USA
| | - Kamen V Vlassakov
- Harvard Medical School, Boston, MA, USA.,Department of Anesthesia, Brigham and Women's Hospital, Boston, MA, USA
| | - Lisa J Kunze
- Harvard Medical School, Boston, MA, USA.,Department of Anesthesia, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Steven E Arnold
- Harvard Medical School, Boston, MA, USA.,Department of Neurology, Massachusetts General Hospital, Boston, MA, USA
| | - Zhongcong Xie
- Harvard Medical School, Boston, MA, USA.,Department of Anesthesia, Massachusetts General Hospital, Boston, MA, USA
| | - Sharon K Inouye
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA.,Marcus Institute for Aging Research, Boston, MA, USA
| | - Towia A Libermann
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
| | - Edward R Marcantonio
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
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Elevated plasma levels of galectin-3 binding protein are associated with post-stroke delirium - A pilot study. J Neuroimmunol 2021; 356:577579. [PMID: 33901789 DOI: 10.1016/j.jneuroim.2021.577579] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2020] [Revised: 04/15/2021] [Accepted: 04/15/2021] [Indexed: 11/22/2022]
Abstract
To explore the role of systemic inflammation in post-stroke delirium, we investigated the level of two inflammatory mediators: high mobility group box 1 (HMGB1) and galectin-3 binding protein (Gal-3BP). Of 571 stroke patients, we compared plasma levels of HMGB1 and Gal-3BP in 79 delirious patients with 81 non-delirious patients matched for age and stroke severity. Delirious patients had higher Gal-3BP level (median: 1440 vs 1053 ng/mL, P < 0.01). An elevated level of Gal-3BP was associated with an increased risk of delirium. HMGB1 levels did not differ between groups. Our results suggest that pro-inflammatory monocytes and macrophages might be involved in delirium pathophysiology.
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Identification of Plasma Proteome Signatures Associated With Surgery Using SOMAscan. Ann Surg 2021; 273:732-742. [PMID: 30946084 DOI: 10.1097/sla.0000000000003283] [Citation(s) in RCA: 32] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
OBJECTIVES To characterize the proteomic signature of surgery in older adults and association with postoperative outcomes. SUMMARY OF BACKGROUND DATA Circulating plasma proteins can reflect the physiological response to and clinical outcomes after surgery. METHODS Blood plasma from older adults undergoing elective surgery was analyzed for 1305 proteins using SOMAscan. Surgery-associated proteins underwent Ingenuity Pathways Analysis. Selected surgery-associated proteins were independently validated using Luminex or enzyme-linked immunosorbent assay methods. Generalized linear models estimated correlations with postoperative outcomes. RESULTS Plasma from a subcohort (n = 36) of the Successful Aging after Elective Surgery (SAGES) study was used for SOMAscan. Systems biology analysis of 110 proteins with Benjamini-Hochberg (BH) corrected P value ≤0.01 and an absolute foldchange (|FC|) ≥1.5 between postoperative day 2 (POD2) and preoperative (PREOP) identified functional pathways with major effects on pro-inflammatory proteins. Chitinase-3-like protein 1 (CHI3L1), C-reactive protein (CRP), and interleukin-6 (IL-6) were independently validated in separate validation cohorts from SAGES (n = 150 for CRP, IL-6; n = 126 for CHI3L1). Foldchange CHI3L1 and IL-6 were associated with increased postoperative complications [relative risk (RR) 1.50, 95% confidence interval (95% CI) 1.21-1.85 and RR 1.63, 95% CI 1.18-2.26, respectively], length of stay (RR 1.35, 95% CI 0.77-1.92 and RR 0.98, 95% CI 0.52-1.45), and risk of discharge to postacute facility (RR 1.15, 95% CI 1.04-1.26 and RR 1.11, 95% CI 1.04-1.18); POD2 and PREOP CRP difference was associated with discharge to postacute facility (RR 1.14, 95% CI 1.04-1.25). CONCLUSION SOMAscan can identify novel and clinically relevant surgery-induced protein changes. Ultimately, proteomics may provide insights about pathways by which surgical stress contributes to postoperative outcomes.
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Wu Z, Li H, Liao K, Wang Y. Association Between Dexamethasone and Delirium in Critically Ill Patients: A Retrospective Cohort Study of a Large Clinical Database. J Surg Res 2021; 263:89-101. [PMID: 33639374 DOI: 10.1016/j.jss.2021.01.027] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2020] [Revised: 01/01/2021] [Accepted: 01/22/2021] [Indexed: 02/08/2023]
Abstract
BACKGROUND Delirium is a common complication in intensive care unit (ICU) patients, and it can significantly increase the length of hospital stay and cost. Dexamethasone is widely used in various inflammatory diseases and must be used with caution in critically ill patients. Previous studies have shown that the effect of corticosteroid use on the development of delirium in critically ill patients is still controversial, and there is inconclusive conclusion about the effect of dexamethasone on delirium in such patients. Therefore, this study aimed to confirm the effect of dexamethasone use and the dose on the incidence of delirium and patient prognosis in critically ill patients through a large cohort study. METHODS A retrospective cohort study was conducted using data extracted from the Medical Information Mart for Intensive Care III database, which is a large and freely available database of all 46,476 patients who visited Beth Israel Deaconess Medical Center in Boston, Massachusetts, USA and were admitted to the ICU between 2001 and 2012. The primary outcome was the development of delirium, using multivariate logistic regression analysis to reveal the relationship between dexamethasone and delirium. Secondary endpoints were in-hospital mortality, ICU mortality, total length of stay, and length of ICU stay, and the relationship between dexamethasone and prognosis was assessed with Cox proportional hazards models. Propensity score matching with 1:1 grouping was used to eliminate the effect of confounders on both cohorts. The locally weighted scatter plot smoothing technique was used to investigate the dose correlation between dexamethasone and outcomes, subgroup analysis was used to account for heterogeneity, and different correction models and propensity matching analysis were used to eliminate potential confounders. RESULTS Finally, 38,509 patients were included, and 2204 (5.7%) used dexamethasone. No significant statistical difference was observed in basic demographic information after propensity score matching between the two study groups. A significantly higher incidence of delirium (5.0% versus 3.4%, P < 0.001), increased in-hospital mortality (14.9% versus 10.3%, P < 0.001), ICU mortality (9.0% versus 7.5%, P = 0.008), and longer length of stay and ICU stay were observed in patients taking dexamethasone compared with those not taking dexamethasone. Multivariate logistic and Cox regression analyses confirmed that dexamethasone was significantly associated with delirium (adjusted odds ratio = 1.48, 95% confidence interval [CI] = 1.09-2.00, P = 0.012), in-hospital mortality (adjusted hazard ratio = 1.19, 95% CI = 1.02-1.40, P = 0.032), and ICU mortality (adjusted hazard ratio = 1.62, 95% CI = 1.22-2.15, P = 0.001). Compared with critically ill patients using high-dose dexamethasone, the risk of delirium was lower in the dose less than the 10 mg group, and patients using 10-14 mg may be associated with a lower risk of in-hospital death and the least ICU mortality, length of hospital stay, and ICU stay. CONCLUSIONS This study demonstrated that the use of dexamethasone in critically ill patients exacerbated the occurrence of delirium while increasing the risk of in-hospital death, ICU death, and length of hospital stay, with a lower risk of delirium and a shorter total length of hospital stay with low-dose dexamethasone than with larger doses.
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Affiliation(s)
- Zehao Wu
- Department of Anesthesiology, Beijing Chaoyang Hospital, Capital Medical University, Beijing, China
| | - Huili Li
- Department of Anesthesiology, Beijing Chaoyang Hospital, Capital Medical University, Beijing, China
| | - Kaihua Liao
- Department of Anesthesiology, Beijing Chaoyang Hospital, Capital Medical University, Beijing, China
| | - Yun Wang
- Department of Anesthesiology, Beijing Chaoyang Hospital, Capital Medical University, Beijing, China.
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Zhou J, Xu X, Liang Y, Zhang X, Tu H, Chu H. Risk factors of postoperative delirium after liver transplantation: a systematic review and meta-analysis. Minerva Anestesiol 2021; 87:684-694. [PMID: 33594873 DOI: 10.23736/s0375-9393.21.15163-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
INTRODUCTION The aim of this study was to summarize the incidence and risk factors of postoperative delirium (POD) after liver transplantation (LT) and associations of POD after LT with outcomes. EVIDENCE ACQUISITION A literature search of Pubmed, EMBASE, and the Cochrane Databases was performed to identify studies reporting POD after LT. The Newcastle-Ottawa Scale was used to rate study quality. Effect estimates were extracted and combined using random-effect model. Pooled mean differences and odds ratios for individual risk factors were calculated using inverse-variance method and Mantel-Haenszel method, as appropriate. EVIDENCE SYNTHESIS Eight articles with 1434 patients were included in the meta-analysis. Overall, the pooled estimated incidence rates of POD after LT were 30% (95% confidence interval: 20-39%). Fourteen statistically significant risk factors were identified in the pooled analysis: alcohol excess, preoperative renal replacement therapy (RRT), preoperative hospital length of stay (LOS), depression, hepatic encephalopathy, alcohol etiology of liver failure, Child-Turcotte-Pugh Score, APACHE II Score, MELD Score, preoperative INR, preoperative bilirubin, intraoperative use of fentanyl, intraoperative RBC transfusion, postoperative ammonia. Patients with POD had a significantly increased mechanical ventilation, postoperative RRT, LOS and mortality rate compared with those without POD. CONCLUSIONS POD after LT was common and multifactorial in etiology. There are significant associations of POD after LT with some clinical outcomes. Effective interventions during perioperative period may be promising to reduce the risk of POD after LT.
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Affiliation(s)
- Jian Zhou
- Department of Anesthesiology, The Affiliated Hospital of Qingdao University, School of Clinical Medicine, Qingdao University, Qingdao, China
| | - Xiaolin Xu
- Department of Anesthesiology, The Affiliated Hospital of Qingdao University, School of Clinical Medicine, Qingdao University, Qingdao, China
| | - Yongxin Liang
- Department of Anesthesiology, The Affiliated Hospital of Qingdao University, School of Clinical Medicine, Qingdao University, Qingdao, China
| | - Xueying Zhang
- Department of Anesthesiology, The Affiliated Hospital of Qingdao University, School of Clinical Medicine, Qingdao University, Qingdao, China
| | - Houan Tu
- Department of Anesthesiology, The Affiliated Hospital of Qingdao University, School of Clinical Medicine, Qingdao University, Qingdao, China
| | - Haichen Chu
- Department of Anesthesiology, The Affiliated Hospital of Qingdao University, School of Clinical Medicine, Qingdao University, Qingdao, China -
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Tripp BA, Dillon ST, Yuan M, Asara JM, Vasunilashorn SM, Fong TG, Metzger ED, Inouye SK, Xie Z, Ngo LH, Marcantonio ER, Libermann TA, Otu HH. Targeted metabolomics analysis of postoperative delirium. Sci Rep 2021; 11:1521. [PMID: 33452279 PMCID: PMC7810737 DOI: 10.1038/s41598-020-80412-z] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2020] [Accepted: 12/15/2020] [Indexed: 01/29/2023] Open
Abstract
Postoperative delirium is the most common complication among older adults undergoing major surgery. The pathophysiology of delirium is poorly understood, and no blood-based, predictive markers are available. We characterized the plasma metabolome of 52 delirium cases and 52 matched controls from the Successful Aging after Elective Surgery (SAGES) cohort (N = 560) of patients ≥ 70 years old without dementia undergoing scheduled major non-cardiac surgery. We applied targeted mass spectrometry with internal standards and pooled controls using a nested matched case-control study preoperatively (PREOP) and on postoperative day 2 (POD2) to identify potential delirium risk and disease markers. Univariate analyses identified 37 PREOP and 53 POD2 metabolites associated with delirium and multivariate analyses achieved significant separation between the two groups with an 11-metabolite prediction model at PREOP (AUC = 83.80%). Systems biology analysis using the metabolites with differential concentrations rendered "valine, leucine, and isoleucine biosynthesis" at PREOP and "citrate cycle" at POD2 as the most significantly enriched pathways (false discovery rate < 0.05). Perturbations in energy metabolism and amino acid synthesis pathways may be associated with postoperative delirium and suggest potential mechanisms for delirium pathogenesis. Our results could lead to the development of a metabolomic delirium predictor.
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Affiliation(s)
- Bridget A Tripp
- Department of Electrical and Computer Engineering, University of Nebraska-Lincoln, Nebraska Hall E419, P.O. Box 880511, Lincoln, NE, 68588, USA.
- PhD Program of Complex Biosystems, University of Nebraska-Lincoln, Lincoln, USA.
| | - Simon T Dillon
- Proteomics, Bioinformatics and Systems Biology Center, Beth Israel Deaconess Medical Center, Boston, USA
- Harvard Medical School, Boston, USA
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, USA
| | - Min Yuan
- Division of Signal Transduction and Mass Spectrometry Core, Beth Israel Deaconess Medical Center, Boston, USA
| | - John M Asara
- Harvard Medical School, Boston, USA
- Division of Signal Transduction and Mass Spectrometry Core, Beth Israel Deaconess Medical Center, Boston, USA
| | - Sarinnapha M Vasunilashorn
- Harvard Medical School, Boston, USA
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, USA
- Harvard T.H. Chan School of Public Health, Boston, USA
| | - Tamara G Fong
- Harvard Medical School, Boston, USA
- Department of Neurology, Beth Israel Deaconess Medical Center, Boston, USA
- Aging Brain Center, Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, USA
| | - Eran D Metzger
- Department of Medicine, Hebrew SeniorLife, Boston, USA
- Department of Psychiatry, Beth Israel Deaconess Medical Center, Boston, USA
| | - Sharon K Inouye
- Harvard Medical School, Boston, USA
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, USA
- Aging Brain Center, Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, USA
| | - Zhongcong Xie
- Harvard Medical School, Boston, USA
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, USA
| | - Long H Ngo
- Harvard Medical School, Boston, USA
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, USA
- Harvard T.H. Chan School of Public Health, Boston, USA
| | - Edward R Marcantonio
- Harvard Medical School, Boston, USA
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, USA
| | - Towia A Libermann
- Proteomics, Bioinformatics and Systems Biology Center, Beth Israel Deaconess Medical Center, Boston, USA
- Harvard Medical School, Boston, USA
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, USA
| | - Hasan H Otu
- Department of Electrical and Computer Engineering, University of Nebraska-Lincoln, Nebraska Hall E419, P.O. Box 880511, Lincoln, NE, 68588, USA
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Seo CL, Park JY, Park J, Kim HE, Cho J, Seok JH, Kim JJ, Shin CS, Oh J. Neutrophil-Lymphocyte Ratio as a Potential Biomarker for Delirium in the Intensive Care Unit. Front Psychiatry 2021; 12:729421. [PMID: 34912245 PMCID: PMC8667224 DOI: 10.3389/fpsyt.2021.729421] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2021] [Accepted: 11/09/2021] [Indexed: 11/13/2022] Open
Abstract
Background: Recognition and early detection of delirium in the intensive care unit (ICU) is essential to improve ICU outcomes. To date, neutrophil-lymphocyte ratio (NLR), one of inflammatory markers, has been proposed as a potential biomarker for brain disorders related to neuroinflammation. This study aimed to investigate whether NLR could be utilized in early detection of delirium in the ICU. Methods: Of 10,144 patients who admitted to the ICU, 1,112 delirium patients (DE) were included in the current study. To compare among inflammatory markers, NLR, C-reactive protein (CRP), and white blood cell (WBC) counts were obtained: the mean NLR, CRP levels, and WBC counts between the initial day of ICU admission and the day of initial delirium onset within DE were examined. The inflammatory marker of 1,272 non-delirium patients (ND) were also comparatively measured as a supplement. Further comparisons included a subgroup analysis based on delirium subtypes (non-hypoactive vs. hypoactive) or admission types (elective vs. emergent). Results: The NLR and CRP levels in DE increased on the day of delirium onset compared to the initial admission day. ND also showed increased CRP levels on the sixth day (the closest day to average delirium onset day among DE) of ICU admission compared to baseline, while NLR in ND did not show significant difference over time. In further analyses, the CRP level of the non-hypoactive group was more increased than that of the hypoactive group during the delirium onset. NLR, however, was more significantly increased in patients with elective admission than in those with emergent admission. Conclusion: Elevation of NLR was more closely linked to the onset of delirium compared to other inflammatory markers, indicating that NLR may play a role in early detection of delirium.
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Affiliation(s)
- Chai Lee Seo
- Department of Neuropsychiatry, Seoul National University Hospital, Seoul, South Korea
| | - Jin Young Park
- Institute of Behavioral Sciences in Medicine, Yonsei University College of Medicine, Seoul, South Korea.,Department of Psychiatry, Yongin Severance Hospital, Yonsei University College of Medicine, Yongin, South Korea
| | - Jaesub Park
- Institute of Behavioral Sciences in Medicine, Yonsei University College of Medicine, Seoul, South Korea.,Department of Psychiatry, National Health Insurance Service Ilsan Hospital, Goyang, South Korea
| | - Hesun Erin Kim
- Institute of Behavioral Sciences in Medicine, Yonsei University College of Medicine, Seoul, South Korea
| | - Jaehwa Cho
- Department of Pulmonary and Critical Care Medicine, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, South Korea
| | - Jeong-Ho Seok
- Institute of Behavioral Sciences in Medicine, Yonsei University College of Medicine, Seoul, South Korea.,Department of Psychiatry, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, South Korea
| | - Jae-Jin Kim
- Institute of Behavioral Sciences in Medicine, Yonsei University College of Medicine, Seoul, South Korea.,Department of Psychiatry, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, South Korea
| | - Cheung Soo Shin
- Department of Anesthesiology and Pain Medicine, Yongin Severance Hospital, Yonsei University College of Medicine, Yongin, South Korea
| | - Jooyoung Oh
- Institute of Behavioral Sciences in Medicine, Yonsei University College of Medicine, Seoul, South Korea.,Department of Psychiatry, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, South Korea
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Lunardelli ML, Crupi R, Siracusa R, Cocuzza G, Cordaro M, Martini E, Impellizzeri D, Di Paola R, Cuzzocrea S. Co-ultraPEALut: Role in Preclinical and Clinical Delirium Manifestations. CNS & NEUROLOGICAL DISORDERS-DRUG TARGETS 2020; 18:530-554. [PMID: 31244434 DOI: 10.2174/1871527318666190617162041] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/18/2019] [Revised: 05/08/2019] [Accepted: 05/15/2019] [Indexed: 11/22/2022]
Abstract
BACKGROUND Delirium is a disorder in awareness, attention and cognition. Pathophysiologically it is a response to stress. Postoperative delirium (POD) is a usual complication in aged patients following hip fracture surgery. Neuroinflammation is an important factor linked with the progress of POD. Though there are no efficient cures for delirium the endocannabinoid system may have a role in neuropsychiatric disorders. OBJECTIVE Therefore, we examined the effects of co-ultramicronized PEALut (co-ultraPEALut) in the LPS murine model of delirium and in elderly hip fractured patients. METHODS In the preclinical study, mice were injected intraperitoneally (i.p.) with Escherichia coli LPS (10 mg/kg). Co-ultraPEALut (1 mg/kg o.s.) was administered 1h before LPS injection or 1h and 6h after LPS injection or 1h before LPS injection and 1h and 6h after LPS. In the clinical study, the effects of Glialia® (co-ultramicronized 700 mg PEA + 70 mg luteolin) administration was evaluated in elderly hip fractured patients with an interventional, randomized, single-blind, monocentric study. RESULTS Administration of co-ultraPEALut to LPS-challenged mice ameliorated cognitive dysfunctions and locomotor activity; moreover, it reduced inflammation and apoptosis, while stimulating antioxidant response and limiting the loss of neurotrophins. In the clinical study, the results obtained demonstrated that administration of Glialia® to these surgical patients prevented the onset of POD and attenuated symptom intensity and their duration. CONCLUSION Therefore, the results obtained enhanced the idea that co-ultraPEALut may be a potential treatment to control cognitive impairment and the inflammatory and oxidative processes associated with delirium.
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Affiliation(s)
- Maria Lia Lunardelli
- Geriatric Unit - Orthogeriatric Ward, Universitary Sant'Orsola Policlinic Bologna, Bologna, Italy
| | - Rosalia Crupi
- Department of Chemical, Biological, Pharmaceutical and Environmental Science, University of Messina, Messina, Italy
| | - Rosalba Siracusa
- Department of Chemical, Biological, Pharmaceutical and Environmental Science, University of Messina, Messina, Italy
| | - Giorgio Cocuzza
- Geriatric Unit - Orthogeriatric Ward, Universitary Sant'Orsola Policlinic Bologna, Bologna, Italy
| | - Marika Cordaro
- Department of Chemical, Biological, Pharmaceutical and Environmental Science, University of Messina, Messina, Italy
| | - Emilio Martini
- Geriatric Unit - Orthogeriatric Ward, Universitary Sant'Orsola Policlinic Bologna, Bologna, Italy
| | - Daniela Impellizzeri
- Department of Chemical, Biological, Pharmaceutical and Environmental Science, University of Messina, Messina, Italy
| | - Rosanna Di Paola
- Department of Chemical, Biological, Pharmaceutical and Environmental Science, University of Messina, Messina, Italy
| | - Salvatore Cuzzocrea
- Department of Chemical, Biological, Pharmaceutical and Environmental Science, University of Messina, Messina, Italy.,Department of Pharmacological and Physiological Science, Saint Louis University School of Medicine, Saint Louis, MO, United States
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Saito T, Toda H, Duncan GN, Jellison SS, Yu T, Klisares MJ, Daniel S, Andreasen A, Leyden L, Hellman M, Shinozaki E, Lee S, Yoshino A, Cho HR, Shinozaki G. Epigenetics of neuroinflammation: Immune response, inflammatory response and cholinergic synaptic involvement evidenced by genome-wide DNA methylation analysis of delirious inpatients. J Psychiatr Res 2020; 129:61-65. [PMID: 32590150 PMCID: PMC7486988 DOI: 10.1016/j.jpsychires.2020.06.005] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Revised: 06/01/2020] [Accepted: 06/01/2020] [Indexed: 01/18/2023]
Abstract
Previously our study has shown that the DNA methylation (DNAm) levels at CpG sites in the pro-inflammatory cytokine gene, TNF-alpha, decrease along with aging, suggesting the potential role of DNAm in aging and heightened inflammatory process leading to increased risk for delirium. However, DNAm differences between delirium cases and non-delirium controls have not been investigated directly. Therefore, we examined genome-wide DNAm differences in blood between patients with delirium and controls to identify useful epigenetic biomarkers for delirium. Data from a total of 87 subjects (43 delirium cases) were analyzed by a genome-wide DNAm case-control association study. A genome-wide significant CpG site near the gene of LDLRAD4 was identified (p = 5.07E-8). In addition, over-representation analysis showed several significant pathways with a false discovery rate adjusted p-value < 0.05. The top pathway with a Gene Ontology term was immune response, and the second top pathway with a Kyoto Encyclopedia of Genes and Genomes term was cholinergic synapse. Significant DNAm differences related to immune/inflammatory response were shown both at gene and pathway levels between patients with delirium and non-delirium controls. This finding indicates that DNAm status in blood has the potential to be used as epigenetic biomarkers for delirium.
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Affiliation(s)
- Taku Saito
- Department of Psychiatry, University of Iowa, Iowa City, Iowa, USA,Department of Psychiatry, School of Medicine, National Defense Medical College, Tokorozawa, Saitama, Japan
| | - Hiroyuki Toda
- Department of Psychiatry, School of Medicine, National Defense Medical College, Tokorozawa, Saitama, Japan
| | | | | | - Tong Yu
- Department of Psychiatry, University of Iowa, Iowa City, Iowa, USA
| | | | - Sophia Daniel
- Department of Psychiatry, University of Iowa, Iowa City, Iowa, USA
| | | | - Lydia Leyden
- Department of Psychiatry, University of Iowa, Iowa City, Iowa, USA
| | - Mandy Hellman
- Department of Psychiatry, University of Iowa, Iowa City, Iowa, USA
| | - Eri Shinozaki
- Department of Internal Medicine, University of Iowa, Iowa City, Iowa, USA
| | - Sangil Lee
- Department of Emergency Medicine, University of Iowa, Iowa City, Iowa, USA
| | - Aihide Yoshino
- Department of Psychiatry, School of Medicine, National Defense Medical College, Tokorozawa, Saitama, Japan
| | - Hyunkeun R. Cho
- Department of Biostatistics, College of Public Health, University of Iowa, Iowa City, Iowa, USA
| | - Gen Shinozaki
- Department of Psychiatry, University of Iowa, Iowa City, IA, USA; Department of Neurosurgery, Carver College of Medicine, University of Iowa, Iowa City, IA, USA; Department of Anesthesia, Carver College of Medicine, University of Iowa, Iowa City, IA, USA; Iowa Neuroscience Institute, University of Iowa, Iowa City, IA, USA; Interdisciplinary Graduate Program in Neuroscience, University of Iowa, Iowa City, IA, USA.
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Fong TG, Vasunilashorn SM, Ngo L, Libermann TA, Dillon ST, Schmitt EM, Pascual-Leone A, Arnold SE, Jones RN, Marcantonio ER, Inouye SK. Association of Plasma Neurofilament Light with Postoperative Delirium. Ann Neurol 2020; 88:984-994. [PMID: 32881052 DOI: 10.1002/ana.25889] [Citation(s) in RCA: 58] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2020] [Revised: 08/21/2020] [Accepted: 08/21/2020] [Indexed: 12/16/2022]
Abstract
OBJECTIVE To examine the association of the plasma neuroaxonal injury markers neurofilament light (NfL), total tau, glial fibrillary acid protein, and ubiquitin carboxyl-terminal hydrolase L1 with delirium, delirium severity, and cognitive performance. METHODS Delirium case-no delirium control (n = 108) pairs were matched by age, sex, surgery type, cognition, and vascular comorbidities. Biomarkers were measured in plasma collected preoperatively (PREOP), and 2 days (POD2) and 30 days postoperatively (PO1MO) using Simoa technology (Quanterix, Lexington, MA). The Confusion Assessment Method (CAM) and CAM-S (Severity) were used to measure delirium and delirium severity, respectively. Cognitive function was measured with General Cognitive Performance (GCP) scores. RESULTS Delirium cases had higher NfL on POD2 and PO1MO (median matched pair difference = 16.2pg/ml and 13.6pg/ml, respectively; p < 0.05). Patients with PREOP and POD2 NfL in the highest quartile (Q4) had increased risk for incident delirium (adjusted odds ratio [OR] = 3.7 [95% confidence interval (CI) = 1.1-12.6] and 4.6 [95% CI = 1.2-18.2], respectively) and experienced more severe delirium, with sum CAM-S scores 7.8 points (95% CI = 1.6-14.0) and 9.3 points higher (95% CI = 3.2-15.5). At PO1MO, delirium cases had continued high NfL (adjusted OR = 9.7, 95% CI = 2.3-41.4), and those with Q4 NfL values showed a -2.3 point decline in GCP score (-2.3 points, 95% CI = -4.7 to -0.9). INTERPRETATION Patients with the highest PREOP or POD2 NfL levels were more likely to develop delirium. Elevated NfL at PO1MO was associated with delirium and greater cognitive decline. These findings suggest NfL may be useful as a predictive biomarker for delirium risk and long-term cognitive decline, and once confirmed would provide pathophysiological evidence for neuroaxonal injury following delirium. ANN NEUROL 2020;88:984-994.
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Affiliation(s)
- Tamara G Fong
- Department of Neurology, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts, USA.,Aging Brain Center, Hebrew SeniorLife, Boston, Massachusetts, USA.,Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts, USA
| | - Sarinnapha M Vasunilashorn
- Division of General Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts, USA.,Department of Epidemiology, Harvard T. H. Chan School of Public Health, Boston, Massachusetts, USA
| | - Long Ngo
- Division of General Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts, USA.,Department of Biostatistics, Harvard T. H. Chan School of Public Health, Boston, Massachusetts, USA
| | - Towia A Libermann
- Division of Interdisciplinary Medicine and Biotechnology, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts, USA.,Beth Israel Deaconess Medical Center Genomics, Proteomics, Bioinformatics, and Systems Biology Center, Boston, Massachusetts, USA
| | - Simon T Dillon
- Division of Interdisciplinary Medicine and Biotechnology, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts, USA.,Beth Israel Deaconess Medical Center Genomics, Proteomics, Bioinformatics, and Systems Biology Center, Boston, Massachusetts, USA
| | - Eva M Schmitt
- Aging Brain Center, Hebrew SeniorLife, Boston, Massachusetts, USA.,Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts, USA
| | - Alvaro Pascual-Leone
- Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts, USA.,Department of Neurology, Harvard Medical School, Boston, Massachusetts, USA.,Guttmann Brain Health Institute, Guttmann Institute, Autonomous University of Barcelona, Barcelona, Spain
| | - Steven E Arnold
- Department of Neurology, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Richard N Jones
- Departments of Psychiatry and Human Behavior and Neurology, Warren Alpert Medical School, Brown University, Providence, Rhode Island, USA
| | - Edward R Marcantonio
- Division of General Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts, USA.,Division of Gerontology, Department of Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts, USA
| | - Sharon K Inouye
- Aging Brain Center, Hebrew SeniorLife, Boston, Massachusetts, USA.,Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts, USA.,Division of Gerontology, Department of Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts, USA
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Katsumi Y, Racine AM, Torrado-Carvajal A, Loggia ML, Hooker JM, Greve DN, Hightower BG, Catana C, Cavallari M, Arnold SE, Fong TG, Vasunilashorn SM, Marcantonio ER, Schmitt EM, Xu G, Libermann TA, Barrett LF, Inouye SK, Dickerson BC, Touroutoglou A, Collins JA. The Role of Inflammation after Surgery for Elders (RISE) study: Examination of [ 11C]PBR28 binding and exploration of its link to post-operative delirium. Neuroimage Clin 2020; 27:102346. [PMID: 32712451 PMCID: PMC7390821 DOI: 10.1016/j.nicl.2020.102346] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2020] [Revised: 06/11/2020] [Accepted: 07/10/2020] [Indexed: 12/11/2022]
Abstract
Major surgery is associated with a systemic inflammatory cascade that is thought, in some cases, to contribute to transient and/or sustained cognitive decline, possibly through neuroinflammatory mechanisms. However, the relationship between surgery, peripheral and central nervous system inflammation, and post-operative cognitive outcomes remains unclear in humans, primarily owing to limitations of in vivo biomarkers of neuroinflammation which vary in sensitivity, specificity, validity, and reliability. In the present study, [11C]PBR28 positron emission tomography, cerebrospinal fluid (CSF), and blood plasma biomarkers of inflammation were assessed pre-operatively and 1-month post-operatively in a cohort of patients (N = 36; 30 females; ≥70 years old) undergoing major orthopedic surgery under spinal anesthesia. Delirium incidence and severity were evaluated daily during hospitalization. Whole-brain voxel-wise and regions-of-interest analyses were performed to determine the magnitude and spatial extent of changes in [11C]PBR28 uptake following surgery. Results demonstrated that, compared with pre-operative baseline, [11C]PBR28 binding in the brain was globally downregulated at 1 month following major orthopedic surgery, possibly suggesting downregulation of the immune system of the brain. No significant relationship was identified between post-operative delirium and [11C]PBR28 binding, possibly due to a small number (n = 6) of delirium cases in the sample. Additionally, no significant relationships were identified between [11C]PBR28 binding and CSF/plasma biomarkers of inflammation. Collectively, these results contribute to the literature by demonstrating in a sizeable sample the effect of major surgery on neuroimmune activation and preliminary evidence identifying no apparent associations between [11C]PBR28 binding and fluid inflammatory markers or post-operative delirium.
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Affiliation(s)
- Yuta Katsumi
- Department of Psychology, Northeastern University, Boston, MA, United States; Japan Society for the Promotion of Science, Tokyo, Japan; Harvard Medical School, Boston, MA, United States
| | - Annie M Racine
- Aging Brain Center, Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, MA, United States
| | - Angel Torrado-Carvajal
- Harvard Medical School, Boston, MA, United States; Department of Radiology, Massachusetts General Hospital, Boston, MA, United States; Athinoula A. Martinos Center for Biomedical Imaging, Massachusetts General Hospital, Boston, MA, United States; Medical Image Analysis and Biometry Laboratory, Universidad Rey Juan Carlos, Madrid, Spain
| | - Marco L Loggia
- Harvard Medical School, Boston, MA, United States; Department of Radiology, Massachusetts General Hospital, Boston, MA, United States; Athinoula A. Martinos Center for Biomedical Imaging, Massachusetts General Hospital, Boston, MA, United States
| | - Jacob M Hooker
- Harvard Medical School, Boston, MA, United States; Department of Radiology, Massachusetts General Hospital, Boston, MA, United States; Athinoula A. Martinos Center for Biomedical Imaging, Massachusetts General Hospital, Boston, MA, United States
| | - Douglas N Greve
- Harvard Medical School, Boston, MA, United States; Department of Radiology, Massachusetts General Hospital, Boston, MA, United States; Athinoula A. Martinos Center for Biomedical Imaging, Massachusetts General Hospital, Boston, MA, United States
| | - Baileigh G Hightower
- Harvard Medical School, Boston, MA, United States; Department of Radiology, Massachusetts General Hospital, Boston, MA, United States; Athinoula A. Martinos Center for Biomedical Imaging, Massachusetts General Hospital, Boston, MA, United States
| | - Ciprian Catana
- Harvard Medical School, Boston, MA, United States; Department of Radiology, Massachusetts General Hospital, Boston, MA, United States; Athinoula A. Martinos Center for Biomedical Imaging, Massachusetts General Hospital, Boston, MA, United States
| | - Michele Cavallari
- Harvard Medical School, Boston, MA, United States; Department of Radiology, Brigham and Women's Hospital, Boston, MA, United States
| | - Steven E Arnold
- Harvard Medical School, Boston, MA, United States; Department of Neurology, Massachusetts General Hospital, Boston, MA, United States
| | - Tamara G Fong
- Harvard Medical School, Boston, MA, United States; Aging Brain Center, Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, MA, United States; Department of Neurology, Beth Israel Deaconess Medical Center, Boston, MA, United States
| | - Sarinnapha M Vasunilashorn
- Harvard Medical School, Boston, MA, United States; Aging Brain Center, Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, MA, United States; Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, United States
| | - Edward R Marcantonio
- Harvard Medical School, Boston, MA, United States; Aging Brain Center, Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, MA, United States; Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, United States
| | - Eva M Schmitt
- Harvard Medical School, Boston, MA, United States; Aging Brain Center, Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, MA, United States
| | - Guoquan Xu
- Aging Brain Center, Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, MA, United States
| | - Towia A Libermann
- Harvard Medical School, Boston, MA, United States; Genomics, Proteomics, Bioinformatics and Systems Biology, Beth Israel Deaconess Medical Center, Boston, MA, United States
| | - Lisa Feldman Barrett
- Department of Psychology, Northeastern University, Boston, MA, United States; Harvard Medical School, Boston, MA, United States; Department of Psychiatry, Massachusetts General Hospital, Boston, MA, United States; Athinoula A. Martinos Center for Biomedical Imaging, Massachusetts General Hospital, Boston, MA, United States
| | - Sharon K Inouye
- Harvard Medical School, Boston, MA, United States; Aging Brain Center, Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, MA, United States; Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, United States
| | - Bradford C Dickerson
- Harvard Medical School, Boston, MA, United States; Frontotemporal Disorders Unit, Massachusetts General Hospital, Boston, MA, United States; Department of Neurology, Massachusetts General Hospital, Boston, MA, United States; Athinoula A. Martinos Center for Biomedical Imaging, Massachusetts General Hospital, Boston, MA, United States
| | - Alexandra Touroutoglou
- Harvard Medical School, Boston, MA, United States; Frontotemporal Disorders Unit, Massachusetts General Hospital, Boston, MA, United States; Department of Neurology, Massachusetts General Hospital, Boston, MA, United States; Athinoula A. Martinos Center for Biomedical Imaging, Massachusetts General Hospital, Boston, MA, United States
| | - Jessica A Collins
- Harvard Medical School, Boston, MA, United States; Frontotemporal Disorders Unit, Massachusetts General Hospital, Boston, MA, United States; Department of Neurology, Massachusetts General Hospital, Boston, MA, United States; Athinoula A. Martinos Center for Biomedical Imaging, Massachusetts General Hospital, Boston, MA, United States
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Hindiskere S, Kim HS, Han I. Postoperative delirium in patients undergoing surgery for bone metastases. Medicine (Baltimore) 2020; 99:e20159. [PMID: 32443331 PMCID: PMC7254856 DOI: 10.1097/md.0000000000020159] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2020] [Revised: 04/05/2020] [Accepted: 04/06/2020] [Indexed: 11/28/2022] Open
Abstract
Postoperative delirium (PD), characterized by acute onset of global impairment in consciousness and cognition, is a common complication following major surgeries and is often associated with adverse outcomes. Because of the multiple comorbidities of the patient along with extensive nature of the surgery, patients undergoing surgery for bone metastases may be prone to developing PD. However, no study exists regarding PD in patients who undergo surgery for bone metastases.Two hundred seventy six patients with mean age of 64 years (range, 16-94) who underwent surgery for bone metastases were reviewed. The diagnosis of PD was made by the psychiatrist, according to fourth edition of the Diagnostic and Statistical Manual of Mental Disorders. Possible perioperative clinic-pathologic factors that may be associated with the development of PD were investigated.Among the 276 patients, 9% (n = 25) developed PD. On multivariate logistic regression analysis, history of psychiatric disorders (odds ratio [OR] = 9.63; 95% confidence interval [CI] 1.78-21.74, P = .004), high preoperative serum C-reactive protein (CRP) level (OR = 1.17; 95% CI 1.06-1.29, P = .001), low preoperative serum albumin level (OR = 0.13; 95% CI 0.03-0.48, P = 0.002), and high dose of opioid analgesics received in the immediate postoperative period (OR = 1.05; 95% CI 1.01-1.07, P = .001) were independently associated with the development of PD. Patients with PD had lower survival (log rank, P = .001) than patients without PD.Incidence of PD is considerable in patients undergoing surgery for bone metastases. History of psychiatric disorders, preoperative serum albumin and CRP levels, and the dose of postoperative opioid analgesics are associated with the development of PD.
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Affiliation(s)
- Suraj Hindiskere
- Department of Orthopaedic Surgery, Seoul National University Hospital
| | - Han-Soo Kim
- Department of Orthopaedic Surgery, Seoul National University Hospital
- Department of Orthopaedic Surgery, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Ilkyu Han
- Department of Orthopaedic Surgery, Seoul National University Hospital
- Department of Orthopaedic Surgery, Seoul National University College of Medicine, Seoul, Republic of Korea
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Amgarth-Duff I, Hosie A, Caplan G, Agar M. A systematic review of the overlap of fluid biomarkers in delirium and advanced cancer-related syndromes. BMC Psychiatry 2020; 20:182. [PMID: 32321448 PMCID: PMC7178636 DOI: 10.1186/s12888-020-02584-2] [Citation(s) in RCA: 8] [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: 07/31/2019] [Accepted: 04/05/2020] [Indexed: 01/07/2023] Open
Abstract
BACKGROUND Delirium is a serious and distressing neurocognitive disorder of physiological aetiology that is common in advanced cancer. Understanding of delirium pathophysiology is largely hypothetical, with some evidence for involvement of inflammatory systems, neurotransmitter alterations and glucose metabolism. To date, there has been limited empirical consideration of the distinction between delirium pathophysiology and that of the underlying disease, for example, cancer where these mechanisms are also common in advanced cancer syndromes such as pain and fatigue. This systematic review explores biomarker overlap in delirium, specific advanced cancer-related syndromes and prediction of cancer prognosis. METHODS A systematic review (PROSPERO CRD42017068662) was conducted, using MEDLINE, PubMed, Embase, CINAHL, CENTRAL and Web of Science, to identify body fluid biomarkers in delirium, cancer prognosis and advanced cancer-related syndromes of interest. Studies were excluded if they reported delirium tremens only; did not measure delirium using a validated tool; the sample had less than 75% of participants with advanced cancer; measured tissue, genetic or animal biomarkers, or were conducted post-mortem. Articles were screened for inclusion independently by two authors, and data extraction and an in-depth quality assessment conducted by one author, and checked by two others. RESULTS The 151 included studies were conducted in diverse settings in 32 countries between 1985 and 2017, involving 28130 participants with a mean age of 69.3 years. Seventy-one studies investigated delirium biomarkers, and 80 studies investigated biomarkers of an advanced cancer-related syndrome or cancer prognosis. Overall, 41 biomarkers were studied in relation to both delirium and either an advanced cancer-related syndrome or prognosis; and of these, 24 biomarkers were positively associated with either delirium or advanced cancer syndromes/prognosis in at least one study. The quality assessment showed large inconsistency in reporting. CONCLUSION There is considerable overlap in the biomarkers in delirium and advanced cancer-related syndromes. Improving the design of delirium biomarker studies and considering appropriate comparator/controls will help to better understanding the discrete pathophysiology of delirium in the context of co-existing illness.
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Affiliation(s)
- Ingrid Amgarth-Duff
- University of Technology Sydney, Faculty of Health, IMPACCT -Improving Palliative, Aged and Chronic Care through Clinical Research and Translation, Sydney, NSW, Australia.
| | - Annmarie Hosie
- grid.117476.20000 0004 1936 7611University of Technology Sydney, Faculty of Health, IMPACCT -Improving Palliative, Aged and Chronic Care through Clinical Research and Translation, Sydney, NSW Australia
| | - Gideon Caplan
- grid.1005.40000 0004 4902 0432Prince of Wales Clinical School, University of New South Wales, Sydney, NSW Australia ,grid.415193.bDepartment of Geriatric Medicine, Prince of Wales Hospital, Sydney, NSW Australia
| | - Meera Agar
- grid.117476.20000 0004 1936 7611University of Technology Sydney, Faculty of Health, IMPACCT -Improving Palliative, Aged and Chronic Care through Clinical Research and Translation, Sydney, NSW Australia ,grid.1005.40000 0004 4902 0432South West Sydney Clinical School, University of New South Wales, Liverpool, New South Wales Australia ,grid.429098.eClinical Trials, Ingham Institute of Applied Medical Research, Liverpool, New South Wales Australia
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