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Viegas A, Araújo R, Ramalhete L, Von Rekowski C, Fonseca TAH, Bento L, Calado CRC. Discovery of Delirium Biomarkers through Minimally Invasive Serum Molecular Fingerprinting. Metabolites 2024; 14:301. [PMID: 38921436 PMCID: PMC11205956 DOI: 10.3390/metabo14060301] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2024] [Revised: 05/21/2024] [Accepted: 05/24/2024] [Indexed: 06/27/2024] Open
Abstract
Delirium presents a significant clinical challenge, primarily due to its profound impact on patient outcomes and the limitations of the current diagnostic methods, which are largely subjective. During the COVID-19 pandemic, this challenge was intensified as the frequency of delirium assessments decreased in Intensive Care Units (ICUs), even as the prevalence of delirium among critically ill patients increased. The present study evaluated how the serum molecular fingerprint, as acquired by Fourier-Transform InfraRed (FTIR) spectroscopy, can enable the development of predictive models for delirium. A preliminary univariate analysis of serum FTIR spectra indicated significantly different bands between 26 ICU patients with delirium and 26 patients without, all of whom were admitted with COVID-19. However, these bands resulted in a poorly performing Naïve-Bayes predictive model. Considering the use of a Fast-Correlation-Based Filter for feature selection, it was possible to define a new set of spectral bands with a wider coverage of molecular functional groups. These bands ensured an excellent Naïve-Bayes predictive model, with an AUC, a sensitivity, and a specificity all exceeding 0.92. These spectral bands, acquired through a minimally invasive analysis and obtained rapidly, economically, and in a high-throughput mode, therefore offer significant potential for managing delirium in critically ill patients.
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Affiliation(s)
- Ana Viegas
- ESTeSL—Escola Superior de Tecnologia da Saúde de Lisboa, Instituto Politécnico de Lisboa, Avenida D. João II, Lote 4.58.01, 1990-096 Lisbon, Portugal;
- Neurosciences Area, Clinical Neurophysiology Unit, ULSSJ—Unidade Local de Saúde São José, Rua José António Serrano, 1150-199 Lisbon, Portugal
- CHRC—Comprehensive Health Research Centre, Universidade NOVA de Lisboa, 1150-082 Lisbon, Portugal; (R.A.)
- NOVA Medical School, Faculdade de Ciências Médicas, Universidade NOVA de Lisboa, 1169-056 Lisbon, Portugal
| | - Rúben Araújo
- CHRC—Comprehensive Health Research Centre, Universidade NOVA de Lisboa, 1150-082 Lisbon, Portugal; (R.A.)
- NOVA Medical School, Faculdade de Ciências Médicas, Universidade NOVA de Lisboa, 1169-056 Lisbon, Portugal
- ISEL—Instituto Superior de Engenharia de Lisboa, Instituto Politécnico de Lisboa, R. Conselheiro Emídio Navarro 1, 1959-007 Lisbon, Portugal
| | - Luís Ramalhete
- NOVA Medical School, Faculdade de Ciências Médicas, Universidade NOVA de Lisboa, 1169-056 Lisbon, Portugal
- Blood and Transplantation Center of Lisbon, Instituto Português do Sangue e da Transplantação, Alameda das Linhas de Torres, n° 117, 1769-001 Lisboa, Portugal
- iNOVA4Health—Advancing Precision Medicine, RG11: Reno-Vascular Diseases Group, NOVA Medical School, Faculdade de Ciências Médicas, Universidade NOVA de Lisboa, 1169-056 Lisbon, Portugal
| | - Cristiana Von Rekowski
- CHRC—Comprehensive Health Research Centre, Universidade NOVA de Lisboa, 1150-082 Lisbon, Portugal; (R.A.)
- NOVA Medical School, Faculdade de Ciências Médicas, Universidade NOVA de Lisboa, 1169-056 Lisbon, Portugal
- ISEL—Instituto Superior de Engenharia de Lisboa, Instituto Politécnico de Lisboa, R. Conselheiro Emídio Navarro 1, 1959-007 Lisbon, Portugal
| | - Tiago A. H. Fonseca
- CHRC—Comprehensive Health Research Centre, Universidade NOVA de Lisboa, 1150-082 Lisbon, Portugal; (R.A.)
- NOVA Medical School, Faculdade de Ciências Médicas, Universidade NOVA de Lisboa, 1169-056 Lisbon, Portugal
- ISEL—Instituto Superior de Engenharia de Lisboa, Instituto Politécnico de Lisboa, R. Conselheiro Emídio Navarro 1, 1959-007 Lisbon, Portugal
| | - Luís Bento
- NOVA Medical School, Faculdade de Ciências Médicas, Universidade NOVA de Lisboa, 1169-056 Lisbon, Portugal
- Intensive Care Department, ULSSJ—Unidade Local de Saúde São José, Rua José António Serrano, 1150-199 Lisbon, Portugal
- Integrated Pathophysiological Mechanisms, CHRC—Comprehensive Health Research Centre, NMS—NOVA Medical School, FCM—Faculdade de Ciências Médicas, Universidade NOVA de Lisboa, Campo Mártires da Pátria 130, 1169-056 Lisbon, Portugal
| | - Cecília R. C. Calado
- ISEL—Instituto Superior de Engenharia de Lisboa, Instituto Politécnico de Lisboa, R. Conselheiro Emídio Navarro 1, 1959-007 Lisbon, Portugal
- iBB—Institute for Bioengineering and Biosciences, The Associate Laboratory Institute for Health and Bioeconomy (i4HB), Instituto Superior Técnico, Universidade de Lisboa, Av. Rovisco Pais, 1049-001 Lisbon, Portugal
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Brummel NE, Hughes CG, McNeil JB, Pandharipande PP, Thompson JL, Orun OM, Raman R, Ware LB, Bernard GR, Harrison FE, Ely EW, Girard TD. Systemic inflammation and delirium during critical illness. Intensive Care Med 2024; 50:687-696. [PMID: 38647548 DOI: 10.1007/s00134-024-07388-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2023] [Accepted: 03/10/2024] [Indexed: 04/25/2024]
Abstract
PURPOSE The purpose of this study was to determine associations between markers of inflammation and endogenous anticoagulant activity with delirium and coma during critical illness. METHODS In this prospective cohort study, we enrolled adults with respiratory failure and/or shock treated in medical or surgical intensive care units (ICUs) at 5 centers. Twice per day in the ICU, and daily thereafter, we assessed mental status using the Richmond Agitation Sedation Scale (RASS) and the Confusion Assessment Method-Intensive Care Unit (CAM-ICU). We collected blood samples on study days 1, 3, and 5, measuring levels of C-reactive protein (CRP), interferon gamma (IFN-γ), interleukin (IL)-1 beta (IL-1β), IL-6, IL-8, IL-10, IL-12, matrix metalloproteinase-9 (MMP-9), tumor necrosis factor-alpha (TNF-α), tumor necrosis factor receptor 1 (TNFR1), and protein C using validated protocols. We used multinomial logistic regression to analyze associations between biomarkers and the odds of delirium or coma versus normal mental status the following day, adjusting for age, sepsis, Sequential Organ Failure Assessment (SOFA), study day, corticosteroids, and sedatives. RESULTS Among 991 participants with a median age (interquartile range, IQR) of 62 [53-72] years and enrollment SOFA of 9 [7-11], higher concentrations of IL-6 (odds ratio [OR] [95% CI]: 1.8 [1.4-2.3]), IL-8 (1.3 [1.1-1.5]), IL-10 (1.5 [1.2-1.8]), TNF-α (1.2 [1.0-1.4]), and TNFR1 (1.3 [1.1-1.6]) and lower concentrations of protein C (0.7 [0.6-0.8])) were associated with delirium the following day. Higher concentrations of CRP (1.4 [1.1-1.7]), IFN-γ (1.3 [1.1-1.5]), IL-6 (2.3 [1.8-3.0]), IL-8 (1.8 [1.4-2.3]), and IL-10 (1.5 [1.2-2.0]) and lower concentrations of protein C (0.6 [0.5-0.8]) were associated with coma the following day. IL-1β, IL-12, and MMP-9 were not associated with mental status. CONCLUSION Markers of inflammation and possibly endogenous anticoagulant activity are associated with delirium and coma during critical illness.
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Affiliation(s)
- Nathan E Brummel
- Division of Pulmonary, Critical Care, and Sleep Medicine, The Ohio State University College of Medicine, Columbus, OH, USA
- Davis Heart and Lung Research Institute, The Ohio State University Wexner Medical Center, Columbus, OH, USA
- Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center, Nashville, TN, USA
| | - Christopher G Hughes
- Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center, Nashville, TN, USA
- Division of Anesthesia Critical Care Medicine, Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN, USA
- Vanderbilt Memory and Alzheimer's Center, Vanderbilt University School of Medicine, Nashville, TN, USA
| | - J Brennan McNeil
- Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center, Nashville, TN, USA
- Division of Allergy, Pulmonary, and Critical Care Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Pratik P Pandharipande
- Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center, Nashville, TN, USA
- Division of Anesthesia Critical Care Medicine, Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN, USA
- Vanderbilt Memory and Alzheimer's Center, Vanderbilt University School of Medicine, Nashville, TN, USA
| | - Jennifer L Thompson
- Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center, Nashville, TN, USA
- Department of Biostatistics, Vanderbilt University School of Medicine, Nashville, TN, USA
| | - Onur M Orun
- Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center, Nashville, TN, USA
- Department of Biostatistics, Vanderbilt University School of Medicine, Nashville, TN, USA
| | - Rameela Raman
- Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center, Nashville, TN, USA
- Department of Biostatistics, Vanderbilt University School of Medicine, Nashville, TN, USA
| | - Lorraine B Ware
- Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center, Nashville, TN, USA
- Division of Allergy, Pulmonary, and Critical Care Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Gordon R Bernard
- Division of Allergy, Pulmonary, and Critical Care Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Fiona E Harrison
- Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center, Nashville, TN, USA
- Vanderbilt Brain Institute, Vanderbilt University School of Medicine, Nashville, TN, USA
- Vanderbilt Memory and Alzheimer's Center, Vanderbilt University School of Medicine, Nashville, TN, USA
| | - E Wesley Ely
- Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center, Nashville, TN, USA
- Center for Quality Aging, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
- Center for Health Services Research, Vanderbilt University Medical Center, Nashville, TN, USA
- Geriatric Research, Education and Clinical Center (GRECC) Service, Department of Veterans Affairs Medical Center, Tennessee Valley Healthcare System, Nashville, TN, USA
| | - Timothy D Girard
- Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center, Nashville, TN, USA.
- Clinical Research Investigation and Systems Modeling of Acute Illness (CRISMA) Center, Department of Critical Care Medicine, University of Pittsburgh, 638 Scaife Hall, 3550 Terrace Street, Pittsburgh, PA, 15261, USA.
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Torbic H, Chen A, Lumpkin M, Yerke J, Mehkri O, Abraham S, Wang X, Duggal A, Scheraga RG. Antipsychotic Use for ICU Delirium and Associated Inflammatory Markers. J Intensive Care Med 2024; 39:313-319. [PMID: 37724016 PMCID: PMC10922065 DOI: 10.1177/08850666231201567] [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] [Indexed: 09/20/2023]
Abstract
Purpose: We sought to evaluate critically ill patients with delirium to evaluate inflammatory cytokine production and delirium progression and the role of antipsychotics. Materials and Methods: Adult critically ill patients with confirmed delirium according to a positive CAM-ICU score were included and IL-6 and IL-8 levels were trended for 24 h in this single-center, prospective, observational cohort study. Results: A total of 23 patients were consented and had blood samples drawn for inclusion. There was no difference in IL-6 and IL-8 levels at baseline, 4 to 8 h, and 22 to 28 h after enrollment when comparing patients based on antipsychotic exposure. We identified 2 patient clusters based on age, APACHE III, need for mechanical ventilation, and concomitant infection. In cluster 1, 5 (33.3%) patients received antipsychotics versus 5 (62.5%) patients in cluster 2 (P = .18). Patients in cluster 1 had more co-inflammatory conditions (P < .0001), yet numerically lower baseline IL-6 (P = .18) and IL-8 levels (P = .80) compared to cluster 2. Patients in cluster 1 had a greater median number of delirium-free days compared to cluster 2 (17.0 vs 6.0 days; P = .05). Conclusions: In critically ill patients with delirium, IL-6 and IL-8 levels were variable and antipsychotics were not associated with improvements in delirium or inflammatory markers.
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Affiliation(s)
- Heather Torbic
- Department of Pharmacy, Cleveland Clinic, Cleveland, OH, USA
| | - Alyssa Chen
- Department of Pharmacy, Cleveland Clinic, Cleveland, OH, USA
| | - Mollie Lumpkin
- Department of Pharmacy, Cleveland Clinic, Cleveland, OH, USA
| | - Jason Yerke
- Department of Pharmacy, Cleveland Clinic, Cleveland, OH, USA
| | - Omar Mehkri
- Department of Critical Care Medicine, Cleveland Clinic, Cleveland, OH, USA
| | - Susamma Abraham
- Department of Inflammation and Immunity, Cleveland Clinic, Cleveland, OH, USA
| | - Xiaofeng Wang
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, OH, USA
| | - Abhijit Duggal
- Department of Critical Care Medicine, Cleveland Clinic, Cleveland, OH, USA
| | - Rachel G. Scheraga
- Department of Inflammation and Immunity, Cleveland Clinic, Cleveland, OH, USA
- Department of Critical Care and Pulmonary Medicine, Cleveland Clinic, Cleveland, OH, USA
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Hong Y, Chen P, Gao J, Lin Y, Chen L, Shang X. Sepsis-associated encephalopathy: From pathophysiology to clinical management. Int Immunopharmacol 2023; 124:110800. [PMID: 37619410 DOI: 10.1016/j.intimp.2023.110800] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2023] [Revised: 07/20/2023] [Accepted: 08/11/2023] [Indexed: 08/26/2023]
Abstract
Sepsis-associated encephalopathy, which presents as delirium and coma, is a significant complication of sepsis characterized by acute brain dysfunction. The presence of inflammatory pathological changes in the brain of sepsis patients and animal models has been recognized since the 1920 s, initially attributed to the entry of microbial toxins into the brain. In the early 2000 s, attention shifted towards the impact of oxidative stress, the cholinergic system, and cytokines on brain function following sepsis onset. More recently, sepsis-associated encephalopathy has been defined as a diffuse brain dysfunction not directly caused by pathogenic infection of the brain. Currently, there is no evidence-based standard for diagnosing sepsis-associated encephalopathy, and clinical management is primarily focused on symptomatic and supportive measures. This review aims to explore the pathophysiology of sepsis-associated encephalopathy and establish the connection between pathophysiological mechanisms and clinical characteristics. We hope that this work will spark the interest of researchers from various fields and contribute to the advancement of sepsis-associated encephalopathy research.
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Affiliation(s)
- Yixiao Hong
- Shengli Clinical Medical College of Fujian Medical University, Fuzhou, China; The Third Department of Critical Care Medicine, Shengli Clinical Medical College of Fujian Medical University, Fujian Provincial Hospital, Fujian Provincial Center for Critical Care Medicine, Fujian Provincial Key Laboratory of Critical Care Medicine, Fuzhou, China
| | - Peiling Chen
- Shengli Clinical Medical College of Fujian Medical University, Fuzhou, China; The Third Department of Critical Care Medicine, Shengli Clinical Medical College of Fujian Medical University, Fujian Provincial Hospital, Fujian Provincial Center for Critical Care Medicine, Fujian Provincial Key Laboratory of Critical Care Medicine, Fuzhou, China
| | - Jingqi Gao
- Shengli Clinical Medical College of Fujian Medical University, Fuzhou, China; The Third Department of Critical Care Medicine, Shengli Clinical Medical College of Fujian Medical University, Fujian Provincial Hospital, Fujian Provincial Center for Critical Care Medicine, Fujian Provincial Key Laboratory of Critical Care Medicine, Fuzhou, China
| | - Yingying Lin
- Shengli Clinical Medical College of Fujian Medical University, Fuzhou, China; The Third Department of Critical Care Medicine, Shengli Clinical Medical College of Fujian Medical University, Fujian Provincial Hospital, Fujian Provincial Center for Critical Care Medicine, Fujian Provincial Key Laboratory of Critical Care Medicine, Fuzhou, China
| | - Linfang Chen
- Shengli Clinical Medical College of Fujian Medical University, Fuzhou, China; The Third Department of Critical Care Medicine, Shengli Clinical Medical College of Fujian Medical University, Fujian Provincial Hospital, Fujian Provincial Center for Critical Care Medicine, Fujian Provincial Key Laboratory of Critical Care Medicine, Fuzhou, China
| | - Xiuling Shang
- Shengli Clinical Medical College of Fujian Medical University, Fuzhou, China; The Third Department of Critical Care Medicine, Shengli Clinical Medical College of Fujian Medical University, Fujian Provincial Hospital, Fujian Provincial Center for Critical Care Medicine, Fujian Provincial Key Laboratory of Critical Care Medicine, Fuzhou, China.
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Ahmed A, Chaudhry M, Nadeem T. Letter to the Editor "Plasma Biomarkers and Delirium in Critically Ill Patients After Cardiac Surgery: A Prospective Observational Cohort Study". Curr Probl Cardiol 2023; 48:101951. [PMID: 37422040 DOI: 10.1016/j.cpcardiol.2023.101951] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2023] [Accepted: 07/04/2023] [Indexed: 07/10/2023]
Affiliation(s)
| | | | - Taha Nadeem
- Allama Iqbal Medical College, Lahore, Pakistan
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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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Maslov GO, Zabegalov KN, Demin KA, Kolesnikova TO, Kositsyn YM, de Abreu MS, Petersen EV, Kalueff AV. Towards experimental models of delirium utilizing zebrafish. Behav Brain Res 2023; 453:114607. [PMID: 37524203 DOI: 10.1016/j.bbr.2023.114607] [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: 05/25/2023] [Revised: 07/28/2023] [Accepted: 07/29/2023] [Indexed: 08/02/2023]
Abstract
Delirium is an acute neuropsychiatric condition characterized by impaired behavior and cognition. Although the syndrome has been known for millennia, its CNS mechanisms and risk factors remain poorly understood. Experimental animal models, especially rodent-based, are commonly used to probe various pathogenetic aspects of delirium. Complementing rodents, the zebrafish (Danio rerio) emerges as a promising novel model organism to study delirium. Zebrafish demonstrate high genetic and physiological homology to mammals, easy maintenance, robust behaviors in various sensitive behavioral tests, and the potential to screen for pharmacological agents relevant to delirium. Here, we critically discuss recent developments in the field, and emphasize the developing utility of zebrafish models for translational studies of delirium and deliriant drugs. Overall, the zebrafish represents a valuable and promising aquatic model species whose use may help understand delirium etiology, as well as develop novel therapies for this severely debilitating disorder.
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Affiliation(s)
- Gleb O Maslov
- Neurobiology Program, Sirius University of Science and Technology, Sochi, Russia; Ural Federal University, Ekaterinburg, Russia
| | | | - Konstantin A Demin
- Institute of Experimental Medicine, Almazov National Medical Research Centre, Ministry of Healthcare of Russian Federation, St. Petersburg, Russia; Institute of Translational Biomedicine, St. Petersburg State University, St. Petersburg, Russia
| | - Tatiana O Kolesnikova
- Neurobiology Program, Sirius University of Science and Technology, Sochi, Russia; Institute of Translational Biomedicine, St. Petersburg State University, St. Petersburg, Russia
| | - Yuriy M Kositsyn
- Institute of Translational Biomedicine, St. Petersburg State University, St. Petersburg, Russia
| | - Murilo S de Abreu
- Laboratory of Cell and Molecular Biology and Neurobiology, Moscow Institute of Physics and Technology, Moscow, Russia.
| | - Elena V Petersen
- Laboratory of Cell and Molecular Biology and Neurobiology, Moscow Institute of Physics and Technology, Moscow, Russia
| | - Allan V Kalueff
- Neurobiology Program, Sirius University of Science and Technology, Sochi, Russia; Institute of Experimental Medicine, Almazov National Medical Research Centre, Ministry of Healthcare of Russian Federation, St. Petersburg, Russia; Institute of Translational Biomedicine, St. Petersburg State University, St. Petersburg, Russia; Novosibirsk State University, Novosibirsk, Russia; Laboratory of Preclinical Bioscreening, Granov Russian Research Center of Radiology and Surgical Technologies, Ministry of Healthcare of Russian Federation, Pesochny, Russia; Ural Federal University, Ekaterinburg, Russia.
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Garcez FB, Garcia de Alencar JC, Fernandez SSM, Avelino-Silva VI, Sabino EC, Martins RCR, Franco LAM, Lima Ribeiro SM, Possolo de Souza H, Avelino-Silva TJ. Association Between Gut Microbiota and Delirium in Acutely Ill Older Adults. J Gerontol A Biol Sci Med Sci 2023; 78:1320-1327. [PMID: 36869725 PMCID: PMC10395556 DOI: 10.1093/gerona/glad074] [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: 06/09/2022] [Indexed: 03/05/2023] Open
Abstract
Our aim was to investigate the association between gut microbiota and delirium occurrence in acutely ill older adults. We included 133 participants 65+ years consecutively admitted to the emergency department of a tertiary university hospital, between September 2019 and March 2020. We excluded candidates with ≥24-hour antibiotic utilization on admission, recent prebiotic or probiotic utilization, artificial nutrition, acute gastrointestinal disorders, severe traumatic brain injury, recent hospitalization, institutionalization, expected discharge ≤48 hours, or admission for end-of-life care. A trained research team followed a standardized interview protocol to collect sociodemographic, clinical, and laboratory data on admission and throughout the hospital stay. Our exposure measures were gut microbiota alpha and beta diversities, taxa relative abundance, and core microbiome. Our primary outcome was delirium, assessed twice daily using the Confusion Assessment Method. Delirium was detected in 38 participants (29%). We analyzed 257 swab samples. After adjusting for potential confounders, we observed that a greater alpha diversity (higher abundance and richness of microorganisms) was associated with a lower risk of delirium, as measured by the Shannon (odds ratio [OR] = 0.77; 95% confidence interval [CI] = 0.60-0.99; p = .042) and Pielou indexes (OR = 0.69; 95% CI = 0.51-0.87; p = .005). Bacterial taxa associated with pro-inflammatory pathways (Enterobacteriaceae) and modulation of relevant neurotransmitters (Serratia: dopamine; Bacteroides, Parabacteroides: GABA) were more common in participants with delirium. Gut microbiota diversity and composition were significantly different in acutely ill hospitalized older adults who experienced delirium. Our work is an original proof-of-concept investigation that lays a foundation for future biomarker studies and potential therapeutic targets for delirium prevention and treatment.
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Affiliation(s)
- Flavia Barreto Garcez
- Laboratorio de Investigacao Medica em Envelhecimento (LIM 66), Servico de Geriatria, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
- Departamento de Medicina, Hospital Universitario, Universidade Federal de Sergipe, São Cristóvão, Brazil
| | - Júlio César Garcia de Alencar
- Laboratorio de Investigacao Medica em Emergencias Clinicas (LIM 51), Departamento de Clínica Médica, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | | | - Vivian Iida Avelino-Silva
- Departamento de Molestias Infecciosas e Parasitarias, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
- Faculdade Israelita de Ciencias da Saude Albert Einstein, Hospital Israelita Albert Einstein, São Paulo, Brazil
| | - Ester Cerdeira Sabino
- Departamento de Molestias Infecciosas e Parasitarias, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
- Laboratório de Parasitologia Medica (LIM 46), Instituto de Medicina Tropical, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | - Roberta Cristina Ruedas Martins
- Laboratório de Parasitologia Medica (LIM 46), Instituto de Medicina Tropical, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | - Lucas Augusto Moysés Franco
- Laboratório de Parasitologia Medica (LIM 46), Instituto de Medicina Tropical, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | | | - Heraldo Possolo de Souza
- Laboratorio de Investigacao Medica em Emergencias Clinicas (LIM 51), Departamento de Clínica Médica, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | - Thiago Junqueira Avelino-Silva
- Laboratorio de Investigacao Medica em Envelhecimento (LIM 66), Servico de Geriatria, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
- Faculdade Israelita de Ciencias da Saude Albert Einstein, Hospital Israelita Albert Einstein, São Paulo, Brazil
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Bassi T, Rohrs E, Nicholas M, Reynolds S. Meta-analysis of serological biomarkers at hospital admission for the likelihood of developing delirium during hospitalization. Front Neurol 2023; 14:1179243. [PMID: 37360340 PMCID: PMC10288875 DOI: 10.3389/fneur.2023.1179243] [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: 03/03/2023] [Accepted: 05/11/2023] [Indexed: 06/28/2023] Open
Abstract
Importance Identifying biomarkers that, at hospital admission, predict subsequent delirium will help to focus our clinical efforts on prevention and management. Objective The study aimed to investigate biomarkers at hospital admission that may be associated with delirium during hospitalization. Data sources A librarian at the Fraser Health Authority Health Sciences Library performed searches from 28 June 2021 to 9 July 2021, using the following sources: Medline, EMBASE, Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, Cochrane Methodology Register, and the Database of Abstracts of Reviews and Effects. Study selection The inclusion criteria were articles in English that investigated the link between serum concentration of biomarkers at hospital admission and delirium during hospitalization. Exclusion criteria were single case reports, case series, comments, editorials, letters to the editor, articles that were not relevant to the review objective, and articles concerning pediatrics. After excluding duplicates, 55 studies were included. Data extraction and synthesis This meta-analysis followed the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) protocol. Independent extraction, with the consensus of multiple reviewers, was used to determine the final studies included. The weight and heterogeneity of the manuscripts were calculated using inverse covariance with a random-effects model. Main outcomes and measures Differences in mean serum concentration of biomarkers at hospital admission between patients who did and did not develop delirium during hospitalization. Results Our search found evidence that patients who developed delirium during hospitalization had, at hospital admission, significantly greater concentrations of certain inflammatory biomarkers and one blood-brain barrier leakage marker than patients who did not develop delirium during hospitalization (differences in the mean: cortisol: 3.36 ng/ml, p < 0.0001; CRP: 41.39 mg/L, p < 0.00001; IL-6: 24.05 pg/ml, p < 0.00001; S100β 0.07 ng/ml, p < 0.00001). These differences were independent of other confounding variables such as the patient's severity of illness. A significantly lower serum concentration, at hospital admission, of acetylcholinesterase (difference in the means -0.86 U/ml, p = 0.004) was also associated with an increased vulnerability to developing delirium during hospitalization. Conclusion and relevance Our meta-analysis supports the hypothesis that patients with hypothalamic-pituitary axis dysfunction, increased blood-brain barrier permeability, and chronic overload of the cholinergic system, at hospital admission, are more vulnerable to developing delirium during hospitalization.
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Affiliation(s)
- Thiago Bassi
- Lungpacer Medical USA Inc., Exton, PA, United States
| | - Elizabeth Rohrs
- Advancing Innovation in Medicine Institute, New Westminster, BC, Canada
- Biomedical, Physiology and Kinesiology Department, Simon Fraser University, Burnaby, BC, Canada
| | - Michelle Nicholas
- Advancing Innovation in Medicine Institute, New Westminster, BC, Canada
- Biomedical, Physiology and Kinesiology Department, Simon Fraser University, Burnaby, BC, Canada
| | - Steven Reynolds
- Advancing Innovation in Medicine Institute, New Westminster, BC, Canada
- Biomedical, Physiology and Kinesiology Department, Simon Fraser University, Burnaby, BC, Canada
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10
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Bircak-Kuchtova B, Chung HY, Wickel J, Ehler J, Geis C. Neurofilament light chains to assess sepsis-associated encephalopathy: Are we on the track toward clinical implementation? Crit Care 2023; 27:214. [PMID: 37259091 DOI: 10.1186/s13054-023-04497-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2023] [Accepted: 05/18/2023] [Indexed: 06/02/2023] Open
Abstract
Sepsis is the most common cause of admission to intensive care units worldwide. Sepsis patients frequently suffer from sepsis-associated encephalopathy (SAE) reflecting acute brain dysfunction. SAE may result in increased mortality, extended length of hospital stay, and long-term cognitive dysfunction. The diagnosis of SAE is based on clinical assessments, but a valid biomarker to identify and confirm SAE and to assess SAE severity is missing. Several blood-based biomarkers indicating neuronal injury have been evaluated in sepsis and their potential role as early diagnosis and prognostic markers has been studied. Among those, the neuroaxonal injury marker neurofilament light chain (NfL) was identified to potentially serve as a prognostic biomarker for SAE and to predict long-term cognitive impairment. In this review, we summarize the current knowledge of biomarkers, especially NfL, in SAE and discuss a possible future clinical application considering existing limitations.
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Affiliation(s)
- Barbora Bircak-Kuchtova
- Section Translational Neuroimmunology, Department for Neurology, Jena University Hospital, Am Klinikum 1, 07747, Jena, Germany
| | - Ha-Yeun Chung
- Section Translational Neuroimmunology, Department for Neurology, Jena University Hospital, Am Klinikum 1, 07747, Jena, Germany.
- Center for Sepsis Control and Care, Jena University Hospital, 07747, Jena, Germany.
| | - Jonathan Wickel
- Section Translational Neuroimmunology, Department for Neurology, Jena University Hospital, Am Klinikum 1, 07747, Jena, Germany
- Center for Sepsis Control and Care, Jena University Hospital, 07747, Jena, Germany
| | - Johannes Ehler
- Department of Anesthesiology and Intensive Care Medicine, Jena University Hospital, 07747, Jena, Germany
| | - Christian Geis
- Section Translational Neuroimmunology, Department for Neurology, Jena University Hospital, Am Klinikum 1, 07747, Jena, Germany
- Center for Sepsis Control and Care, Jena University Hospital, 07747, Jena, Germany
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11
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Nelligan M, Nellis ME, Mauer EA, Gerber LM, Traube C. Association between Platelet Transfusion and Delirium in Critically Ill Children. CHILDREN (BASEL, SWITZERLAND) 2023; 10:825. [PMID: 37238373 PMCID: PMC10216991 DOI: 10.3390/children10050825] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Revised: 04/25/2023] [Accepted: 04/26/2023] [Indexed: 05/28/2023]
Abstract
Delirium is a frequent, serious, and preventable complication in critically ill children. Inflammation has been implicated as a mechanism for the development of delirium. Platelet transfusions may potentiate the body's pro-inflammatory responses. We hypothesized that receipt of platelets would be associated with delirium development in a pediatric intensive care unit (PICU). We performed a single-center retrospective cohort analysis including children admitted to the PICU between 2014 and 2018 who were transfused platelets within the first 14 days of admission. Data obtained included severity of illness, level of respiratory support, exposure to medications and blood products, as well as daily cognitive status. To account for time-dependent confounding, a marginal structural model (MSM) was constructed to delineate the relationship between platelet transfusion and next-day delirium. MSM demonstrated a 75% increase in the development of next-day delirium after transfusion of platelets (aOR 1.75, 95% CI 1.03-2.97). For every 1 cc/kg of platelet transfused, odds of next-day delirium increased by 9% (odds ratio 1.09, 95% CI 1.03-1.51). We reported an independent association between platelet transfusion and next-day delirium/coma after accounting for time-dependent confounders, with a dose-response effect. Minimizing platelet transfusions as much as clinically feasible may decrease delirium risk in critically ill children.
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Affiliation(s)
- Matthew Nelligan
- Morgan Stanley Children’s Hospital, NewYork-Presbyterian Columbia University, New York, NY 10032, USA
| | - Marianne E. Nellis
- Department of Pediatrics, Weill Cornell Medical College, New York, NY 10065, USA
| | - Elizabeth A. Mauer
- Department of Pediatrics, Weill Cornell Medical College, New York, NY 10065, USA
| | - Linda M. Gerber
- Department of Pediatrics, Weill Cornell Medical College, New York, NY 10065, USA
| | - Chani Traube
- Department of Pediatrics, Weill Cornell Medical College, New York, NY 10065, USA
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12
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da Rocha FR, Gonçalves RC, Prestes GDS, Damásio D, Goulart AI, Vieira AADS, Michels M, da Rosa MI, Ritter C, Dal-Pizzol F. Biomarkers of neuropsychiatric dysfunction in intensive care unit survivors: a prospective cohort study. CRITICAL CARE SCIENCE 2023; 35:147-155. [PMID: 37712803 PMCID: PMC10406403 DOI: 10.5935/2965-2774.20230422-en] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/15/2022] [Accepted: 03/16/2023] [Indexed: 09/16/2023]
Abstract
OBJECTIVE To assess factors associated with long-term neuropsychiatric outcomes, including biomarkers measured after discharge from the intensive care unit. METHODS A prospective cohort study was performed with 65 intensive care unit survivors. The cognitive evaluation was performed through the Mini-Mental State Examination, the symptoms of anxiety and depression were evaluated using the Hospital Anxiety and Depression Scale, and posttraumatic stress disorder was evaluated using the Impact of Event Scale-6. Plasma levels of amyloid-beta (1-42) [Aβ (1-42)], Aβ (1-40), interleukin (IL)-10, IL-6, IL-33, IL-4, IL-5, tumor necrosis factor alpha, C-reactive protein, and brain-derived neurotrophic factor were measured at intensive care unit discharge. RESULTS Of the variables associated with intensive care, only delirium was independently related to the occurrence of long-term cognitive impairment. In addition, higher levels of IL-10 and IL-6 were associated with cognitive dysfunction. Only IL-6 was independently associated with depression. Mechanical ventilation, IL-33 levels, and C-reactive protein levels were independently associated with anxiety. No variables were independently associated with posttraumatic stress disorder. CONCLUSION Cognitive dysfunction, as well as symptoms of depression, anxiety, and posttraumatic stress disorder, are present in patients who survive a critical illness, and some of these outcomes are associated with the levels of inflammatory biomarkers measured at discharge from the intensive care unit.
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Affiliation(s)
- Franciani Rodrigues da Rocha
- Laboratory of Translational Biomedicine, Postgraduate Program in
Health Sciences, Universidade do Extremo Sul Catarinense - Criciúma (SC),
Brazil
| | - Renata Casagrande Gonçalves
- Laboratory of Experimental Pathophysiology, Postgraduate Program in
Health Sciences, Health Sciences Unit, Universidade do Extremo Sul Catarinense -
Criciúma (SC), Brazil
| | - Gabriele da Silveira Prestes
- Laboratory of Translational Biomedicine, Postgraduate Program in
Health Sciences, Universidade do Extremo Sul Catarinense - Criciúma (SC),
Brazil
| | - Danusa Damásio
- Research Centre, Hospital São José - Criciúma
(SC), Brazil
| | - Amanda Indalécio Goulart
- Laboratory of Experimental Pathophysiology, Postgraduate Program in
Health Sciences, Health Sciences Unit, Universidade do Extremo Sul Catarinense -
Criciúma (SC), Brazil
| | - Andriele Aparecida da Silva Vieira
- Laboratory of Experimental Pathophysiology, Postgraduate Program in
Health Sciences, Health Sciences Unit, Universidade do Extremo Sul Catarinense -
Criciúma (SC), Brazil
| | - Monique Michels
- Laboratory of Experimental Pathophysiology, Postgraduate Program in
Health Sciences, Health Sciences Unit, Universidade do Extremo Sul Catarinense -
Criciúma (SC), Brazil
| | - Maria Inês da Rosa
- Laboratory of Translational Biomedicine, Postgraduate Program in
Health Sciences, Universidade do Extremo Sul Catarinense - Criciúma (SC),
Brazil
| | - Cristiane Ritter
- Laboratory of Experimental Pathophysiology, Postgraduate Program in
Health Sciences, Health Sciences Unit, Universidade do Extremo Sul Catarinense -
Criciúma (SC), Brazil
| | - Felipe Dal-Pizzol
- Laboratory of Experimental Pathophysiology, Postgraduate Program in
Health Sciences, Health Sciences Unit, Universidade do Extremo Sul Catarinense -
Criciúma (SC), Brazil
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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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Yıldırım YE, Umut G, Evren C, Yeral E, Secerli H. Neutrophil-lymphocyte ratio as a predictor of delirium tremens in hospitalized patients with alcohol withdrawal. Alcohol 2023; 109:43-48. [PMID: 36709009 DOI: 10.1016/j.alcohol.2022.12.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2022] [Revised: 12/11/2022] [Accepted: 12/28/2022] [Indexed: 01/27/2023]
Abstract
Delirium Tremens (DT) is a severe form of alcohol withdrawal that can be fatal if not recognized early and treated appropriately. In our study, we aimed to determine the role of Neutrophil-Lymphocyte ratio (NLR), a marker of systemic inflammation, in predicting the development of DT. This retrospective study was conducted in an alcohol and drug treatment center between March 2017 and March 2020. A total of 212 patients with a diagnosis of alcohol use disorder who were admitted to a special care unit after alcohol withdrawal were included. Blood tests were collected within 24 hours of the patients' admission. Comparisons were made according to whether the patients developed DT during the hospitalization. DT was diagnosed in 24.1% of the patients. It was determined that higher NLR level (odds ratio [OR]: 4.38, 95%CI: 2.58-7.43) and history of DT (OR: 1.33, 95%CI: 1.23-11.73) are independent risk factors for the development of DT in the logistic regression analysis. The optimal cut-off value of NLR in predicting DT was 2.67 (sensitivity: 82.4%, specificity: 88.8%). The ROC curve of NLR showed a larger area under the curve (AUC) than the curves of other systemic inflammation markers. NLR is a simple, practical and inexpensive marker that can predict the development of DT in patients with alcohol withdrawal syndrome.
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Affiliation(s)
- Yusuf Ezel Yıldırım
- Department of Psychiatry, University of Health Sciences, Medicine Faculty, Bakirkoy Prof. Dr. Mazhar Osman Training and Research Hospital for Psychiatric, Neurological and Neurosurgical Diseases, Istanbul, Turkey.
| | - Gökhan Umut
- Department of Psychiatry, University of Health Sciences, Medicine Faculty, Bakirkoy Prof. Dr. Mazhar Osman Training and Research Hospital for Psychiatric, Neurological and Neurosurgical Diseases, Istanbul, Turkey
| | - Cüneyt Evren
- Department of Psychiatry, University of Health Sciences, Medicine Faculty, Bakirkoy Prof. Dr. Mazhar Osman Training and Research Hospital for Psychiatric, Neurological and Neurosurgical Diseases, Istanbul, Turkey
| | - Eylül Yeral
- Department of Psychiatry, University of Health Sciences, Medicine Faculty, Bakirkoy Prof. Dr. Mazhar Osman Training and Research Hospital for Psychiatric, Neurological and Neurosurgical Diseases, Istanbul, Turkey
| | - Hikmet Secerli
- Department of Psychiatry, University of Health Sciences, Medicine Faculty, Bakirkoy Prof. Dr. Mazhar Osman Training and Research Hospital for Psychiatric, Neurological and Neurosurgical Diseases, Istanbul, Turkey
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15
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Preoperative Inflammatory Markers and the Risk of Postoperative Delirium in Patients Undergoing Lumbar Spinal Fusion Surgery. J Clin Med 2022; 11:jcm11144085. [PMID: 35887857 PMCID: PMC9324332 DOI: 10.3390/jcm11144085] [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: 06/26/2022] [Revised: 07/13/2022] [Accepted: 07/13/2022] [Indexed: 02/04/2023] Open
Abstract
We investigated the possible associations between postoperative delirium (POD) and routinely available preoperative inflammatory markers in patients undergoing lumbar spinal fusion surgery (LSFS) to explore the role of neuroinflammation and oxidative stress as risk factors for POD. We analyzed 11 years’ worth of data from the Smart Clinical Data Warehouse. We evaluated whether preoperative inflammatory markers, such as the neutrophil-to-lymphocyte ratio (NLR), the monocyte-to-lymphocyte ratio (MLR), and the CRP-to-albumin ratio (CAR), affected the development of POD in patients undergoing LSFS. Of the 3081 subjects included, 187 (7.4%) developed POD. A significant increase in NLR, MLR, and CAR levels was observed in POD patients (p < 0.001). A multivariate analysis showed that the second, third, and highest quartiles of the NLR were significantly associated with the development of POD (adjusted OR (95% CI): 2.28 (1.25−4.16], 2.48 (1.3−4.73], and 2.88 (1.39−5.96], respectively). A receiver operating characteristic curve analysis showed that the discriminative ability of the NLR, MLR, and CAR for predicting POD was low, but almost acceptable (AUC (95% CI): 0.60 (0.56−0.64], 0.61 (0.57−0.65], and 0.63 (0.59−0.67], respectively, p < 0.001). Increases in preoperative inflammatory markers, particularly the NLR, were associated with the development of POD, suggesting that a proinflammatory state is a potential pathophysiological mechanism of POD.
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16
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Navia KL, Anthony BK, Berlau DJ. A case for continuing statin medications in the intensive care unit: Reducing the risk for delirium. Am J Health Syst Pharm 2022; 79:1431-1437. [PMID: 35526279 DOI: 10.1093/ajhp/zxac132] [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: 11/13/2022] Open
Abstract
DISCLAIMER In an effort to expedite the publication of articles related to the COVID-19 pandemic, AJHP is posting these manuscripts online as soon as possible after acceptance. Accepted manuscripts have been peer-reviewed and copyedited, but are posted online before technical formatting and author proofing. These manuscripts are not the final version of record and will be replaced with the final article (formatted per AJHP style and proofed by the authors) at a later time. PURPOSE The objective of this review is to detail the utility of statin medications in the prevention and treatment of intensive care unit (ICU) delirium. SUMMARY Delirium is a syndrome characterized by altered mental status, inattention, and disorganized thinking. It is particularly concerning in the ICU where specific risk factors are much more prevalent. Nonpharmacological therapy is the mainstay of treatment, aimed at increasing patient awareness; pharmacological therapies have also been explored with varying success. The utility of statin medications in this scenario has been investigated because of the numerous pleiotropic effects of these drugs. Although the benefits in terms of treating delirium are uncertain, statins may be good candidates for prevention. The peak anti-inflammatory effect of statins is delayed, so initiating a statin on admission will likely have little protective benefit, whereas continuation of a home regimen seems more likely to exert an effect. CONCLUSION Statin medications are very commonly used, and, while their role in treating delirium is unclear, continuation of these medications from a home regimen is reasonable to decrease the odds of delirium in the intensive care population.
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Affiliation(s)
- Kyra L Navia
- Regis University School of Pharmacy, Denver, CO, USA
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17
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Jiang L, Lei G. Albumin/fibrinogen ratio, an independent risk factor for postoperative delirium after total joint arthroplasty. Geriatr Gerontol Int 2022; 22:412-417. [PMID: 35365967 DOI: 10.1111/ggi.14381] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2021] [Revised: 02/09/2022] [Accepted: 03/08/2022] [Indexed: 12/16/2022]
Abstract
AIM Postoperative delirium (POD) is a very common and serious complication after total joint arthroplasty (TJA), which is closely associated with many adverse consequences and a poor prognosis. This study aimed to establish the potential risk factors for POD. METHODS In total, 336 patients who underwent elective TJA under general anesthesia between 2018 and 2021 were included and deemed eligible for inclusion. POD was diagnosed based on the criteria by the Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM V). The receiver operating characteristic curve was drawn to evaluate the predictive and cut-off values of continuous variables for POD. Potential risk factors for POD were evaluated by binary univariate and multivariate analysis with the "Enter" method. RESULTS According to the criteria by DSM V, 43 patients were categorized into the POD group, with an incidence of 12.8% (43 of 336). The receiver operating characteristic curve showed that albumin/fibrinogen ratio (AFR) was a good predictor for POD with an area under the curve of 0.754, cut-off value of 9.65, sensitivity of 57.00% and specificity of 83.72% (P <0.001). A low preoperative AFR level (<9.65) was determined as the only independent risk factor for POD by the univariate and multivariate logistic regression analyses (OR: 2.45, 95% CI: 2.01-2.94, P = 0.008). CONCLUSIONS Our results indicate that a low AFR is an independent risk factor for POD in elderly subjects after TJA. Geriatr Gerontol Int 2022; 22: 412-417.
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Affiliation(s)
- Liuying Jiang
- Department of Anesthesiology, Zhongshan Hospital Xiamen University, Xiamen City, China
| | - Gaofeng Lei
- Xiamen Medical Emergency Center, Xiamen City, China
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18
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Ulsa MC, Xi Z, Li P, Gaba A, Wong PM, Saxena R, Scheer FAJL, Rutter M, Akeju O, Hu K, Gao L. Association of Poor Sleep Burden in Middle Age and Older Adults With Risk for Delirium During Hospitalization. J Gerontol A Biol Sci Med Sci 2022; 77:507-516. [PMID: 34558609 PMCID: PMC8893188 DOI: 10.1093/gerona/glab272] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2021] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Delirium is a distressing neurocognitive disorder recently linked to sleep disturbances. However, the longitudinal relationship between sleep and delirium remains unclear. This study assessed the associations of poor sleep burden, and its trajectory, with delirium risk during hospitalization. METHODS About 321 818 participants from the UK Biobank (mean age 58 ± 8 years [SD]; range 37-74 years) reported (2006-2010) sleep traits (sleep duration, excessive daytime sleepiness, insomnia-type complaints, napping, and chronotype-a closely related circadian measure for sleep timing), aggregated into a sleep burden score (0-9). New-onset delirium (n = 4 775) was obtained from hospitalization records during a 12-year median follow-up. About 42 291 (mean age 64 ± 8 years; range 44-83 years) had repeat sleep assessment on average 8 years after their first. RESULTS In the baseline cohort, Cox proportional hazards models showed that moderate (aggregate scores = 4-5) and severe (scores = 6-9) poor sleep burden groups were 18% (hazard ratio = 1.18 [95% confidence interval: 1.08-1.28], p < .001) and 57% (1.57 [1.38-1.80], p < .001), more likely to develop delirium, respectively. The latter risk magnitude is equivalent to 2 additional cardiovascular risks. These findings appeared robust when restricted to postoperative delirium and after exclusion of underlying dementia. Higher sleep burden was also associated with delirium in the follow-up cohort. Worsening sleep burden (score increase ≥2 vs no change) further increased the risk for delirium (1.79 [1.23-2.62], p = .002) independent of their baseline sleep score and time lag. The risk was highest in those younger than 65 years at baseline (p for interaction <.001). CONCLUSION Poor sleep burden and worsening trajectory were associated with increased risk for delirium; promotion of sleep health may be important for those at higher risk.
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Affiliation(s)
- Ma Cherrysse Ulsa
- Medical Biodynamics Program, Division of Sleep and Circadian Disorders, Brigham and Women’s Hospital, Boston, Massachusetts, USA
| | - Zheng Xi
- Medical Biodynamics Program, Division of Sleep and Circadian Disorders, Brigham and Women’s Hospital, Boston, Massachusetts, USA
| | - Peng Li
- Medical Biodynamics Program, Division of Sleep and Circadian Disorders, Brigham and Women’s Hospital, Boston, Massachusetts, USA
- Division of Sleep Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | - Arlen Gaba
- Medical Biodynamics Program, Division of Sleep and Circadian Disorders, Brigham and Women’s Hospital, Boston, Massachusetts, USA
| | - Patricia M Wong
- Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | - Richa Saxena
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, USA
- Broad Institute of MIT and Harvard, Cambridge, Massachusetts, USA
| | - Frank A J L Scheer
- Division of Sleep Medicine, Harvard Medical School, Boston, Massachusetts, USA
- Broad Institute of MIT and Harvard, Cambridge, Massachusetts, USA
| | - Martin Rutter
- Division of Diabetes, Endocrinology & Gastroenterology, The University of Manchester, UK
| | - Oluwaseun Akeju
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, USA
| | - Kun Hu
- Medical Biodynamics Program, Division of Sleep and Circadian Disorders, Brigham and Women’s Hospital, Boston, Massachusetts, USA
- Division of Sleep Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | - Lei Gao
- Medical Biodynamics Program, Division of Sleep and Circadian Disorders, Brigham and Women’s Hospital, Boston, Massachusetts, USA
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, USA
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19
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Barichello T, Generoso JS, Singer M, Dal-Pizzol F. Biomarkers for sepsis: more than just fever and leukocytosis-a narrative review. Crit Care 2022; 26:14. [PMID: 34991675 PMCID: PMC8740483 DOI: 10.1186/s13054-021-03862-5] [Citation(s) in RCA: 130] [Impact Index Per Article: 65.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2021] [Accepted: 12/08/2021] [Indexed: 02/08/2023] Open
Abstract
A biomarker describes a measurable indicator of a patient's clinical condition that can be measured accurately and reproducibly. Biomarkers offer utility for diagnosis, prognosis, early disease recognition, risk stratification, appropriate treatment (theranostics), and trial enrichment for patients with sepsis or suspected sepsis. In this narrative review, we aim to answer the question, "Do biomarkers in patients with sepsis or septic shock predict mortality, multiple organ dysfunction syndrome (MODS), or organ dysfunction?" We also discuss the role of pro- and anti-inflammatory biomarkers and biomarkers associated with intestinal permeability, endothelial injury, organ dysfunction, blood–brain barrier (BBB) breakdown, brain injury, and short and long-term mortality. For sepsis, a range of biomarkers is identified, including fluid phase pattern recognition molecules (PRMs), complement system, cytokines, chemokines, damage-associated molecular patterns (DAMPs), non-coding RNAs, miRNAs, cell membrane receptors, cell proteins, metabolites, and soluble receptors. We also provide an overview of immune response biomarkers that can help identify or differentiate between systemic inflammatory response syndrome (SIRS), sepsis, septic shock, and sepsis-associated encephalopathy. However, significant work is needed to identify the optimal combinations of biomarkers that can augment diagnosis, treatment, and good patient outcomes.
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Affiliation(s)
- Tatiana Barichello
- Laboratory of Experimental Pathophysiology, Graduate Program in Health Sciences, University of Southern Santa Catarina (UNESC), Criciúma, SC, Brazil. .,Faillace Department of Psychiatry and Behavioral Sciences, McGovern Medical School, The University of Texas Health Science Center at Houston (UTHealth), Houston, TX, 77054, USA.
| | - Jaqueline S Generoso
- Laboratory of Experimental Pathophysiology, Graduate Program in Health Sciences, University of Southern Santa Catarina (UNESC), Criciúma, SC, Brazil
| | - Mervyn Singer
- Bloomsbury Institute of Intensive Care Medicine, Division of Medicine, University College London, London, UK
| | - Felipe Dal-Pizzol
- Laboratory of Experimental Pathophysiology, Graduate Program in Health Sciences, University of Southern Santa Catarina (UNESC), Criciúma, SC, Brazil
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Thisayakorn P, Tangwongchai S, Tantavisut S, Thipakorn Y, Sukhanonsawat S, Wongwarawipat T, Sirivichayakul S, Maes M. Immune, Blood Cell, and Blood Gas Biomarkers of Delirium in Elderly Individuals with Hip Fracture Surgery. Dement Geriatr Cogn Disord 2021; 50:161-169. [PMID: 34350874 DOI: 10.1159/000517510] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2021] [Accepted: 05/28/2021] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Postoperative delirium in elderly people with hip fracture is associated with various adverse clinical outcomes. Nevertheless, the pathophysiological processes underpinning delirium have remained elusive. OBJECTIVES The aim of this study was to explore the associations between delirium and its features and immune-inflammatory and blood gas biomarkers. METHODS In this prospective study, we examined 65 patients who underwent a hip fracture surgery and assessed the Confusion Assessment Method for the Intensive Care Unit, Richmond Agitation-Sedation Scale (RASS), and Delirium Rating Scale Revised-98 (DRS-R-98) before and during 4 days after the surgery. Complete blood count and venous blood gas markers were obtained at the same time points. RESULTS Delirium was observed in 19 patients and was accompanied by significantly increased pO2, number of white blood cells, neutrophil percentage, and neutrophil/lymphocyte ratio, and lower mean platelet volume (MPV) after adjusting for age, central nervous system (CNS) disease, blood loss during surgery, sleep disorders, and body mass index. The severity of delirium was associated with lowered number of platelets and MPV. Psychomotor disorders were associated with lower bicarbonate levels. The requirement of physical restraint of the patients was predicted by increased percentages of neutrophils and lymphocytes. Prior CNS disease was together with these biomarkers a significant predictor of delirium and severity of delirium. CONCLUSION Delirium and psychomotor disorders following hip fracture and surgery may be caused by immune-inflammatory and oxidative stress pathways probably attributable to an aseptic inflammatory process.
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Affiliation(s)
- Paul Thisayakorn
- Department of Psychiatry, Hip Fracture Research Unit, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | | | - Saran Tantavisut
- Department of Orthopedics, Hip Fracture Research Unit, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Yanin Thipakorn
- Department of Psychiatry, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Siree Sukhanonsawat
- Department of Psychiatry, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | | | - Sunee Sirivichayakul
- Department of Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Michael Maes
- Department of Psychiatry, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
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21
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Feng Q, Ai M, Huang L, Peng Q, Ai Y, Zhang L. Relationship Between Cerebral Hemodynamics, Tissue Oxygen Saturation, and Delirium in Patients With Septic Shock: A Pilot Observational Cohort Study. Front Med (Lausanne) 2021; 8:641104. [PMID: 34901041 PMCID: PMC8660998 DOI: 10.3389/fmed.2021.641104] [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: 12/14/2020] [Accepted: 10/11/2021] [Indexed: 11/13/2022] Open
Abstract
Background: Septic shock patients have tendencies toward impairment in cerebral autoregulation and imbalanced cerebral oxygen metabolism. Tissue Oxygen Saturation (StO2) and Transcranial Doppler (TCD) monitoring were undertaken to observe the variations of cerebral hemodynamic indices and cerebral/peripheral StO2 to find risk factors that increase the sepsis-associated delirium (SAD). Materials and Methods: The research cohort was chosen from septic shock patients received in the Department of Critical Care Medicine, Xiangya Hospital, Central South University between May 2018 and March 2019. These patients were separated into two groups, SAD and non-SAD as assessed by using the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU). Comparisons were made between the two groups in terms of peripheral StO2, fluctuations in regional cerebral oxygen saturation (rSO2), cerebral vascular automatic regulation function [Transient Hyperemic Response Ratio (THRR) index], cerebral hemodynamic index, organ function indicators, blood gas analysis indices, and patient characteristics. Results: About 39% of the patients (20/51) suffered from SAD. Nearly 43% of the patients died within 28 days of admission (22/51). Individuals in the SAD cohort needed a longer period of mechanical ventilation [5 (95% CI 2, 6) vs. 1 days (95% CI 1, 4), p = 0.015] and more time in ICU [9 (95% CI 5, 20) vs. 5 days (95% CI 3, 9), p = 0.042]; they also experienced more deaths over the 28-day period (65 vs. 29%, p = 0.011). The multivariate regression analysis indicated that independent variables associated with SAD were THRR index [odds ratio (OR) = 5.770, 95% CI: 1.222-27.255; p = 0.027] and the mean value for rSO2 was < 55% (OR = 3.864, 95% CI: 1.026-14.550; p = 0.046). Conclusion: Independent risk factors for SAD were mean cerebral oxygen saturation below 55% and cerebrovascular dysregulation (THRR < 1.09).
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Affiliation(s)
- Qing Feng
- Department of Intensive Care Unit, Central South University, Xiangya Hospital, Changsha, China.,Department of Intensive Care Unit, Peking University, Shenzhen Hospital, Shenzhen, China
| | - Meilin Ai
- Department of Intensive Care Unit, Central South University, Xiangya Hospital, Changsha, China
| | - Li Huang
- Department of Intensive Care Unit, Central South University, Xiangya Hospital, Changsha, China
| | - Qianyi Peng
- Department of Intensive Care Unit, Central South University, Xiangya Hospital, Changsha, China
| | - Yuhang Ai
- Department of Intensive Care Unit, Central South University, Xiangya Hospital, Changsha, China
| | - Lina Zhang
- Department of Intensive Care Unit, Central South University, Xiangya Hospital, Changsha, China
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Avan R, Sahebnasagh A, Hashemi J, Monajati M, Faramarzi F, Henney NC, Montecucco F, Jamialahmadi T, Sahebkar A. Update on Statin Treatment in Patients with Neuropsychiatric Disorders. Life (Basel) 2021; 11:1365. [PMID: 34947895 PMCID: PMC8703562 DOI: 10.3390/life11121365] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2021] [Revised: 11/26/2021] [Accepted: 12/04/2021] [Indexed: 02/06/2023] Open
Abstract
Statins are widely accepted as first-choice agents for the prevention of lipid-related cardiovascular diseases. These drugs have both anti-inflammatory and anti-oxidant properties, which may also make them effective as potential treatment marked by perturbations in these pathways, such as some neuropsychiatric disorders. In this narrative review, we have investigated the effects of statin therapy in individuals suffering from major depressive disorder (MDD), schizophrenia, anxiety, obsessive-compulsive disorder (OCD), bipolar disorder (BD), delirium, and autism spectrum disorders using a broad online search of electronic databases. We also explored the adverse effects of these drugs to obtain insights into the benefits and risks associated with their use in the treatment of these disorders. Lipophilic statins (including simvastatin) because of better brain penetrance may have greater protective effects against MDD and schizophrenia. The significant positive effects of statins in the treatment of anxiety disorders without any serious adverse side effects were shown in numerous studies. In OCD, BD, and delirium, limitations, and contradictions in the available data make it difficult to draw conclusions on any positive effect of statins. The positive effects of simvastatin in autism disorders have been evaluated in only a small number of clinical trials. Although some studies showed positive effect of statins in some neuropsychiatric disorders, further prospective studies are needed to confirm this and define the most effective doses and treatment durations.
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Affiliation(s)
- Razieh Avan
- Department of Clinical Pharmacy, Medical Toxicology and Drug Abuse Research Center (MTDRC), School of Pharmacy, Birjand University of Medical Sciences, Birjand 9717853577, Iran;
| | - Adeleh Sahebnasagh
- Clinical Research Center, Department of Internal Medicine, North Khorasan University of Medical Sciences, Bojnurd 9453155166, Iran;
| | - Javad Hashemi
- Department of Pathobiology and Laboratory Sciences, School of Medicine, North Khorasan University of Medical Sciences, Bojnurd 9453155166, Iran;
| | - Mahila Monajati
- Department of Internal Medicine, Golestan University of Medical Sciences, Gorgan 4934174515, Iran;
| | - Fatemeh Faramarzi
- Clinical Pharmacy Research Center, Iran University of Medical Sciences, Tehran 1445613131, Iran;
| | - Neil C. Henney
- Pharmacy & Biomolecular Sciences, Liverpool John Moores University, Liverpool L3 5UX, UK;
| | - Fabrizio Montecucco
- IRCCS Ospedale Policlinico San Martino Genoa-Italian Cardiovascular Network, 10 Largo Benzi, 16132 Genoa, Italy;
- First Clinic of Internal Medicine, Department of Internal Medicine, University of Genoa, 6 Viale Benedetto XV, 16132 Genoa, Italy
| | - Tannaz Jamialahmadi
- Department of Nutrition, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad 9177948564, Iran;
| | - Amirhossein Sahebkar
- Applied Biomedical Research Center, Mashhad University of Medical Sciences, Mashhad 9177948564, Iran
- Biotechnology Research Center, Pharmaceutical Technology Institute, Mashhad University of Medical Sciences, Mashhad 9177948954, Iran
- Department of Biotechnology, School of Pharmacy, Mashhad University of Medical Sciences, Mashhad 9177948954, Iran
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Garcia MA, Barreras PV, Lewis A, Pinilla G, Sokoll LJ, Kickler T, Mostafa H, Caturegli M, Moghekar A, Fitzgerald KC, Pardo CA. Cerebrospinal fluid in COVID-19 neurological complications: Neuroaxonal damage, anti-SARS-Cov2 antibodies but no evidence of cytokine storm. J Neurol Sci 2021; 427:117517. [PMID: 34090021 PMCID: PMC8166041 DOI: 10.1016/j.jns.2021.117517] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2021] [Revised: 05/25/2021] [Accepted: 05/28/2021] [Indexed: 12/23/2022]
Abstract
OBJECTIVE To study in cerebrospinal fluid (CSF) of COVID-19 subjects if a "cytokine storm" or neuroinflammation are implicated in pathogenesis of neurological complications. METHODS Cross-sectional study of CSF neuroinflammatory profiles from 18 COVID-19 subjects with neurological complications categorized by diagnosis (stroke, encephalopathy, headache) and illness severity. COVID-19 CSF was compared with CSF from healthy, infectious and neuroinflammatory disorders and stroke controls (n = 82). Cytokines (IL-6, TNFα, IFNγ, IL-10, IL-12p70, IL-17A), inflammation and coagulation markers (high-sensitivity-C Reactive Protein [hsCRP], ferritin, fibrinogen, D-dimer, Factor VIII) and neurofilament light chain (NF-L), were quantified. SARS-CoV2 RNA and SARS-CoV2 IgG and IgA antibodies in CSF were tested with RT-PCR and ELISA. RESULTS CSF from COVID-19 subjects showed absence of pleocytosis or specific increases in pro-inflammatory markers (IL-6, ferritin, or D-dimer). Although pro-inflammatory cytokines (IL-6, TNFα, IL-12p70) and IL-10 were increased in CSF of stroke COVID-19 subjects, a similar increase was observed in non-COVID-19 stroke subjects. Anti-SARS-CoV2 antibodies in CSF of COVID-19 subjects (77%) were observed despite no evidence of SARS-CoV2 viral RNA. CSF-NF-L was elevated in subjects with stroke and critical COVID-19 as compared to controls and other COVID-19 severity categories. CSF-hsCRP was present in all subjects with critical stages of COVID-19 (7/18) but only in 1/82 controls. CONCLUSION The paucity of neuroinflammatory changes in CSF of COVID-19 subjects and lack of SARS-CoV2 RNA do not support the presumed neurovirulence of SARS-CoV2 or neuroinflammation in pathogenesis of neurological complications in COVID-19. The role of CSF SARS-CoV2 IgG antibodies and mechanisms of neuronal damage are still undetermined.
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Affiliation(s)
- Maria A Garcia
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, United States of America; Bloomberg School of Public Health, Johns Hopkins University School of Medicine, Baltimore, MD, United States of America
| | - Paula V Barreras
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, United States of America
| | - Allie Lewis
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, United States of America
| | | | - Lori J Sokoll
- Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, MD, United States of America
| | - Thomas Kickler
- Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, MD, United States of America
| | - Heba Mostafa
- Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, MD, United States of America
| | - Mario Caturegli
- Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, MD, United States of America
| | - Abhay Moghekar
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, United States of America
| | - Kathryn C Fitzgerald
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, United States of America
| | - Carlos A Pardo
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, United States of America; Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, MD, United States of America.
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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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25
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Chan CK, Song Y, Greene R, Lindroth H, Khan S, Rios G, Khan B, Wang S. Meta-analysis of ICU Delirium Biomarkers and Their Alignment With the NIA-AA Research Framework. Am J Crit Care 2021; 30:312-319. [PMID: 34195769 DOI: 10.4037/ajcc2021771] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
BACKGROUND Between 30% and 80% of survivors of critical illness experience cognitive impairment, but the underlying mechanisms remain unknown. OBJECTIVE To determine whether intensive care unit (ICU) delirium biomarkers align with the National Institute on Aging-Alzheimer's Association (NIA-AA) research framework for diagnostic biomarkers for Alzheimer disease and other related dementias (ADRD). METHODS Ovid MEDLINE, PsycInfo, Embase, and the Cochrane Library were systematically searched for articles published between January 1, 2000, and February 20, 2020, on the relationship between delirium and biomarkers listed in the NIA-AA framework. Only studies that addressed delirium in the ICU setting and fluid biomarkers were included in these analyses. RESULTS Of 61 256 records screened, 38 studies met inclusion criteria, 8 of which were suitable for meta-analysis. In pooled analysis, significant associations were found between ICU delirium and amyloid β-peptide 1-40 (standard mean difference [SMD], 0.42; 95% CI, 0.09-0.75), interleukin (IL)-1 receptor antagonist (SMD, 0.58; 95% CI, 0.21-0.94), and IL-6 (SMD, 0.31; 95% CI, 0.06-0.56). No significant association was observed in pooled analyses between ICU delirium and the other biomarkers. Few studies have examined ICU delirium and pathologic tau or neurodegeneration biomarkers. CONCLUSIONS Inflammatory biomarkers and amyloid β are associated with ICU delirium and point to potential overlapping mechanisms between delirium and ADRD. Critical care providers should consider integrating diagnostic approaches used in ADRD in their assessment of post-ICU cognitive dysfunction.
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Affiliation(s)
- Carol K. Chan
- Carol K. Chan is a clinical fellow in geriatric psychiatry, Department of Psychiatry and Behavioral Sciences, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Yiqing Song
- Yiqing Song is a professor, Fairbanks School of Public Health, Indiana University, Indianapolis
| | - Ryan Greene
- Ryan Greene is an assistant professor, Department of Psychiatry, Indiana University School of Medicine, Indianapolis
| | - Heidi Lindroth
- Heidi Lindroth is a postdoctoral fellow, Division of Pulmonary, Critical Care, Sleep and Occupational Medicine, Department of Medicine, Indiana University School of Medicine; Indiana Center for Aging Research, Regenstrief Institute, Indianapolis; and Center for Health Innovation and Implementation Science, Indianapolis
| | - Sikandar Khan
- Sikandar Khan is an assistant professor, Division of Pulmonary, Critical Care, Sleep and Occupational Medicine, Department of Medicine, Indiana University School of Medicine; Indiana Center for Aging Research, Regenstrief Institute, Indianapolis; and Center for Health Innovation and Implementation Science, Indianapolis
| | - Gabriel Rios
- Gabriel Rios is director, Ruth Lilly Medical Library, Indiana University School of Medicine
| | - Babar Khan
- Babar Khan is an associate professor, Division of Pulmonary, Critical Care, Sleep and Occupational Medicine, Department of Medicine, Indiana University School of Medicine; Indiana Center for Aging Research, Regenstrief Institute, Indianapolis; and Center for Health Innovation and Implementation Science, Indianapolis
| | - Sophia Wang
- Sophia Wang is an assistant professor, Department of Psychiatry, Indiana University School of Medicine, and Indiana Alzheimer’s Disease Research Center, Indiana University School of Medicine
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Sui X, Duan Q, Liu K, Li C. Postoperative delirium after long-term general anesthesia in elderly patients, how to reduce it?: Protocol of a double-blinded, randomized, placebo-controlled trial. Medicine (Baltimore) 2021; 100:e25885. [PMID: 34087831 PMCID: PMC8183711 DOI: 10.1097/md.0000000000025885] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Accepted: 04/21/2021] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND Long operation duration (>4 hours' anesthesia) of laparotomy in elderly patients would increase the risk of postoperative delirium (POD), which is characterized by acute cognitive dysfunction, changes in the level of consciousness, obvious attention disorder, emotional disorder, and sleep-waking cycle disorder. The occurrence of POD is closely related to the risk of death, and it will also seriously affect the cognitive function of patients, prolong postoperative hospital stays, and increase medical expenses. It is known that dexmetomidine could function in sedation, analgesia and anti-sympathetic effect, and it also could simulate the normal sleep state of human body, but there is still a lack of clinical study of dexmedetomidine on the incidence of POD in elderly patients undergoing long-term general anesthesia in laparotomy. METHODS This is a single-center, double-blinded, randomized controlled study. With the approval of the Ethics Committee of Chongqing Shapingba District People's Hospital, participants who meet the requirements will be randomly divided into the treatment group (continuous infusion of dexmetomidine) and the control group (continuous infusion of 0.9% sodium chloride solution) in a ratio of 1:1. The incidence of delirium, cognitive function score, inflammatory factors, and adverse reactions will be evaluated after the operation. Finally, the data will be analyzed by SPSS 22.0. CONCLUSION The results of this study will explore the efficacy and safety of dexmetomidine in reducing the incidence of postoperative delirium in elderly patients undergoing long-term general anesthesia in laparotomy. TRIAL REGISTRATION OSF Registration number: DOI 10.17605/OSF.IO/2GJY6.
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Affiliation(s)
| | | | - Kunling Liu
- Chongqing Shapingba District People's Hospital
| | - Cuicui Li
- Xinqiao Community Health Service Center, Shapingba District, Chongqing, China
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Sedhai YR, Shrestha DB, Budhathoki P, Jha V, Mandal SK, Karki S, Baniya R, Cable CA, Kashiouris MG. Effect of thiamine supplementation in critically ill patients: A systematic review and meta-analysis. J Crit Care 2021; 65:104-115. [PMID: 34118501 DOI: 10.1016/j.jcrc.2021.05.016] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2020] [Revised: 03/31/2021] [Accepted: 05/26/2021] [Indexed: 12/15/2022]
Abstract
INTRODUCTION Several studies have previously shown the benefit of thiamine supplementation in critically ill patients. In order to fully appraise the available data, we performed a meta-analysis of 18 published studies. METHODS A thorough systematic search was conducted. The studies enrolling critically ill patients receiving thiamine supplementation was compared with the standard of care (SOC) group. Data was analyzed using RevMan 5.4. Clinical outcomes were pooled using Odds Ratio (OR) and mean differences. RESULT Eighteen studies (8 RCTs and 10 cohort studies) met the criteria for quantitative synthesis. In the analysis of RCTs, thiamine supplementation showed 42% lower odds of developing ICU delirium (OR 0.58, 95% CI, 0.34-0.98). A reduction in mortaliy was observed on performing fixed effect model analysis however, a level of statistical significance could not be reached on performing randon effect model analysis (OR, 0.78; 95% CI, 0.59 to 1.04). Further sub-group analysis of 13 studies in patients with sepsis, there was no difference in mortality between the two groups (OR, 0.83; 95% CI, 0.63 to 1.09). CONCLUSION Thiamine supplementation in critically ill patients showed a reduction in the incidence of ICU delirium among RCTs. However, there was no significant benefit in terms of overall mortality, and mortality in patients with sepsis. Further, large scale randomized prospective studies are warranted to investigate the role of thiamine supplementation in critically ill patients.
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Affiliation(s)
- Yub Raj Sedhai
- Department of Internal Medicine, Division of Hospital Medicine, Virginia Commonwealth University, School of Medicine, Richmond, VA, USA.
| | | | - Pravash Budhathoki
- Department of Internal Medicine, BronxCare Health System, Bronx, NY, USA
| | - Vivek Jha
- Department of Cardiology, Manmohan Cardiothoracic Vascular and Transplant Center, Kathmandu, Nepal
| | - Sujit Kumar Mandal
- Department of Cardiology, Manmohan Cardiothoracic Vascular and Transplant Center, Kathmandu, Nepal; Nepalese Army Institute of Health Sciences, Kathmandu, Nepal
| | | | - Ramkaji Baniya
- Our Lady of the Lake Regional Medical Center, Baton Rouge, LA, USA
| | - Casey A Cable
- Department of Internal Medicine, Division of Pulmonary and Critical Care Medicine, VCU School of Medicine, Richmond, VA, USA
| | - Markos G Kashiouris
- Department of Internal Medicine, Division of Pulmonary and Critical Care Medicine, VCU School of Medicine, Richmond, VA, USA.
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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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Yamanashi T, Saito T, Yu T, Alario A, Comp K, Crutchley KJ, Sullivan EJ, Anderson ZEM, Marra PS, Chang G, Wahba NE, Jellison SS, Meyer AA, Mathur S, Pandharipande P, Yoshino A, Kaneko K, Lee S, Toda H, Iwata M, Shinozaki G. DNA methylation in the TNF-alpha gene decreases along with aging among delirium inpatients. Neurobiol Aging 2021; 105:310-317. [PMID: 34192631 DOI: 10.1016/j.neurobiolaging.2021.05.005] [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: 12/17/2020] [Revised: 04/25/2021] [Accepted: 05/10/2021] [Indexed: 12/12/2022]
Abstract
It has been suggested that aging and inflammation play key roles in the development of delirium. In the present study, we investigated the differences of the DNAm patterns in the TNF gene between patients with delirium and without. The data and samples derived from previous and ongoing cohort studies were analyzed. DNAm levels of the TNF gene were analyzed using the Illumina EPIC array genome-wide method and pyrosequencing method. Correlations between age and DNAm levels of each CpG were calculated. Several CpG in the TNF gene in blood showed negative correlation between their DNAm and age in delirium cases both with the EPIC array and by the pyrosequencing method. However, there was no CpG that had significant correlation between their DNAm and age regardless of delirium status among buccal samples. On the other hand, among peripheral blood mononuclear cells samples, it was found that several CpG showed negative correlation between their DNAm and age in delirium cases. The evidence of DNAm change in the TNF gene among delirious subjects was demonstrated.
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Affiliation(s)
- 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, Tottori, Japan
| | - Taku Saito
- Department of Psychiatry, University of Iowa Carver College of Medicine, Iowa City, IA, USA; Department of Psychiatry, National Defense Medical College School of Medicine, Tokorozawa, Saitama, Japan
| | - Tong Yu
- Department of Psychiatry, University of Iowa Carver College of Medicine, Iowa City, IA, USA
| | - Alexandra Alario
- Department of Psychiatry, University of Iowa Carver College of Medicine, Iowa City, IA, USA
| | - Katie Comp
- Department of Psychiatry, University of Iowa Carver College of Medicine, Iowa City, IA, USA
| | - Kaitlyn J Crutchley
- Department of Psychiatry, University of Iowa Carver College of Medicine, Iowa City, IA, USA
| | - Eleanor J Sullivan
- Department of Psychiatry, University of Iowa Carver College of Medicine, Iowa City, IA, USA
| | - Zoe-Ella M Anderson
- Department of Psychiatry, University of Iowa Carver College of Medicine, Iowa City, IA, USA
| | - Pedro S Marra
- Department of Psychiatry, University of Iowa Carver College of Medicine, Iowa City, IA, USA
| | - Gloria Chang
- Department of Psychiatry, University of Iowa Carver College of Medicine, Iowa City, IA, USA
| | - Nadia E Wahba
- Department of Psychiatry, University of Iowa Carver College of Medicine, Iowa City, IA, USA
| | - Sydney S Jellison
- Department of Psychiatry, University of Iowa Carver College of Medicine, Iowa City, IA, USA
| | - Alissa A Meyer
- Department of Psychiatry, University of Iowa Carver College of Medicine, Iowa City, IA, USA
| | - Srishti Mathur
- Department of Psychiatry, University of Iowa Carver College of Medicine, Iowa City, IA, USA
| | - Pratik Pandharipande
- Department of anesthesiology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Aihide Yoshino
- Department of Psychiatry, National Defense Medical College School of Medicine, Tokorozawa, Saitama, Japan
| | - Koichi Kaneko
- Department of Neuropsychiatry, Tottori University Faculty of Medicine, Yonago, Tottori, Japan
| | - Sangil Lee
- Department of Emergency Medicine, 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
| | - Masaaki Iwata
- Department of Neuropsychiatry, Tottori University Faculty of Medicine, Yonago, 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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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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Wanderlind ML, Gonçalves R, Tomasi CD, Dal-Pizzol F, Ritter C. Association of neurogranin with delirium among critically ill patients. Biomark Med 2020; 14:1613-1617. [PMID: 33336596 DOI: 10.2217/bmm-2020-0328] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Background: Neurogranin (Ng) concentrates at dendritic spines. In patients with Alzheimer disease Ng levels are elevated. The role of Ng in delirium development has not been assessed, therefore we hypothesized that Ng levels are associated with delirium in critically ill patients. Materials & methods: From 94 critically ill patients, 47 developed delirium and 47 controls were included. Blood was collected during the first 24 h of intensive care unit (ICU) admission, and on the day of delirium diagnoses. Ng and IL-1β were determined. Results: Ng and IL-1β levels were higher in the delirium group at ICU admission and on the day of delirium diagnoses. IL-1β and Ng were independently associated with delirium occurrence. Conclusion: Ng levels are associated with delirium development in ICU patients.
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Affiliation(s)
- Márcia Lz Wanderlind
- Laboratório de Fisiopatologia Experimental Universidade do Extremo Sul Catarinense, Criciúma, SC, Brazil
| | - Renata Gonçalves
- Laboratório de Fisiopatologia Experimental Universidade do Extremo Sul Catarinense, Criciúma, SC, Brazil
| | - Cristiane D Tomasi
- Laboratório de Fisiopatologia Experimental Universidade do Extremo Sul Catarinense, Criciúma, SC, Brazil
| | - Felipe Dal-Pizzol
- Laboratório de Fisiopatologia Experimental Universidade do Extremo Sul Catarinense, Criciúma, SC, Brazil.,Intensive Care Unit, Hospital São José, Criciúma, SC, Brazil
| | - Cristiane Ritter
- Laboratório de Fisiopatologia Experimental Universidade do Extremo Sul Catarinense, Criciúma, SC, Brazil.,Intensive Care Unit, Hospital São José, Criciúma, SC, Brazil
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Tauber SC, Djukic M, Gossner J, Eiffert H, Brück W, Nau R. Sepsis-associated encephalopathy and septic encephalitis: an update. Expert Rev Anti Infect Ther 2020; 19:215-231. [PMID: 32808580 DOI: 10.1080/14787210.2020.1812384] [Citation(s) in RCA: 83] [Impact Index Per Article: 20.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
INTRODUCTION Sepsis-associated encephalopathy (SAE) and septic encephalitis (SE) are associated with increased mortality, long-term cognitive impairment, and focal neurological deficits. AREAS COVERED The PUBMED database was searched 2016-2020. The clinical manifestation of SAE is delirium, SE additionally is characterized by focal neurological symptoms. SAE is caused by inflammation with endothelial/microglial activation, increase of permeability of the blood-brain-barrier, hypoxia, imbalance of neurotransmitters, glial activation, axonal, and neuronal loss. Septic-embolic (SEE) and septic-metastatic encephalitis (SME) are characterized by focal ischemia (SEE) and small abscesses (SME). The continuum between SAE, SME, and SEE is documented by imaging techniques and autopsies. The backbone of treatment is rapid optimum antibiotic therapy. Experimental approaches focus on modulation of inflammation, stabilization of the blood-brain barrier, and restoration of membrane/mitochondrial function. EXPERT OPINION The most promising diagnostic approaches are new imaging techniques. The most important measure to fight delirium remains establishment of daily structure and adequate sensory stimuli. Dexmedetomidine and melatonin appear to reduce the frequency of delirium, their efficacy in SAE and SE remains to be established. Drugs already licensed for other indications or available as food supplements which may be effective in SAE are statins, L-DOPA/benserazide, β-hydroxybutyrate, palmitoylethanolamide, and tetracyclines or other bactericidal non-lytic antibiotics.
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Affiliation(s)
- Simone C Tauber
- Department of Neurology, Rheinisch-Westfälische Technische Hochschule (RWTH) , Aachen, Germany
| | - Marija Djukic
- Institute of Neuropathology, University Medical Center , Göttingen, Germany.,Department of Geriatrics, Protestant Hospital Göttingen-Weende , Göttingen, Germany
| | - Johannes Gossner
- Department of Diagnostic and Interventional Radiology, Protestant Hospital Göttingen-Weende , Göttingen, Germany
| | - Helmut Eiffert
- Amedes MVZ for Laboratory Medicine, Medical Microbiology and Infectiology , Göttingen, Germany
| | - Wolfgang Brück
- Institute of Neuropathology, University Medical Center , Göttingen, Germany
| | - Roland Nau
- Institute of Neuropathology, University Medical Center , Göttingen, Germany.,Department of Geriatrics, Protestant Hospital Göttingen-Weende , Göttingen, Germany
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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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Moslemi R, Khalili H, Mohammadi M, Mehrabi Z, Mohebbi N. Thiamine for Prevention of Postoperative Delirium in Patients Undergoing Gastrointestinal Surgery: A Randomized Clinical Trial. J Res Pharm Pract 2020; 9:30-35. [PMID: 32489958 PMCID: PMC7235453 DOI: 10.4103/jrpp.jrpp_19_124] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2019] [Accepted: 12/23/2019] [Indexed: 12/04/2022] Open
Abstract
Objective: Postoperative delirium is a common complication after gastrointestinal surgery that is associated with adverse outcomes. Thiamine is an essential cofactor for the glycolysis, oxidative metabolism, production of neurotransmitters in the crebs cycle. In this study, efficacy of thiamine was assessed as a preventive strategy of delirium in patients undergoing gastrointestinal surgery. Methods: In this randomized clinical trial, 96 adult patients admitted to the intensive care unit (ICU) following gastrointestinal surgery were included. Patients were allocated to receive either 200 mg intravenous thiamine daily or an equal volume of 0.9% saline for 3 days. Delirium was evaluated twice daily based on the confusion assessment method-ICU. The incidence of postoperative delirium was considered as the primary outcome, and total analgesic use and ventilation days has been defined as secondary outcomes of the study. Findings: The incidence rate of delirium was significantly lower in the thiamine group than the placebo group on the first day (8.3% vs. 25%; Odds ratio: 0.27 [95% confidence interval (CI): 0.08–0.92]; P= 0.026) and on the second day (4.2% vs. 20.8%; or: 0.16 [95% CI: 0.03–0.81]; P= 0.014). No adverse effect related to thiamine was detected during the study course. Conclusion: Study results suggest that thiamine is a safe option for the prevention of postoperative delirium in patients after gastrointestinal surgery.
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Affiliation(s)
- Rohollah Moslemi
- Department of Clinical Pharmacy, Tehran University of Medical Sciences, Tehran, Iran
| | - Hossein Khalili
- Department of Clinical Pharmacy, Tehran University of Medical Sciences, Tehran, Iran
| | - Mostafa Mohammadi
- Department of Intensive Care Unit, School of Medicine, Imam Khomeini Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Zeinab Mehrabi
- Department of Internal Medicine, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Niayesh Mohebbi
- Department of Clinical Pharmacy, Tehran University of Medical Sciences, Tehran, Iran
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Abdelrahman I, Vieweg R, Irschik S, Steinvall I, Sjöberg F, Elmasry M. Development of delirium: Association with old age, severe burns, and intensive care. Burns 2020; 46:797-803. [PMID: 32183993 DOI: 10.1016/j.burns.2020.02.013] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2019] [Revised: 02/17/2020] [Accepted: 02/25/2020] [Indexed: 11/28/2022]
Abstract
BACKGROUND Delirium is defined as a disturbance of attention and awareness that develops over a short period of time, is a change from the baseline, and typically fluctuates over time. Burn care involves a high prevalence of known risk factors for delirium such as sedation, inflammation, and prolonged stay in hospital. Our aim was to explore the extent of delirium and the impact of factors associated with it for adult patients who have been admitted to hospital with burns. METHODS In this retrospective study, all adult patients who had been admitted with burns during a four-year period were studied, including both those who were treated with intensive care and intermediate care only (no intensive care). Daily records of the assessment of delirium using the Nursing Delirium Screening Scale (Nu-DESC) were analysed together with age, sex, the percentage of total body surface area burned, operations, and numbers of wound care procedures under anaesthesia, concentrations of plasma C-reactive protein, and other clinical variables. Logistic regression was used to analyse factors that were associated with delirium and its effect on mortality, and linear regression was used to analyse its effect on the duration of hospital stay. RESULTS Fifty-one patients (19%) of the total 262 showed signs of delirium (Nu-DESC score of 2 or more) at least once during their stay in hospital. Signs of delirium were recorded in 42/89 patients (47%) who received intensive care, and in 9/173 (5%) who had intermediate care. Independent factors for delirium in the multivariable regression were: age over 74 years; number of operations and wound care procedures under anaesthesia; and the provision of intensive care (area under the curve 0.940, 95% CI 0.899-0.981). Duration of hospital stay, adjusted for age and burn size, was 13.2 (95% CI 7.4-18.9, p < 0.001) days longer in the group who had delirium. We found no independent effects of delirium on mortality. CONCLUSION We found a strong association between delirium and older age, provision ofr intensive care, and number of interventions under anaesthesia. A further 5% of patients who did not receive intensive care also showed signs of delirium, which is a finding that deserves to be thoroughly investigated in the future.
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Affiliation(s)
- Islam Abdelrahman
- Department of Hand Surgery, Plastic Surgery and Burns, and Department of Biomedical and Clinical Sciences Linköping University, Linköping, Sweden.
| | - Rosa Vieweg
- Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden; Department of Anaesthesiology and Intensive Care, Linköping University, Linköping, Sweden
| | - Stefan Irschik
- Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | - Ingrid Steinvall
- Department of Hand Surgery, Plastic Surgery and Burns, and Department of Biomedical and Clinical Sciences Linköping University, Linköping, Sweden
| | - Folke Sjöberg
- Department of Hand Surgery, Plastic Surgery and Burns, and Department of Biomedical and Clinical Sciences Linköping University, Linköping, Sweden; Department of Anaesthesiology and Intensive Care, Linköping University, Linköping, Sweden
| | - Moustafa Elmasry
- Department of Hand Surgery, Plastic Surgery and Burns, and Department of Biomedical and Clinical Sciences Linköping University, Linköping, Sweden
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Khan BA, Perkins AJ, Prasad NK, Shekhar A, Campbell NL, Gao S, Wang S, Khan SH, Marcantonio ER, Twigg HL, Boustani MA. Biomarkers of Delirium Duration and Delirium Severity in the ICU. Crit Care Med 2020; 48:353-361. [PMID: 31770149 PMCID: PMC7242000 DOI: 10.1097/ccm.0000000000004139] [Citation(s) in RCA: 62] [Impact Index Per Article: 15.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
OBJECTIVES Both delirium duration and delirium severity are associated with adverse patient outcomes. Serum biomarkers associated with delirium duration and delirium severity in ICU patients have not been reliably identified. We conducted our study to identify peripheral biomarkers representing systemic inflammation, impaired neuroprotection, and astrocyte activation associated with delirium duration, delirium severity, and in-hospital mortality. DESIGN Observational study. SETTING Three Indianapolis hospitals. PATIENTS Three-hundred twenty-one critically ill delirious patients. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS We analyzed the associations between biomarkers collected at delirium onset and delirium-/coma-free days assessed through Richmond Agitation-Sedation Scale/Confusion Assessment Method for the ICU, delirium severity assessed through Confusion Assessment Method for the ICU-7, and in-hospital mortality. After adjusting for age, gender, Acute Physiology and Chronic Health Evaluation II score, Charlson comorbidity score, sepsis diagnosis and study intervention group, interleukin-6, -8, and -10, tumor necrosis factor-α, C-reactive protein, and S-100β levels in quartile 4 were negatively associated with delirium-/coma-free days by 1 week and 30 days post enrollment. Insulin-like growth factor-1 levels in quartile 4 were not associated with delirium-/coma-free days at both time points. Interleukin-6, -8, and -10, tumor necrosis factor-α, C-reactive protein, and S-100β levels in quartile 4 were also associated with delirium severity by 1 week. At hospital discharge, interleukin-6, -8, and -10 retained the association but tumor necrosis factor-α, C-reactive protein, and S-100β lost their associations with delirium severity. Insulin-like growth factor-1 levels in quartile 4 were not associated with delirium severity at both time points. Interleukin-8 and S-100β levels in quartile 4 were also associated with higher in-hospital mortality. Interleukin-6 and -10, tumor necrosis factor-α, and insulin-like growth factor-1 were not found to be associated with in-hospital mortality. CONCLUSIONS Biomarkers of systemic inflammation and those for astrocyte and glial activation were associated with longer delirium duration, higher delirium severity, and in-hospital mortality. Utility of these biomarkers early in delirium onset to identify patients at a higher risk of severe and prolonged delirium, and delirium related complications during hospitalization needs to be explored in future studies.
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Affiliation(s)
- Babar A. Khan
- Indiana University School of Medicine, Indianapolis, IN
- Indiana University Center for Aging Research, Indianapolis, IN
- Regenstrief Institute, Inc., Indianapolis, IN
- Indiana University Center for Health Innovation and Implementation Science; Indiana Clinical and Translational Sciences Institute, Indianapolis, IN
| | | | | | | | - Noll L. Campbell
- Indiana University School of Medicine, Indianapolis, IN
- Indiana University Center for Aging Research, Indianapolis, IN
- Regenstrief Institute, Inc., Indianapolis, IN
- Indiana University Center for Health Innovation and Implementation Science; Indiana Clinical and Translational Sciences Institute, Indianapolis, IN
- Sandra Eskenazi Center for Brain Care Innovation at Eskenazi Health, Indianapolis, IN
- Department of Pharmacy Practice, Purdue University College of Pharmacy, West Lafayette, IN
| | - Sujuan Gao
- Indiana University School of Medicine, Indianapolis, IN
| | - Sophia Wang
- Indiana University School of Medicine, Indianapolis, IN
| | | | - Edward R. Marcantonio
- Divisions of General Medicine and Gerontology, Department of Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston MA
| | | | - Malaz A. Boustani
- Indiana University School of Medicine, Indianapolis, IN
- Indiana University Center for Aging Research, Indianapolis, IN
- Regenstrief Institute, Inc., Indianapolis, IN
- Indiana University Center for Health Innovation and Implementation Science; Indiana Clinical and Translational Sciences Institute, Indianapolis, IN
- Sandra Eskenazi Center for Brain Care Innovation at Eskenazi Health, Indianapolis, IN
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Naghibi T, Shafigh N, Mazloomzadeh S. Role of omega-3 fatty acids in the prevention of delirium in mechanically ventilated patients. JOURNAL OF RESEARCH IN MEDICAL SCIENCES 2020; 25:10. [PMID: 32055250 PMCID: PMC7003546 DOI: 10.4103/jrms.jrms_567_18] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/13/2018] [Revised: 04/28/2019] [Accepted: 11/11/2019] [Indexed: 12/14/2022]
Abstract
Background: Inflammation is an important mechanism in the pathogenesis of delirium. Since delirium might reduce by anti-inflammatory effects of omega-3 fatty acids. Based on this respect, a study was conducted to indicate the effect of omega-3 fatty acids in the prevention of delirium in mechanically ventilated patients. Materials and Methods: This study is a randomized, double-blind, placebo-controlled clinical trial. One hundred and sixty-eight mechanically ventilated patients were selected in the investigation. Patients were randomly allocated to receive either 2 g of omega-3 syrup or placebo once a day. Twice daily delirium was assessed due to Confusion Assessment Method and the Richmond Agitation-Sedation Scale. The number of days with delirium during the first 10 days of admission was the primary outcome. Secondary outcomes had been included duration of mechanical ventilation, length of intensive care unit (ICU) stay, and mortality. Results: Patient-days with delirium (P = 0.032), the number of ICU stay (P = 0.02), and mechanical ventilation (P = 0.042) days in omega-3 group significantly were lower than control group. Mortality was not significantly different between two groups. Conclusion: Omega-3 fatty acids can reduce the risk of delirium in mechanically ventilated patients.
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Affiliation(s)
- Taraneh Naghibi
- Department of Anesthesiology and Critical Care Medicine, School of Medicine, Mosavi Educational Hospital, Zanjan University of Medical Sciences, Zanjan, Iran
| | - Navid Shafigh
- Department of Anesthesiology and Critical Care Medicine, School of Medicine, Mosavi Educational Hospital, Zanjan University of Medical Sciences, Zanjan, Iran
| | - Saideh Mazloomzadeh
- Department of Epidemiology, School of Medicine, Zanjan University of Medical Sciences, Zanjan, Iran
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Impact of Vitamin C and Thiamine Administration on Delirium-Free Days in Patients with Septic Shock. J Clin Med 2020; 9:jcm9010193. [PMID: 31936824 PMCID: PMC7019730 DOI: 10.3390/jcm9010193] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2019] [Revised: 01/03/2020] [Accepted: 01/07/2020] [Indexed: 12/29/2022] Open
Abstract
Sepsis is a common cause of delirium in the intensive care unit (ICU). Recently, vitamin C and thiamine administration has been gaining interest as a potential adjunct therapy for sepsis. We investigated the impact of early vitamin C and thiamine administration on ICU delirium-free days among critically ill patients in septic shock. We performed a single-center, retrospective study of patients who visited the emergency department (ED) from January 2017 to July 2018. We categorized patients into a treatment (received vitamin C and thiamine) and control group. We compared delirium-free days within 14 days after ICU admission using propensity score matching. Of 435 patients with septic shock, we assigned 89 propensity score-matched pairs to the treatment and control groups. The median delirium-free days did not differ between treatment (11, interquartile range [IQR] 5–14 days) and control (12, IQR 6–14 days) groups (p = 0.894). Secondary outcomes were not different between the two groups, including delirium incidence and 28-day mortality. These findings were consistent after subgroup analysis for patients who met the sepsis-3 definition of septic shock. Vitamin C and thiamine administration showed no association with ICU delirium-free days among patients in septic shock.
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Mungan İ, Türksal E, Sari S, Bostanci E, Turan S. The relationship between postoperative outcomes and delirium after liver transplantation in intensive care unit: A single-center experience. INDIAN JOURNAL OF TRANSPLANTATION 2020. [DOI: 10.4103/ijot.ijot_31_19] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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McNeil JB, Hughes CG, Girard T, Ware LB, Ely EW, Chandrasekhar R, Han JH. Plasma biomarkers of inflammation, coagulation, and brain injury as predictors of delirium duration in older hospitalized patients. PLoS One 2019; 14:e0226412. [PMID: 31856187 PMCID: PMC6922408 DOI: 10.1371/journal.pone.0226412] [Citation(s) in RCA: 40] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2019] [Accepted: 11/26/2019] [Indexed: 12/21/2022] Open
Abstract
Background Delirium's pathophysiology is poorly understood. We sought to determine if plasma biomarkers of inflammation, coagulation, endothelial activation, and blood brain barrier (BBB) injury were associated with emergency department (ED) delirium duration. Methods We enrolled hospitalized patients who were 65 years or older from the ED. Plasma biomarkers of inflammation (interleukin-6 [IL-6], IL-8, soluble tumor necrosis factor receptor I [sTNFRI]), coagulation (Protein C), endothelial activation (plasminogen activating inhibitor-1 [PAI-1]), and BBB injury (S100B) at were measured using blood obtained at enrollment. The dependent variable was ED delirium duration which was determined by the Brief Confusion Assessment Method assessed in the ED and hospitalization. Proportional odds logistic regression analyses were performed adjusted for relevant confounders and allowing for interaction by baseline dementia status. Results A total of 156 patients were enrolled. IL-6 (POR = 1.59, 95%CI: 1.09–2.32) and PAI-1 (POR = 2.96, 95%CI: 1.48 to 6.85) were independently associated with more prominent ED delirium duration in subjects without dementia only. No significant associations between IL-8, Protein C, sTNRFI, and S100B and ED delirium duration were observed. Conclusions Plasma Biomarkers of systemic inflammation and endothelial activation are associated with ED delirium duration in older ED patients without dementia.
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Affiliation(s)
- J. Brennan McNeil
- Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, United States of America
- The Critical Illness, Brain Dysfunction and Survivorship (CIBS) Center, Vanderbilt University Medical Center, Nashville, Tennessee, United States of America
| | - Christopher G. Hughes
- The Critical Illness, Brain Dysfunction and Survivorship (CIBS) Center, Vanderbilt University Medical Center, Nashville, Tennessee, United States of America
- Division of Anesthesiology Critical Care Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, United States of America
| | - Timothy Girard
- The Critical Illness, Brain Dysfunction and Survivorship (CIBS) Center, Vanderbilt University Medical Center, Nashville, Tennessee, United States of America
- Clinical Research, Investigation, and Systems Modeling of Acute illness (CRISMA) Center in the Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, United States of America
| | - Lorraine B. Ware
- Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, United States of America
- The Critical Illness, Brain Dysfunction and Survivorship (CIBS) Center, Vanderbilt University Medical Center, Nashville, Tennessee, United States of America
| | - E. Wesley Ely
- Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, United States of America
- The Critical Illness, Brain Dysfunction and Survivorship (CIBS) Center, Vanderbilt University Medical Center, Nashville, Tennessee, United States of America
- Veteran Affairs Geriatric Research, Education, and Clinical Center (GRECC), Nashville, Tennessee, United States of America
| | - Rameela Chandrasekhar
- The Critical Illness, Brain Dysfunction and Survivorship (CIBS) Center, Vanderbilt University Medical Center, Nashville, Tennessee, United States of America
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee, United States of America
| | - Jin H. Han
- The Critical Illness, Brain Dysfunction and Survivorship (CIBS) Center, Vanderbilt University Medical Center, Nashville, Tennessee, United States of America
- Veteran Affairs Geriatric Research, Education, and Clinical Center (GRECC), Nashville, Tennessee, United States of America
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, United States of America
- * E-mail:
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The Role of Secretase Pathway in Long-term Brain Inflammation and Cognitive Impairment in an Animal Model of Severe Sepsis. Mol Neurobiol 2019; 57:1159-1169. [DOI: 10.1007/s12035-019-01808-1] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2019] [Accepted: 09/30/2019] [Indexed: 01/17/2023]
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Milioli MVM, Burger H, Olivieri R, Michels M, Ávila P, Abatti M, Indalécio A, Ritter C, Dal-Pizzol F. The impact of age on long-term behavioral and neurochemical parameters in an animal model of severe sepsis. Neurosci Lett 2019; 708:134339. [DOI: 10.1016/j.neulet.2019.134339] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2019] [Revised: 06/12/2019] [Accepted: 06/17/2019] [Indexed: 11/29/2022]
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Toft K, Tontsch J, Abdelhamid S, Steiner L, Siegemund M, Hollinger A. Serum biomarkers of delirium in the elderly: a narrative review. Ann Intensive Care 2019; 9:76. [PMID: 31263968 PMCID: PMC6603109 DOI: 10.1186/s13613-019-0548-1] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2019] [Accepted: 06/20/2019] [Indexed: 12/17/2022] Open
Abstract
Delirium after surgery and in the intensive care unit (ICU) remains a challenge for patients, families, and caregivers. Over the years, many promising biomarkers have been investigated as potential instruments for risk stratification of delirium. This review aimed to identify and assess the clinical usefulness of candidate serum biomarkers associated with hospital delirium in patients aged 60 years and older. We performed a time-unlimited review of publications indexed in PubMed, Cochrane, Embase, and MEDLINE databases until June 2019 that evaluated baseline and/or longitudinal biomarker measurements in patients suffering from delirium at some point during their hospital stay. A total of 32 studies were included in this review reporting information on 7610 patients. Of these 32 studies, twenty-four studies reported data from surgical patients including four studies in ICU cohorts, five studies reported data from medical patients (1026 patients), and three studies reported data from a mixed cohort (1086 patients), including one study in an ICU cohort. Findings confirm restricted clinical usefulness to predict or diagnose delirium due to limited evidence on which biomarkers can be used and limited availability due to non-routine use.
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Affiliation(s)
- Katharina Toft
- Department for Anesthesia, Intensive Care and Emergency Medicine, See-Spital, Horgen, Kilchberg, Switzerland.,Institute for Anesthesia and Intensive Care, Hirslanden Klinik Zurich, Zurich, Switzerland
| | - Janna Tontsch
- Department for Intensive Care, University Hospital Basel, Basel, Switzerland
| | - Salim Abdelhamid
- Department for Intensive Care, University Hospital Basel, Basel, Switzerland
| | - Luzius Steiner
- Medical Faculty of the University of Basel, Basel, Switzerland.,Department for Anesthesia, Prehospital Emergency Medicine and Pain Therapy, University Hospital Basel, Basel, Switzerland
| | - Martin Siegemund
- Department for Intensive Care, University Hospital Basel, Basel, Switzerland.,Medical Faculty of the University of Basel, Basel, Switzerland
| | - Alexa Hollinger
- Department for Intensive Care, University Hospital Basel, Basel, Switzerland.
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Type D personality is a predictor of prolonged acute brain dysfunction (delirium/coma) after cardiovascular surgery. BMC Psychol 2019; 7:27. [PMID: 31046844 PMCID: PMC6498670 DOI: 10.1186/s40359-019-0303-2] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2018] [Accepted: 04/16/2019] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Previous studies have shown a relationship between delirium and depressive symptoms after cardiac surgery with distress personalities linking to negative surgical outcomes. The aim of the present study is to further investigate the association between patients with Type D (distressed) personality with regards to delirium after cardiac surgery. METHODS We conducted a consecutive-sample observational cohort pilot study with an estimated 142 patients needed. Enrollment criteria included patients aged ≥18 years who were undergoing planned cardiovascular, thoracic and abdominal artery surgery between October 2015 to August 2016 at the University of Tsukuba Hospital, Japan. All patients were screened by Type-D Personality Scale-14 (DS14) as well as the Hospital Anxiety and Depression Scale (HADS) the day before surgery. Following surgery, daily data was collected during recovery and included severity of organ dysfunction, sedative/analgesic exposure and other relevant information. We then evaluated the association between Type D personality and delirium/coma days (DCDs) during the 7-day study period. We applied regression and mediation modeling for this study. RESULTS A total of 142 patients were enrolled in the present study and the total prevalence of delirium was found to be 34% and 26% of the patients were Type D. Non-Type D personality patients experienced an average of 1.3 DCDs during the week after surgery while Type D patients experienced 2.1 days over the week after surgery. Multivariate analysis showed that Type D personality was significantly associated with increased DCDs (OR:2.8, 95%CI:1.3-6.1) after adjustment for depressive symptoms and clinical variables. Additionally, there was a significant Type D x depression interaction effect (OR:1.7, 95% CI:1.2-2.2), and depressive symptoms were associated with DCDs in Type D patients, but not in non-Type D patients. Mediation modeling showed that depressive symptoms partially mediated the association of Type D personality with DCDs (Aroian test =0.04). CONCLUSIONS Type D personality is a prognostic predictor for prolonged acute brain dysfunction (delirium/coma) in cardiovascular patients independent from depressive symptoms and Type D personality-associated depressive symptoms increase the magnitude of acute brain dysfunction.
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Michels M, Michelon C, Damásio D, Vitali AM, Ritter C, Dal-Pizzol F. Biomarker Predictors of Delirium in Acutely Ill Patients: A Systematic Review. J Geriatr Psychiatry Neurol 2019; 32:119-136. [PMID: 30852930 DOI: 10.1177/0891988719834346] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Delirium is a serious and common disorder that affects up to 80% of acutely ill patients, mainly the aged. In recent years, several studies pointed out possible biomarkers that could be used alone or in combination with other resources in the diagnosis and follow-up of critically ill patients who develop delirium. In this context, a systematic review was conducted to determine the predictive value of several biomarkers in acutely (critically and noncritically) ill adult patients with delirium. Studies that used the confusion assessment method (CAM) and CAM-intensive care unit as the diagnostic method were considered. The most recent search was performed in November 2017. There was no language restriction. Initially, 626 articles were screened and 39 were included in the study. A comprehensive evaluation of the abstracts resulted in the exclusion of 202 studies, leaving 39 articles as potentially relevant. Inflammatory markers, S100β and cortisol, could predict delirium occurrence in a specific subgroup population of critically ill patients.
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Affiliation(s)
- Monique Michels
- 1 Laboratory of Experimental Pathophysiology, Graduate Program in Health Sciences, Health Sciences Unit, University of Southern Santa Catarina (UNESC), Criciúma, Santa Catarina, Brazil
| | - Cleonice Michelon
- 1 Laboratory of Experimental Pathophysiology, Graduate Program in Health Sciences, Health Sciences Unit, University of Southern Santa Catarina (UNESC), Criciúma, Santa Catarina, Brazil
| | - Danusa Damásio
- 2 São José Hospital Research Centre, Criciúma, Santa Catarina, Brazil
| | | | - Cristiane Ritter
- 1 Laboratory of Experimental Pathophysiology, Graduate Program in Health Sciences, Health Sciences Unit, University of Southern Santa Catarina (UNESC), Criciúma, Santa Catarina, Brazil.,2 São José Hospital Research Centre, Criciúma, Santa Catarina, Brazil
| | - Felipe Dal-Pizzol
- 1 Laboratory of Experimental Pathophysiology, Graduate Program in Health Sciences, Health Sciences Unit, University of Southern Santa Catarina (UNESC), Criciúma, Santa Catarina, Brazil.,2 São José Hospital Research Centre, Criciúma, Santa Catarina, Brazil
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Abstract
Delirium is an acute and transient brain dysfunction that is characterized by disturbances in consciousness, affecting both its content (i.e., attention) and level (i.e., arousal). It affects as many as 50% of those admitted to an intensive care unit (ICU). Once believed to be an inconsequential outcome of critical illness, it is now recognized that delirium is harmful in both the short- and long-term. Despite occurring frequently in critically ill patients, delirium often goes unrecognized. Well-validated delirium screening tools, designed for use in the ICU, should be used to reliably detect delirium. The first step in delirium treatment is to identify and address potentially modifiable risk factors. Multiple trials have shown that benzodiazepines are a risk factor for delirium in a dose-dependent manner. Sedation with nonbenzodiazepine-based strategies are an effective means by which to reduce delirium. Nonpharmacologic strategies such as those which seek to reduce sensory impairment, sleep deprivation, and immobility are effective. Pharmacologic treatment with antipsychotics, though commonly used, is not supported by findings from placebo-controlled trials. Recent data support from multiple trials support the use of the "ABCDEF bundle" as a means by which to reduce delirium.
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Affiliation(s)
- Nathan E Brummel
- Division of Pulmonary, Critical Care, and Sleep Medicine, The Ohio State University Wexner Medical Center, Columbus, OH, United States
| | - Timothy D Girard
- Department of Critical Care Medicine, Clinical Research, Investigation, and Systems Modeling of Acute Illness Center, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States.
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Low doses of ketamine reduce delirium but not opiate consumption in mechanically ventilated and sedated ICU patients: A randomised double-blind control trial. Anaesth Crit Care Pain Med 2018; 37:589-595. [DOI: 10.1016/j.accpm.2018.09.006] [Citation(s) in RCA: 58] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2018] [Revised: 09/13/2018] [Accepted: 09/15/2018] [Indexed: 12/15/2022]
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Correlation of Nutritional Indices on Admission to the Coronary Intensive Care Unit with the Development of Delirium. Nutrients 2018; 10:nu10111712. [PMID: 30413062 PMCID: PMC6267104 DOI: 10.3390/nu10111712] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2018] [Revised: 11/04/2018] [Accepted: 11/06/2018] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Delirium is a common occurrence in patients admitted to the intensive care unit and is related to mortality and morbidity. Malnutrition is a predisposing factor for the development of delirium. Nevertheless, whether the nutritional status on admission anticipates the development of delirium in patients with acute cardiovascular diseases remains unknown. OBJECTIVE This study aims to assess the correlation between the nutritional status on admission using the nutritional index and the development of delirium in the coronary intensive care unit. DESIGN We examined 653 consecutive patients (mean age: 70 ± 14 years) admitted to the coronary intensive care unit of Juntendo University Hospital between January 2015 and December 2016. We evaluated three nutritional indices frequently used to assess the nutritional status, i.e., Geriatric Nutritional Risk Index (GNRI), Prognostic Nutritional Index (PNI), and Controlling Nutritional Status (CONUT). We defined delirium as patients with a delirium score >4 using the Intensive Care Delirium Screening Checklist. RESULTS Delirium was present in 58 patients. All nutritional indices exhibited a tendency for malnutrition in the delirium group compared with the non-delirium group (GNRI, 86.5 ± 9.38 versus 91.6 ± 9.89; PNI, 36.4 ± 6.95 versus 41.6 ± 7.62; CONUT, 5.88 ± 3.00 versus 3.61 ± 2.56; for all, p < 0.001). Furthermore, the maximum delirium score increased progressively from the low- to the high-risk group, as evaluated by each nutritional index (GNRI, PNI, CONUT; for all, p < 0.001). A multivariate analysis revealed that the PNI and CONUT were independent risk factors for the occurrence of delirium. CONCLUSIONS A marked correlation exists between the nutritional index on admission, especially PNI and CONUT, and the development of delirium in patients with acute cardiovascular diseases, suggesting that malnutrition assessment upon admission could help identify patients at high risk of developing delirium.
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Association Between Transfusion of RBCs and Subsequent Development of Delirium in Critically Ill Children. Pediatr Crit Care Med 2018; 19:925-929. [PMID: 30059476 PMCID: PMC6170711 DOI: 10.1097/pcc.0000000000001675] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
OBJECTIVES To determine the temporal relationship between the transfusion of RBCs and the subsequent development of delirium in a cohort of critically ill children. DESIGN Nested retrospective cohort study within prospective cohort study. SETTING Urban academic tertiary care PICU. PATIENTS All consecutive admissions from September 2014 through August 2015. INTERVENTIONS Children were screened twice daily for delirium during their PICU admission. MEASUREMENTS AND MAIN RESULTS Among 1,547 independent admissions screened for delirium, 166 (10.7%) were transfused RBCs. Children who were transfused RBCs were more than twice as likely to be delirious during their admission compared with children who were never transfused, after controlling for known predictors of delirium development (adjusted odds ratio, 2.16; 95% CI, 1.38-3.37; p = 0.001). Among transfused children, a temporal relationship was observed between receipt of RBCs and the subsequent development of delirium. For each additional 10 mL/kg of RBCs transfused, the recipients were 90% more likely to develop delirium or coma in the 72 hours following the transfusion, after controlling for confounders (adjusted odds ratio, 1.90; 95% CI, 1.14-3.17; p = 0.01). Anemia (represented by nadir hemoglobin prior to transfusion) was not associated with delirium development. CONCLUSIONS In this cohort of critically ill children, there is an independent association between the receipt of an RBC transfusion and the subsequent development of delirium. Further prospective studies are warranted to replicate this finding and investigate possible pathophysiologic mechanisms for this association.
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Kalantar K, LaHue SC, DeRisi JL, Sample HA, Contag CA, Josephson SA, Wilson MR, Douglas VC. Whole-Genome mRNA Gene Expression Differs Between Patients With and Without Delirium. J Geriatr Psychiatry Neurol 2018; 31:203-210. [PMID: 29991314 PMCID: PMC6817976 DOI: 10.1177/0891988718785774] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVE To identify differences in gene expression between patients with in-hospital delirium from a known etiology (urinary tract infection [UTI]) and patients with delirium from an unknown etiology, as well as from nondelirious patients. METHODS Thirty patients with delirium (8 with UTI) and 21 nondelirious patients (11 with UTI) were included in this prospective case-control study. Transcriptomic profiles from messenger RNA sequencing of peripheral blood were analyzed for gene expression and disease-specific pathway enrichment patterns, correcting for systemic inflammatory response syndrome. Genes and pathways with significant differential activity based on Fisher exact test ( P < .05, |Z score| >2) are reported. RESULTS Patients with delirium with UTI, compared to patients with delirium without UTI, exhibited significant activation of interferon signaling, upstream cytokines, and transcription regulators, as well as significant inhibition of actin cytoskeleton, integrin, paxillin, glioma invasiveness signaling, and upstream growth factors. All patients with delirium, compared to nondelirious patients, had significant complement system activation. Among patients with delirium without UTI, compared to nondelirious patients without UTI, there was significant activation of elF4 and p7056 K signaling. CONCLUSIONS Differences exist in gene expression between delirious patients due to UTI presence, as well as due to the presence of delirium alone. Transcriptional profiling may help develop etiology-specific biomarkers for patients with delirium.
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Affiliation(s)
- Katrina Kalantar
- Department of Biochemistry and Biophysics, University of California, San Francisco, San Francisco, CA, USA
| | - Sara C. LaHue
- Department of Neurology, School of Medicine, University of California, San Francisco, San Francisco, CA, USA,Department of Neurology, Weill Institute for Neurosciences, University of California, San Francisco, San Francisco, CA, USA
| | - Joseph L. DeRisi
- Department of Biochemistry and Biophysics, University of California, San Francisco, San Francisco, CA, USA
| | - Hannah A. Sample
- Department of Biochemistry and Biophysics, University of California, San Francisco, San Francisco, CA, USA
| | - Caitlin A. Contag
- School of Medicine, University of California, San Francisco, San Francisco, CA, USA
| | - Scott A. Josephson
- Department of Neurology, School of Medicine, University of California, San Francisco, San Francisco, CA, USA,Department of Neurology, Weill Institute for Neurosciences, University of California, San Francisco, San Francisco, CA, USA
| | - Michael R. Wilson
- Department of Neurology, School of Medicine, University of California, San Francisco, San Francisco, CA, USA,Department of Neurology, Weill Institute for Neurosciences, University of California, San Francisco, San Francisco, CA, USA
| | - Vanja C. Douglas
- Department of Neurology, School of Medicine, University of California, San Francisco, San Francisco, CA, USA,Department of Neurology, Weill Institute for Neurosciences, University of California, San Francisco, San Francisco, CA, USA
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