Neutrophil-lymphocyte ratio as a predictor of delirium in older internal medicine patients: a prospective cohort study

The Role of Neutrophil-to-Lymphocyte Ratio (NLR) in Urosepsis-Associated Delirium

Introduction Urosepsis is a systemic, dysregulated, inflammatory reaction to a urinary tract infection and can have severe effects on all systems, which can often lead to multi-organ failure and death. Sepsis-associated delirium is a common complication in critically ill patients, contributing to adverse outcomes and prolonged hospital stays. The neutrophil-to-lymphocyte ratio (NLR) has emerged as a potential biomarker for sepsis severity and prognosis. Material and methods Our study investigates the utility of NLR in the diagnostic strategies for urosepsis-associated delirium in a cohort of 76 patients with sepsis and septic shock admitted to the Intensive Care Unit (ICU). We performed a single-centre retrospective observational study in the Craiova Clinical Emergency Hospital between June and October 2023. Results Patients with urological conditions that were diagnosed with urosepsis included 76 patients. These patients were clustered as follows: a group with delirium (37 patients, 48.7%) and another group without delirium (39 patients, 51.3%). Complete blood count parameters were obtained upon admission, and delirium was assessed using standardized diagnostic criteria. We identified a strong significant positive correlation between elevated NLR values on ICU admission and the development of delirium during hospitalization in urosepsis patients. Receiver operating characteristic (ROC) analysis showed similar diagnostic performance for NLR score. Conclusions The findings suggest that NLR may serve as a valuable biomarker for early detection, risk stratification, and guiding therapeutic interventions in urosepsis-associated delirium, thus improving outcomes in critically ill patients.

Immunological Analysis of Postoperative Delirium after Thoracic Aortic Surgery

Background

Delirium is a recognized neurological complication following cardiac surgery and is associated with adverse clinical outcomes, including elevated mortality and prolonged hospitalization. While several clinical risk factors for post-cardiac surgery delirium have been identified, the pathophysiology related to the immune response remains unexamined. This study was conducted to investigate the immunological factors contributing to delirium in patients after thoracic aortic surgery.

Methods

We retrospectively evaluated 43 consecutive patients who underwent thoracic aortic surgery between July 2017 and June 2018. These patients were categorized into 2 groups: those with delirium and those without it. All clinical characteristics were compared between groups. Blood samples were collected and tested on the day of admission, as well as on postoperative days 1, 3, 7, and 30. Levels of helper T cells (CD4), cytotoxic T cells (CD8), B cells (CD19), natural killer cells (CD56+CD16++), and monocytes (CD14+CD16-) were measured using flow cytometry.

Results

The median patient age was 71 years (interquartile range, 56.7 to 79.0 years), and 21 of the patients (48.8%) were male. Preoperatively, most immune cell counts did not differ significantly between groups. However, the patients with delirium exhibited significantly higher levels of interleukin-6 and lower levels of tumor necrosis factor-alpha (TNF-α) than those without delirium (p<0.05). Multivariate analysis revealed that lower TNF-α levels were associated with an increased risk of postoperative delirium (p<0.05).

Conclusion

Postoperative delirium may be linked to perioperative changes in immune cells and preoperative cytokine levels. Additional research is required to elucidate the pathophysiological mechanisms underlying delirium.

The evaluation of frequency and predictors of delirium and its short-term and long-term outcomes in hospitalized older adults'

BACKGROUND

Delirium is a common complication in hospitalized older adults with multifactorial etiology and poor health outcomes.

AIM

To determine the frequency and predictors of delirium and its short-term and long-term outcomes in hospitalized older adults.

METHODS

A prospective observational study was performed in patients aged ≥60 years consecutively admitted to geriatric ward. Potential risk factors were assessed within 24 hours of hospital admission. Delirium screening was performed on admission and daily thereafter throughout the hospital stay using Confusion Assessment Method (CAM). Patients were followed up at 1-year post-discharge.

RESULTS

The study included 200 patients with mean age 73.1 ± 8.83 years. Incidence and prevalence rate of delirium were 5% and 20% respectively. Multivariable regression analysis revealed emergency admission (OR= 5.12 (1.94-13.57), p=0.001), functional dependency (Katz index of Independence in Activities of Daily Living (Katz-ADL) score <5) 2 weeks before admission (OR= 3.08 (1.30-7.33), p=0.011) and more psychopathological symptoms (higher Brief Psychiatric Rating Scale (BPRS) total score) (OR=1.12 (1.06-1.18), p=0.001) to be independently associated with delirium. Patients in delirium group had significantly high in-hospital mortality (OR= 5.02 (2.12-11.8), p=0.001) and post-discharge mortality (HR= 2.02 (1.13-3.61), p=0.017) and functional dependency (Katz-ADL score <5) (OR= 5.45 (1.49-19.31), p=0.01) at 1-year follow up.

CONCLUSION

Delirium is quite frequent in geriatric inpatients and is associated with high in-hospital and post-discharge mortality risk and long-term functional dependency. Emergency admission, pre-hospitalization functional dependency, and more general psychopathological symptoms are independently associated factors. Hence, earliest identification and treatment with early implementation of rehabilitation services is warranted.

A novel risk assessment tool for postoperative delirium in vascular surgery: The stress model (Siena posTopeRative dElirium in vaScular Surgery)

OBJECTIVE

Postoperative delirium (POD) is a common complication with a high health-related impact. The creation of a model (Siena posTopeRative dElirium in vaScular Surgery) to identify high-risk patients with consecutive prompt diagnosis and correct management.

METHODS

This is an observational retrospective study to evaluate POD incidence in patients who underwent elective vascular surgery procedures between 2018 and 2020. POD was detected using CAM and defined as the onset of an acute confusional state, clinically manifesting as a disturbed state of consciousness, cognitive dysfunction, or alteration in perception and behavior. The total population was divided in the development and validation subsamples. Multivariable logistic regression analysis was performed, identifying variables related to the occurrence of POD. An additive score was created and the STRESS score was internally validated using the Validation subgroup.

RESULTS

A total of 1067 patients were enrolled. POD occurred in 111 cases (10.4%). Multivariable logistic regression analysis for POD occurrence revealed as significant predictors: age>75 years, CKD, dyslipidaemia, psychiatric disease, CAD, hospitalization in the previous month, preoperative NLR >3.59, preoperative Hb < 12 g/dl, preoperative Barthel score <75, major amputation, CLTI revascularization, general anesthesia, and postoperative urinary catheter. These variables were used to create the STRESS score. The model was applied to both development and validation subgroups; AUC was respectively 0.7079 (p < .0001) and 0.7270 (p < .0001).

CONCLUSION

The STRESS score has a good predictive potentiality for POD occurrence in elective vascular surgery procedures. However, implementation and external validation are needed to be correctly used in everyday clinical practice.

Association between the neutrophil-to-lymphocyte ratio and cognitive impairment: a meta-analysis of observational studies

Background

Systemic inflammation is one of the underlying mechanisms of cognitive impairment. The neutrophil-to-lymphocyte ratio (NLR) has emerged as a systemic inflammation indicator. This meta-analysis aimed to evaluate the association between high NLR and cognitive impairment (CI) risk.

Method

A comprehensive systematic search was conducted to identify eligible studies published until May 30, 2023. The reference group comprised patients with the lowest NLR level, whereas the exposure group comprised those with the highest NLR level. The main outcome was to examine the relationship between NLR and CI risk. The secondary outcome included the association between patient characteristics or comorbidities and CI risk.

Results

This meta-analysis included 11 studies published between 2018 and 2023, involving 10,357 patients. Patients with CI had a higher NLR than those without (mean difference=0.35, 95% confidence interval [CI]: 0.26-0.44, p < 00001, I2 = 86%). Consistently, pooled results revealed an association between high NLR and CI risk (odds ratio [OR]=2.53, 95% CI:1.67-3.82, p<0.0001, I2 = 84%). Furthermore, aging (mean difference =4.31 years, 95% CI:2.83-5.8, p < 0.00001, I2 = 92%), diabetes (OR=1.59, 95% CI:1.35-1.88, p < 0.00001, I2 = 66%), and hypertension (OR=1.36, 95% CI:1.19-1.57, p < 0.00001, I2 = 0%) were significant risk factors for CI. However, no significant associations were observed between CI and male gender (OR = 0.84, 95% CI:0.64-1.11, p = 0.22, I2 = 81%), body mass index (mean = -0.32 kg/m2, 95% CI: -0.82, 0.18, p = 0.2, I2 = 82%), alcohol consumption (OR = 1.11, 95% CI:0.95-1.3, p = 1.35, I2 = 0%), and smoking (OR = 0.99, 95% CI:0.87-1.13, p = 0.86, I2 = 0%). Meta-regression found that diabetes and hypertension, but not age, significantly moderated the association between NLR and CI.

Conclusion

This meta-analysis showed a significant association between high NLR and increased CI risk. Moreover, meta-regression identified diabetes and hypertension, but not age, as significant moderating factors in the relationship between NLR and CI. To validate and strengthen these findings, further large-scale studies are required.

Systematic Review Registration

https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42023430384, identifier CRD42023430384.

Neutrophil-to-lymphocyte ratio (NLR) predicts mortality in hospitalized geriatric patients independent of the admission diagnosis: a multicenter prospective cohort study

BACKGROUND

The Neutrophil-to-lymphocyte ratio (NLR) is a marker of poor prognosis in hospitalized older patients with different diseases, but there is still no consensus on the optimal cut-off value to identify older patients at high-risk of in-hospital mortality. Therefore, in this study we aimed at both validating NLR as a predictor of death in older hospitalized patients and assess whether the presence of specific acute diseases can modify its predictive value.

METHODS

This prospective cohort study included 5034 hospitalizations of older patients admitted to acute care units in the context of the ReportAge study. NLR measured at admission was considered as the exposure variable, while in-hospital mortality was the outcome of the study. ROC curves with Youden's method and restricted cubic splines were used to identify the optimal NLR cut-off of increased risk. Cox proportional hazard models, stratified analyses, and Kaplan-Meier survival curves were used to analyse the association between NLR and in-hospital mortality.

RESULTS

Both continuous and categorical NLR value (cut-off ≥ 7.95) predicted mortality in bivariate and multivariate prognostic models with a good predictive accuracy. The magnitude of this association was even higher in patients without sepsis, congestive heart failure, and pneumonia, and those with higher eGFR, albumin, and hemoglobin (p < 0.001). A negative multiplicative interaction was found between NLR and eGFR < 45 (p = 0.001).

CONCLUSIONS

NLR at admission is a readily available and cost-effective biomarker that could improve identification of geriatric patients at high risk of death during hospital stay independent of admitting diagnosis, kidney function and hemoglobin levels.

The Association Between Neutrophil-Lymphocyte Ratio and Variability with New-Onset Dementia: A Population-Based Cohort Study

BACKGROUND

Previous studies identified that neutrophil-to-lymphocyte ratio (NLR) may be a predictor of dementia. However, the associations between NLR and dementia at the population level were less explored.

OBJECTIVE

This retrospective population-based cohort study was designed to identify the associations between NLR and dementia among patients visiting for family medicine consultation in Hong Kong.

METHODS

The patients were recruited from January 1, 2000, to December 31, 2003, and followed up until December 31, 2019. The demographics, prior comorbidities, medications, and laboratory results were collected. The primary outcomes were Alzheimer's disease and related dementia and non-Alzheimer's dementia. Cox regression and restricted cubic spline were applied to identify associations between NLR and dementia.

RESULTS

A cohort of 9,760 patients (male: 41.08% ; baseline age median: 70.2; median follow-up duration: 4756.5 days) with complete NLR were included. Multivariable Cox regression identified that patients with NLR >5.44 had higher risks of developing Alzheimer's disease and related dementia (hazard ratio [HR]: 1.50, 95% Confidence interval [CI]: 1.17-1.93) but not non-Alzheimer's dementia (HR: 1.33; 95% CI: 0.60-2.95). The restricted cubic splines demonstrated that higher NLR was associated with Alzheimer's disease and related dementia. The relationship between the NLR variability and dementia was also explored; of all the NLR variability measures, only the coefficient of variation was predictive of non-Alzheimer's dementia (HR: 4.93; 95% CI: 1.03-23.61).

CONCLUSION

In this population-based cohort, the baseline NLR predicts the risks of developing dementia. Utilizing the baseline NLR during family medicine consultation may help predict the risks of dementia.

Predictability of Neutrophil to Lymphocyte Ratio in preoperative elderly hip fracture patients for post-operative short-term complications: a retrospective study

PURPOSE

Neutrophil to Lymphocyte Ratio (NLR) is a simple biomarker of systemic inflammatory response. We investigated predictability of NLR for early adverse outcome after surgery for hip fracture in elderly population.

METHODS

We reviewed a total of 971 elderly patients with hip fracture who underwent emergency surgery between January 2017 and July 2020 in the Department of Orthopaedics Surgery at the Wollongong Hospital. After considering exclusion criteria, data from a total of 834 patients included in our study. Socio-demographic data, NLR in admission, updated Charlson comorbidity index (uCCI), biochemical markers, mortality rate and 15 short term post-operative complications were collected to determine predictability of NLR for post-operative complications and mortality.

RESULTS

After hip surgery, Hospital in-patient case fatality rate was 3.7% (31). In addition, 63.1% (511) of the patients had at least one complication or more. Logistic regression demonstrated that raised NLR (P-value < 0.001, OR 1.05) and uCCI≥4 (P-Value < 0.001, OR 1.75) are associated with post-operative complications. Moreover, decreased haemoglobin was associated with adverse effects (P-value < 0.001, OR 0.97). No association was found for any of these variables with in-patient mortality except for albumin (P-value: 0.03). In addition, despite significant association, ROC analyses showed a low predictability for each of the above variables including NLR (AUC 0.59) for post-operative complications.

CONCLUSIONS

Despite significant association, NLR was unable to prognosticate early adverse outcomes. However, it can be considered as a risk factor in admission for postoperative complications in combination with other risk factors and clinical context.

Neutrophil to lymphocyte ratio and platelet to lymphocyte ratio as prognostic predictors for delirium in critically ill patients: a systematic review and meta-analysis

INTRODUCTION

In this systematic review and meta-analysis, we aim to analyze the current literature to evaluate neutrophil to lymphocyte ratio (NLR) and platelet to lymphocyte ratio (PLR) values among critically ill patients who develop delirium as compared to those who do not.

METHODS

PubMed, Web of Science, and Scopus were used to conduct a systematic search for relevant publications published before June 12, 2022. The Newcastle-Ottawa scale was used for quality assessment. Because a significant level of heterogeneity was found, we used the random-effects model to generate pooled effects.

RESULTS

Twenty-four studies including 11,579 critically ill patients, of whom 2439 were diagnosed with delirium, were included in our meta-analysis. Compared with the non-delirious group, the delirious group's NLR levels were significantly higher (WMD = 2.14; CI 95% = 1.48-2.80, p < 0.01). In the subgroup analysis according to the type of critical condition, the NLR levels in patients of delirious group were significantly more than those of non-delirious group in studies on POD, PSD and PCD (WMD = 1.14, CI 95% = 0.38-1.91, p < 0.01, WMD = 1.38, CI 95% = 1.04-1.72, p < 0.001, and WMD = 4.22, CI 95% = 3.47-4.98, p < 0.001, respectively). However, compared with the non-delirious group, the delirious group's PLR levels were not significantly different (WMD = 1.74; CI 95% = -12.39-15.86, p = 0.80).

CONCLUSION

Our findings support NLR to be a promising biomarker that can be readily integrated into clinical settings to aid in the prediction and prevention of delirium.

Neutrophil-lymphocyte ratio as a predictor of delirium tremens in hospitalized patients with alcohol withdrawal

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.

Efficacy of Neutrophil-to-Lymphocyte Ratio for Cancer-Specific Survival in Elderly Patients with Localized Colon Cancer: A Single Center Propensity Score-Matched Analysis

Purpose

The prognostic value of neutrophil-to-lymphocyte ratio (NLR) has been studied for colorectal cancer. Elderly patients in general tend to have comorbidities and decreased organ function that potentially influence the NLR score. The aim of this study was to investigate the relationship between NLR and cancer-specific survival in elderly patients with colon cancer, using a propensity score-matched analysis.

Patients and Methods

A total of 203 patients aged over 75 years who underwent curative resection for colon cancer and were diagnosed pathologically with stage II/III disease were eligible for entry to the study. Patients were divided into two groups according to NLR score: NLR-High (NLR≥4.5) group (NLR-H, n=60) and NLR-Low (NLR<4.5) group (NLR-L, n=143). After propensity score matching, 57 patients in each group were matched.

Results

Before matching, Charlson comorbidity index was significantly higher in the NLR-H group (4 vs 2, p<0.001). After matching, all factors were similar between the groups. The median follow-up period was 43 months (range, 1-160 months). Five-year relapse-free-survival (69.8% vs 87.3%, p=0.030) and cancer-specific survival (83.0% vs 96.0%, p=0.042) were significantly lower in the NLR-H group.

Conclusion

NLR appears to be a cancer-specific prognostic marker in elderly patients with colon cancer.

Predisposing and Precipitating Factors Associated With Delirium: A Systematic Review

IMPORTANCE

Despite discrete etiologies leading to delirium, it is treated as a common end point in hospital and in clinical trials, and delirium research may be hampered by the attempt to treat all instances of delirium similarly, leaving delirium management as an unmet need. An individualized approach based on unique patterns of delirium pathophysiology, as reflected in predisposing factors and precipitants, may be necessary, but there exists no accepted method of grouping delirium into distinct etiologic subgroups.

OBJECTIVE

To conduct a systematic review to identify potential predisposing and precipitating factors associated with delirium in adult patients agnostic to setting.

EVIDENCE REVIEW

A literature search was performed of PubMed, Embase, Web of Science, and PsycINFO from database inception to December 2021 using search Medical Subject Headings (MeSH) terms consciousness disorders, confusion, causality, and disease susceptibility, with constraints of cohort or case-control studies. Two reviewers selected studies that met the following criteria for inclusion: published in English, prospective cohort or case-control study, at least 50 participants, delirium assessment in person by a physician or trained research personnel using a reference standard, and results including a multivariable model to identify independent factors associated with delirium.

FINDINGS

A total of 315 studies were included with a mean (SD) Newcastle-Ottawa Scale score of 8.3 (0.8) out of 9. Across 101 144 patients (50 006 [50.0%] male and 49 766 [49.1%] female patients) represented (24 015 with delirium), studies reported 33 predisposing and 112 precipitating factors associated with delirium. There was a diversity of factors associated with delirium, with substantial physiological heterogeneity.

CONCLUSIONS AND RELEVANCE

In this systematic review, a comprehensive list of potential predisposing and precipitating factors associated with delirium was found across all clinical settings. These findings may be used to inform more precise study of delirium's heterogeneous pathophysiology and treatment.

Development and validation of a nomogram to predict postoperative delirium in type B aortic dissection patients underwent thoracic endovascular aortic repair

Objective

Postoperative delirium (POD) is a common postoperative complication after cardiovascular surgery with adverse outcomes. No prediction tools are currently available for assessing POD in the type B aortic dissection (TBAD) population. The purposes of this study were to develop and validate a nomogram for predicting POD among TBAD patients who underwent thoracic endovascular aortic repair (TEVAR).

Methods

The retrospective cohort included 631 eligible TBAD patients who underwent TEVAR from January 2019 to July 2021. 434 patients included before 2021 were in the develop set; 197 others were in the independent validation set. Least absolute shrinkage and selection operator (LASSO) and logistic regression were applied to identify the most useful predictive variables for constructing the nomogram. Discrimination and the agreement of the model was assessed with the area under the receiver operating characteristic curve (AUC), Brier score and the Hosmer-Lemeshow goodness-of-fit test. The results were validated using a bootstrap resampling and the validation set.

Results

The incidence rate of POD observed in the development and validation cohort were 15.0% and 14.2%, respectively. Seven independent risk factors, including age ≥60 years, syncope or coma, postoperative blood transfusion, atelectasis, estimated glomerular filtration rate (eGFR) &lt;80 ml/min/1.73 m2, albumin &lt;30 g/L, and neutrophil to lymphocyte ratio, were included in the nomogram. The model showed a good discrimination with an AUC of 0.819 (95% CI, 0.762–0.876) in the developed set, and adjusted to 0.797 (95% CI, 0.735–0.849) and 0.791 (95% CI, 0.700–0.881) in the internal validation set and the external validation, respectively. Favorable calibration of the nomogram was confirmed in both the development and validation cohorts.

Conclusion

The nomogram based on seven readily available predictors has sufficient validity to identify POD risk in this population. This tool may facilitate targeted initiation of POD preventive intervention for healthcare providers.

Challenges in the Detection of Clinically Useful Biomarkers for the Diagnosis of Delirium in Older People in the Emergency Department-A Case-Control Study

Background: The identification of biomarkers associated with delirium in the emergency department could contribute to the understanding, prediction and diagnosis of this disorder. The present study was carried out to identify biomarkers included in easily and quickly obtained standard blood examinations in older patients with delirium in the emergency department. Methods: A case–control study was carried out in the emergency department of Francesc de Borja Hospital (Gandía, Valencia, Spain). Older adults (≥65 years of age) diagnosed with delirium (n = 128) were included. Cases due to alcohol or substance abuse were excluded. Controls were selected on a randomized basis from the remaining patients (n = 128). All laboratory test parameters included in the routine blood and urine tests of the emergency department were collected. Results: The mean age of the patients was 81.24 ± 7.51 years, and 56.2% were males, while the mean age of the controls was 78.97 ± 7.99 years, and 45.3% were males. Significant differences were found between the cases and controls in relation to the following parameters: urea 43 (32–58) mg/dL versus 50 (37–66) mg/dL, respectively; neutrophils 69.6 (62.05–78.75)% versus 75.5 (65.1–83.2)%; monocytes 8.7 (7–10.4)% versus 7.6 (5.5–9.2)%; platelets 213 (159–266) × 10⁹/L versus 224 (182–289) × 10⁹/L; neutrophil–lymphocyte ratio 3.88 (2.45–7.07) versus 5 (2.75–8.83); platelet–lymphocyte ratio 281.4 (210–360) versus 357.1 (257.8–457.1); and mean platelet volume 10.6 (10–11.5) fl versus 10.4 (9.67–10.9) fl. Although the mean values were above desirable levels in both groups, they were higher for most parameters in the control group. No significant differences were observed in C-reactive protein concentration (9.99 (1.69–51) mg/L versus 12.3 (3.09–65.97) mg/L). Conclusions: The identification of delirium biomarkers poses difficulties due to the urgent nature of the disorders found in older people admitted to the emergency department. Research in this field is needed, since it would allow early identification and treatment of delirium.

Neutrophil-lymphocyte ratio as a potential marker for differential diagnosis between spinal tuberculosis and pyogenic spinal infection

Objective

Distinguishing spinal tuberculosis and pyogenic spinal infection is extremely important. The neutrophil–lymphocyte ratio (NLR), a simple indicator, has been shown to be a novel inflammatory marker. The objective of our study was to determine whether the NLR could be a potential indicator for discriminating spinal tuberculosis (STB) from pyogenic spinal infection (PSI).

Methods

We compared the clinical and laboratory characteristics of 146 patients diagnosed with STB and 60 participants with PSI from the First Affiliated Hospital of Nanjing Medical University. The NLR's diagnostic ability for differential diagnosis was assessed and compared to other hematological indicators, including the platelet–lymphocyte ratio (PLR).

Results

The NLR in STB patients was considerably lower than that in PSI patients [3.85 (2.70–5.71) vs. 10.82 (6.79–17.62), P < 0.001]. An NLR of 6.742 was proposed as an optimal cutoff value for distinguishing patients with STB from those with PSI (sensitivity 78.33%, specificity 83.56%). However, the NLR's area under the curve [0.87, 95% confidence interval (CI) 0.81–0.92] was considerably higher than that of the PLR (0.73, 95% CI 0.65–0.80; P < 0.0001).

Conclusion

NLR levels could be a valuable laboratory diagnostic for distinguishing patients with STB from those who have PSI.

Perivascular spaces visible on magnetic resonance imaging predict subsequent delirium in older patients

Background

It remains unknown whether perivascular spaces (PVS) are associated with delirium in older hospitalized patients. We aimed to determine the association between magnetic resonance imaging (MRI)-visible PVS and the risk of delirium in a cohort of older patients.

Methods

We consecutively recruited older patients (≥70 years) admitted to the Geriatric Department of West China Hospital between March 2016 and July 2017, and their imaging data within one year before admission were reviewed retrospectively. PVS was rated on axial T2-weighted images in the basal ganglia (BG) and centrum semiovale (CS) using the validated semiquantitative 4-point ordinal scale. Delirium was screened within 24 h of admission and three times daily thereafter, using the confusion assessment method. Binary logistic regression analyses were performed to investigate the associations between PVS and delirium.

Results

Among 114 included patients (mean age 84.3 years, 72.8% male), delirium occurred in 20 (17.5%). In patients with MRI examined within 6 months before admission, CS-PVS was found to be associated with delirium (odds ratio [OR] 3.88, 95% confidence interval [CI] 1.07-14.06, unadjusted; and OR 4.24, 95% CI 1.11-16.28, adjusted for age). The associations were enhanced and remained significant even after full adjustment of covariates (OR 7.16, 95% CI 1.16-44.32, adjusted for age, cognitive impairment, smoking, and Charlson Comorbidity Index). Similarly, the relationships between high CS-PVS and delirium were also strengthened after sequentially adjusting all variables of interest, with OR 4.17 (95% CI 1.04-16.73) in unadjusted model and OR 7.95 (95% CI 1.14-55.28) in fully-adjusted model. Adding CS-PVS to the established risk factors improved the risk reclassification for delirium (continuous net reclassification index 62.1%, P = 0.04; and integrated discrimination improvement 12.5%, P = 0.01).

Conclusions

CS-PVS on MRI acquired 6 months earlier predicts subsequent delirium in older patients and may have clinical utility in delirium risk stratification to enable proactive interventions.

Melatonin and Its Analogs for Prevention of Post-cardiac Surgery Delirium: A Systematic Review and Meta-Analysis

Background

The effectiveness of melatonin and its analogs in preventing postoperative delirium (POD) following cardiac surgery is controversial. The purpose of this systematic review and meta-analysis was to confirm the benefits of melatonin and its analogs on delirium prevention in adults who underwent cardiac surgery.

Methods

We systematically searched the PubMed, Cochrane Library, Web of Science, Embase, and EBSCOhost databases, the last search was performed in October 2021 and repeated before publication. The controlled studies were included if investigated the impact of melatonin and its analogs on POD in adults who underwent cardiac surgery. The primary outcome was the incidence of delirium. The Stata statistical software 17.0 was used to perform this study.

Results

This meta-analysis included eight randomized controlled trials (RCTs) and two cohort studies with a total of 1,714 patients. The results showed that melatonin and ramelteon administration were associated with a significantly lower incidence of POD in adults who underwent cardiac surgery (odds ratio [OR], 0.46; 95% confidence interval [CI], 0.29–0.74; P = 0.001). The subgroup analyses confirmed that melatonin 3 mg (OR, 0.37; 95% CI, 0.18–0.76; P = 0.007) and 5 mg (OR, 0.34; 95% CI, 0.21–0.56; P < 0.001) significantly reduced the incidence of POD.

Conclusion

Melatonin at dosages of 5 and 3 mg considerably decreased the risk of delirium in adults who underwent cardiac surgery, according to our results. Cautious interpretation of our results is important owing to the modest number of studies included in this meta-analysis and the heterogeneity among them.

Systematic Review Registration

PROSPERO registration number: CRD42021246984.

COVID-19: Financial well-being of older Australians in times of crisis

OBJECTIVE

The aim of the present study was to explore the impact of the COVID-19 pandemic on the financial well-being of older Australian retirees.

METHODS

Thirty Australian retirees (16 females and 14 males), older than 65 years of age, were asked 'Have your finances been affected by the events surrounding COVID-19?'. Data were analysed using Braun and Clarke's six-step approach, and Bronfenbrenner's socio-ecological model was utilised to analyse thematic responses at individual, household, community and societal levels.

RESULTS

Two COVID-19-related themes emerged from interviews: COVID-19 and increased financial stress and COVID-19 and frustration with digital banking.

CONCLUSIONS

This study revealed that the financial well-being of older Australians and especially self-funded retirees has been negatively impacted by the COVID-19 pandemic. Participants felt financially worse off primarily due to the volatility of the financial markets, the need to support adult children and the increased cost of living. Also, participants expressed their hesitation and frustration with digital banking services, and their desire for greater personal contact with financial institutions, particularly during times of uncertainty.

Prospective Analysis Between Neutrophil-to-Lymphocyte Ratio on Admission and Development of Delirium Among Older Hospitalized Patients With COVID-19

Objective: To examine any prospective association between neutrophil-to-lymphocyte ratio (NLR) at hospital admission and subsequent delirium in older COVID-19 hospitalized patients comparing by sex and age groups. Methods: The sample consisted of 1,785 COVID-19 adult inpatients (minimum sample size required of 635 participants) admitted to a public general hospital in Madrid (Spain) between March 16th and April 15th, 2020. Variables were obtained from electronic health records. Binary logistic regression models were performed between baseline NLR and delirium adjusting for age, sex, medical comorbidity, current illness severity, serious mental illness history and use of chloroquine and dexamethasone. An NLR cut-off was identified, and stratified analyses were performed by age and sex. Also, another biomarker was tested as an exposure (the systemic immune-inflammation index -SII). Results: 55.3% of the patients were men, with a mean age of 66.8 years. Roughly 13% of the patients had delirium during hospitalization. NLR on admission predicted subsequent delirium development (adjusted OR = 1.02, 95 percent CI: 1.00-1.04, p = 0.024). Patients between 69 and 80 years with NLR values > 6.3 presented a twofold increased risk for delirium (p = 0.004). There were no sex differences in the association between baseline NLR and delirium (p > 0.05) nor SII predicted delirium development (p = 0.341). Conclusion: NLR is a good predictor of delirium during hospitalization, especially among older adults, independently of medical comorbidity, illness severity, and other covariates. Routine blood tests on admission might provide valuable information to guide the decision-making process to be followed with these especially vulnerable patients.

Credibility of the Neutrophil-to-Lymphocyte Count Ratio in Severe Traumatic Brain Injury

Traumatic brain injury (TBI) is one of the leading causes of morbidity and mortality worldwide. The consequences of a TBI generate the activation and accumulation of inflammatory cells. The peak number of neutrophils entering into an injured brain is observed after 24 h; however, cells infiltrate within 5 min of closed brain injury. Neutrophils release toxic molecules including free radicals, proinflammatory cytokines, and proteases that advance secondary damage. Regulatory T cells impair T cell infiltration into the central nervous system and elevate reactive astrogliosis and interferon-γ gene expression, probably inducing the process of healing. Therefore, the neutrophil-to-lymphocyte ratio (NLR) may be a low-cost, objective, and available predictor of inflammation as well as a marker of secondary injury associated with neutrophil activation. Recent studies have documented that an NLR value on admission might be effective for predicting outcome and mortality in severe brain injury patients.

Delirium Severely Worsens Outcome in Patients with COVID-19-A Retrospective Cohort Study from Temporary Critical Care Hospitals

Delirium is a sign of deterioration of homeostasis and worse prognosis. The aim of this study was to investigate the frequency, risk factors and prognosis of delirium in patients with COVID-19 in a temporary acute setting hospital. A retrospective cohort analysis of data collected between October 2020 and February 2021 from two temporary acute care hospitals was performed. All consecutive hospitalized patients ≥18 years old with COVID-19 were included. An assessment of consciousness was carried out at least two times a day, including neurological examination. Delirium was identified through retrospective chart review according to DSM-5 criteria if present at least once during hospitalization. Analysis included 201 patients, 39 diagnosed with delirium (19.4%). Delirious patients were older (p < 0.001), frailer (p < 0.001) and the majority were male (p = 0.002). Respiratory parameters were worse in this group with higher oxygen flow (p = 0.013), lower PaO2 (p = 0.043) and higher FiO2 (p = 0.006). The mortality rate was significantly higher in patients with delirium (46.15% vs 3.70%, p < 0.001) with OR 17.212 (p < 0.001) corrected for age and gender. Delirious patients experienced significantly more complications: cardiovascular (OR 7.72, p < 0.001), pulmonary (OR 8.79, p < 0.001) or septic (OR 3.99, p = 0.029). The odds of mortality in patients with COVID-19 presenting with delirium at any point of hospitalization were seventeen times higher.

Neutrophil-Lymphocyte Ratio as a Potential Biomarker for Delirium in the Intensive Care Unit

Background: Recognition and early detection of delirium in the intensive care unit (ICU) is essential to improve ICU outcomes. To date, neutrophil-lymphocyte ratio (NLR), one of inflammatory markers, has been proposed as a potential biomarker for brain disorders related to neuroinflammation. This study aimed to investigate whether NLR could be utilized in early detection of delirium in the ICU. Methods: Of 10,144 patients who admitted to the ICU, 1,112 delirium patients (DE) were included in the current study. To compare among inflammatory markers, NLR, C-reactive protein (CRP), and white blood cell (WBC) counts were obtained: the mean NLR, CRP levels, and WBC counts between the initial day of ICU admission and the day of initial delirium onset within DE were examined. The inflammatory marker of 1,272 non-delirium patients (ND) were also comparatively measured as a supplement. Further comparisons included a subgroup analysis based on delirium subtypes (non-hypoactive vs. hypoactive) or admission types (elective vs. emergent). Results: The NLR and CRP levels in DE increased on the day of delirium onset compared to the initial admission day. ND also showed increased CRP levels on the sixth day (the closest day to average delirium onset day among DE) of ICU admission compared to baseline, while NLR in ND did not show significant difference over time. In further analyses, the CRP level of the non-hypoactive group was more increased than that of the hypoactive group during the delirium onset. NLR, however, was more significantly increased in patients with elective admission than in those with emergent admission. Conclusion: Elevation of NLR was more closely linked to the onset of delirium compared to other inflammatory markers, indicating that NLR may play a role in early detection of delirium.