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Fergie R, Maxwell AP, Cunningham EL. Latest advances in frailty in kidney transplantation: A narrative review. Transplant Rev (Orlando) 2024; 38:100833. [PMID: 38309184 DOI: 10.1016/j.trre.2024.100833] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2023] [Revised: 01/19/2024] [Accepted: 01/20/2024] [Indexed: 02/05/2024]
Abstract
Frailty is a clinical syndrome that is characterised by decline in multiple systems with associated decreased physiological reserve and ability to respond to stressor events. It is associated with greater healthcare burden. It is common in patients with end-stage renal disease (ESRD). Kidney transplantation is considered the optimal form of renal replacement therapy for suitable patients with ESRD. However, surgery and immunosuppression are physiological stresses that can disproportionately affect frail individuals. Frailty is emerging as a potentially important risk factor in patients waitlisted for kidney transplantation. Most of the published research to date in this area comes from a single transplant centre in the USA. Frailty, as measured using the Physical Frailty Phenotype (FP), is prevalent in waitlisted patients and has been associated with early hospital re-admission, prolonged length of stay, delayed graft function and increased mortality after kidney transplantation. However, although kidney transplantation is a substantial physiological stress to a patient's reserve, by restoring kidney function, kidney transplantation has also been shown to improve a patient's frailty status. The FP is the most studied tool in patients waitlisted for transplantation, but it has not been able to distinguish those whose frailty is improved by kidney transplantation. In summary, there remain significant gaps in knowledge and uncertainties as to how to effectively use existing frailty measures to inform decision-making around kidney transplantation. Further research is needed to address these important gaps in the literature.
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Affiliation(s)
- Ruth Fergie
- Centre for Public Health, Queen's University of Belfast, Belfast BT12 6AB, UK; Regional Nephrology Unit, Belfast City Hospital, Lisburn Road, BT9 7BA Belfast, UK.
| | - Alexander P Maxwell
- Centre for Public Health, Queen's University of Belfast, Belfast BT12 6AB, UK.
| | - Emma L Cunningham
- Centre for Public Health, Queen's University of Belfast, Belfast BT12 6AB, UK.
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Bowman EML, Sweeney AM, McAuley DF, Cardwell C, Kane J, Badawi N, Jahan N, Iqbal HK, Mitchell C, Ballantyne JA, Cunningham EL. Assessment and report of individual symptoms in studies of delirium in postoperative populations: a systematic review. Age Ageing 2024; 53:afae077. [PMID: 38640126 PMCID: PMC11028403 DOI: 10.1093/ageing/afae077] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2023] [Revised: 03/06/2024] [Indexed: 04/21/2024] Open
Abstract
OBJECTIVES Delirium is most often reported as present or absent. Patients with symptoms falling short of the diagnostic criteria for delirium fall into 'no delirium' or 'control' groups. This binary classification neglects individual symptoms and may be hindering identification of the pathophysiology underlying delirium. This systematic review investigates which individual symptoms of delirium are reported by studies of postoperative delirium in adults. METHODS Medline, EMBASE and Web of Science databases were searched on 03 June 2021 and 06 April 2023. Two reviewers independently examined titles and abstracts. Each paper was screened in duplicate and conflicting decisions settled by consensus discussion. Data were extracted, qualitatively synthesised and narratively reported. All included studies were quality assessed. RESULTS These searches yielded 4,367 results. After title and abstract screening, 694 full-text studies were reviewed, and 62 deemed eligible for inclusion. This review details 11,377 patients including 2,049 patients with delirium. In total, 78 differently described delirium symptoms were reported. The most reported symptoms were inattention (N = 29), disorientation (N = 27), psychomotor agitation/retardation (N = 22), hallucination (N = 22) and memory impairment (N = 18). Notably, psychomotor agitation and hallucinations are not listed in the current Diagnostic and Statistical Manual for Mental Disorders-5-Text Revision delirium definition. CONCLUSIONS The 78 symptoms reported in this systematic review cover domains of attention, awareness, disorientation and other cognitive changes. There is a lack of standardisation of terms, and many recorded symptoms are synonyms of each other. This systematic review provides a library of individual delirium symptoms, which may be used to inform future reporting.
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Affiliation(s)
- Emily M L Bowman
- Centre for Public Health, Queen’s University Belfast, Block B, Institute of Clinical Sciences, Royal Victoria Hospital site, Grosvenor Road, Belfast BT12 6BA, Northern Ireland
- Centre for Experimental Medicine, Queen’s University Belfast, Wellcome-Wolfson Institute for Experimental Medicine, 97 Lisburn Road, Belfast BT9 7BL, Northern Ireland
| | - Aoife M Sweeney
- Centre for Public Health, Queen’s University Belfast, Block B, Institute of Clinical Sciences, Royal Victoria Hospital site, Grosvenor Road, Belfast BT12 6BA, Northern Ireland
| | - Danny F McAuley
- Centre for Experimental Medicine, Queen’s University Belfast, Wellcome-Wolfson Institute for Experimental Medicine, 97 Lisburn Road, Belfast BT9 7BL, Northern Ireland
| | - Chris Cardwell
- Centre for Public Health, Queen’s University Belfast, Block B, Institute of Clinical Sciences, Royal Victoria Hospital site, Grosvenor Road, Belfast BT12 6BA, Northern Ireland
| | - Joseph Kane
- Centre for Public Health, Queen’s University Belfast, Block B, Institute of Clinical Sciences, Royal Victoria Hospital site, Grosvenor Road, Belfast BT12 6BA, Northern Ireland
| | - Nadine Badawi
- Centre for Public Health, Queen’s University Belfast, Block B, Institute of Clinical Sciences, Royal Victoria Hospital site, Grosvenor Road, Belfast BT12 6BA, Northern Ireland
| | - Nusrat Jahan
- Centre for Public Health, Queen’s University Belfast, Block B, Institute of Clinical Sciences, Royal Victoria Hospital site, Grosvenor Road, Belfast BT12 6BA, Northern Ireland
| | - Halla Kiyan Iqbal
- Centre for Public Health, Queen’s University Belfast, Block B, Institute of Clinical Sciences, Royal Victoria Hospital site, Grosvenor Road, Belfast BT12 6BA, Northern Ireland
| | - Callum Mitchell
- Centre for Public Health, Queen’s University Belfast, Block B, Institute of Clinical Sciences, Royal Victoria Hospital site, Grosvenor Road, Belfast BT12 6BA, Northern Ireland
| | - Jessica A Ballantyne
- Centre for Public Health, Queen’s University Belfast, Block B, Institute of Clinical Sciences, Royal Victoria Hospital site, Grosvenor Road, Belfast BT12 6BA, Northern Ireland
| | - Emma L Cunningham
- Centre for Public Health, Queen’s University Belfast, Block B, Institute of Clinical Sciences, Royal Victoria Hospital site, Grosvenor Road, Belfast BT12 6BA, Northern Ireland
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Bowman EML, Brummel NE, Caplan GA, Cunningham C, Evered LA, Fiest KM, Girard TD, Jackson TA, LaHue SC, Lindroth HL, Maclullich AMJ, McAuley DF, Oh ES, Oldham MA, Page VJ, Pandharipande PP, Potter KM, Sinha P, Slooter AJC, Sweeney AM, Tieges Z, Van Dellen E, Wilcox ME, Zetterberg H, Cunningham EL. Advancing specificity in delirium: The delirium subtyping initiative. Alzheimers Dement 2024; 20:183-194. [PMID: 37522255 PMCID: PMC10917010 DOI: 10.1002/alz.13419] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Revised: 05/26/2023] [Accepted: 07/10/2023] [Indexed: 08/01/2023]
Abstract
BACKGROUND Delirium, a common syndrome with heterogeneous etiologies and clinical presentations, is associated with poor long-term outcomes. Recording and analyzing all delirium equally could be hindering the field's understanding of pathophysiology and identification of targeted treatments. Current delirium subtyping methods reflect clinically evident features but likely do not account for underlying biology. METHODS The Delirium Subtyping Initiative (DSI) held three sessions with an international panel of 25 experts. RESULTS Meeting participants suggest further characterization of delirium features to complement the existing Diagnostic and Statistical Manual of Mental Disorders Fifth Edition Text Revision diagnostic criteria. These should span the range of delirium-spectrum syndromes and be measured consistently across studies. Clinical features should be recorded in conjunction with biospecimen collection, where feasible, in a standardized way, to determine temporal associations of biology coincident with clinical fluctuations. DISCUSSION The DSI made recommendations spanning the breadth of delirium research including clinical features, study planning, data collection, and data analysis for characterization of candidate delirium subtypes. HIGHLIGHTS Delirium features must be clearly defined, standardized, and operationalized. Large datasets incorporating both clinical and biomarker variables should be analyzed together. Delirium screening should incorporate communication and reasoning.
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Affiliation(s)
- Emily M. L. Bowman
- Centre for Public HealthQueen's University Belfast, Block B, Institute of Clinical Sciences, Royal Victoria Hospital SiteBelfastNorthern Ireland
- Centre for Experimental MedicineQueen's University Belfast, Wellcome‐Wolfson Institute for Experimental MedicineBelfastNorthern Ireland
| | - Nathan E. Brummel
- The Ohio State University College of MedicineDivision of PulmonaryCritical Care, and Sleep MedicineColumbusOhioUSA
| | - Gideon A. Caplan
- Department of Geriatric MedicinePrince of Wales Hospital, Sydney, Australia University of New South WalesSydneyAustralia
| | - Colm Cunningham
- School of Biochemistry & ImmunologyTrinity Biomedical Sciences InstituteTrinity College, DublinRepublic of Ireland
| | - Lis A. Evered
- Department of AnesthesiologyWeill Cornell MedicineNew YorkNew YorkUSA
- Department of Critical CareUniversity of MelbourneMelbourneAustralia
- Department of Anaesthesia & Acute Pain MedicineSt. Vincent's HospitalMelbourneAustralia
| | - Kirsten M. Fiest
- Department of Community Health SciencesCumming School of MedicineUniversity of CalgaryCalgaryAlbertaCanada
- Department of Critical Care MedicineUniversity of Calgary and Alberta Health ServicesCalgaryAlbertaCanada
- O'Brien Institute for Public HealthUniversity of CalgaryCalgaryAlbertaCanada
- Hotchkiss Brain InstituteUniversity of CalgaryCalgaryAlbertaCanada
- Department of PsychiatryCumming School of MedicineUniversity of CalgaryCalgaryAlbertaCanada
| | - Timothy D. Girard
- Clinical ResearchInvestigation, and Systems Modeling of Acute Illness (CRISMA) CenterDepartment of Critical Care MedicineUniversity of PittsburghPittsburghPennsylvaniaUSA
| | - Thomas A. Jackson
- Institute of Inflammation and AgeingUniversity of BirminghamBirminghamUK
| | - Sara C. LaHue
- Department of NeurologySchool of MedicineUniversity of CaliforniaSan FranciscoCaliforniaUSA
- Weill Institute for NeurosciencesDepartment of NeurologyUniversity of CaliforniaSan FranciscoCaliforniaUSA
- Buck Institute for Research on AgingNovatoCaliforniaUSA
| | - Heidi L. Lindroth
- Department of NursingMayo ClinicRochesterMinnesotaUSA
- Center for Aging ResearchRegenstrief InstituteSchool of MedicineIndiana UniversityIndianapolisIndianaUSA
| | - Alasdair M. J. Maclullich
- Edinburgh Delirium Research Group, Ageing and HealthUsher InstituteUniversity of EdinburghEdinburghUK
| | - Daniel F. McAuley
- Centre for Experimental MedicineQueen's University Belfast, Wellcome‐Wolfson Institute for Experimental MedicineBelfastNorthern Ireland
| | - Esther S. Oh
- Departments of MedicinePsychiatry and Behavioral Sciences and PathologyJohns Hopkins University School of MedicineBaltimoreMarylandUSA
| | - Mark A. Oldham
- Department of PsychiatryUniversity of Rochester Medical CenterRochesterNew YorkUSA
| | | | - Pratik P. Pandharipande
- Departments of Anesthesiology and SurgeryDivision of Anesthesiology Critical Care Medicine and Critical IllnessBrain Dysfunction, and Survivorship CenterVanderbilt University Medical CenterNashvilleTennesseeUSA
| | - Kelly M. Potter
- Clinical ResearchInvestigation, and Systems Modeling of Acute Illness (CRISMA) CenterDepartment of Critical Care MedicineUniversity of PittsburghPittsburghPennsylvaniaUSA
| | - Pratik Sinha
- Division of Clinical and Translational ResearchWashington University School of MedicineSt. LouisMissouriUSA
| | - Arjen J. C. Slooter
- Departments of Psychiatry and Intensive Care Medicine and UMC Utrecht Brain CenterUniversity Medical Center UtrechtUtrecht UniversityUtrechtthe Netherlands
- Department of NeurologyUZ Brussel and Vrije Universiteit BrusselBrusselsBelgium
| | - Aoife M. Sweeney
- Centre for Public HealthQueen's University Belfast, Block B, Institute of Clinical Sciences, Royal Victoria Hospital SiteBelfastNorthern Ireland
| | - Zoë Tieges
- Edinburgh Delirium Research Group, Ageing and HealthUsher InstituteUniversity of EdinburghEdinburghUK
- School of ComputingEngineering and Built EnvironmentGlasgow Caledonian UniversityGlasgowScotland
| | - Edwin Van Dellen
- Departments of Psychiatry and Intensive Care Medicine and UMC Utrecht Brain CenterUniversity Medical Center UtrechtUtrecht UniversityUtrechtthe Netherlands
- Department of NeurologyUZ Brussel and Vrije Universiteit BrusselBrusselsBelgium
| | - Mary Elizabeth Wilcox
- Department of Critical Care MedicineFaculty of Medicine and DentistryUniversity of AlbertaEdmontonAlbertaCanada
| | - Henrik Zetterberg
- Department of Psychiatry and NeurochemistryInstitute of Neuroscience and PhysiologyThe Sahlgrenska Academy at the University of GothenburgMölndalSweden
- Clinical Neurochemistry LaboratorySahlgrenska University HospitalMölndalSweden
- Department of Neurodegenerative DiseaseUCL Institute of NeurologyQueen SquareLondonUK
- UK Dementia Research Institute at UCLLondonUK
- Hong Kong Center for Neurodegenerative DiseasesClear Water BayHong KongChina
- Wisconsin Alzheimer's Disease Research CenterUniversity of Wisconsin School of Medicine and Public HealthUniversity of Wisconsin–MadisonMadisonWisconsinUSA
| | - Emma L. Cunningham
- Centre for Public HealthQueen's University Belfast, Block B, Institute of Clinical Sciences, Royal Victoria Hospital SiteBelfastNorthern Ireland
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Cunningham EL, Bowman EML. Author response to: Factors influencing resilience to postoperative delirium in adults undergoing elective orthopaedic surgery. Br J Surg 2023; 110:282. [PMID: 36427191 PMCID: PMC10364495 DOI: 10.1093/bjs/znac407] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2022] [Accepted: 11/01/2022] [Indexed: 11/27/2022]
Affiliation(s)
- Emma L Cunningham
- Centre for Public Health, Queen's University Belfast, Institute of Clinical Sciences, Belfast, UK
| | - Emily M L Bowman
- Centre for Public Health, Queen's University Belfast, Institute of Clinical Sciences, Belfast, UK
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Sweeney A, Passmore AP, Beverland D, McGuinness B, McAuley DF, Mawhinney T, Schott JM, Heslegrave A, Zetterberg H, Cunningham EL. Cerebrospinal Fluid Markers of Neurodegeneration Associated with Postoperative Delirium in an Older Elective Arthroplasty Population. Alzheimers Dement 2022. [DOI: 10.1002/alz.068131] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Affiliation(s)
| | | | | | - Bernadette McGuinness
- Ageing Research Group, Centre for Public Health, Queen's University Belfast Belfast United Kingdom
| | | | | | - Jonathan M Schott
- Dementia Research Centre, UCL Queen Square Institute of Neurology London United Kingdom
| | | | - Henrik Zetterberg
- Department of Neurodegenerative Disease and UK Dementia Research Institute, UCL Institute of Neurology, Queen Square London United Kingdom
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Sweeney A, Passmore AP, Beverland D, McGuinness B, McAuley DF, Mawhinney T, O'Brien S, Schott JM, Heslegrave A, Zetterberg H, Cunningham EL. Plasma Markers of Neurodegeneration Associated with Postoperative Delirium in an Older Elective Arthroplasty Population. Alzheimers Dement 2022. [DOI: 10.1002/alz.068193] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Affiliation(s)
| | | | | | - Bernadette McGuinness
- Ageing Research Group, Centre for Public Health, Queen's University Belfast Belfast United Kingdom
| | | | | | | | - Jonathan M Schott
- Dementia Research Centre, UCL Queen Square Institute of Neurology London United Kingdom
| | - Amanda Heslegrave
- UCL Queen Square Institute of Neurology London United Kingdom
- UK Dementia Research Institute at UCL London United Kingdom
| | - Henrik Zetterberg
- Department of Neurodegenerative Disease and UK Dementia Research Institute, UCL Institute of Neurology, Queen Square London United Kingdom
- Institute of Neuroscience and Physiology, Sahlgrenska Academy, University of Gothenburg Gothenburg Sweden
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Sweeney A, Passmore AP, Beverland D, McGuinness B, McAuley DF, Mawhinney T, O'Brien S, Schott JM, Heslegrave A, Zetterberg H, Cunningham EL. Preoperative Cerebrospinal Fluid and Plasma Markers of Inflammation and Neurodegeneration Predict Mortality Eight Years Later in an Observational Cohort Study of Postoperative delirium in an Older Elective Arthroplasty Populatio. Alzheimers Dement 2022. [DOI: 10.1002/alz.068179] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Affiliation(s)
| | | | | | - Bernadette McGuinness
- Ageing Research Group, Centre for Public Health, Queen's University Belfast Belfast United Kingdom
| | | | | | | | - Jonathan M Schott
- Dementia Research Centre, UCL Queen Square Institute of Neurology London United Kingdom
| | | | - Henrik Zetterberg
- Department of Neurodegenerative Disease and UK Dementia Research Institute, UCL Institute of Neurology, Queen Square London United Kingdom
- Institute of Neuroscience and Physiology, Sahlgrenska Academy, University of Gothenburg Gothenburg Sweden
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Bowman EML, Cardwell C, McAuley DF, McGuinness B, Passmore AP, Beverland D, Zetterberg H, Schott JM, Cunningham EL. Factors influencing resilience to postoperative delirium in adults undergoing elective orthopaedic surgery. Br J Surg 2022; 109:908-911. [PMID: 35707934 PMCID: PMC10364747 DOI: 10.1093/bjs/znac197] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2022] [Revised: 04/15/2022] [Accepted: 05/13/2022] [Indexed: 01/18/2023]
Affiliation(s)
- Emily M L Bowman
- Centre for Public Health, Queen's University Belfast, Institute of Clinical Sciences, Belfast, UK
| | - Christopher Cardwell
- Centre for Public Health, Queen's University Belfast, Institute of Clinical Sciences, Belfast, UK
| | - Daniel F McAuley
- Centre for Experimental Medicine, Queen's University Belfast, Wellcome-Wolfson Institute for Experimental Medicine, Belfast, UK
| | - Bernadette McGuinness
- Centre for Public Health, Queen's University Belfast, Institute of Clinical Sciences, Belfast, UK
| | - Anthony P Passmore
- Centre for Public Health, Queen's University Belfast, Institute of Clinical Sciences, Belfast, UK
| | - David Beverland
- Outcomes Assessment Unit, Musgrave Park Hospital, Belfast Trust, Belfast, UK
| | - Henrik Zetterberg
- UK Dementia Research Institute at UCL, London, UK.,Department of Neurodegenerative Disease, National Hospital for Neurology and Neurosurgery, UCL Institute of Neurology, London, UK.,Clinical Neurochemistry Laboratory, Sahlgrenska University Hospital, Mölndal, Sweden.,Department of Psychiatry and Neurochemistry, Institute of Neuroscience and Physiology, the Sahlgrenska Academy at the University of Gothenburg, Mölndal, Sweden
| | - Jonathan M Schott
- Dementia Research Centre, Department of Neurodegenerative Disease, National Hospital for Neurology and Neurosurgery, UCL Institute of Neurology, London, UK
| | - Emma L Cunningham
- Centre for Public Health, Queen's University Belfast, Institute of Clinical Sciences, Belfast, UK
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Jung M, Pan X, Cunningham EL, Passmore AP, McGuinness B, McAuley DF, Beverland D, O’Brien S, Mawhinney T, Schott JM, Zetterberg H, Green BD. The Influence of Orthopedic Surgery on Circulating Metabolite Levels, and their Associations with the Incidence of Postoperative Delirium. Metabolites 2022; 12:616. [PMID: 35888740 PMCID: PMC9319890 DOI: 10.3390/metabo12070616] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2022] [Revised: 06/15/2022] [Accepted: 06/16/2022] [Indexed: 02/05/2023] Open
Abstract
The mechanisms underlying the occurrence of postoperative delirium development are unclear and measurement of plasma metabolites may improve understanding of its causes. Participants (n = 54) matched for age and gender were sampled from an observational cohort study investigating postoperative delirium. Participants were ≥65 years without a diagnosis of dementia and presented for primary elective hip or knee arthroplasty. Plasma samples collected pre- and postoperatively were grouped as either control (n = 26, aged: 75.8 ± 5.2) or delirium (n = 28, aged: 76.2 ± 5.7). Widespread changes in plasma metabolite levels occurred following surgery. The only metabolites significantly differing between corresponding control and delirium samples were ornithine and spermine. In delirium cases, ornithine was 17.6% higher preoperatively, and spermine was 12.0% higher postoperatively. Changes were not associated with various perioperative factors. In binary logistic regression modeling, these two metabolites did not confer a significantly increased risk of delirium. These findings support the hypothesis that disturbed polyamine metabolism is an underlying factor in delirium that warrants further investigation.
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Affiliation(s)
- Mijin Jung
- Institute for Global Food Security, School of Biological Sciences, Queen’s University Belfast, 8 Malone Road, Belfast BT9 5BN, Northern Ireland, UK; (M.J.); (X.P.)
| | - Xiaobei Pan
- Institute for Global Food Security, School of Biological Sciences, Queen’s University Belfast, 8 Malone Road, Belfast BT9 5BN, Northern Ireland, UK; (M.J.); (X.P.)
| | - Emma L. Cunningham
- Centre for Public Health, Institute of Clinical Sciences, Queen’s University Belfast, Block B, Royal Victoria Hospital Site, Grosvenor Road, Belfast BT12 6BA, Northern Ireland, UK; (E.L.C.); (A.P.P.); (B.M.)
| | - Anthony P. Passmore
- Centre for Public Health, Institute of Clinical Sciences, Queen’s University Belfast, Block B, Royal Victoria Hospital Site, Grosvenor Road, Belfast BT12 6BA, Northern Ireland, UK; (E.L.C.); (A.P.P.); (B.M.)
| | - Bernadette McGuinness
- Centre for Public Health, Institute of Clinical Sciences, Queen’s University Belfast, Block B, Royal Victoria Hospital Site, Grosvenor Road, Belfast BT12 6BA, Northern Ireland, UK; (E.L.C.); (A.P.P.); (B.M.)
| | - Daniel F. McAuley
- Centre for Experimental Medicine, Wellcome-Wolfson Institute for Experimental Medicine, Queen’s University Belfast, 97 Lisburn Road, Belfast BT9 7BL, Northern Ireland, UK;
| | - David Beverland
- Outcomes Assessment Unit, Musgrave Park Hospital, Belfast Trust, Stockman’s Lane, Belfast BT9 7JB, Northern Ireland, UK;
| | - Seamus O’Brien
- Cardiac Surgical Intensive Care Unit, Belfast Trust, Royal Victoria Hospital, Grosvenor Road, Belfast BT12 6BA, Northern Ireland, UK; (S.O.); (T.M.)
| | - Tim Mawhinney
- Cardiac Surgical Intensive Care Unit, Belfast Trust, Royal Victoria Hospital, Grosvenor Road, Belfast BT12 6BA, Northern Ireland, UK; (S.O.); (T.M.)
| | - Jonathan M. Schott
- Department of Neurodegenerative Disease, UCL Institute of Neurology, Queen Square, London WC1E 6BT, UK; (J.M.S.); (H.Z.)
| | - Henrik Zetterberg
- Department of Neurodegenerative Disease, UCL Institute of Neurology, Queen Square, London WC1E 6BT, UK; (J.M.S.); (H.Z.)
- UK Dementia Research Institute at UCL, London WC1E 6BT, UK
- Clinical Neurochemistry Laboratory, Sahlgrenska University Hospital, House V, S-431 80 Mölndal, Sweden
- Department of Psychiatry and Neurochemistry, Institute of Neuroscience and Physiology, The Sahlgrenska Academy at the University of Gothenburg, House V, S-431 80 Mölndal, Sweden
- Hong Kong Center for Neurodegenerative Diseases, Clear Water Bay, Hong Kong, China
| | - Brian D. Green
- Institute for Global Food Security, School of Biological Sciences, Queen’s University Belfast, 8 Malone Road, Belfast BT9 5BN, Northern Ireland, UK; (M.J.); (X.P.)
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Bowman EML, Cunningham EL, Page VJ, McAuley DF. Phenotypes and subphenotypes of delirium: a review of current categorisations and suggestions for progression. Crit Care 2021; 25:334. [PMID: 34526093 PMCID: PMC8441952 DOI: 10.1186/s13054-021-03752-w] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2021] [Accepted: 08/31/2021] [Indexed: 02/08/2023] Open
Abstract
Delirium is a clinical syndrome occurring in heterogeneous patient populations. It affects 45-87% of critical care patients and is often associated with adverse outcomes including acquired dementia, institutionalisation, and death. Despite an exponential increase in delirium research in recent years, the pathophysiological mechanisms resulting in the clinical presentation of delirium are still hypotheses. Efforts have been made to categorise the delirium spectrum into clinically meaningful subgroups (subphenotypes), using psychomotor subtypes such as hypoactive, hyperactive, and mixed, for example, and also inflammatory and non-inflammatory delirium. Delirium remains, however, a constellation of symptoms resulting from a variety of risk factors and precipitants with currently no successful targeted pharmacological treatment. Identifying specific clinical and biological subphenotypes will greatly improve understanding of the relationship between the clinical symptoms and the putative pathways and thus risk factors, precipitants, natural history, and biological mechanism. This will facilitate risk factor mitigation, identification of potential methods for interventional studies, and informed patient and family counselling. Here, we review evidence to date and propose a framework to identify subphenotypes. Endotype identification may be done by clustering symptoms with their biological mechanism, which will facilitate research of targeted treatments. In order to achieve identification of delirium subphenotypes, the following steps must be taken: (1) robust records of symptoms must be kept at a clinical level. (2) Global collaboration must facilitate large, heterogeneous research cohorts. (3) Patients must be clustered for identification, validation, and mapping of subphenotype stability.
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Affiliation(s)
- Emily M L Bowman
- Centre for Public Health, Block B, Institute of Clinical Sciences, Royal Victoria Hospital Site, Queen's University Belfast, Grosvenor Road, Belfast, BT12 6BA, Northern Ireland.
| | - Emma L Cunningham
- Centre for Public Health, Block B, Institute of Clinical Sciences, Royal Victoria Hospital Site, Queen's University Belfast, Grosvenor Road, Belfast, BT12 6BA, Northern Ireland
| | - Valerie J Page
- Department of Anaesthetics, Watford General Hospital, Vicarage Road, Watford, WD19 4DZ, UK
| | - Daniel F McAuley
- Centre for Experimental Medicine, Wellcome-Wolfson Institute for Experimental Medicine, Queen's University Belfast, 97 Lisburn Road, Belfast, BT9 7BL, Northern Ireland
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McMichael AJ, Zafeiridi E, Ryan M, Cunningham EL, Passmore AP, McGuinness B. Anticholinergic drug use and risk of mortality for people with dementia in Northern Ireland. Aging Ment Health 2021; 25:1475-1482. [PMID: 33073601 DOI: 10.1080/13607863.2020.1830028] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
OBJECTIVE Anticholinergic burden refers to the cumulative effect of medications which contain anticholinergic properties. We assessed how anticholinergic burden and different types of anticholinergic medications influence mortality rates among people with dementia in Northern Ireland. Our secondary aim was to determine what demographic characteristics predict the anticholinergic burden of people with dementia. METHODS Data were extracted from the Enhanced Prescribing database for 25,418 people who were prescribed at least one dementia management medication between 2010 and 2016. Information was also extracted on the number of times each available anticholinergic drug was prescribed between 2010 and 2016, allowing the calculation of an overall anticholinergic burden. Cox proportional hazard models were used to determine how anticholinergic burden influenced mortality whilst multilevel model regression determined what demographic characteristics influence overall anticholinergic burden. RESULTS Of the 25,418 people with dementia, only 15% (n = 3880) had no anticholinergic burden. Diazepam (42%) and risperidone (18%) were the two most commonly prescribed drugs. Unadjusted Cox proportional hazard models indicated that higher anticholinergic burden was associated with significantly higher mortality rates in comparison to people with dementia who had no anticholinergic burden (HR = 1.59: 95% CI = 1.07-2.36). In particular, urological (HR = 1.20: 95% CI = 1.05-1.38) and respiratory (HR = 1.17: 95% CI = 1.08-1.27) drugs significantly increased mortality rates. People with dementia living in areas with low levels of deprivation had significantly lower anticholinergic burden (HR=-.39: 95% CI=-.47:-30). CONCLUSIONS Reducing anticholinergic burden is essential for people with dementia. Further research should address the unfavourable prognosis of people living with dementia in highly deprived areas.
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Affiliation(s)
- A J McMichael
- Centre for Public Health, Institute for Clinical Sciences Block B, Queens University Belfast, Belfast, Northern Ireland
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Cunningham EL, Todd SA, Passmore P, Bullock R, McGuinness B. Pharmacological treatment of hypertension in people without prior cerebrovascular disease for the prevention of cognitive impairment and dementia. Cochrane Database Syst Rev 2021; 5:CD004034. [PMID: 34028812 PMCID: PMC8142793 DOI: 10.1002/14651858.cd004034.pub4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
BACKGROUND This is an update of a Cochrane Review first published in 2006 (McGuinness 2006), and previously updated in 2009 (McGuinness 2009). Hypertension is a risk factor for dementia. Observational studies suggest antihypertensive treatment is associated with lower incidences of cognitive impairment and dementia. There is already clear evidence to support the treatment of hypertension after stroke. OBJECTIVES To assess whether pharmacological treatment of hypertension can prevent cognitive impairment or dementia in people who have no history of cerebrovascular disease. SEARCH METHODS We searched the Specialised Register of the Cochrane Dementia and Cognitive Improvement Group, CENTRAL, MEDLINE, Embase, three other databases, as well as many trials registries and grey literature sources, most recently on 7 July 2020. SELECTION CRITERIA We included randomised controlled trials (RCTs) in which pharmacological interventions to treat hypertension were given for at least 12 months. We excluded trials of pharmacological interventions to lower blood pressure in non-hypertensive participants. We also excluded trials conducted solely in people with stroke. DATA COLLECTION AND ANALYSIS Two authors independently assessed trial quality and extracted data. We contacted study authors for additional information. We collected information regarding incidence of dementia, cognitive decline, change in blood pressure, adverse effects and quality of life. We assessed the certainty of evidence using GRADE. MAIN RESULTS We included 12 studies, totaling 30,412 participants, in this review. Eight studies compared active treatment with placebo. Of the four non-placebo-controlled studies, two compared intensive versus standard blood pressure reduction. The two final included studies compared different classes of antihypertensive drug. Study durations varied from one to five years. The combined result of four placebo-controlled trials that reported incident dementia indicated no evidence of a difference in the risk of dementia between the antihypertensive treatment group and the placebo group (236/7767 versus 259/7660, odds ratio (OR) 0.89, 95% confidence interval (CI) 0.72 to 1.09; very low certainty evidence, downgraded due to study limitations and indirectness). The combined results from five placebo-controlled trials that reported change in Mini-Mental State Examination (MMSE) may indicate a modest benefit from antihypertensive treatment (mean difference (MD) 0.20, 95% CI 0.10 to 0.29; very low certainty evidence, downgraded due to study limitations, indirectness and imprecision). The certainty of evidence for both cognitive outcomes was downgraded on the basis of study limitations and indirectness. Study durations were too short, overall, to expect a significant difference in dementia rates between groups. Dementia and cognitive decline were secondary outcomes for most studies. Additional sources of bias include: the use of antihypertensive medication by the placebo group in the placebo-controlled trials; failure to reach recruitment targets; and early termination of studies on safety grounds. Meta-analysis of the placebo-controlled trials reporting results found a mean change in systolic blood pressure of -9.25 mmHg (95% CI -9.73, -8.78) between treatment (n = 8973) and placebo (n = 8820) groups, and a mean change in diastolic blood pressure of -2.47 mmHg (95% CI -2.70, -2.24) between treatment (n = 7700) and placebo (n = 7509) groups (both low certainty evidence downgraded on the basis of study limitations and inconsistency). Three trials - SHEP 1991, LOMIR MCT IL 1996 and MRC 1996 - reported more withdrawals due to adverse events in active treatment groups than placebo groups. Participants on active treatment in Syst Eur 1998 were less likely to discontinue treatment due to side effects, and participants on active treatment in HYVET 2008 reported fewer 'serious adverse events' than in the placebo group. There was no evidence of a difference in withdrawals rates between groups in SCOPE 2003, and results were unclear for Perez Stable 2000 and Zhang 2018. Heterogeneity precluded meta-analysis. Five of the placebo-controlled trials provided quality of life (QOL) data. Heterogeneity again precluded meta-analysis. SHEP 1991, Syst Eur 1998 and HYVET 2008 reported no evidence of a difference in QOL measures between active treatment and placebo groups over time. The SCOPE 2003 sub-study (Degl'Innocenti 2004) showed a smaller drop in QOL measures in the active treatment compared to the placebo group. LOMIR MCT IL 1996 reported an improvement in a QOL measure at twelve months in one active treatment group and deterioration in another. AUTHORS' CONCLUSIONS High certainty randomised controlled trial evidence regarding the effect of hypertension treatment on dementia and cognitive decline does not yet exist. The studies included in this review provide low certainty evidence (downgraded primarily due to study limitations and indirectness) that pharmacological treatment of hypertension, in people without prior cerebrovascular disease, leads to less cognitive decline compared to controls. This difference is below the level considered clinically significant. The studies included in this review also provide very low certainty evidence that pharmacological treatment of hypertension, in people without prior cerebrovascular disease, prevents dementia.
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Affiliation(s)
| | - Stephen A Todd
- Care of the Elderly Medicine, Western Health and Social Care Trust, Londonderry, UK
| | - Peter Passmore
- Centre for Public Health, Queen's University Belfast, Belfast, UK
| | - Roger Bullock
- Kingshill Research Centre, Victoria Hospital, Swindon, UK
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Cuperlovic-Culf M, Cunningham EL, Teimoorinia H, Surendra A, Pan X, Bennett SAL, Jung M, McGuiness B, Passmore AP, Beverland D, Green BD. Metabolomics and computational analysis of the role of monoamine oxidase activity in delirium and SARS-COV-2 infection. Sci Rep 2021; 11:10629. [PMID: 34017039 PMCID: PMC8138024 DOI: 10.1038/s41598-021-90243-1] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2021] [Accepted: 05/05/2021] [Indexed: 02/03/2023] Open
Abstract
Delirium is an acute change in attention and cognition occurring in ~ 65% of severe SARS-CoV-2 cases. It is also common following surgery and an indicator of brain vulnerability and risk for the development of dementia. In this work we analyzed the underlying role of metabolism in delirium-susceptibility in the postoperative setting using metabolomic profiling of cerebrospinal fluid and blood taken from the same patients prior to planned orthopaedic surgery. Distance correlation analysis and Random Forest (RF) feature selection were used to determine changes in metabolic networks. We found significant concentration differences in several amino acids, acylcarnitines and polyamines linking delirium-prone patients to known factors in Alzheimer's disease such as monoamine oxidase B (MAOB) protein. Subsequent computational structural comparison between MAOB and angiotensin converting enzyme 2 as well as protein-protein docking analysis showed that there potentially is strong binding of SARS-CoV-2 spike protein to MAOB. The possibility that SARS-CoV-2 influences MAOB activity leading to the observed neurological and platelet-based complications of SARS-CoV-2 infection requires further investigation.
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Affiliation(s)
- Miroslava Cuperlovic-Culf
- Digital Technologies Research Centre, National Research Council of Canada, Ottawa, Canada.
- Department of Biochemistry, Microbiology, and Immunology, University of Ottawa, Ottawa, ON, K1H 8M5, Canada.
| | - Emma L Cunningham
- Centre for Public Health, Queen's University Belfast, Block B, Institute of Clinical Sciences, Royal Victoria Hospital Site, Grosvenor Road, Belfast, BT12 6BA, Northern Ireland
| | - Hossen Teimoorinia
- NRC Herzberg Astronomy and Astrophysics, 5071 West Saanich Road, Victoria, BC, V9E 2E7, Canada
| | - Anuradha Surendra
- Digital Technologies Research Centre, National Research Council of Canada, Ottawa, Canada
| | - Xiaobei Pan
- Institute for Global Food Security, School of Biological Sciences, Queen's University Belfast, 8 Malone Road, Belfast, BT9 5BN, Northern Ireland
| | - Steffany A L Bennett
- Department of Biochemistry, Microbiology, and Immunology, University of Ottawa, Ottawa, ON, K1H 8M5, Canada
- Neural Regeneration Laboratory, Ottawa Institute of Systems Biology, Brain and Mind Research Institute, Department of Biochemistry, Microbiology, and Immunology, University of Ottawa, Ottawa, ON, Canada
| | - Mijin Jung
- Institute for Global Food Security, School of Biological Sciences, Queen's University Belfast, 8 Malone Road, Belfast, BT9 5BN, Northern Ireland
| | - Bernadette McGuiness
- Centre for Public Health, Queen's University Belfast, Block B, Institute of Clinical Sciences, Royal Victoria Hospital Site, Grosvenor Road, Belfast, BT12 6BA, Northern Ireland
| | - Anthony Peter Passmore
- Centre for Public Health, Queen's University Belfast, Block B, Institute of Clinical Sciences, Royal Victoria Hospital Site, Grosvenor Road, Belfast, BT12 6BA, Northern Ireland
| | - David Beverland
- Outcomes Assessment Unit, Musgrave Park Hospital, Stockman's Lane, Belfast, BT9 7JB, Northern Ireland
| | - Brian D Green
- Institute for Global Food Security, School of Biological Sciences, Queen's University Belfast, 8 Malone Road, Belfast, BT9 5BN, Northern Ireland.
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McMichael AJ, Zafeiridi E, Passmore P, Cunningham EL, McGuinness B. Factors Associated with Mortality Including Nursing Home Transitions: A Retrospective Analysis of 25,418 People Prescribed Anti-Dementia Drugs in Northern Ireland. J Alzheimers Dis 2021; 73:1233-1242. [PMID: 31903992 PMCID: PMC7081092 DOI: 10.3233/jad-190751] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
BACKGROUND Understanding factors associated with mortality after a dementia diagnosis can provide essential information to the person with dementia, their family, and caregivers. To date very little is known about the factors associated with mortality after a dementia diagnosis in Northern Ireland. OBJECTIVE To determine how demographic and other factors such as deprivation and comorbidity medications influence mortality rates after a dementia diagnosis in Northern Ireland and whether these factors are influenced through nursing home transitions. METHODS 25,418 people prescribed anti-dementia medication were identified through the enhanced prescribing database between 2010 and 2016. The impact of covariates including age, gender, marital status, deprivation measure, urban/rural classification, and comorbidity medications were examined using cox proportional hazard models with hazard ratios (HR) and 95% confidence intervals. RESULTS Between 2010 and 2016, 12,129 deaths occurred, with 114 deaths/1,000 person years. Males had significantly higher mortality rates in comparison to females (HR = 1.28; 95% CI = 1.23-1.33); this was true regardless of whether the person with dementia transitioned to a nursing home. People prescribed anti-dementia drugs living with lower levels of deprivation had significantly lower mortality rates in comparison to people living with the highest levels of deprivation (HR = 0.93; 95% CI = 0.89-0.97). Diabetic (HR = 1.18; 95% CI = 1.07-1.29) and anti-arrhythmic (HR = 2.44; 95% CI = 1.01-5.91) medication in particular significantly influenced mortality. CONCLUSION Male gender, higher comorbidity medications, and living in areas of higher deprivation significantly increased mortality rates for people prescribed anti-dementia drugs in our study population. When comorbidity medications were classified, only anti-arrhythmia and diabetic medications significantly increased mortality. Future research should continue to investigate factors which influence mortality after a dementia diagnosis.
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Affiliation(s)
- Alan J McMichael
- Queen's University Belfast, Centre for Public Health, Institute for Clinical Sciences, Block B, Belfast, Northern Ireland
| | - Evi Zafeiridi
- Queen's University Belfast, Centre for Public Health, Institute for Clinical Sciences, Block B, Belfast, Northern Ireland
| | - Peter Passmore
- Queen's University Belfast, Centre for Public Health, Institute for Clinical Sciences, Block B, Belfast, Northern Ireland
| | - Emma L Cunningham
- Queen's University Belfast, Centre for Public Health, Institute for Clinical Sciences, Block B, Belfast, Northern Ireland
| | - Bernadette McGuinness
- Queen's University Belfast, Centre for Public Health, Institute for Clinical Sciences, Block B, Belfast, Northern Ireland
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15
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Pan X, Cunningham EL, Passmore AP, McGuinness B, McAuley DF, Beverland D, O'Brien S, Mawhinney T, Schott JM, Zetterberg H, Green BD. Cerebrospinal Fluid Spermidine, Glutamine and Putrescine Predict Postoperative Delirium Following Elective Orthopaedic Surgery. Sci Rep 2019; 9:4191. [PMID: 30862889 PMCID: PMC6414730 DOI: 10.1038/s41598-019-40544-3] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2018] [Accepted: 02/19/2019] [Indexed: 12/11/2022] Open
Abstract
Delirium is a marker of brain vulnerability, associated with increasing age, pre-existing cognitive impairment and, recently, cerebrospinal fluid (CSF) biomarkers of Alzheimer’s disease. This nested case-control study used a targeted quantitative metabolomic methodology to profile the preoperative CSF of patients (n = 54) who developed delirium following arthroplasty (n = 28) and those who did not (n = 26). The aim was to identify novel preoperative markers of delirium, and to assess potential correlations with clinical data. Participants without a diagnosis of dementia (≥65 years) undergoing elective primary hip or knee arthroplasty were postoperatively assessed for delirium once-daily for three days. Groups were compared using multivariate, univariate and receiving operator characteristic (ROC) methods. Multivariate modelling using Orthogonal Partial Least Squares-Discriminant Analysis (OPLS-DA) of metabolomic data readily distinguished between delirium and control groups (R2 ≤ 0.56; Q2 ≤ 0.10). Three metabolites (spermidine, putrescine and glutamine) significantly differed between groups (P < 0.05; FDR < 0.07), and performed well as CSF biomarkers (ROC > 0.75). The biomarker performance of the two polyamines (spermidine/putrescine) was enhanced by ratio with CSF Aβ42 (ROC > 0.8), and spermidine significantly correlated with Aβ42 (pearson r = −0.32; P = 0.018). These findings suggest that spermidine and putrescine levels could be useful markers of postoperative delirium risk, particularly when combined with Aβ42, and this requires further investigation.
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Affiliation(s)
- Xiaobei Pan
- Institute for Global Food Security, School of Biological Sciences, Queen's University Belfast, 8 Malone Road, Belfast, BT9 5BN, Northern Ireland
| | - Emma L Cunningham
- Centre for Public Health, Queen's University Belfast, Block B, Institute of Clinical Sciences, Royal Victoria Hospital site, Grosvenor Road, Belfast, BT12 6BA, Northern Ireland.
| | - Anthony P Passmore
- Centre for Public Health, Queen's University Belfast, Block B, Institute of Clinical Sciences, Royal Victoria Hospital site, Grosvenor Road, Belfast, BT12 6BA, Northern Ireland
| | - Bernadette McGuinness
- Centre for Public Health, Queen's University Belfast, Block B, Institute of Clinical Sciences, Royal Victoria Hospital site, Grosvenor Road, Belfast, BT12 6BA, Northern Ireland
| | - Daniel F McAuley
- Centre for Experimental Medicine, Queen's University Belfast, Wellcome-Wolfson Institute for Experimental Medicine, 97 Lisburn Road, Belfast, BT9 7BL, Northern Ireland
| | - David Beverland
- Outcomes Assessment Unit, Musgrave Park Hospital, Belfast Trust, Stockman's Lane, Belfast, BT9 7JB, Northern Ireland
| | - Seamus O'Brien
- Outcomes Assessment Unit, Musgrave Park Hospital, Belfast Trust, Stockman's Lane, Belfast, BT9 7JB, Northern Ireland
| | - Tim Mawhinney
- Cardiac Surgical Intensive Care Unit, Belfast Trust, Royal Victoria Hospital, Grosvenor Road, Belfast, BT12 6BA, Northern Ireland
| | - Jonathan M Schott
- Dementia Research Centre, Department of Neurodegenerative Disease, UCL Institute of Neurology, UK, Box 16, National Hospital for Neurology and Neurosurgery, Queen Square, London, WC1N 3BG, UK
| | - Henrik Zetterberg
- UK Dementia Research Institute at UCL, Cruciform Building, Gower Street, London, London, WC1E 6BT, UK.,Department of Neurodegenerative Disease, UCL Institute of Neurology, London, UK, Box 16, National Hospital for Neurology and Neurosurgery, Queen Square, London, WC1N 3BG, UK.,Clinical Neurochemistry Laboratory, Sahlgrenska University Hospital, House V, S-431 80 Mölndal, Göteborg, Sweden.,Department of Psychiatry and Neurochemistry, Institute of Neuroscience and Physiology, the Sahlgrenska Academy at the University of Gothenburg, Blå Stråket 15, S-413 45, Gothenburg, Sweden
| | - Brian D Green
- Institute for Global Food Security, School of Biological Sciences, Queen's University Belfast, 8 Malone Road, Belfast, BT9 5BN, Northern Ireland.,Core Technology Unit for Mass Spectrometry, Faculty of Medicine, Health and Life Sciences, Queen's University Belfast, Belfast, UK
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Magill P, Cunningham EL, Hill JC, Beverland DE. Identifying the period of greatest blood loss after lower limb arthroplasty. Arthroplast Today 2018; 4:499-504. [PMID: 30569010 PMCID: PMC6288045 DOI: 10.1016/j.artd.2018.09.002] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2018] [Revised: 08/30/2018] [Accepted: 09/03/2018] [Indexed: 11/11/2022] Open
Abstract
Background The use of tranexamic acid (TXA) in total hip replacement (THR) typically reduces blood loss by approximately 400 mL, and typical total blood loss is still approximately 1 L. A barrier to harnessing the full potential of TXA is disagreement on the optimum timing of administration. To address this, we aimed to identify the period of greatest blood loss. Methods We analyzed the perioperative data of 870 patients who had undergone THR, total knee replacement, or unicompartmental knee replacement just before the introduction of TXA to our unit. Total blood loss was calculated on postoperative day (POD) 1 and POD2 using an equation based on change in hematocrit. Results Average total blood loss at POD2 was 1505, 1322, and 611 mL for THR, total knee replacement, and unicompartmental knee replacement, respectively. Between 86% and 96% of this blood loss occurred in the period between skin closure and POD1. Intraoperative loss did not correlate with total loss at POD2. Blood transfusion was more likely if the patient was female (odds ratio [OR], 6.8) or if they had preoperative anemia (OR, 8.3) than if there was a high-volume blood loss (OR, 1.6). Conclusions Approximately 90% of blood loss occurs between skin closure and the first postoperative 24 hours. “Intraoperative blood loss” and “transfusion rate” are not reliable markers of total blood loss. The full potential of TXA could be harnessed by using it during the period of greatest blood loss, that is, during the first postoperative 24 hours.
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Affiliation(s)
- Paul Magill
- Primary Joint Outcomes Unit, Musgrave Park Hospital, Belfast, Northern Ireland
| | - Emma L Cunningham
- Primary Joint Outcomes Unit, Musgrave Park Hospital, Belfast, Northern Ireland.,Centre for Public Health, Queen's University Belfast, Northern Ireland
| | - Janet C Hill
- Primary Joint Outcomes Unit, Musgrave Park Hospital, Belfast, Northern Ireland
| | - David E Beverland
- Primary Joint Outcomes Unit, Musgrave Park Hospital, Belfast, Northern Ireland
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Cunningham EL, McGuinness B, Beverland D, McAuley DF, O'Brien S, Mawhinney T, Toombs J, Zetterberg H, Schott JM, Lunn M, Passmore AP. [P1–348]: CSF Aβ42 CONCENTRATION INDEPENDENTLY PREDICTS POSTOPERATIVE DELIRIUM IN AN ELDERLY ELECTIVE ARTHROPLASTY POPULATION. Alzheimers Dement 2017. [DOI: 10.1016/j.jalz.2017.06.364] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Affiliation(s)
| | | | | | | | | | | | | | - Henrik Zetterberg
- Institute of Neuroscience and PhysiologyThe Sahlgrenska Academy at University of GothenburgGothenburgSweden
- Clinical Neurochemistry LaboratorySahlgrenska University HospitalMölndalSweden
- Institute of Neuroscience and PhysiologyDepartment of Psychiatry and NeurochemistryThe Sahlgrenska Academy at University of GothenburgGothenburgSweden
- University of GothenburgGothenburgSweden
- University College LondonLondonUnited Kingdom
| | - Jonathan M. Schott
- University College LondonLondonUnited Kingdom
- Dementia Research CentreInstitute of Neurology, University College LondonLondonUnited Kingdom
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Cunningham EL, Passmore AP, McAuley DF, Beverland D, O'Brien S, McGuinness B. P1‐242: Utility of Neuropsychological Tests in Predicting Post‐Operative Delirium Following Elective Primary Arthroplasty. Alzheimers Dement 2016. [DOI: 10.1016/j.jalz.2016.06.991] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Cunningham EL, McGuinness B, Herron B, Passmore AP. Dementia. Ulster Med J 2015; 84:79-87. [PMID: 26170481 PMCID: PMC4488926] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Accepted: 04/04/2015] [Indexed: 11/17/2022]
Abstract
Dementia is a clinical diagnosis requiring new functional dependence on the basis of progressive cognitive decline. It is estimated that 1.3% of the entire UK population, or 7.1% of those aged 65 or over, have dementia. Applying these to 2013 population estimates gives an estimated number of 19,765 people living with dementia in Northern Ireland. The clinical syndrome of dementia can be due to a variety of underlying pathophysiological processes. The most common of these is Alzheimer's disease (50-75%) followed by vascular dementia (20%), dementia with Lewy bodies (5%) and frontotemporal lobar dementia (5%). The clinical symptoms and pathophysiological processes of these diseases overlap significantly. Biomarkers to aid diagnosis and prognosis are emerging. Acetylcholinesterase inhibitors and memantine are the only medications currently licensed for the treatment of dementia. The nature of symptoms mean people with dementia are more dependent and vulnerable, both socially and in terms of physical and mental health, presenting evolving challenges to society and to our healthcare systems.
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Affiliation(s)
| | - B McGuinness
- Centre for Public Health, Queen's University Belfast ; Belfast Health and Social Care Trust
| | - B Herron
- Belfast Health and Social Care Trust
| | - A P Passmore
- Centre for Public Health, Queen's University Belfast ; Belfast Health and Social Care Trust
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Affiliation(s)
- E L Cunningham
- Centre for Public Health, Queen's University Belfast, Block B, Institute Clinical Sciences, Royal Victoria Hospital, Belfast, BT12 6BA
| | - A P Passmore
- Centre for Public Health, Queen's University Belfast, Block B, Institute Clinical Sciences, Royal Victoria Hospital, Belfast, BT12 6BA
| | - D F McAuley
- Centre for Public Health, Queen's University Belfast, Block B, Institute Clinical Sciences, Royal Victoria Hospital, Belfast, BT12 6BA
| | - B McGuinness
- Centre for Public Health, Queen's University Belfast, Block B, Institute Clinical Sciences, Royal Victoria Hospital, Belfast, BT12 6BA
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Cunningham EL, Passmore AP, McAuley DF, McGuinness B. Reciting the months of the year backwards: what is a 'normal' score? Age Ageing 2015. [DOI: 10.1093/ageing/el_719] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
| | - AP Passmore
- Clinical Research Fellow, Queen's University Belfast
| | - DF McAuley
- Clinical Research Fellow, Queen's University Belfast
| | - B McGuinness
- Clinical Research Fellow, Queen's University Belfast
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Purvis JA, Cunningham EL, McGlinchey PG, Barr SH. Drugs, electrolytes and tako-tsubo cardiomyopathy: triple aetiology of acquired long QT syndrome and torsades de pointes. Ulster Med J 2009; 78:188-9. [PMID: 19907690 PMCID: PMC2773607] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Abstract
The folding of the extracellular serine protease, alpha-lytic protease (alphaLP; EC 3.4.21.12) reveals a novel mechanism for stability that appears to lead to a longer functional lifetime for the protease. For alphaLP, stability is based not on thermodynamics, but on kinetics. Whereas this has required the coevolution of a pro region to facilitate folding, the result has been the optimization of native-state properties independent of their consequences on thermodynamic stability. Structural and mutational data lead to a model for catalysis of folding in which the pro region binds to a conserved beta-hairpin in the alphaLP C-terminal domain, stabilizing the folding transition state and the native state. The pro region is then proteolytically degraded, leaving the active alphaLP trapped in a metastable conformation. This metastability appears to be a consequence of pressure to evolve properties of the native state, including a large, highly cooperative barrier to unfolding, and extreme rigidity, that reduce susceptibility to proteolytic degradation. In a test of survival under highly proteolytic conditions, homologous mammalian proteases that have not evolved kinetic stability are much more rapidly degraded than alphaLP. Kinetic stability as a means to longevity is likely to be a mechanism conserved among the majority of extracellular bacterial pro-proteases and may emerge as a general strategy for intracellular eukaryotic proteases subject to harsh conditions as well.
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Affiliation(s)
- E L Cunningham
- Graduate Group in Biophysics, Howard Hughes Medical Institute, Department of Biochemistry, University of California, San Francisco, CA 94143-0448, USA
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Abstract
The Coomassie brilliant blue dye-binding method for protein assay has become important relatively recently. The basis of the assay method is the binding of dye to protein, with production of a dye-protein complex which absorbs light intensely at 620 nm, but the mechanism of the binding process is not well understood. In this paper, two mathematical models for the binding process are developed, one involving the binding of both protonated (green) and deprotonated (blue) forms of the dye. The second model allows only binding of the blue species to proteins. These models are tested for their ability to estimate number of dye-binding sites (n) and binding constants (Kd) from protein assay data. The models are also tested for their ability to reproduce the experimental assay curve using either known values or reasonable estimates of the equation parameters. The models are shown to be approximately equal in ability to reproduce experimental data related to the protein assay, which somewhat favors the simpler of the two models. In this paper, a method for estimating n and Kd from standard curve-fitting procedures is established. Hitherto, binding constants were only available from assay data taken under conditions of very large molar protein/dye ratios. The possibility of protonated forms of the dye binding to proteins was not ruled out by this study, but for many purposes the use of the simple dye-binding model, in which only the deprotonated dye species binds, is sufficient.
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Affiliation(s)
- B A Atherton
- Department of Chemistry, Gustavus Adolphus College, St. Peter, Minnesota 56082, USA
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Abstract
Recombinant human heparin cofactor II (rHCII) was expressed as a fully active protein in the High-Five insect cell line. A maximal protein concentration of 6 micrograms/10(6) cells was achieved 2 days postinfection. Approximately 40 micrograms of partially purified rHCII was routinely recovered from 50 ml of media after sequential heparin and Q-Sepharose affinity adsorption. rHCII had a slightly lower apparent molecular weight than blood plasma HCII (pHCII) due to differences in N-glycosylation. Like pHCII, rHCII formed a stable bimolecular complex with thrombin when assessed by sodium dodecyl sulfate-polyacrylamide gel electrophoresis. The thrombin and chymotrypsin inhibitory properties of rHCII and pHCII were quite similar. In the absence of glycosaminoglycan, the thrombin inhibition rate (k2 x 10(-4) M-1 min-1) was 2.29 +/- 0.36 for rHCII and 3.38 +/- 0.34 for pHCII. Chymotrypsin inhibition rates (k2 x 10(-5) M-1 min-1) were 6.2 +/- 2.0 for rHCII and 8.0 +/- 2.6 for pHCII. In the presence of glycosaminoglycans, the maximal thrombin inhibition rate (k2 x 10(-3) M-1 min-1) for rHCII was 10.4 +/- 2.5 at 100 micrograms/ml heparin and 16.0 +/- 4.3 at 1000 micrograms/ml dermatan sulfate compared to 9.0 +/- 0.7 at 200 micrograms/ml heparin and 18.5 +/- 5.3 at 1000 micrograms/ml dermatan sulfate for pHCII. HCII inhibition of thrombin was blocked by a synthetic sulfated hirudin peptide in both the presence and the absence of glycosaminoglycan. The present report describes for the first time the expression and characterization of HCII in a baculovirus system and demonstrates the feasibility of using this system to obtain adequate amounts of biologically active rHCII for future structure-function studies.
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Affiliation(s)
- A V Ciaccia
- Department of Pharmacology, University of North Carolina School of Medicine, Chapel Hill 27599-7035, USA
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Cunningham EL, González M, Rodríguez Servera RJ. The restrictive pattern of pulmonary dysfunction in bronchiectasis. Bol Asoc Med P R 1985; 77:471-5. [PMID: 3867359] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
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Stanley NN, Cunningham EL, Altose MD, Kelsen SG, Levinson RS, Cherniack NS. Evaluation of breath holding in hypercapnia as a simple clinical test of respiratory chemosensitivity. Thorax 1975; 30:337-43. [PMID: 1145539 PMCID: PMC470288 DOI: 10.1136/thx.30.3.337] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Breath holding was used as the basis of a simple test of respiratory chemosensitivity. Breath holding was begun at selected degrees of hypercapnia produced by CO2 rebreathing. In 16 healthy control subjects there was a linear regression of the log of breath-holding time on the PCO2 at the start of breath holding. Breath-holding time (BHT) and the slope of a log BHT/Pco2 plot were closely correlated with the ventilatory response to CO2. In five cases of the idiopathic hypoventilation syndrome, CO2 retention and reduced ventilatory response to CO2 were accompanied by prolonged breath-holding time and the regression of log BHT on Pco2 was abnormally flat. However, in 17 patients with chronic airways obstruction, breath-holding time was never prolonged and the log BHT/Pco2 relationship was normal, even though 13 had a diminished ventilatory response to CO2 and four had chronic CO2 retention. It is concluded that the BHT/Pco2 relationship provides a useful index of respiratory chemosensitivity which is not influenced by airways obstruction. This may be helpful in the detection of impaired chemosensitivity as a cause of CO2 retention even when the ventilation CO2 response is reduced non-specifically by coexisting airways obstruction.
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Stanley NN, Alper R, Cunningham EL, Cherniack NS, Kefalides NA. Effects of a molecular change in collagen on lung structure and mechanical function. J Clin Invest 1975; 55:1195-1201. [PMID: 1133168 PMCID: PMC301873 DOI: 10.1172/jci108037] [Citation(s) in RCA: 24] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
Semicarbazide, a lathyrogen, was given to growing rats to elucidate the consequences of altering the molecular structure of fibrous proteins within the lung. Static pressure-volume (P-V) measurements during deflation of saline-filled lungs showed normal recoil pressure and compliance values within the physiological range of lung volume. Quasi-static P-V measurements were also normal during slow reinflation, even beyond physiological limits to a recoil pressure of 20 cm H20. However, the lungs of experimental rats ruptured at much lower recoil pressures than controls. Histology was normal in lungs fixed at 20 cm H20. In contrast, lungs showed dilation of terminal air spaces, rupture of alveolar walls, and an increase in mean linear intercept in experimental compared with control specimens, when fixed at 30 cm H20. Biochemical analyses revealed reduced cross-linking of lung collagen without change in its total content. There were no detectable changes in the quantity or quality of lung elastin. It is concluded that semicarbazide may selectively impair the maturation of lung collagen and that immaturity of lung collagen is associated with a reduction in the tensile strength of lung tissue, without changes in elasticity within physiological volume limits.
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