Risk Factors and Outcomes of Delirium in Older Patients Admitted to Postacute Care with and without Dementia

BACKGROUND

Delirium research is poorly studied in postacute care, a growing setting due to aging populations, as well as in dementia, a critical risk factor for delirium and particularly prevalent in postacute care. We investigated risk factors for delirium and its outcomes in older adults with and without dementia admitted to a subacute care unit (SCU) after exacerbated chronic conditions.

METHODS

This is a prospective cohort study including patients ≥65 years old admitted to an SCU for 12 months. We collected demographics, comprehensive geriatric assessments, and presence of dementia and delirium at admission. Outcomes included discharge to previous living situation, mortality, and functional evolution. Due to the high prevalence of dementia, a subgroup analysis was performed to investigate specific risk factors for delirium and related outcomes.

RESULTS

Of 909 patients (mean age [±SD] 85.8 ± 6.7; 60% women, 47.5% with dementia), 352 (38.7%) developed delirium. The main risk factor for delirium was dementia (HR [95% CI] 5.2 [3.5-7.7]); age, functional status, and urinary tract infections were also independently associated with delirium. In dementia patients, only age (HR [95% CI] 1.0 [1.004-1.1]) and being male (HR [95% CI] 1.7 [1.04-2.6]) were associated with delirium. Delirium was associated with greater mortality (10.8 vs. 3.9%; p < 0.001) and greater functional decline in the entire sample (-12.3 vs. -6.4 Barthel index points; p < 0.001). In the dementia subgroup, patients with delirium experienced greater functional loss (p = 0.013) and less functional recovery (p = 0.025).

CONCLUSIONS

In older patients admitted to postacute care, dementia is the main risk factor for delirium, and delirium carries worse clinical and functional outcomes. In patients with dementia, delirium is also relevant, since it entails a functional loss at admission and lower functional recovery.

[18F]tetrafluoroborate-PET/CT enables sensitive tumor and metastasis in vivo imaging in a sodium iodide symporter-expressing tumor model

Cancer cell metastasis is responsible for most cancer deaths. Non-invasive in vivo cancer cell tracking in spontaneously metastasizing tumor models still poses a challenge requiring highest sensitivity and excellent contrast. The goal of this study was to evaluate if the recently introduced PET radiotracer [18F]tetrafluoroborate ([18F]BF4-) is useful for sensitive and specific metastasis detection in an orthotopic xenograft breast cancer model expressing the human sodium iodide symporter (NIS) as a reporter. In vivo imaging was complemented by ex vivo fluorescence microscopy and γ-counting of harvested tissues. Radionuclide imaging with [18F]BF4- (PET/CT) was compared to the conventional tracer [123I]iodide (sequential SPECT/CT). We found that [18F]BF4- was superior due to better pharmacokinetics, i.e. faster tumor uptake and faster and more complete clearance from circulation. [18F]BF4--PET was also highly specific as in all detected tissues cancer cell presence was confirmed microscopically. Undetected comparable tissues were similarly found to be free of metastasis. Metastasis detection by routine metabolic imaging with [18F]FDG-PET failed due to low standard uptake values and low contrast caused by adjacent metabolically active organs in this model. [18F]BF4--PET combined with NIS expressing disease models is particularly useful whenever preclinical in vivo cell tracking is of interest.

Vitexin and isovitexin from the Leaves of Ficus deltoidea with in-vivo α-glucosidase inhibition

ETHNOPHARMACOLOGICAL RELEVANCE

The leaves of Ficus deltoidea are used as a traditional medicine by diabetes patients in Malaysia.

AIM OF THE STUDY

The objective of the study is to identify and evaluate bioactive constituents with in vivo α-glucosidase inhibition.

MATERIALS AND METHODS

The partitioned extracts, subfractions and pure bioactive constituents were subjected to α-glucosidase inhibition assay. The identified bioactive constituents were administered orally to sucrose loaded normoglycemic mice and induced diabetic rats. The postprandial blood glucose levels were monitored at 30 min interval. Acute toxicity was evaluated in both normoglycemic mice and induced diabetic rats.

RESULTS

Bioactivity guided fractionation led to the isolation of both vitexin (1) and isovitexin (2). Oral administration of 1mg/kg of either vitexin (1) or isovitexin (2) significantly (p<0.05) reduced the postprandial blood glucose level in sucrose loaded normoglycemic mice at 30 min. The percentage of postprandial blood glucose reduction was highest in sucrose loaded induced diabetic rats administered orally with 200mg/kg of vitexin (1) or 100mg/kg of isovitexin (2). Both vitexin (1) and isovitexin (2) did not exert any signs of toxicity at the highest dose of 2g/kg administered orally to normoglycemic mice and induced diabetic rats.

CONCLUSION

Both the C-glycosyl bioflavonoids, namely, vitexin (1) and isovitexin (2) exhibited in vivo α-glucosidase inhibition.

MR imaging findings of the uveal schwannoma

BACKGROUND AND PURPOSE

Uveal schwannoma is a rare benign neoplastic proliferation of pure Schwann cells. The purpose of this study was to describe MR imaging features of uveal schwannoma.

MATERIALS AND METHODS

MR images in 6 female patients with uveal schwannoma confirmed by pathologic examination were retrospectively reviewed. MR imaging was performed in all 6 patients, with postcontrast T1-weighted imaging (T1WI) completed in all 6 patients and dynamic contrast-enhanced MR imaging, in 5. MR imaging findings of the tumor were evaluated with emphasis on the location, size, shape, margin, signal intensity, and pattern of enhancement.

RESULTS

The lesions appeared as solitary well-defined ovoid masses in the ciliochoroidal region in 5 patients and in the choroid in 1. With respect to the vitreous body, uveal schwannoma was hyperintense on T1WI spin-echo (SE) images in all 6 patients. The tumors were hypointense to the vitreous body on fast SE (FSE) T2-weighted images (T2WI) in 4 patients and isointense in 1. However, with respect to the brain, uveal schwannoma demonstrated isointensity on T1WI SE images in all 6 patients, isointensity on FSE T2WI images in 5 patients, and hyperintensity on T2WI SE images in 1. On postcontrast T1WI images, 3 patients showed markedly heterogeneous enhancement, and 3 showed markedly homogeneous enhancement.

CONCLUSIONS

Uveal schwannoma should be included in the differential diagnosis when an oval isointense mass relative to brain is seen in the ciliochoroidal region.

[Experimental model of infection of Helicobacter pylori in the mouse. A study of gastric damage caused by indomethacin]

INTRODUCTION

The action of non-steroidal anti-inflammatory drugs (NSAIDs) on the Helicobacter Pylori (Hp) infected mucosa is a matter of debate. Some authors consider them to cause additive iatrogeny whilst others attribute a purportedly protective action to them. The development of on experimental animal model could help clarify this phenomenon.

OBJECTIVES

1--To develop an animal model of Hp gastric infection. 2--To evaluate the aggressiveness of NSAIDs in this model.

MATERIALS AND METHODS

Male 6 month old BALC/C mice weighing 38 g were studied. Pylori Hp infection was ruled out. On three occasions, in the same week, 18 mice were inoculated intra-gastrically with 0.6 ml of Hp culture broth (brain-heart infusion) containing 1 x 10 8-1 x 10 9 CFU/ml. Another group of mice were inoculated with sterile saline. After two months the mice were killed and their stomachs studied. They were divided into groups: a) 6 Hp negative control mice. b) 8 Hp negative mice with prior intra-peritoneal injection of 25 mg/Kg indomethacin (24 hs.) c) 8 mice inoculated with Hp with indomethacin. d) 8 mice inoculated with Hp, without indomethacin. The stomachs were opened along the greater curvature and photographed macroscopically in order to map the necrotic area. The antrums were biopsied to test for urease and separate antrum and body specimens were send for staining with Warthin-Starry H & B and histopathology.

RESULTS

All the mice inoculated with Hp acquired the infection. The necrotic area was larger in Group B: 55.5 +/- 7.87 mm than in Group C: 15 +/- 1.82 mm P < 0.00019.

HISTOLOGY

Group A: normal mucosa. Group B: extensive coagulation necrosis and focal erosions. Group C: ulcers with inflammatory infiltrate and smaller necrotic area, presence of Hp on the surface epithelium. Group D: no ulcers, Hp present.

CONCLUSION

An animal model of Hp infection was successfully developed Hp infection could play a potentially protective role against indomethacin aggression in the mouse.

Motivational structure of alcoholic and nonalcoholic Czech men

This investigation examined the motivational structures of 26 patients diagnosed with alcoholism in comparison to 30 demographically similar technical university students. Responding to the Motivational Structure Questionnaire, the clinical group listed 40% fewer goals, responded as if they needed richer incentives to form strong commitments to goal striving, displayed marginally less average commitment to their goals, and, after other variables were partialled out, expressed less ability to influence the course of goal attainment. There were no differences in their scores on over-all subjective probability of success, the time frame for goal attainment, and their relative scores on anticipated positive and negative emotions and ambivalence. The results suggest group differences in the effects of brain-reward mechanisms.

Helicobacter pylori in recently-diagnosed versus chronic duodenal ulcer

Helicobacter pylori is one of the main causes of type B gastritis and is frequently found in the gastric antrum or in areas of gastric metaplasia in duodenal ulcer patients. The aim of this study was to evaluate Helicobacter pylori and gastric metaplasia prevalence in duodenal ulcer patients within their first diagnosed episode compared to those with chronic ulcer disease. Eighty three patients were prospectively studied in a 2-year period, they were divided into 3 groups: Group I, control, included 29 patients; Group II, 17 patients, included patients with first diagnosed duodenal ulcer episode; and Group III, 37 patients, with chronic ulcer disease. Helicobacter pylori prevalence in duodenum was significatively lower in Group II versus Group III and controls (67.5%, 0% and 3.2% respectively) (p < 0.001). In the antrum Hp prevalence was also lower in Group II compared to Group III and I (41%, 78.3% and 24.1%) with a significative difference (p < 0.001). Gastric metaplasia was significantly higher in Group III versus Group II and controls. These results suggest that Helicobacter pylori plays an important but not exclusive role in the pathogenesis of these disease together with other factors.

Selenium status prior to and during one month total parenteral nutrition in gastroenterological patients: A randomised study of two dosages of Se supplementation

13 consecutive adult gastroenterological patients with non-malignant disease who were candidates for total parenteral nutrition (TPN), and who had mild protein-energy malnutrition (82 +/- 3% of ideal body weight, serum albumin 32 +/- 2 g/l, mean +/- SEM) were found to have, prior to TPN, a Selenium level 50% less than controls (p < 0.001) as assayed by Se and glutathione peroxidase (GSHPx) in plasma and erythrocytes. Compared with other trace metals and minerals, eg, Mn, Zn and Cu, depletion of Selenium was the most marked in this population. Patients were randomised to be supplemented with either 100 or 200 microg/d of sodium-selenite, equal to 32 microg (0.4 micromol) or 64 microg (0.8 micromol) of selenium, in two cross-over periods of TPN, each of two weeks. In this short term study, significant increases in the four measurements of Se status (p < 0.05) were seen in all patients, but there was no difference between those receiving the high or low dose of the element. GSHPx in plasma was normalised within 1 month whereas the increase seen in the erythrocyte pool was consistent with a 4-month half-life. Pooled Se values for patients and controls showed logarithmic correlations between Se and GSHPx in erythrocytes (p < 0.001) and plasma (p < 0.01). Changes in GSHPx provided further evidence of Se depletion in our patients. This study suggests that malnourished gastroenterological patients receiving TPN require Se supplements and that 100 microg (0.4 micromol)/d of sodium-selenite is adequate for most patients since there was no additional benefit from the higher dose of 200 microg (0.8 micromol).

Antibiotic-lock technique is an effective treatment of bacterial catheter-related sepsis during parenteral nutrition

Catheter-related sepsis is one of the most frequent and troublesome complications of parenteral nutrition. In a 2-year survey of 19 home parenteral nutrition patients, with a total of 25.2 years of cyclic nocturnal parenteral nutrition, the annual incidence of catheter-related sepsis was 1.27, of which 84% were due to bacterial catheter infection without any cutaneous focus. These 27 episodes were treated by a daily, 2 ml injection of antibiotic-saline solution, mainly amikacin, locked for 12 h per day within the infected catheter for 15 (7-20) days. On admission the parenteral nutrition was halted for 2 days and the catheter hub was changed. In 7 cases, an average of 3 days (2-5) of systemic antibiotic therapy was given in addition to the 2-week antibiotic-lock. Control of catheter-sepsis was achieved in 93% of the 27 episodes and parenteral nutrition was resumed using the same catheter with only one episode of recurrent sepsis. The present data confirm our preliminary report of the efficacy of the antibiotic-lock technique for the control of bacterial catheter-related sepsis. This treatment offers the advantage over current therapies of avoiding repeated catheter change and 2-6 weeks of systemic antibiotic therapy.