Prevalence and features of delirium in older patients admitted to rehabilitation facilities: a multicenter study

BACKGROUND

Delirium is thought to be common across various settings of care; however, still little research has been conducted in rehabilitation.

AIM

We investigated the prevalence of delirium, its features and motor subtypes in older patients admitted to rehabilitation facilities during the three editions of the "Delirium Day project".

METHODS

We conducted a cross-sectional study in which 1237 older patients (age ≥ 65 years old) admitted to 50 Italian rehabilitation wards during the three editions of the "Delirium Day project" (2015 to 2017) were included. Delirium was evaluated through the 4AT and its motor subtype with the Delirium Motor Subtype Scale.

RESULTS

Delirium was detected in 226 patients (18%), and the most recurrent motor subtype was mixed (37%), followed by hypoactive (26%), hyperactive (21%) and non-motor one (16%). In a multivariate Poisson regression model with robust variance, factors associated with delirium were: disability in basic (PR 1.48, 95%CI: 1.17-1.9, p value 0.001) and instrumental activities of daily living (PR 1.58, 95%CI: 1.08-2.32, p value 0.018), dementia (PR 2.10, 95%CI: 1.62-2.73, p value < 0.0001), typical antipsychotics (PR 1.47, 95%CI: 1.10-1.95, p value 0.008), antidepressants other than selective serotonin reuptake inhibitors (PR 1.3, 95%CI: 1.02-1.66, p value 0.035), and physical restraints (PR 2.37, 95%CI: 1.68-3.36, p value < 0.0001).

CONCLUSION

This multicenter study reports that 2 out 10 patients admitted to rehabilitations had delirium on the index day. Mixed delirium was the most prevalent subtype. Delirium was associated with unmodifiable (dementia, disability) and modifiable (physical restraints, medications) factors. Identification of these factors should prompt specific interventions aimed to prevent or mitigate delirium.

The association between low skeletal muscle mass and delirium: results from the nationwide multi-centre Italian Delirium Day 2017

Introduction

Delirium and sarcopenia are common, although underdiagnosed, geriatric syndromes. Several pathological mechanisms can link delirium and low skeletal muscle mass, but few studies have investigated their association. We aimed to investigate (1) the association between delirium and low skeletal muscle mass and (2) the possible role of calf circumference mass in finding cases with delirium.

Methods

The analyses were conducted employing the cross-sectional “Delirium Day” initiative, on patient 65 years and older admitted to acute hospital medical wards, emergency departments, rehabilitation wards, nursing homes and hospices in Italy in 2017. Delirium was diagnosed as a 4 + score at the 4-AT scale. Low skeletal muscle mass was operationally defined as calf circumference ≤ 34 cm in males and ≤ 33 cm in females. Logistic regression models were used to investigate the association between low skeletal muscle mass and delirium. The discriminative ability of calf circumference was evaluated using non-parametric ROC analyses.

Results

A sample of 1675 patients was analyzed. In total, 73.6% of participants had low skeletal muscle mass and 24.1% exhibited delirium. Low skeletal muscle mass and delirium showed an independent association (OR: 1.50; 95% CI 1.09–2.08). In the subsample of patients without a diagnosis of dementia, the inclusion of calf circumference in a model based on age and sex significantly improved its discriminative accuracy [area under the curve (AUC) 0.69 vs 0.57, p < 0.001].

Discussion and conclusion

Low muscle mass is independently associated with delirium. In patients without a previous diagnosis of dementia, calf circumference may help to better identify those who develop delirium.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40520-021-01950-8.

Hospital discharge in patients at risk of surgical site infection: antimicrobial stewardship at Ferrara University Hospital, Italy

INTRODUCTION

The appropriate use of antibiotics is a global priority in order to avoid antibiotic resistance. Up to 50% of antibiotics usage in hospital is inappropriate (e.g. prolonged surgical prophylaxis, "defensive medicine" approach). In 2015, at the Ferrara University Hospital, an antimicrobial stewardship intervention to reduce antimicrobial prescription at the time of hospital discharge in patients at risk of surgical site infection was implemented. This programme included: update meetings for health professionals, focused meetings for critical wards, reviews of some surgical prophylaxis protocols, recommendations to reduce broad-spectrum antimicrobials use, and planning of an audit. The purpose of this study has been to evaluate the effect of this antimicrobial stewardship programme.

METHODS

To evaluate the effect of this intervention, a study has been carried out including inpatients in surveillance for surgical site infection who had surgery during the last quarter of 2014 (pre-intervention group; 461 patients) and of 2015 (post-intervention group; 532 patients).

RESULTS

The proportion of patients with prescription of at least one antimicrobial at discharge decreased from 33% to 24.4% (p = 0.002). The most prescribed categories of antimicrobials in both groups were the combination of penicillins with beta-lactamase inhibitors (with prescription rate reduced from 21.9% to 18%; p = 0.13) and fluoroquinolones (from 8.2% to 3.2%; p < 0.001).

CONCLUSIONS

This statistically significant reduction in antimicrobial prescription after the intervention was registered without a change in surgical site infections rate (from 3.5% to 3.2%; p = 0.08). Therefore, this intervention was effective in reducing the antimicrobial prescription at discharge, without affecting patients' safety.

Prognostic Value of Autoantibodies against Erythrocytes and Platelets in Chronic Lymphocytic Leukemia (CLL)

Antiglobulin test (AT) and Dixon tests were performed in 100 patients with CLL. Thirty-five of them had Rai stages 0 or 1, 19 stage 2, 13 stage 3, and 33 stage 4. Twelve patients showed red blood cells autoantibodies (RBCAb) positivity; positivity at Dixon test (direct, indirect, or both) was observed in 74 %. The presence of autoantibodies against erythrocytes and platelets did not influence survival curves, but anemia and thrombocytopenia are considered risk factors, independently of the presence of an autoimmune disorder. Nine RBCAb positive patients with positive Dixon test had the worst survival curves, 5 of these were anemic and 1 thrombocytopenic and anemic.

CO(2) pneumoperitoneum induces in vitro hypoxic response culminating in apoptosis of human neuroblastoma cells

The ablative role of minimally invasive surgery (MIS) in neuroblastoma (NB) is still controversial due to the possible CO₂ pneumoperitoneum side-effects on tumor aggressiveness. It is known that CO₂ produces hypoxic condition with changes in tumor microenvironment influencing cell functions. Here we investigated whether CO₂ exposure affects the transcription factor HIF-1α and the apoptotic signalling pathway in SH-SY5Y NB cells. SH-SY5Y cells were exposed to a pressure of 15 mmHg CO₂ (100%) for 4 h (T0) and then moved to normal condition for 24 h (T₂₄). In control and CO₂ -exposed cells, we analyzed the mRNA levels and DNA binding activity of HIF-1α. We also evaluated the proliferative activity and cell viability as well as caspase-9/3 cleavage and nuclear fragmentation. A significant increase in HIF- 1α activation was observed in SH-SY5Y cells exposed to CO₂ compared to control cells. CO₂ treatment also decreased the proliferation rate and the percentage of viable cells. In addition, the expression and cleavage of caspase-9 and -3 were significantly increased in NB cells exposed to CO₂. These data correlated with apoptotic feature observed in CO₂ -treated NB cells. Our findings show that CO₂ -induced hypoxic condition exerts cytotoxic effects on NB cells by eliciting mitochondrial apoptotic pathway and thereby improving the understanding of the possible clinical impact of CO₂ pneumoperitoneum on NB behaviour.

Orthorexia nervosa in the general population: a preliminary screening using a self-administered questionnaire (ORTO-15)

OBJECTIVE

Orthorexia, from the Greek words orthos (straight, proper) and orexis (appetite), is a newly conceptualized disorder characterized by distorted eating habits and cognitions concerning supposedly healthy nutrition. In this article we present preliminary results of a wider research aimed to investigate the diffusion of Orthorexia in the general population and to highlight its characteristics and particularly the relationship with Eating Disorder and Obsessive-Compulsive Disorder.

METHOD

One-hundred and seventy seven adult subjects from the general population, were administered the ORTO-15 test, a selfadministered questionnaire specifically designed to assess orthorexic symptomatology; note that statistical analyses were repeated twice, referring to different diagnostic thresholds (40/35).

RESULTS

Orthorexia had a 57.6% prevalence in our sample, using the 40-point threshold, with a female/male ratio 2:1; the figure was sensibly lower with the 35-point threshold (21%).

CONCLUSION

The results of this study highlight the diffusion of Orthorexia which may constitute an important risk factor for mental and physical health, but also the opportunity of more specific diagnostic instruments, so to facilitate a thorough understanding of this disorder.

Prevalence of penicillin-nonsusceptible pneumococcal bacteremia in a Staten Island community hospital

BACKGROUND

Although the first reports of infection due to penicillin-nonsusceptible Streptococcus pneumoniae in the United States were in children, these strains have circulated widely in recent years, with the prevalence increasing dramatically among the elderly. Regional surveillance of pneumococcal susceptibility profiles may assist clinicians in management decisions, increase awareness of this microbial threat, and target potential areas of intervention.

METHODS

As part of ongoing surveillance, we surveyed single-patient pneumococcal blood isolates in our 440-bed Staten Island community teaching hospital from June 1, 1996, through May 31, 1998.

RESULTS

Overall, of 47 single-patient isolates, 16 (35%) were penicillin nonsusceptible. Of 35 isolates from adults, 15 (44%) were nonsusceptible, compared with 1 of 12 (8%) from children. Seven of the nonsusceptible isolates (44%) were from persons > or = 65 years old and represented 47% of the isolates from this age group.

CONCLUSIONS

Community-acquired penicillin-nonsusceptible pneumococcal bacteremia is not simply a pediatric problem, but also a threat to the elderly.

Focally folded myelin in Charcot-Marie-Tooth neuropathy type 1B with Ser49Leu in the myelin protein zero

Charcot-Marie-Tooth disease type 1 B (CMT1B) is a demyelinating neuropathy caused by mutations in the myelin protein zero (P0) gene (MPZ). A few cases of CMT1B were recently found to be characterized by focally folded myelin sheaths in nerve biopsy specimens; the significance of this association is unknown. Here, we describe two unrelated pedigrees harboring a heterozygous Ser49Leu substitution in P0ex. In both pedigrees, the mutation caused a late-onset, relatively mild CMT1B; in one pedigree, two patients had atrophy of peroneal muscles but hypertrophy of the gastrocnemius muscles. The sural nerve biopsy performed in the two index cases revealed an identical chronic demyelinating and remyelinating neuropathy dominated by focal foldings of the myelin sheath shaped either as tomacula or as out/infoldings. The report adds Ser49Leu to the mutations of P0ex associated with focally folded myelin and provides strong evidence that such a structural alteration of the myelin sheath reflects a distinct pathogenetic mechanism in a subgroup of CMT1B.

Umbilical cord blood transplant from unrelated HLA-mismatched donors in children with high risk leukemia

In the last 3 years, 14 children with high-risk leukemia (11 ALL, 2 AML and 1 CML) underwent cord blood transplantation from unrelated HLA-mismatched donors at a median of 99 days from the start of search. Eight patients were transplanted in second CR, one in accelerated phase, three at relapse and two patients in first CR. Conditioning regimen (fractionated TBI, etoposide, CY and anti-lymphocyte serum) and prophylaxis of GVHD (CsA and 6-methylprednisolone) were identical for all patients. Neutrophils >0.5x10(9)/l were reached at a median of 33 days from transplant, but in four cases we observed an autologous hematopoietic reconstitution (three spontaneous, one after autologous BM rescue). Acute and chronic GVHD were observed in 10/14 and 3/8 evaluable cases, respectively. Three patients died of transplant-related toxicity and three patients relapsed. The probabilities of event-free, disease-free and overall survival were 50, 53 and 64%, respectively. Cord blood transplant from HLA-mismatched unrelated donor is a valid option for the treatment of children with high-risk leukemia. With our eligibility criteria, conditioning regimen and prophylaxis of graft-versus-host disease, the main obstacles to successful transplant were represented by graft failure and fatal acute GVHD.

N alpha- and N epsilon-D-galacturonoyl-L-lysine amides: properties and possible occurrence in plant cell walls

Three representatives of a novel class of amide (isopeptide) glycoconjugates have been synthesised: N alpha-D-galacturonoyl-L-lysine and N epsilon-D-galacturonoyl-L-lysine and N epsilon-D-polygalacturonoyl-L-lysine. Galacturonoyl-lysine amide bonds were labile in 2 M trifluoroacetic acid at 120 degrees and in alkali, but relatively stable in cold acid. The amide bonds were resistant to digestion by Driselase, Pronase and trypsin. The polysaccharide backbone of N epsilon-D-polygalacturonoyl-L-lysine was hydrolysed by Driselase to yield two major ninhydrin-positive compounds which were shown by 1H and 13C NMR spectroscopy to be tri- and tetra-alpha-(1-->4)-D-galacturonoyl-L-lysines. To investigate the possible natural occurrence of N-galacturonoyl isopeptide bonds, we fed cell-suspension cultures of spinach and tomato with D-[6-14C]glucuronic acid, which radio-labels pectic polysaccharides. The radioactive cell walls were digested with, sequentially, Driselase, mild acid, and proteinases. On electrophoresis at pH 2.0, several of the radioactive digestion-products were cathodic. Some of the cathodic products yielded [14C]galacturonic acid upon complete acid hydrolysis. The existence of these products is compatible with the presence of novel N-galacturonoyl isopeptide bonds, which could serve as cross-links in plant cell walls.

Umbilical cord blood (UCB) transplant from unrelated mismatched donor in patients with high risk (HR) leukemia

Ten consecutive children with high risk leukemia have been submitted to UCB transplant from unrelated HLA mismatched donors. All patients received an identical regimen for conditioning and GVHD prophylaxis. The median dose of viable nucleated cells infused was 2.6 x 10(6)/kg b.w. Among the nine patients evaluable for engraftment the hematopoiesis was of full donor origin in six patients and autologous in three. At a median follow-up of 9 months, six of nine (67%) patients are alive in CR.

Umbilical cord blood transplant from HLA-mismatched unrelated donor in high-risk leukemia

Twelve consecutive children with high-risk leukemia have been submitted to UCB transplant from unrelated 1 or 2 loci HLA-mismatched donor. All patients received an identical regimen for conditioning and GVHD prophylaxis. The median dose of viable nucleated cells infused was 2.8 x 10(7)/kg bw (range 1.4-7.9). Of 11 patients evaluable for engraftment, the hematopoiesis was of full donor origin in seven patients and autologous in four. The probability of disease-free survival at 1 and 2 years from UCB transplant is 60 and 42%, respectively.

The diabetic cataract: an unusual presentation in a young subject: case report

This case report concerns a 14-year-old female patient, whose insulin-dependent diabetes mellitus was displayed by one infrequent complication, the cataract. This is an unusual manifestation in a 14-year-old patient; indeed, there are many findings in experimental animals demonstrating the development of this complication by maintaining blood glucose levels above 12 mM. After surgical therapy, complete vision was recovered, but we think that an earlier diagnosis and therapy of metabolic derangement of diabetes may have avoided this complication.

Serum uric acid and insulin secretion in diabetes mellitus

In order to define the relationship, if any, between serum uric acid and insulin pattern in different types of diabetes mellitus, 4 groups of subjects (controls, and affected by type 1 and type 2 diabetes mellitus, with and without obesity) were considered. In each group, successively cleared of the long-term and complicated diabetic patients, serum and urinary uric acid and insulin secretion (serum C-peptide values) were determined. Serum uric acid and C-peptide values were higher in type 2 obese diabetic subjects vs the other groups of patients and controls (p < 0.001). No difference was found, on the contrary, between creatinine clearance and urinary excretion of uric acid among the groups. Moreover, serum uric acid values were in positive correlation (p < 0.02) with serum C-peptide values considering, among the diabetic subjects, only those with duration of diabetes less than 5 years and without micro-macrovascular complications. In conclusion, these data lead to presume that diabetic patients with short duration of disease and without complications show a different serum uric acid pattern, strictly related to beta-cellular secretion.

[Somatosensory evoked potentials in the evaluation and follow-up of patients with cervical vertebral and spinal cord injuries]

Somatosensory evoked potentials have been serially recorded in 21 patients with cervical spinal cord injury. Each patient received the SEP test and a full neurological examination within 1 day after admission, after surgery, and 3-6 weeks following admission. Further SEP test and clinical evaluation were carried out 3-6 months after injury. Neurological status was graded according to the Sunnybrook Scale. In all patients we evaluated latency and amplitude of SEPs obtained from both median and tibial nerve stimulation. Immediately following injury SEPs were absent in 6 patients, abnormal in 10, and normal in 5 patients. No surgery was carried out in patients with normal SEPs where myelography and CT scan could not demonstrate surgical lesions. Four patients had some distal motor improvement but SEPs still absent, one had traceable SEPs following surgery but no motor improvement. Surgery was performed in all 10 patients with abnormal SEPs: 7 patients improved following surgery. In two patients SEPs showed an early postoperative recovery with subsequent late clinical improvement. The SEP technique is well suited to the non invasive study of spinal cord condition and serial recording in patients with spinal cord injury. Although SEPs are of limited clinical value when absent immediately following trauma, the presence of well preserved median and tibial SEP in the postinjury period indicates the best prognosis for motor and sensory functions.

Brain contusion in minor cranial traumas

Minor cranial traumas without surgical emergency account for about 4% of admissions to our Neurological Service. We consider here 226 consecutive cases. Investigations include: clinical examination, skull X-rays, CSF, EEG, CT, isotopic cisternography. The aim of this study is to define the clinical characteristics of patients with minor head trauma and the priority of instrumental investigations. Correlation between clinical and laboratory findings suggests that: X-ray examination is not predictive of CSF hemorrhage or brain contusion; the CSF is bloody in 1/3 of asymptomatic cases and in 1/6 of cases without fracture; the EEG shows indirect signs of brain contusion even in cases without CT evidence; small subdural hematomas are best diagnosed by CT scan.

High performance liquid chromatographic profiles of nucleosides, bases and tryptophan in the plasma of the Tasmanian devil and four other marsupial species

Plasma profiles of nucleosides, bases and trytophan of five marsupial species were established using the reversed-phase mode of high performance liquid chromatography (RHPLC). Within each species, the profiles were highly reproducible and between species there were distinct differences. In the Tasmanian devil, the circulating levels of constituents examined with one exception, were generally lower than in the other marsupials. The exception was a constituent present in large amounts and having the characteristics of a purine nucleoside derivative which was found only in the plasma of the devil.

Bilateral TIAs and unilateral seizures due to orthostatic hypotension. A case report

After a reversible right hemispheric stroke, a patient with bilateral carotid occlusion developed left motor seizures and bilateral TIAs, both triggered by orthostatic hypotension. A CT-scan showed a right frontal hypodense area. Hemodynamic factors may cause focal seizures in patients with cortical lesions.

Right-left asymmetry in anterior speech region

The extent of the anterior speech region (defined as pars opercularis and pars triangularis of the third frontal convolution) and of the planum temporale was measured in 12 brains belonging to strictly right-handed persons. When the portion of the anterior speech region visible on the hemispheric surface was measured, no interhemispheric difference was found. By contrast, when both the extrasulcal and intrasulcal portions of cortex were considered, the anterior speech region in the left hemisphere was found to be significantly larger than the homologous areas in the right hemisphere. The planum temporale was significantly larger on the left than on the right, but there was no necessary correspondence between the presence of a larger right planum and a larger right anterior speech region.

A randomized trial of aspirin and sulfinpyrazone in patients with TIA

In a double-blind multicenter study, 124 patients with transient ischemic attacks were randomly allocated to one of two groups treated with aspirin (ASA) or sulfinpyrazone respectively. Patients were followed up to assess the relative efficacy of the two treatments in the prevention of the outcomes of stroke, myocardial infarction, vascular death, and worsening or no improvement of TIAs. No significant difference was observed between the two treatments at the end of the follow-up period. Statistical analysis revealed a significant interaction of sex, treatment, and occurrence of events. Analysis of the results according to sex showed that male patients treated with ASA had a highly significant benefit (p less than 0.001) with a 53% risk reduction for further events. In female patients, sulfinpyrazone showed a favorable trend which was not statistically significant.

Assessment of inter-observer differences in the Italian multicenter study on reversible cerebral ischemia

A standardized protocol was used for duplicate examination by two neurologists of the clinical history and neurological signs in 55 patients with reversible cerebral ischemia. One trained examiner from each of eight clinical centres involved in the Italian Cooperative Study on reversible cerebral ischemia participated in this research. Duplicate examination were compared in order to evaluate the percentage of agreement achieved in the responses. Several discrepancies relating to either historical data or neurological signs were detected. Possible causes of this disagreement are discussed. The inter-observer differences appear to be an important problem to be faced in cooperative studies on reversible ischemic attacks. The purpose of the study was to estimate these differences in the attempt to increase the degree of agreement by repeated training sessions and discussion between the different examiners. These efforts are needed to improve the quality of clinical investigations on reversible cerebral ischemia and to increase the validity of their results.

CT evaluation in patients with transient ischemic attack. Correlation between clinical and angiographic findings

35 patients clinically diagnosed with transient ischemic attack (TIA) and 15 patients clinically diagnosed with reversible ischemic neurological deficits (RIND) were examined by computerized tomography (CT). 34% of TIA patients showed positive CT scans consisting of small hypodenase areas: 60% of RIND patients had larger lesions. In 20% of the overall group the only pathological finding consisted of unilateral focal atophy or ventricular asymmetry. Correlation between angiographically demonstrated atherosclerotic lesions and positive CT was high. On the contrary, no correlation was found between either the risk factors or the natural history of ischemic attack and positive CT findings.