Validity and Reliability of the Memorial Delirium Assessment Scale-Thai Version (MDAS-T) for Assessment of Delirium in Palliative Care Patients

Background

Delirium, a neuropsychiatric syndrome that occurs throughout medical illness trajectories, is frequently misdiagnosed. The Memorial Delirium Assessment Scale (MDAS) is a commonly used tool in palliative care (PC) settings. Our objective was to establish and validate the Memorial Delirium Assessment Scale-Thai version (MDAS-T) in PC patients.

Materials and Methods

The MDAS was translated into Thai. Content validity, inter-rater reliability, and internal consistency were explored. The construct validity of the MDAS-T was analyzed using exploratory factor analysis. Instrument testing of the MDAS-T, the Thai version of the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU-T), and the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition as the gold standard was performed. The receiver operating characteristic (ROC) curve was used to determine the optimal cutoff score. The duration of each assessment was recorded.

Results

The study enrolled 194 patients. The content validity index was 0.97. The intraclass correlation coefficient and Cronbach's α coefficient were 0.98 and 0.96, respectively. A principal component analysis indicated a homogeneous, one-factor structure. The area under the ROC curve was 0.96 (95% confidence interval [CI], 0.93–0.99). The best combination of sensitivity and specificity (95% CI) of the MDAS-T were 0.92 (0.85–0.96) and 0.90 (0.82–0.94), respectively, with a cutoff score of 9, whereas the CAM-ICU-T yielded 0.58 (0.48–0.67) and 0.98 (0.93–0.99), respectively. The median MDAS-T assessment time was 5 minutes.

Conclusion

This study established and validated the MDAS-T as a good and feasible tool for delirium screening and severity rating in PC settings.

Implications for Practice

Delirium is prevalent in palliative care (PC) settings and causes distress to patients and families, thereby making delirium screening necessary. This study found that the MDAS-T is a highly objective and feasible test for delirium screening and severity monitoring in PC settings and can greatly improve the quality of care for this population.

     

Gender differences in cerebrovascular reactivity to carbon dioxide during sevoflurane anesthesia in children: preliminary findings

Background: Cerebrovascular reactivity to carbon dioxide (CO₂R) is affected by age, gender and anesthetic agents. While gender differences in CO₂R are described in adults, there are no such data in children. Aim: To examine the gender differences in CO₂R in children during sevoflurane anesthesia. Methods: Five girls and five boys <15 years of age and ASA physical status I, undergoing general anesthesia for elective surgery were enrolled. Under steady‐state anesthesia with <1.0 MAC sevoflurane, middle cerebral artery blood flow velocity changes were monitored using Transcranial Doppler ultrasound while endtidal carbon dioxide (EtCO₂) was adjusted from 40 to 30 mmHg (hypocapnia) and then from 40 to 50 mmHg (hypercapnia). CO₂R was calculated between EtCO₂ ranges 30–40 and 40–50 mmHg. Cerebrovascular resistance (eCVR) was estimated as MAP/Vmca and the change in eCVR (ΔeCVR) between EtCO₂ 30 and 40 mmHg and between EtCO₂ 40 and 50 mmHg was calculated. Results: There was no gender difference in CO₂R. However, both CO₂R and ΔeCVR were lower in the EtCO₂ 40–50 mmHg range compared to EtCO₂ 30–40 mmHg range only in girls (P = 0.01 and P = 0.01, respectively). Vmca increased significantly with increase in CO₂ (P < 0.001) for both boys and girls. The coefficient of nonlinear correlation (r) between Vmca and EtCO₂ was 0.88 in girls vs 0.66 in boys. Conclusion: While there were no gender differences in CO₂R within the individual EtCO₂ ranges examined, girls but not boys had a significantly lower CO₂R and ΔeCVR in the higher EtCO₂ range during <1.0 MAC sevoflurane anesthesia.     

Role of nitric oxide in hepatic ischemia-reperfusion injury

Hepatic ischemia-reperfusion injury (IRI) occurs upon restoration of hepatic blood flow after a period of ischemia. Decreased endogenous nitric oxide (NO) production resulting in capillary luminal narrowing is central in the pathogenesis of IRI. Exogenous NO has emerged as a potential therapy for IRI based on its role in decreasing oxidative stress,cytokine release,leukocyte endothelial-adhesion and hepatic apoptosis. This review will highlight the influence of endogenous NO on hepatic IRI,role of inhaled NO in ameliorating IRI,modes of delivery,donor drugs and potential side effects of exogenous NO.     

Vasopressor Use and Effect on Blood Pressure After Severe Adult Traumatic Brain Injury

Background  

We describe institutional vasopressor usage, and examine the effect of vasopressors on hemodynamics: heart rate (HR), mean arterial blood pressure (MAP), intracranial pressure (ICP), cerebral perfusion pressure (CPP), brain tissue oxygenation (PbtO₂), and jugular venous oximetry (SjVO₂) in adults with severe traumatic brain injury (TBI).