Derivation and validation of a novel comorbidity‐based delirium risk index to predict postoperative delirium using national administrative healthcare database

ObjectiveTo derive and validate a comorbidity‐based delirium risk index (DRI) to predict postoperative delirium.Data Source/Study SettingData of 506 438 hip fracture repair surgeries from 2006 to 2016 were collected to derive DRI and perform internal validation from the Premier Healthcare Database, which provided billing information on 20‐25 percent of hospitalizations in the USA. Additionally, data of 1 130 569 knee arthroplasty surgeries were retrieved for external validation.Study DesignThirty‐six commonly seen comorbidities were evaluated by logistic regression with the outcome of postoperative delirium. The hip fracture repair surgery cohort was separated into a training dataset (60 percent) and an internal validation (40 percent) dataset. The least absolute shrinkage and selection operator (LASSO) procedure was applied for variable selection, and weights were assigned to selected comorbidities to quantify corresponding risks. The newly developed DRI was then compared to the Charlson‐Deyo Index for goodness‐of‐fit and predictive ability, using the Akaike information criterion (AIC), Bayesian information criterion (BIC), area under the ROC curve (AUC) for goodness‐of‐fit, and odds ratios for predictive performance. Additional internal validation was performed by splitting the data by four regions and in 4 randomly selected hospitals. External validation was conducted in patients with knee arthroplasty surgeries.Data CollectionHip fracture repair surgeries, knee arthroplasty surgeries, and comorbidities were identified by using ICD‐9 codes. Postoperative delirium was defined by using ICD‐9 codes and analyzing billing information for antipsychotics (specifically haloperidol, olanzapine, and quetiapine) typically recommended to treat delirium.Principal FindingsThe derived DRI includes 14 comorbidities and assigns comorbidities weights ranging from 1 to 6. The DRI outperformed the Charlson‐Deyo Comorbidity Index with better goodness‐of‐fit and predictive performance.ConclusionsDelirium risk index is a valid comorbidity index for covariate adjustment and risk prediction in the context of postoperative delirium. Future work is needed to test its performance in different patient populations and varying definitions of delirium.     

Universal HIV testing and treatment and HIV stigma reduction: a comparative thematic analysis of qualitative data from the HPTN 071 (PopART) trial in South Africa and Zambia

Despite continued development of effective HIV treatment, expanded access to care and advances in prevention modalities, HIV‐related stigma persists. We examine how, in the context of a universal HIV‐testing and treatment trial in South Africa and Zambia, increased availability of HIV services influenced conceptualisations of HIV. Using qualitative data, we explore people’s stigma‐related experiences of living in ‘intervention’ and ‘control’ study communities. We conducted exploratory data analysis from a qualitative cohort of 150 households in 13 study communities, collected between 2016 and 2018. We found that increased availability of HIV‐testing services influenced conceptualisations of HIV as normative (non‐exceptional) and the visibility of people living with HIV (PLHIV) in household and community spaces impacted opportunities for stigma. There was a shift in community narratives towards individual responsibility to take up (assumingly) widely available service – for PLHIV to take care of their own health and to prevent onward transmission. Based on empirical data, we show that, despite a growing acceptance of HIV‐related testing services, anticipated stigma persists through the mechanism of shifting responsibilisation. To mitigate the responsibilisation of PLHIV, heath implementers need to adapt anti‐stigma messaging and especially focus on anticipated stigma.     

Impact of COVID‐19 on access to healthcare in low‐ and middle‐income countries: Current evidence and future recommendations

The COVID‐19 pandemic continues to be a major public health threat globally and low‐ and middle‐income countries (LMICs) are not an exception. The impact of the COVID‐19 pandemic is far‐reaching on many areas including but not limited to global health security, economic and healthcare delivery with a potential impact on access to healthcare in LMICs. We evaluate the impact of the COVID‐19 pandemic on access to healthcare in LMICs, as well as plausible strategies that can be put in place to ensure that the delivery of healthcare is not halted. In order to mitigate the devastating effect of the COVID‐19 pandemic on the already weak health systems in LMICs, it is much necessary to reinforce and scale up interventions and proactive measures that will ensure that access to healthcare is not disrupted even in course of the pandemic.     

Histological observations on the evolution of nutritional encephalomalacia in chick cerebellum

Summary A study was made of the histological alterations which occur in the development of nutritional encephalomalacia in the chick cerebellum. 3 categories of chicks were discernible according to severity of symptoms.The earliest changes consisted of focal edema in the folial and medullary white matter. These became progressively more severe and resulted in widespread spongy degeneration. Edema of the Purkinje layer consistently appeared and led to a separation of this layer from the underlying granular layer. Apparent capillary proliferation was noted in all layers and distention of blood vessels finally resulted in hemorrhage and in necrosis of the folia.Clinical signs occasionally occurred without apparent morphological alterations. The edematous process, when noted, was considered to be intracellular, involving glial elements in the white matter and the Golgi epithelial cells (Bergmann astroglia) in the Purkinje layer. The condition results from altered permeability of the cerebellar blood-brain barrier which is selectively affected by the metabolic changes brought about by vitamin E deficiency.

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Zusammenfassung Die histologischen Veränderungen in der Entwicklung von nutritiver Encephalomalacie im Kleinhirn des Huhnes wurden untersucht. Nach der Schwere der klinischen Symptome wurden 3 Gruppen von Tieren unterschieden.Die frühesten Veränderungen bestanden in Ödemherden im Läppchenmark und Marklager, die progredient an Schwere zunehmen und ausgedehnte spongiöse Degeneration bewirken. Ödem der Purkinje-Zellschicht trat regelmäßig auf und führte zu ihrer Ablösung von der darunterliegenden Körnerschicht. Deutliche Capillarproliferation war in allen Schichten erkennbar. Die Gefäßerweiterung führte schließlich zu Blutungen und Nekrosen in den Läppchen.Klinische Symptome traten gelegentlich ohne manifeste morphologische Läsionen auf. Der ödematöse Prozeß wurde, wenn nachweisbar, als intracellulär aufgefaßt. Er betraf Gliaelemente des Markes und die Golgi Epithelzellen in der Purkinje-Zellschicht (Bergmann Astroglia). Diese Veränderung ist bedingt durch Permeabilitätsveränderungen der cerebellaren Bluthirnschranke, die selektiv betroffen erscheint, wenn der Stoffwechsel durch Vitamin E-Mangel gestört wird.

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This investigation was supported by United States Public Health Service Grants HD 00217 and FR 05388.     

Akt/PKB activation in gastric carcinomas correlates with clinicopathologic variables and prognosis

Akt/protein kinase B (PKB) plays an important role in cell survival. However, the role of Akt in the biology of gastric cancer has not been well studied. We sought to investigate the expression of Akt or phosphorylated Akt (pAkt) in human gastric carcinomas and to analyze the relationship between Akt or pAkt and the clinicopathologic parameters. The expressions of Akt and pAkt were evaluated immunohistochemically in 311 gastric carcinomas using the tissue array method. Akt expression was detected in 74% of the tumors and pAkt expression in 78%. pAkt was highly expressed in the early stage of pTNM (p=0.011). We also found an inverse association between pAkt and lymphatic invasion (p=0.01) or lymph node metastasis (p=0.008). pAkt expression was significantly correlated with a higher survival in patients with stage I carcinomas (p=0.0003). Interestingly, combined evaluation revealed that the group with pAkt-positive and lymph node-negative carcinomas showed a better prognosis than the other groups (p<0.0001). In addition, pAkt was shown to correlate positively with APC (p=0.002) and Smad4 (p<0.0001) expression. These findings suggest that pAkt expression may help to predict the clinical outcome of gastric cancer patients.     

TheIL-4 andIL-5 genes are closely linked and are part of a cytokine gene cluster on mouse chromosome 11

The murine IL-4and IL-5genes encode hemopoietic growth factors involved in the stimulation, proliferation, and differentiation of cells of the T lymphocyte, B lymphocyte, and granulocyte lineages. We have mapped the Il-4 and Il-5 loci representing the structural genes for IL-4and IL-5,respectively, to mouse chromosome 11 using Chinese hamster ×mouse and rat × mouse somatic cell hybrids. Physical linkage studies of the IL-4and IL-5genes by pulsed field gel electrophoresis have shown that they are closely linked, being 110–180 kb apart. Since the Il-5 locus maps to the interface of bands A5 and B1 in the same location as the genes for IL-3and GM-CSF, this places these three cytokine genes, as well as the IL-4 gene, within a region of about 5000–10,000 kb. The present physical linkage studies indicate that the IL-4and IL-5genes are a minimum of 600 kb apart from the closely linked IL-3and GM-CSFgenes. The gene clustering, together with similarities in gene structure, regulation, and biological function, raises the possibility that the four genes may be part of a distantly related cytokine gene family.