Cytokines and acute phase response in delirium

OBJECTIVE: This study aimed to examine the expression patterns of pro- and anti-inflammatory cytokines in elderly patients with and without delirium who were acutely admitted to the hospital. METHODS: All consecutive patients aged 65 years and older, who were acutely admitted to the Department of Internal Medicine of the Academic Medical Center, Amsterdam, a tertiary university teaching hospital, were invited. Members of the geriatric consultation team completed a multidisciplinary evaluation for all study participants within 48 h after admission, including cognitive and functional examination by validated measures of delirium, memory, and executive function. C-reactive protein and cytokines (IL-1beta, IL-6, TNF-alpha, IL-8, and IL-10) were determined within 3 days after admission. RESULTS: In total, 185 patients were included; mean age was 79 years; 42% were male; and 34.6% developed delirium within 48 h after admission. Compared to patients without delirium, patients with delirium were older and had experienced preexistent cognitive impairment more often. In patients with delirium, significantly more IL-6 levels (53% vs. 31%) and IL-8 levels (45% vs. 22%) were above the detection limit as compared with patients who did not have delirium. After adjusting for infection, age, and cognitive impairment, these differences were still significant. CONCLUSIONS: Proinflammatory cytokines may contribute to the pathogenesis of delirium in acutely admitted elderly patients.     

Safety profile of Tysabri: international risk management plan

An 83-year-old man was admitted for right lower lobe pneumonia which did not improve after a 5-day outpatient treatment with amoxicillin/clavulinate and clarithromycin. An empiric treatment with levofloxacin was started with a significant improvement after 24 h of this treatment. On the third day of hospitalization, delirium developed, while the patient was afebrile and with normal blood oxygenation. Treatment with levofloxacin was stopped, and a complete resolution of the patient’s delirium was observed 2 days later. To the best of our knowledge, this is the third case of levofloxacin-induced delirium described in the medical literature.     

Implementation,reliability testing,and compliance monitoring of the Confusion Assessment Method for the Intensive Care Unit in trauma patients

OBJECTIVE: To implement delirium monitoring, test reliability, and monitor compliance of performing the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU) in trauma patients. DESIGN AND SETTING: Prospective, observational study in a level 1 trauma unit of a tertiary care, university-based medical center. PATIENTS: Acutely injured patients admitted to the trauma unit between 1 February 2006 and 16 April 2006. MEASUREMENTS AND RESULTS: Following web-based teaching modules and group in-services, bedside nurses evaluated patients daily for depth of sedation with the Richmond Agitation-Sedation Scale (RASS) and for the presence of delirium with the CAM-ICU. On randomly assigned days over a 10-week period, evaluations by nursing staff were followed by evaluations by an expert evaluator of the RASS and the CAM-ICU to assess compliance and reliability of the CAM-ICU in trauma patients. Following the audit period the nurses completed a postimplementation survey. The expert evaluator performed 1,011 random CAM-ICU assessments within 1[Symbol: see text]h of the bedside nurse's assessments. Nurses completed the CAM-ICU assessments in 84% of evaluations. Overall agreement (kappa) between nurses and expert evaluator was 0.77 (0.721-0.822; p[Symbol: see text]<[Symbol: see text]0.0001), in TBI patients 0.75 (0.667-0.829; p[Symbol: see text]<[Symbol: see text]0.0001) and in mechanically ventilated patients 0.62 (0.534-0.704; p[Symbol: see text]<[Symbol: see text]0.0001). The survey revealed that nurses were confident in performing the CAM-ICU, realized the importance of delirium, and were satisfied with the training that they received. It also acknowledged obstacles to implementation including nursing time and failure of physicians/surgeons to address treatment approaches for delirium. CONCLUSIONS: The CAM-ICU can be successfully implemented in a university-based trauma unit with high compliance and reliability. Quality improvement projects seeking to implement delirium monitoring would be wise to address potential pitfalls including time complaints and the negative impact of physician indifference regarding this form of organ dysfunction.     

Delirium following abrupt discontinuation of fluoxetine

Sudden discontinuation of serotonin reuptake inhibitors (SRI) can lead to a number of psychological (e.g., nervousness, anxiety, crying spells, psychomotor agitation, irritability, depersonalization, decreased mood, memory disturbances, confusion, decreased concentration, and/or slowed thinking) and somatic (e.g., nausea, dizziness, headache) symptoms. Recent studies have shown that withdrawal symptoms are common with paroxetine, venlafaxine and fluvoxamine, but relatively rare and mild with fluoxetine cessation, likely as a result of its longer half-life. We report an unusual case of a patient who developed delirium after abrupt discontinuation of fluoxetine.     

Delirium in two patients with Bickerstaff's brainstem encephalitis

In this report, we describe the case of two patients with Bickerstaff's brainstem encephalitis (BBE) who developed delirium manifested as emotional incontinence, restlessness, and aggressive behavior from disease onset. Serum anti-GQ1b and anti-GT1a IgG antibodies were detected in both patients. When unusual psychiatric symptoms are observed, in addition to acute ophthalmoplegia and ataxia, neurologists should take into account the possibility of BBE. Brain MRI findings were normal in both patients and SPECT was performed on only patient 1. SPECT of patient 1 showed reversible hypoperfusion in the brainstem, bilateral thalami, and medial frontal lobe. Brain SPECT appears to be useful for detecting lesions of the brainstem as well as the basal ganglia or cerebrum in BBE.     

Our Tiny Organization Packs a National Wallop

The relationships between drinking history, housing history, several clinical variables and treatment retention after detoxification were evaluated in 109 inner-city alcoholics. Compared to men with a fisxed abode, homeless subjects (N = 50) reported a history of alcoholism of ealry onset and increased severity. No differences in aftercare retention were found between homeless and non-homeless subjects.     

Review of the epidemiology and characteristics of intentional cyproheptadine overdose in Hong Kong

Objectives. To identify the epidemiological characteristics and clinical outcome in patients who intentionally ingested cyproheptadine or cyproheptadine-containing sleeping pills, and to investigate any association between dose ingested and reported adverse effects. Method. A retrospective study was performed based on data from the Hong Kong Poison Information Centre from July 2005 to December 2009. Fifty-seven eligible patients were recruited. Patients’ epidemiological data, type and dose of cyproheptadine or cyproheptadine-containing sleeping pills ingested, symptoms, clinical outcome, and length of stay in hospital were reviewed. Results. The majority of patient with intentional overdose had no (42.1%) or mild (40.4%) sedative symptoms. Some 17% of patients developed anticholinergic symptoms, such as delirium, agitation, disorientation, and hallucination. The mean dose ingested was found to be significantly higher in patients who presented with delirium (188.6 mg) than those who were asymptomatic (49.8 mg) (p < 0.001). The time of symptom onset in all symptomatic patients was less than 6 h. Conclusions. The majority of patients with intentional cyproheptadine overdose had no or mild symptoms only. Patients who have ingested a significant amount of cyproheptadine are more prone to develop delirium. Patients who remain asymptomatic 6 h after exposure are unlikely to develop serious symptoms.     

Importance of recognizing and managing delirium in intensive care unit

Delirium is an acute and fluctuating change in mental status, with inattention and altered levels of consciousness. It is a common comorbidity in intensive care units (ICU), resulting in delayed withdrawal of mechanical ventilation, prolonged length of stay in ICU, increased ICU mortality and impaired long-term cognitive function of the survivors.