Individual delirium symptoms: do they matter?

OBJECTIVES: To evaluate the impact of individual manifestations of delirium on outcome, describe them in critically ill adults, and validate nurses' bedside item assessments from the Intensive Care Delirium Screening Checklist (ICDSC). DESIGN: Prospective study. SETTING: Single 16-bed medical/surgical university hospital intensive care unit. PATIENTS: Six hundred consecutive patients admitted to the intensive care unit for >24 hrs. INTERVENTIONS: All patients were evaluated with the eight-item ICDSC throughout their intensive care unit stay. In all patients scoring positive on any ICDSC item, individual checklist items were tallied throughout the intensive care unit stay and assessed for impact on mortality. In addition, when the ICDSC score indicated delirium (> or = 4 of 8), the subsequent overall frequency of each item was also independently documented to describe delirious patient symptoms. ICDSC items were tested for discrimination between delirious and nondelirious patients. Throughout the study, the validity of bedside delirium assessments was assessed in 30 nurses. MEASUREMENTS AND MAIN RESULTS: We were able to assess 537 patients. In nondelirious patients, psychomotor agitation by ICDSC assessment was associated with a higher risk of mortality after adjustment for Acute Physiology and Chronic Health Evaluation, age, and the presence of coma. One hundred eight-nine patients (35.1%) developed delirium (i.e., ICDSC score > or = 4). On presentation (and throughout the intensive care unit stay), the most frequent features of delirium were inattention, disorientation, and psychomotor agitation. Each ICDSC item was highly discriminating between delirious vs. nondelirious patients. Correlation between gold standard adjudicators and nurses for the overall bedside evaluations of delirium were excellent (Pearson's correlation R = 0.924, p < .0005). Individual symptom evaluation by nurses varied: Alteration in level of consciousness was poorest (R = 0.681, p < .0005), and both disorientation and hallucinations evaluated best (R = 1.000). CONCLUSIONS: In nondelirious patients, agitation was associated with a higher risk of mortality. Each of the eight ICDSC items is highly discriminating for the diagnosis of delirium, suggesting that any screening or diagnostic scales should incorporate them. Quality assurance and educational efforts should, therefore, emphasize independent assessment of the individual features of delirium.     

The Impact of Breast Cancer Treatment Delays on Survival Among South African Women

BackgroundIn high-income settings, delays from breast cancer (BC) diagnosis to initial treatment worsen overall survival (OS). We examined how time to BC treatment initiation (TTI) impacts OS in South Africa (SA).MethodsWe evaluated women enrolled in the South African BC and HIV Outcomes study between July 1, 2015 and June 30, 2019, selecting women with stages I-III BC who received surgery and chemotherapy. We constructed a linear regression model estimating the impact of sociodemographic and clinical factors on TTI and separate multivariable Cox proportional hazard models by first treatment (surgery and neoadjuvant chemotherapy (NAC)) assessing the effect of TTI (in 30-day increments) on OS.ResultsOf 1260 women, 45.6% had upfront surgery, 54.4% had NAC, and 19.5% initiated treatment >90 days after BC diagnosis. Compared to the surgery group, more women in the NAC group had stage III BC (34.8% vs 81.5%). Living further away from a hospital and having hormone receptor positive (vs negative) BC was associated with longer TTI (8 additional days per 100 km, P = .003 and 8 additional days, P = .01, respectively), while Ki67 proliferation index >20 and upfront surgery (vs NAC) was associated with shorter TTI (12 and 9 days earlier; P = .0001 and.007, respectively). Treatment initiation also differed among treating hospitals (P < .0001). Additional 30-day treatment delays were associated with worse survival in the surgery group (HR 1.11 [95%CI 1.003-1.22]), but not in the NAC group.ConclusionsDelays in BC treatment initiation are common in SA public hospitals and are associated with worse survival among women treated with upfront surgery.     

T cell receptor transfection shows non-HLA-restricted recognition of nickel by CD8+ human T cells to be mediated by alphabeta T cell receptors

CD8+ T cells have been assigned a prominent role in allergic contact dermatitis, including nickel allergy; however, human nickel-reactive T cells of the CD8+ phenotype have largely escaped detailed investigation. Here we characterize two quite unusual nickel-specific cytotoxic T cell clones isolated from the peripheral blood of two nickel-sensitized patients. These clones mediate nickel-specific cytolysis of many human cell lines, independent of the expression of HLA class I, CD1, or HLA class II molecules. Lysis is mediated by the alphabeta T cell receptors and involves the perforin, but not the Fas/Fas ligand pathway. Both antigen receptors lack sequence homology to each other as well as to typical natural killer T cell receptors. A transfectant expressing the rearranged alphabeta T cell receptor derived from one of the T cell clones unequivocally demonstrates that the T cell receptor itself is necessary and sufficient to confer HLA-independent nickel specificity. The independent isolation of these clones from two individuals points to an important role of such cells in the pathology of nickel contact dermatitis.     

A methodology for assessing the professional development needs of nurses and midwives in Indonesia: paper 1 of 3

Background  

Despite recent developments, health care provision in Indonesia remains suboptimal. Difficult terrain, economic crises, endemic diseases and high population numbers, coupled with limited availability of qualified health care professionals, all contribute to poor health status. In a country with a population of 220 million, there are currently an estimated 50 nurses and 26 midwives per 100 000 people. In line with government initiatives, this series of studies was undertaken to establish the training and development needs of nurses and midwives working within a variety of contexts in Indonesia, with the ultimate aim of enhancing care provision within these domains.     

Delirium in critically ill patients

Delirium in the intensive care unit is a serious problem that has recently attracted much attention. User-friendly and reliable tools, such as the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU), offer the clinician the opportunity to identify delirium in patients better. Diagnosis of delirium in a critical care population is often a difficult task because classical psychiatric evaluation is impossible for a number of reasons. The CAM-ICU makes use of nonverbal assessments to evaluate the cardinal features of delirium (i.e. acute or fluctuating onset, inattention, disorganized thinking and altered level of consciousness). Its development for use in the critical care setting represents a significant advance that could lead to better care for such patients.