Background:
Delirium is a common and distressing neurocognitive condition that frequently affects patients in palliative care settings and is often underdiagnosed.
Aim:
Expanding on a 2013 review, ...this systematic review examines the incidence and prevalence of delirium across all palliative care settings.
Design:
This systematic review and meta-analyses were prospectively registered with PROSPERO and included a risk of bias assessment.
Data sources:
Five electronic databases were examined for primary research studies published between 1980 and 2018. Studies on adult, non-intensive care and non-postoperative populations, either receiving or eligible to receive palliative care, underwent dual reviewer screening and data extraction. Studies using standardized delirium diagnostic criteria or valid assessment tools were included.
Results:
Following initial screening of 2596 records, and full-text screening of 153 papers, 42 studies were included. Patient populations diagnosed with predominantly cancer (n = 34) and mixed diagnoses (n = 8) were represented. Delirium point prevalence estimates were 4%–12% in the community, 9%–57% across hospital palliative care consultative services, and 6%–74% in inpatient palliative care units. The prevalence of delirium prior to death across all palliative care settings (n = 8) was 42%–88%. Pooled point prevalence on admission to inpatient palliative care units was 35% (confidence interval = 0.29–0.40, n = 14). Only one study had an overall low risk of bias. Varying delirium screening and diagnostic practices were used.
Conclusion:
Delirium is prevalent across all palliative care settings, with one-third of patients delirious at the time of admission to inpatient palliative care. Study heterogeneity limits meta-analyses and highlights the future need for rigorous studies.
Purpose. Delirium frequently affects critically ill patients in the intensive care unit (ICU). The purpose of this study is to evaluate the impact of delirium on ICU and hospital length of stay (LOS) ...and perform a cost analysis. Materials and Methods. Prospective studies and randomized controlled trials of patients in the ICU with delirium published between January 1, 2015, and December 31, 2020, were evaluated. Outcome variables including ICU and hospital LOS were obtained, and ICU and hospital costs were derived from the respective LOS. Results. Forty-one studies met inclusion criteria. The mean difference of ICU LOS between patients with and without delirium was significant at 4.77 days (p<0.001); for hospital LOS, this was significant at 6.67 days (p<0.001). Cost data were extractable for 27 studies in which both ICU and hospital LOS were available. The mean difference of ICU costs between patients with and without delirium was significant at $3,921 (p<0.001); for hospital costs, the mean difference was $5,936 (p<0.001). Conclusion. ICU and hospital LOS and associated costs were significantly higher for patients with delirium, compared to those without delirium. Further research is necessary to elucidate other determinants of increased costs and cost-reducing strategies for critically ill patients with delirium. This can provide insight into the required resources for the prevention of delirium, which may contribute to decreasing healthcare expenditure while optimizing the quality of care.
We present Os and Sr isotopes and Mg, Os, and Sr concentrations for ridge-crest high-temperature and diffuse hydrothermal fluids, plume fluids and ridge-flank warm spring fluids from the Juan de Fuca ...Ridge. The data are used to evaluate the extent to which (1) the high- and low-temperature hydrothermal alteration of mid-ocean ridge basalts (MORBs) provides Os to the deep oceans, and (2) hydrothermal contributions of non-radiogenic Os and Sr to the oceans are coupled. The Os and Sr isotopic ratios of the high-temperature fluids (265–353
°C) are dominated by basalts (
187Os/
188Os
=
0.2;
87Sr/
86Sr
=
0.704) but the concentrations of these elements are buffered approximately at their seawater values. The
187Os/
188Os of the hydrothermal plume fluids collected ∼1
m above the orifice of Hulk vent is close to the seawater value (=1.05). The low-temperature diffuse fluids (10–40
°C) associated with ridge-crest high-temperature hydrothermal systems on average have Os
=
31
fmol
kg
−1,
187Os/
188Os
=
0.9 and Sr
=
86
μmol
kg
−1,
87Sr/
86Sr
=
0.709. They appear to result from mixing of a high-temperature fluid and a seawater component. The ridge-flank warm spring fluids (10–62
°C) on average yield Os
=
22
fmol
kg
−1,
187Os/
188Os
=
0.8 and Sr
=
115
μmol kg
−1,
87Sr/
86Sr
=
0.708. The data are consistent with isotopic exchange of Os and Sr between basalt and circulating seawater during low-temperature hydrothermal alteration. The average Sr concentration in these fluids appears to be similar to seawater and consistent with previous studies. In comparison, the average Os concentration is less than seawater by more than a factor of two. If these data are representative they indicate that low-temperature alteration of MORB does not provide adequate non-radiogenic Os and that another source of mantle Os to the oceans must be investigated. At present, the magnitude of non-radiogenic Sr contribution via low-temperature seawater alteration is not well constrained. If non-radiogenic Sr to the oceans is predominantly from the alteration of MORB, our data suggest that there must be a different source of non-radiogenic Os and that the Os and Sr isotope systems in the oceans are decoupled.
Background. ICU care is costly, and there is a large variation in cost among patients. Methods. This is an observational study conducted at two ICUs in an academic centre. We compared the ...demographics, clinical data, and outcomes of the highest decile of patients by total costs, to the rest of the population. Results. A total of 7,849 patients were included. The high-cost group had a longer median ICU length of stay (26 versus 4 days, P<0.001) and amounted to 49% of total costs. In-hospital mortality was lower in the high-cost group (21.1% versus 28.4%, P<0.001). Fewer high-cost patients were discharged home (23.9% versus 45.2%, P<0.001), and a large proportion were transferred to long-term care (35.1% versus 12.1%, P<0.001). Patients with younger age or a diagnosis of subarachnoid hemorrhage, acute respiratory failure, or complications of procedures were more likely to be high cost. Conclusions. High-cost users utilized half of the total costs. While cost is associated with LOS, other drivers include younger age or admission for respiratory failure, subarachnoid hemorrhage, or after a procedural complication. Cost-reduction interventions should incorporate strategies to optimize critical care use among these patients.
Ischémie aiguë des membres Rosenberg, Hans; Rosenberg, Erin; Kubelik, Dalibor
Canadian Medical Association journal (CMAJ),
02/2024, Volume:
196, Issue:
4
Journal Article
Ischemie aigue des membres Rosenberg, Hans; Rosenberg, Erin; Kubelik, Dalibor
CMAJ. Canadian Medical Association journal,
02/2024, Volume:
196, Issue:
4
Journal Article
Acute limb ischemia Rosenberg, Hans; Rosenberg, Erin; Kubelik, Dalibor
CMAJ. Canadian Medical Association journal,
10/2023, Volume:
195, Issue:
40
Journal Article
Peer reviewed
Open access
Acute limb ischemia is a condition characterized by a sudden decrease in blood flow to the limbs, which can lead to limb amputation, cardiovascular events, and death. While the incidence of acute ...limb ischemia is decreasing, the mortality rate remains high. The most common symptom of acute limb ischemia is acute onset pain, along with other symptoms such as paresthesias, pallor, poikilothermia, paralysis, and pulselessness. It is important to perform a thorough clinical examination, including assessing the 6 Ps (pain, paresthesias, pallor, poikilothermia, paralysis, and pulselessness) and ankle-brachial index (ABI), as failure to do so is associated with a higher risk of amputation and death. Computed tomography (CT) angiography is the preferred initial investigation, although contrast-enhanced magnetic resonance imaging can be used in certain cases. Systemic anticoagulation with intravenous unfractionated heparin is usually initiated, and early contact with a vascular surgery center is necessary. Treatment options include embolectomy, revascularization, thrombolysis, and, in severe cases, primary amputation. It is important to initiate treatment promptly, as patients with loss of motor function have worse outcomes.
To compare the relative efficacy of pharmacologic interventions in the prevention of delirium in ICU trauma patients.
We searched Medical Literature Analysis and Retrieval System Online, Embase, and ...Cochrane Registry of Clinical Trials from database inception until June 7, 2022. We included randomized controlled trials comparing pharmacologic interventions in critically ill trauma patients.
Two reviewers independently screened studies for eligibility, extracted data, and assessed risk of bias.
Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines for network analysis were followed. Random-effects models were fit using a Bayesian approach to network meta-analysis. Between-group comparisons were estimated using hazard ratios (HRs) for dichotomous outcomes and mean differences for continuous outcomes, each with 95% credible intervals. Treatment rankings were estimated for each outcome in the form of surface under the cumulative ranking curve values.
A total 3,541 citations were screened; six randomized clinical trials (
= 382 patients) were included. Compared with combined propofol-dexmedetomidine, there may be no difference in delirium prevalence with dexmedetomidine (HR 1.44, 95% CI 0.39-6.94), propofol (HR 2.38, 95% CI 0.68-11.36), nor haloperidol (HR 3.38, 95% CI 0.65-21.79); compared with dexmedetomidine alone, there may be no effect with propofol (HR 1.66, 95% CI 0.79-3.69) nor haloperidol (HR 2.30, 95% CI 0.88-6.61).
The results of this network meta-analysis suggest that there is no difference found between pharmacologic interventions on delirium occurrence, length of ICU stay, length of hospital stay, or mortality, in trauma ICU patients.
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