Postoperative delirium. Part 2: detection, prevention and treatment.

To target pharmacological prevention, instruments giving an approximation of an individual patient's risk of developing postoperative delirium are available. In view of the variable clinical presentation, identifying patients in whom prophylaxis has failed (that is, who develop delirium) remains a challenge. Several bedside instruments are available for the routine ward and ICU setting. Several have been shown to have a high specificity and sensitivity when compared with the standard definitions according to DSM-IV-TR and ICD-10. The Confusion Assessment Method (CAM) and a version specifically developed for the intensive care setting (CAM-ICU) have emerged as a standard. However, alternatives allowing grading of the severity of delirium are also available. In many units, the approach to delirium follows a three-step strategy. Initially, non-pharmacological multicomponent strategies are used for primary prevention. As a second step, pharmacological prophylaxis may be added. Perioperative administration of haloperidol has been shown to reduce the severity, but not the incidence, of delirium. Perioperative administration of atypical antipsychotics has been shown to reduce the incidence of delirium in specific groups of patients. In patients with delirium, both symptomatic and causal treatment of delirium need to be considered. So far symptomatic treatment of delirium is primarily based on antipsychotics. Currently, cholinesterase inhibitors cannot be recommended and the data on dexmedetomidine are inconclusive. With the exception of alcohol-withdrawal delirium, there is no role for benzodiazepines in the treatment of delirium. It is unclear whether treating delirium prevents long-term sequelae.

Noninvasive coronary vessel wall and plaque imaging with magnetic resonance imaging.

BACKGROUND: Conventional x-ray angiography frequently underestimates the true burden of atherosclerosis. Although intravascular ultrasound allows for imaging of coronary plaque, this invasive technique is inappropriate for screening or serial examinations. We therefore sought to develop a noninvasive free-breathing MR technique for coronary vessel wall imaging. We hypothesized that such an approach would allow for in vivo imaging of coronary atherosclerosis. METHODS AND RESULTS: Ten subjects, including 5 healthy adult volunteers (aged 35+/-17 years, range 19 to 56 years) and 5 patients (aged 60+/-4 years, range 56 to 66 years) with x-ray-confirmed coronary artery disease (CAD), were studied with a T2-weighted, dual-inversion, fast spin-echo MR sequence. Multiple adjacent 5-mm cross-sectional images of the proximal right coronary artery were obtained with an in-plane resolution of 0.5x1.0 mm. A right hemidiaphragmatic navigator was used to facilitate free-breathing MR acquisition. Coronary vessel wall images were readily acquired in all subjects. Both coronary vessel wall thickness (1.5+/-0.2 versus 1.0+/-0.2 mm) and wall area (21.2+/-3.1 versus 13.7+/-4.2 mm(2)) were greater in patients with CAD (both P:<0.02 versus healthy adults). CONCLUSIONS: In vivo free-breathing coronary vessel wall and plaque imaging with MR has been successfully implemented in humans. Coronary wall thickness and wall area were significantly greater in patients with angiographic CAD. The presented technique may have potential applications in patients with known or suspected atherosclerotic CAD or for serial evaluation after pharmacological intervention.

Treatment options related to clinical type

Treatment of status epilepticus (SE) consists in the sequential administration of three lines of drugs. The first is represented by benzodiazepines, and enjoys quite robust scientific evidence. The second one includes (phos-) phenytoin, valproate, phenobarbital, and increasingly levetiracetam, but its rationale is relatively scarce. The third line is pharmacological coma induction with barbiturates, propofol, or midazolam, which lacks the support of prospective, controlled studies and is reserved for refractory SE. Several other drugs are used after failure of this scheme, including newer antiepileptic compounds, other medications, and non-pharmacological approaches; no comparative assessment of their respective role has been conducted. It is important to tailor this relatively simple protocol to each particular situation; the supposed advantages of coma induction should be balanced with the morbidity related to prolonged mechanical ventilation. Awide consensus exists to treat generalized-convulsive SE and SE in coma soon and aggressively, to prevent a dismal outcome. On the other side, it is unclear if complex-partial SE induces permanent neuronal damage, and absence SE has an excellent prognosis: it appears therefore advisable not to proceed automatically to coma induction in these cases. SE related to post-anoxic coma has generally a poor prognosis, but some selected cases seem to be amenable to a better outcome if treated. SE prognosis depends on etiology, the biological background including age and comorbidities, and, possibly, treatment; each of these points deserves to be specifically addressed. A simple prognostic score has been recently validated and, helping to orient early treatment strategies and improve SE management.

L'apathie, un symptôme transnosographique: diagnostic différentiel et prise en charge [Apathy, a transnosographic symptom: diagnosis and treatment]

Apathy defined as a loss of motivation and interest for novelty is a frequent symptom encountered in a number of psychiatric and somatic disorders. The purpose of this article is to provide an overview of the many different medical contexts where apathy may occur and help clinicians to differentiate it from a depressive syndrome. The treatment of apathy requires a diagnostic clarification in order to treat the underlying condition. Then, pharmacological or non-pharmacological interventions may help to specifically improve apathy.

Alimentation et hypertension artérielle: au-delà du sel de table [Nutrition and hypertension: more than table salt].

The role of dietary sodium intake in the development, and its impact on the treatment, of hypertension are well recognized. However, many other nutritional compounds have been shown, or are believed, to influence blood pressure. Some compounds, such as caffeine and fructose, may raise arterial blood pressure, whereas others might lower arterial blood pressure, for example garlic, dark chocolate, fibers and potassium. In this article, we review several alimentary compounds and their (hypothesized) mechanisms of action, as well as the available evidence supporting a role of these compounds in the "non pharmacological" treatment and prevention of hypertension.

L'arthrose érosive des doigts [Erosive hand osteoarthritis].

Erosive hand osteoarthritis is common and debilitating. Diagnosis is based on the presence of bone erosions which can appear late. Ultrasonography allows earlier diagnosis. The presence of apatite deposits could be of poor prognosis. Non pharmacological treatment includes the explanation of the inflammatory phenomena involved and the use of splints and physical therapy. Drug therapy includes analgesics, NSAIDs and infiltration of a steroid. Chondroitin sulfates have an analgesic and functional effect proven. DMARDs such as hydroxychloroquine and methotrexate have been used successfully. Some patients also benefited from isotope synoviortheses. New therapeutic ways, based on the pathophysiology of the disease, are new under evaluation.

Hypotension orthostatique: à quoi penser et que faire? [Orthostatic hypotension: what to think of it and what to do?].

Orthostatic hypotension is encountered frequently in everyday practice. It is often very disabling because of its troublesome symptomalogy. Orthostatic hypotension may be due to several causes and can be easily diagnosed by measuring blood pressure and heart rate after 3 minutes in upright posture. Its treatment comprises in all cases non-pharmacological interventions which can be associated whenever required by medications, in particular midodrine and fludrocortisone.

Development of a Sensitive Resource Use Questionnaire

Alcoholism is a chronic disease and the evaluation of its burden usually focuses on long-term co-morbidity and mortality. Clinical Trials evaluating new interventions for alcohol-dependent patients rarely last more than 12 to 24 months. OBJECTIVES: Develop a questionnaire capable of capturing principal resource use yet sensitive enough to show short-term economic benefit of drugs developed to reduce consump¬tion in alcohol-dependent patients. METHODS: Comprehensive Medline literature search using keywords: Alcohol-related-disorders, economics, cost of illness. Further, experts panel discussions provided additional data. RESULTS: Two key cost drivers, hospitalisation and sick leaves were identified by the literature review. Expert findings related to costs of social consequences were incorporated. These three important resources were included in the questionnaire in addition to standard medical resource use consumption input. Finally, the following items were included: consultation visits, hospitalisations, sick leaves and working situation, living situation, social environ¬ment, accidents, arrests and domestic violence. The recall period is 3 months. DISCUSSION: A great deal of information is collected in this questionnaire in order to capture all relevant resources. Tests to validate the questionnaire in a real-life setting will be conducted (face validity, concurrent validity, and test-retest) in a cohort of dependent patients initiated at Lausanne University hospital ( Switzerland). Items not sensitive enough to capture short-term costs and consequences will be removed. Translation into other major languages and adaptation to different settings after cultural validation is planned. CONCLUSIONS: Publication of this tool should facilitate additional knowledge about resource utilisation at the patient level and enable evaluation of short-term economic impact of pharmacological and non-pharmacological interventions.

Meta-analysis of 28,141 individuals identifies common variants within five new loci that influence uric acid concentrations.

Elevated serum uric acid levels cause gout and are a risk factor for cardiovascular disease and diabetes. To investigate the polygenetic basis of serum uric acid levels, we conducted a meta-analysis of genome-wide association scans from 14 studies totalling 28,141 participants of European descent, resulting in identification of 954 SNPs distributed across nine loci that exceeded the threshold of genome-wide significance, five of which are novel. Overall, the common variants associated with serum uric acid levels fall in the following nine regions: SLC2A9 (p = 5.2x10(-201)), ABCG2 (p = 3.1x10(-26)), SLC17A1 (p = 3.0x10(-14)), SLC22A11 (p = 6.7x10(-14)), SLC22A12 (p = 2.0x10(-9)), SLC16A9 (p = 1.1x10(-8)), GCKR (p = 1.4x10(-9)), LRRC16A (p = 8.5x10(-9)), and near PDZK1 (p = 2.7x10(-9)). Identified variants were analyzed for gender differences. We found that the minor allele for rs734553 in SLC2A9 has greater influence in lowering uric acid levels in women and the minor allele of rs2231142 in ABCG2 elevates uric acid levels more strongly in men compared to women. To further characterize the identified variants, we analyzed their association with a panel of metabolites. rs12356193 within SLC16A9 was associated with DL-carnitine (p = 4.0x10(-26)) and propionyl-L-carnitine (p = 5.0x10(-8)) concentrations, which in turn were associated with serum UA levels (p = 1.4x10(-57) and p = 8.1x10(-54), respectively), forming a triangle between SNP, metabolites, and UA levels. Taken together, these associations highlight additional pathways that are important in the regulation of serum uric acid levels and point toward novel potential targets for pharmacological intervention to prevent or treat hyperuricemia. In addition, these findings strongly support the hypothesis that transport proteins are key in regulating serum uric acid levels.

La vitesse de l'onde de pouls et la pression artérielle centrale devraient-elles être mesurées chez les patients hypertendus [Not Available].

Diagnosis and treatment of arterial hypertension are essential in order to reduce the mortality and the morbidity associated with this condition. The decision to treat hypertension is often based on serial office blood pressure measurements, but new non-invasive measurements such as pulse wave velocity or central blood pressure measurement using pulse wave analysis can be useful to assess the cardiovascular risk with more precision. Indeed, pulse vawe velocity, which is a marker of arterial stiffness, is an independent risk factor for future cardiovascular events. Non-pharmacological and pharmacological therapies can affect both pulse wave velocity and central pressure. However, more studies are needed in order to determine if these measurements can be use as surrogate marker of cardiovascular disease.

Educación de Enfermería para el autocuidado y control de la Hipertensión Arterial (HTA) en personas con HTA Crónica

La Hipertensión Arterial (HTA) es uno de los principales factores de riesgo de morbilidad y mortalidad cardíaca y cerebrovascular, que afecta mundialmente, por lo que conlleva a un problema de salud pública universal. Es por ello que, el JNC7 recomienda una serie de actividades de autocuidado (AC), que se dividen en el tratamiento farmacológico y no-farmacológico, en el que deberá intervenir el personal sanitario, entre ellos, enfermería, para lograr el control de la enfermedad y evitar complicaciones.

Fatigue prolongée ou chronique d'origine indéterminée [Prolonged or chronic fatigue of unknown origin].

Although prolonged or chronic fatigue is a very common complaint in primary care medicine, a biomedical obvious cause is often not found. In such a case, for women between 18 and 50 years with a ferritin level of less than 50 µg/l in the absence of anaemia, an iron supplementation may be associated with an improvement in fatigue. Appropriate treatment is also important for depression, anxiety or insomnia. In other cases, the approach is essentially non-pharmacological in the form of lifestyle advice, empathy and cognitive behavioural therapy as well as progressive and adapted physical exercises. Bien que la fatigue prolongée ou chronique soit une plainte très fréquente en médecine de premier recours, une cause biomédicale évidente n'est souvent pas retrouvée. Dans une telle situation, pour les femmes entre 18 et 50 ans avec un taux de ferritine inférieur à 50 µg/l en l'absence d'anémie, un traitement de fer peut être associé à une amélioration de la fatigue. Un traitement adapté est également important en cas de dépression, d'anxiété ou d'insomnie. Dans les autres situations, la prise en charge est essentiellement non pharmacologique sous forme de conseils d'hygiène de vie, d'empathie, de thérapie cognitivo-comportementale ainsi que d'exercices physiques progressifs et adaptés.

Delirium in the elderly: Current problems with increasing geriatric age.

Delirium is an acute disorder of attention and cognition seen relatively commonly in people aged 65 yr or older. The prevalence is estimated to be between 11 and 42 per cent for elderly patients on medical wards. The prevalence is also high in nursing homes and long term care (LTC) facilities. The consequences of delirium could be significant such as an increase in mortality in the hospital, long-term cognitive decline, loss of autonomy and increased risk to be institutionalized. Despite being a common condition, it remains under-recognised, poorly understood and not adequately managed. Advanced age and dementia are the most important risk factors. Pain, dehydration, infections, stroke and metabolic disturbances, and surgery are the most common triggering factors. Delirium is preventable in a large proportion of cases and therefore, it is also important from a public health perspective for interventions to reduce further complications and the substantial costs associated with these. Since the aetiology is, in most cases, multfactorial, it is important to consider a multi-component approach to management, both pharmacological and non-pharmacological. Detection and treatment of triggering causes must have high priority in case of delirium. The aim of this review is to highlight the importance of delirium in the elderly population, given the increasing numbers of ageing people as well as increasing geriatric age.

Treatment of cancer with oral drugs: a position statement by the Spanish Society of Medical Oncology

Cancer treatment involves the participation of multiple medical specialties and, as our knowledge of the disease increases, this fact becomes even more apparent. The degree of multidisciplinarity is determined by several factors, which include the severity and type of disease, the increasing diversity in the available pharmacological and non-pharmacological therapies, and the range of specialists involved in cancer therapy, such as medical oncologists, radiotherapists, gynecologists, gastroenterologists, urologists, surgeons, and pneumologists, among others. Across Europe, the situation of cancer care can be variable due to the diversity of health systems, differences in drug reimbursement, and the degree of establishment of Medical Oncology as a medical specialty in the European Union states.

Parents as Pain Killers in the Pain Management of Preterm Infants

Vanhemmat keskoslasten kivun lievittäjinä Tutkimuksen tarkoituksena oli kehittää uusi kivunlievitysmenetelmä, Vanhempien käsikapalo, keskoslasten kivunhoitoon vastasyntyneiden teho-osastolla. Vanhempien käsikapalon tehokkuutta verrattiin kahdessa satunnaistetussa kontrolloidussa crossover-tutkimusasetelmassa ei-lääkkeelliseen näyttöön perustuvaan hoitoon (P.O. glukoosiliuos), lääkkeelliseen menetelmään (I.V. oksikodoni) ja lumeeseen (P.O. vesi) tai kontrolli hoitoon kantapääpiston ja hengitysteiden imemisen aikana. Lisäksi mitattiin kivunhoidon lyhytaikaisia sivuvaikutuksia (hapetuksen- ja pulssinlasku) ja pidempiaikaisia vaikutuksia uneen. Tutkittujen lasten ikä oli 28 raskausviikkoa (n = 20) ja 28 1/7 (n = 20). Toimenpidekipua arvioitiin Premature Infant Pain Profile (PIPP) -kipumittarilla. Interventioiden jälkeen unen rakenne analysoitiin 13 tunnin polysomnografia-rekisteröinneistä. Viimeisessä vaiheessa haastateltiin äitejä (n = 23), jotka olivat käyttäneet vanhempien käsikapaloa 2–4 viikkoa vastasyntyneiden teho-osastolla, strukturoidulla the Clinical Interview for Parents of High-Risk Infants -haastattelulla, johon oli lisätty kysymyksiä lapsen kivunhoidosta. Kantapääpiston aikana PIPP–pisteet olivat merkitsevästi matalampia P.O. glukoosiliuoksella (ka 4,85 ± 1,73, p ≤ 0,001) ja vanhempien käsikapalolla (ka 5,20 ± 1,70, p = 0,004) verrattuna lumeeseen (ka 7,05 ± 2,16). Hengitysteiden imemisen yhteydessä PIPP–pisteet olivat matalampia P.O. glukoosiliuoksella (ka 11,05 ± 2,31, p = 0,014) ja vanhempien käsikapalolla (ka 11,25 ± 2,47, p = 0,034) verrattuna lumeeseen (ka 12,40 ± 2,06). Oksikodonin teho oli verrattavissa lumeeseen kummankin toimenpiteen aikana. P.O. glukoosiliuoksen (21,3 %) ja lumeen (12,5 %) annosteluun liittyi merkittävästi enemmän lyhytaikaisia sivuvaikutuksia verrattuna oksikodoniin (5 %) tai vanhempien käsikapaloon (5 %). Oksikodoni muutti keskoslasten unen rakennetta vähentämällä merkittävästi aktiivisen unen määrää verrattuna muihin hoitoihin. Vanhemmat suhtautuivat positiivisesti käsikapalon käyttöön. Äitien osallistuminen kivunhoitoon voitiin jaotella kolmeen eri tyylin, jotka selittyivät äidin kiintymyksen tunteilla ja lapsen tehohoitoon liittyvällä stressillä. Vanhempien käsikapalo on suositeltavampi lyhyen toimenpidekivun lievittäjä kuin P.O. glukoosiliuos tai I.V. oksikodoni, kun tehokkuus, turvallisuus ja perhe otetaan huomioon.