Decreased functional connectivity and disturbed directionality of information flow in the electroencephalography of intensive care unit patients with delirium after cardiac surgery.

BACKGROUND: In this article, the authors explore functional connectivity and network topology in electroencephalography recordings of patients with delirium after cardiac surgery, aiming to improve the understanding of the pathophysiology and phenomenology of delirium. The authors hypothesize that disturbances in attention and consciousness in delirium may be related to alterations in functional neural interactions. METHODS: Electroencephalography recordings were obtained in postcardiac surgery patients with delirium (N = 25) and without delirium (N = 24). The authors analyzed unbiased functional connectivity of electroencephalography time series using the phase lag index, directed phase lag index, and functional brain network topology using graph analysis. RESULTS: The mean phase lag index was lower in the α band (8 to 13 Hz) in patients with delirium (median, 0.120; interquartile range, 0.113 to 0.138) than in patients without delirium (median, 0.140; interquartile range, 0.129 to 0.168; P < 0.01). Network topology in delirium patients was characterized by lower normalized weighted shortest path lengths in the α band (t = -2.65; P = 0.01). δ Band-directed phase lag index was lower in anterior regions and higher in central regions in delirium patients than in nondelirium patients (F = 4.53; P = 0.04, and F = 7.65; P < 0.01, respectively). CONCLUSIONS: Loss of α band functional connectivity, decreased path length, and increased δ band connectivity directed to frontal regions characterize the electroencephalography during delirium after cardiac surgery. These findings may explain why information processing is disturbed in delirium.

Delirium detection based on monitoring of blinks and eye movements.

OBJECTIVE: To investigate whether delirious patients differ from nondelirious patients with regard to blinks and eye movements to explore opportunities for delirium detection. METHODS: Using a single-center, observational study in a tertiary hospital in the Netherlands, we studied 28 delirious elderly and 28 age- and gender-matched (group level) nondelirious elderly, postoperative cardiac surgery patients. Patients were evaluated for delirium by a geriatrician, psychiatrist, or neurologist using the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition criteria. Blinks were automatically extracted from electro-oculograms and eye movements from electroencephalography recordings using independent component analysis. The number and duration of eye movements and blinks were compared between patients with and without delirium, based on the classification of the delirium experts described above. RESULTS: During eyes-open registrations, delirious patients showed, compared with nondelirious patients, a significant decrease in the number of blinks per minute (median: 12 [interquartile range {IQR}: 5-18] versus 18 [IQR: 8-25], respectively; p = 0.02) and number of vertical eye movements per minute (median: 1 [IQR: 0-13] versus 15 [IQR: 2-54], respectively; p = 0.01) as well as an increase in the average duration of blinks (median: 0.5 [IQR: 0.36-0.95] seconds versus 0.34 [IQR: 0.23-0.53] seconds, respectively; p <0.01). During eyes-closed registrations, the average duration of horizontal eye movements was significantly increased in delirious patients compared with patients without delirium (median: 0.41 [IQR: 0.15-0.75] seconds versus 0.08 [IQR: 0.06-0.22] seconds, respectively; p <0.01). CONCLUSION: Spontaneous eye movements and particularly blinks appear to be affected in delirious patients, which holds promise for delirium detection.

[A severe G6PD deficiency revealed during a chemotherapy protocol including rasburicase]. / Un déficit sévère en G6PD découvert au décours d'une chimiothérapie avec utilisation de rasburicase.

We present here the case-report of a man with a severe G6PD deficiency revealed after the use of rasburicase (uricolytic drug) during a chemotherapy protocol. The genotypic analysis done to confirm the biochemical measurement revealed the 'Mediterranean mutation' at the hemizygous state (G6PD gene is located on chromosome X). Consequently to this diagnose, a search for G6PD deficiency has been performed (at the biochemical and genotypic levels) for the 9 children (7 daughters and 2 sons) of the proband. Surprisingly, one of his son was found to be hemizygous for the mediterranean mutation and one of his daughter appeared homozygous for this same mutation. This implies that the proband's wife (not studied) is certainly heterozygous for the mediterranean mutation, as it is very unlikely that this mutation had appeared de novo for two children of this couple.

Hemoglobin Nouakchott [alpha 114(GH2)Pro----Leu]: a new hemoglobin variant displaying an unusual increase in hydrophobicity.

The most striking fact in Hb Nouakchott [alpha 114(GH2)Pro----Leu] is the highly increased hydrophobicity of the abnormal chain. In comparison to other variants carrying the same amino-acid substitution, but at another position, the involvement of the environmental domains in the expression of the hydrophobicity is shown. Even though the substitution concerned a proline residue, it was without consequences on the oxygen binding and the stability of the molecule.

Hemoglobin Roanne [alpha 94(G1) Asp-->Glu]: a variant of the alpha 1 beta 2 interface with an unexpected high oxygen affinity.

In hemoglobin (Hb) Roanne, the aspartate residue alpha 94(G1) is replaced by a glutamic acid. This residue plays a key role in the structural changes affecting the alpha 1 beta 2 contact area during the deoxy- to oxy-state transition in the hemoglobin molecule. Aspartate alpha 94(G1) is involved in several contacts both in the deoxy- and oxy-structures. The most important of those is a hydrogen bond with asparagine beta 102 (G4), stabilizing the oxygenated structure. Alteration of this contact usually leads to a decrease in oxygen affinity. Hb Roanne is the first example in which an increased oxygen affinity was found as a result of a structural modification at this position. Functional data suggested that the mechanisms responsible for this altered property are a destabilisation of the T-structure and a modification of the allosteric equilibrium.

[DEFI-ALPHA cohort and POLYGEN DEFI-ALPHA clinical research hospital programme. A study about clinical, biological and genetics factors associated with the occurrence and the evolution of hepatic complications in children with alpha-1 antitrypsin deficiency]. / Cohorte DEFI-ALPHA et projet hospitalier de recherche clinique POLYGEN DEFI-ALPHA. Étude des facteurs cliniques, biologiques et génétiques associés à l'apparition et à l'évolution de complications hépatiques chez les enfants présentant un déficit en alpha-1 antitrypsine.

INTRODUCTION: The alpha-1 antitrypsin (α1-AT) deficiency, most frequently caused by homozygosity for the Z variant (SERPINA1: c.1096 G>A; Glu342Lys), can give rise to two clinical patterns: (i) respiratory impairment with emphysema (mainly in adulthood) because of a pulmonary quantitative defect in anti-elastase activity; (ii) hepatic impairment (mainly in childhood) due to the misfolding of the PiZ protein which accumulates in hepatocytes thus providing cytotoxicity. CURRENT KNOWLEDGE: To date, the clinical and genetic factors responsible for the development of major hepatic injuries (fibrosis and portal hypertension) during childhood in PiZ patients are not known. METHODS: The DEFI-ALPHA cohort, created in 2008, aims to inventory and prospectively study all α1-AT deficient children diagnosed and included after occurrence of a hepatic sign. The POLYGEN DEFI-ALPHA PHRC has recently (2013) been added to the project to identify modifiers genes by two complementary approaches: (i) the candidate genes strategy with the SERPINA1, CFTR (cystic fibrosis gene), MAN1B1 and SORL1 genes, these two latter being implied in the degradation of misfolding proteins; (ii) the whole exome sequencing (WES) strategy in families in which the PiZ proband has a PiZ brother or sister free of any hepatic sign. EXPECTED RESULTS: The clinical parameter we want to explain is the apparition of a portal hypertension in PiZ children. In the DEFI-ALPHA project, three criteria will be tested: (i) age of inclusion in the cohort, (ii) the way of inclusion (neo-natal icterus or later hepatic impairment) and (iii) treatment or not with ursodesoxycholic acid and, if so, its duration. Genetically, polymorphisms on the SERPINA1 and MAN1B1 genes have already been associated in the literature with different clinical evolutions of the A1ATD but very inconstantly. Our study thus aims to confirm or not this association. The CFTR and SORL1 genes have never been studied in the α1-AT deficiency. Finally, the whole exome sequencing strategy could allow the discovery of new unexpected modifiers genes in this disease.

Delirium detection using EEG: what and how to measure.

BACKGROUND: Despite its frequency and impact, delirium is poorly recognized in postoperative and critically ill patients. EEG is highly sensitive to delirium but, as currently used, it is not diagnostic. To develop an EEG-based tool for delirium detection with a limited number of electrodes, we determined the optimal electrode derivation and EEG characteristic to discriminate delirium from nondelirium. METHODS: Standard EEGs were recorded in 28 patients with delirium and 28 age- and sex-matched patients who had undergone cardiothoracic surgery and were not delirious, as classified by experts using Diagnostic and Statistical Manual of Mental Disorders, 4th edition, criteria. The first minute of artifact-free EEG data with eyes closed as well as with eyes open was selected. For each derivation, six EEG parameters were evaluated. Using Mann-Whitney U tests, all combinations of derivations and parameters were compared between patients with delirium and those without. Corresponding P values, corrected for multiple testing, were ranked. RESULTS: The largest difference between patients with and without delirium and highest area under the receiver operating curve (0.99; 95% CI, 0.97-1.00) was found during the eyes-closed periods of the EEG, using electrode derivation F8-Pz (frontal-parietal) and relative δ power (median [interquartile range (IQR)] for delirium, 0.59 [IQR, 0.47-0.71] and for nondelirium, 0.20 [IQR, 0.17-0.26]; P = .0000000000018). With a cutoff value of 0.37, it resulted in a sensitivity of 100% (95% CI, 100%-100%) and specificity of 96% (95% CI, 88%-100%). CONCLUSIONS: In a homogenous population of nonsedated patients who had undergone cardiothoracic surgery, we observed that relative δ power from an eyes-closed EEG recording with only two electrodes in a frontal-parietal derivation can distinguish among patients who have delirium and those who do not.

Decarboxylation of [1-(13)C]leucine by hydroxyl radicals.

The decarboxylation of [1-13C]leucine by hydroxyl radicals was studied by using gas chromatography-isotope ratio mass spectrometry (GC-IRMS) to follow the production of 13CO2. A Fenton reaction between a (Fe2+)-porphyrin and hydrogen peroxide under aerobic conditions yielded hydroxyl radicals. The decarboxylation rates (VLeu) measured by GC-IRMS were dependent on [1-13C]leucine, porphyrin and hydrogen peroxide concentrations. The 13CO2 production was also dependent on bicarbonate or carbon dioxide added in the reaction medium. Bicarbonate facilitated 13CO2 production, whereas carbon dioxide decreased 13CO2 production. Proton effects on some decarboxylation intermediates could explain bicarbonate or carbon dioxide effects. No effect on the decarboxylation rates was observed in the presence of the classical hydroxyl radicals scavengers dimethyl sulfoxide, mannitol, and uric acid. By contrast, a competitive effect with a strong decrease of the decarboxylation rates was observed in the presence of various amino acids: unlabeled leucine, valine, phenylalanine, cysteine, lysine, and histidine. Two reaction products, methyl-4 oxo-2 pentanoate and methyl-3 butanoate were identified by gas chromatography-mass spectrometry in comparison with standards. The present results suggest that [1-13C]leucine can participate to the coordination sphere of (Fe2+)-porphyrin, with a caged process of the hydroxyl radicals which cannot get out of the coordination sphere.

Hemoglobin Grange-Blanche [beta 27(B9) Ala----Val], a new variant with normal expression and increased affinity for oxygen.

Hemoglobin Grange-Blanche [beta 27(B9) Ala----Val] is a new variant found in a Portuguese family. The carriers present moderate erythrocytosis. Upon isoelectric focusing, Hb Grange-Blanche was slightly more cathodic than Hb A. beta Grange-Blanche chain migrated like the G gamma chain when submitted to electrophoresis in the presence of urea-Triton X-100. The precentage of Hb Grange-Blanche was about 50% in the heterozygous state. Oxygen affinity was increased (P50 = 22 mmHg), but heme-heme interaction was normal. An abnormal tryptic peptide (beta T3) was isolated using HPLC. Its composition allowed us to deduce unambiguously the amino acid change. The latter is the third mutation found in position 27 of the beta-chain. Because of its normal expression and its elevated affinity for oxygen, Hb Grange-Blanche contrasts with Hb Knossos [beta 27(B9) Ala----Ser], a beta-thalassemic variant with low affinity.

Oxidative decarboxylation of benzoic acid by peroxyl radicals.

A chemical model based on the thermal decomposition of AAPH (2,2'-azobis(2-amidinopropane) dihydrochloride is used for the production of peroxyl radicals. Peroxyl radicals induces the decarboxylation of [7-13C]benzoic acid and the production of 13CO2, which is measured by gas chromatography-isotope ratio mass spectrometry (GC-IRMS). The decarboxylation depends on temperature, AAPH, and benzoic acid concentrations. The decarboxylation also depends on the presence of oxygen. Electron spin resonance studies are performed to confirm the presence of peroxyl radicals under oxygen and of carbon-centered radicals in the absence of oxygen. Decarboxylation rates are measured in the presence of various antioxidants: ascorbate, dimethylsulfoxide, mannitol, and uric acid. It turns out that the decarboxylation is inhibited by each of these antioxidants. The ratio of decarboxylation rates, with and without the antioxidant, varies linearly with the antioxidant concentration. HPLC and GC-MS analyses of reaction products between benzoic acid and AAPH-derived radicals do not detect the presence of radical substitution products on the aromatic ring or the products derived from benzoic acid. There is no doubt that GC-IRMS is a powerful technique to investigate the effects of peroxyl radicals on benzoic acid. In addition, it is possible to follow the degradation of 13C-labeled chemical targets exposed to peroxyl radicals through the production of 13CO2.

A rapid and sensitive non-competitive avidin-biotin immuno-enzymatic assay for lysozyme.

A non-competitive avidin-biotin immuno-enzymatic assay (NABA) for lysozyme is described. The assay was found to be more sensitive than a competitive assay with biotinylated lysozyme. The lower detection limit of NABA was 0.1 ng lysozyme/ml compared to 1 ng/ml for the competitive assay. The intra-assay and inter-assay coefficients of variation for NABA were 5.9 and 9.1%, respectively. The total time for NABA can be decreased (to less than 1 h) without influencing the detection limit or the analytical range. Serum lysozyme levels measured by NABA and the enzymatic assay in 32 samples showed a correlation coefficient of r = 0.97.

Continuous flow isotope ratio mass spectrometry for the measurement of nanomole amounts of (13)CO(2) by a reverse isotope dilution method.

A simple method for the determination of nanomole amounts of (13)CO(2) generated from an in vitro reaction is reported. The incubation medium contains a known amount of unlabeled sodium bicarbonate and the gaseous (13)CO(2) enriches the atmosphere upon which a measurement of the isotopic enrichment ((13)CO(2)/(12)CO(2)) is made corresponding to a reverse isotope dilution. The quantification of the (13)CO(2) was performed by gas chromatography/isotope ratio mass spectrometry. This assay was validated in terms of linearity, accuracy and precision using three different substrates which produce (13)CO(2) either by enzymatic reaction [(13)C]urea, sodium [(13)C]formate) or by chemical reaction (sodium [(13)C]bicarbonate). Four calibration curves were tested for each (13)C-labeled substrate, allowing the quantification of (13)CO(2) from 25 pmol to 150 nmol. The dynamics of the assay were obtained as a function of the quantity of unlabeled sodium bicarbonate added to each sample.

Combined mass spectrometric methods for the characterization of human hemoglobin variants localized within alpha T9 peptide: identification of Hb Villeurbanne alpha 89 (FG1) His-->Tyr.

Mutation-induced amino acid exchanges occurring on the large T9 peptide of the alpha-chain of human hemoglobin (residues 62-90) are difficult to identify. Despite their high m/z value (around m/z 3000), collision-induced dissociation spectra of liquid secondary ion mass spectrometrically generated protonated alpha T9 peptides were performed successfully. In parallel electrospray mass spectrometry (MS) was used both to measure the molecular mass of the intact proteins and to determine the number of protonatable sites in the alpha T9 peptides. Peptide ladder sequencing using carboxypeptidase digestions and analysis of the truncated peptides by matrix-assisted laser desorption ionization time-of-flight MS confirmed the interpretation. This set of methods allowed the characterization of three hemoglobin variants, with amino acid exchanges located in the alpha T9 part of the sequence. Two of them, Hb Aztec [alpha 76(EF5) Met-->Thr] and Hb M-Iwate [alpha 87(F8) His-->Tyr] were already known. The third [alpha 89(FG1) His-->Tyr] was novel and named Hb Villeurbanne.

The effects of high molecular weight- and low molecular weight-heparins on superoxide ion production and degranulation by human polymorphonuclear leukocytes.

High molecular weight (HMW) and low molecular weight (LMW) heparins affected superoxide ion production and degranulation by polymorphonuclear leukocytes (PMNL) isolated from either chronic hemodialyzed patients or healthy controls. Low concentrations in HMW-heparin, below 1.76 aXa IU/ml for patients and 1.34 aXa IU/ml for controls, increased O2- production started by phorbol myristate acetate. High concentrations above these values decreased it. Increasing LMW-heparin concentrations constantly decreased O2- production using the same stimulus. Myeloperoxidase (MPO) released by PMNL was found to be significantly HMW- and LMW-heparins dose-dependent. The addition of calcium chloride significantly increased MPO release. Lactoferrin release was not dose-dependent of HMW- or LMW-heparins. However, an increase of the percentage of positive responses for lactoferrin release was observed in the simultaneous presence of HMW-heparin and CaCl2 compared to HMW-heparin alone. Lysozyme release was also not dose-dependent of HMW- or LMW-heparins. An increase of the percentage of positive responses for lysozyme release was observed in the presence of CaCl2 alone compared to HMW-heparin.

Serum ferritin spectrotypes in patients with heterozygous beta-thalassaemia.

Serum ferritin spectrotypes from patients heterozygous for beta-thalassaemia were determined after agarose isoelectric focusing followed by radio-immunofixation with anti-ferritin antibody. Multivariate analysis demonstrated a specific spectrotype for heterozygous beta-thalassaemia. This spectrotype was shown to be different from those in hereditary spherocytosis and idiopathic haemochromatosis. Statistical discrimination reached 100% of well-classified patients between these pathological conditions.

Hemoglobin J-Baltimore (beta 16(A13)Gly----Asp): interference with the assay of HbA1c.

Three independent cases of Hemoglobin J-Baltimore(beta 16(A13)Gly----Asp) were detected through the assay of HbA1c in diabetic patients. Using chromatography on Bio-Rex 70 resin, one large peak replaced the usually well resolved peaks of HbA1a + b and HbA1c. The species that overlapped the latter fractions was identified as HbJ1c. HbJ-Baltimore itself was identified using HPLC of the beta-chain tryptic peptides. This observation emphasizes the errors that hemoglobin variants may introduce in the assay of HbA1c.

Glycosyltransferase activities in normal and leukaemic monocytic cells.

Glycosyltransferase activities were measured in normal monocytes and in leukaemic monoblasts. Biosynthesis of glycosylated derivatives of dolichyl-monophosphate, which act as intermediates in glycosylation, was measured. Transfer of mannose from GDP-mannose was greatly increased in leukaemic monoblasts. Galactosyltransferase activities, using endogenous protein acceptors, were increased in leukaemic cells of the monocytic lineage compared to normal cells. No significant difference was observed on specific exogenous glycoprotein acceptors. These selective increases of some glycosyltransferase activities in normal and leukaemic monocytic cells can be correlated either with different expression of specific carbohydrate structures or with changes in glycosylation regulation.

[Unexpected occurence of hemoglobin Athens-Georgia]. / Révélation inattendue de l'hémoglobine Athens-Georgia.

The following report concerned a 47 year old Caucasian diabetic patient. Routine HPLC of HbA1c (Variant II Biorad Laboratories - hemoglobin A1c program) resulted only in the evidence of HbF (1%) and increase in HbA1c (10%). Considering the presence of HbF a standard agarose gel electrophoresis of patient's hemoglobin was performed and revealed the presence of Hb Athens-Georgia. Consequently the occurrence of HbF during determination of HbA1c by HPLC should lead to perform a standard hemoglobin electrophoresis in order to explore an hidden, unsuspected and clinically silent occurrence of rare Hb variant or additional unsuspected increase in HbA2.

Effect of α-thalassaemia on exercise-induced oxidative stress in sickle cell trait.

AIM: Alpha-thalassaemia is known to reduce intra-erythrocyte HbS (sickle haemoglobin) concentration in sickle cell trait (SCT) subjects. Because HbS was shown to increase oxidative stress, the purpose of this study was to assess the effects of the coexistence of α-thalassaemia and SCT on oxidative stress markers and nitric oxide (NO) metabolism after an acute physical exercise. METHODS: Forty subjects (age: 23.5 ± 2.21 years), SCT carriers (HbAS) or healthy subjects (HbAA), with (-αT) or without (-NαT) an associated α-thalassaemia took part in the study. Plasma markers of oxidative stress [advanced oxidation protein products (AOPP), protein carbonyl, malondialdehyde (MDA) and nitrotyrosine], anti-oxidant defences and NO metabolism (NOx) were measured at rest (T(rest)), immediately following an incremental maximal exercise test (T(ex)) and during recovery (T(1h), T(2h) and T(24h)). RESULTS: Malondialdehyde expressed as the percentage of changes from baseline was significantly higher in the HbAS-NαT compared with HbAS-αT during recovery (+36.3 ± 14.1% vs. -1.8 ± 13.2% at T(1h), P = 0.02; +36.6 ± 13.4% vs. -11.4 ± 12.5% at T(2h), P = 0.004 and +24.1 ± 12.3% vs. -14.4 ± 11.5% at T(24h), P = 0.02 in HbAS-NαT vs. HbAS-αT). Compared with HbAS-NαT, HbAS-αT had a higher NOx change from baseline at T(ex) (-23.4 ± 20.6% vs. +57.7 ± 19.3%, respectively; P = 0.005) and lower nitrotyrosine change from baseline at T(1h) (+7.2 ± 22.2% vs. +93.5%±29.3%, respectively; P = 0.04). CONCLUSION: All these data suggest that the presence of α-thalassaemia may blunt the higher level of oxidative stress and the impaired bioavailability of NO observed in the SCT carriers.

Emotional consequences of intensive care unit delirium and delusional memories after intensive care unit admission: a systematic review.

PURPOSE: The aim of this study was to review literature exploring the emotional consequences of delirium and delusional memories in intensive care unit patients. METHODS: A systematic review was performed using PubMed, Embase, Cumulative Index to Nursing and Allied Health Literature, and PsychINFO. RESULTS: Fourteen articles were eligible for this review. Five of them assessed delirium during intensive care unit admission, and the remainder assessed delusional memories during or after admission. No association was found for delirium and adverse emotional outcome. Data regarding delusional memories and emotional outcome were heterogenic. Some studies presented worse scores on posttraumatic stress disorder screening tools in patients with delusional memories, whereas other studies found better scores in patients with delirium or delusional memories. CONCLUSIONS: Based on current literature, no relationship could be shown for delirium and emotional outcome. Regarding delusional memories and adverse emotional outcome, results were in contradiction.