Influence of Sedation Level and Ventilation Status on the Diagnostic Validity of Delirium Screening Tools in the ICU-An International, Prospective, Bi-Center Observational Study (IDeAS).

Background and objectives: The use of delirium screening instruments (DSIs) is recommended in critical care practice for a timely detection of delirium. We hypothesize that the patient-related factors "level of sedation" and "mechanical ventilation" impact test validity of DSIs. Materials and Methods: This is a prospective, bi-center observational study (clinicaltrials.gov: NCT01720914). Critically ill patients were screened for delirium daily for up to seven days after enrollment using the Nursing Delirium Screening Scale (Nu-DESC), Intensive Care Delirium Screening Checklist (ICDSC), and Confusion Assessment Method for the Intensive Care Unit (CAM-ICU). Reference standard for delirium diagnosis was the neuropsychiatric examination using the criteria of the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR). Immediately before delirium assessment, ventilation status and sedation levels were documented. Results: 160 patients were enrolled and 151 patients went into final analysis. Delirium incidence was 23.2%. Nu-DESC showed a sensitivity and specificity of 88.5%, a positive predictive value (PPV) of 71.9%, and a negative predictive value (NPV) of 95.8%. ICDSC had a sensitivity of 62.5%, a specificity of 92.4%, a PPV of 71.4%, and a NPV of 89.0%. CAM-ICU showed a sensitivity of 75.0%, a specificity of 94.7%, a PPV of 85.7%, and a NPV of 90.0%. For Nu-DESC and ICDSC, test validity was significantly better for non-sedated patients (Richmond Agitation Sedation Scale (RASS) 0/-1), whereas test validity for CAM-ICU in a severity scale version showed no significant differences for different sedation levels. No DSI showed a significant difference in test validity between noninvasively and invasively ventilated patients. Conclusions: Test validities of DSIs were comparable to previous studies. The observational scores ICDSC and Nu-DESC showed a significantly better performance in awake and drowsy patients (RASS 0/-1) when compared with other sedation levels. Physicians should refrain from sedation whenever possible to avoid suboptimal performance of DSIs.

Modafinil to treat fatigue in amyotrophic lateral sclerosis: an open label pilot study.

An open label trial of modafinil was conducted to determine whether it would be tolerated and effective in treating fatigue for people with amyotrophic lateral sclerosis (ALS). Fifteen patients with ALS were treated for two weeks with either 200 mg or 400 mg of modafinil. Reported side effects of the medication were mild and included diarrhea, headache, nervousness, and insomnia. Side effects did not result in any study dropouts. Following treatment, mean scores on the Fatigue Severity Scale (FSS) decreased from 51.3 (SD 9.2) to 42.8 (SD 10.2). On the Epworth Sleepiness Scale (ESS), mean scores decreased from 8.2 (SD 2.0) to 4.5 (SD 2.4). Reductions in both the FSS and the ESS were significant at p < 0.001. Mean scores on the self-report version of the Functional Independence Measure (FIM-SR) increased from 115.2 (SD 5.6) to 118.1 (SD 5.4), with p < 0.01. This pilot study suggests that modafinil is well-tolerated and may reduce symptoms of fatigue in ALS. Further blinded, controlled studies of modafinil in larger numbers of ALS patients are warranted.

Electrodiagnostic evaluation of hereditary motor and sensory neuropathies.

Electrodiagnosis can classify hereditary motor and sensory neuropathies (HMSN) into two basic types: primarily demyelinating with secondary axonal loss and primarily axonal. For the most part, the various forms of HMSN show uniform symmetric nerve conduction slowing, in contrast to acquired neuropathies, which may be multifocal with nonuniform conduction velocity slowing and temporal dispersion. Nevertheless, there are exceptions. This article reviews the available literature and describes the electrodiagnostic approach to HMSN, detailing potential sources of error that can lead to misinterpretation of data.

A review of early gadiform evolution and diversification: first record of a rattail fish skull (Gadiformes, Macrouridae) from the Eocene of Antarctica, with otoliths preserved in situ.

Codfishes, the Gadiformes, are quite abundant in modern temperate and polar waters with a fossil record ranging back into the Palaeogene. The oldest records are from the Danian and Selandian of Europe and South Australia. The bipolar distribution early in their evolutionary history implies that their origin must have occurred quite early in the Palaeocene, or even in the Late Cretaceous with subsequent rapid diversification. By the Eocene, gadiforms were highly abundant and widespread. With the exception of gadiforms, no Eocene Antarctic teleostean group is present in the modern Antarctic fauna. Here, we review the early evolution and diversification of gadiforms in general and of macrouroids in particular. We also describe the undoubtedly oldest skeletal macrourid specimen with otoliths preserved in situ. It is the first definitive record of this group from the Eocene of Antarctica filling a gap in its stratigraphic distribution. The fossil record of gadiforms in general and macrouroids in particular indicates that the origin of both was in shallow shelf environments but with adaptations to deep-water settings early in their evolution. While gadoids seemingly originated in the earliest Palaeogene and rapidly experienced a first major radiation event in the eastern North Atlantic and/or North Sea Basin, macrouroids evolved in the Southern Ocean and migrated northwards into the South Atlantic before the establishment of the circum-Antarctic current and subsequent isolation of the Antarctic fish fauna. These two timely and regional separated adaptive radiation events in the Palaeogene gave rise to their modern taxonomic diversity and global distribution.