Effects of uncomfortable care and histamine H2-antagonists on delirium in acute stroke: A propensity score analysis.

BACKGROUND AND PURPOSE: Uncomfortable care and histamine H2 antagonist (H2A) are implicated in precipitating delirium. In acute stroke, however, the need for them depends on stroke severity, an established risk factor for delirium. So, it is unclear whether care or H2A itself is responsible for delirium. We aimed to evaluate their causal effects on delirium in acute stroke patients. METHODS: This is a prospective cohort study on acute stroke patients admitted to a stroke care unit. Patients without stupor, coma, sedation, or delirium upon admission were enrolled. The treatment was H2A and five care modalities given during the first 24 h: restraint use, prohibited self-transfer, no oral feeding, indwelling catheters, and frequent nighttime care. The outcome was delirium within 5 days defined as Intensive Care Delirium Screening Checklist ≥4 points. We estimated the relative risk (RR) for delirium with regression models weighted by overlap weights using propensity scores estimated through logistic models incorporating known and potential confounders, including stroke severity. RESULTS: Of the 387 participants, 188 were given at least one care modality and 130 were given H2A. A total of 42 developed delirium. Delirium was significantly associated with prohibited self-transfer (RR 1.7, 95% CI 1.0-3.0), frequent nighttime care (RR 2.1, 95% CI 1.2-3.7), and multiple care modalities (RR 2.4, 95% CI 1.3-4.4), while other care modalities and H2A were not. CONCLUSIONS: This study showed possible causal effects of uncomfortable care on delirium and suggests that minimizing it could prevent delirium in acute stroke.

Development of a clinical score, PANDA, to predict delirium in stroke care unit.

BACKGROUND AND PURPOSE: Delirium frequently complicates acute stroke and worsens outcomes. Because delirium is potentially preventable, predicting its occurrence is essential. Although several prediction scores have been proposed, nurses need to quickly predict delirium in stroke care units (SCUs). We aimed to develop a simple tool for this purpose by examining a comprehensive set of potential predictors. METHODS: This is a prospective cohort study on acute stroke patients admitted to an SCU. Patients without stupor, coma, or delirium upon admission were eligible. Participants were followed for 5 days from admission. Delirium was defined as Intensive Care Delirium Screening Checklist ≥4 points. We examined 27 potential predictors, of which 13 predictors were used to developed a least absolute shrinkage and selection operator-penalized logistic regression model. Five variables with the largest coefficients were assigned one point each in the prediction score. The internal validation was performed by bootstrapping. RESULTS: Delirium occurred in 42 of the 387 participants. The score consisted of prior delirium, alcohol, NIHSS ≥5, dementia, and auditory/visual impairment (PANDA). The apparent AUC was 0.84 (95% confidence interval [CI], 0.78-0.89), and the optimism-corrected AUC was 0.81 (95% CI, 0.73-0.88). With a cutoff of ≥2 points, sensitivity was 0.78 (95% CI, 0.65-0.90), and specificity was 0.74 (95% CI, 0.70-0.79). CONCLUSIONS: PANDA score is simple and predicts delirium in an SCU satisfactorily.

Plasma organochlorine levels and subsequent risk of breast cancer among Japanese women: a nested case-control study.

To our knowledge, no prospective study has examined the association between blood levels of organochlorines and breast cancer risk in Asian countries. Here, we tested the hypothesis that higher blood levels of organochlorines are associated with an increased risk of breast cancer in Japanese women. A total of 24,226 women subjects of the Japan Public Health Center-based Prospective Study aged 40 to 69 years who responded to the baseline questionnaire and provided blood in 1990-1995 were followed to December 2002. During 10.7 years follow-up, 144 cases of breast cancer were newly diagnosed. Two matched-controls for each case were selected from the cohort. Plasma levels of p,p'-dichlorodiphenyltrichloroethane (p,p'-DDT), p,p'-dichlorodiphenyldichloroethylene (p,p'-DDE), hexachlorobenzene (HCB), and beta-hexachlorocyclohexane (beta-HCH) were measured. A conditional logistic regression was used to estimate the odds ratio (OR) of breast cancer according to cholesterol-adjusted organochlorine levels based on 139 matched pairs. We found no statistically significant positive association between plasma organochlorine level and breast cancer risk. Adjusted ORs for p,p'-DDT, HCB, and beta-HCH were less than 1. For p,p'-DDE, adjusted OR for the highest versus lowest quartile was 1.48 (95% confidence interval 0.70-3.13; p for trend=0.25). A stratified analysis by menopausal status showed positive associations for p,p'-DDT and p,p'-DDE in premenopausal but not postmenopausal women, although without statistical significance. Our data do not support the hypothesis that plasma levels of p,p'-DDT, p,p'-DDE, HCB, and beta-HCH are associated with an overall increased risk of breast cancer among Japanese women.

Hospital-based survey of pesticide poisoning in Japan, 1998--2002.

Data concerning clinical cases of pesticide poisoning from 1998 to 2002 from the hospitals affiliated with the Japanese Association of Rural Medicine were analyzed. 346 cases of poisoning by agricultural chemicals were reported from 65 hospitals. Suicides accounted for 70% of pesticide poisoning cases, followed by accidental exposures during spraying work (16%) and accidental ingestion (8%). The majority of cases were acute or subacute systemic poisonings (90%), followed by acute dermatitis (5%) and chemical burns (3%). Organophosphate insecticide was the most frequent inducer of clinical cases (36%), followed by bipyridylium herbicide (20%) and carbamate insecticide (6%). The death rate from poisoning by the herbicide paraquat was more than 70% of clinical cases, even though it is a low-concentration product, whereas those from the alternative herbicides, glufosinate and glyphosate, were less than 10%.