The Management and Prevention of Delirium in Elderly Patients Hospitalised in Intensive Care Units: A Systematic Review.

BACKGROUND: Delirium or an acute confusional state (ACS) is characterised as being a frequent and complex hospital complication in older adult patients, which can affect their level of independence and increase patient morbidity and mortality. Critically ill patients in the intensive care unit (ICU) frequently develop ICU delirium, leading to longer hospital and ICU stays, increased mortality and long-term impairment. OBJECTIVES: This review aims to assess existing evidence of interventions that can be considered effective for the management and prevention of delirium in ICUs, reducing short-term morbidity and mortality, ICU and hospital admission times and the occurrence of other long-term complications. METHODOLOGY: For this systematic review, we searched Medline, PubMed, Cochrane Library, CINHAL, LILACS, SciELO and Dialnet from January 2018 to August 2024, in English, Spanish and French. MeSH descriptors were adjusted to search the different databases. We also checked Prospero for ongoing systematic reviews. MAIN RESULTS: The electronic search yielded a total of 2656 studies, of which 14 trials met the eligibility criteria, with a total of 14,711 participants. We included eight randomised clinical trial (RCTs), four cohort analyses, one systematic review and one observational trial, including participants over 65 years admitted to the ICU. Ten of these studies were based on pharmacological interventions, three of them examined non-pharmacological interventions and the remaining study examined mixed (pharmacological and non-pharmacological) interventions. Six placebo RCTs were included, plus four reported comparisons between different drugs. Regarding non-pharmacological interventions, nursing programmes focused on optimising modifiable risk factors or the use of therapies such as bright light are emerging. Regarding mixed interventions, we found the combination of invasive techniques and with sedoanalgesia. CONCLUSIONS: Due to its satisfactory level of sedation, dexmedetomidine is presented as a viable option because, although olanzapine offers safer results, postoperative administration angiotensin inhibitor systems significantly reduced the incidence of delirium. As for propofol, no significant differences were found. Among the non-pharmacological and mixed therapies, bright light therapy was able to reduce the incidence of delirium, and the combination of epidural/general anaesthesia was effective in all subtypes of delirium. Concerning the remaining interventions, the scientific evidence is still insufficient to provide a definitive recommendation.

Epidemiology, use, and practice of the intraosseous route in an out-of-hospital emergency department: a retrospective cross-sectional study.

Introduction: The Spanish Emergency Medical Services, according to the model we know today, were formed during the 80s and 90s of the 20th century. The Health Emergency Service (EMS), 061 La Rioja, began to assist the population of La Rioja in November 1999. An essential part of the mission of the SES is the provision of care and the transfer of critical patients using advanced life support unit (ALSU) techniques. In daily practice, out-of-hospital emergency services are faced with situations in which they must deal with the care of serious or critically ill patients, in which the possibility of being able to channel peripheral vascular access as part of ALSU quickly may be difficult or impossible. In these cases, cannulation of intraosseous (IO) vascular access may be the key to early and adequate care. Aim: This study aimed to determine the incidence and epidemiology use of IO vascular access in SES 061 La Rioja during the year 2022. Matherial and methods: We performed observational retrospective cross-sectional studies conducted in 2022. It included a population of 4.364 possible patients as a total of interventions in the community of La Rioja in that year. Results: A total of 0.66% of patients showed a clinical situation that required the establishment of IO vascular access to enable out-of-hospital stabilization; this objective was achieved in 41.3%. A total of 26.1% of patients who presented with cardiorespiratory arrest (CA) were stabilized, while 100% presented with shock and severe trauma. Discussion: IO vascular access provides a suitable route for out-of-hospital stabilization of critically ill patients when peripheral vascular access is difficult or impossible.

Approximation to the economic cost of healthcare for hypertensive patients diagnosed with COVID-19.

Introduction: Many researchers have focused their studies on hypertension due to its over-representation among COVID-19 patients. Both retrospective and observational studies conducted close to the Wuhan area have reported that hypertension is the most common comorbidity observed in patients affected by COVID-19. Objective: Our objective is that patients with arterial hypertension have a worse prognosis in terms of evolution leading to higher costs. Methods: A retrospective cross-sectional study was conducted. A total of 3,581 patients from La Paz University Hospital (LPUH) during the period between 15 July 2020 and 31 July 2020 were included in this study. Results: It should be noted that 40.71% of the patients were hypertensive. As expected, hypertension was associated with men, among whom we observed a higher prevalence and a higher age (median age of 77 years (IQI: 65-85) versus 52 years (IQI: 37-64), p-value < 0.001). Hypertensive patients had a higher prevalence of dyspnea (52.14% vs. 47.15%, p-value = 0.004) and altered awareness (14.89% vs. 4.30%, p-value <0.001). The non-parametric Kaplan-Meier curve estimates the survival of patients in the two study groups. We can see how patients with hypertension have a higher associated mortality, with the difference being statistically significant, p-value (log-rank) = 0.004. Only for the appearance of complications during hospitalization, the group of hypertensive patients reached the figure of €1,355,901.71 compared to the total of 421,403.48 € for normotensive patients. Conclusion: Our study shows the worse clinical evolution of patients with COVID-19 in terms of associated morbidity and mortality. It also shows that the cost of managing patients with hypertension is greater than that of managing normotensive patients.

Profile and characteristics of the adequacy of blood transfusions in Trauma Intensive Care. A cross sectional multicenter study.

Introduction: Major trauma is one of the major health care problems facing modern society, trauma systems require careful planning to achieve an ideal level of coverage for the population. The Patient Blood Management Program is an integrated and global strategy to provide patient care that aims to assess and address, when possible, the etiology of blood abnormalities rather than transfuse without treating the underlying cause. We aimed to describe the factors that are associated with the clinical decision to transfuse polytraumatized patients admitted to the Intensive Care Unit (ICU). Method: We performed a cross sectional multicenter study of patients admitted to ICUs for trauma in 14 Spanish hospitals from September 2020 to December 2021. Results: A total of 69 patients were treated in the emergency room due to polytrauma, 46% of them were considered serious in the initial triage. Thirty were caused by a fall from considerable height (43.47%), followed by 39 patients admitted due to trac accidents (56.52%). The location of the trauma was mainly cranioencephalic, followed by thoracic trauma. Of the 69 patients, 25 received a blood transfusion during their ICU stay (36.23%). Discussion: No significant differences were observed between transfused and non-transfused patients, except for the severity scales, where transfused patients have a higher score on all the scales assessed in the ICU except for the Revised Trauma Score. As we can see, the incidence of kidney failure was also different between the groups analyzed, reaching 44.00% in transfused patients and 13.64% in the group of patients without blood transfusion, p = 0.005. In this sense, 92.00% of the transfusions performed were inadequate according to the criteria of Hb in blood prior to the decision to transfuse (Hb < 9). Our data support the need to consider clinical practice guidelines regarding blood transfusion and its practices.

Development and validation of an educational software based in artificial neural networks for training in radiology (JORCAD) through an interactive learning activity.

The use of Computer Aided Detection (CAD) software has been previously documented as a valuable tool to improve specialist training in Radiology. This research assesses the utility of an educational software tool aimed to train residents in Radiology and other related medical specialties and students from Medicine degree. This in-house developed software, called JORCAD, integrates a CAD system based in Convolutional Neural Networks (CNNs) with annotated cases from radiological image databases. The methodology followed for software validation was expert judgement after completing an interactive learning activity. Participants received a theoretical session and a software usage tutorial and afterwards utilized the application in a dedicated workstation to analyze a series of proposed cases of thorax computed tomography (CT) and mammography. A total of 26 expert participants from the Radiology Department at Salamanca University Hospital (15 specialists and 11 residents) fulfilled the activity and evaluated different aspects through a series of surveys: software usability, case navigation tools, CAD module utility for learning and JORCAD educational capabilities. Participants also graded imaging cases to establish JORCAD usefulness for training radiology residents. According to the statistical analysis of survey results and expert cases scoring, along with their opinions, it can be concluded that JORCAD software is a useful tool for training future specialists. The combination of CAD with annotated cases from validated databases enhances learning, offering a second opinion and changing the usual training paradigm. Including software as JORCAD in residency training programs of Radiology and other medical specialties would have a positive effect on trainees' background knowledge.

Clinical and Sociodemographic Profile of Psychomotor Agitation in Mental Health Hospitalisation: A Multicentre Study.

Psychomotor agitation is characterised by an increase in psychomotor activity, restlessness and irritability. People with psychomotor agitation respond by over-reacting to both intrinsic and extrinsic stimuli, experiencing stress and/or altered cognition. The objective of this study is to assess the clinical and sociodemographic profile of psychomotor agitation in patients with severe mental disorders. The study was carried out in Spain by means of multicentre cross-sectional convenience sampling involving 140 patients who had been admitted to psychiatric hospital units and had experienced an episode of psychomotor agitation between 2018 and 2021.Corrigan's Agitated Behaviour Scale was used to assess psychomotor agitation. The results show that the predominant characteristic in psychomotor agitation is aggressiveness, which is also the most reported factor in patients with severe mental disorder. Patients who also have anxiety develop psychomotor agitation symptoms of moderate/severe intensity. The clinical and sociodemographic profile found in our study is consistent with other studies on the prevalence of psychomotor agitation.

Adverse Effects in Patients with Intellectual and Developmental Disabilities Hospitalized at the University Clinical Hospital.

(1) Background: Providing the patient with the health care they need in a personalized and appropriate manner and without adverse effects (AEs) is a part of quality of care and patient safety. The aim of this applied research project was the assessment of AEs as a clinical risk in patients with high social vulnerability such as persons with intellectual and developmental disabilities (PwIDD). (2) Methods: A retrospective epidemiological cohort study was performed on exposed and unexposed groups (the control group) in order to estimate the incidence of AEs in PwIDDs and assess their importance for this category of patients. (3) Results: AEs were observed with a frequency of 30.4% (95% CI) in the PwIDD exposed group, with significant differences to the unexposed group (p = 0.009). No differences were observed with regards to gender. Age was as a marker of care risk, with the highest incidence of AEs in the group of 60-69 years. (4) Conclusions: PwIDDs have a high risk of suffering AEs while receiving health care assistance due to their high social and clinical vulnerability. Health care practitioners must therefore be aware of these results and keep these observations in mind in order to carry out personalized, preventive, competent, effective, and safe medical care.

New Prognostic Factors in Operated Extracapsular Hip Fractures: Infection and GammaTScore.

There is no universal postoperative classification of extracapsular hip fractures (ECFs). We wondered if infection (according to infection after fracture fixation criteria (IAFF)), immediate partial weight bearing (PWB) and/or the new GammaTScore tool could predict early cut-out. We also examined the correlation between GammaTScore and time to consolidation and studied long-term survival. This was a retrospective cohort study of low-energy complete ECFs operated with Gamma3T nailing in 2014 and fully monitoring, in patients aged over 65. Ten not distally locked cases, one late cut-out, one cut-through, one osteonecrosis and one pseudarthrosis were discarded. Patients were classified into early cut-out (7/204; 3.55%) and no early cut-out (197/204; 96.45%). There was a lower percentage of A2 fractures according to the AO Foundation/Orthopaedic Trauma Association classification (AO/OTA, 1997) in early cut-out. IAFF and only the GammaTScore reduction parameter were different for early cut-out, in opposition to immediate PWB, tip-to-apex distance (TAD) or the Baumgaertner-Fogagnolo classification. GammaTScore inversely correlated with consolidation (p < 0.01). Long-term survival time was not statistically significantly lower in the early cut-out group. Small sample of cases may limit our results. Apart from an important role of IAFF, GammaTScore would be useful for predicting consolidation, avoiding complications and reducing costs. Further studies are needed for reliability.

A Cohort Study in Intensive Care Units: Health Decisions Related to Blood Transfusion during the COVID-19 Pandemic.

Critically ill polytrauma patients with hemorrhage require a rapid assessment to initiate hemostatic resuscitation in the shortest possible time with the activation of a massive transfusion or a critical hemorrhage management protocol. The hospital reality experienced during the COVID-19 pandemic in all countries was critical, as it was in Spain; according to the data published daily by the Ministry of Health on its website, during the period of this study, the occupancy rate of intensive care units (ICUs) by patients diagnosed with the novel coronavirus disease (COVID-19) rose to 23.09% in Spain, even reaching 45.23% at the end of January 2021. We aimed to analyze the changes observed during the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic period regarding the effectiveness of Spanish ICUs in terms of mortality reduction. We present a cross-sectional study that compares two cohorts of patients admitted to ICUs across all autonomous communities of Spain with a diagnosis of polytrauma. Results: Only age was slightly higher at admission during the first wave of the pandemic (47.74 ± 18.65 vs. 41.42 ± 18.82 years, p = 0.014). The transfusion rate during the pandemic increased by 10.4% compared to the previous stage (p = 0.058). Regarding hemostatic components, the use of tranexamic acid increased from 1.8% to 10.7% and fibrinogen concentrates from 0.9% to 1.9%. In the case of prothrombin complex concentrates, although there was a slight increase in their use, there were no significant differences during the pandemic compared to the previous period. Conclusion: Mortality showed no difference before and during the pandemic, despite the observed change in the transfusion policy. In summary, the immediate and global implementation of patient blood management (PBM) based on clinical transfusion algorithms should be mandatory in all hospitals in our country.

Clinical and Epidemiological Approach to Delirium in an Acute Care Unit: A Cross-Sectional Study.

During hospital admissions, the union of various factors, those related to acute pathology, dependency conditions, cognitive impairment, change of habitual environment, and others, can cause delirium. Acute delirium in the elderly (ADE) occurs in around a third of patients over 70 years of age. The syndrome generates serious complications that increase hospital morbidity and mortality and a high cost for the health administration. This study aimed to determine the clinical and epidemiological profile of ADE in an internal medicine unit. A descriptive cross-sectional study was carried out using a convenience test. A total of 356 patients participated between September and November 2021. Sociodemographic variables, predisposing and precipitating factors of ADE, methods of action against ADE, and the impact on functional and cognitive deterioration were analyzed. A total of 35.1% of the patients developed ADE, mostly of the hyperactive type and of nocturnal appearance. ADE was mainly treated with psychoactive drugs and 22% required mechanical restraint, with non-pharmacological preventive strategies, support, and caregiver training being the main tools for controlling ADE during hospital admission.

Therapeutic and Preventive Efficacy of an Intervention on Workers in a Back School.

Back pain and its ailments are the main cause of absenteeism and sick leave. Furthermore, the cause of pain and disability in a large number of workers is unknown, and treatments are not effective in controlling it. For this reason, the Back Schools (BSs) provide theoretical and practical training to workers so that they can acquire knowledge and skills that will allow them to adequately manage their back problems, enabling them to recover their autonomy and prevent relapses. The aim of the study is to analyse the efficacy of a BS by means of the evaluation of pain and disability scales in workers in different sectors and in construction. The most important clinical benefits obtained after the intervention of a BS are the reduction of pain and disability. Statistically significant and clinically relevant results have been observed between the initial assessment and the 6-month review. BS has been shown to be effective in reducing low back and neck pain and disability during the first 6 months of follow-up. Construction workers have pain and disability rates at the overall mean and with improvements between the initial assessment and the 6-month review. Their rates of improvement are clinically more relevant than for the overall population analysed.

Long-term outcomes of distal locking in extracapsular fractures treated with trochanteric Gamma3 nails.

BACKGROUND: Few publications have assessed long-term results of distal locking of short endomedullary nails for extracapsular hip fracture. Virtually all of them focus on immediate differences. Criteria for the use of static or dynamic locking are unclear in most nailing systems, and use is advised in unstable fracture patterns or with risk of bell-clapper effect, but often influenced by the "orthopaedic school". MATERIALS AND METHODS: This is a historical cohort study on patients diagnosed and operated in 2014 and followed up until endpoint, considered as consolidation or major complication, plus evaluation of overall long-term survival. They were categorised as static distal locking (ST) or dynamic distal locking (DN). Both are comparable, except for all stable pre-operative classifications, Fracture Mobility Score (FMS) at discharge, and immediate post-operative loading, all of which were in favour of DN. RESULTS: Consolidation took place in > 95% of patients, with a non-statistically significant delay trend in ST. Less than 6% in both ST and DN had major complications, with no differences. Most cases suffered early cut-out. Significant fracture collapse was the most frequent minor complication. There were more statistically significant minor and total complications in ST. Infection, without differences, can precede cut-out. Lateral thigh pain was similar and could be related to back-out. In DN, 21.1% of cases were truly dynamised. We did not find differences in mobility or in long-term survival. CONCLUSIONS: Any type of distal locking seems to be safe for consolidation, despite a slightly longer consolidation time in static locking. Early cut-out was the main complication, while others were very infrequent, which is an advantage over helical blade devices. There was a higher rate of minor and overall mechanical complications in ST, but infection and lateral thigh pain were similar. Most non-traumatic mechanical complications occurred around 5-6 weeks. About one in five of the DN truly dynamised, with all cases occurring before 8 weeks. Mobility until endpoint and overall long-term survival were not influenced by the locking mode used. LEVEL OF EVIDENCE: Therapeutic study, level 2b.

Investigating a potential biological treatment to prevent pathological fractures caused by unicameral bone cysts in children under 8 years.

INTRODUCTION: There is no consensus on when and how to treat unicameral bone cysts (UBCs), partly because of a lack of knowledge of the aetiology. PURPOSE: To review the different treatment techniques for UBCs and to describe our results with a single injection of autogenous bone marrow (BM) mixed with demineralised bone matrix (DBM) in very young children. PATIENTS AND METHODS: We reviewed five patients under the age of 8 years with UBCs treated by percutaneous aspiration and a single injection of BM associated with DBM. The cyst was located in the proximal humerus in four patients and in the proximal femur in one patient. Assessment of the need for surgery was based on the clinical and radiographic suspicion of new pathological fractures. The administration of a second injection, when necessary, was based on the surgeon's judgement regarding the risk of fracture. The mean follow-up after first injection was 41 months. RESULTS: There were no complications related to the procedure, except a non-displaced fracture, which healed without problems. All patients were pain free and progressively resumed their activities without restriction until a new fracture occurred in two cases. According to Capanna's classification, only one case healed completely (grade 1), one lesion was classified as grade 2, and there were three recurrences at 11, 12 and 27 months after initial treatment (grade 3). The final outcome was treatment failure for three out of the five patients. Two patients were treated with a second injection and one patient is waiting for surgery. CONCLUSION: A single injection of aspirated autogenous BM mixed with DBM in very young children with active UBCs at risk of fracture is very simple, comfortable and safe. Nevertheless, the results seem to be unpredictable and are probably more dependent on the natural evolution of the cyst than on the treatment. Further comparative studies with larger sample numbers are needed.

Ewing sarcoma of the first metacarpal with a 9-year follow-up: case report.

Ewing sarcoma is a primary bone tumor that rarely occurs in the hand. We present a case involving the thumb metacarpal with long-term follow-up. Carpometacarpal and metacarpophalangeal arthrodeses with autograft are relatively simple procedures that stabilized the thumb and preserved satisfactory function.