Prospective analysis of plasma amyloid beta and postoperative delirium in the Interventions for Postoperative Delirium: Biomarker-3 study.

BACKGROUND: The effect of postoperative delirium on the amyloid cascade of Alzheimer's dementia is poorly understood. Using early postoperative plasma biomarkers, we explored whether surgery and delirium are associated with changes in amyloid pathways. METHODS: We analysed data from 100 participants in the Interventions for Postoperative Delirium: Biomarker-3 (IPOD-B3) cohort study in the USA (NCT03124303 and NCT01980511), which recruited participants aged >65 yr undergoing non-intracranial surgery. We assessed the relationship between the change in plasma amyloid beta ratio (AßR; Aß42:Aß40) and delirium incidence (defined by the 3-Minute Diagnostic Confusion Assessment Method) and severity (quantified by the Delirium Rating Scale-Revised-98, the study's primary outcome). We also tested the relationship between plasma amyloid beta and intraoperative variables. RESULTS: Across all participants, the plasma AßR increased from the preoperative period to postoperative Day 1 (Wilcoxon P<0.001). However, this increase was not associated with delirium incidence (Wilcoxon P=0.22) or peak severity after adjusting for confounders (log[incidence rate ratio]=0.43; P=0.14). Postoperative Day 1 change in plasma AßR was not associated with postoperative Day 1 change in plasma tau, neurofilament light, or inflammatory markers (interleukin [IL]-1ß, IL-1Ra, IL-2, IL-4, IL-6, IL-8, IL-10, and IL-12), or with operative time or low intraoperative arterial pressure. CONCLUSIONS: Perioperative changes in plasma amyloid do not appear to be associated with postoperative delirium. Our findings do not support associations of dynamic changes in amyloid with postoperative delirium. CLINICAL TRIAL REGISTRATION: .NCT03124303 and NCT01980511.

Connected consciousness after tracheal intubation in young adults: an international multicentre cohort study.

BACKGROUND: Connected consciousness, assessed by response to command, occurs in at least 5% of general anaesthetic procedures and perhaps more often in young people. Our primary objective was to establish the incidence of connected consciousness after tracheal intubation in young people aged 18-40 yr. The secondary objectives were to assess the nature of these responses, identify relevant risk factors, and determine their relationship to postoperative outcomes. METHODS: This was an international, multicentre prospective cohort study using the isolated forearm technique to assess connected consciousness shortly after tracheal intubation. RESULTS: Of 344 enrolled subjects, 338 completed the study (mean age, 30 [standard deviation, 6.3] yr; 232 [69%] female). Responses after intubation occurred in 37/338 subjects (11%). Females (13%, 31/232) responded more often than males (6%, 6/106). In logistic regression, the risk of responsiveness was increased with female sex (odds ratio [ORadjusted]=2.7; 95% confidence interval [CI], 1.1-7.6; P=0.022) and was decreased with continuous anaesthesia before laryngoscopy (ORadjusted=0.43; 95% CI, 0.20-0.96; P=0.041). Responses were more likely to occur after a command to respond (and not to nonsense, 13 subjects) than after a nonsense statement (and not to command, four subjects, P=0.049). CONCLUSIONS: Connected consciousness occured after intubation in 11% of young adults, with females at increased risk. Continuous exposure to anaesthesia between induction of anaesthesia and tracheal intubation should be considered to reduce the incidence of connected consciousness. Further research is required to understand sex-related differences in the risk of connected consciousness.

Sevoflurane dose and postoperative delirium: a prospective cohort analysis.

BACKGROUND: Recent trials are conflicting as to whether titration of anaesthetic dose using electroencephalography monitoring reduces postoperative delirium. Titration to anaesthetic dose itself might yield clearer conclusions. We analysed our observational cohort to clarify both dose ranges for trials of anaesthetic dose and biological plausibility of anaesthetic dose influencing delirium. METHODS: We analysed the use of sevoflurane in an ongoing prospective cohort of non-intracranial surgery. Of 167 participants, 118 received sevoflurane and were aged >65 yr. We tested associations between age-adjusted median sevoflurane (AMS) minimum alveolar concentration fraction or area under the sevoflurane time×dose curve (AUC-S) and delirium severity (Delirium Rating Scale-98). Delirium incidence was measured with 3-minute Diagnostic Confusion Assessment Method (3D-CAM) or CAM-ICU. Associations with previously identified delirium biomarkers (interleukin-8, neurofilament light, total tau, or S100B) were tested. RESULTS: Delirium severity did not correlate with AMS (Spearman's ρ=-0.014, P=0.89) or AUC-S (ρ=0.093, P=0.35), nor did delirium incidence (AMS Wilcoxon P=0.86, AUC-S P=0.78). Further sensitivity analyses including propofol dose also demonstrated no relationship. Linear regression confirmed no association for AMS in unadjusted (log (IRR)=-0.06 P=0.645) or adjusted models (log (IRR)=-0.0454, P=0.735). No association was observed for AUC-S in unadjusted (log (IRR)=0.00, P=0.054) or adjusted models (log (IRR)=0.00, P=0.832). No association of anaesthetic dose with delirium biomarkers was identified (P>0.05). CONCLUSION: Sevoflurane dose was not associated with delirium severity or incidence. Other biological mechanisms of delirium, such as inflammation and neuronal injury, appear more plausible than dose of sevoflurane. CLINICAL TRIAL REGISTRATION: NCT03124303, NCT01980511.

COVID-19 and pre-tenure counseling faculty: A collaborative autoethnographic investigation.

Higher education faculty worldwide experienced heightened stressors due to the COVID-19 pandemic, from completing their professional roles and responsibilities virtually to balancing personal and professional stressors. Consequently, the pandemic created many adjustments for pre-tenure counseling faculty across research, teaching, and service. In response to this pandemic, we explored the impact of the COVID-19 pandemic on the personal and professional lives of four pre-tenure counseling faculty members. Accordingly, we used collaborative autoethnography to investigate our experiences and narratives as pre-tenure counseling faculty, which resulted in seven overarching themes. We discussed the implications for practice, advocacy, education, and faculty training.

Social connectedness, mindfulness, and coping as protective factors during the COVID-19 pandemic.

The COVID-19 pandemic has had an unprecedented psychological impact, revealing immense emotional disturbances among the general population. This study examined the extent to which social connectedness, dispositional mindfulness, and coping moderate symptoms of anxiety and depression in 1242 adults under the same government-issued COVID-19 stay-at-home mandate. Participants completed measures of anxiety, depression, dispositional mindfulness, social connectedness, and coping, and regression analyses were used to examine associations and interaction effects. Results indicated that social connectedness and dispositional mindfulness were associated with reduced symptoms. For individuals living with a partner, decreased mindfulness and avoidant coping were associated with anxious symptoms. In households with children, overutilization of approach coping served to increase symptoms of depression. Results indicate the importance of considering social connectedness, mindfulness, and coping in counseling to enhance factors serving to protect clients during a public health crisis. Implications for professional counselors and areas of future research are discussed.

Psychological impact of coronavirus disease 2019 (COVID-19) social distancing mandates on trauma survivors.

Objective: Despite recognition that coronavirus disease 2019 (COVID-19) pandemic created an unprecedented impact on global mental health, information on the psychological health among trauma survivors during the COVID-19 pandemic is rare. We sought to examine psychological outcomes among individuals with preexisting traumatic experiences during COVID-19. Methods: We sampled 1 242 adults in the mid-Atlantic region of the United States under a state-issued Phase 1 stay-at-home mandate to examine associations between pre-pandemic trauma exposure as measured by the Brief Trauma Questionnaire (BTQ) and anxiety and depression, as measured by the Patient Reported Outcome Scale Anxiety and Depression (PROMIS-A and PROMIS-D). Results: Pre-pandemic trauma exposure among the sample was reported, with 281 (22.6%) participants identifying as experiencing one trauma, 209 (16.8%) reporting two, and 468 (37.7%) reporting three or more. As reported experiences of trauma increased, so did participant anxiety and depressive symptomatology. One-way Analysis of Variance indicated that reported trauma was significantly positively correlated with anxiety (P < 0.01) and depressive symptomatology (P < 0.01). Conclusion: Findings highlight the immense psychological toll of the COVID-19 pandemic, specifically with individuals who were previously exposed to trauma. Public health officials can encourage physicians, employers, and universities to screen patients, employees, and students to assess previous trauma, psychological functioning, and risk factors. Collaboration between physicians and mental health providers including psychiatrists, psychologists, counselors, and social workers to provide evidence informed rapid coordination of care can better meet the global mental health crisis that is arising as a result of this unprecedented global trauma.

Just Say Yes? A Cluster Analytic Approach to Evaluating College Students' Understandings of Affirmative Consent.

Affirmative consent policies on college campuses establish more stringent standards for inferring consent to sex. Although these policies often permit nonverbal communication of consent, they rarely outline finer-grained distinctions about which specific behaviors can stand-in for verbal affirmation. It thus remains possible that students hold different understandings of this policy vis-à-vis the nonverbals used to convey and infer consent, which could undermine the purported utility of affirmative consent initiatives. We presently sampled 442 college undergraduates and asked them to rate whether specific behaviors often present during sexual interaction constitute affirmative indicators of consent. We hypothesized that students would separate into one of three groups depending on how restrictive (e.g., verbal communication only), inclusive (e.g., verbal and clear nonverbals) or potentially non-diagnostic (e.g., sexual arousal, passivity) their behavioral definitions were of affirmative consent. Using cluster analysis, we ultimately identified two groups adhering to a restrictive versus more inclusive operationalization. The former cluster understood affirmative consent as comprising verbal affirmation with variable endorsements of specific nonverbals, whereas the latter consistently endorsed a broader set of nonverbals along with variable ascription to behaviors that do not strongly imply consent. Students in the more inclusive group were more sexually experienced, less likely to use condoms, and viewed casual sex more favorably; as well as were likelier to have received sexual assault education from their parents before and during college, as well as from social media. These findings suggest that subgroups of college students construe affirmative consent policy differently and that these understandings may relate broadly to an individual's sexual experiences, attitudes, and/or education.

Reduced Electroencephalogram Complexity in Postoperative Delirium.

Delirium is associated with electroencephalogram (EEG) slowing and impairments in connectivity. We hypothesized that delirium would be accompanied by a reduction in the available cortical information (ie, there is less information processing occurring), as measured by a surrogate, Lempil-Ziv Complexity (LZC), a measure of time-domain complexity. Two ongoing perioperative cohort studies (NCT03124303, NCT02926417) contributed EEG data from 91 patients before and after surgery; 89 participants were used in the analyses. After cleaning and filtering (0.1-50Hz), the perioperative change in LZC and LZC normalized (LZCn) to a phase-shuffled distribution were calculated. The primary outcome was the correlation of within-patient paired changes in delirium severity (Delirium Rating Scale-98 [DRS]) and LZC. Scalp-wide threshold-free cluster enhancement was employed for multiple comparison correction. LZC negatively correlated with DRS in a scalp-wide manner (peak channel r2 = .199, p < .001). This whole brain effect remained for LZCn, though the correlations were weaker (peak channel r2 = .076, p = .010). Delirium diagnosis was similarly associated with decreases in LZC (peak channel p < .001). For LZCn, the topological significance was constrained to the midline posterior regions (peak channel p = .006). We found a negative correlation of LZC in the posterior and temporal regions with monocyte chemoattractant protein-1 (peak channel r2 = .264, p < .001, n = 47) but not for LZCn. Complexity of the EEG signal fades proportionately to delirium severity implying reduced cortical information. Peripheral inflammation, as assessed by monocyte chemoattractant protein-1, does not entirely account for this effect, suggesting that additional pathogenic mechanisms are involved.

Relationships between preoperative cortical thickness, postoperative electroencephalogram slowing, and postoperative delirium.

BACKGROUND: It is unclear how preoperative neurodegeneration and postoperative changes in EEG delta power relate to postoperative delirium severity. We sought to understand the relative relationships between neurodegeneration and delta power as predictors of delirium severity. METHODS: We undertook a prospective cohort study of high-risk surgical patients (>65 yr old) to identify predictors of peak delirium severity (Delirium Rating Scale-98) with twice-daily delirium assessments (NCT03124303). Participants (n=86) underwent preoperative MRI; 54 had both an MRI and a postoperative EEG. Cortical thickness was calculated from the MRI and delta power from the EEG. RESULTS: In a linear regression model, the interaction between delirium status and preoperative mean cortical thickness (suggesting neurodegeneration) across the entire cortex was a significant predictor of delirium severity (P<0.001) when adjusting for age, sex, and performance on preoperative Trail Making Test B. Next, we included postoperative delta power and repeated the analysis (n=54). Again, the interaction between mean cortical thickness and delirium was associated with delirium severity (P=0.028), as was postoperative delta power (P<0.001). When analysed across the Desikan-Killiany-Tourville atlas, thickness in multiple individual cortical regions was also associated with delirium severity. CONCLUSIONS: Preoperative cortical thickness and postoperative EEG delta power are both associated with postoperative delirium severity. These findings might reflect different underlying processes or mechanisms. CLINICAL TRIAL REGISTRATION: NCT03124303.