Period-Prevalence and Risk Factors for Delirium in a Tertiary Referral ICU: A prospective cohort study.

BACKGROUND: Delirium is common in intensive care and leads to increases in morbidity, mortality, Intensive Care Unit (ICU) length of stay, and hospital length of stay. Certain risk factors predict the appearance of delirium. STUDY OBJECTIVES: To determine the rates of delirium, the rate of risk factors, and their relationship to the occurrence of delirium in an adult ICU. METHODS: Single-centre, prospective, observational study. Demographic and treatment data were collected. The Confusion Assessment Method for ICU (CAM-ICU) was performed twice daily to assess for delirium continuously during a 3-week period. Statistical analysis was used to determine the relationship between risk factors and the occurrence of delirium. RESULTS: 86 patients were screened, 44 patients were included, and 260 patient-days were analyzed. The incidence of delirium was 42.9%, the prevalence of delirium in ICU was 50%. Urinary catheters and use of opioids were the most common factors with a positive association for occurrence of delirium. Exposure to daylight and sleeping for more than 4 hours at night were the factors most commonly associated with a lack of delirium. CONCLUSION: The rates of delirium in ICU were high and risk factors occurred frequently. Addressing modifiable risk factors, including the promotion of adequate sleep, could improve outcomes.

Ethanol and caffeine consumption modulates the expression of miRNAs in the cerebellum and plasma of UChB rats.

AIMS: The present study aimed to verify changes in cerebellar and plasmatic expression of miRNAs after the chronic consumption of ethanol and caffeine in the UChB rat, an experimental model for alcoholism. MATERIAL AND METHODS: Male rats at 5 months of age, were divided into the following groups (n = 10/group): 1. Ethanol (UChB rats receiving 10% ethanol solution and water ad libitum); 2. Ethanol + caffeine (UChB rats receiving 10% ethanol solution + 3g/l caffeine and water ad libitum); 3. Control (rats receiving water ad libitum). The cerebellum and plasma of the animals were collected and processed by RT-PCR for the miRNAs-155-5p, -146a-5p, -126-3p, -132-3p, -339-5p. KEY FINDINGS: Ethanol and caffeine were capable of regulating the expression of miRNAs associated with the inflammatory process in the tissue and plasma of the UChB rats. Increased expression of the analyzed miRNAs-155-5p, -146a-5p, -126-3p, -132-3p was observed for the cerebellar tissue in the Ethanol group and reduced expression of them in the Ethanol + caffeine group. In plasma, caffeine significantly elevated the miR-126-3p and miR-132-3p levels and decreased miR-155-5p levels. Ethanol consumption increased miR-146a-5p expression and decreased miR-339-5p levels. In brief, altered plasmatic levels of the miRNAs did not reflect the miRNAs levels found in cerebellar tissue. SIGNIFICANCE: Considering the results herein, we concluded that ethanol predisposes to an inflammatory process while caffeine has a neuroprotective effect on the cerebellar tissue.

Serum miRNAs are differentially altered by ethanol and caffeine consumption in rats.

Alcoholism is a multifactorial disease with high risk for dependence determined by genetic background, environmental factors and neuroadaptations. The excessive consumption of this substance is related to psychiatric problems, epilepsy, cardiovascular disease, cirrhosis and cancers. Caffeine is one of the most popular psychostimulants currently consumed in the world. The combination of ethanol and caffeine ingested by consuming "energy drinks" is becoming increasingly popular among young people. We analyzed the effect of simultaneous consumption of ethanol and caffeine on the serum profile of miRNAs differentially expressed in the ethanol-drinking rat model (UChB strain). Adult rats were divided into three groups (n = 5 per group): UChB group (rats fed with 1 : 10 (v/v) ethanol ad libitum); UChB + caffeine group (rats fed with 1 : 10 (v/v) ethanol ad libitum + 3 g L-1 of caffeine); control group (rats drinking water used as the control for UChB). The treatment with caffeine occurred from day 95 to 150 days old, totalizing 55 days of ethanol + caffeine ingestion. The expressions of microRNAs (miR) -9-3p, -15b-5p, -16-5p, -21-5p, -200a-3p and -222-3p were detected by Real Time-PCR (RT-PCR). The expressions of miR-9-3p, -15b-5p, -16-5p and -222-3p were upregulated in the UChB group. Conversely, simultaneous ingestion of ethanol and caffeine significantly reversed these expressions to similar levels to control animals, thus emphasizing that caffeine had a protective effect in the presence of ethanol. In addition, miR-21-5p was downregulated with ethanol consumption whereas miR-222-3p was unchanged. Ethanol and caffeine consumption was capable of altering serum miRNAs, which are potential biomarkers for the systemic effects of these addictive substances.

Association between type of feeding at discharge from the hospital and nutritional status of very low birth weight preterm infants.

The ideal feeding for premature babies has been the source of extensive debate. The aim of this study was to assess the association between type of feeding at discharge and the nutritional status of very low birth weight infants. This was a retrospective cohort of preterm babies with birth weight ≤1500 g, born between January 2006 and December 2013. The infants were divided into 3 groups according to type of feeding at discharge: exclusive breast milk (group 1), mixed feeding (group 2) and exclusive artificial formula (group 3). Frequencies of each group were calculated, as well as mean Z-score differences in weight, length and head circumference. Six hundred and forty-nine newborns were included. The mean weight of groups 1, 2, and 3 was 1338.7, 1104.0, and 1254.7 g, respectively, and their mean gestational age was 31.9, 30, and 31.2 weeks, respectively. The Z-score differences (means±SD) for groups 1, 2, and 3 were: -0.84±0.68, -1.02±0.75, and -0.86±0.71 for weight, -0.21±1.23, -0.52±1.64 and -0.08±1.34 for head circumference, and -1.10±1.18, -1.54±1.37, and -0.97±1.21 for length. A significant difference was observed between groups 2 and 3 in the adjusted Z-score model for length, with no significant differences in anthropometric measurements for the other comparative analyses. Because of its many advantages, breastfeeding should be stimulated within neonatal units since nutritional status was not influenced by the different types of feeding.

Idiopathic interstitial pneumonia in the ICU: an observational cohort.

In the absence of a clearly identifiable cause, the prognosis of patients with interstitial lung disease is grim. This study describes our institutional experience in management of patients who are admitted to an ICU with respiratory insufficiency secondary to idiopathic interstitial pneumonia (IIP). This study was performed to obtain Australian data on patients admitted to an ICU with respiratory insufficiency secondary to IIP. This is a retrospective cohort study of patients with IIP who were admitted to the ICU between December 2007 and December 2013 at one of two university-affiliated academic hospitals in Newcastle, New South Wales. Thirty-six patients (69% male) were admitted to the ICU in respiratory insufficiency from IIP. The median age of the cohort was 71 (66 to 77) years. The median APACHE III score was 68 (56 to 97). Sixty-nine percent (25/36) of patients died in hospital. The median ICU and hospital lengths of stay were 6 (2 to 13.5) and 12 (4.8 to 18.3) days respectively. No significant difference was observed between admission characteristics and mortality. Patients admitted to ICU with respiratory failure secondary to IIP are aggressively investigated and treated, but still have a high mortality rate. Accurate predictors of mortality would be useful in offering aggressive treatment to patients who would benefit from it.

Examining the side effects of sucrose for pain relief in preterm infants: a case-control study

Sucrose solution is recommended as relevant pain relief management in neonates during acute painful procedures; however, only a few studies have analyzed the potentially adverse effects of sucrose administration to preterm neonates. The goal of this study was to examine the potential side effects of sucrose for pain relief in preterm infants, assessing feeding and weight gain during hospitalization and their feeding patterns postdischarge. The study sample consisted of 43 preterm neonates divided into two groups: a sucrose group (SG, n=18) and a control group (CG, n=25) in which no sucrose was administered. The SG received 0.5 mL/kg 25% oral sucrose for 2 min prior to all acute painful procedures during three consecutive days. A prospective review of medical charts was performed for all samples. The study was done prior to implementation of the institutional sucrose guidelines as a routine service, and followed all ethical requirements. There were no statistically significant differences between groups in terms of weight gain, length of stay with orogastric tubes, and parenteral feeding. Postdischarge, infant nutritional intake included feeding human milk to 67% of the SG and 74% of the CG. There were no statistically significant differences between groups regarding human milk feeding patterns postdischarge. Neonate feeding patterns and weight gain were unaffected following the short-term use of sucrose for pain relief.

Examining the side effects of sucrose for pain relief in preterm infants: a case-control study.

Sucrose solution is recommended as relevant pain relief management in neonates during acute painful procedures; however, only a few studies have analyzed the potentially adverse effects of sucrose administration to preterm neonates. The goal of this study was to examine the potential side effects of sucrose for pain relief in preterm infants, assessing feeding and weight gain during hospitalization and their feeding patterns postdischarge. The study sample consisted of 43 preterm neonates divided into two groups: a sucrose group (SG, n=18) and a control group (CG, n=25) in which no sucrose was administered. The SG received 0.5 mL/kg 25% oral sucrose for 2 min prior to all acute painful procedures during three consecutive days. A prospective review of medical charts was performed for all samples. The study was done prior to implementation of the institutional sucrose guidelines as a routine service, and followed all ethical requirements. There were no statistically significant differences between groups in terms of weight gain, length of stay with orogastric tubes, and parenteral feeding. Postdischarge, infant nutritional intake included feeding human milk to 67% of the SG and 74% of the CG. There were no statistically significant differences between groups regarding human milk feeding patterns postdischarge. Neonate feeding patterns and weight gain were unaffected following the short-term use of sucrose for pain relief.

Pain reactivity in preterm neonates: examining the sex differences.

BACKGROUND: Early and repeated experiences of pain may have long-term effects on vulnerable newborns hospitalized in the Neonatal Intensive Care Unit (NICU), and neonatal pain responses may be affected by a variety of factors that neonates encounter. We tested the hypothesis that male preterm neonates exhibited greater pain sensitivity than females by assessing biobehavioural pain reactivity and recovery patterns to painful procedure. METHODS: Fifty-three infants born preterm and low birthweight who were admitted to NICU were observed during five phases (baseline, antisepsis, puncture, recovery-dressing and recovery-resting). Behavioural pain reactivity was measured using the Neonatal Facial Coding System (NFCS) and the Sleep-Wake States Scale (SWS). The heart rate (HR) was continuously recorded. All measures were assessed based on scores and magnitude of responses. RESULTS: We found that male and female preterm neonates had similar patterns of behavioural pain reactivity and recovery; there were no statistical differences between groups in NFCS and SWS scores. However, male preterm infants presented higher HR immediately in the first minute of the puncture phase and also higher change in maximum HR between the baseline and puncture phases, than female preterm infants. CONCLUSION: Although we found that male infants showed higher physiological reactivity to painful stimulus in some HR parameters than female infants, the evidences were not sufficient to confirm the influence of sex on biobehavioural response to pain in vulnerable neonates.

Application of continuous positive airway pressure in the delivery room: a multicenter randomized clinical trial

This study evaluated whether the use of continuous positive airway pressure (CPAP) in the delivery room alters the need for mechanical ventilation and surfactant during the first 5 days of life and modifies the incidence of respiratory morbidity and mortality during the hospital stay. The study was a multicenter randomized clinical trial conducted in five public university hospitals in Brazil, from June 2008 to December 2009. Participants were 197 infants with birth weight of 1000-1500 g and without major birth defects. They were treated according to the guidelines of the American Academy of Pediatrics (APP). Infants not intubated or extubated less than 15 min after birth were randomized for two treatments, routine or CPAP, and were followed until hospital discharge. The routine (n=99) and CPAP (n=98) infants studied presented no statistically significant differences regarding birth characteristics, complications during the prenatal period, the need for mechanical ventilation during the first 5 days of life (19.2 vs 23.4%, P=0.50), use of surfactant (18.2 vs 17.3% P=0.92), or respiratory morbidity and mortality until discharge. The CPAP group required a greater number of doses of surfactant (1.5 vs 1.0, P=0.02). When CPAP was applied to the routine group, it was installed within a median time of 30 min. We found that CPAP applied less than 15 min after birth was not able to reduce the need for ventilator support and was associated with a higher number of doses of surfactant when compared to CPAP applied as clinically indicated within a median time of 30 min.

Application of continuous positive airway pressure in the delivery room: a multicenter randomized clinical trial.

This study evaluated whether the use of continuous positive airway pressure (CPAP) in the delivery room alters the need for mechanical ventilation and surfactant during the first 5 days of life and modifies the incidence of respiratory morbidity and mortality during the hospital stay. The study was a multicenter randomized clinical trial conducted in five public university hospitals in Brazil, from June 2008 to December 2009. Participants were 197 infants with birth weight of 1000-1500 g and without major birth defects. They were treated according to the guidelines of the American Academy of Pediatrics (APP). Infants not intubated or extubated less than 15 min after birth were randomized for two treatments, routine or CPAP, and were followed until hospital discharge. The routine (n=99) and CPAP (n=98) infants studied presented no statistically significant differences regarding birth characteristics, complications during the prenatal period, the need for mechanical ventilation during the first 5 days of life (19.2 vs 23.4%, P=0.50), use of surfactant (18.2 vs 17.3% P=0.92), or respiratory morbidity and mortality until discharge. The CPAP group required a greater number of doses of surfactant (1.5 vs 1.0, P=0.02). When CPAP was applied to the routine group, it was installed within a median time of 30 min. We found that CPAP applied less than 15 min after birth was not able to reduce the need for ventilator support and was associated with a higher number of doses of surfactant when compared to CPAP applied as clinically indicated within a median time of 30 min.

Interaction of maternal separation on the UCh rat cerebellum.

Maternal care is the main source of signals and stimuli for proper development, growth, and production of adjustment responses to stressful factors. Adverse experiences in childhood are associated with a vulnerability to developing abusive ethanol ingestion via alterations of the response of the hypothalamic-pituitary-adrenal axis. Alcoholism causes global brain abnormalities, with the cerebellum being one of the most susceptible areas. We evaluated the effect of maternal separation on the cerebellum structure of male UCh rats. Adult male UChA (low 10% ethanol consumption) and UChB (high 10% ethanol consumption) rats were divided in to four experimental groups: (1) UChA, (2) UChA maternal separation (MS), (3) UChB, and (4) UChB MS. The MS occurred between the 4th and 14th days of age, for 240 min day(-1) . Euthanasia was performed at 120 days of age. An image analysis system was used to measure cerebellar cortical height and Purkinje cellular area and height in five rats from each group. The cerebellar sections were stained with antibodies against IGFR-I. MS did not alter the ethanol consumption of UChA and UChB rats. Corticosterone level was significantly higher in UChA MS and UChB MS rats than in UChA and UChB rats. The Purkinje cellular area and height were higher in UChA MS rats. IGFR-I expression was observed in the cortical glomerular area of UChA MS and UChB MS rats. MS altered the Purkinje cells in the cerebella of male UCh rats.

Nasal CPAP in the delivery room for newborns with extremely low birth weight in a hospital in a developing country.

The objective of this study was to determine the feasibility of the use of continuous positive airway pressure installed prophylactically in the delivery room (DR-CPAP), for infants with a birth weight between 500 and 1000 g in settings with limited resources. During 23 months, infants with a birth weight between 500 and 1000 g consecutively received DR-CPAP. A total of 33 infants with low birth weight were enrolled, 16 (48.5%) were females. Only 14 (42.4%) received antenatal corticosteroids and only 2 of those 14 (14.3%) infants weighing 500-750 g were not intubated in the delivery room, and apnea was given as the reason for intubation of these patients. Of the 19 infants in the 751-1000 g weight range, 9 (47.4%) were intubated in the delivery room, 6 due to apnea and 3 due to respiratory discomfort. For DR-CPAP to be successful, it is probably necessary for preterm babies to be more prepared at birth to withstand the respiratory effort without the need for intubation. Antenatal corticosteroids and better prenatal monitoring are fundamental for success of DR-CPAP.

Nasal CPAP in the delivery room for newborns with extremely low birth weight in a hospital in a developing country

The objective of this study was to determine the feasibility of the use of continuous positive airway pressure installed prophylactically in the delivery room (DR-CPAP), for infants with a birth weight between 500 and 1000 g in settings with limited resources. During 23 months, infants with a birth weight between 500 and 1000 g consecutively received DR-CPAP. A total of 33 infants with low birth weight were enrolled, 16 (48.5%) were females. Only 14 (42.4%) received antenatal corticosteroids and only 2 of those 14 (14.3%) infants weighing 500-750 g were not intubated in the delivery room, and apnea was given as the reason for intubation of these patients. Of the 19 infants in the 751-1000 g weight range, 9 (47.4%) were intubated in the delivery room, 6 due to apnea and 3 due to respiratory discomfort. For DR-CPAP to be successful, it is probably necessary for preterm babies to be more prepared at birth to withstand the respiratory effort without the need for intubation. Antenatal corticosteroids and better prenatal monitoring are fundamental for success of DR-CPAP.

Pediatric pain: prevalence, assessment, and management in a teaching hospital

The goal of this study was to examine the prevalence, assessment and management of pediatric pain in a public teaching hospital. The study sample consisted of 121 inpatients (70 infants, 36 children, and 15 adolescents), their families, 40 physicians, and 43 nurses. All participants were interviewed except infants and children who could not communicate due to their clinical status. The interview included open-ended questions concerning the inpatients’ pain symptoms during the 24 h preceding data collection, as well as pain assessment and pharmacological/non-pharmacological management of pain. The data were obtained from 100% of the eligible inpatients. Thirty-four children/adolescents (28%) answered the questionnaire and for the other 72% (unable to communicate), the family/health professional caregivers reported pain. Among these 34 persons, 20 children/adolescents reported pain, 68% of whom reported that they received pharmacological intervention for pain relief. Eighty-two family caregivers were available on the day of data collection. Of these, 40 family caregivers (49%) had observed their child’s pain response. In addition, 74% reported that the inpatients received pharmacological management. Physicians reported that only 38% of the inpatients exhibited pain signs, which were predominantly acute pain detected during clinical procedures. They reported that 66% of patients received pharmacological intervention. The nurses reported pain signs in 50% of the inpatients, which were detected during clinical procedures. The nurses reported that pain was managed in 78% of inpatients by using pharmacological and/or non-pharmacological interventions. The findings provide evidence of the high prevalence of pain in pediatric inpatients and the under-recognition of pain by health professionals.

Pediatric pain: prevalence, assessment, and management in a teaching hospital.

The goal of this study was to examine the prevalence, assessment and management of pediatric pain in a public teaching hospital. The study sample consisted of 121 inpatients (70 infants, 36 children, and 15 adolescents), their families, 40 physicians, and 43 nurses. All participants were interviewed except infants and children who could not communicate due to their clinical status. The interview included open-ended questions concerning the inpatients' pain symptoms during the 24 h preceding data collection, as well as pain assessment and pharmacological/non-pharmacological management of pain. The data were obtained from 100% of the eligible inpatients. Thirty-four children/adolescents (28%) answered the questionnaire and for the other 72% (unable to communicate), the family/health professional caregivers reported pain. Among these 34 persons, 20 children/adolescents reported pain, 68% of whom reported that they received pharmacological intervention for pain relief. Eighty-two family caregivers were available on the day of data collection. Of these, 40 family caregivers (49%) had observed their child's pain response. In addition, 74% reported that the inpatients received pharmacological management. Physicians reported that only 38% of the inpatients exhibited pain signs, which were predominantly acute pain detected during clinical procedures. They reported that 66% of patients received pharmacological intervention. The nurses reported pain signs in 50% of the inpatients, which were detected during clinical procedures. The nurses reported that pain was managed in 78% of inpatients by using pharmacological and/or non-pharmacological interventions. The findings provide evidence of the high prevalence of pain in pediatric inpatients and the under-recognition of pain by health professionals.

Physical exercise on the rat ventral prostate: steroid hormone receptors, apoptosis and cell proliferation.

Studies have investigated the effect of exercise on prostate cancer risk. However, there are still doubts regarding the correlation between physical activity and the steroid hormones with respect to the reduction of the risk for prostatic lesions. We evaluated the levels of corticosterone, dihydrotestosterone (DHT), testosterone, estradiol, and steroid hormone receptors, and investigated the relationship between apoptosis and cell proliferation in the rat ventral prostate after training. Two groups were included in this study: control and trained. The trained group was submitted to training for 13 weeks (1 week of adaptation). Two days after the last training session, all animals were euthanized, and the intermediate and distal regions of the ventral prostate were collected and processed for immunohistochemistry, Western blotting and hormonal analyses. Physical exercise increased the corticosterone plasma, DHT and testosterone. In addition, androgen receptor expression was lower and estrogen receptor (ER) α and ER ß expression were higher in the trained group. However, the trained group showed disruption of the ratio of apoptotic to proliferating cells, indicating a predominance of apoptosis. We conclude that physical exercise alters the sex hormones and their receptors and is associated with the disruption of the balance between apoptosis and cell proliferation in the rat ventral prostate.

Proactive management of extreme prematurity: disagreement between obstetricians and neonatologists.

OBJECTIVE: To verify, in extremely preterm infants, if disagreement between obstetricians and neonatologists regarding proactive management is associated with early death. STUDY DESIGN: Prospective cohort of 484 infants with 23(0/7) to 26(6/7) weeks, without malformations, born from January 2006 to December 2009 in eight Brazilian hospitals. Pro-active management was defined as indication of ≥1 dose of antenatal steroid or cesarean section (obstetrician) and resuscitation at birth according to the international guidelines (neonatologist). Main outcome was neonatal death in the first 24 h of life. RESULT: Obstetricians and neonatologists disagreed in 115 (24%) patients: only neonatologists were proactive in 107 of them. Disagreement between professionals increased 2.39 times the chance of death in the first day (95% confidence interval 1.40 to 4.09), adjusted for center and maternal/neonatal clinical conditions. CONCLUSION: In infants with 23 to 26 weeks of gestation, disagreement between obstetricians and neonatologists, translated as lack of antenatal steroids and/or vaginal delivery, despite resuscitation procedures, increases the odds of death in the first day.

Does the neonatal clinical risk for illness severity influence pain reactivity and recovery in preterm infants?

BACKGROUND: The biobehavioural pain reactivity and recovery of preterm infants in the neonatal period may reflect the capacity of the central nervous system to regulate neurobiological development. OBJECTIVE: The aim of the present study was to analyse the influence of the neonatal clinical risk for illness severity on biobehavioural pain reactivity in preterm infants. METHODS: Fifty-two preterm infants were allocated into two groups according to neonatal severity of illness, as measured by the Clinical Risk Index for Babies (CRIB). The low clinical risk (LCr) group included 30 neonates with CRIB scores <4, and the high clinical risk (HCr) group included 22 neonates with CRIB scores ≥4. Pain reactivity was assessed during a blood collection, which was divided into five phases (baseline, antisepsis, puncture, recovery-dressing and recovery-resting). Behavioral pain reactivity was measured using the scores, and magnitude of responses in Neonatal Facial Coding System (NFCS) and Sleep-Wake States Scale (SWS). The heart rate was continuously recorded. RESULTS: The HCr demonstrated a higher magnitude of response on the SWS score from the baseline to the puncture phase than the LCr. Also, the HCr exhibited a higher mean heart rate and minimum heart rate than the LCr in the recovery-resting phase. In addition, the HCr exhibited a higher minimum heart rate from the baseline to the recovery-resting phase than the LCr. CONCLUSION: The infants exhibiting a high neonatal clinical risk showed high arousal during the puncture procedure and higher physiological reactivity in the recovery phase.