Analysis of neuron-specific enolase and S100B as biomarkers of cognitive decline following surgery in older people.

BACKGROUND/AIMS: Post-operative cognitive decline is frequent in older individuals following major surgery; however, biomarkers of this decline are less clearly defined. METHODS: Sixty-eight participants over the age of 60 provided blood samples at baseline and 24 h post-surgery. Cognitive decline was measured at baseline and 52 weeks post-surgery using the Cambridge Assessment for Mental Disorder in the Elderly, section B (CAMCOG) score. Plasma levels of neuron-specific enolase (NSE) and S100B were measured by ELISA. RESULTS: Baseline NSE and the change in NSE levels between baseline and 24 h were correlated with the change in CAMCOG score between baseline and 52 weeks. CONCLUSION: NSE concentrations may be a useful predictor of individuals at risk of more severe long-term cognitive decline.

Optimised anaesthesia to reduce post operative cognitive decline (POCD) in older patients undergoing elective surgery, a randomised controlled trial.

BACKGROUND: The study determined the one year incidence of post operative cognitive decline (POCD) and evaluated the effectiveness of an intra-operative anaesthetic intervention in reducing post-operative cognitive impairment in older adults (over 60 years of age) undergoing elective orthopaedic or abdominal surgery. METHODS AND TRIAL DESIGN: The design was a prospective cohort study with a nested randomised, controlled intervention trial, using intra-operative BiSpectral index and cerebral oxygen saturation monitoring to enable optimisation of anaesthesia depth and cerebral oxygen saturation in older adults undergoing surgery. RESULTS: In the 52 week prospective cohort study (192 surgical patients and 138 controls), mild (χ(2) = 17.9 p<0.0001), moderate (χ(2) = 7.8 p = 0.005) and severe (χ(2) = 5.1 p = 0.02) POCD were all significantly higher after 52 weeks in the surgical patients than among the age matched controls. In the nested RCT, 81 patients were randomized, 73 contributing to the data analysis (34 intervention, 39 control). In the intervention group mild POCD was significantly reduced at 1, 12 and 52 weeks (Fisher's Exact Test p = 0.018, χ(2) = 5.1 p = 0.02 and χ(2) = 5.9 p = 0.015), and moderate POCD was reduced at 1 and 52 weeks (χ(2) = 4.4 p = 0·037 and χ(2) = 5.4 p = 0.02). In addition there was significant improvement in reaction time at all time-points (Vigilance Reaction Time MWU Z = -2.1 p = 0.03, MWU Z = -2.7 p = 0.004, MWU Z = -3.0 p = 0.005), in MMSE at one and 52 weeks (MWU Z = -2.9 p = 0.003, MWU Z = -3.3 p = 0.001), and in executive function at 12 and 52 weeks (Trail Making MWU Z = -2.4 p = .0.018, MWU Z = -2.4 p = 0.019). CONCLUSION: POCD is common and persistent in older adults following surgery. The results of the nested RCT indicate the potential benefits of intra-operative monitoring of anaesthetic depth and cerebral oxygenation as a pragmatic intervention to reduce post-operative cognitive impairment. TRIAL REGISTRATION: Controlled-Trials.com ISRCTN39503939.

Efficacy of treating pain to reduce behavioural disturbances in residents of nursing homes with dementia: cluster randomised clinical trial.

OBJECTIVE: To determine whether a systematic approach to the treatment of pain can reduce agitation in people with moderate to severe dementia living in nursing homes. DESIGN: Cluster randomised controlled trial. SETTING: 60 clusters (single independent nursing home units) in 18 nursing homes within five municipalities of western Norway. PARTICIPANTS: 352 residents with moderate to severe dementia and clinically significant behavioural disturbances randomised to a stepwise protocol for the treatment of pain for eight weeks with additional follow-up four weeks after the end of treatment (33 clusters; n = 175) or to usual treatment (control, 27 clusters; n = 177). INTERVENTION: Participants in the intervention group received individual daily treatment of pain for eight weeks according to the stepwise protocol, with paracetamol (acetaminophen), morphine, buprenorphine transdermal patch, or pregabaline. The control group received usual treatment and care. MAIN OUTCOME MEASURES: Primary outcome measure was agitation (scores on Cohen-Mansfield agitation inventory). Secondary outcome measures were aggression (scores on neuropsychiatric inventory-nursing home version), pain (scores on mobilisation-observation-behaviour-intensity-dementia-2), activities of daily living, and cognition (mini-mental state examination). RESULTS: Agitation was significantly reduced in the intervention group compared with control group after eight weeks (repeated measures analysis of covariance adjusting for baseline score, P < 0.001): the average reduction in scores for agitation was 17% (treatment effect estimate -7.0, 95% confidence interval -3.7 to -10.3). Treatment of pain was also significantly beneficial for the overall severity of neuropsychiatric symptoms (-9.0, -5.5 to -12.6) and pain (-1.3, -0.8 to -1.7), but the groups did not differ significantly for activities of daily living or cognition. CONCLUSION: A systematic approach to the management of pain significantly reduced agitation in residents of nursing homes with moderate to severe dementia. Effective management of pain can play an important part in the treatment of agitation and could reduce the number of unnecessary prescriptions for psychotropic drugs in this population. Trial registration ClinicalTrials.gov NCT01021696 and Norwegian Medicines Agency EudraCTnr 2008-007490-20.

Good outcome in every fourth resuscitation attempt is achievable--an Utstein template report from the Stavanger region.

AIM OF THE STUDY: Out-of-hospital cardiac arrest (OHCA) is a major cause of death in the western world. We wanted to study changes in survival over time and factors linked to this in a region which have already reported high survival rates. METHODS: We used a prospectively collected Utstein template database to identify all resuscitation attempts in adult patients with OHCA of presumed cardiac origin. We included 846 resuscitation attempts and compared survival to discharge with good outcome in two time periods (2001-2005 vs. 2006-2008). RESULTS: We found no significant differences between the two time periods for mean age (71 and 70 years (p=0.309)), sex distribution (males 70% and 71% (p=0.708)), location of the OHCA (home 64% and 63% (p=0.732)), proportion of shockable rhythms (44% and 47% (p=0.261)) and rate of return of spontaneous circulation (38% and 43% (p=0.136)), respectively. Bystander cardiopulmonary resuscitation (CPR), however, increased significantly from 60% to 73% (p<0.0001), as did the overall rate of survival to discharge from 18% to 25% (p=0.018). In patients with a shockable first rhythm, rate of survival to discharge increased significantly from 37% to 48% (p=0.036). In witnessed arrest with shockable rhythm survival to discharge increased from 37% to 52% (p=0.0105). CONCLUSION: Overall, good outcome is now achievable in every fourth resuscitation attempt and in every second resuscitation attempt when patients have a shockable rhythm. The reason for the better outcomes is most likely multi-factorial and linked to improvements in the local chain of survival.

Is there an increase of postpartum hemorrhage, and is severe hemorrhage associated with more frequent use of obstetric interventions?

OBJECTIVE: To analyze changes in postpartum hemorrhage over a 10-year period from 1998 to 2007, and to explore factors associated with severe hemorrhage. DESIGN: Retrospective cohort study, prospectively collected information. SETTING: Stavanger University Hospital, a secondary referral center, Norway. POPULATION: An unselected population of 41,365 women giving birth at the hospital. METHODS: We analyzed changes over time in mean postpartum hemorrhage, severe postpartum hemorrhage and associated factors. Estimated blood loss >1,000 ml was defined as severe hemorrhage. Data were collected from the hospital's database. MAIN OUTCOME MEASURES: Severe postpartum hemorrhage and obstetric interventions. RESULTS: We observed an increase in severe hemorrhage during the study period. After cesarean sections, the risk of severe hemorrhage was twice the risk of severe hemorrhage after vaginal deliveries (5.9%; 95% CI 5.3-6.6 vs. 2.8%; 95% CI 2.6-2.9). The most important factors associated with severe hemorrhage following vaginal deliveries were twin deliveries (OR 6.8), retained placenta (OR 3.9) and inductions of labor (OR 2.2). For cesarean sections, twin deliveries had the strongest association with severe hemorrhage (OR 3.7) followed by general anesthesia (OR 3.0). Obstetric interventions became more frequent; elective cesarean sections increased from 2.4 to 4.9%, acute cesarean sections from 5.5 to 8.9%, operative vaginal deliveries from 9.3 to 12.5%, inductions of labor from 14.3 to 15.8% and augmentations of labor from 5.8 to 29.3%. CONCLUSIONS: The incidence of severe postpartum hemorrhage increased, and this may be related to more frequent use of obstetric interventions.

Health state values during the first year of drug treatment in early-stage Parkinson's disease: a prospective, population-based, cohort study.

BACKGROUND: Parkinson's disease (PD) is a common neurodegenerative disorder in the elderly that may lead to both motor and non-motor symptoms with consequent severe impairment of quality of life. PD also represents a substantial economic burden on society because of the patient's decreased ability to work, increased need for care and need for costly treatment. Evaluation of quality-adjusted life-years (QALYs) is an important tool in cost-effectiveness analyses. To date, however, few data have become available about the utility gains or losses associated with the disease and its management. OBJECTIVES: To evaluate the changes in health state values in patients with newly diagnosed PD during their first year of drug treatment, and to calculate the gain in QALYs and the incremental cost-effectiveness ratio (ICER) for this patient group. METHODS: In this prospective, population-based, cohort study, 199 patients with incident PD and 172 controls were followed over 1 year. Clinical data, drug use and utility scores obtained from the Short Form 6D (SF-6D) health state questionnaire were documented. RESULTS: Patients with PD had lower SF-6D utility scores than controls at baseline. Patients started on antiparkinsonian drugs had an improvement in mean utility scores of 0.039 from 0.667 to 0.706 (p < 0.05). The ICER was euros 45,259 (2007 values) per QALY, of which two-thirds consisted of the costs of drugs and one-third represented the costs of clinical consultations. CONCLUSION: Drug treatment in patients with early-stage PD increases health state values, but the ICER is high. Further investigations will be necessary to capture the full consequences of treatment of PD and to evaluate the efficacy of disease management in this setting.

APOE alleles in Parkinson disease and their relationship to cognitive decline: a population-based, longitudinal study.

Apolipoprotein E gene alleles have been linked to various cardiovascular and neurodegenerative disorders. There have been conflicting reports of associations between Apolipoprotein E alleles and Parkinson disease and Parkinson disease dementia. To investigate the role of Apolipoprotein E alleles in Parkinson disease and Parkinson disease dementia, we have determined Apolipoprotein E genotypes in a group of patients with Parkinson disease (n = 95) and compared them with those of healthy control participants (n = 73). Additionally, in 64 longitudinally followed patients with Parkinson disease, the allele types were correlated to development and progression of dementia and to time from onset of Parkinson disease to dementia using multivariate and survival analyses. The Apolipoprotein E e4e4 genotype was more common in patients with Parkinson disease (7.4%) than in healthy controls (1.4%; P = .03). No significant associations between the Apolipoprotein E genotype and development and progression of dementia or time to dementia were found. More studies with larger Parkinson disease samples are warranted.

Mechanical ventilation in the ICU--is there a gap between the time available and time used for nurse-led weaning?

BACKGROUND: Mechanical ventilation (MV) is a key component in the care of critically ill and injured patients. Weaning from MV constitutes a major challenge in intensive care units (ICUs). Any delay in weaning may increase the number of complications and leads to greater expense. Nurse-led, protocol-directed weaning has become popular, but it remains underused. The aim of this study was to identify and quantify discrepancies between the time available for weaning and time actually used for weaning. Further, we also wished to analyse patient and systemic factors associated with weaning activity. METHODS: This retrospective study was performed in a 12-bed general ICU at a university hospital. Weaning data were collected from 68 adult patients on MV and recorded in terms of ventilator-shifts. One ventilator-shift was defined as an 8-hour nursing shift for one MV patient. RESULTS: Of the 2000 ventilator-shifts analysed, 572 ventilator-shifts were available for weaning. We found that only 46% of the ventilator shifts available for weaning were actually used for weaning. While physician prescription of weaning was associated with increased weaning activity (p < 0.001), a large amount (22%) of weaning took place without physician prescription. Both increased nursing workload and night shifts were associated with reduced weaning activity. During the study period there was a significant increase in performed weaning, both when prescribed or not (p < 0.001). CONCLUSION: Our study identified a significant gap between the time available and time actually used for weaning. While various patient and systemic factors were linked to weaning activity, the most important factor in our study was whether the intensive care nurses made use of the time available for weaning.

Low levels of cellular omega-3 increase the risk of ventricular fibrillation during the acute ischaemic phase of a myocardial infarction.

AIM OF THE STUDY: Animal studies have demonstrated evidence of an anti-arrhythmic effect of marine n-3 fatty acids (FAs). In humans the same mechanism may explain the observed reduction in sudden cardiac death (SCD) associated with intake of fish. Whether high levels of n-3 FAs could protect against ventricular fibrillation (VF) during the acute ischaemic phase of a myocardial infarction (MI) is, however, not known. MATERIALS AND METHODS: We measured red blood cell content of eicosapentaenoic acid (EPA)+docosahexaenoic acid (DHA) expressed as a percentage of total FAs (the omega-3 index) at admission in 460 patients hospitalised with an acute coronary syndrome. Out of 265 patients suffering their first MI, 10 (cases) experienced an episode of VF during the initial 6h of symptom onset. The omega-3 index of these patients was compared to that of 185 first-MI patients (controls) free of VF for at least 30 days post-admission. RESULTS: The median value of the omega-3 index in the VF cases was 4.88% as compared to 6.08% in the controls (p=0.013). After adjustment for age, sex, ejection fraction, high-sensitivity C-reactive protein, use of beta-blocker, differences of infarct characteristics and previous angina pectoris, a 1% increase of the omega-3 index was associated with a 48% reduction in risk of VF (odds ratio (OR) 0.52, 95% confidence interval (CI) 0.28-0.96; p=0.037). CONCLUSION: Our study supports an anti-arrhythmic effect of n-3 FAs through their incorporation into myocardial cell membranes, reducing the risk of VF during ischaemia.

Quality of chest compressions during 10min of single-rescuer basic life support with different compression: ventilation ratios in a manikin model.

INTRODUCTION: Good quality basic life support (BLS) improves outcome during cardiac arrest. As fatigue may reduce BLS performance over time we wanted to examine the quality of chest compressions in a single-rescuer scenario during prolonged BLS with different compression:ventilation ratios (C:V ratios). MATERIAL AND METHODS: Professional paramedics were asked to perform single-rescuer BLS with C:V ratios of 15:2, 30:2 and 50:2 for 10 min each in random order. A Laerdal Medical Resusci Anne Simulator with PC Skillreporting System was used for BLS quality analysis. Total number of chest compressions, compression depth and compression rate were measured and the differences between the C:V ratios were analysed with repeated measures ANOVA. For analysis of fatigue, chest compression variables for each 2-min period were analysed and compared with the first 2-min period using repeated measures ANOVA. RESULTS: Altogether 50 paramedics completed the study. The mean number of chest compressions increased significantly from 604 to 770 and 862 with C:V ratios of 15:2, 30:2 and 50:2, respectively. Chest compression rate was significantly higher with C:V ratio of 15:2 compared to 30:2 and 50:2 but was above 100 per minute for all three ratios. However, the mean chest compression depth did not change significantly between the different C:V ratios. The number of chest compressions did not change significantly with time for any of the three C:V ratios. Compression depth did decline after the first 2-min period for 30:2 and 50:2 as did compression rate for all three ratios. However all were above the guideline limits for the entire test period. CONCLUSION: Increasing the C:V ratio increases the number of chest compressions during 10 min of BLS. Compression depth and compression rate were within guideline recommendations for all three ratios. We found no decline in chest compression quality below guideline recommendations during 10 min of BLS with any of the three different C:V ratios.

A pilot study of key nursing aspects with different cooling methods and devices in the ICU.

INTRODUCTION: Therapeutic hypothermia (TH) has become an integrated part of neurointensive care. Still, little data exists on the actual experience with cooling patients in the ICU from the intensive care nurse (ICN) perspective. The purpose of this survey was to evaluate important nursing aspects with different cooling methods and devices in ICU use. MATERIALS AND METHODS: The ICNs used a four-point rating scale (1=worst, 4=best possible) to evaluate (a) ease of application, (b) visual patient monitoring, (c) work load, (d) hygiene and (e) noise level with four cooling methods used in our ICU. Our simple, initial method of towels soaked in iced water spread over the torso was compared to three commercial cooling methods used; (1) Coolgard 3000 (Alsius, Irvine, USA), (2) Thermowrap (MTRE, Yavne, Israel) and (3) Artic Sun (Medivance, Louisville, USA). RESULT: There were significant differences in how the ICNs rated the nursing aspects of the different cooling methods. Ice-water soaked towels over the torso scored high with respect to ease of application and noise level. For work-load, all the three commercial devices scored significantly better than ice-water soaked towels (P<0.05). Only the Coolgard 3000 system scored significantly better than ice-water soaked towels for visual patient monitoring (P<0.001). For hygienic aspects, Artic Sun and Coolgard scored significantly higher than the others (P<0.05). Overall, the ICNs involved felt they had a general good understanding of TH but were only partly prepared in terms of training and knowledge of protocols and complications when TH was introduced in our ICU. The majority felt the new cooling protocol was acceptable. CONCLUSION: We identified significant differences in the rating of key nursing aspects of the different cooling methods. More studies on implementation of new cooling methods and devices seem warranted.