Septic Shock in Advanced Age: Transcriptome Analysis Reveals Altered Molecular Signatures in Neutrophil Granulocytes.

Sepsis is one of the highest causes of mortality in hospitalized people and a common complication in both surgical and clinical patients admitted to hospital for non-infectious reasons. Sepsis is especially common in older people and its incidence is likely to increase substantially as a population ages. Despite its increased prevalence and mortality in older people, immune responses in the elderly during septic shock appear similar to that in younger patients. The purpose of this study was to conduct a genome-wide gene expression analysis of circulating neutrophils from old and young septic patients to better understand how aged individuals respond to severe infectious insult. We detected several genes whose expression could be used to differentiate immune responses of the elderly from those of young people, including genes related to oxidative phosphorylation, mitochondrial dysfunction and TGF-ß signaling, among others. Our results identify major molecular pathways that are particularly affected in the elderly during sepsis, which might have a pivotal role in worsening clinical outcomes compared with young people with sepsis.

Incidence, clinical features and subtypes of delirium in elderly patients treated for hip fractures.

OBJECTIVE: To describe the incidence, risk factors and clinical features (subtypes) of delirium during the postoperative period after hip fracture surgery in elderly patients. DESIGN: Prospective study. METHODS: Thirty-four consecutive patients (9 men and 25 women) were included in this study between June 16 to July 14, 2003. All patients underwent surgery for a fractured neck of femur and were pre- and postoperatively cared for at a combined geriatric/orthopedic ward. ASSESSMENT: The diagnosis of delirium was based on the criteria of the DSM-IV and the Confusion Assessment Method Scale. Subtypes of delirium were classified according to the criteria proposed by Lipowski: hyperactive-hyperalert (or agitated), hypoactive-hypoalert (somnolent) and mixed delirium. RESULTS: Fifty-five percent (n = 19) of the 34 patients developed delirium after surgery. The development of delirium was associated with the medication midazolam taken perioperatively. Nine (47%) of the delirious patients had a hyperactive type of delirium; 5 (26%) developed a hypoactive delirium, and 5 (26%) had a mixed type. We did not find any association among subtypes of delirium and clinical features. CONCLUSIONS: Delirium is a common complication in the postoperative period of elderly patients treated for hip fractures. The use of midazolam in the perioperative period increased the risk of developing postoperative delirium. The hyperactive type of delirium was the most common subtype of delirium.

Adverse events and death in stroke patients admitted to the emergency department of a tertiary university hospital.

OBJECTIVES: To identify the occurrence of adverse events in stroke patients presenting to the emergency department of a tertiary university facility, and to disclose the categories of adverse events associated with death. METHODS: This matched case-control study enrolled 468 patients admitted with stroke to the emergency department from March 1996 to September 1999. The cases comprised 234 consecutive deaths and the controls 234 discharged patients, matched for primary diagnosis and admission period. Adverse events, detected by chart review, were classified according to the degree of severity, immediate causes, and professional category. The association with death was analysed by conditional logistic regression. RESULTS: Adverse events totaled 1218 and occurred in 295 patients: 932 events (76.5%) in 170 cases and 286 (23.5%) in 125 controls. Major adverse events equaled 54.1% of all events (659 episodes): 538 events in 143 cases and 121 in 65 controls. Diagnostic or therapeutic procedures and nursing activities accounted for 55.2% of events. Nursing (38.4%) and medical (31%) adverse events represented the most common related professional categories. A significant association with death was found for major adverse events, medical adverse events, and nosocomial infections, with adjusted odds ratio estimates of 3.74 [95% confidence interval (CI) 1.64-8.54], 3.71 (95% CI 1.61-8.53), and 3.22 (95% CI 1.21-8.59), respectively. CONCLUSION: Adverse events, mostly severe, predominated among deceased patients, resulting mainly from diagnostic or therapeutic procedures and nursing activities. In spite of limitations concerning the observational retrospective nature of this study, we found that severe adverse events, medical adverse events, and nosocomial infections were significantly associated with death in stroke patients.