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2.
Pan Afr Med J ; 35(Suppl 2): 136, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-33193951

RESUMO

Introduction: SARS-CoV-2 is an emerging health threat outbreak. It may cause severe viral pneumonia with Acute Respiratory Distress Syndrome requiring critical care. Aim: to describe clinical features and outcomes of critically ill patients with SARS-CoV-2 infection. Methods: it was a retrospective study carried out in the medical ICU of Farhat Hached teaching hospital between March 11 and May 7, 2020. All consecutive patients with RT-PCR confirmed COVID-19 were included. Clinical characteristics and outcomes were collected by reviewing medical records. Results: during the study period, 10 critically ill patients with COVID-19 were enrolled. Mean age, 51.8±6.3 years; 8(80%), male. The most common comorbidities were; diabetes mellitus, 6(60%), obesity 2(20%), chronic kidney disease 2(20%) and hypertension 1(10%). Mean SAPS II, 23.2±1.8. The mean arterial oxygen partial pressure to fractional inspired oxygen ratio at admission was 136.2±79.7. Noninvasive mechanical ventilation was used in 4(40%) patients and 7(70%) received invasive mechanical ventilation. Tidal volume and PEEP were set respectively within the median [IQR] of, 5.7[5.6-6.3]ml/Kg and 10.7[6.5-11.7]cm H2O. Plateau pressure was monitored in the median [IQR] of 27.9 [25.9-28.5] cm H2O. Four patients received hydroxychloroquine alone and five hydroxychloroquine associated with an antiviral. Five patients developed respectively hyperactive (n=2), hypoactive (n=2) and mixed delirium (n=1). Mortality rate was at 70%. Conclusion: this study demonstrated a particular profile of COVID-19 in the critically ill as a severe presentation in aged males with comorbidities presenting with an ARDS-like and neurological impairment with poor prognosis. The only survivals seem to have benefited from noninvasive ventilatory support.


Assuntos
Betacoronavirus , Infecções por Coronavirus/epidemiologia , Estado Terminal/epidemiologia , Pneumonia Viral/epidemiologia , Antivirais/uso terapêutico , Doenças Cardiovasculares/epidemiologia , Comorbidade , Infecções por Coronavirus/tratamento farmacológico , Delírio/etiologia , Diabetes Mellitus/epidemiologia , Feminino , Mortalidade Hospitalar , Hospitais de Ensino/estatística & dados numéricos , Humanos , Hidroxicloroquina/uso terapêutico , Masculino , Pessoa de Meia-Idade , Obesidade/epidemiologia , Pandemias , Pneumonia Viral/tratamento farmacológico , Prognóstico , Insuficiência Renal Crônica/epidemiologia , Respiração Artificial/estatística & dados numéricos , Síndrome do Desconforto Respiratório do Adulto/etiologia , Estudos Retrospectivos , Escala Psicológica Aguda Simplificada , Tunísia/epidemiologia
3.
Zh Nevrol Psikhiatr Im S S Korsakova ; 120(10. Vyp. 2): 39-45, 2020.
Artigo em Russo | MEDLINE | ID: mdl-33205929

RESUMO

Cognitive impairment or delirium occurs in about 40% of elderly patients after surgery. The increasing number of elderly people has led to a significant increase in the number of cases of postoperative cognitive dysfunction (POCD). This is one of the most important medical and social problems, the analysis of which is especially difficult, since it requires the coordination of a large number of specialties: anesthesiology, surgery, neurology, psychiatry, neuropsychology, as well as fundamental neurosciences. Thus, a systematic multidisciplinary approach that takes into account all possible factors affecting the condition of patients should be considered. The article is devoted to the main aspects of the pathogenesis, prevention and treatment of POCD.


Assuntos
Transtornos Cognitivos , Disfunção Cognitiva , Delírio , Idoso , Cognição , Transtornos Cognitivos/diagnóstico , Transtornos Cognitivos/epidemiologia , Transtornos Cognitivos/etiologia , Disfunção Cognitiva/epidemiologia , Disfunção Cognitiva/etiologia , Humanos , Complicações Pós-Operatórias/epidemiologia , Período Pós-Operatório
4.
Annu Int Conf IEEE Eng Med Biol Soc ; 2020: 5527-5530, 2020 07.
Artigo em Inglês | MEDLINE | ID: mdl-33019231

RESUMO

The incidence of delirium in intensive care units is high and associated with poor outcomes; therefore, its prediction is desirable to establish preventive treatments. This retrospective study proposes a novel approach for delirium prediction. We analyzed static and temporal data from 10,475 patients admitted to one of 15 intensive care units (ICUs) in Alberta, Canada between January 1, 2014 and June 30, 2016. We tested 168 different combinations of study design parameters and five different predictive models (logistic regression, support vector machines, random forests, adaptive boosting and neural networks). The area under the receiver operating characteristic curve (AUROC) ranged from 0.754 (CI 95% ± 0.018) to 0.852 (± 0.033), with sensitivity and specificity respectively ranging from 0.739 (CI 95% ± 0.047) to 0.840 (CI 95% ± 0.064), and 0.770 (CI 95% ± 0.030) to 0.865 (CI 95% ± 0.038). These results are similar to previous studies; however, our approach allows for continuous updates and short-term prediction horizons which might provide major advantages.


Assuntos
Delírio , Alberta , Delírio/diagnóstico , Humanos , Unidades de Terapia Intensiva , Modelos Logísticos , Estudos Retrospectivos
7.
Medicine (Baltimore) ; 99(43): e22884, 2020 Oct 23.
Artigo em Inglês | MEDLINE | ID: mdl-33120832

RESUMO

Delirium is a neuropsychiatric syndrome commonly encountered in critically ill patients, and systemic inflammation has been strongly implicated to underlie its pathophysiology. This study aimed to investigate the predictive value of the platelet-to-lymphocyte ratio (PLR) for delirium in the intensive care unit (ICU).In this retrospective observational study, we analyzed the clinical and laboratory data of 319 ICU patients from October 2016 to December 2017. Using the Locally Weighted Scatterplot Smoothing technique, a PLR knot was detected at a value of approximately 100. Logistic regression was used to investigate the association between the PLR and delirium.Of the 319 patients included in this study, 29 (9.1%) were diagnosed with delirium. In the delirium group, the duration of mechanical ventilation was significantly longer than that in the no-delirium group (40.2 ±â€Š65.5 vs. 19.9 ±â€Š26.5 hours, respectively; P < .001). A multiple logistic regression analysis showed that PLR > 100 (odds ratio [OR]: 1.003, 95% confidence interval [CI]: 1.001-1.005), age (OR: 2.76, 95% CI: 1.110-6.861), and the ratio of arterial oxygen partial pressure to the inspired oxygen fraction (OR: 0.996, 95% CI: 0.992-0.999) were independent predictors of delirium.In our study, a high PLR value on ICU admission was associated with a higher incidence of delirium. Owing to easy calculability, the PLR could be a useful delirium predictive index in ICUs, thereby enabling early interventions to be implemented.


Assuntos
Plaquetas/citologia , Estado Terminal/psicologia , Delírio/sangue , Linfócitos/citologia , Idoso , Monitorização Transcutânea dos Gases Sanguíneos/métodos , Estudos de Casos e Controles , China/epidemiologia , Delírio/diagnóstico , Delírio/epidemiologia , Delírio/fisiopatologia , Feminino , Humanos , Incidência , Inflamação/metabolismo , Inflamação/patologia , Inalação/fisiologia , Unidades de Terapia Intensiva , Masculino , Pessoa de Meia-Idade , Oxigênio/análise , Valor Preditivo dos Testes , Respiração Artificial/estatística & dados numéricos , Estudos Retrospectivos
9.
Medicine (Baltimore) ; 99(35): e21595, 2020 Aug 28.
Artigo em Inglês | MEDLINE | ID: mdl-32871875

RESUMO

BACKGROUND: Delirium is a frequent form of acute brain dysfunction in mechanically ventilated patients. Screening tools have been developed to identify delirium, but it is unclear which tool is the most accurate. Therefore, we provide a protocol of systematic evaluation to assess the accuracy of delirium screening tools in mechanically ventilated patients. METHODS: PubMed, PsycINFO, EMBASE, and the Cochrane Library will be searched. Studies involving mechanically ventilated patients which compared diagnostic tools with the Diagnostic and Statistical Manual of Mental Disorders criteria as a reference standard will be included. We will use MetaDiSC and STATA 15.1 to analyze carefully when a network meta-analysis is allowed. RESULTS: This study will provide a high-quality synthesis to assess the accuracy of different screening methods in mechanically ventilated patients. CONCLUSION: The conclusion of our systematic review will provide evidence to judge which screening method is the best for mechanically ventilated patients.


Assuntos
Encéfalo/fisiopatologia , Delírio/etiologia , Programas de Rastreamento/métodos , Respiração Artificial/efeitos adversos , Delírio/diagnóstico , Delírio/prevenção & controle , Testes Diagnósticos de Rotina/estatística & dados numéricos , Manual Diagnóstico e Estatístico de Transtornos Mentais , Feminino , Humanos , Masculino , Metanálise em Rede
10.
Medicine (Baltimore) ; 99(33): e21639, 2020 Aug 14.
Artigo em Inglês | MEDLINE | ID: mdl-32872027

RESUMO

INTRODUCTION: Anabolic steroids are commonly used by athletes, body builders, and young adults to improve muscle strength. Deleterious effects of anabolic steroids on physical health are well-established. Psychiatric aspects are of particular importance and include psychosis, delirium, mania, depression, and aggression. We describe the case of a young gentleman who was managed as a case of androgenic steroid induced delirium. PATIENT CONCERN: A 33-year-old gentleman presented with increased aggression, hostility, and destructive impulses. He was a regular user of testosterone propionate, testosterone cyprionate and trenbolone acetate up to 200 mg daily in injectable form. His mental status examination showed labile effect, flight of ideas and persecutory delusions. Physical examination was positive for atrophic testes. Laboratory results showed a decreased plasma testosterone level of 9.59 nmol/l (10.4-37.4 nmol/l). Sex Hormone Binding Globulin was 23.8 nmol/l (18.3-54.1 nmol/l) and bioavailable testosterone was 5.110 nmol/l (4.36-14.30 nmol/l). DIAGNOSIS: He was diagnosed as a case of anabolic steroids induced delirium. INTERVENTIONS AND OUTCOME: Patient was treated with regular haloperidol and quetiapine after which his sensorium, speech and behavior improved. He was discharged on haloperidol 7.5 mg and quetiapine 700 mg daily. CONCLUSION: The purpose of this case report is to emphasize on the neuropsychiatric effects and management of anabolic steroids manifested by delirium, increased aggression, hostility, and destructive impulses.


Assuntos
Delírio/induzido quimicamente , Congêneres da Testosterona/efeitos adversos , Adulto , Agressão/efeitos dos fármacos , Antipsicóticos/administração & dosagem , Delírio/tratamento farmacológico , Haloperidol/administração & dosagem , Humanos , Masculino , Fumarato de Quetiapina/administração & dosagem , Testosterona/sangue , Congêneres da Testosterona/administração & dosagem
14.
PLoS One ; 15(9): e0234801, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32877411

RESUMO

BACKGROUND: Significant improvements in clinical outcome can be achieved by implementing effective strategies to optimise pain management, reduce sedative exposure, and prevent and treat delirium in ICU patients. One important strategy is the monitoring of pain, agitation and delirium (PAD bundle). We hypothesised that there is no sufficient financial benefit to implement a monitoring strategy in a Diagnosis Related Group (DRG)-based reimbursement system, therefore we expected better clinical and decreased economic outcome for monitored patients. METHODS: This is a retrospective observational study using routinely collected data. We used univariate and multiple linear analysis, machine-learning analysis and a novel correlation statistic (maximal information coefficient) to explore the association between monitoring adherence and resulting clinical and economic outcome. For univariate analysis we split patients in an adherence achieved and an adherence non-achieved group. RESULTS: In total 1,323 adult patients from two campuses of a German tertiary medical centre, who spent at least one day in the ICU between admission and discharge between 1. January 2016 and 31. December 2016. Adherence to PAD monitoring was associated with shorter hospital LoS (e.g. pain monitoring 13 vs. 10 days; p<0.001), ICU LoS, duration of mechanical ventilation shown by univariate analysis. Despite the improved clinical outcome, adherence to PAD elements was associated with a decreased case mix per day and profit per day shown by univariate analysis. Multiple linear analysis did not confirm these results. PAD monitoring is important for clinical as well as economic outcome and predicted case mix better than severity of illness shown by machine learning analysis. CONCLUSION: Adherence to PAD bundles is also important for clinical as well as economic outcome. It is associated with improved clinical and worse economic outcome in comparison to non-adherence in univariate analysis but not confirmed by multiple linear analysis. TRIAL REGISTRATION: clinicaltrials.gov NCT02265263, Registered 15 October 2014.


Assuntos
Delírio/terapia , Hipnóticos e Sedativos/uso terapêutico , Manejo da Dor/métodos , Adulto , Idoso , Delírio/diagnóstico , Delírio/economia , Gerenciamento Clínico , Feminino , Humanos , Hipnóticos e Sedativos/economia , Unidades de Terapia Intensiva/economia , Masculino , Pessoa de Meia-Idade , Dor/diagnóstico , Dor/economia , Manejo da Dor/economia , Respiração Artificial/economia , Respiração Artificial/métodos , Estudos Retrospectivos
15.
Emerg Med Clin North Am ; 38(4): 919-930, 2020 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-32981626

RESUMO

The geriatric population is growing and is the largest utilizer of emergency and critical care services; the emergency clinician should be comfortable in the management of the acutely ill geriatric patient. There are important physiologic changes in geriatric patients, which alters their clinical presentation and management. Age alone should not determine the prognosis for elderly patients. Premorbid functional status, frailty, and severity of illness should be considered carefully for the geriatric population. Emergency clinicians should have honest conversations about goals of care based not only a patient's clinical presentation but also the patient's values.


Assuntos
Envelhecimento/fisiologia , Estado Terminal , Ressuscitação , Idoso , Cuidados Críticos , Tomada de Decisão Compartilhada , Delírio/induzido quimicamente , Efeitos Colaterais e Reações Adversas Relacionados a Medicamentos , Serviço Hospitalar de Emergência , Fragilidade/classificação , Humanos , Farmacocinética , Polimedicação , Ordens quanto à Conduta (Ética Médica) , Assistência Terminal , Triagem
16.
Aging Clin Exp Res ; 32(10): 2159-2166, 2020 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-32946031

RESUMO

BACKGROUND: Delirium incidence and clinical correlates in coronavirus disease-19 (COVID-19) pneumonia are still poorly investigated. AIM: To describe the epidemiology of delirium in patients hospitalized for suspect COVID-19 pneumonia during the pandemic peak in an academic hospital of Northern Italy, identify its clinical correlations and evaluate the association with mortality. METHODS: The clinical records of 852 patients admitted for suspect COVID-19 pneumonia, defined as respiratory symptoms or fever or certain history of contact with COVID-19 patients, plus chest CT imaging compatible with alveolar-interstitial pneumonia, were retrospectively analyzed. Delirium was defined after careful revision of daily clinical reports in accordance with the Confusion Assessment Method criteria. Data on age, clinical presentation, comorbidities, drugs, baseline lab tests and outcome were collected. The factors associated with delirium, and the association of delirium with mortality, were evaluated through binary logistic regression models. RESULTS: Ninety-four patients (11%) developed delirium during stay. They were older (median age 82, interquartile range, IQR 78-89, vs 75, IQR 63-84, p < 0.001), had more neuropsychiatric comorbidities and worse respiratory exchanges at baseline. At multivariate models, delirium was independently and positively associated with age [odds ratio (OR) 1.093, 95% confidence interval (CI) 1.046-1.143, p < 0.001], use of antipsychotic drugs (OR 4.529, 95% CI 1.204-17.027, p = 0.025), serum urea and lactate-dehydrogenase at admission. Despite a higher mortality in patients with delirium (57% vs 30%), this association was not independent of age and respiratory parameters. CONCLUSIONS: Delirium represents a common complication of COVID-19 and a marker of severe disease course, especially in older patients with neuropsychiatric comorbidity.


Assuntos
Infecções por Coronavirus/diagnóstico , Infecções por Coronavirus/epidemiologia , Delírio/epidemiologia , Hospitais Universitários , Pneumonia Viral/diagnóstico , Pneumonia Viral/epidemiologia , Idoso , Idoso de 80 Anos ou mais , Betacoronavirus , Técnicas de Laboratório Clínico , Feminino , Humanos , Itália/epidemiologia , Masculino , Pessoa de Meia-Idade , Pandemias , Estudos Retrospectivos
18.
Internist (Berl) ; 61(11): 1193-1195, 2020 Nov.
Artigo em Alemão | MEDLINE | ID: mdl-32995904

RESUMO

This article presents the case of a 95-year-old patient with acute urinary retention, postrenal acute renal failure, and subsequent delirium. Especially in older men, urinary retention is often the cause of clinically ambiguous confusional state and should always be considered in the differential diagnosis. This case report demonstrates the value of a good medical history and physical examination as fundamental elements of daily practice.


Assuntos
Lesão Renal Aguda/complicações , Delírio/etiologia , Retenção Urinária , Idoso de 80 Anos ou mais , Delírio/diagnóstico , Diagnóstico Diferencial , Humanos , Masculino
19.
Anesth Analg ; 131(4): 1228-1236, 2020 10.
Artigo em Inglês | MEDLINE | ID: mdl-32925344

RESUMO

BACKGROUND: Recent limited evidence suggests that the use of a processed electroencephalographic (EEG) monitor to guide anesthetic management may influence postoperative cognitive outcomes; however, the mechanism is unclear. METHODS: This exploratory, single-center, randomized clinical trial included patients who were ≥65 years of age undergoing elective noncardiac surgery. The study aimed to determine whether monitoring the brain using a processed EEG monitor reduced EEG suppression and subsequent postoperative delirium. The interventional group received processed EEG-guided anesthetic management to keep the Patient State Index (PSI) above 35 computed by the SEDline Brain Function Monitor (Masimo, Inc, Irvine, CA), while the standard care group was also monitored, but the EEG data were blinded from the clinicians. The primary outcome was intraoperative EEG suppression. A secondary outcome was incident postoperative delirium during the first 3 days after surgery. RESULTS: All outcomes were analyzed using the intention-to-treat paradigm. Two hundred and four patients with a mean age of 72 ± 5 years were studied. Minutes of EEG suppression adjusted by the length of surgery was found to be less for the interventional group than the standard care group (median [interquartile range], 1.4% [5.0%] and 2.5% [10.4%]; Hodges-Lehmann estimated median difference [95% confidence interval {CI}] of -0.8% [-2.1 to -0.000009]). The effect of the intervention on EEG suppression differed for those with and without preoperative cognitive impairment (interaction P = .01), with the estimated incidence rate ratio (95% CI) of 0.39 (0.33-0.44) for those with preoperative cognitive impairment and 0.48 (0.44-0.51) for those without preoperative cognitive impairment. The incidence of delirium was not found to be different between the interventional (17%) and the standard care groups (20%), risk ratio = 0.85 (95% CI, 0.47-1.5). CONCLUSIONS: The use of processed EEG to maintain the PSI >35 was associated with less time spent in intraoperative EEG suppression. Preoperative cognitive impairment was associated with a greater percent of surgical time spent in EEG suppression. A larger prospective cohort study to include more cognitively vulnerable patients is necessary to show whether an intervention to reduce EEG suppression is efficacious in reducing postoperative delirium.


Assuntos
Monitores de Consciência , Eletroencefalografia , Monitorização Neurofisiológica Intraoperatória/métodos , Procedimentos Cirúrgicos Operatórios/métodos , Idoso , Idoso de 80 Anos ou mais , Anestesia , Anestésicos/administração & dosagem , Disfunção Cognitiva/epidemiologia , Disfunção Cognitiva/etiologia , Delírio/epidemiologia , Delírio/etiologia , Delírio do Despertar/epidemiologia , Feminino , Humanos , Incidência , Masculino , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/psicologia , Estudos Prospectivos
20.
S Afr Med J ; 110(6): 519-524, 2020 May 29.
Artigo em Inglês | MEDLINE | ID: mdl-32880565

RESUMO

BACKGROUND: Delirium is a common, serious, underdiagnosed condition in medical and surgical inpatients with acute conditions. It is associated with increased risk of mortality and morbidity. Data of geriatric cohorts are largely limited to developed countries. OBJECTIVES: To describe prevalence, risk factors and outcomes of delirium among general medical patients admitted to two hospitals in Cape Town, South Africa. METHODS: This was a prospective cohort study of patients with acute conditions admitted to a general medical inpatient service in secondary- and tertiary-level public hospitals in the Metro West area of Cape Town. Patients ≥18 years of age were recruited daily from all acute medical admissions. Patients were excluded if they were aphasic or their Glasgow coma scale was <8/15. Delirium was diagnosed using the validated confusion assessment method (CAM) tool and performed by trained neuropsychologists. Demographic data were collected by a clinical team and short- and long-term mortality data were obtained using linkage analysis of hospitalised patients and routinely collected provincial death certification records. RESULTS: The median age of inpatients was 51 (interquartile range 36 - 65) years, 29% were HIV-infected and the overall prevalence of delirium was 12.3%. Multivariate predictors of delirium included the presence of an indwelling urinary catheter (odds ratio (OR) 4.47; confidence interval (CI) 2.43 - 8.23), admission with a central nervous system disease (OR 4.34; CI 2.79 - 7.90), pre-existing cognitive impairment (OR 3.02; CI 1.22 - 7.43) and immobility (OR 1.88; CI 1.01 - 3.51). HIV infection was not associated with increased risk of delirium. Delirium was associated with an increased risk of inhospital (delirium v. no delirium: 29% v. 12%; p<0.01) and 12-month (30% v. 20%; p<0.01) mortality, as well as increased length of hospital stay (7 days v. 5 days; p<0.01). CONCLUSIONS: In this cohort of medical inpatients (relatively young and with a high HIV prevalence) 1 of 8 (12.3%) patients was delirious. Delirium was associated with adverse outcomes. Delirium risk factors in this young cohort were similar to those in geriatric cohorts in developed countries, and neither HIV nor opportunistic infections increased risk.


Assuntos
Delírio/epidemiologia , Pacientes Internados , Adulto , Idoso , Delírio/mortalidade , Feminino , Hospitais Públicos , Humanos , Masculino , Pessoa de Meia-Idade , Testes Neuropsicológicos , Prevalência , Estudos Prospectivos , Fatores de Risco , África do Sul/epidemiologia
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