Risk Factors for Delirium and Association of Antipsychotic Use with Delirium Progression in Critically Ill Trauma Patients.

BACKGROUND: Delirium occurs frequently in critically ill and injured patients and is associated with significant morbidity and mortality. Limited data exists on the risk factors for developing delirium in critically ill trauma patients and the effect of antipsychotic (AP) medications on delirium progression. OBJECTIVE: The objective of this study is to determine the incidence of delirium in critically ill trauma versus non-trauma surgical patients and determine if the presence of trauma was associated with intensive care unit (ICU) delirium. Secondary outcomes included identifying risk factors for delirium and determining the impact of AP medication use on delirium progression in critically ill trauma patients. METHODS: This retrospective review studies adult trauma/surgical ICU patients admitted between May 2017-July 2018 to a level I trauma and tertiary referral center. Regression modeling was used to determine the impact of AP use on delirium-free days. RESULTS: Delirium was more common in critically ill trauma patients versus non-trauma surgical ICU patients [54/157 (34.4%) vs 42/270 (15.6%), P < .001]. Of the 54 trauma patients with delirium, 28 (52%) received an AP medication for delirium treatment and in the multiple linear regression analysis, AP use was significantly associated with fewer delirium-free days (P = .02). DISCUSSION: Higher admission sequential organ failure assessment scores and increased length of stay were significantly associated with delirium onset in critically ill trauma patients. Use of AP medications for delirium treatment in this population had a negative impact on delirium-free days.

Hindfoot plantarflexion: a radiographic aid to the diagnosis of achilles tendon rupture.

Although tendo Achilles (TA) rupture is a clinical diagnosis, radiographs are sometimes taken to exclude bony injury. In equivocal clinical examination findings, an ultrasound examination is often performed. We investigated whether any radiographic signs of TA rupture existed that could help diagnose TA rupture in equivocal cases. We examined the case notes of 25 consecutive patients who had undergone repair for complete TA rupture. Their lateral radiographs were reviewed and the following angles were measured: calcaneal pitch, lateral talocalcaneal, and tibiocalcaneal. These were compared with a control group of patients who had undergone radiographic examination for ankle injuries resulting in a diagnosis of ankle sprain. The results were compared using an unpaired Student's t test. The mean tibiocalcaneal angle of the patients with complete TA rupture was 87.0 compared with 69.4 for the control group (p < .05). No significant difference was found with the other angles measured. The tibiocalcaneal angle can be a useful adjunct to the clinical examination in the diagnosis of TA rupture. It might also have a role in the evaluation of serial cast application after TA repair.

Cognitive function in late versus early postmenopausal stage.

OBJECTIVES: There are relatively few studies of cognitive performance in the first few postmenopausal years and insufficient data on whether there is differential decline in different cognitive abilities. The aim of the present analysis was to determine the nature of cognitive decline across a range of functions within a period of 5 years from early to late postmenopausal stage. METHODS: In a cross-sectional study, 189 postmenopausal women, who had experienced a natural menopause, were not taking hormonal medication and had not done so in the previous 12 months, were divided according to their postmenopausal stage into early (stage +1, < or =5 years since the last menstrual period, aged 55.4+/-0.3 years, n=80), or late (stage +2, >5 years since the last menstrual period, aged 59.8+/-0.4 years, n=109) postmenopausal stages. Participants completed a comprehensive battery of tests measuring attention, episodic and semantic memory, planning and mental flexibility. Participants also completed self-ratings of mood, sleepiness and menopausal symptoms. RESULTS: There were no differences between the groups in their performance in tests of attention, verbal fluency or memory. However, in the two tests of executive function (planning and mental flexibility) the women in the late postmenopausal stage performed significantly worse than the women in the early postmenopausal stage. These differences remained significant when effects of age and IQ were taken into account by analyses of covariance. There were no differences between the groups in their ratings of mood or of habitual sleepiness, or of feeling sleepy at the start of testing. However, by the end of testing the women in the late postmenopausal stage rated themselves as feeling sleepier than did the women in the early postmenopausal stage. The group differences in executive function remained significant when these differences in sleepiness were accounted for. CONCLUSIONS: Although there were no differences in attention, verbal fluency and memory, executive function was significantly poorer in the late postmenopausal stage women, suggesting that this aspect of cognition deteriorates more rapidly than other functions. This change was independent of change in age, suggesting that hormonal changes between the early and late postmenopausal stages may be responsible.

Cognitive improvement after 6 weeks of soy supplements in postmenopausal women is limited to frontal lobe function.

OBJECTIVE: To assess the effects of 6 weeks of treatment with soy supplements on mood, menopausal symptoms, and cognition in postmenopausal women not taking other forms of hormone therapy. DESIGN: In a double-blind, placebo-matched parallel groups study, 50 postmenopausal women (aged 51-66 y) were randomly allocated to receive daily treatment with a soy supplement (Novasoy, 60 mg total isoflavone equivalents/day) or matching placebo capsules. They were tested at baseline before treatment began and after 6 weeks of treatment in tests of attention, memory, and frontal lobe function, and completed questionnaires to assess sleepiness, mood, and menopausal symptoms. RESULTS: After 6 weeks of treatment, there was a significant (P < 0.02) reduction in somatic menopausal symptoms in the group taking soy supplements, but there were no other significant effects of soy on menopausal symptoms or mood. On the test of nonverbal short-term memory, the soy group showed greater improvement than the placebo group (P < 0.03), but there were no effects of soy on long-term memory, category generation, or sustained attention. However, the soy treatment produced significantly better performance on the two tests of frontal lobe function, those of mental flexibility (simple rule reversal, P < 0.05; complex rule reversal, P < 0.03) and of planning ability (P < 0.05). CONCLUSIONS: The results suggest that the main improvement after 6 weeks of soy supplementation was in frontal lobe function. Significant improvements in the same three measures of frontal lobe function were previously found after 12 weeks of soy supplements in postmenopausal women. The effects of soy on memory seem less robust.

Differential cognitive effects of Ginkgo biloba after acute and chronic treatment in healthy young volunteers.

RATIONALE: Acute doses of Ginkgo biloba have been shown to improve attention and memory in young, healthy participants, but there has been a lack of investigation into possible effects on executive function. In addition, only one study has investigated the effects of chronic treatment in young volunteers. OBJECTIVES: This study was conducted to compare the effects of ginkgo after acute and chronic treatment on tests of attention, memory and executive function in healthy university students. METHODS: Using a placebo-controlled double-blind design, in experiment 1, 52 students were randomly allocated to receive a single dose of ginkgo (120 mg, n=26) or placebo (n=26), and were tested 4 h later. In experiment 2, 40 students were randomly allocated to receive ginkgo (120 mg/day; n=20) or placebo (n=20) for a 6-week period and were tested at baseline and after 6 weeks of treatment. In both experiments, participants underwent tests of sustained attention, episodic and working memory, mental flexibility and planning, and completed mood rating scales. RESULTS: The acute dose of ginkgo significantly improved performance on the sustained-attention task and pattern-recognition memory task; however, there were no effects on working memory, planning, mental flexibility or mood. After 6 weeks of treatment, there were no significant effects of ginkgo on mood or any of the cognitive tests. CONCLUSIONS: In line with the literature, after acute administration ginkgo improved performance in tests of attention and memory. However, there were no effects after 6 weeks, suggesting that tolerance develops to the effects in young, healthy participants.

Limited cognitive benefits in Stage +2 postmenopausal women after 6 weeks of treatment with Ginkgo biloba.

Gingko biloba has cognitive benefits both in populations suffering from dementia and after acute treatment in healthy volunteers, with some evidence indicating that those with poorer cognitive performance show greater benefit. We have previously found that 1 week of treatment with ginkgo improved attention, memory and mental flexibility in post-menopausal women, but the evidence for any beneficial effects of longer treatment is less well-established. The present study aimed to determine whether cognitive benefits, similar to those previously found after 1 week of treatment, would persist after 6 weeks of treatment, and whether those with poorer cognitive performance would benefit more. In a placebo-controlled, double-blind study, postmenopausal women (aged 51-67 years) were randomly allocated to receive a standardized extract of ginkgo (LI 1370, Lichtwer Pharma, Marlow, UK) (one capsule/day of 120 mg, n = 45) or matching placebo (n = 42) for 6 weeks. According to an established reproductive staging system, subjects were divided into those in the early (Stage +1; mean age 55 years) and late (Stage +2: mean age 61 years) stages of menopause. At baseline and after 6 weeks of treatment, subjects completed tests of mental flexibility, planning, memory and sustained attention, and ratings of mood, sleepiness, bodily and menopausal symptoms. The only significant effects of ginkgo were in the test of mental flexibility, in which there were significant menopausal stage-ginkgo interactions. This was because subjects in Stage +2 required fewer trials to complete the task and made fewer errors after ginkgo treatment, whereas those in Stage +1 showed no benefits. Subjects in Stage +2 had poorer performance at baseline compared to those in Stage +1 both in this task and the test of planning ability. The beneficial effects of ginkgo were limited to the test of mental flexibility and to those with poorer performance.

Binge drinking and sex: effects on mood and cognitive function in healthy young volunteers.

This study compared the mood and cognitive performance of male and female teetotal and binge drinking students. The binge drinkers had significantly lower self-ratings of trait anxiety and depression and of state alertness at the time of testing than did the teetotallers. The females had significantly higher ratings of trait and state anxiety, but there were no Sex x Bingeing interactions on mood. The binge drinkers made significantly fewer correct responses in a test of sustained attention and recalled fewer line drawings. There was a significant Sex x Binge interaction in a spatial recognition task because the male, but not the female, binge drinkers were slower to make correct responses. Males performed better than females in both the spatial and pattern recognition memory tasks. There were three tests of executive function. In a spatial working memory task, males performed better than females, but there were no effects of binge drinking. There were no effects in a test of mental flexibility. However, in a test of planning, the binge drinkers were significantly slower than the teetotallers were. Thus, compared with a group of teetotallers, the binge drinkers had lower trait anxiety and depression and poorer performance in tests of sustained attention, episodic memory and planning ability.

Mood changes after cognitive testing in late middle-age: impacts of sex and habitual alcohol consumption.

Men and women (50-67 years) completed drinking diaries and, on the basis of this, were divided into low (<2 units/day, 1 UK unit=8 g alcohol) and moderate (2-5 units/day) alcohol groups. They completed analogue rating scales of mood and bodily symptoms before and after two extended computerised cognitive tests. After the tests, the women showed significantly greater increases in self-ratings on the factors of anxiety and discontentment and felt significantly less alert than did the men. They also showed significantly greater increases in bodily symptoms of somatic anxiety and ratings of aggressive mood than did the men. There were no significant effects of alcohol or Sex x Alcohol interactions on the self-ratings, but the men showed significant positive correlations of alcohol and negative mood. On both the cognitive tests, there were significant Sex x Alcohol interactions because the moderate-drinking men performed worse than the low-drinking men, whereas the moderate-drinking women performed better than the low-drinking women. Thus, the middle-aged women responded much more than did the men with negative mood changes to the psychological stress of cognitive testing, although their cognitive performance was not worse.

Effects on cognition and mood in postmenopausal women of 1-week treatment with Ginkgo biloba.

In a double-blind, placebo-controlled study, postmenopausal women (53-65 years old) were randomly assigned to 7-day treatment with Ginkgo (120 mg/day, n=15) or matched placebo (n=16). They were given a battery of cognitive tests and measurements of mood and menopausal symptoms at baseline (before treatment began) and at the end of 7 days. The group treated with Ginkgo was significantly better than the placebo group in a matching-to-sample test of nonverbal memory, but the groups did not differ in immediate or delayed paragraph recall or in delayed recall of pictures. In a test of frontal lobe function (rule shifting) and in the Paced Auditory Serial Addition Test (PASAT) (which measures sustained attention but also involves frontal lobe function), the group treated with Ginkgo performed significantly better than the placebo group. However, the groups did not differ in a test of planning. The treatments did not differ in their effects on the volunteers' ratings of menopausal symptoms, sleepiness, bodily symptoms or aggression. The benefits of Ginkgo on memory and frontal lobe function found in this study are modest but are unlikely to be secondary to major mood changes.

Does drinking have effects on mood and cognition in male and female students?

Self-ratings of mood and bodily symptoms were made by groups of IQ and education-matched male and female students [teetotal, low (2-9 units/week for both sexes; 1 UK unit=8 g alcohol) and moderate (12-34 units/week for males; 10-24 units/week for females) drinkers], before the start and at the end of cognitive testing. Multivariate analyses of variance (MANOVAs) showed that there were significant Alcohol x Time interactions, because the teetotal group responded to the cognitive tests with greater increases in the factors of somatic anxiety and aggressive mood than did the other two groups. Thus, the teetotallers had greater ratings of anxiety, sweating, palpitations, irritability, headache, feeling angry, quarrelsome, belligerent, resentful, hostile, spiteful and rebellious. No differences were found in immediate or delayed logical memory, in verbal fluency, trails, clock-drawing or mental flexibility tests. In tests of sustained attention [rapid visual information processing (RVIP)] and planning, males performed better than females. The moderate-alcohol group performed better than the low-alcohol group in RVIP and planning (completed significantly more tasks in the minimum moves), although in the hardest parts of the latter test, they took longer in planning the initial move. In conclusion, there was no evidence that the group drinking moderate levels of alcohol had any cognitive impairment and the teetotal group responded to the cognitive tests with the greatest increases in negative mood.

A longer duration of schizophrenic illness has sex-specific associations within the working memory neural network in schizophrenia.

An association has previously been demonstrated between prefrontal cortex (PFC) volume decreases and illness progression in schizophrenia. The impact of illness duration on the fronto-parietal working memory neural network, however, remains unexplored. We investigated the effect of ageing and duration of illness, and explored possible sex-specific effects of duration of illness, in working memory-related brain activity in schizophrenia. Fifty individuals (25 stable schizophrenia outpatients, 25 healthy controls) underwent functional magnetic resonance imaging during performance of an 'n-back' task. Patients performed significantly worse than controls. Duration of illness correlated with reduced dorsolateral prefrontal cortex activity in males and reduced cerebellum activity in females, regardless of performance and age. Sex-specific effects of illness duration were also evident in the inferior frontal and superior temporal gyri (females) and the inferior parietal cortex (males) which generally show sexually dimorphic activation in healthy people. We detected no significant effect of ageing on neural activation of the working memory network in patients though such an effect was present in healthy controls. In conclusion, our findings demonstrate that a longer duration of schizophrenic illness has sex-specific associations within the working memory neural network, with expected association between illness duration and impaired PFC activation apparent in male, but not in female patients. Additionally, brain regions that exhibit sexually dimorphic activation in healthy people may become compromised in the corresponding sex with illness progression.

Does modafinil enhance cognitive performance in young volunteers who are not sleep-deprived?

In a double-blind, parallel groups study, 60 healthy student volunteers (29 men and 31 women, aged 19-22 years) were randomly allocated to receive placebo, 100 or 200 mg modafinil. Two hours later, in the early evening, they completed an extensive cognitive battery. The 3 groups did not differ in self-ratings of sleepiness or tiredness before the testing session, and there were no treatment-associated changes in these or in mood ratings during the tests. Modafinil was without effect in several tests of reaction time and attention, but the 200-mg group was faster at simple color naming of dots and performed better than placebo in the Rapid Visual Information Processing test of sustained attention. Modafinil was without effect on spatial working memory, but the 100-mg group performed better in the backward part of the digit span test. Modafinil was without effect on verbal short-term memory (story recall), but 100 mg improved digit span forward, and both doses improved pattern recognition, although this was accompanied by a slowing of response latency in the 200-mg group. There were no significant effects of modafinil compared with placebo in tests of long-term memory, executive function, visuospatial and constructional ability, or category fluency. These results suggest that the benefits of modafinil are not clearly dose-related, and those from 100 mg are limited to the span of immediate verbal recall and short-term visual recognition memory, which is insufficient for it to be considered as a cognitive enhancer in non-sleep-deprived individuals.