DeltaScan for the Assessment of Acute Encephalopathy and Delirium in ICU and non-ICU Patients, a Prospective Cross-Sectional Multicenter Validation Study.

OBJECTIVES: To measure the diagnostic accuracy of DeltaScan: a portable real-time brain state monitor for identifying delirium, a manifestation of acute encephalopathy (AE) detectable by polymorphic delta activity (PDA) in single-channel electroencephalograms (EEGs). DESIGN: Prospective cross-sectional study. SETTING: Six Intensive Care Units (ICU's) and 17 non-ICU departments, including a psychiatric department across 10 Dutch hospitals. PARTICIPANTS: 494 patients, median age 75 (IQR:64-87), 53% male, 46% in ICUs, 29% delirious. MEASUREMENTS: DeltaScan recorded 4-minute EEGs, using an algorithm to select the first 96 seconds of artifact-free data for PDA detection. This algorithm was trained and calibrated on two independent datasets. METHODS: Initial validation of the algorithm for AE involved comparing its output with an expert EEG panel's visual inspection. The primary objective was to assess DeltaScan's accuracy in identifying delirium against a delirium expert panel's consensus. RESULTS: DeltaScan had a 99% success rate, rejecting 6 of the 494 EEG's due to artifacts. Performance showed and an Area Under the Receiver Operating Characteristic Curve (AUC) of 0.86 (95% CI: 0.83-0.90) for AE (sensitivity: 0.75, 95%CI=0.68-0.81, specificity: 0.87 95%CI=0.83-0.91. The AUC was 0.71 for delirium (95%CI=0.66-0.75, sensitivity: 0.61 95%CI=0.52-0.69, specificity: 72, 95%CI=0.67-0.77). Our validation aim was an NPV for delirium above 0.80 which proved to be 0.82 (95%CI: 0.77-0.86). Among 84 non-delirious psychiatric patients, DeltaScan differentiated delirium from other disorders with a 94% (95%CI: 87-98%) specificity. CONCLUSIONS: DeltaScan can diagnose AE at bedside and shows a clear relationship with clinical delirium. Further research is required to explore its role in predicting delirium-related outcomes.

Geriatric assessment in older patients with a hematologic malignancy: a systematic review.

The aim of this systematic review is to give an update of all currently available evidence on the relevance of a geriatric assessment in the treatment of older patients with hematologic malignancies. A systematic search in MEDLINE and EMBASE was performed to find studies in which a geriatric assessment was used to detect impaired geriatric domains or to address the association between geriatric assessment and survival or clinical outcome measures. The literature search included 4,629 reports, of which 54 publications from 44 studies were included. Seventy-three percent of the studies were published in the last 5 years. The median age of the patients was 73 years (range, 58-86) and 71% had a good World Health Organization (WHO) performance status. The median prevalence of geriatric impairments varied between 17% and 68%, even in patients with a good WHO performance status. Polypharmacy, nutritional status and instrumental activities of daily living were most frequently impaired. Whereas several geriatric impairments and frailty (based on a frailty screening tool or summarized geriatric assessment score) were predictive for a shorter overall survival, WHO performance status lost its predictive value in most studies. The association between geriatric impairments and treatment-related toxicity varied, with a trend towards a higher risk of (non-)hematologic toxicity in frail patients. During the follow-up, frailty seemed to be associated with treatment non-completion, especially when patients were malnourished. Patients with a good physical capacity had a shorter stay in hospital and a lower rate of hospitalization. Geriatric assessment, even in patients with a good performance status, can detect impaired geriatric domains and these impairments may be predictive of mortality. Moreover, geriatric impairments suggest a higher risk of treatment-related toxicity, treatment non-completion and use of healthcare services. A geriatric assessment should be considered before starting treatment in older patients with hematologic malignancies.

Multidisciplinary decision-making and course of treatment in older patients with colorectal cancer: Effect of geriatrician input.

INTRODUCTION: We evaluated the effect of the inclusion of a geriatrician in the multidisciplinary cancer team (MDT) on decision-making for chemotherapy with curative intent in older patients with colorectal cancer. MATERIALS AND METHODS: We audited all patients aged 70 years and older with colorectal cancer discussed at MDT meetings between January 2010 and July 2018; selection was limited to those patients for whom guidelines recommended chemotherapy with curative intent as part of the primary treatment. We assessed how treatment decisions came about, and what the course of treatment was in the period before (2010-2013) and after (2014-2018) the geriatrician joined the MDT meetings. RESULTS: There were 157 patients included: 80 patients from 2010 to 2013 and 77 patients from 2014 to 2018. Age was mentioned significantly less often as the reason to withhold chemotherapy in the 2014-2018 cohort (10% vs 27% in 2010-2013, p = 0.04). Instead, patient preferences, physical condition, and comorbidities were the main reasons stated for withholding chemotherapy. Although a similar proportion of patients started chemotherapy in both cohorts, patients treated in 2014-2018 required many fewer treatment adaptations and were thus more likely to complete their treatments as planned. DISCUSSION: Over time and by incorporating a geriatrician's input, the multidisciplinary selection of older patients with colorectal cancer for chemotherapy with curative intent has improved. By basing decisions on an assessment of the patient's ability to tolerate treatment rather than using a more general parameter such as age, both overtreatment of not-so-fit patients and undertreatment of fit-but-old patients can be prevented.

Factors associated with survival in older patients with stage I-III colorectal carcinoma who were not managed curatively in the Netherlands.

AIM: Some patients with stage I-III colorectal cancer (CRC) do not undergo tumor resection. Little is known about survival of these non-curatively managed patients. The aim of this study is to report all-cause mortality and to identify which factors are associated with survival in these patients. METHODS: A retrospective review of electronic medical records was performed in two hospitals in the Netherlands. Patients diagnosed with CRC without distant metastases (radiologically determined stage I-III) and managed without tumor resection between 2011 and 2017 were included. The primary outcome was all-cause mortality. The effect of several variables on survival was evaluated with a multivariate logistic regression. RESULTS: Of the 107 patients with stage I-III CRC that did not undergo resection of the primary tumor, 80% died within two years; median survival time was 8.5 months (IQR 2.5-22 months). Malnutrition risk (OR 6.36 (CI 1.21-33.25); p = 0.03) and comorbidity burden (OR 1.51 (CI 1.05-2.18 p = 0.03) were significantly associated with decreased survival after two years in a multivariate model. Age and disease stage were not. When treatment decision was mainly patient driven instead of based on the multi-disciplinary tumor board's decision, survival was longer (mean overall survival 16 months vs 10 months, respectively) p < 0.05. CONCLUSION: Survival of patients with radiologically determined stage I-III CRC who did not undergo surgical resection was approximately 20% at two years and associated with the number of comorbidities, malnutrition risk status and dependent living, but not with age or disease stage.

Functional decline after surgery in older patients with head and neck cancer.

INTRODUCTION: In addition to classical endpoints such as survival and complication rates, other outcomes such as quality of life and functional status are increasingly recognized as important endpoints, especially for elderly patients. However, little is known about the long-term effect of surgery with regard to these other outcomes. Our aim is to investigate the functional status and self-reported health status of patients ≥ 70 years one year after surgery for head and neck cancer. METHODS: We present one-year follow-up data of patients ≥ 70 year who underwent surgery for HNC. During an interview by telephone, functional status was evaluated by using the Katz-15 Index of Independence questionnaire including six items covering basic Activities of Daily Living (ADL) and nine items covering Instrumental Activities of Daily Living (IADL). Measurements were compared with those obtained preoperatively. RESULTS: In total, 126 patients were included and eventually we collected follow-up data of 68 patients. There was a statistically significant decrease in functional status on the total Katz-15 and on the IADL questionnaire scores one year after surgery (mean 1.34 versus 2.42,p-value 0.00 and mean 1.21 versus 1.94,p-value 0.00). There was no significant change concerning ADL dependence (p-value 0.18) and cognitive status (p-value 0.11). The self-reported health status improved postoperatively, although not statistically significantly so (mean 67.36 versus 71.25,p-value 0.12). CONCLUSION: Approximately-one year after surgery for HNC, there is a significant decline in functional status indicating a higher level of dependency.

Anticholinergic drug exposure at intensive care unit admission affects the occurrence of delirium. A prospective cohort study.

BACKGROUND: Anticholinergic drugs may increase the risk of delirium in non-critically ill patients, but it is unclear whether exposure to these drugs is also a risk factor for Intensive Care Unit (ICU) delirium. In this study the hypothesis was tested that anticholinergic drug exposure at ICU admission increases the risk to develop delirium during ICU stay, particularly in patients with advanced age and severe sepsis. METHODS: A prospective cohort study was performed in the mixed 32-bed medical-surgical ICU of the University Medical Center Utrecht, the Netherlands in the period from January 2011 till June 2013. Included were nonneurological patients that were consecutively admitted for more than 24 hours. The presence of delirium was evaluated each day using a validated algorithm based on the Confusion Assessment Method for the ICU (CAM-ICU), the initiation of delirium treatment as well as chart review by researchers. Anticholinergic drug exposure at ICU admission was assessed using the Anticholinergic Drug Scale (ADS). To evaluate the association between anticholinergic drug exposure at ICU admission and the risk of developing delirium, we performed multivariable competing risk Cox proportional hazard analysis corrected for confounding factors. RESULTS: Approximately half (47%, n=513) of the 1090 included patients developed delirium during ICU admission. The absolute risk for delirium development increased with more anticholinergic drug exposure: 42% in patients with ADS score=0, 49% in patients with ADS score=1, and 53% in patients with ADS higher than 1. Taking competing events (death and discharge) and potential confounding factors into account, the subdistribution hazard ratio (SHR) was 1.13 (95% CI: 0.91-1.40) for ADS score=1 point and 1.35 (95% CI: 1.09-1.68) for ADS ≥2 compared with an ADS score=0 (no anticholinergic drug exposure). The effect was strongest during the first days of ICU admittance and was strongest in patients above 65 year without severe sepsis and/or septic shock (SHR 2.15, 95% CI 1.43-3.25). CONCLUSIONS: Anticholinergic drug exposure at ICU admission increases the risk of delirium in critically ill patients. This effect was most pronounced in patients older than 65 years without severe sepsis and/or septic shock, and declining over time.

Development of a self-reported version of the G8 screening tool.

INTRODUCTION: The G8 is a widely used frailty screening tool in patients with cancer that was designed to be completed by healthcare professionals. A patient-reported version would enable a broader application. Aim of this study was to develop a self-reported version of the G8 and to assess its agreement with the original G8. MATERIALS AND METHODS: A self-reported version of the G8 was developed with the aid of communication specialists. Patients aged ≥ 70 years from two different study populations were included: 1. Patients with cancer and 2. Patients visiting the geriatric outpatient clinic. The original G8 was completed by an oncology nurse or clinical research assistant and patients completed the self-reported G8. Patients were blinded to results of the original G8. Kappas were calculated to measure the agreement between the self-reported and original G8 for both the individual items as well as for the cut-off for potential frailty (≤14). RESULTS: 161 patients participated, of whom 104 had cancer (65%). Patients with cancer more frequently completed all items than geriatric patients (all items completed in 94% versus 72%, p < 0.001). The agreement for potential frailty was substantial for patients with cancer (Kappa 0.63) and poor for geriatric patients (Kappa 0.05). CONCLUSION: Completion of the self-reported G8 is feasible and agreement of its outcome with the original G8 outcome is sufficient for patients with cancer but not for geriatric patients. The self-reported G8 may therefore be a useful alternative to the original G8 in older patients with cancer.

Prevalence of hyponatremia on geriatric wards compared to other settings over four decades: a systematic review.

Aim of the study was to analyze temporal trends in prevalence of hyponatremia over four decades in different settings. A systematic review of the literature from 1966 to 2009 yielded prevalences of hyponatremia, with standard errors (SE) and pooled estimated means (PEM), calculated by year and setting (geriatric, ICU, other hospital wards, psychiatric hospitals, nursing homes, outpatients). 53 studies were included. Prevalence of hyponatremia was stable from 1976 to 2006, and higher on geriatric wards accept for ICU: e.g. PEM prevalence of mild hyponatremia (serum sodium <135 mM) was 22.2% (95%CI 20.2-24.3) on geriatric wards, 6.0% (95%CI 5.9-6.1) on other hospital wards and 17.2% (SE 7.0) in one ICU-study; for severe hyponatremia (serum sodium<125 mM) these figures were 4.5% (95%CI 3.0-6.1), 0.8% (95%CI 0.7-0.8) and 10.3% (SE 5.6). In nursing homes PEM prevalence of mild hyponatremia was 18.8% (95%CI 15.6-22.2). The higher prevalence on geriatric wards could partly be explained by age-related changes in the regulation of serum sodium. Other underlying factors can be the presence of multiple diagnoses and the use of polypharmacy.

[Fever, malaise and eosinophilia after consumption of raw fish in Italy: infection by a liver fluke (Opisthorchis felineus)]. / Koorts, malaise en eosinofilie na eten van rauwe vis in Italië: infectie met leverbot (Opisthorchis felineus).

BACKGROUND: Infection by a liver fluke (trematode) is rare in Western Europe, but recently a few outbreaks caused by this parasite have been described after consumption of raw freshwater fish caught in Italy. CASE DESCRIPTION: A 35-year-old Dutch woman presented with fever, without localising symptoms. Laboratory tests showed pronounced eosinophilia. Microscopy of the faeces showed a liver fluke egg. Upon inquiry, it appeared that she had consumed raw fish (carpaccio of tench) three weeks earlier in a restaurant in Northern Italy. In Italy, 45 people with comparable symptoms were found to be infected by the same parasite. All patients had eaten in the same restaurant. They were treated successfully with praziquantel. The stool egg was from the trematode Opisthorchis felineus. CONCLUSION: O. felineus lives in the bile ducts of fish-eating mammals. Its life cycle includes freshwater snails and fish. Acute symptoms are fever, malaise and abdominal pain and complications such as liver and bile duct abscesses and cholangitis. Diagnosis is made by microscopic examination of the faeces, confirmed by PCR or by serology.