Validation of the Delirium Diagnostic Tool-Provisional (DDT-Pro) With Medical Inpatients and Comparison With the Confusion Assessment Method Algorithm.

OBJECTIVE: Delirium remains underdetected as a result of its broad constellation of symptoms and the inadequate neuropsychiatric expertise of most medical-surgical clinicians. Brief, accurate tools are needed to enhance detection. METHODS: The authors extended validation of the Delirium Diagnostic Tool-Provisional (DDT-Pro), originally validated in a study of inpatients with traumatic brain injury for diagnosis of delirium by nonexpert clinicians, for 200 general medical inpatients in Colombia. The three structured, quantitatively rated items in DDT-Pro represent the three core delirium domains. RESULTS: High interrater reliability between physician and nurse (0.873) administrators, internal consistency (>0.81), and content validity were found. Compared with independent reference standard diagnosis with DSM-5 or the Delirium Rating Scale-Revised-98, the area under the receiver operating characteristic (ROC) curve (global diagnostic accuracy) range was 93.8%-96.3%. ROC analysis revealed the same cutoff score (≤6) as that for the original study, with somewhat lower sensitivities of 88.0%-90.0% and specificities of 85.3%-81.2% (independent expert physician or nurse ratings). Even when rated by a trained expert physician, the original version of the Confusion Assessment Method algorithm (CAM-A) performed moderately, with lower sensitivities (61.8%-70.0%) than the DDT-Pro (88.0%-100%) and somewhat higher specificities (84.8%-95.3% versus 67.4%-86.7%), with values depending on dementia status, reference standard, and rater type. Accuracies for the DDT-Pro and CAM-A were comparable (DDT-Pro: 83.0%-87.5% versus CAM-A: 87.5%-88.5%), although lower in the dementia subgroup, especially for CAM-A. However, these tools were significantly discordant, especially in negative cases, which suggests that they do not detect diagnosis of patients in the same way. CONCLUSIONS: The DDT-Pro had high validity and reliability in provisional delirium diagnosis by physicians and nonexpert clinicians, although further validation is warranted before widespread use can be recommended.

Discriminant Performance of Dysexecutive and Frontal Release Signs for Delirium in Patients With High Dementia Prevalence: Implications for Neural Network Impairment.

BACKGROUND: Prevalence of signs of abnormal executive function (EF) and primitive reflexes (PR) with delirium in older hospitalized patients with or without comorbid dementia has not been reported. OBJECTIVE: To describe prevalence of signs of EF deficits and PR in older inpatients and their discriminant value for delirium while accounting for dementia. METHODS: Participants were evaluated for delirium using the Diagnostic and Statistical Manual of Mental Disorders 5th edition and the Delirium Rating Scale Revised-98, dementia using Informant Questionnaire on Cognitive Decline in the Elderly, and signs of PR (n = 5) and EF deficits (n = 3) using bedside neuropsychiatric examination. Three indices (PR, EF, and Combined) and 4 diagnostic groups were created for correlational and discriminant analyses. RESULTS: Correlations of indices were higher with the Delirium Rating Scale Revised-98 than with the Informant Questionnaire on Cognitive Decline in the Elderly and even higher in those with dementia, especially the Combined index (Delirium Frontal Index). Among individual signs, glabellar and Simple Luria Hand Sequence were most common in delirium and the best for delirium discrimination irrespective of dementia status. The Combined index had about 80% sensitivity and specificity at the ≥2 cutoff in the whole cohort (positive and negative predictive values and likelihood ratios: PPV 50.0%, NPV 93.8%, +LR 3.82, -LR 0.25). The Combined index also had the best performance on discriminating delirium in dementia patients at the ≥3 cutoff, with about 80% for both sensitivity and specificity. CONCLUSIONS: PR and EF deficit signs are consistent with reduced neural network integration during delirium, even worse in those with dementia whose baseline structural injury impairs network connectivity with frontal regions. We recommend simple bedside assessment of PR and EF signs to help assess for delirium as an indicator of cerebral cortical neural network impairment in older persons.

Delirium diagnostic tool-provisional (DDT-Pro) scores in delirium, subsyndromal delirium and no delirium.

OBJECTIVE: To evaluate whether the Delirium Diagnostic Tool-Provisional (DDT-Pro), a 0-9 point scale with three items each representing symptoms from delirium's three core domains, differentiates subsyndromal delirium (SSD) from delirium and no delirium. METHODS: We applied cluster analyses of DDT-Pro scores from 200 consecutive inpatients using three reference standards for delirium diagnosis to determine DDT-Pro cutoff values for delirium, SSD and no delirium groups. Clinical validators and DDT-Pro item scores were compared among groups. RESULTS: DDT-Pro SSD range was 6-7 (n = 54), with no delirium having higher scores (n = 98) and delirium lower (n = 48). Dementia prevalence in the SSD group (40.7%) was intermediate between no delirium (20.4%) and delirium (66.7%). SSD and delirium groups were more affected than no delirium regarding medical comorbidities, hospital stay (no delirium <1 week, SSD and delirium >1 week) and mortality (SSD = 7.4%, delirium = 18.8%, no delirium = 1%). Values for motor subtypes, frontal lobe signs, and DRS-R98 in the SSD group were intermediate between no delirium and delirium, as well as for the DDT-Pro items (all p < 0.05). CONCLUSIONS: All DDT-Pro items, which represent the three delirium core domains, are important for SSD diagnosis. Patients scoring in the SSD 6-7 range have significant clinical and prognostic features and deserve clinical attention.

Antecedentes, hábitos, características de género y escalas de riesgo cardiovascular en trabajadores hospitalarios / Medical history, habits, gender characteristics and cardiovascular risk scores in health care workers

Introducción: La enfermedad cardiovascular es la principal causa de morbilidad y mortalidad. Contribuye a la muerte de 1 por cada 3 mujeres. En los trabajadores hospitalarios no se encuentra información acerca de los factores de riesgo que influyen en eventos cardiovasculares. Material y Métodos: Se realizó un estudio de corte transversal. Se realizaron registros de aquellos trabajadores hospitalarios sometidos a tamizaje de riesgo cardiovascular. Se documentan 4 escalas de riesgo cardiovascular y se analiza su relación con variables sociodemográficas y laborales. Resultados: Se obtuvieron 179 registros de trabajadores hospitalarios. Los principales factores de riesgo cardiovascular fueron hipertensión arterial en 17% y diabetes mellitus en 5.6%, historia familiar de enfermedad cardiovascular en 27.4%. Al evaluar la estratificación del riesgo cardiovascular en la mujer el 8.5% tiene salud cardiovascular ideal, 82% en riesgo y el 7.7% en riesgo alto. Al comparar relaciones entre hipertensión arterial con otros factores de riesgo en las mujeres se encontró que las pacientes con diabetes mellitus tiene más proporción de hipertensión arterial (P = 0.028). Conclusiones: Los factores de riesgo cardiovascular son altamente prevalentes en la población, incluso en trabajadores hospitalarios y pacientes jóvenes. La población femenina se ve más afectada comparado con la población masculina. La identificación temprana de estos factores es clave para la prevención de eventos cardiovasculares. (AU)

Introduction: cardiovascular disease is the principal cause of Mortality in the world. It causes 1 in 3 women´s death. In health workers, there is no information about the risk factors that can affect cardiovascular events. Material and Methods: a cross-sectional study was performed. Medical history, habits, gender characteristics, and cardiovascular risk scores were screened out in health workers and then analysed their cardiovascular health relationship. Results: a total of 179 records of health workers were obtained. The main cardiovascular risk factors were hypertension in 17%, and diabetes mellitus in 5.6%, family history of cardiovascular disease were in 27.4% of patients. In women, cardiovascular disease was classified in ideal cardiovascular health in 8.5%, at risk in 82%, and high risk in 7.7%. We found women with diabetes have higher proportion of hypertension (P = 0.028). Conclusions: cardiovascular risk factors are highly prevalent in people, even in health workers and young patients. Women are more affected compared with men. Early recognition of cardiovascular risk factors is a fundamental factor to cardiovascular disease prevention. (AU)

Síndrome de Budd-Chiari de aparición en el puerperio: reporte de caso y revisión de la literatura / Case report and literature review of Budd-Chiari syndrome during the puerperium

Resumen El síndrome de Budd-Chiari es una entidad definida como la obstrucción al flujo sanguíneo en el tracto de salida hepático. Esta obstrucción se puede localizar desde las pequeñas venas hepáticas hasta la entrada de la vena cava inferior a la aurícula derecha. En la mayoría de los casos, se ocasiona por una trombosis endoluminal conocida como Budd-Chiari primario y secundario, cuando ocurre por una compresión extrínseca asociada a las lesiones que ocupan espacio como malignidad. Por tanto, los estados trombofílicos hereditarios se conocen como los principales factores de riesgo. El embarazo y el puerperio, al ser estados hipercoagulables, se pueden asociar al síndrome de Budd-Chiari, sin embargo, la prevalencia reportada en la literatura es muy variable dependiendo de la población estudiada. En Colombia no hay estudios de incidencia o prevalencia de la enfermedad; existen varios reportes de caso, pero no relacionados con el embarazo. Reportamos el caso de una paciente, que 12 semanas posparto presentó un síndrome de Budd-Chiari; además presentamos el manejo ofrecido, la evolución clínica y una revisión de la literatura de los casos asociados con el embarazo.

Abstract Budd-Chiari syndrome is defined as obstruction of hepatic blood outflow. This obstruction can be located anywhere from the small hepatic veins at the entrance of the inferior vena cava to the right atrium. Most cases are primary Budd-Chiari syndrome which is caused by endoluminal thrombosis. Secondary Budd-Chiari syndrome occurs as the result of extrinsic compression associated with space-occupying lesions such as malignant tumors. Hereditary thrombophilic states are the main risk factors, but since pregnancy and the puerperium are hypercoagulable states, they can be associated with Budd-Chiari syndrome. Nevertheless, the prevalence of this type of case in the literature varies according to the population studied. There have been no studies on the incidence or prevalence of this disease in Colombia. The small number of case reports here have not been related to pregnancy. We report the case of a patient who developed Budd-Chiari syndrome 12 weeks postpartum. Our report includes management and clinical evolution as well as a review of the literature of cases associated with pregnancy.