Delirium, how does it end? Mortality as an outcome in older medical inpatients.

OBJECTIVES: Delirium is associated with poor outcomes. Previous research in delirium and mortality gave rather inconclusive results. This study aims to find out the rates of mortality at 1 year and the factors associated with it in a cohort of hospitalized older patients. METHOD: Prospective, observational, longitudinal study. All acute medical admissions 70 years of age and above were approached within 72 h of admission. Exclusion criteria are as follows: severe aphasia; intubation; severe sensory problems; and non-English speakers. Patients eligible for inclusion were assessed four times, twice weekly during admission. Delirium was defined using the Confusion Assessment Method. RESULTS: Two hundred patients were recruited. The mean age was 81.13 years (SD = 6.45; minimum 70 and maximum 100 years old), of which 100 (50%) participants were women. One hundred fifty-four (77%) patients never developed delirium during hospitalization. The overall rate of delirium was 23%. A total of 55 (27.5%) patients died during the 1-year follow-up. Although at 1-year follow-up, more people with delirium died (χ(2) = 9.873, df:1, p = 0.002), survival analysis after controlling for other variables showed that mortality was independent of delirium and that severity of illness, longer hospital stay and cognition were significant risk factors for mortality. CONCLUSION: Although the sample size precludes drawing any definite conclusion, the findings of this study suggest that delirium is not an important risk factor for subsequent mortality. Perhaps delirium and cognitive impairment share common pathophysiological pathways that are related to mortality and in which the currently used methods cannot detect.

Percutaneous image-guided treatment of mucoid degeneration of the ACL in advanced knee osteoarthritis-Preliminary observations.

OBJECTIVES: To describe the percutaneous image-guided treatment of mucoid degeneration of the ACL causing deep knee pain on flexion in patients with advanced knee osteoarthritis. METHODS: Five patients with mucoid degeneration of the ACL complicating knee osteoarthritis underwent percutaneous image-guided steroid bupivacaine ACL sleeve injections over a 3-year period. RESULTS: There were four males and one female of mean age 54 (range 48-59 years). Each patient had Kellgren and Lawrence grade 4 medial compartment knee osteoarthritis with coexistent mucoid degeneration of the ACL sleeve. Each patient complained of deep knee pain on flexion as a dominant symptom. Each patient underwent image-guided (CT or ultrasound) steroid bupivacaine injection of the ACL sleeve resulting in symptom resolution and improved mobility for a mean duration of 8 months, (range 6-15 months.) CONCLUSION: Mucoid degeneration of the ACL should be sought in patients with osteoarthritis presenting with deep knee pain on flexion. Image-guided ACL sleeve injection in affected patients may result in symptom resolution and potential deferral of planned knee replacement surgery. ADVANCES IN KNOWLEDGE: Emphasises Image guided percutaneous treatment of Mucoid degeneration of ACL in patients with knee osteoarthritis.

End of the road? The career intentions of under-represented STEM students in higher education.

Background: The analogy of the leaky pipeline has been used to describe STEM education, with lower student diversity from compulsory to post-compulsory education and beyond. Although extensive research has explored the views and experiences of school-aged children about STEM, fewer studies have examined the career intentions of STEM students at university, especially those from under-represented backgrounds (e.g., racial/ethnic minority, women and working class students). This paper draws on a large qualitative study that interviewed 110 under-represented STEM undergraduates in the UK. We focus on students' STEM career intentions and the likely directions of their post-degree trajectories, drawing on the lenses of science identity and Social Cognitive Career Theory. Results: Three pathways were identified. The first group plans to pursue a career in or from STEM. While social inequalities may persist, the potential impact of these challenges may be neutralised by the personal drive and passion of STEM career-oriented students, who seem committed to drive into an STEM future. The second group stated intentions for non-STEM-related careers, leaving the STEM pipeline. The reasons students gave for their imminent departure from STEM are the better financial reward on offer in some non-STEM sectors, especially in finance and business, as well as wider social inequalities and stereotypes. The third group was undecided, those who are uncertain or unclear about their futures. Students described a general lack of direction or clear career pathway, from a complete lack of career ideas to an overload of options. Conclusions: We conclude with a reminder that the STEM pipeline is far from secured or equitable, despite apparent progress in participation and representation. We reiterate the importance of fostering a diverse, inclusive and supportive learning environment that maximises the participation, strengths and potential of all students, especially those from under-represented backgrounds. While it is not uncommon for STEM students to pursue careers outside of STEM, we need to be wary that those who exit the STEM pipeline are not forced off the road by social inequalities and exclusions. Supplementary Information: The online version contains supplementary material available at 10.1186/s40594-022-00366-8.

Voriconazole-induced periostitis post lung transplantation.

Voriconazole is a broad-spectrum triazole antifungal used to treat invasive fungal infections. It is commonly used prophylactically in immunocompromized patient cohorts, including transplant recipients. Diffuse periostitis is a very rare complication of chronic voriconazole use. It is associated with diffuse bone pain, elevated serum alkaline phosphatase and fluorine levels. Characteristic imaging findings include periosteal thickening with a dense, nodular, irregular and often bilateral pattern. We describe the case of a 71-year-old female who presented with multifocal bone pain six years following double lung transplantation. Her post transplantation course had been complicated by a life threatening episode of sepsis secondary to Scedosporium apiospermum, a rare invasive fungal infection following which lifelong prophylaxis with oral Voriconazole was commenced. We discuss the characteristic clinical and imaging manifestations of this rare condition.

Asymmetric addition of Grignard reagents to ketones: culmination of the ligand-mediated methodology allows modular construction of chiral tertiary alcohols.

A new class of biaryl chiral ligands derived from 1,2-diaminocyclohexane (1,2-DACH) has been designed to enable the asymmetric addition of aliphatic and, for the first time, aromatic Grignard reagents to ketones for the preparation of highly enantioenriched tertiary alcohols (up to 95% ee). The newly developed ligands L12 and L12' together with the previously reported L0 and L0' define a set of complementary chiral promoters, which provides access to the modular construction of a broad range of structurally diverse non-racemic tertiary alcohols, bearing challenging quaternary stereocenters. The present advancements bring to completion our asymmetric Grignard methodology by expanding the scope to aromatic organomagnesium reagents, while facilitating its implementation in organic synthesis thanks to improved synthetic routes for the straightforward access to the chiral ligands. The synthetic utility of the method has been demonstrated by the development of a novel and highly enantioselective formal synthesis of the antihistamine API clemastine via intermediate (R)-3a. Exploiting the power of the 3-disconnection approach offered by the Grignard synthesis, (R)-3a is obtained in 94% ee with ligand (R,R)-L12. The work described herein marks the finalization of our ongoing effort towards the establishment of an effective and broadly applicable methodology for the asymmetric Grignard synthesis of chiral tertiary alcohols.

Scintigraphic assessment of arterial embolism at mixed thrombin and technetium 99m injection therapy for femoral pseudoaneurysms.

BACKGROUND: Clinically evident arterial thrombosis is rare following thrombin injection therapy for femoral pseudoaneurysm. However, it is unclear to what extent injected thrombin may pass to the ipsilateral lower limb arteries. AIMS: To assess if technetium 99m injected at the time of thrombin injection for femoral artery pseudoaneurysm therapy passes into the adjacent lower limb arteries. METHODS: This was a prospective trial with institutional review board approval. Four consecutive patients with common femoral pseudoaneurysms and failed manual compression were enrolled. Under real-time colour flow doppler ultrasound, a mixture of 1000 IU thrombin and approximately 200 MBq technetium 99m was injected in 0.1-mL doses into the pseudoaneurysm until thrombosis occurred. Gamma camera imaging of the syringe before injection, the injected groin after thrombosis and the syringe after injection were performed. Analysis of the gamma camera information was performed to determine the amount of technetium 99m deposited in the arterial tree. RESULTS: All the procedures were technically successful. A mean of 33% (range 3-50%; SD 21) of the administered technetium 99m dose was deposited in the arterial circulation during pseudoaneurysm therapy. No clinically evident arterial thrombosis was identified. CONCLUSION: Technetium 99m is routinely deposited in the arterial circulation following injection of a mixture of thrombin and technetium for therapy of common femoral artery pseudoaneurysms. This suggests that arterial passage of thrombin is more common than clinically evident.

Evaluating attention in delirium: A comparison of bedside tests of attention.

AIM: Impaired attention is a core diagnostic feature for delirium. The present study examined the discriminating properties for patients with delirium versus those with dementia and/or no neurocognitive disorder of four objective tests of attention: digit span, vigilance "A" test, serial 7s subtraction and months of the year backwards together with global clinical subjective rating of attention. METHODS: This as a prospective study of older patients admitted consecutively in a general hospital. Participants were assessed using the Confusion Assessment Method, Delirium Rating Scale-98 Revised and Montreal Cognitive Assessment scales, and months of the year backwards. Pre-existing dementia was diagnosed according to the Diagnostic and Statistical Manual of Mental Disorders fourth edition criteria. RESULTS: The sample consisted of 200 participants (mean age 81.1 ± 6.5 years; 50% women; pre-existing cognitive impairment in 126 [63%]). A total of 34 (17%) were identified with delirium (Confusion Assessment Method +). The five approaches to assessing attention had statistically significant correlations (P < 0.05). Discriminant analysis showed that clinical subjective rating of attention in conjunction with the months of the year backwards had the best discriminatory ability to identify Confusion Assessment Method-defined delirium, and to discriminate patients with delirium from those with dementia and/or normal cognition. Both of these approaches had high sensitivity, but modest specificity. CONCLUSION: Objective tests are useful for prediction of non-delirium, but lack specificity for a delirium diagnosis. Global attentional deficits were more indicative of delirium than deficits of specific domains of attention. Geriatr Gerontol Int 2016; 16: 1028-1035.