Diagnosis, prevention, and management of delirium in the intensive cardiac care unit.

Delirium is a frequent complication in patients admitted to intensive cardiac care units (ICCU) with potentially severe consequences including increased risks of mortality, cognitive impairment and dependence at discharge, and longer times on mechanical ventilation and hospital stay. Delirium has been widely documented and studied in general intensive care units and in patients after cardiac surgery, but it has barely been studied in acute nonsurgical cardiac patients. Moreover, delirium (especially in its hypoactive form) is commonly misdiagnosed. We propose a protocol for delirium prevention and management in ICCUs. A daily comprehensive assessment to improve detection should be done using validated scales (ie, confusion assessment method). Preventive measures are particularly relevance and constitute the basis of treatment as well, acting on reversible risk factors, including environmental interventions, such as quiet time, sleep promotion, family support, communication, and adequate treatment of pain and dyspnea. Pharmacological prophylaxis is not indicated with the exception of patients at risk of withdrawal syndrome but should only be used in patients with confirmed delirium. Dexmedetomidine is the drug of choice in patients with severe agitation, and those weaning from invasive mechanical ventilation. As the complexity of ICCUs increases, clinical scenarios posing challenges for the management of delirium become more frequent. Efforts should be done to improve the identification of patients at risk during admission in order to establish preventive interventions to avoid this complication. Patient-centered protocols will increase the awareness of the healthcare professionals for better prevention and earlier diagnosis and will positively impact on prognosis.

Adsorption study and detection of the high performance organic pigments quinacridone and 2,9-dimethylquinacridone on Ag nanoparticles by surface-enhanced optical spectroscopy.

In this work, surface-enhanced Raman scattering (SERS) and surface-enhanced fluorescence (SEF) were employed in the study of the adsorption and detection of the pigments quinacridone (QA) and 2,9-dimethylquinacridone (2,9-DMQA). These pigments are of great relevance in artwork and textile, plastic, and photochemical industries due to their condition as high performance pigments since they possess a high tinting strength. Due to this fact, they have been employed at relatively low concentrations. Therefore, the analysis and detection of these pigments requires the application of a highly sensitivity technique, such as SERS and SEF. The adsorption of QA and 2,9-DMQA on silver nanoparticles was extensively studied by means of SERS at different surface coverages. This study was completed by carrying out an in depth vibrational (Raman and IR) analysis of these pigments in solid state by ab initio density functional theory (DFT) calculations. In addition, UV-vis spectroscopy was employed to investigate the aggregation undergone by both pigments in solid state and in solution. 2,9-DMQA was demonstrated to have a lower tendency toward aggregation due to the presence of methyl groups. Even so, this molecule follows a BET adsorption mechanism on the metal nanoparticles due to its high tendency toward intermolecular interaction. From the analysis of the adsorption mechanism of this molecule, the limit of detection was deduced to be ca. 55 ppb.

Effect of metal-liquid interface composition on the adsorption of a cyanine dye onto gold nanoparticles.

Synthesis of asymmetric nanoparticles, such as gold nanorods, with tunable optical properties providing metal structures with improved SERS performance is playing a critical role in expanding the use of SERS to imaging and sensing applications. However, the synthetic methods usually require surfactants or polymers as shape-directing agents. These chemicals normally remain firmly bound to the metal after the synthesis, preventing the direct adsorption of a large number of potential analytes and often hampering the chemical functionalization of the surface unless extended, and critical for the nanoparticle stability, postremoval steps were performed. For this reason, it is of great importance for the full exploitation of these nanostructures to gain a deeper insight into the dependence of the analyte-metal interaction to the metal-liquid interface composition. In this article, we investigated in detail the role played by each component of the gold nanorod (GNR) interface in the adsorption of indocyanine green (ICG) as a probe molecule. Citrate-reduced gold nanospheres were used as a model substrate since the negative citrate anions adsorbed onto the metal surface can be easily displaced by those chemicals usually involved in the GNR synthesis, allowing the GNR-like interface composition to be progressively rebuilt and modified at will on the citrate-capped nanoparticles. The obtained results provide a meticulous description of the role played by each individual component of the metal-liquid interface on the ICG interaction with the metal, illustrating how apparently minor experimental changes can dramatically modify the affinity and optical properties of the ICG probe adsorbed onto the nanoparticle.

Electrochemical SERS study on a copper electrode of the insoluble organic pigment quinacridone quinone using ionic liquids (BMIMCl and TBAN) as dispersing agents.

SERS detection of quinacridone quinone (QAQ), an insoluble synthetic organic pigment relevant to modern artworks, is reported here. The use of ionic liquids (BMIMCl and TBAN) as dispersing agents has allowed us to carry out electrochemical SERS experiments of QAQ in aqueous solution using a Cu electrode. No SERS spectra were obtained either from the ionic liquids (ILs) or from QAQ when silver/gold colloids were employed. The spectra of the Cu electrode in 0.1 M KCl aqueous solutions containing either BMIMCl or TBAN indicate that the corresponding cations approach the metal surface through formation of an ion pair with specifically adsorbed Cl⁻, but the corresponding cyclic voltammograms only show reduction and oxidation of the Cu surface. In the case of QAQ dispersed in BMIMCl and TBAN, two different SERS spectra due to QAQ species are observed between -0.4 and -1.0 V. One of the spectra agrees with the SERS of QAQ previously reported by us, using calixarenes as dispersing agents and silver colloids as SERS substrates. The other spectrum reveals a reallocation of the charge of the QAQ molecule, concomitant with a change in its relative orientation to the Cu surface. The SERS detection of QAQ is free from interferences of bands corresponding to the ILs.

Prognosis of cardiogenic shock secondary to culprit left main coronary artery lesion-related myocardial infarction.

AIMS: This study aimed to assess, in patients with cardiogenic shock secondary to unprotected left main coronary artery-related myocardial infarction (ULMCA-related AMICS), the incidence and predictors of no recovery of left ventricular function during the admission. METHODS AND RESULTS: This was an observational study conducted at two tertiary care centres (2012-20). The main outcome measured was death or requirement for heart transplantation (HT) or left ventricular assist devices (LVAD) during the admission. A total of 70 patients were included. Percutaneous coronary intervention (PCI) was successful in 53/70 patients (75.7%). The combined endpoint of death or requirement of HT or LVAD during the admission occurred in 41/70 patients (58.6%). The highest incidence of the primary endpoint was observed among patients with profound shock and occluded left main coronary artery (LMCA) (20/23, 87%, P < 0.001). Although a successful PCI reduced the incidence of the event in the whole cohort (51.9% vs. 82.4% in failed PCI, P = 0.026), this association was not observed among this last group of complex patients (86.7% vs. 87.5% in failed PCI, P = 0.731). The predictive model included left ventricular ejection fraction, baseline ULMCA Thrombolysis In Myocardial Infarction flow, and severity of shock and showed an optimal ability for predicting death or requirements for HT or LVAD during the admission (area under the curve 0.865, P < 0.001). CONCLUSIONS: ULMCA-related AMICS was associated with a high in-hospital mortality or need for HT or LVAD. Prognosis was especially poor among patients with profound shock and baseline occluded LMCA, with a low probability of recovery regardless of successful PCI.

Interaction between VA-ECMO and the right ventricle.

BACKGROUND: The response of the right ventricle (RV) to the hemodynamic effects of veno-arterial extracorporeal membrane oxygenation (VA-ECMO) is currently unpredictable. We hypothesized that the presence of uni- or bi-ventricular failure before implantation and the cannulation strategy may influence this interaction. We sought to assess the RV performance during VA-ECMO support and identify RV-related predictors of successful weaning. METHODS: Changes in RV size and function during VA-ECMO support by echocardiography were retrospectively analyzed in 87 consecutive adult patients between February 2008 and June 2017. Predictors of successful weaning due to myocardial recovery were evaluated by multivariable logistic regression. RESULTS: RV echocardiographic parameters did not vary significantly during VA-ECMO support and neither after stratification by the type of cannulation or the presence of isolated or biventricular failure. Successful weaning was conditioned by the absence of RV dysfunction before implantation (OR, 14.7; 95% CI, 13.3-140.3; p = 0.025) or in the last day of support (OR, 9.5; 95% CI, 1.6-54; p = 0.011) and was favored by a total or partial recovery of RV function during the assistance (OR, 6.2; 95%CI, 1.7-22.4; p = 0.005). RV improvement was more often observed in patients with acute RV failure and longer support, while VA-ECMO configuration, additional mechanical support, or pharmacological therapy had no effect. CONCLUSIONS: Preservation or improvement of RV function during VA-ECMO is essential for successful weaning. RV echocardiographic performance does not change significantly during VA-ECMO support and is not influenced by cannulation type or the presence of uni- or bi-ventricular failure before implantation.

Temporal Trends in Mechanical Complications of Acute Myocardial Infarction in the Elderly.

BACKGROUND: Reperfusion therapy led to an important decline in mortality after ST-segment elevation myocardial infarction (STEMI). Because the rate of cardiogenic shock has not changed dramatically, the authors speculated that a reduction in the incidence or fatality rate of mechanical complications (MCs), the second cause of death in these patients, could explain this decrease. OBJECTIVES: This study sought to assess time trends in the incidence, management, and fatality rates of MC, and its influence on short-term mortality in old patients with STEMI. METHODS: Trends in the incidence and outcomes of MC between 1988 and 2008 were analyzed by Mantel-Haenszel linear association test in 1,393 consecutive patients ≥75 years of age with first STEMI. RESULTS: Overall in-hospital mortality decreased from 34.3% to 13.4% (relative risk reduction, 61%; p < 0.001). Although the absolute mortality due to MC decreased from 9.6% to 3.3% (p < 0.001), the proportion of deaths due to MC among all deaths did not change (28.1% to 24.5%; p = 0.53). The incidence of MC decreased from 11.1% to 4.3% (relative risk reduction 61%) with no change in their hospital fatality rate over time (from 87.1% to 82.4%; p = 0.66). The proportion of patients undergoing surgical repair decreased from 45.2% to 17.6% (p = 0.04), with no differences in post-operative survival (from 28.6% to 33.3%; p = 0.74). CONCLUSIONS: Although the incidence of MC has decreased substantially since the initiation of reperfusion therapy in elderly STEMI patients, this reduction was proportional to other causes of death and was not accompanied by an improvement in fatality rates, with or without surgery. MCs are less frequent but remain catastrophic complications of STEMI in these patients.

Solution SERS of an insoluble synthetic organic pigment-quinacridone quinone-employing calixarenes as dispersive cavitands.

A possibility of getting SERS spectra of insoluble aromatic compounds in colloidal silver solutions is described. The method tested for the organic pigment quinacridone quinone consists of dispersing it in calix[n]arenes. The potentials of such cavitands, both as dispersing and as silver functionalization agents, is reported as a function of the substitution in their lower rim and their cavity size.