ContextIn the intensive care unit (ICU), delirium is a common yet underdiagnosed
form of organ dysfunction, and its contribution to patient outcomes is unclear.ObjectiveTo determine if delirium is an independent predictor of clinical outcomes,
including 6-month mortality and length of stay among ICU patients receiving
mechanical ventilation.Design, Setting, and ParticipantsProspective cohort study enrolling 275 consecutive mechanically ventilated
patients admitted to adult medical and coronary ICUs of a US university-based
medical center between February 2000 and May 2001. Patients were followed
up for development of delirium over 2158 ICU days using the Confusion Assessment
Method for the ICU and the Richmond Agitation-Sedation Scale.Main Outcome MeasuresPrimary outcomes included 6-month mortality, overall hospital length
of stay, and length of stay in the post-ICU period. Secondary outcomes were
ventilator-free days and cognitive impairment at hospital discharge.ResultsOf 275 patients, 51 (18.5%) had persistent coma and died in the hospital.
Among the remaining 224 patients, 183 (81.7%) developed delirium at some point
during the ICU stay. Baseline demographics including age, comorbidity scores,
dementia scores, activities of daily living, severity of illness, and admission
diagnoses were similar between those with and without delirium (P>.05 for all). Patients who developed delirium had higher 6-month
mortality rates (34% vs 15%, P = .03) and spent 10
days longer in the hospital than those who never developed delirium (P<.001). After adjusting for covariates (including age,
severity of illness, comorbid conditions, coma, and use of sedatives or analgesic
medications), delirium was independently associated with higher 6-month mortality
(adjusted hazard ratio [HR], 3.2; 95% confidence interval [CI], 1.4-7.7; P = .008), and longer hospital stay (adjusted HR, 2.0;
95% CI, 1.4-3.0; P<.001). Delirium in the ICU
was also independently associated with a longer post-ICU stay (adjusted HR,
1.6; 95% CI, 1.2-2.3; P = .009), fewer median days
alive and without mechanical ventilation (19 [interquartile range, 4-23] vs
24 [19-26]; adjusted P = .03), and a higher incidence
of cognitive impairment at hospital discharge (adjusted HR, 9.1; 95% CI, 2.3-35.3; P = .002).ConclusionDelirium was an independent predictor of higher 6-month mortality and
longer hospital stay even after adjusting for relevant covariates including
coma, sedatives, and analgesics in patients receiving mechanical ventilation.

https://jamanetwork.com/journals/jama/articlepdf/198503/JCE30038.pdf

Delirium as a predictor of mortality in mechanically ventilated patients in the intensive care unit

Sexual Behavior in the Human Male

Burns are one of the most common and devastating forms of trauma. Patients with serious thermal injury require immediate specialized care in order to minimize morbidity and mortality. Significant thermal injuries induce a state of immunosuppression that predisposes burn patients to infectious complications. A current summary of the classifications of burn wound infections, including their diagnosis, treatment, and prevention, is given. Early excision of the eschar has substantially decreased the incidence of invasive burn wound infection and secondary sepsis, but most deaths in severely burn-injured patients are still due to burn wound sepsis or complications due to inhalation injury. Burn patients are also at risk for developing sepsis secondary to pneumonia, catheter-related infections, and suppurative thrombophlebitis. The introduction of silver-impregnated devices (e.g., central lines and Foley urinary catheters) may reduce the incidence of nosocomial infections due to prolonged placement of these devices. Improved outcomes for severely burned patients have been attributed to medical advances in fluid resuscitation, nutritional support, pulmonary and burn wound care, and infection control practices.

Burn Wound Infections

Geriatricians have embraced the term "geriatric syndrome," using it extensively to highlight the unique features of common health conditions in older people. Geriatric syndromes, such as delirium, falls, incontinence, and frailty, are highly prevalent, multifactorial, and associated with substantial morbidity and poor outcomes. Nevertheless, this central geriatric concept has remained poorly defined. This article reviews criteria for defining geriatric syndromes and proposes a balanced approach of developing preliminary criteria based on peer-reviewed evidence. Based on a review of the literature, four shared risk factors-older age, baseline cognitive impairment, baseline functional impairment, and impaired mobility-were identified across five common geriatric syndromes (pressure ulcers, incontinence, falls, functional decline, and delirium). Understanding basic mechanisms involved in geriatric syndromes will be critical to advancing research and developing targeted therapeutic options, although given the complexity of these multifactorial conditions, attempts to define relevant mechanisms will need to incorporate more-complex models, including a focus on synergistic interactions between different risk factors. Finally, major barriers have been identified in translating research advances, such as preventive strategies of proven effectiveness for delirium and falls, into clinical practice and policy initiatives. National strategic initiatives are required to overcome barriers and to achieve clinical, research, and policy advances that will improve quality of life for older persons.

/pdf/geriatric-syndromes-clinical-research-and-policy-3gikzwk4jf.pdf

Geriatric Syndromes: Clinical, Research, and Policy Implications of a Core Geriatric Concept

Geriatric syndromes : Clinical, research, and policy implications of a core geriatric concept. Commentary

Delirium is a sign of deterioration in the homeostasis and physical status of the patient. The objective of our study was to investigate the predisposing factors for delirium in a surgical intensive care unit (ICU) setting. Between January 1996 and 1997, we screened prospectively 818 patients who were consecutive applicants to the general surgery service of Dicle-University Hospital and had been kept in the ICU for delirium. All patients were hospitalized either for elective or emergency services and were treated either with medication and/or surgery. Suspected cases of delirium were identified during daily interviews. The patients who had changes in the status of consciousness (n = 150) were consulted with an experienced consultation-liaison psychiatrist. The diagnosis of delirium was based on Diagnostic and Statistical Manual of Mental Disorders (revised third edition) criteria and established through psychiatric interviews. Patients were divided into two groups: the 'delirious group' (DG) (n = 90) and the 'non-delirious group' (NDG) (n = 728). During delirium, all abnormal findings related to physical conditions, laboratory features, and additional diseases were evaluated as probable risk factors of delirium. Of 818 patients, 386 (47.2%) were male and 432 (52.8%) were female. Delirium developed in 90 of 818 patients (11%). The cases of delirium in the DG were more frequent among male patients (63.3%) than female patients (36.7%) (χ2 = 10.5, P = 0.001). The mean age was 48.9 ± 18.1 and 38.5 ± 13.8 years in the DG and NDG, respectively (t = 6.4, P = 0.000). Frequency of delirium is higher in the patients admitted to the Emergency Department (χ2 = 43.6, P = 0.000). The rate of postoperative delirium was 10.9%, but there was no statistical difference related to operations between the DG and NDG (χ2 = 0.13, P = 0.71). The length of stay in the ICU was 10.7 ± 13.9 and 5.6 ± 2.9 days in the DG and NDG, respectively (t = 0.11, P = 0.000). The length of stay in hospital was 15.6 ± 16.5 and 8.1 ± 2.7 days in the DG and NDG, respectively (t = 11.08, P = 0.000). Logistic regression was used to explore the associations between probable risk factors and delirium. Delirium was not correlated with conditions such as hypertension, hypo/hyperpotassemia, hypernatremia, hypoalbuminemia, hypo/hyperglycemia, cardiac disease, emergency admission, age, length of stay in the ICU, length of stay in hospital, and gender. It was determined that conditions such as respiratory diseases (odds ratio [OR] = 30.6, 95% confidence interval [CI] = 9.5–98.4), infections (OR = 18.0, 95% CI = 3.5–90.8), fever (OR = 14.3, 95% CI = 4.1–49.3), anemia (OR = 5.4, 95% CI = 1.6–17.8), hypotension (OR = 19.8, 95% CI = 5.3–74.3), hypocalcemia (OR = 30.9, 95% CI = 5.8–163.2), hyponatremia (OR = 8.2, 95% CI = 2.5–26.4), azotemia (OR = 4.6, 95% CI = 1.4–15.6), elevated liver enzymes (OR = 6.3, 95% CI = 1.2–32.2), hyperamylasemia (OR = 43.4, 95% CI = 4.2–442.7), hyperbilirubinemia (OR = 8.7, 95% CI = 2.0–37.7) and metabolic acidosis (OR = 4.5, 95% CI = 1.1–17.7) were predicting factors for delirium. We determined that conditions such as respiratory diseases, infections, fever, anemia, hypotension, hypocalcemia, hyponatremia, azotemia, elevated liver enzymes, hyperamylasemia, hyperbilirubinemia and metabolic acidosis were predicting factors for delirium.

/pdf/predisposing-factors-for-delirium-in-the-surgical-intensive-4wwi9shbrm.pdf

Predisposing factors for delirium in the surgical intensive care unit

A case-control study was performed using the records of patients hospitalized for typhoid fever at Dicle University Hospital, Diyarbakir, Turkey, between 1994 and 1998. Case patients with enteric perforation were compared with control patients with typhoid fever but no enteric perforation. Risk factors for perforation were determined using logistic regression modeling. Forty case patients who had surgery because of typhoid enteric perforation were compared with 80 control patients. In univariate analyses, male sex (p = 0.01), age (p = 0.01), leukopenia (p = 0.01), inadequate antimicrobial therapy prior to admission (p = 0.01), and short duration of symptoms (p = 0.01) were significantly associated with perforation. In multivariate analysis, male sex (odds ratio (OR) = 4.39, 95% confidence interval (CI): 1.37, 14.09; p = 0.01), leukopenia (OR = 3.88, 95% CI: 1.46, 10.33; p = 0.04), inadequate treatment prior to admission (OR = 4.58, 95% CI: 1.14, 18.35; p = 0.03), and short duration of symptoms (OR = 1.22, 95% CI: 1.10, 1.35; p = 0.001) were significant predictors of perforation. A short duration of symptoms, inadequate antimicrobial therapy, male sex, and leukopenia are independent risk factors for enteric perforation in patients with typhoid fever.

Risk Factors for Enteric Perforation in Patients with Typhoid Fever

Malaria has long been among the most common diseases in the southeast Anatolia region of Turkey In 1992, 18676 cases were diagnosed in Turkey, and Diyarbakir city had the highest incidence (4168 cases), followed by SanliUrfa city (3578 cases) Malaria was especially common during 1994 and 1995, with 84 345 and 82 094 cases being diagnosed in these years, respectively Spontaneous rupture of malarial spleen is rare We saw two cases during 1998, which are reported herein Both patients were male, and were receiving chloroquine treatment for an acute attack of malaria One of the patients had developed abdominal pain and palpitations, followed by fainting The other patient had abdominal pain and fever Explorative laparotomy revealed an enlarged spleen in both patients Splenectomy was performed in both patients We have identified 15 episodes of spontaneous rupture of the spleen in the English language literature published since 1961 Because of increased travel to endemic areas and resistance to antimalarial drugs, malaria is a major medical problem that is becoming increasingly important to surgeons worldwide Malaria is a particularly important problem in the southeast Anatolia region of Turkey Prophylactic precautions should be taken by tourists who travel to this region, especially during the summer

/pdf/spontaneous-rupture-of-malarial-spleen-two-case-reports-and-4ro7cmp5vi.pdf

Spontaneous rupture of malarial spleen: two case reports and review of literature.

AIM: To evaluate seven patients with non-traumatic splenic rupture (NSR). NSR is an uncommon dramatic abdominal emergency that requires immediate diagnosis and prompt surgical treatment to ensure the patient’s survival.

METHODS: Within 11 years, seven cases were evaluated for patient characteristics, anamnesis and symptoms, method of diagnosis, findings of laparotomy, and etiology of NSR.

RESULTS: There were six (86%) male and one female (14%) patient, whose mean age was 36 ± 12.8 (17-56) years. We report here four cases of Plasmodium vivax malaria (cases I-IV), one case of hemodialysis (case V), one case of spontaneous splenic rupture (case VI), and one case of hairy cell leukemia (case VII). Splenectomy was performed in all patients. All of them made an uneventful recovery and were discharged in stable condition.

CONCLUSION: NSR is a rare entity that needs a high index of suspicion for diagnosis. Using ultrasonography or computer tomography, and peritoneal aspiration of fresh blood may assist in the diagnosis of NSR. Increased awareness of NSR can enhance early diagnosis and effective treatment.

Non-traumatic splenic rupture: Report of seven cases and review of the literature

Purpose: penetrating abdominal trauma (PAT) is still a serious problem all over the world. This study was made to define and discuss the factors that could affect mortality in the PAT.Methods: the ...

Mustafa Aldemir

Papers

Predisposing factors for delirium in the surgical intensive care unit

Risk Factors for Enteric Perforation in Patients with Typhoid Fever

Spontaneous rupture of malarial spleen: two case reports and review of literature.

Non-traumatic splenic rupture: Report of seven cases and review of the literature

Predicting factors for mortality in the penetrating abdominal trauma.