Predicting delirium: are we there yet?

Postoperative delirium is an extremely common complication after all types of surgery in the elderly, with an incidence as high as 65% in patients admitted for hip fracture repair.¹ The implications of an episode of delirium are serious and include an increased risk of dementia, increased length of stay, increased costs, and increased risk of mortality.¹ Delirium is associated with progression of cognitive decline even in those with normal baseline cognition.² It is widely acknowledged that delirium is a preventable complication, with the Australian Council for Safety and Quality in Health Care (ACSQHC), the National Institute for Health and Clinical Excellence (NICE, UK),³ and the American Society of Anesthesiologists (ASA) defining risk-prevention models for implementation in all hospitals. In Australia, the ACSQHC 'Cognitive Care' package⁴ has been distributed as a set of Clinical Care Standards highlighting the importance of preoperative cognitive assessment; NICE in the UK includes similar Clinical Guidelines; while in the USA, the ASA has commenced the 'Brain Health Initiative'.⁵ These organizations have developed guidelines for identifying at-risk patients, strategies for prevention, and for targeting research areas specific to reducing delirium.

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Association of intraoperative changes in brain-derived neurotrophic factor and postoperative delirium in older adults

Abstract

Background. Delirium is common after surgery, although the aetiology is poorly defined. Brain-derived neurotrophic factor (BDNF) is a neurotrophin important in neurotransmission and neuroplasticity. Decreased levels of BDNF have been associated with poor cognitive outcomes, but few studies have characterized the role of BDNF perioperatively. We hypothesized that intraoperative decreases in BDNF levels are associated with postoperative delirium.Methods. Patients undergoing spine surgery were enrolled in a prospective cohort study. Plasma BDNF was collected at baseline and at least hourly intraoperatively. Delirium was assessed using rigorous methods, including the Confusion Assessment Method (CAM) and CAM for the intensive care unit. Associations of changes in BDNF and delirium were examined using regression models.Results. Postoperative delirium developed in 32 of 77 (42%) patients. The median baseline BDNF level was 7.6 ng ml⁻¹ [interquartile range (IQR) 3.0–11.2] and generally declined intraoperatively [median decline 61% (IQR 31–80)]. There was no difference in baseline BDNF levels by delirium status. However, the percent decline in BDNF was greater in patients who developed delirium [median 74% (IQR 51–82)] vs in those who did not develop delirium [median 50% (IQR 14–79); P=0.03]. Each 1% decline in BDNF was associated with increased odds of delirium in unadjusted {odds ratio [OR] 1.02 [95% confidence interval (CI) 1.00–1.04]; P=0.01}, multivariable-adjusted [OR 1.02 (95% CI 1.00–1.03); P=0.03], and propensity score–adjusted models [OR 1.02 (95% CI 1.00–1.04); P=0.03].Conclusions. We observed an association between intraoperative decline in plasma BDNF and delirium. These preliminary results need to be confirmed but suggest that plasma BDNF levels may be a biomarker for postoperative delirium.

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Critical airways, critical language

British Journal of Anaesthesia, 2017; 118(5): 649–54, DOI 10.1093/bja/aex075

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Pemphigus : vers une réduction drastique de la corticothérapie grâce au rituximab

Publication date: Available online 29 June 2017
Source:Annales de Dermatologie et de Vénéréologie
Author(s): P. Joly




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Éducation thérapeutique du patient dans la dermatite atopique : où en est-on ?

Publication date: Available online 29 June 2017
Source:Annales de Dermatologie et de Vénéréologie
Author(s): S. Barbarot




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La photographie en dermatologie. Questions éthiques

Publication date: Available online 29 June 2017
Source:Annales de Dermatologie et de Vénéréologie
Author(s): M. Moyal-Barracco, J.-M. Debarre, A. Petit, L. Haddad, L. Martin, D. Penso-Assathiany




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Traitement de la maladie de Hailey-Hailey par toxine botulique : étude rétrospective de huit cas

Publication date: Available online 29 June 2017
Source:Annales de Dermatologie et de Vénéréologie
Author(s): L. Dousset, A. Pham-Ledard, M.-S. Doutre, M. Beylot-Barry, O. Cogrel
IntroductionLa maladie de Hailey-Hailey (MHH) est caractérisée par des poussées de lésions érythémateuses et suintantes en particulier dans les zones de friction ou de macération. Sa prise en charge thérapeutique est difficile. Plusieurs séries ou cas ponctuels ont montré l'intérêt de la toxine botulique.ObjectifRapporter les données cliniques et évolutives de 8 cas de MHH traités par injections de toxine botulique A (BTX-A) après avoir résisté à plusieurs lignes thérapeutiques.Patients et méthodesHuit patients (trois hommes et cinq femmes), d'âge médian 52,5 ans (31–80), ont été inclus dans cette étude rétrospective. Une histoire familiale était notée chez 75 % d'entre eux. Les lésions atteignaient les régions axillaires dans 62 % des cas, sous-mammaires chez quasiment toutes les femmes, inguinales dans 75 % des cas, génitale dans 25 %. La dose moyenne injectée par site et par séance était de 300UI de Dysport^®. L'évaluation clinique était appréciée sur des clichés photographiques pris avant traitement et 6 mois plus tard.RésultatsL'effet sur la sudation était rapide, dès le quatrième jour. En moyenne, les patients ressentaient le bénéfice de l'injection dans un délai de 7jours, avec disparition de l'érythème et cicatrisation des rhagades. À 6 mois, une réponse clinique complète était constatée sur 80 % des zones traitées (12 sites sur 15), une réponse partielle au niveau de 3 zones profuses (sous-mammaires et inguinales). Des séances d'entretien ont été mises en place chez 6 des 8 patients en raison de récidives au-delà du sixième mois.ConclusionLa toxine botulique semble une alternative thérapeutique dans les formes résistantes de MHH, en traitement séquentiel ou en adjuvant de traitements plus radicaux comme le laser CO2. Ces données rétrospectives, ainsi que les modalités optimales en matière de doses et de rythme des injections, doivent être précisées par des études prospectives.BackgroundHailey-Hailey disease (HHD) is characterised by episodes of weeping erythematous lesions, particularly in areas subject to friction or maceration. Treatment is complex. The value of botulinum toxin has been demonstrated in several studies and in individual cases.AimTo report clinical and progressive data for 8 patients treated for HHD with injections of botulinum toxin A (BTX-A), following the failure of several other therapeutic approaches.Patients and methodsEight patients (three males and five females), of median age 52.5 years (31–80), were included in this retrospective study. Familial history of the disease was noted in 75% of cases. The lesions affected the axillary regions (62% of cases), the sub-mammary region (almost all female patients), the inguinal region (75%) and the genital area (25%). The mean dose injected per site and per session was 300IU of Dysport^®. Clinical evaluation was based on photographs taken before treatment and then after 6 months.ResultsEffects on sweating were rapid and occurred as of the fourth day treatment. On average, patient felt the benefits of the injection within 7 days, with subsidence of their erythema and healing of the rhagades. At 6 months, complete clinical response was noted in 80% of the treated zones (12 sites of 15), with partial response in 3 profuse zones (sub-mammary and inguinal). Maintenance sessions were initiated for 6 of the 8 patients due to relapse beyond six months.ConclusionBotulin toxin appears to offer a therapeutic alternative in resistant forms of HHD, either as follow-on treatment or as an adjuvant to more radical forms of therapy such as CO2 laser. These retrospective data, as well as the optimal doses and injection rates, require further refinement by means of prospective studies.



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