Delirium in geriatric patients

SummaryDelirium is the most common acute disorder of cognitive function in older patients. Delirium is life threatening, often under-recognized, serious, and costly. The causes are multifactorial, with old age and neurocognitive disorders as the main risk factors. Etiologies are various and multifactorial, and often related to acute medical illness, adverse drug reactions, or medical complications. To date, diagnosis is clinically based, depending on the presence or absence of certain features. In view of the multifactorial etiology, multicomponent approaches seem most promising for facing patients’ needs. Pharmacological intervention, neither for prevention nor for treatment, has been proven effective unanimously. This article reviews the current clinical practice for delirium in geriatric patients, including etiology, pathophysiology, diagnosis, prognosis, treatment, prevention, and outcomes.

Epilepsy and pregnancy: identifying risks

Pregnancy is a time of physical, physiological and psychological challenge. For women with epilepsy, as well as its potential for joy and fulfilment, pregnancy may bring additional risks and difficulties. Clinicians must anticipate and prevent these complications, ensuring that pregnancy, delivery and motherhood proceed without obstetric or medical complications, using available evidence to balance individual risks of undertreatment and overtreatment. Here we review epilepsy management in pregnancy, identifying some of the known effects of epilepsy and its treatment on gestation, fetal malformation, delivery, and neurocognitive and behavioural development. We outline strategies to reduce obstetric and fetal complications in women with epilepsy, while recognising the sometimes competing need to maintain or improve seizure control. We reinforce the importance of identifying those at highest risk, who may require additional measures or safeguards.

Crohn's Disease Increases In-Hospital Lengths of Stay, Medical Complications, and Costs of Care following Primary Total Knee Arthroplasty

The literature has shown an increase in prevalence of Crohn's disease (CD) within the United States alongside a concomitant rise in primary total knee arthroplasty (TKA) procedures. As such, with these parallel increases, orthopaedic surgeons will invariably encounter CD patients requiring TKA. Limited studies exist evaluating the impact of this disease on patients undergoing the procedure; therefore, this study endeavors to determine whether CD patients undergoing primary TKA have higher rates of (1) in-hospital lengths of stay (LOS), (2) medical complications, and (3) episode of care (EOC) costs. To accomplish this, a nationwide database was queried from January 1, 2005 to March 31, 2014 to identify patients undergoing TKA. The study group, patients with CD, was randomly matched to the controls, patients without CD, in a 1:5 ratio after accounting for age, sex, and medical comorbidities associated with CD. Patients consuming corticosteroids were excluded, as they are at risk of higher rates of adverse events following TKA. This query ultimately yielded a total of 96,213 patients, with 16,037 in the study cohort and 80,176 in the control one. The study compared in-hospital (LOS), 90-day medical complications, and day of surgery and total global 90-day EOC costs between CD and non-CD patients undergoing primary TKA. The results found CD patients undergoing primary TKA had significantly longer in-hospital LOS (4- vs. 3 days, p < 0.0001) compared with non-CD patients. CD patients were also found to have significantly higher incidence and odds of 90-day medical complications (25.31 vs. 10.75; odds ratio: 2.05, p < 0.0001) compared with their counterparts. Furthermore, CD patients were found to have significantly higher 90-day EOC costs ($15,401.63 vs. 14,241.15, p < 0.0001) compared with controls. This study demonstrated that, after adjusting for age, sex, and medical comorbidities, patients with CD have prolonged in-hospital LOS, increased medical complications, and higher EOC costs following primary TKA. Therefore, it establishes the importance for orthopaedists to adequately counsel CD patients of the potential complications and outcomes following their procedure.

Personality characteristics and medical impact of stimulant laxative abuse in eating disorder patients—a pilot study

Background Stimulant laxative abuse as a purging behavior can be profound in those with eating disorders. However, the psychopathology leading to stimulant laxative abuse is poorly understood. Furthermore, the medical impact of stimulant laxative abuse has not been studied in this population. Methods Six individuals abusing stimulant laxatives underwent a barium enema to assess for evidence of the cathartic colon syndrome and 29 individuals engaging in any purging behaviors completed the Tri-dimensional Personality Questionnaire-Short Form, Sensitivity to Punishment/Sensitivity to Reward Questionnaire-Short Form, Beck Depression Inventory, and the State Trait Anxiety Inventory questionnaires. Results Three of the six patients completing the barium enema had the radiographic findings consistent with cathartic colon. Individuals engaging in laxative abuse showed higher Novelty Seeking compared to those engaging in other forms of purging, and those engaging in any form of purging behavior showed greater Sensitivity to Punishment compared to Sensitivity to Reward. There was also the presence of greater Harm Avoidance than Reward Dependence in this population. Conclusion There may be different psychopathology that contributes to the abuse of stimulant laxatives than that associated with other forms of purging. Regardless of the driving factor, further research is warranted to discover best therapeutic interventions given the potential to develop the cathartic colon syndrome with ongoing use of stimulant laxatives. Plain English Summary Cathartic colon is a condition whereby the colon, or lower intestine, is converted into an inert tube incapable of propagating fecal matter. It is thought to develop due to over-use of stimulant laxatives. However, it is unclear if this condition truly exists and whether it contributes to the constipation experienced by individuals with eating disorders who have extensive past histories of abusing laxatives. It is also unclear if laxative abuse presents with different medical complications than other forms of purging. The purpose of this study is to determine whether radiographic evidence of cathartic colon can be found in eating disorder patients abusing stimulant laxatives, whether there are different medical complications with laxative abuse versus other forms of purging, and to examine the psychological composition of individuals who engage in severe laxative abuse. Specifically, the authors investigated the interrelationship between Harm Avoidance and Reward Dependence, with emphasis on gaining a better understanding of Reward Dependence by examining both Sensitivity to Reward and Sensitivity to Punishment in patients who engage in severe laxative abuse. Our findings suggest that stimulant laxative abuse may cause the development of cathartic colon changes and that there may be unique psychopathology that contributes to the abuse of stimulant laxatives. Given the higher Novelty Seeking personality-dimension in those abusing laxatives, it is possible that this purging behavior may be considered addiction-like in nature, which would have distinct treatment implications.

294. Surveillance for Potential Post-Acute COVID-19 Syndrome Medical Complications in the Emergency Department (ED) – A Retrospective Longitudinal Study of ED Patients Who Had Evidence of SARS-CoV-2 Infection Versus Those Who Did Not

Background As the COVID-19 pandemic continues, growing attention has been placed on whether patients previously infected with SARS-CoV-2 have an increased risk of developing and/or exacerbating medical complications. Our study aimed to determine whether individuals with previous evidence of SARS-CoV-2 infection prior to their current emergency department (ED) visit were more likely to present with specific clinical sign/symptoms, laboratory markers, and/or clinical complications. Methods A COVID-19 seroprevalence study was conducted at Johns Hopkins Hospital ED (JHH ED) from March 16 to May 31, 2020. Evidence of ever having SARS-CoV-2 infection (PCR positive or IgG Ab positive) was found in 268 ED patients at this time (i.e. infected and/or previously infected). These patients were matched 1:2 to controls, by date, to other patients who attended the JHHED. Clinical signs/symptoms, laboratory markers, and/or clinical complications associated with ED visits and/or hospitalizations at JHH within 6 months after their initial ED visit was abstracted through chart review for these 804 patients. Cox proportional hazards regression analyses were performed. Results Among 804 ED patients analyzed, 50% were female, 56% Black race, and 15% Hispanic with a mean age of 47 years. 323 (40%) patients had at least 1 subsequent ED visit and additional 70 (9%) had been admitted to JHH. After controlling for race and ethnicity, patients with evidence of current or prior COVID-19 infection were more likely to require supplemental oxygen [hazards ratio (HR) =2.53; p=0.005] and have a cardiovascular complication [HR =2.13; p=0.008] during the subsequent ED visit than the non-infected patients. Conclusion Our findings demonstrate that those previously infected with SARS-CoV-2 have an increased frequency of cardiovascular complications and need for supplemental oxygen in ED visits in the months after their initial SARS-CoV-2 infection was detected. EDs could serve as a critical surveillance site for monitoring post-acute COVID-19 syndrome complications. Disclosures Richard E. Rothman, PhD, MD, Chem bio (Grant/Research Support)

Higher rates of surgical and medical complications and mortality following TKA in patients aged ≥ 80 years: a systematic review of comparative studies

The purpose of this systematic review was to synthesize studies published since the last systematic review in 2015 that compare outcomes of primary total knee arthroplasty (TKA) in older patients (≥ 80 years) and in younger patients (< 80 years), in terms of complication rates and mortality. An electronic literature search was conducted using PubMed, Embase®, and Cochrane Register. Studies were included if they compared outcomes of primary TKA for osteoarthritis in patients aged 80 years and over to patients aged under 80 years, in terms of complication rates, mortality, or patient-reported outcomes (PROs). Thirteen studies were eligible. Surgical complications in older patients ranged from 0.6–21.1%, while in younger patients they ranged from 0.3–14.6%. Wound complications in older patients ranged from 0.5–20%, while in younger patients they ranged from 0.8–22.0%. Medical complications (cardiac, respiratory, thromboembolic) in older patients ranged from 0.4–17.3%, while in younger patients they ranged from 0.2–11.5%. Mortality within 90 days in older patients ranged between 0–2%, while in younger patients it ranged between 0.0–0.03%. Compared to younger patients, older patients have higher rates of surgical and medical complications, as well as higher mortality following TKA. The literature also reports greater length of stay for older patients, but inconsistent findings regarding PROs. The present findings provide surgeons and older patients with clearer updated evidence, to make informed decisions regarding TKA, considering the risks and benefits within this age group. Patients aged over 80 years should therefore not be excluded from consideration for primary TKA based on age alone. Cite this article: EFORT Open Rev 2021;6:1052-1062. DOI: 10.1302/2058-5241.6.200150

COVID-19 in Children with Down Syndrome: Data from the Trisomy 21 Research Society Survey

Adults with Down Syndrome (DS) are at higher risk for severe outcomes of coronavirus disease 2019 (COVID-19) than the general population, but evidence is required to understand the risks for children with DS, which is necessary to inform COVID-19 shielding advice and vaccination priorities. We aimed to determine the epidemiological and clinical characteristics of COVID-19 in children with DS. Using data from an international survey obtained from a range of countries and control data from the United States, we compared the prevalence of symptoms and medical complications and risk factors for severe outcomes between DS and non-DS paediatric populations with COVID-19. Hospitalised COVID-19 patients <18 years with DS had a higher incidence of respiratory symptoms, fever, and several medical complications from COVID-19 than control patients without DS <18 years. Older age, obesity, and epilepsy were significant risk factors for hospitalisation among paediatric COVID-19 patients with DS, and age and thyroid disorder were significant risk factors for acute respiratory distress syndrome. Mortality rates were low in all paediatric COVID-19 patients (with and without DS), contrasting with previous findings in adults with DS (who exhibit higher mortality than those without DS). Children with DS are at increased risk for more severe presentations of COVID-19. Efforts should be made to ensure the comprehensive and early detection of COVID-19 in this population and to identify children with DS who present comorbidities that pose a risk for a severe course of COVID-19. Our results emphasize the importance of vaccinating children with DS as soon as they become eligible.

Dysphagia intervention in NICU set up: a report of case studies in an Indian public hospital

<p class="abstract">A retrospective study was conducted in the Neonatal Intensive Care Unit (NICU) of a public hospital in Mumbai, India wherein 13 neonates with varying pathophysiologies were taken up for swallowing intervention. Of these, 7 neonates had history of prematurity, 1 was born of twin birth with prematurity, 3 had clefts of lip/palate and 2 had Pierre Robin Syndrome. For 7 neonates with prematurity, the swallowing regimen consisted of oro motor intervention (OMI) followed with therapeutic oral feeds. With improved tolerance of oral feeds while maintaining airway safety, they were graduated to oral feeds progressively increasing in volume until they reached optimum prescribed oral feeds. 6 out of 7(86%) progressed to breast feeds while1 succumbed to medical complications. 3 babies with CLP graduated to complete oral feeds through bondla, when they were fitted with obturators and had swallowing intervention but were unable to move to breastfeeds while in NICU. 2 babies with PRS could not tolerate oral feeds even after multiple sessions and had to be maintained on orogastric feeds. 1 infant, one of a twin delivery with prematurity although was showing improvement to OMI succumbed to medical complications. Among these neonates, those with prematurity showed the maximum improvement with swallowing intervention followed by infants with CLP. Co-morbidities such as prematurity in twin births worsened the prognosis as did a disorder such as PRS. This preliminary study, done on a small sample, stressed the importance of swallowing intervention in neonates with high risk factors by the SLP in the NICU in an Indian set up. </p>

Unusual Case of Low-Velocity Large Object Penetrating the Frontal Bone with Favorable Outcome: A Case Report in Pediatric Patient

BACKGROUND: Penetrating head injury is one of the deadliest forms of head trauma; the outcome is usually low, and patients who survive long enough require complex medical treatment. Immediate imaging assessment with appropriate management can improve patient recovery. CASE REPORT: We reported a case of head penetration trauma on a 12-year-old child with embedded cylindrical iron that enters the skull without any signs of neurological deficit. CONCLUSIONS: This case shows that aggressive diagnostic imaging and emergency care followed by proper immediate head surgery management and postoperative intensive care to monitor and intervene in possible surgical and medical complications could significantly improve patient outcomes.