Delirium in hospitalized older patients

Delirium is a common, serious problem for hospitalized older patients. Recognition of delirium poses challenges requiring cognitive assessment and knowledge of the clinical course. Delirium often is of multiple causes and is associated with a poor long-term prognosis. Nonpharmacologic approaches for delirium management are recommended; pharmacologic management should be reserved for patients who pose a danger to themselves or others. Importantly, delirium and its complications may be preventable through a targeted risk factor approach.     

Hyperkalemia in hospitalized patients treated with trimethoprim-sulfamethoxazole

OBJECTIVE: To determine the effect of standard-dose trimethoprim-sulfamethoxazole on serum potassium concentration in hospitalized patients. DESIGN: Prospective chart review. SETTING: Community-based teaching hospital. PATIENTS: 105 patients with various infections were hospitalized and treated. Eighty patients treated with standard-dose trimethoprim-sulfamethoxazole (trimethoprim, < or = 320 mg/d; sulfamethoxazole, < or = 1600 mg/d) composed the treatment group; 25 patients treated with other antibiotic agents served as the control group. MEASUREMENTS: Serum sodium, potassium, and chloride concentrations; serum carbon dioxide content; anion gap; blood urea nitrogen level; and serum creatinine level. RESULTS: The serum potassium concentration in the treatment group (mean +/- SD) was 3.89 +/- 0.46 mmol/L (95% CI, 3.79 to 3.99 mmol/L), and it increased by 1.21 mmol/L (CI, 1.09 to 1.32 mmol/L) 4.6 +/- 2.2 days after trimethoprim-sulfamethoxazole therapy was initiated. Blood urea nitrogen levels increased from 7.92 +/- 5.7 mmol/L (CI, 6.67 to 9.16 mmol/L) to 9.2 +/- 5.8 mmol/L (CI, 7.9 to 10.5 mmol/L), and serum creatinine levels increased from 102.5 +/- 49.5 mumol/L (CI, 91.4 to 113.6 mumol/L) to 126.1 +/- 70.7 mumol/L (CI, 110.3 to 141.9 mumol/L). Patients with a serum creatinine level of 106 mumol/L (1.2 mg/dL) or more developed a higher peak potassium concentration (5.37 +/- 0.59 mmol/L [CI, 5.15 to 5.59 mmol/L]) than patients with a serum creatinine level of less than 106 mumol/L (4.95 +/- 0.48 mmol/L [CI, 4.80 to 5.08 mmol/L]). Patients with diabetes had a slightly higher peak potassium concentration (5.14 +/- 0.45 mmol/L [CI, 4.93 to 5.39 mmol/L]) than did patients without diabetes (5.08 +/- 0.59 mmol/L [CI, 4.93 to 5.23 mmol/L]), but the difference was not statistically significant. The serum potassium concentration in the control group was 4.33 +/- 0.45 mmol/L (CI, 4.15 to 4.51 mmol/L), and it decreased nonsignificantly over 5 days of therapy. CONCLUSIONS: Standard-dose trimethoprim-sulfamethoxazole therapy used to treat various infections leads to an increase in serum potassium concentration. A peak serum potassium concentration greater than 5.0 mmol/L developed in 62.5% of patients; severe hyperkalemia (peak serum potassium concentration > or = 5.5 mmol/L) occurred in 21.2% of patients. Patients treated with standard-dose trimethoprim-sulfamethoxazole should be monitored closely for the development of hyperkalemia, especially if they have concurrent renal insufficiency (serum creatinine level > or = 106 mumol/L).     

Delirium risk factors in elderly hospitalized patients

BACKGROUND: The relation of parental smoking to wheezing and asthma occurring after the first year of life was assessed by a systematic quantitative review of case-control and longitudinal studies, complementing earlier reviews of cross sectional surveys and wheezing in early childhood. METHODS: Fifty one relevant publications were identified after consideration of 1593 abstracts selected by electronic search of the Embase and Medline databases using keywords relevant to passive smoking in children. The search was completed in April 1997 and identified six studies of asthma incidence, seven of prognosis, 22 case-control studies, and 10 case series addressing disease severity. RESULTS: Maternal smoking was associated with an increased incidence of wheezing illness up to age 6 (pooled odds ratio 1.31, 95% CI 1.22 to 1.41), but less strongly thereafter (1.13, 95% CI 1.04 to 1.22). The long term prognosis of early wheezing illness was better if the mother smoked. The pooled odds ratio for asthma prevalence from 14 case-control studies was 1.37 (95% CI 1.15 to 1.64) if either parent smoked. Four studies suggest that parental smoking is more strongly associated with wheezing among non-atopic children. Indicators of disease severity including symptom scores, attack frequency, medication use, hospital attendance, and life threatening bronchospasm were in general positively related to household smoke exposure. CONCLUSIONS: The excess incidence of wheezing in smoking households appears to be largely non-atopic "wheezy bronchitis" with a relatively benign prognosis, but among children with established asthma, parental smoking is associated with more severe disease. This apparent paradox may be reconciled if environmental tobacco smoke is considered a co-factor provoking wheezing attacks, rather than a cause of the underlying asthmatic tendency.     

Documenting for patient-focused care

Hospitals across the country are rethinking the way health care is delivered. With a shift from inpatient to outpatient care, there is an effort to deliver quality, "patient-focused care" in the hospital setting. Multidisciplines have embarked in cross-training to provide immediate services at the bedside. The premise of "nursing" documentation is no longer feasible in multicaregiver environments. One hospital's adaptation to documentation methods to meet the needs of a patient-focused system is described.     

Delivered dialysis dose is suboptimal in hospitalized patients

Resistance to the action of endotoxin varies among inbred strains of mice, indicating that a component of this resistance has a genetic basis. Different responses to endotoxin that are characteristic of individual inbred strains represent phenotypes that can be used to genetically map the response modifier genes. This study compares the acute histologic lesions in 8-week-old male A/J and C57BL/6J (B6) mice injected intraperitoneally with endotoxin of E. coli O265:B6 (15 mg/kg). Animals of both strains exhibited splenitis, splenic lymphoid hyperplasia, splenic lymphoid necrosis, and sequestration of neutrophils in the pulmonary alveoli. The B6 mice showed increased margination of white blood cells to the pulmonary vascular endothelium relative to A/J mice. A large number of degenerating neutrophils was observed in the liver sinusoids of most B6 animals, while this lesion was much less severe in A/J mice. This difference was quantified, demonstrating a highly significant difference in neutrophil infiltration in B6 mice relative to A/J mice. Analysis of this phenotype in F1 mice demonstrates that major genes encoding the trait are not X-linked, imprinted, or maternally inherited and do not show the codominant inheritance expected if Lps(d) were primarily responsible. The distinctive, quantitative nature of these differences provides a useful assay for mapping genes that modify endotoxin responsiveness using the AXB and BXA recombinant inbred (RI) strains derived from A/J and B6 mice.     

Psychiatric consultation among hospitalized arthritis patients

Fifty consecutive psychiatric consultations on 48 patients over an 18-month period in an arthritis hospital are analyzed. The range of psychiatric disorders and their relationship to characteristics of the patient population, such as age, sex, and medical diagnosis, are described. Approximately 2% of patients admitted to the hospital during this period elicited psychiatric consultation. This rate is one-third of the consultation rate of an acute medical and surgical hospital serviced by the same consultants. The relative distribution of psychiatric diagnoses--depression 59%, personality disorders and drug abuse 15%, psychosis 10%, conversion reaction 10%, and "other" 6%--was similar to that encountered in an acute general hospital setting. Although depression was the most prevalent psychiatric problem, it was severe enough to elicit consultation only in 1% of the total hospitalized population; its severity did not correlate directly with the severity of rheumatoid arthritis, the most common medical diagnosis encountered. Neither a particular medical illness nor sex accounted for a disproportionate share of the psychiatric consultations.     

Determinants of pain expression in hospitalized burn patients

This study examines the relationship between extent of injury, degree and type of psychological distress and self-report of pain in burn survivors. One hundred eighty burn patients were interviewed within 2 weeks of their burn trauma. Using a visual analogue scale to assess subjective pain and pain relief, and self-report measures of post-traumatic stress symptoms and general psychological distress, we assessed the relationship between PTSD symptoms, general distress and pain. Subjective pain was unrelated to sex, ethnicity, or total body surface area burned. The most important correlate of subjective pain was general psychological distress. Intrusive PTSD symptoms had no independent power to predict the variance in pain scores. However, among women, more severe avoidant symptoms were associated with greater subjective pain.     

Tuberculin skin testing of hospitalized patients

OBJECTIVES: We sought to define the prevalence of tuberculin skin test (TST) positivity in a group of newly hospitalized patients, to identify risk factors for positive tests, and to examine the impact of testing on infection control practices. DESIGN: Unblinded cohort study over 5 days in July 1992. SETTING: A 1,000-bed university-affiliated hospital. PATIENTS: All patients admitted (excluding obstetric patients and newborns) were interviewed. Patients without a history of tuberculosis (TB) or a positive TST were offered a TST with Candida and tetanus controls. RESULTS: Of 346 patients offered the test, 21 (6%) had a prior history of TB or a positive TST, and 36 (10%) declined to participate; 279 of the remaining 289 completed the study. Anergy was demonstrated in 94 (33.7%) of 279 patients. New positive TSTs were identified in 19 (10.3%) of 185 nonanergic patients. Of the 19 TST-positive patients, 6 (32%) had infiltrates on chest radiographs and were evaluated for active TB. One patient was treated empirically for active TB, and five received isoniazid prophylaxis. Risk factors for a new positive TST included age (odds ratio [OR], 1.56 per decade of life; P = .021), African American race (OR, 4.81; P = .008), alcohol abuse (OR, 5.53; P = .005), and peptic ulcer disease (OR, 4.53; P = .017). Risk factors for anergy included admission to a surgical service (OR, 2.1; P = .006), current use of steroids (OR, 2.65; P = .005), and human immunodeficiency virus (HIV) infection (OR, undefined; P = .034). CONCLUSIONS: Despite a high rate of anergy, routine tuberculin skin testing identified a substantial number of patients with TB infection who might otherwise have gone unrecognized.     

An evaluation of intravenous ethanol in hospitalized patients

A series of arabinofuranosyl oligosaccharides found as constituent parts of the polysaccharide portion of the cell wall of Mycobacterium tuberculosis have been chemically synthesized. Screening of these oligosaccharides as substrates for arabinosyltransferases present in mycobacterial membrane preparations suggests that modified oligosaccharide analogs as small as disaccharides may be inhibitors of glycan biosynthesis. Such inhibitors would be of potential utility as lead compounds in the identification of new drugs for the treatment of mycobacterial infections.     

Folic acid deficiency in chronically hospitalized mental patients

Studies over the past 30 years have shown a relationship between folic acid deficiency and psychopathology. FA deficiency was observed more often in depressed and in psychotic patients, in alcoholics, in those suffering from organic mental disorders and in the psycho-geriatric population. In a chronic inpatient population of 120 patients, of the 106 in whom FA serum levels were examined, only 1 had a definitely subnormal level. An additional 16 had close to the lower limit of normal (2 ng/ml) and were considered borderline cases. FA-deficient and borderline patients were then compared to matched patients with normal FA levels on the MMSE and PANSS scales by blinded raters. Small differences were found between the 2 groups. The FA-deficient and borderline patients had more organic and psychotic symptoms, but the differences were not statistically significant.     

Evaluation of recalcitrant pain in HIV-infected hospitalized patients

Betaseron is a new medication that decreases the frequency and severity of exacerbations in persons with relapsing-remitting MS. It is the first to alter the disease itself and has, therefore, generated considerable hope among patients, families and health care providers. Patients who meet the criteria for use of Betaseron will be confronted with a number of decisions and cost factors. Further, they must be willing to prepare and administer Betaseron injections. Potential adverse effects, direct and indirect costs of Betaseron, and administration and monitoring requirements determine the nursing implications. To provide optimum care and education to patients with MS, nurses must maintain current knowledge about this new medication.     

Selective bowel decontamination in hospitalized patients awaiting liver transplantation

BACKGROUND: Infection remains a major contributor to morbidity and mortality following orthotopic liver transplantation (OLT). Selective bowel decontamination (SBD) in hospitalized patients is one strategy for prophylaxis. METHODS: A retrospective case-control study was performed using 18 consecutive hospitalized patients receiving SBD prior to OLT during the period September 1995 to September 1996. Eighteen consecutive hospitalized patients without SBD transplanted during the period March 1995 to September 1995 served as a historical control group. RESULTS: Selective bowel decontamination was associated with a significantly decreased prevalence of positive cultures for gram-negative bacteria and fungi and reduced overall hospital charges. CONCLUSION: In hospitalized patients awaiting OLT, SBD is an effective prophylactic measure against infectious morbidity associated with gram-negative bacteria and fungi.     

Presurgical profile preferences of patients and clinicians

BACKGROUND: Aortic regurgitation results from a pressure gradient across the aortic valve during left ventricular (LV) isovolumic relaxation, LV filling, and isovolumic contraction periods. Assuming the applicability of the simplified Bernoulli equation to this pressure-flow relation and constancy of aortic pressure during LV isovolumic relaxation and contraction periods, one can theoretically obtain estimates of the rates of LV isovolumic pressure fall and rise (deltaP/delta t) from the aortic regurgitation (AR) velocity signal. METHODS AND RESULTS: Mitral regurgitation (MR) and AR signals were recorded by using the continuous wave Doppler technique in 26 patients with combined mitral and aortic regurgitant lesions. The LV negative deltaP/delta t was obtained by dividing the time taken for the AR velocity to rise from 1 m/sec to 2.5 m/sec into 21 mm Hg, which is the estimated LV pressure drop between these points. In a similar fashion, the LV positive deltaP/delta t was obtained between 2.5 m/sec and 1 m/sec of the fast decelerating portion of the AR signal. The LV negative deltaP/delta t by the AR method ranged from 420 to 3500 mm Hg/sec and correlated well with that obtained by the MR method obtained in a blinded fashion (r = 0.95, p < 0.0001). The mean (SD) difference between the two methods was 30 (129) mm Hg/sec. Similarly, the LV positive deltaP/delta t by the AR method (range 420 to 2625 mm Hg/sec) correlated closely with that obtained by the MR method (r = 0.93, p < 0.0001), with the mean (SD) difference between the two methods being 38 (138) mm Hg/sec. CONCLUSIONS: Preliminary data presented in this study indicate the feasibility of obtaining a reliable estimate of LV positive and negative deltaP/delta t from the AR velocity profile. Thus the examination of the AR signal may give valuable insights into both LV systolic and diastolic functions.     

Method to study anhedonia in hospitalized psychiatric patients.

Loss of the ability to experience or anticipate pleasure is characteristic of depressive disorders. It plays a central role in psychosocial theories of depression that relate the etiology of depression to a poverty of positive reinforcement from the social and nonsocial environment. This experiment studied the voluntary utilization of putative pleasurable activities in hospitalized psychiatric patients. A computer-based selection of motor-skills, cognitive, and chance games was available to 73 inpatients on a 24-hour/day, 7-day/week schedule. Patients had the following diagnoses: Unipolar Depressed (n?=?25), Delusional Depressed (n?=?9), Secondary Depressed (n?=?10), Bipolar (n?=?12, Schizophrenic (n?=?5), and Other (n?=?12). Patients were studied over the course of their hospitalization with regard to self-rated mood, game and difficulty selection, expectancy of success, and actual game scores. A total of 7,744 games were voluntarily played by the patients. Analyses revealed that different diagnostic groups engaged in the games differently, showing "styles" of play that suggest personality-motivated differences in the use of pleasurable activities. (PsycINFO Database Record (c) 2010 APA, all rights reserved)