Prevalence and features of delirium in older patients admitted to rehabilitation facilities: a multicenter study

BACKGROUND

Delirium is thought to be common across various settings of care; however, still little research has been conducted in rehabilitation.

AIM

We investigated the prevalence of delirium, its features and motor subtypes in older patients admitted to rehabilitation facilities during the three editions of the "Delirium Day project".

METHODS

We conducted a cross-sectional study in which 1237 older patients (age ≥ 65 years old) admitted to 50 Italian rehabilitation wards during the three editions of the "Delirium Day project" (2015 to 2017) were included. Delirium was evaluated through the 4AT and its motor subtype with the Delirium Motor Subtype Scale.

RESULTS

Delirium was detected in 226 patients (18%), and the most recurrent motor subtype was mixed (37%), followed by hypoactive (26%), hyperactive (21%) and non-motor one (16%). In a multivariate Poisson regression model with robust variance, factors associated with delirium were: disability in basic (PR 1.48, 95%CI: 1.17-1.9, p value 0.001) and instrumental activities of daily living (PR 1.58, 95%CI: 1.08-2.32, p value 0.018), dementia (PR 2.10, 95%CI: 1.62-2.73, p value < 0.0001), typical antipsychotics (PR 1.47, 95%CI: 1.10-1.95, p value 0.008), antidepressants other than selective serotonin reuptake inhibitors (PR 1.3, 95%CI: 1.02-1.66, p value 0.035), and physical restraints (PR 2.37, 95%CI: 1.68-3.36, p value < 0.0001).

CONCLUSION

This multicenter study reports that 2 out 10 patients admitted to rehabilitations had delirium on the index day. Mixed delirium was the most prevalent subtype. Delirium was associated with unmodifiable (dementia, disability) and modifiable (physical restraints, medications) factors. Identification of these factors should prompt specific interventions aimed to prevent or mitigate delirium.

The association between low skeletal muscle mass and delirium: results from the nationwide multi-centre Italian Delirium Day 2017

Introduction

Delirium and sarcopenia are common, although underdiagnosed, geriatric syndromes. Several pathological mechanisms can link delirium and low skeletal muscle mass, but few studies have investigated their association. We aimed to investigate (1) the association between delirium and low skeletal muscle mass and (2) the possible role of calf circumference mass in finding cases with delirium.

Methods

The analyses were conducted employing the cross-sectional “Delirium Day” initiative, on patient 65 years and older admitted to acute hospital medical wards, emergency departments, rehabilitation wards, nursing homes and hospices in Italy in 2017. Delirium was diagnosed as a 4 + score at the 4-AT scale. Low skeletal muscle mass was operationally defined as calf circumference ≤ 34 cm in males and ≤ 33 cm in females. Logistic regression models were used to investigate the association between low skeletal muscle mass and delirium. The discriminative ability of calf circumference was evaluated using non-parametric ROC analyses.

Results

A sample of 1675 patients was analyzed. In total, 73.6% of participants had low skeletal muscle mass and 24.1% exhibited delirium. Low skeletal muscle mass and delirium showed an independent association (OR: 1.50; 95% CI 1.09–2.08). In the subsample of patients without a diagnosis of dementia, the inclusion of calf circumference in a model based on age and sex significantly improved its discriminative accuracy [area under the curve (AUC) 0.69 vs 0.57, p < 0.001].

Discussion and conclusion

Low muscle mass is independently associated with delirium. In patients without a previous diagnosis of dementia, calf circumference may help to better identify those who develop delirium.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40520-021-01950-8.

Phialemoniopsis limonesiae sp. nov. causing cutaneous phaeohyphomycosis in an immunosuppressed woman

Rare or opportunistic fungal infections are mostly described in immunosuppressed patients. We present a case of a cutaneous phaeohyphomycosis that developed on the dorsal foot in an immunosuppressed woman suffering from AIDS, caused by a novel Phialemoniopsis species. It clinically presented as an indurated violaceous plaque, surmounted by nodules exuding a sero-purulent discharge. A filamentous fungus was isolated from pus and cutaneous biopsy. ITS and LSU sequences phylogenetically resolved the fungus as an unknown species of Phialemoniopsis, which is an unresolved family within Sordariomycetes. In this study we describe the new species as Phialemoniopsis limonesiae, which clusters on a single branch clearly separated from its closest phylogenetic neighbours. This new strain showed low MIC to itraconazole, voriconazole and posaconazole.

Cutaneous ulcers revealing diphtheria: A re-emerging disease imported from Indian Ocean countries?

INTRODUCTION

Diphtheria due to Corynebacteriumdiphtheriae (C. diphtheriae) has become rare in developed countries. In France only 10 cases of toxigenic diphtheria have been reported since 1989, in all cases causing pharyngitis and all emanating from endemic countries with exception of one contact case. We report herein 13 cases with cutaneous diphtheria, in 5 of which diphtheria toxin was produced, and all imported into France between 2015 and 2018.

OBSERVATIONS

Thirteen patients aged 4 to 77 years presented painful and rapidly progressive round ulcerations of the legs, that were superficial and in some cases purulent, with an erythematous-purple border covered with greyish membrane. Bacteriological sampling of ulcers revealed the presence of C. diphtheriae. Only 6 patients had been properly immunized over the preceding 5 years.

DISCUSSION

These cases underline the resurgence of cutaneous diphtheria and the circulation of toxigenic strains in France following importation from Indian Ocean countries. This may constitute an important reservoir for ongoing transmission of the disease. Re-emergence of this pathogen stems from the current migratory flow and decreased adult booster coverage.

CONCLUSION

Cutaneous diphtheria should be considered in cases of rapidly developing painful skin ulcers with greyish membrane, especially among patients returning from endemic areas, regardless of their vaccination status. The clinician should order specific screening for C. diphtheriae from the bacteriologist, since with routine swabbing Corynebacteriaceae may be reported simply as normal skin flora. Vaccination protects against toxigenic manifestations but not against actual bacterial infection. Early recognition and treatment of cutaneous diphtheria and up-to-date vaccination are mandatory to avoid further transmission and spread of both cutaneous and pharyngeal diphtheria.

NOAC in "real world" patients with atrial fibrillation in Italy: results from the ISPAF-2 (Indagine Sicoa Paziente Con Fibrillazione Atriale) survey study

In the past few years, new oral anticoagulants (NOACs) targeting directly a single activated clotting factor, have been developed for the treatment of non-valvular atrial fibrillation (AF), which are currently recommended as first-line therapy in AF. The aim of this study is to provide an overall picture on the extent to which oral anticoagulation (OAC) with NOACs correspond to actually prescribed OAC therapy in an unselected, real world, population of consecutive patients with AF in Italy. Compliance with the therapy and quality of life were also assessed. A 50 cardiology unit network located in different geographic areas of Italy enrolled a total of 1742 consecutive outpatients with AF (54.6% males, 45.4% females, mean age 72.5 years). NOACs were prescribed in 56.1% patients and VKA in 43.9% (P < 0.0001). NOACs were significantly more prescribed than VKA in patients with high thrombo-embolic risk score (i.e., CHA₂DS₂-VASc > 2) (78.2 vs 67.3%, P < 0.0001), but also patients at low risk (i.e., CHA₂DS₂-VASc < 1 and HAS-BLED < 3) were still under OAC therapy with either NOACs (27%) or VKA (73%). Adherence to therapy (Morisky test) was greater in patients taking NOACs as was the quality of life. The ISPAF-2 study shows that in an Italian population of real-world patients with AF the prescription of OAC according to current guidelines and stroke-risk scoring system is rather high although it still needs to be improved. Contrary to recommendations, in a high proportion of low-risk patients, anticoagulation therapy, with either NOACs and VKA is still prescribed, and this exposes patients to unjustified risks.

[Infection by Staphylococcus lugdunensis: clinico-microbiologic characterization of 25 cases]

INTRODUCTION

S. lugdunensis is a recently described staphylococcal species with morphologic characteristic similar to those of S. aureus. It has been associated to a variety of clinical infections. In this paper we present the clinical and microbiological features of S. lugdunensis isolates from 25 patients.

MATERIALS AND METHODS

We have studied the S. lugdunensis isolates obtained from clinical specimens in our laboratory over a three-year period, 1994-96. For all isolates we determined the presence of clumping factor, Dnase, free coagulase in tube and ornithine decarboxylase (ODC). Full identification was performed with API ID32-Staph strips (bioMérieux) and antimicrobial susceptibility with commercial broth microdilution MIC panels (PASCO System, Difco).

RESULTS

We obtained 38 S. lugdunensis isolates from 25 patients. The clinical specimens were: breast exudate/pus (8), blood (5), surgical wound (2), urine (2), nasal exudate (2), peritoneal fluid (1), pleural fluid (1), venous catheter (1), Tenckoff catheter (1), bartholin pus (1), ulcer (1). The isolates were considered clinically significant in 20 patients, whereas those of the remaining 5 patients were considered mere colonizers. All isolates were clumping factor (+), ODC (+), Dnase (-) and free coagulase (-). 16/23 (69.5%) were susceptible to penicillin and only one isolate was methicillin-resistant.

CONCLUSIONS

We have isolated S. lugdunensis from a great variety of clinical specimens (blood, sterile body fluids, urine, skin, abscesses and nasal mucosa). It is specially remarkable the association with non-puerperal mastitis. The presence of clumping factor in all isolates can easily lead to misidentification as S. aureus. The ODC test appears as a good screening method for detecting S. lugdunensis. S. lugdunensis shows a good susceptibility to betalactamic an other antimicrobial agents.

[Comparison between centrifugation and sedimentation prior to cultures in the isolation of cytomegalovirus in the urine of renal transplant recipients]

BACKGROUND

To compare the capacity of conventional centrifugation and spontaneous sedimentation to detect the presence of cytomegalovirus (CMV) in urine samples.

MATERIAL AND METHODS

We studied urine samples from 45 renal transplant recipients. After decontamination half of each sample was centrifuged (1,500 rpm for 10 minutes) and the other half was allowed to sediment at room temperature for 30 minutes. From the supernatant of each of these 250 microliters was inoculated in a shell-vial (MRC-5). Cultures were incubated for 48 hours at 37 degrees C and stained by an indirect immunofluorescence assay. The samples considered totally toxic were re-inoculated after dilution 1:1 with maintainance medium.

RESULTS

Of 845 urine samples analyzed, 743 (88%) were negative and 102 (12%) positive. 66 (7.8%) were considered toxic: 35 (4.1%) partially toxic and 31 (3.6%) totally toxic. Of the centrifuged urine samples 86.2% were positive against 98% of the sedimented samples (p = 0.004). Of the 31 samples considered totally toxic, 17 (2.2%) corresponded with negative urine samples and 14 (13.7%) with positive samples. Off these, 12 (85.7%) were detected in centrifuged samples and 2 (14.3%) in sedimented samples (p = 0.001).

CONCLUSIONS

The percentage of toxicity in the urine samples was low (7.8%) which does not seem to suggest the need for systematic dilution of all samples. The sedimentation process enabled us to detect a greater number of urine samples positive for CMV with a lower rate of toxicity of the monolayers. The use of this process would reduce the number of samples requiring reinoculation.

Laryngeal involvement in pediatric neurofibromatosis: a case report and review of the literature

A case of neurofibroma of the larynx occurring in generalized neurofibromatosis (von Recklinghausen's disease) is presented, and the previously reported pediatric cases are reviewed. Laryngeal involvement in neurofibromatosis is rare and the predominant signs and symptoms include dyspnea, stridor, loss or change of voice and dysphagia. Problems posed related to diagnosis, management and course of this infrequent laryngeal localization are discussed.

A phosphorylation epitope on MAP 1B that is transiently expressed in growing axons in the developing rat nervous system

We have isolated a monoclonal antibody (150) that recognizes a phosphorylation epitope on the microtubule-associated protein (MAP) 1B. Immunoblot analysis of the developing rat central nervous system shows that monoclonal antibody 150 is directed against a protein of approximately 325 kDa (MAP 1B) that copolymerizes with microtubules through successive cycles of temperature-dependent assembly and disassembly. Furthermore, immunoprecipitated MAP 1B contains the epitope recognized by monoclonal antibody 150. Removal of phosphate from blotted proteins using alkaline phosphatase abolishes the binding of monoclonal antibody 150 to MAP 1B, indicating that the epitope is phosphorylated. In the developing rat nervous system, immunohistochemistry with monoclonal antibody 150 shows that the phosphorylation epitope on MAP 1B is transiently expressed in growing axons but not in dendrites. For instance, in the neonatal rat cerebellum, the parallel fibres of granule cells are stained only during elongation and not after synaptogenesis. The monoclonal antibody 150 epitope is also transiently expressed in radial glial fibres and in certain cell nuclei. All immunostaining of sections with monoclonal antibody 150 was completely abolished by alkaline phosphatase treatment. These observations and previous ones made by us in cell culture (Mansfield et al., J. Neurocytol., 20, 654-666, 1991) suggest that the phosphorylation epitope on MAP 1B recognized by monoclonal antibody 150, which has not been previously detected in vivo, may be important in axonogenesis.

Rearrangement of microtubule associated protein parallels the morphological transformation of neurons from dorsal root ganglion

In primary cultures of dorsal root ganglion cells from rat embryos, neurons undergo a morphological transformation from a bipolar to a differentiated pseudo-unipolar shape, resembling their developmental stages in vivo. Cells present in these cultures are characterized here by immunological criteria using monoclonal and polyclonal antibodies against microtubule associated proteins MAP1 and MAP2 and against tubulin. After development for seven days in culture, antibodies against microtubule associated proteins MAP1 brightly labeled cells with neuronal morphology and lightly stained cells with the shape of Schwann cells. In addition, an extended network of neuronal processes was labeled with this antibody. Anti-microtubule associated protein MAP2 stained only neurons and a more restricted network of neuronal processes. The compartmentalization of microtubule associated protein MAP2 during the maturation process was followed by double-labeling with antibodies to microtubule associated proteins MAP1 and MAP2. Initially, microtubule associated protein MAP2 was present in the cell body and the two processes of bipolar neurons. Subsequently, the labeling of both processes changed, depending on neuronal morphology. In neurons in which both processes were approaching one another, one of these neurites was stained predominantly with anti-microtubule associated protein MAP2. Finally, in pseudo, unipolar neurons, anti-microtubule associated protein MAP2 labeling was found in the cell body and excluded from the more distal processes.

Humero-spinal dysostosis

A 2 year old boy with humero-spinal dysostosis is described. This is the third case of this disease reported in the literature. Humero-spinal dysostosis is characterised radiologically by distal humeral bifurcation, elbow subluxation and coronal cleft vertebrae. Congenital, progressive heart disease, possibly with fatal outcome, is probably part of the syndrome.

[Radiological diagnosis of primitive hepatic tumors in infants (author's transl)]

Six primitive hepatic tumours (two benign and four malignant) collected over a period of seven years, are studied. The symptoms were mild or absent in many of the cases, and all were discovered after investigation of hepatomegaly or abdominal mass. The importance of the co-ordinated use of radiological and gammagraphical findings is pointed out.

Indications for pneumoperitoneum in the diagnosis of congenital anomalies in the umbilical region

Thirty pneumoperitoneograms were performed postmortem and 5 were performed for diagnosis: the technique itself, the radiological anatomy of the umbilical region, and the usefulness of the procedure in diagnosis are discussed. Pneumoperitoneum may be indicated in the investigation of a bleeding Meckel's diverticulum, in the exclusion or confirmation of remnants of the omphalomesenteric duct, in chronically moist lesions of the umbilicus resistant to symptomatic treatment, in suspected cases of non-communicating urachal cysts which cannot be diagnosed by cystogram, and in the differential diagnosis of abdominal tumours related to the umbilical region.

The Weissenbacter-Zweymuller syndrome. A case report with review of the world literatue

This report describes a patient with a form of chondrodysplasia characterised by a rhizomelic shorteining of the limbs, metaphyseal widening, vertebral coronal clefts and retrognathia. This syndrome was first described by Weissenbacher and Zweymuller in 1964. All the relevant literature available has been reviewed and it has been concluded there are mild and severe forms of this syndrome.

[Bacterial meningitis in valencia: epidemiology and therapeutic results in 208 cases (author's transl)]

Review of 208 patients with bacterial meningitis, admitted from march 1, 1971 to march 1, 1976. Incidence peak was found in Winter (december to march). Etiologically N. meningitiditis, 39, 9%, was the mainly predominate germ. In 49% of the patients C.S.F. cultures were negative, significantly influenced by the previous treatment with antibiotics (P less than 0.001). Cure was obtained in 86.5% Convulsions, 12%, were the most frequent complication, followed by subdural effussion, 3.8%, and arthritis, 2.4%. Twenty patients died, 9.6%; fifteen of them with endotoxic shock. Definitive sequelae was present in the 3.8%, mainly hidrocephaly. A comparative study with other series in Spain is performed.