Reliability and Validity of the Spanish Adaptation of the Stanford Proxy Test for Delirium in Two Clinical Spanish-Speaking Communities

BACKGROUND

Delirium is the most prevalent neuropsychiatric syndrome experienced by patients admitted to inpatient clinical units, occurring in at least 20% of medically hospitalized patients and up to 85% of those admitted to critical care units. Although current guidelines recommend the implementation of universal prevention strategies, the use of management strategies largely depends on constant surveillance and screening. This allows for the timely diagnosis and correction of its underlying causes and implementation of management strategies.

OBJECTIVE

It was to adapt and analyze the Spanish adaptation of the Stanford Proxy Test for Delirium (S-PTDsv) instrument for its use among Spanish-speaking populations. The S-PTD is an instrument consisting of 13 observational items to be completed by a clinician observer, usually the patient's nurse. The completion of the questionnaire takes about 1 minute and does not require the active participation of the person evaluated, which has important clinical advantages compared to other available instruments (e.g., the Confusion Assessment Method).

METHODS

The psychometric properties of the S-PTDsv were evaluated in a population of 123 patients using a quantitative, cross-sectional design. All subjects were over 18 years of age and hospitalized in various inpatient medico-surgical and intensive care unit services, either at the Barcelona Clinical Hospital (Barcelona, Spain) or the UC-Christus Health Network Clinical Hospital (Santiago, Chile, S.A.). The ultimate diagnosis of delirium was made by a member of the Psychiatry Consult Service by means of an independent neuropsychiatric evaluation based on the Fifth Edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) criteria, published in 2013, which is the latest version of the diagnostic manual. All study tests were performed by study personnel who were blinded to each other's test results within an hour of each other.

RESULTS

In the receiver operator characteristic (ROC) curve analysis, the S-PTDsv demonstrated excellent classification qualities when compared with the DSM-5 as the classification reference standard. Using a cutoff point of ≥3, the S-PTDsv had a sensitivity of 94% and a specificity of 97%. The area under the curve indicator was equal to 0.95, suggesting the S-PTDsv has an excellent overall performance in accurately identifying cases of delirium. Accordingly, the S-PTDsv's positive predictive value = 0.93, and the negative predictive value = 0.97. The internal reliability measured with Cronbach's alpha was 0.96. Confirmatory factor analysis revealed a 1-dimensional structure with high loadings (>0.72), demonstrating that all items similarly contribute to the total diagnostic dimension, suggesting adequate construct validity. This provided evidence of convergent validity.

CONCLUSIONS

The performance of the S-PTDsv, as compared to a blinded neuropsychiatric assessment based on DSM-5, indicates that it is an effective instrument for the detection of delirium, in the Spanish-speaking populations. These results are comparable and consistent with previously published studies in the English language version.

An Interdisciplinary Reappraisal of Delirium and Proposed Subtypes

An interdisciplinary plenary session entitled "Rethinking and Rehashing Delirium" was held during the 2021 Annual Meeting of the Academy of Consultation-Liaison Psychiatry to facilitate dialog on the prevalent approach to delirium. Panel members included a psychiatrist, neurointensivist, and critical care specialist, and attendee comments were solicited with the goal of developing a statement. Discussion was focused on a reappraisal of delirium and, in particular, its disparate terminology and history in relation to acute encephalopathy. The authors endorse a recent joint position statement that describes acute encephalopathy as a rapidly evolving (<4 weeks) pathobiological brain process that presents as subsyndromal delirium, delirium, or coma and suggest the following points of refinement: (1) to suggest that "delirium disorder" describe the diagnostic construct including its syndrome, precipitant(s), and unique pathophysiology; (2) to restrict the term "delirium" to describing the clinical syndrome encountered at the bedside; (3) to clarify that the disfavored term "altered mental status" may occasionally be an appropriate preliminary designation where the diagnosis cannot yet be specified further; and (4) to provide rationale for rejecting the terms acute brain injury, failure, or dysfunction. The final common pathway of delirium appears to involve higher-level brain network dysfunction, but there are many insults that can disrupt functional connectivity. We propose that future delirium classification systems should seek to characterize the unique pathophysiological disturbances ("endotypes") that underlie delirium and delirium's individual neuropsychiatric symptoms. We provide provisional means of classification in hopes that novel subtypes might lead to specific intervention to improve patient experience and outcomes. This paper concludes by considering future directions for the field. Key areas of opportunity include interdisciplinary initiatives to harmonize efforts across specialties and settings, enhance underrepresented groups in research, integration of delirium and encephalopathy in coding, development of relevant quality and safety measures, and exploration of opportunities for translational science.

Research Needs for Inpatient Management of Severe Alcohol Withdrawal Syndrome: An Official American Thoracic Society Research Statement

Background: Severe alcohol withdrawal syndrome (SAWS) is highly morbid, costly, and common among hospitalized patients, yet minimal evidence exists to guide inpatient management. Research needs in this field are broad, spanning the translational science spectrum. Goals: This research statement aims to describe what is known about SAWS, identify knowledge gaps, and offer recommendations for research in each domain of the Institute of Medicine T0-T4 continuum to advance the care of hospitalized patients who experience SAWS. Methods: Clinicians and researchers with unique and complementary expertise in basic, clinical, and implementation research related to unhealthy alcohol consumption and alcohol withdrawal were invited to participate in a workshop at the American Thoracic Society 2019 International Conference. The committee was subdivided into four groups on the basis of interest and expertise: T0-T1 (basic science research with translation to humans), T2 (research translating to patients), T3 (research translating to clinical practice), and T4 (research translating to communities). A medical librarian conducted a pragmatic literature search to facilitate this work, and committee members reviewed and supplemented the resulting evidence, identifying key knowledge gaps. Results: The committee identified several investigative opportunities to advance the care of patients with SAWS in each domain of the translational science spectrum. Major themes included 1) the need to investigate non-γ-aminobutyric acid pathways for alcohol withdrawal syndrome treatment; 2) harnessing retrospective and electronic health record data to identify risk factors and create objective severity scoring systems, particularly for acutely ill patients with SAWS; 3) the need for more robust comparative-effectiveness data to identify optimal SAWS treatment strategies; and 4) recommendations to accelerate implementation of effective treatments into practice. Conclusions: The dearth of evidence supporting management decisions for hospitalized patients with SAWS, many of whom require critical care, represents both a call to action and an opportunity for the American Thoracic Society and larger scientific communities to improve care for a vulnerable patient population. This report highlights basic, clinical, and implementation research that diverse experts agree will have the greatest impact on improving care for hospitalized patients with SAWS.

Clinical Profile and Length of Hospital Stay in a Sample of Psychogeriatric Patients Referred to Consultation Liaison Psychiatric Unit

Background and objectives: There has been a recent increase in older patients admitted to general hospitals. A significant percentage of hospitalized older patients are ≥75 years old, which differ from the patients aged 65 to 74 years old in terms of functional status at patient discharge. This study aims to compare sociodemographic, clinical features, and factors associated with length of hospital stay in youngest-old and oldest-old populations of inpatients referred to the consultation liaison psychiatry unit. Material and methods: This is an observational, cross-sectional, retrospective, and comparative study. We obtained data from a sample of 1017 patients (≥65 years) admitted to a general hospital and referred from different services (medicine, surgery, etc.) to the consultation liaison psychiatry unit. The sample was divided into two groups of patients: youngest-old (65–74 years) and oldest-old (≥75 years). Psychiatric evaluations were performed while the patients were on wards at the hospital. Psychopharmacs were started as needed. A comparative analysis was carried out and predictive factors related to length of hospital stay were calculated. Results: The reference rate to consultation liaison psychiatry unit was 1.45% of the total older patients hospitalized. Our study demonstrates differences between the groups of older people: the oldest-old group were mainly female (p < 0.001), had more previous psychiatric diagnoses (p < 0.001), physical disabilities (p = 0.02), and neurocognitive disorders (p < 0.001), they used more antipsychotics (p < 0.001), and more frequently had a discharge disposition to a nursing home (p = 0.036). The presence of physical disability (beta = 0.07, p < 0.001) and logtime to referral to consultation liaison psychiatry unit (beta = 0.58, p < 0.001) were associated with increased length of hospital stay. Conclusions: Youngest-old and oldest-old people should be considered as two different types of patients when we consider clinical features. The time to referral to consultation liaison psychiatry unit seems to be a relevant factor associated with length of hospital stay.

Medical Course and Complications After Lung Transplantation

Lung transplant prolongs life and improves quality of life in patients with end-stage lung disease. However, survival of lung transplant recipients is shorter compared to patients with other solid organ transplants, due to many unique features of the lung allograft. Patients can develop a multitude of noninfectious (e.g., primary graft dysfunction, pulmonary embolism, rejection, acute and chronic, renal insufficiency, malignancies) and infectious (i.e., bacterial, fungal, and viral) complications and require complex multidisciplinary care. This chapter discusses medical course and complications that patients might experience after lung transplantation.

Delirium pathophysiology: An updated hypothesis of the etiology of acute brain failure

BACKGROUND

Delirium is the most common neuropsychiatric syndrome encountered by clinicians dealing with older adults and the medically ill and is best characterized by 5 core domains: cognitive deficits, attentional deficits, circadian rhythm dysregulation, emotional dysregulation, and alteration in psychomotor functioning.

DESIGN

An extensive literature review and consolidation of published data into a novel interpretation of known pathophysiological causes of delirium.

RESULTS

Available data suggest that numerous pathological factors may serve as precipitants for delirium, each having differential effects depending on patient-specific patient physiological characteristics (substrate). On the basis of an extensive literature search, a newly proposed theory, the systems integration failure hypothesis, was developed to bring together the most salient previously described theories, by describing the various contributions from each into a complex web of pathways-highlighting areas of intersection and commonalities and explaining how the variable contribution of these may lead to the development of various cognitive and behavioral dysfunctions characteristic of delirium. The specific cognitive and behavioral manifestations of the specific delirium picture result from a combination of neurotransmitter function and availability, variability in integration and processing of sensory information, motor responses to both external and internal cues, and the degree of breakdown in neuronal network connectivity, hence the term acute brain failure.

CONCLUSIONS

The systems integration failure hypothesis attempts to explain how the various proposed delirium pathophysiologic theories interact with each other, causing various clinically observed delirium phenotypes. A better understanding of the underlying pathophysiology of delirium may eventually assist in designing better prevention and management approaches.

Validation of the Stanford Proxy Test for Delirium (S-PTD) among critical and noncritical patients

BACKGROUND

The Stanford Proxy Test for Delirium (S-PTD) is a tool developed to be completed by nurses at the end of their shift. It was designed to use the knowledge acquired during a full shift of nurse-patient interaction. The objective of our study was to validate the S-PTD among a mixed sample of patients in both the intensive care unit (ICU) and non-ICU settings.

METHODS

A cross-sectional study was conducted in an ICU and three general medical wards in a tertiary care hospital. Patients were independently and blindly assessed for delirium by (1) the patients' primary nurses using the S-PTD at the end of their shift, and (2) a Consultation liaison psychiatrist who conducted a neuropsychiatric evaluation based on the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5).

RESULTS

A total 288 patients were included in current analysis. Using the S-PTD, delirium was identified in 72 (25.0%), while an expert neuropsychiatric examination, based on DSM-5 identified delirium in 75 (26.0%) patients. This study demonstrated that the S-PTD has very strong discriminative ability (area under the curve= 0.946, p<0.001). An S-PTD cut-off score ≥3 was associated with an 82.7% sensitivity, an 95.3% specificity, an 86.1% positive predictive value, a 94.0% negative predictive value, and a 92.0% overall diagnostic accuracy. These results were similar in both ICU and general ward patients.

CONCLUSION

The S-PTD has excellent sensitivity and specificity in detecting delirium in both ICU and ward patients, even when compared with the gold-standard, a DSM-based neuropsychiatric examination.

Transvenous Versus Epicardial Pacing in Fontan Patients

Up to 10% of Fontan patients require pacemakers; an epicardial approach has historically been used. A transvenous approach can be used but carries risk of Fontan obstruction, thromboembolism, and can be technically challenging. The safety and efficacy of these approaches is not well described. The aim of this study was to compare epicardial and transvenous pacemaker outcomes in Fontan patients, specifically, device performance and adverse event rate. A retrospective review was performed on Fontan pacemaker patients followed at a single institution. Thirty-one Fontan pacemaker patients were identified between 1985 and 2017. Twenty-six had an epicardial system, five transvenous, and three converted from epicardial to transvenous. Average atrial lead sensing at placement was 3.23 versus 2.35 mV (p = 0.52) for epicardial and transvenous leads, respectively. Median atrial and ventricular lead longevity was 86.4 versus 98.8 months (p = 0.56) and 73.2 versus 140 months (p = 0.3) with generator longevity of 65.5 versus 73.9 (p = 0.16) months for epicardial versus transvenous systems, respectively. One major complication occurred in a transvenous patient, and two minor complications occurred in epicardial patients. All transvenous patients received warfarin except one, who converted to dabigatran. Epicardial patients received aspirin (n = 20), warfarin (n = 3) or a warfarin/aspirin combination (n = 3). No thromboembolic events occurred. System revision was required in 13 epicardial and 5 transvenous patients. There were two deaths, none related to the pacemaker system. Transvenous pacemakers can be utilized with equal efficacy compared to epicardial pacemakers with trends toward longer lead longevity in transvenous pacemaker systems.

Acute Brain Failure: Pathophysiology, Diagnosis, Management, and Sequelae of Delirium

Delirium is the most common psychiatric syndrome found in the general hospital setting, with an incidence as high as 87% in the acute care setting. Delirium is a neurobehavioral syndrome caused by the transient disruption of normal neuronal activity secondary to systemic disturbances. The development of delirium is associated with increased morbidity, mortality, cost of care, hospital-acquired complications, placement in specialized intermediate and long-term care facilities, slower rate of recovery, poor functional and cognitive recovery, decreased quality of life, and prolonged hospital stays. This article discusses the epidemiology, known etiological factors, presentation and characteristics, prevention, management, and impact of delirium.

The intensive care delirium research agenda: a multinational, interprofessional perspective

Delirium, a prevalent organ dysfunction in critically ill patients, is independently associated with increased morbidity. This last decade has witnessed an exponential growth in delirium research in hospitalized patients, including those critically ill, and this research has highlighted that delirium needs to be better understood mechanistically to help foster research that will ultimately lead to its prevention and treatment. In this invited, evidence-based paper, a multinational and interprofessional group of clinicians and researchers from within the fields of critical care medicine, psychiatry, pediatrics, anesthesiology, geriatrics, surgery, neurology, nursing, pharmacy, and the neurosciences sought to address five questions: (1) What is the current standard of care in managing ICU delirium? (2) What have been the major recent advances in delirium research and care? (3) What are the common delirium beliefs that have been challenged by recent trials? (4) What are the remaining areas of uncertainty in delirium research? (5) What are some of the top study areas/trials to be done in the next 10 years? Herein, we briefly review the epidemiology of delirium, the current best practices for management of critically ill patients at risk for delirium or experiencing delirium, identify recent advances in our understanding of delirium as well as gaps in knowledge, and discuss research opportunities and barriers to implementation, with the goal of promoting an integrated research agenda.

Delirium after lung transplantation: Association with recipient characteristics, hospital resource utilization, and mortality

BACKGROUND

Delirium is associated with increased morbidity and mortality. The factors associated with post-lung transplant delirium and its impact on outcomes are under characterized.

METHODS

The medical records of 163 consecutive adult lung transplant recipients were reviewed for delirium within 5 days (early-onset) and 30 hospital days (ever-onset) post-transplantation. A multivariable logistic regression model assessed factors associated with delirium. Multivariable negative binomial regression and Cox proportional hazards models assessed the association of delirium with ventilator duration, intensive care unit (ICU) length of stay (LOS), hospital LOS, and one-year mortality.

RESULTS

Thirty-six percent of patients developed early-onset, and 44% developed ever-onset delirium. Obesity (OR 6.35, 95% CI 1.61-24.98) and bolused benzodiazepines within the first postoperative day (OR 2.28, 95% CI 1.07-4.89) were associated with early-onset delirium. Early-onset delirium was associated with longer adjusted mechanical ventilation duration (P=.001), ICU LOS (P<.001), and hospital LOS (P=.005). Ever-onset delirium was associated with longer ICU (P<.001) and hospital LOS (P<.001). After adjusting for clinical variables, delirium was not significantly associated with one-year mortality (early-onset HR 1.65, 95% CI 0.67-4.03; ever-onset HR 1.70, 95% CI 0.63-4.55).

CONCLUSIONS

Delirium is common after lung transplant surgery and associated with increased hospital resources.

Adjunctive Valproic Acid in Management-Refractory Hyperactive Delirium: A Case Series and Rationale

Patients with delirium may fail to respond to standard therapies. Sixteen patients with management-refractory hyperactive delirium responded to adjunctive valproic acid, with complete resolution of hyperactive delirium in 13 cases. A rationale for using valproic acid in such circumstances is discussed.

Valproic Acid for Treatment of Hyperactive or Mixed Delirium: Rationale and Literature Review

BACKGROUND

Delirium is the most often encountered psychiatric diagnosis in the general hospital, with an incidence of up to 82% in the intensive care unit setting and with significant detrimental effects on patients' morbidity and mortality. Antipsychotics are often considered the first-line pharmacological treatment of delirium, but their use may be limited by lack of efficacy, existing contraindications (e.g., prolonged QTc intervals), or resulting side effects (e.g., akathisia). Valproic acid (VPA) is a potential alternative or adjunct treatment. It has multiple mechanisms of action, including effects on neurotransmitter modulation, neuroinflammation, oxidative stress, and transcription, all of which are implicated in the pathophysiology of delirium. Yet, data on the use of this agent in delirium are limited.

OBJECTIVE/METHODS

In this article, we discuss postulated mechanisms of VPA action that provide a theoretical basis for its use in the treatment of hyperactive and mixed type delirium, based on the known and theorized pathophysiology of delirium. We also discuss potential side effects and considerations with use of VPA.

CONCLUSIONS

VPA has multiple modulatory effects on neurotransmitter systems, inflammation, oxidative stress, and transcriptional changes implicated in pathophysiology of delirium. When carefully chosen, VPA can be an effective and well-tolerated treatment option for the management of hyperactive and mixed type delirium. Randomized controlled trials are needed to establish tolerability and efficacy of VPA for treatment of delirium.

The "Prediction of Alcohol Withdrawal Severity Scale" (PAWSS): systematic literature review and pilot study of a new scale for the prediction of complicated alcohol withdrawal syndrome

BACKGROUND

To date, no screening tools for alcohol withdrawal syndromes (AWS) have been validated in the medically ill. Although several tools quantify the severity of AWS (e.g., Clinical Institute Withdrawal Assessment for Alcohol [CIWA]), none identify subjects at risk of AWS, thus missing the opportunity for timely prophylaxis. Moreover, there are no validated tools for the prediction of complicated (i.e., moderate to severe) AWS in the medically ill.

OBJECTIVES

Our goals were (1) to conduct a systematic review of the published literature on AWS to identify clinical factors associated with the development of AWS, (2) to use the identified factors to develop a tool for the prediction of alcohol withdrawal among patients at risk, and (3) to conduct a pilot study to assess the validity of the tool.

METHODS

For the creation of the Prediction of Alcohol Withdrawal Severity Scale (PAWSS), we conducted a systematic literature search using PRISMA (preferred reporting items for systematic reviews and meta-analyses) guidelines for clinical factors associated with the development of AWS, using PubMed, PsychInfo, MEDLINE, and Cochrane Databases. Eligibility criteria included: (i) manuscripts dealing with human subjects, age 18 years or older, (ii) manuscripts directly addressing descriptions of AWS or its predisposing factors, including case reports, naturalistic case descriptions, and all types of clinical trials (e.g., randomized, single-blind, or open label studies), (iii) manuscripts describing characteristics of alcohol use disorder (AUD), and (iv) manuscripts dealing with animal data (which were considered only if they directly dealt with variables described in humans). Obtained data were used to develop the Prediction of Alcohol Withdrawal Severity Scale, in order to assist in the identification of patients at risk for complicated AWS. A pilot study was conducted to assess the new tool's psychometric qualities on patients admitted to a general inpatient medicine unit over a 2-week period, who agreed to participate in the study. Blind to PAWSS results, a separate group of researchers retrospectively examined the medical records for evidence of AWS.

RESULTS

The search produced 2802 articles describing factors potentially associated with increased risk for AWS, increased severity of withdrawal symptoms, and potential characteristics differentiating subjects with various forms of AWS. Of these, 446 articles met inclusion criteria and underwent further scrutiny, yielding a total of 233 unique articles describing factors predictive of AWS. A total of 10 items were identified as correlated with complicated AWS (i.e., withdrawal hallucinosis, withdrawal-related seizures, and delirium tremens) and used to construct the PAWSS. During the pilot study, a total of 68 subjects underwent evaluation with PAWSS. In this pilot sample the sensitivity, specificity, and positive and negative predictive values of PAWSS were 100%, using the threshold score of 4.

DISCUSSION

The results of the literature search identified 10 items which may be correlated with risk for complicated AWS. These items were assembled into a tool to assist in the identification of patients at risk: PAWSS. The results of this pilot study suggest that PAWSS may be useful in identifying risk of complicated AWS in medically ill, hospitalized individuals. PAWSS is the first validated tool for the prediction of severe AWS in the medically ill and its use may aid in the early identification of patients at risk for complicated AWS, allowing for prophylaxis against AWS before severe alcohol withdrawal syndromes develop.

Neuropathogenesis of delirium: review of current etiologic theories and common pathways

Delirium is a neurobehavioral syndrome caused by dysregulation of neuronal activity secondary to systemic disturbances. Over time, a number of theories have been proposed in an attempt to explain the processes leading to the development of delirium. Each proposed theory has focused on a specific mechanism or pathologic process (e.g., dopamine excess or acetylcholine deficiency theories), observational and experiential evidence (e.g., sleep deprivation, aging), or empirical data (e.g., specific pharmacologic agents' association with postoperative delirium, intraoperative hypoxia). This article represents a review of published literature and summarizes the top seven proposed theories and their interrelation. This review includes the "neuroinflammatory," "neuronal aging," "oxidative stress," "neurotransmitter deficiency," "neuroendocrine," "diurnal dysregulation," and "network disconnectivity" hypotheses. Most of these theories are complementary, rather than competing, with many areas of intersection and reciprocal influence. The literature suggests that many factors or mechanisms included in these theories lead to a final common outcome associated with an alteration in neurotransmitter synthesis, function, and/or availability that mediates the complex behavioral and cognitive changes observed in delirium. In general, the most commonly described neurotransmitter changes associated with delirium include deficiencies in acetylcholine and/or melatonin availability; excess in dopamine, norepinephrine, and/or glutamate release; and variable alterations (e.g., either a decreased or increased activity, depending on delirium presentation and cause) in serotonin, histamine, and/or γ-aminobutyric acid. In the end, it is unlikely that any one of these theories is fully capable of explaining the etiology or phenomenologic manifestations of delirium but rather that two or more of these, if not all, act together to lead to the biochemical derangement and, ultimately, to the complex cognitive and behavioral changes characteristic of delirium.

Benzodiazepine loading versus symptom-triggered treatment of alcohol withdrawal: a prospective, randomized clinical trial

OBJECTIVES

The objectives were to compare the efficacy of a benzodiazepine loading versus a symptom-triggered protocol in the management of alcohol withdrawal.

METHODS

We conducted a prospective, randomized, controlled trial including 47 consecutive patients admitted to one of two tertiary care medical centers who developed alcohol withdrawal syndrome. Patients were randomly assigned to either a benzodiazepine loading protocol or a symptom-triggered treatment protocol. The Clinical Institute Withdrawal Assessment for Alcohol-Revised scale (CIWA-Ar) was recorded throughout the length of stay, along with measures of autonomic system functioning.

RESULTS

The average rate of change of CIWA-Ar scores was -1.5 ± 1.3 for the symptom-triggered group and -2.3 ± 2.5 for the loading group. Average rate of change for systolic blood pressure was -2.7 ± 5.3 for the symptom-triggered group and -2.3 ± 6.4 for the loading group. There was no significant difference between the rates of change for either group on either measure. Similarly, there was no significant difference in total benzodiazepine use between groups. Within 72 h of treatment, 69.6% of patients in the loading group were free of withdrawal symptoms versus 41.7% in the symptom-triggered group, a difference not reaching statistical significance.

CONCLUSIONS

This study did not reveal clear evidence of a clinical advantage for choosing either treatment method.

The Stanford Integrated Psychosocial Assessment for Transplantation (SIPAT): a new tool for the psychosocial evaluation of pre-transplant candidates

BACKGROUND

While medical criteria have been well established for each end-organ system, psychosocial listing criteria are less standardized. To address this limitation, we developed and tested a new assessment tool: the Stanford Integrated Psychosocial Assessment for Transplantation (SIPAT).

METHODS

The SIPAT was developed from a comprehensive review of the literature on the psychosocial factors that impact transplant outcomes. Five examiners blindly applied the SIPAT to 102 randomly selected transplant cases, including liver, heart, and lung patients. After all subject's files had been rated by the examiners, the respective transplant teams provided the research team with the patient's outcome data.

RESULTS

Univariate logistic regression models were fit in order to predict the transplant psychosocial outcome (positive or negative) using each rater's SIPAT scores. These results show that SIPAT scores are highly predictive of the transplant psychosocial outcome (P < 0.0001). The instrument has excellent inter-rater reliability (Pearson's correlation coefficient = 0.853), even among novice raters.

CONCLUSIONS

The SIPAT is a comprehensive screening tool to assist in the psychosocial assessment of organ transplant candidates. Its strengths includes the standardization of the evaluation process and its ability to identify subjects who are at risk for negative outcomes after the transplant, in order to allow for the development of interventions directed at improving the patient's candidacy. Our goal is that the SIPAT, in addition to a set of agreed upon minimal psychosocial listing criteria, would be used in combination with organ-specific medical listing criteria in order to establish standardized criteria for the selection of transplant recipients.

The impact of depression in heart disease

Depression and heart disease affect millions of people worldwide. Studies have shown that depression is a significant risk factor for new heart disease and that it increases morbidity and mortality in established heart disease. Many hypothesized and studied mechanisms have linked depression and heart disease, including serotonergic pathway and platelet dysfunction, inflammation, autonomic nervous system and hypothalamic-pituitary-adrenal axis imbalance, and psychosocial factors. Although the treatment of depression in cardiac patients has been shown to be safe and modestly efficacious, it has yet to translate into reduced cardiovascular morbidity and mortality. Understanding the impact and mechanisms behind the association of depression and heart disease may allow for the development of treatments aimed at altering the devastating consequences caused by these comorbid illnesses.

Delirium in the acute care setting: characteristics, diagnosis and treatment

Delirium is a neurobehavioral syndrome caused by the transient disruption of normal neuronal activity secondary to systemic disturbances. It is also the most common psychiatric syndrome found in the general hospital setting, its prevalence surpassing better known psychiatric disorders. This article reviews the published literature on delirium and addresses the epidemiology, known etiologic factors, presentation and characteristics of delirium, while emphasizing what is known about treatment strategies and prevention. Given increasing evidence that delirium is not always reversible and the many sequelae associated with its development, physicians must do everything possible to prevent its occurrence or shorten its duration, by recognizing its symptoms early, correcting underlying contributing causes, and using treatment strategies proven to help recover functional status.

Acute stress reactions following the assassination of Mexican presidential candidate Colosio

Considerable evidence suggests that exposure to traumatic events increases the risk of developing anxiety-spectrum disorders in response to later traumatization. We conducted a survey in Guadalajara, Mexico to assess factors associated with acute stress reactions to the assassination of a political figure. Participants included 86 adults who completed the Stanford Acute Stress Reaction Questionnaire (SASRQ) and measures of the perceived impact of the assassination, exhibited emotional behavior following the assassination, and had exposure to a specific prior disaster (a gas pipeline explosion). The results suggest that acute stress reactions can occur in response to an assassination, and that those most susceptible are those most emotionally invested, those who engage in emotional behavioral responses, and those whose lives have been affected by a previous potentially traumatic event.

Diagnoses of children and adolescents on initial presentation to a Nigerian outpatient psychiatry clinic

Child and adolescent psychiatry is an underdeveloped specialty in Nigeria, relegated by more entrenched cultural systems, such as traditional healers and syncretic churches, to merely an auxiliary role in child mental health care. Little is therefore known about the epidemiology of childhood disorders as encountered in psychiatric settings. We reviewed the outpatient psychiatric clinic's patient register at the Psychiatric Hospital of Uselu in Benin City, Nigeria, over a twenty-four week period. Fifty-three patients who presented in the twenty-four week index period had definite diagnoses indicated in the register. Of these, 68% had diagnoses denoting significant behavioral disturbances that would motivate their visit to allopathic hospitals after other, more culturally sanctioned healers were of little help. Our findings are compared with similar studies in other cultures.

Liver transplantation for alcoholic liver disease: selection and outcome

There is clear consensus that patients with alcoholic cirrhosis should be considerated for liver transplantation, barring complicating medical or psychosocial problems. Short-term and long-term survival rates are comparable to patients receiving transplants for other conditions, and the relapse rate to alcohol use averages 15%, with troublesome drinking seen uncommonly. To date, no nationally accepted selection criteria have been established and proved effective in predicting long-term sobriety and compliance. To maximize the outcome of liver transplantation in patients with alcoholic liver disease, an approach to the selection of candidates is outlined herewith. 1. Minimum pretransplant sobriety period of 6 months. 2. Assessment of overall psychosocial support and stress. 3. Assessment of comorbid psychiatric conditions that may impair ability to comply with the transplant protocol during and after transplantation. 4. Assessment of past and present compliance with medical treatment. 5. Acceptance of problem with alcohol and willingness to sign an alcohol contract. 6. Willingness to participate in alcohol rehabilitation treatment program. 7. Willingness to participate in liver support groups to improve understanding of the condition and obtain social support. 8. Willingness to undergo random toxicology screening to assess compliance with sobriety.