Changes In Level Of Consciousness Research Articles

From Traditional Typing to Intelligent Insights: A Narrative Review of Directions Toward Targeted Therapies in Delirium.

Delirium is a heterogeneous syndrome characterized by an acute change in level of consciousness that is associated with inattention and disorganized thinking. Delirium affects most critically ill patients and is associated with poor patient-oriented outcomes such as increased mortality, longer ICU and hospital length of stay, and worse long-term cognitive outcomes. The concept of delirium and its subtypes has existed since nearly the beginning of recorded medical literature, yet robust therapies have yet to be identified. Analogous to other critical illness syndromes, we suspect the lack of identified therapies stems from patient heterogeneity and prior subtyping efforts that do not capture the underlying etiology of delirium. The time has come to leverage machine learning approaches, such as supervised and unsupervised clustering, to identify clinical and pathophysiological distinct clusters of delirium that will likely respond differently to various interventions. We use sedation in the ICU as an example of how precision therapies can be applied to critically ill patients, highlighting the fact that while for some patients a sedative drug may cause delirium, in another cohort sedation is the specific treatment. Finally, we conclude with a proposition to move away from the term delirium, and rather focus on the treatable traits that may allow precision therapies to be tested.

Rocuronium-neuromuscular blockade does not influence the patient state index in anesthetized dogs.

To evaluate the effects of rocuronium and sugammadex on the patient state index (PSI) in dogs anesthetized with propofol. 6 intact healthy male Beagles. Anesthesia was induced with and maintained on a propofol infusion. The estimated plasma propofol concentration (ePC) was recorded. Baseline PSI and train-of-four ratio (TOFR) readings were collected for 2 minutes in stable general anesthesia. Neuromuscular blockade (NMB) was induced with 0.6 mg/kg, IV, rocuronium, and full NMB was confirmed with a TOFR of 0. After 5 minutes, the neuromuscular function was restored with 4 mg/kg sugammadex, IV (reversal), and monitored for 5 minutes. Throughout the data collection, ePC, PSI, and TOFR were recorded every 15 seconds and compared with mixed-effect ANOVA. Baseline ePC, PSI, and TOFR were 3.63 ± 0.38, 41 ± 6, and 0.97 ± 0.08 µg/mL, respectively. There was no difference between the baseline of ePC and PSI from NMB or reversal. Compared to the baseline, the TOFR decreased to 0 with NMB (P < .001) and returned to 0.96 ± 0.08 (P = .721) on reversal. After 5 minutes, sugammadex fully reversed 5 out of 6 dogs to TOFR > 0.90 and partially reversed 1 animal to TOFR = 0.80. There was no evidence that NMB with rocuronium and sugammadex-induced reversal interfered with PSI readings under steady-state total intravenous anesthesia with propofol. Further evaluation of PSI is warranted to assess its utility in a clinical population to detect changes in levels of consciousness during NMB.

Behavioral scales variability in patients with prolonged disorders of consciousness

BackgroundThe principal conditions differentiating disorders of consciousness (DOC) patients are the unresponsive wakefulness syndrome/vegetative state (UWS/VS) and the minimally conscious state (MCS). Many individuals who suffer from sudden-onset severe brain injury move through stages of UWS/VS and MCS before regaining full awareness. In some patients, the DOC condition is protracted for years (PDOC). In this study, we observed PDOC patients for 6 months to assess possible changes in their level of consciousness.MethodsWe enrolled 40 PDOC patients, 23 UWS/VS and 17 MCS hosted in a dedicated unit for long-term brain injury care. The time from injury was 472 ± 533 days for UWS/VS and 1090 ± 1079 days for MCS. The Wessex Head Injury Matrix (WHIM), Coma Recovery Scale-R (CRS-R), and Nociception Coma Scale were administered monthly for 6 months.ResultsDuring the period of assessment, the percentage of UWS/VS shifted from 58 to 45%, while for the MCS, from 42 to 55%. A positive correlation was found for the UWS/VS patients between the months of observation with the CRS-R total score and WHIM total numbers of behaviors (TNB). In the UWS/VS group, the CRS-R auditive and visual subscales correlated positively with the observation time. During the whole period of observation, 8 patients had constant CRS-R total scores while the WHIM TNB changed in 7 of them.ConclusionOur findings demonstrated that the monthly assessment of PDOC by means of the CRS-R and WHIM was able to detect also subtle changes in consciousness level.

Specialized intensive inpatient rehabilitation is crucial and time-sensitive for functional recovery from disorders of consciousness.

Disorders of consciousness (DoCs) after severe brain injury are considered to be conditions with dire prognosis. Despite the accumulating evidence, inpatient rehabilitation is often denied by payers referring to the Medicare/Medicaid criteria, under the assumption that such patients will not "actively" participate in therapy or make "measurable improvements." This study aimed to report on the effectiveness and efficiency of a specialized inpatient DoC rehabilitation program based on measurable clinical parameters. A retrospective cohort study was conducted. The cohort comprised 137 patients with DoC admitted to a specialized acute inpatient rehabilitation program between January 2014 and October 2018. Patients were categorized as having been admitted at the acute stage (<=28 days post-injury), subacute stage (29-365 days following a traumatic brain injury (TBI) or 29-90 days following a non-TBI), or chronic stage (>365 days following a TBI or >90 days following a non-TBI). Outcomes included changes in level of consciousness (based on the Coma Recovery Scale-Revised (CRS-R), while also acknowledging scenarios beyond those captured by the CRS-R via Individualized Qualitative Behavioral Assessment and team consensus); Functional Independence Measure (FIM) levels; achievements in decannulation and initiation of oral diet; and time to those achievements. The rates of emergence from a minimally conscious state were 90, 62, and 18% among patients admitted at the acute, subacute, and chronic stages, respectively. Among patients who emerged, 100, 85, and 67%, respectively, had measurable FIM scores. Approximately 60 and 20% of patients at the acute and subacute stages, respectively, required moderate assistance or less in transfer/communication/eating/grooming/upper body dressing by the time of discharge from Phase I admission. The decannulation rates were 94, 67, and 17%. The oral diet initiation rates were 70, 23, and 6%. The time to reach these achievements lengthened as chronicity increased. There was a weak positive correlation (r s = 0.308) in the case of decannulation and a strong positive correlation (r s = 0.606, both p < 0.01) in the case of oral diet between days since injury on admission and days to the achievement after admission. Patients with TBI and hypoxic brain injury had comparable recovery rates when admitted at the acute and subacute stages. Specialized intensive inpatient rehabilitation is crucial and time-sensitive for functional recovery from DoC caused by TBI and hypoxic-ischemic brain injury. Specific goals and different outcome measures need to be developed to appraise the benefits of acute inpatient rehabilitation for DoC.

Delirium en los pacientes mayores

Delirium is a clinical syndrome characterized by transitory changes in level of consciousness that has an acute onset and fluctuating course and is associated with cognition and behavior changes. It tends to occur secondary to organic causes (infections or drugs) and is very prevalent in hospitalized older adults. It is classified as hypoactive, hyperactive, or mixed. Its diagnosis is fundamentally clinical. Several rapid diagnostic tools have been validated (4AT, CAM) which complement the clinical assessment. Multicomponent non-pharmacological interventions have been demonstrated to be the most effective in both its prevention and its treatment. The key point in treatment is treating the triggering causes. Pharmacological control could be justified when the patient's or healthcare team's safety is compromised or when symptoms cause the patient great emotional stress. Neuroleptics are the most used drugs. The drug with the most favorable side effects profile according to each patient's characteristics should be chosen and they should be used for the shortest possible time.

Sex-Related Differences in Symptoms Among Patients Presenting with Acute Stroke: A Systematic Review and Meta-analysis

Background: Recognising acute stroke symptoms is crucial in providing timely treatment. However, evidence suggests that females often experience unique symptoms compared with males, resulting in delays to seeking medical attention and treatment. This systematic review and meta-analysis evaluated whether sex is associated with differences in acute stroke symptoms. Methods: Searches from 1946 to 7th September 2021 were carried out using MEDLINE, Embase, Cumulative Index to Nursing and Allied Health Literature (CINAHL), and the Cochrane Library. Studies reporting acute stroke symptoms in adult females and males were eligible for inclusion. Eleven observational studies met the inclusion criteria. Methodological quality was assessed using the Newcastle–Ottawa scale (NOS). Data were meta-analysed using a random-effects model. Results: Compared with males, females had higher odds of experiencing headache (odds ratio [OR]: 1.27; 95% confidence interval [CI]: 1.01–1.59); change in level of consciousness (OR: 1.36; 95% CI: 1.13–1.63); fatigue (OR: 1.53; 95% CI: 1.04–2.25); and incontinence (OR: 1.44; 95% CI: 1.29–1.60). In contrast, females were at lower odds of experiencing trouble speaking (OR: 0.79; 95% CI: 0.64–0.96); trouble walking, loss of balance, or co-ordination (OR: 0.55; 95% CI: 0.39–0.76); and dizziness (OR: 0.77; 95% CI: 0.64–0.94) compared with males. No difference was found in confusion, difficulty understanding speech, trouble seeing in one or both eyes, mental status change, and nausea or vomiting. Discussion: Sex differences do exist in some acute stroke symptoms. At the same time, the overlap in symptoms between sexes was substantial. Healthcare professionals and public health campaigns should continue to promote classic symptoms of acute stroke, whilst taking into account the less common symptoms and the potential differences in symptoms experienced by females and males.

Brain connectivity changes of propofol-induced altered states of consciousness using High-Density EEG Source Estimation.

Through source estimation, high-density electroencephalogram (EEG) signals at scalp level can be converted into signals at cerebral cortex level, which helps to measure cortical activity during anesthesia induced changes in consciousness level to explore the mechanism. In this research, the high-density EEG of propofol-induced consciousness states alterations in 20 healthy adults were converted into cortical signals of 68 regions of interest (ROI), after alpha bandpass filtering, the pairwise orthogonal power envelope connectivity (PEC) was calculated. Then, due to the number of PECs was huge, the least absolute shrinkage and selection operator (LASSO) was used to select as few PECs as possible as the indicators to distinguish baseline (BS) and moderate sedation (MD) states. The results show that most PECs that can be used as indicators are related to ROI related to default mode network (DMN). At the same time, changes of thalamocortical connectivity and frontal-parietal connectivity could be observed, similar to the neuroimaging method of directly measuring cerebral cortical activity. By extracting the PEC as a classifier to classify the BS and MD States, the accuracy could reach more than 70%. Therefore, this method can not only reflect the mechanism of cortical activity alterations induced by anesthetics, but also provide a new idea for monitoring the depth of anesthesia in the future. Clinical Relevance - This shows that the high-density EEG of scalp level can be converted into cortical signals by source estimation, which is similar to the neuroimaging method of directly measuring cortical activity.

Clinical features and epidemiological analysis of respiratory human adenovirus infection in hospitalized children: a cross-sectional study in Zhejiang

BackgroundHAdV is one of the common pathogens in hospitalized children with acute respiratory infections (ARIs). We aim to describe the clinical and laboratory features, epidemiological characteristics, and HAdV species and/or types of inpatients with HAdV respiratory infections.MethodsRespiratory samples were gathered from inpatients diagnosed ARIs in Children’s Hospital, Zhejiang University School of Medicine, and were detected by using Direct Immunofluorescence Assay from 2018 to 2019. PCR amplification and sequencing of the hypervariable zone of hexon gene were used for genotyping. The clinical and laboratory features, and HAdV genotyping, and epidemiological characteristic analysis were retrospectively performed.ResultsOf 7072 samples collected, 488 were identified as HAdV-positive. The overall detection rate was 6.9%. The peaked detection rate was 14.1% in January 2019. HAdV-positive cases with ARIs mainly appeared in winter. The detection rate was highest among children between 6 months and 2 years (8.7%, 123/1408). Clinical diagnosis included pneumonia (70.3%, 343/488), bronchitis (7.0%, 34/488) and acute upper respiratory tract infection (22.7%, 111/488). The common clinical manifestations were fever (93.4%, 456/488), cough (94.7%, 462/488), wheezing (26.2%, 128/488), and shortness of breath (14.8%, 72/488). 213 (43.6%) cases had co-infection and 138 (28.3%) cases had extrapulmonary symptoms. 96(19.7%) cases had intrapulmonary and intrathoracic complications.78 (16.0%) had an underlying condition, most of which were congenital heart diseases (20.5%, 16/78). The proportions of hyperpyrexia, duration of fever > 10 days, severe pneumonia, and wheezing in the co-infection group were remarkably higher than those in HAdV single-infection group (all p < 0.05). The proportions of duration of hospitalization, duration of fever > 10 days, wheezing, shortness of breath, change in level of consciousness, serosal fluids, extrapulmonary symptoms, co-infections and underlying diseases were significantly higher in severe pneumonia group than those in the mild pneumonia group (all p < 0.05). Four HAdV species were successfully identified in 155 cases and presented by 8 genotypes. HAdV-B3 (56.1%, 87/155) and HAdV -B7 (31.0%, 48/155) were the most predominant detected types and occurred commonly in different severity groups (p = 0.000), while, HAdV-B55 was detected only in the severe group. HAdV-B7’s detection rate in the severe pneumonia group was significantly higher than the non-severe pneumonia group.ConclusionHAdV detection rate is related to age and season. Bronchopneumonia accounts for about 70% HAdV-positive inpatients. The common clinical manifestations include hyperpyrexia, cough, wheezing, and shortness of breath. HAdV-B3 and HAdV-B7 are the most common types in children diagnosed with respiration infections.

Return of the Righting Reflex Does Not Portend Recovery of Cognitive Function in Anesthetized Rats.

As the number of individuals undergoing general anesthesia rises globally, it becomes increasingly important to understand how consciousness and cognition are restored after anesthesia. In rodents, levels of consciousness are traditionally captured by physiological responses such as the return of righting reflex (RORR). However, tracking the recovery of cognitive function is comparatively difficult. Here we use an operant conditioning task, the 5-choice serial reaction time task (5-CSRTT), to measure sustained attention, working memory, and inhibitory control in male and female rats as they recover from the effects of several different clinical anesthetics. In the 5-CSRTT, rats learn to attend to a five-windowed touchscreen for the presentation of a stimulus. Rats are rewarded with food pellets for selecting the correct window within the time limit. During each session we tracked both the proportion of correct (accuracy) and missed (omissions) responses over time. Cognitive recovery trajectories were assessed after isoflurane (2% for 1 h), sevoflurane (3% for 20 min), propofol (10 mg/kg I.V. bolus), ketamine (50 mg/kg I.V. infusion over 10 min), and dexmedetomidine (20 and 35 μg/kg I.V. infusions over 10 min) for up to 3 h following RORR. Rats were classified as having recovered accuracy performance when four of their last five responses were correct, and as having recovered low omission performance when they missed one or fewer of their last five trials. Following isoflurane, sevoflurane, and propofol anesthesia, the majority (63–88%) of rats recovered both accuracy and low omission performance within an hour of RORR. Following ketamine, accuracy performance recovers within 2 h in most (63%) rats, but low omission performance recovers in only a minority (32%) of rats within 3 h. Finally, following either high or low doses of dexmedetomidine, few rats (25–32%) recover accuracy performance, and even fewer (0–13%) recover low omission performance within 3 h. Regardless of the anesthetic, RORR latency is not correlated with 5-CSRTT performance, which suggests that recovery of neurocognitive function cannot be inferred from changes in levels of consciousness. These results demonstrate how operant conditioning tasks can be used to assess real-time recovery of neurocognitive function following different anesthetic regimens.

Arousal effect and potential mechanism of dopamine-mediated acupuncture on traumatic brain injury

Abstract Traumatic brain injury (TBI) is a brain injury caused by direct external forces, and its prognosis depends on the extent of the damage and the changes in level of consciousness. Timely awakening from a coma is the first thorny problem to be solved in TBI treatment. Therefore, there is a need for the development of safe and effective methods for timely awakening after TBI coma. Dopamine (DA) and its receptors in the nervous system are involved in the regulation of wakefulness. The amount and activity of dopaminergic neurons can affect cellular function and neuroinflammatory response, and are also significant for the awakening process after TBI. The current common awakening therapy for TBI may also be related to the activation of dopaminergic neurons. Acupuncture plays a beneficial role in timely awakening, recovery of conscious level, and functional rehabilitation after TBI. The mechanism may be related to the targeted regulation of DA and its receptors via acupuncture. Among acupuncture first aid therapies, acupuncture at hand 12 Jing-Well points, with its advantages of simple operation and ultra-early intervention, has shown great promise in timely awakening following TBI and triggering a series of subsequent nerve repair effects in the treatment of TBI. We here present a review that provides a new perspective for the timely awakening from TBI-induced coma, with a focus on the role of DA in the regulation of wakefulness and the efficacy and potential mechanism of DA systems in the treatment of TBI by acupuncture.

Effect of Proprioceptive Neuromuscular Facilitation Neck Pattern Exercises on Balance in Stroke - An Evidence Based Study

Background: Stroke is the sudden loss of neurological function which is caused by an interruption of blood flow to the brain. A variety of focal deficits are possible that include changes in level of consciousness and impairments of sensory, motor, cognitive, perceptual and language functions. Trunk muscles are impaired in the patients with stroke so there is diminished ability to maintain balance because of weakened muscle strength of trunk. Resistance to neck motion during PNF provides irradiation to the trunk muscles. Purpose: The purpose is to study the scientific evidences regarding the effect of proprioceptive neuromuscular facilitation neck pattern exercises on balance in stroke. Methodology: A search for relevant articles was carried out using key words- Neck proprioceptive neuromuscular facilitation, Balance, Trunk control and Stroke. Search engines used were Google Scholar, PubMed, PEDro, ScienceDirect and ResearchGate. Studies were selected from year 2011-2020. Eight studies were included in which there were 6 randomized control trial, 1 case series, 1 single subject design. Results: All the 8 articles concluded that proprioceptive neuromuscular facilitation neck pattern exercise is effective in improving balance in the patients with stroke. (level of evidence :1b,2a,4,5) Conclusion: Based on evidences, it can be concluded that proprioceptive neuromuscular facilitation neck pattern exercise is found to be effective in improving balance in the patients with stroke. Clinical Implication: Proprioceptive neuromuscular facilitation neck pattern exercises can be used as an adjunct to other treatment in improving balance in stroke. Keywords: Neck proprioceptive neuromuscular facilitation, Balance, Trunk control and Stroke.

Changes of Consciousness Level and Blood Pressure of Acute Stroke Patients Administering Mannitol Therapy

Objects: To analyze changes in consciousness level and blood pressure of acute stoke patients administeringmannitol therapy.Methods: The study was a descriptive cohort. Thirty-four respondents were applied to selecting by purposivesampling. Data were analyzed by descriptive.Results: The results showed that there was an improvement in consciousness level (GCS). The improvementin the patient’s level of consciousness occurred after more than twenty-four hours of getting mannitol therapy.While the blood pressure until the third day, there were still suffering from hypertension.Conclusion: Improvements in consciousness level after administering mannitol therapy indicate loss ofcerebral edema, improvement in cerebral blood flow (CBF) and brain perfusion pressure (CPP), and repairof damaged nerve cells.

Hypoglycemia Protocol Institution at SNF/LTC facility

The geriatric population is at high risk of severe low blood glucose (LBG) events due to diminished homeostatic mechanisms, especially on hypoglycemic medications. Moderate to severe LBG events in these patients can contribute to behavior changes such as agitation, change in level of consciousness, disruption of sleep, instability and increased risk of myocardial infarction, stroke and falls. Rapid recognition and appropriate treatment and prevention of LBG and recurrences can reduce risk for hospitalization in the geriatric population. In most skilled nursing (SNF) and long-term care (LTC) facilities, patients do not have a hypoglycemia treatment plan ordered by providers nor standard hypoglycemia protocols.

A184 NON-CIRRHOTIC HYPERAMMONEMIA SECONDARY TO EXTRAHEPATIC PORTOSYSTEMIC VENOUS SHUNT PRESENTING AS A CONGNITIVE DYSFUNCTION: A CASE REPORT AND LITERATURE REVIEW

Abstract Background Hyperammonemia secondary to liver disease is a very common cause of hepatic encephalopathy (HE) and it is easily recognized in patients with advanced liver disease. Non-cirrhotic causes of hyperammonemia are rare, particularly extrahepatic portosystemic venous shunts (EPS). The majority of these shunts are between a mesenteric vein and the inferior vena cava. We report a case of a non-cirrhotic hyperammonemia secondary to a shunt between the superior mesenteric vein (SMV) and the right renal vein (RRV) that presented with encephalopathy. Diagnosis was delayed due to lack of awareness of non-cirrhotic hyperammonemia underscoring the importance of measuring ammonia in all patients presenting with encephalopathic symptoms irrespective of their liver function. Aims To report our experience with a patient with unexplained cognitive dysfunction that was eventually attributed to hyperammonemia secondary to a rare non-cirrhotic portosystemic shunt. Also, we discuss the differential diagnoses of non-cirrhotic hyperammonemia and the pathophysiology, classification and diagnosis of spontaneous portosystemic shunts. Methods A retrospective chart review Results A 57-year-old woman with longstanding essential tremors on topiramate presented with a 30-month history of recurrent disabling episodes of unexplained “zoning out”. Her neurologists undertook extensive investigations which excluded primary neurological conditions. These episodes persisted despite discontinuation of topiramate, treatment of urinary tract infection (UTI) and continuing daily prophylactic antibiotics for recurrent UTIs as presumed etiologies. Due to her unexplained and disabling symptoms she was referred to an internist. During further evaluation, ammonia level was measured for first time, in the absence of any obvious features of chronic liver disease, and the level was strikingly elevated 152uml/l. Hence, an abdominal CT was obtained and revealed a prominent shunt between SMV and RRV. The patient was diagnosed with non-cirrhotic hyperammonemia secondary to EPS. She is currently stable on lactulose and rifaximin with a drop in her ammonia level to 63uml/l, and an interventional radiological procedure is being considered. Conclusions While hyperammonemia is most commonly related to liver failure, our case highlights the importance of awareness of non-cirrhotic hyperammonemia. Any unexplained change in level of consciousness, cognition and/or behavior merits measurement of serum ammonia irrespective of clinical liver status. Funding Agencies None

Thalamus Modulates Consciousness via Layer-Specific Control of Cortex

Functional MRI and electrophysiology studies suggest that consciousness depends on large-scale thalamocortical and corticocortical interactions. However, it is unclear how neurons in different cortical layers and circuits contribute. We simultaneously recorded from central lateral thalamus (CL) and across layers of the frontoparietal cortexin awake, sleeping, and anesthetized macaques. We found that neurons in thalamus and deep cortical layers are most sensitive to changes in consciousness level, consistent across different anesthetic agents and sleep. Deep-layer activity is sustained by interactions with CL. Consciousness also depends on deep-layer neurons providing feedback to superficial layers (notto deep layers), suggesting that long-range feedback and intracolumnar signaling are important. To show causality, we stimulated CL in anesthetized macaques and effectively restored arousal and wake-like neural processing. This effect waslocation and frequency specific. Our findings suggest layer-specific thalamocortical correlates of consciousness and inform how targeted deep brain stimulation can alleviate disorders of consciousness.

Development and validation of a screening tool for early identification of bloodstream infection in older patients \u2013 a retrospective case-control study

BackgroundDelayed diagnosis of bloodstream infection (BSI) occurs in > 20% of older patients, with misdiagnosis in 35%. Our objective was to develop and validate a clinically useful screening tool to identify older patients with a high probability of having a BSI.MethodsHospitalized patients > 80 years old with BSI (n = 105/group) were evaluated for the tool development in this retrospective matched case-controlled study (learn cohort). The tool was validated in different retrospectively matched case and control patients > 80 years old (n = 120/group) and 65 to 79 years old (n = 250/group) (test cohort). Binary logistic regression was used to develop a screening tool using laboratory and clinical parameters that were significantly associated with BSI (P < 0.05; adjusted odds ratio (OR) > 1); and Classification and Regression Tree (CART) analysis was used to identify parameter breakpoints. Performance metrics were used to evaluate and validate the tool.ResultsThe significant parameters associated with BSI were maximum temperature (Tmax)(> 37.55C)(OR = 42.575), neutrophils (> 7.95)(OR = 1.923), a change in level of consciousness (LOC) (Yes = 1, No = 0)(OR = 1.571), blood urea nitrogen (BUN)(> 10.05)(OR = 1.359), glucose (> 7.35)(OR = 1.167), albumin (< 33.5)(OR = 1.038) and alanine aminotransferase (ALT) (> 19.5)(OR = 1.005). The optimal screening tool [Ln (odds of BSI) = − 150.299 + 3.751(Tmax) + 0.654(neutrophils) + 0.452(change in LOC) + 0.307(BUN) + 0.154(glucose) + 0.038(albumin) + 0.005(ALT)] had favorable performance metrics in the learn and test cohorts (sensitivity, specificity and accuracy of 95% in the learn cohort and 77, 89, and 81% in the total test cohort); and performed better than using only temperature and neutrophil count.ConclusionsThe validated tool had high predictive value which may improve early identification and management of BSI in older patients.

FACTORS ASSOCIATED WITH MORTALITY AMONG LONG-TERM CARE RESIDENTS TRANSITIONING TO AND FROM EMERGENCY DEPARTMENTS

Studies examining risk of death during acute care transitions have highlighted potential predictors of death during transition. However, they have not closely examined the relationships and directional effects of organizational context, care processes, resident demographics and health conditions on death during transition. By employing structural equation modeling, we aimed to 1) identify predictive factors for residents who died during transitions from long term care (LTC) to emergency departments (EDs) and back; 2) examine relationships between identified organizational, process and resident factors with resident death during these transitions; and 3) identify areas for further investigation and improvement in practice. We tracked every resident transfer from 38 participating LTC facilities to two included EDs in two Western Canadian provinces from July 2011 to July 2012. Overall, 524 residents were involved in 637 transfers of whom 63 residents (12%) died during the transition. Sustained dyspnea (in both LTC and the ED), sustained change in level of consciousness (LOC) and severity measured by triage score were direct and significant predictors of resident death during transition. The model fit the data, (x2 = 83.77, df = 64, p = 0.049) and explained 15% variance in resident death. Dyspnea and change in LOC in both LTC and ED needs to be recognized regardless of primary reason for transfer. More research is needed to determine the specific influences of LTC ownership models, family involvement in decision-making, LTC staff decision-making on resident death during transition, and interventions to prevent pre-death transfers.

Nurse Decision Making in Acute Care.

Effective nurse decision making is essential for best patient outcomes in the acute care nurse practice environment. The purpose of this study was to explore acute care RNs' perceptions of clinical decision making for a patient who experienced a clinical event. Clinical events include changes in patient condition and are manifested by fever, pain, bleeding, changes in output, changes in respiratory status, and changes in level of consciousness. Naturalistic decision making framework supported the exploration of important contextual factors associated with decision making, provided new information for nursing science, and served as the conceptual framework for this research. Data collected from interviews of 20 acute care nurses were analyzed using qualitative content analysis. The emergent categories included Awareness of Patient Status, Experience and Decision Making, Following Established Routine, Time Pressure, Teamwork/Support From Staff, Goals, Education, Resources, Patient Education, Consideration of Options to Meet Goals, and Nursing Roles. Acute care nurses incorporated a wide variety of complex factors when decision making. This study sought to improve understanding of the factors nurses found important to their decision making for the potential development of improved decision support in the electronic health record.

Thalamus Modulates Consciousness Via Layer-Specific Control of Cortex

Functional MRI and electrophysiology studies suggest consciousness depends on large-scale thalamocortical and corticocortical interactions. However, it is unclear how neurons in different cortical layers and circuits contribute. We simultaneously recorded from central lateral thalamus (CL) and across layers of fronto-parietal cortex in awake, sleeping and anesthetized macaques. We found that neurons in thalamus and deep cortical layers are most sensitive to changes in consciousness level, consistent across different anesthetic agents and sleep. Deep layer activity is sustained by interactions with CL. Consciousness also depends on deep layer neurons providing feedback to superficial layers (not to deep layers), suggesting long-range feedback is important, as well as intracolumnar signaling. To show causality, we stimulated CL in anesthetized macaques, and effectively restored arousal and wake-like neural processing. This effect was location- and frequency-specific. Our findings suggest layer-specific thalamocortical correlates of consciousness and explain how targeted deep brain stimulation can alleviate disorders of consciousness.

Relationship Between Near-Infrared Spectroscopy-Derived Cerebral Oxygenation and Delirium in Critically Ill Patients: A Systematic Review.

A common neurological complication of critical illness is delirium, defined as an acute change in level of consciousness, with impaired attention and disorganized thinking. Patients with delirium have increased risk of long-term cognitive dysfunction and mortality. The cause is unknown, which limits our ability to design therapeutic interventions. In patients undergoing surgery, low regional cerebral oxygenation (rSO2), as measured by near-infrared spectroscopy (NIRS), is associated with postoperative neurological dysfunction (eg delirium and long-term cognitive impairment). However, the relationship between NIRS-derived rSO2 and neurological outcomes in critically ill patients is unclear. The objective of this study was to assess the utilization of NIRS-derived rSO2 in critically ill patients outside the operating theater. We aimed to examine the relationship between rSO2 and neurological outcomes as well as to report rSO2 values in this population. The following databases were searched from inception to August 14, 2017: Ovid MedLine, Embase, Cochrane Library, and Web of Science. Of 1410 articles identified by the search strategy, 8 were ultimately selected for final review. Most (7 of 8) were published since 2014. These studies included a total of 213 patients primarily with shock or respiratory failure. A variety of devices were used to measure rSO2, including INVOS and FORESIGHT. The duration of recording varied from 5 minutes to 72 hours. Four of the 8 studies reported on neurological outcomes. In all 4 studies, rSO2 was lower in critically ill patients who were delirious compared to controls, but this was only statistically significant in 2 of the studies. The heterogeneity in devices and duration of recording precluded meta-analysis. There is limited literature describing rSO2 in critically ill patients outside the operating room. Although there may be a slight signal of an association between low rSO2 and delirium, more study is needed to explore this relationship.