A population heath study from the Regenstrief Institute and Indiana University Center for Aging Research has determined that haloperidol, the drug most commonly used to treat delirium in hospital medical and surgical intensive care units (ICUs), did not benefit elective thoracic surgery ICU patients when given prophylactically, with the possible exception of those who have had surgery to remove their oesophagus. The study results indicate the need for a personalized approach to delirium in the ICU.
The work is the first to evaluate the use of the antipsychotic drug haloperidol to reduce post-operative delirium in elderly patients undergoing elective non-cardiac thoracic surgery.
Researchers found no differences in delirium incidence or severity between haloperidol and placebo in patients who had undergone elective non-cardiac thoracic surgery except in the small number of study participants who were admitted to the ICU after removal of the oesophagus, a procedure known as oesophagectomy. Removal of this organ is a treatment for oesophageal cancer.
“Our work suggests that just as you can’t lump all cancer patients together for treatment, you can’t put all delirium patients in the same bucket,” said Regenstrief Institute investigator Babar A, Khan, M.D., M.S., who led the new study. “We need a personalized approach to delirium, focusing on people at higher risk of developing this complication.”
He notes that while elective surgery patients typically are healthier than other ICU patients, they are very much at risk of delirium. He counsels those considering elective surgery to consult with their primary care clinicians and their surgeon to weigh the significant risks of delirium with the benefits of the proposed procedure.
“Because we now know that haloperidol, the most commonly used drug to treat ICU delirium doesn’t, with possibly few exceptions, work, we need to focus on non-pharmacological therapies and vigilantly curtail administration of drugs that are harmful to the brain, especially the aging brain,” said Dr. Khan.
Approximately five million Americans are admitted to a surgical or medical ICU annually. Delirium, a sudden and serious change in brain function causing confusion, occurs in as many as three quarters of those treated in the ICU. Causes include sepsis, metabolic problems such as liver and kidney disease as well as drugs that injure the brain.
Individuals who experience delirium are more likely to have longer hospital stays and hospital-associated complications. They also have a greater likelihood of dying in the hospital for up to a year after their hospital stay than ICU patients who did not experience delirium. They are also more likely to lose physical functioning and experience cognitive impairment.

Regenstrief Institute
www.regenstrief.org/article/icu-acquired-delirium-requires-personalized-approach/

Patients who survive acute respiratory distress syndrome (ARDS) often leave a hospital intensive care unit with debilitating mental, physical, or cognitive problems that may limit their quality of life.
Now, a new study of 645 ARDS survivors by researchers at Intermountain Medical Center, Johns Hopkins University, and the University of Utah, has identified subgroups of ARDS survivors who suffer what’s been called post-intensive care syndrome, a collection of symptoms that can linger for years.
ARDS is a potentially life-threatening injury to the lungs that occurs most often in an intensive care unit among critically-ill patients with pneumonia or other infections, although it can have other causes.
For many ARDS patients, the primary symptom is shortness of breath so severe they require lung life-support therapies in order to breathe. ARDS can kill, and older patients are especially vulnerable.
Many ARDS survivors leave the hospital with an array of challenges that form post-intensive care syndrome. The survivors may live with long-term effects, including permanent lung damage and different degrees of physical, cognitive, and mental health problems.
During the last quarter-century, the symptoms of post-intensive care syndrome have been increasingly recognized and understood. Critical care specialists say between half and two-thirds of ARDS survivors struggle with it after they’re released from the hospital.
To that end, researchers at Intermountain Medical Center and Johns Hopkins University have been seeking common threads among survivors, focusing on combinations of impairments, including physical health, mental health, and brain function. The study builds on previous research by the team.
Researchers say the threads within survivor subgroups may help them better identify factors that increase risk, and could potentially lead to tailored treatments to bolster patients’ recovery.
In the study of ARDS survivors six months out of intensive care, the researchers found four different patient subgroups:

• those with mildly impaired physical and mental health (22% of patients)
• those with moderately impaired physical and mental health (39%)
• those with severely impaired physical health and moderately impaired mental health (15%)
• those with severe physical and mental health impairments (24%).

According to the research, physical and psychological injuries tend to go hand in hand. Cognitive impairment is independent of those two, however.
The study found people who have worse physical problems have worse symptoms of anxiety, depression, or post-traumatic stress disorder. The one exception was a small but distinct group (15% of all survivors) who had severe physical limitations, but only moderately severe mental health problems.
Researchers speculate that could mean those individuals already had some chronic physical challenges before developing ARDS and were more accustomed to living with physical limitations.
“It’s also possible that group might have more resilience, so they’re better able to respond to the new physical disability, which is consistent with other recent studies suggesting that improving resilience may help ARDS survivors,” Dr. Brown said.
The study noted that six months after leaving intensive care, about half of the subjects in the study still weren’t living independently, even though 91 percent of them had done so prior to contracting ARDS. Instead, they lived in nursing homes or with relatives.

Intermountain Healthcarehttps://tinyurl.com/ycfcnl8s

A team of Massachusetts General Hospital (MGH) researchers has developed a potential alternative to gadolinium-based contrast agents (GBCAs) for magnetic resonance imaging (MRI). In their report, the team describes experiments showing in a primate model that the manganese-based agent Mn-PyC3A produced contrast enhancement of blood vessels equivalent to that of gadolinium-based agents, which carry significant health risks for some patients.
“About 40 percent of MRI procedures use a contrast agent to produce a signal that can detect cancers, diagnose aneurysms or arterial narrowing, or identify the area of a heart damaged by a heart attack,” says Peter Caravan, PhD, of the Martinos Center for Biomedical Imaging and co-director of the Institute for Innovation in Imaging at MGH, corresponding author of the Radiology paper. “All current FDA-approved MR contrast agents contain gadolinium, which in 2006 was associated with a devastating condition called nephrogenic systemic fibrosis in patients with impaired kidney function. We estimate that around 2 million contrast-enhanced scans are not performed in the U.S. every year because of the inability to use GBCAs in patients with poor renal function.”
More recent reports finding gadolinium deposits in the brains and other organs of patients have added to concerns about the safety of GBCAs, leading the U.S. FDA to reiterate the need for caution and restraint in the use of the agents and the European Medical Association to remove three of seven previously approved agents from the market and restrict the use of others earlier this year.
Caravan and his colleague Eric Gale, PhD, of the Martinos Center developed their manganese-based agent Mn-PyC3A based on two properties of the element: its ability to produce an MR signal comparable to that of GBCAs and the fact that that – in contrast to gadolinium, which is not naturally found in the human body – manganese is an essential element, and intake of small amounts is required for vital bodily functions. The body has natural mechanisms to process and excrete excess manganese, but any gadolinium that is released from GBCAs is likely to be retained in the body indefinitely.
Previous studies conducted by the team in mouse models showed that Mn-PyC3A was very resistant to the release of manganese ions; that it provided good enhancement of blood vessels, liver and kidneys; that more than 99 percent was excreted from the body within 24 hours, and that it was eliminated by both the liver and the kidneys, reducing the likelihood of prolonged retention in subjects with poor kidney function.  For the current study, the researchers compared the use of Mn-PyC3A to a commonly used GBCA in a baboon model.
Each animal underwent two MR imaging sessions, one with Mn-PyC3A and one with the GBCA. The scans were performed under identical conditions – the scanner used, the dosages and imaging protocols were the same as would be used for human patients – and the enhanced images of major arteries, kidneys, livers and specific muscles produced by both agents were comparable.  As in the mouse study, Mn-PyC3A was quickly excreted though both kidney and liver clearance, and there was no evidence of the release of free manganese.
Gale explains, “While we did not test it here, we believe that having an alternative route of elimination through the liver will provide an efficient mechanism for elimination of Mn-PyC3A in patients with kidney disease and prevent any retention of the contrast agent in the body.  Our next steps are to manufacture Mn-PyC3A on a larger scale and conduct additional preclinical safety studies before we can begin testing in human patients.”

Massachusetts General Hospitalhttps://tinyurl.com/y8oq4r8q

Cardiovascular disease pervades Appalachia, yet many Appalachians live far from any heart and vascular specialist. Follow-up doctor’s visits in the weeks after cardiovascular surgery can involve hours-long drives down narrow, winding roads.
A recent study led by Albeir Mousa, a professor in the West Virginia University School of Medicine, suggests telemedicine may improve these patients’ satisfaction with their postoperative care as well as their quality of life.
With telemedicine, a healthcare provider can use a computer, tablet or other electronic device to remotely evaluate their patients’ symptoms, diagnose illnesses or injuries, and prescribe treatments. They can also field their patients’ questions.
The 30 participants in Mousa’s study were recovering from vascular surgery. In each case, the surgeon made an incision in the patient’s groin to access the arteries that needed rebuilding or rerouting. Whether the incisions healed without complications was the study’s focus.
Sixteen patients received tablets with Enform—a telemedicine app developed by TeleMed 2020 Inc.—that facilitated communication with nurses managing their care. As part of an in-home monitoring kit, patients also received thermometers, blood pressure cuffs, scales and devices to measure blood oxygen saturation levels.
Each day, patients who had been discharged from the hospital weighed themselves, took their temperature, measured their pulse and blood pressure, and determined their blood oxygen levels using the Enform app. They completed a wellness and symptom tracking quiz that included questions like “How is your pain today?” Each week they answered satisfaction and emotional wellness questions as well. These data, along with photos of the surgical incision sites that patients captured with the app—were made available to the patients’ care team.
Care managers, in turn, logged into the telemedicine platform daily to review the information patients had submitted from their homes. Cares managers received notifications of abnormalities, such as blood pressure spikes and fevers. Based on the information they gathered, the care managers intervened, answered patients’ questions about symptoms or wound care, called in prescriptions, scheduled appointments with physicians, and modified care plans based on consultations with the medical director.
Meanwhile, the other 14 participants had standard-of-care treatment. They received no monitoring equipment, tablet or telemedicine app.
After 30 days, the researchers made a number of comparisons between the two groups. For example, were wound infections more common in one group than the other? Did one group require more hospital readmissions? How did members of each group rate their own well-being? Were they happy with the postoperative care they received?
Hospital-readmission and wound-infection rates did not differ significantly between groups. The researchers attribute this fact to the study’s small sample size. But patients in the telemedicine group scored better on measures of their physical function, mental health and role limitations due to physical health problems. In addition, the vast majority of patients who used the app found it intuitive to use. Using a five-point scale to measure ease of use, 91 percent of patients gave it a score of 4 or 5. A similar percentage of patients said the app enriched the quality of care they received.
Likewise, the telemedicine patients’ scores on quality-of-life assessments surged more dramatically between the study’s beginning and end.
Patients assigned to the telemedicine group lived an average of 60 miles from their vascular care center. Almost a third of them lived more than 77 miles away and had to drive for two to three hours to get there.
“Telemedicine would save a lot of headache in Appalachia—in areas where people don’t even have the money to get in the car to get to the hospital,” said Mousa, who teaches surgery at the WVU Health Sciences Charleston Campus.
He envisions that, one day, patients will be able to download a cell phone app that provides these telemedicine services. That way, they won’t even need a tablet. “Each household has at least one cell phone, and most likely, it’s a smartphone.”
“You’re getting the same service,” he said, “but with a very minor hassle for the patient and the physician.”

West Virginia University
medicine.hsc.wvu.edu/News/Story?headline=wvu-researchers-find-telemedicine-may-increase-patients-satisfaction-with-their-medical-care