Archive for the ‘Annals of Internal Medicine’ Category

Hospital-induced delirium: part one: the basics

Friday, July 13th, 2012

When they return from surgery, will some be delirious?

About two months ago I visited a friend in the hospital. He's a little over 80 years old, has several significant chronic medical problems and had recently undergone surgery. When I arrived in his room, he was in bed, didn't recognize me and then sat up and started rowing. Obviously he was delirious and hallucinating.

I've seen him at home since and he's back to baseline, but the topic of post-surgery delirium surfaced in the July 4, 2012 issue of JAMA, so I started reading on the subject

I found an article in a 2004 issue of the American Journal of Psychiatry (AJP) that was a good start, but was clearly aimed at medical folk, especially those who would be prescribing medication for the mostly severely affected patients with delirium. The AJP piece said the first step is determining the cause...if possible. It mentioned that the word itself comes from the Latin word delirare, loosely translated as "to be out of one's furrow." My online dictionary defines delirium as an acute (as opposed to chronic) disturbed state of mind that occurs in fever, intoxication, and other disorders and is characterized by restlessness, illusions, and incoherence of thought and speech.

The most recent mental health Diagnostic and Statistical Manual of Mental Disorders, DSM-IV-TR, a much-used but somewhat controversial tome (I'll write about the DSM in a later post), says delirium is a syndrome (a collection of symptoms and physical signs) of many different causes and that its major features are confusion and loss of short-term memory. It mentions one classic sign, not seen in all cases by any means, is carpologia, a term I'd never heard before, but a behavior I've seen many times; it means picking at the bed sheets in a purposeless, repetitive fashion. The patient may be agitated, have delusions and hallucinations, and may try to remove their IV lines or climb out of bed.

On the other hand, some people have a lethargic, hypoactive form of the syndrome; those may be even tougher to diagnose.

A Mayo Clinic website mentions one hallmark of delirium is a sudden or relatively sudden onset with symptoms that tend to wax and wane. Input from family members as to the patient's pre-illness/surgery mental status may be very helpful in sorting out those who had pre-existing dementia from those who didn't, as the two conditions not infrequently co-exist.

too much alcohol can lead to delirium

It's not just surgical patients, of course; when I was in practice the term internists used was "ICU-itis, and medical patients, especially the elderly who were in Intensive Care for a prolonged period, were the ones we had to deal with most commonly. So a better term might be hospital-induced delirium. But some delirious patients have ingested substances causing the condition (PCP would be one example and alcohol withdrawal another), have heavy metal poisoning, medication-caused delirium, infections involving the central nervous system or metabolic disorders.

It's common, but much more so in older patients and a 2010 meta-analysis of forty-two high-quality studies concluded that delirium in this group is associated with poor outcomes, regardless of age, gender, preceding dementia, and other illnesses.

I'll come back to this frequent and often ominous issue in my next post. As our population ages, we'll likely see more of this condition. Planning in advance for hospital stays may help prevent some episodes of delirium.



More on salt, actually salts

Saturday, June 30th, 2012

What should we make with our CSA-supplied spinach today?

We're in the prime of our CSA delivery season; fresh vegetables started three weeks ago and fruits this week. Many of our meals consist of spinach, lettuce, beets, rhubarb, apricots & cherries, with milk and/or cheese or yogurt. We rarely, if ever, shop for any "prepared foods," always check labels for sodium content, and only eat out, other than our weekly Thai food splurge, for birthdays and other occasions. I'm firmly convinced that less sodium (often termed "table salt," but most typically found in processed foods and restaurant dishes) is better for us.

So when I started reading an article in the ACP Journal Club section of the January 2012 issues of the Annals of Internal Medicine that was titled "Review: Interventions to reduce dietary salt do not reduce mortality or morbidity," I was skeptical. The original article, published in England, was a meta-analysis, a statistical look at a group of research studies. In this case seven randomized controlled trials were lumped together, and according to the Journal Club, the conclusion was as in the article's title.

But the US and Canadian reviewers disagreed. In people with normal, borderline, or elevated blood pressure, 6 of the 7 studies showed variable results and the pooled data did not reveal statistically significant decreases in death rates or medical complications. I went to the original article and the authors actually say, "Despite collating more event data than previous systemic reviews...there is still insufficient power to exclude clinically important effects of reduced dietary salt..."

That translates, to me, as "we don't know yet what happens when millions of people lower their salt intake." The reviewers, being ultra cautious, say, "...we are unaware of compelling evidence showing that consuming less sodium in the general population is harmful."

A free-lance science writer wrote an article in Scientific American in 2011 with the title, "It's Time to End the War on Salt." She argues that the data linking increased salt intake and various diseases is not solid.

Should I believe those statistics?

Yet there are lots of studies showing a strong link between salt intake and blood pressure and others claiming a similar correlation between dietary sodium and cardiovascular disease.

One country that decided to act on these supposed connections was Finland. In the late 1970s a national-level campaign was started to include mass media education, monitoring of urinary sodium excretion and food-industry cooperation using salt substitutes. The average sodium intake was cut by nearly 30% and over the next ~24 years stoke and heart attack deaths went down by 60%. Was this cause and effect? I'm not sure, since other factors may have played a role and the initial average salt intake was quite high.

But a December, 2011, New York Times article, with the striking title, "Sodium-Saturated Diet Is a Threat for All" led me to find another kind of salt that plays a role. I found the July, 2011, Archives of Internal Medicine research report, "Sodium and Potassium Intake and Mortality Among US Adults" and realized I was on the right track with our diet.

It's not just too much sodium chloride, the kind of salt some use at their dining room tables, manufacturers add to processed foods and restaurants to their recipes to add flavor and preserve food. It's also how much potassium you eat (in fruits, juices, vegetables, fish, nuts and meat), that makes a difference. In this case, within reason and assuming you have normal kidney function, more is better.

I'm going downstairs and eat some fruit and perhaps a baked potato and yogurt, all high in potassium and relatively low in calories.

Tick-borne Disease part four: the chronic Lyme Disease controversy

Monday, April 30th, 2012

Sometimes you need an expert panel to resolve a controversy

A March 27, 2012, Wall Street Journal article, "This Season's Ticking Bomb,"predicted that the unusually warm weather most of the country has been experiencing meant we would also see many more cases of tick-borne diseases, If you click on the link, be sure to look at the section called "View Interactive" to get to a series of suggestions on reducing your family's risk of tick bites.

The article itself talked mainly about Lyme disease. There is an International Lyme and Associated Diseases Society (ILADS), but much of their Lyme disease website information was from 2006.  They are on one side of a major medical controversy, how to care for patients who have had Lyme disease and continue to have problems, especially with short-term memory, fatigue, or musculoskeletal issues, well after they have been appropriately treated with short-term antibiotics.

Two articles were published on this subject in 2007-8: the first one, "Chronic Lyme Disease: an appraisal"  is available online; the other, "A Critical Appraisal of Chronic Lyme Disease," appeared in the New England Journal of Medicine.

The real question is whether the bacteria involved, Borrelia burgdorferi, remains in the body of a patient after relatively short-term antibiotic therapy and if a considerably longer course of drug treatment is warranted. The ILADS says, "Yes" to both questions and refers back to a Harvard & Tufts study published in the Annals of Internal Medicine in 1994.

The most recent CDC online information states that 10 to 20% of those who receive standard therapy for Lyme disease will have some lingering symptoms. However they term this "Post-treatment Lyme disease Syndrome." I found that European cases of Lyme and similar diseases are usually caused by our Borrelia borgdorferi's cousins; data from that literature may not be relevant here.

In November 2006, the Attorney General of Connecticut (CAG) pushed the Infectious Disease Society of America (IDSA) into a detailed review of their Lyme Disease guidelines by starting an investigation to decide if they had violated existing antitrust laws. By April 2008, the IDSA and the CAG agreed to end the probe by convening a review panel, with members from Duke, the NIH, Dartmouth, the U.S. Navy, Baylor, Tulane and other centers, to decide if the original guidelines had been based on sound medical/scientific evidence and if they needed changes. An MD, PhD medical ethicist screened panel members for any conflict of interest. A public hearing was held to include other viewpoints. The Final Report of the Review Panel was published in April, 2010.

Some will think the decision ties their doc's hands.

It basically upheld the 2006 IDSA guidelines, but added 1). In some cases (non-pregnant adults or kids 8 or older who've had a tick of the Lyme-carrying species attached for 36+ hours in an area with high infectivity rate of ticks with B. burgdorferi), a single dose of doxycycline (if they have no allergy to this drug) may be given  if the tick was removed within 72 hours; 2). Antibiotics are appropriate for adults and children 8 or older with early, uncomplicated Lyme disease; 3).  "Reports purporting to show the persistence of viable B. burgdorferi organisms after treatment with recommended regimens for Lyme disease have not been conclusive or corroborated by controlled studies." and 4). "The risk/benefit ratio from prolonged antibiotic therapy strongly discourages prolonged antibiotic courses for Lyme disease.

And at the end of the report, they mentioned a disease I'd never heard of; I'll do some more reading and write about it later.