Bench-to-bedside review: delirium in ICU patients - importance of sleep deprivation.

Delirium occurs frequently in critically ill patients and has been associated with both short-term and long-term consequences. Efforts to decrease delirium prevalence have been directed at identifying and modifying its risk factors. One potentially modifiable risk factor is sleep deprivation. Critically ill patients are known to experience poor sleep quality with severe sleep fragmentation and disruption of sleep architecture. Poor sleep while in the intensive care unit is one of the most common complaints of patients who survive critical illness. The relationship between delirium and sleep deprivation remains controversial. However, studies have demonstrated many similarities between the clinical and physiologic profiles of patients with delirium and sleep deprivation. This article aims to review the literature, the clinical and neurobiologic consequences of sleep deprivation, and the potential relationship between sleep deprivation and delirium in intensive care unit patients. Sleep deprivation may prove to be a modifiable risk factor for the development of delirium with important implications for the acute and long-term outcome of critically ill patients.

Identification of endogenous morphine and a mu3-like opiate alkaloid receptor in human brain tissue taken from a patient with intractable complex partial epilepsy.

BACKGROUND: We set out to detect whether morphine is present in tissue taken from a patient with intractable temporal lobe epilepsy and to characterize the presence and nature of mu opiate receptor subtypes in this tissue. CASE REPORT: In temporal lobe tissue, resected during anteromedial temporal lobectomy for intractable focal epilepsy, morphine was identified by quantitative radioimmunoassay (RIA) coupled to electrochemical detection via high-pressure liquid chromatography (HPLC). In addition, RNA isolated from the medial and lateral temporal lobe specimens was analyzed by conventional and real time reverse transcriptase-polymerase chain reaction (RT-PCR) for the expression of different human receptor gene transcripts. RIA revealed the presence of morphine at 3.4 nanograms per gram of tissue wet weight. Using RT-PCR and a primer specifically set for the mu3 (550 base pair fragment) and mu4 (880 base pair fragment) MOR splice variants, a mu4 splice variant was identified in both brain sections. CONCLUSIONS: This human brain tissue study of a subject with temporal lobe epilepsy documents the presence of endogenous morphine and of a mu4 splice variant. These findings may have implications for our understanding of the mechanism of temporal lobe epilepsy.

Clinical characteristics of psychogenic nonepileptic seizure status in the long-term monitoring unit.

Patients with psychogenic nonepileptic seizures (PNES) mimicking status epilepticus (PNES-status) are at risk of iatrogenic complications. Our aim was to assess whether the population of patients with PNES who develop PNES-status are distinguishable. Retrospectively, we identified patients with PNES-status and compared them with patients with PNES without status and with patients with electroclinical status epilepticus (SE). Of 49 patients with PNES, 9 had PNES-status (18.2%) and 40 had PNES only. Compared with patients with PNES, subjects with PNES-status had taken fewer than three antiepileptic medications (P=0.016), had more than one event per week (P=0.026), were more likely to be admitted emergently to the monitoring unit (P=0.007), had shorter long-term monitoring (LTM) stays (P=0.003), and tended to be diagnosed sooner after initial presentation (P=0.058). Use of fewer than three antiepileptic drugs and emergent admission were independent predictors of PNES-status classification on logistic regression. Of 154 patients with epilepsy, 8 had SE during LTM (5.2%), significantly fewer than the proportion with PNES-status relative to PNES (P=0.008); the only clinical variable distinguishing these two groups was a baseline lower seizure frequency among the patients with epileptic seizures (P=0.045). Our results suggest that patients with PNES-status have features that differentiate them from patients with PNES without status and, to a lesser extent, from patients with epileptic seizures.