Association of delirium screening on hospitalized adults and postacute care utilization: A retrospective cohort study.

BACKGROUND: Patients with delirium have increased hospital length of stay (LOS), morbidity and mortality. Impact of delirium on postacute care (PAC) utilization is not fully characterized. Impact of screening for delirium on general medicine patients is unknown. The objective of this study was to assess impact of screening for delirium on inpatient PAC utilization. METHODS: This was a single center, retrospective cohort study at an academic tertiary care center in Charleston, SC. Patients were selected from adults hospitalized from home and discharged alive between June 2014 and June 2018. The brief confusion assessment method (bCAM) screening was conducted and documented by nursing on admission and every shift thereafter. Outcome measure was the proportion of patients discharged to facility. RESULTS: Of 93,388 non-ICU adult admission between June 2014 and June 2018, 4.4% of those not screened for delirium were discharged to facility versus 15.0% in those screened and 41.4% in those screening positive. Multivariable regression analysis showed that patients screened for delirium were 2.3 times more likely to discharge to facility (95% CI (2.145, 2.429)) while those with a positive bCAM were 3.3 times more likely than those with a negative bCAM to discharge to facility (95% CI (2.949, 3.712)). CONCLUSIONS: After adjusting for demographics, medication orders and comorbidities there was an association between screening for delirium, positive delirium screen and discharge to facility. An appreciation of where and why patients are discharged is imperative to optimize both patient care and cost utilization.

A Woman in Her 60s With Fever and Altered Mental Status in a Psychiatric Hospital.

A woman in her 60s with a history of hepatitis C with cirrhosis and major depressive disorder with psychotic features was admitted to the inpatient psychiatric unit for suicidal ideation. She was initially treated with a combination of sertraline and paliperidone. The paliperidone was subsequently changed to risperidone and ultimately to olanzapine. She developed worsening mental status and was then treated for catatonia with benzodiazepines. Over 2 days, her mental status continued to worsen and she developed fever and tachycardia. She was transferred to the ICU and endotracheally intubated for inability to protect her airway. She was started on lactulose via orogastric tube but showed no improvement in her mental status after 2 days despite having two or three bowel movements per day.

Corticostriatal circuitry in regulating diseases characterized by intrusive thinking.

Intrusive thinking triggers clinical symptoms in many neuropsychiatric disorders. Using drug addiction as an exemplar disorder sustained in part by intrusive thinking, we explore studies demonstrating that impairments in corticostriatal circuitry strongly contribute to intrusive thinking. Neuroimaging studies have long implicated this projection in cue-induced craving to use drugs, and preclinical models show that marked changes are produced at corticostriatal synapses in the nucleus accumbens during a relapse episode. We delineate an accumbens microcircuit that mediates cue-induced drug seeking becoming an intrusive event. This microcircuit harbors many potential therapeutic targets. We focus on preclinical and clinical studies, showing that administering N-acetylcysteine restores uptake of synaptic glutamate by astroglial glutamate transporters and thereby inhibits intrusive thinking. We posit that because intrusive thinking is a shared endophenotype in many disorders, N-acetylcysteine has positive effects in clinical trials for a variety of neuropsychiatric disorders, including drug addiction, gambling, trichotillomania, and depression.

Los pensamientos invasores activan síntomas clínicos en muchos trastornos neuropsiquiátricos. Se recurre a la adicción a drogas, como modelo de trastorno que se sustenta en parte por pensamientos invasores, para explorar estudios que demuestran que los deterioros en los circuitos corticoestriatales contribuyen de manera importante a los pensamientos invasores. Los estudios de neuroimágenes han vinculado hace tiempo esta proyección con la apetencia imperiosa para emplear drogas inducidas por señales, y los modelos preclínicos muestran que durante un episodio de recaída los cambios importantes son producidos en las sinapsis corticoestriatales en el núcleo accumbens. Se describe un micro circuito del núcleo accumbens que media la búsqueda de droga inducida por una señal, la que llega a constituirse en un acontecimiento invasor. Este micro circuito contiene muchas dianas potencialmente terapéuticas. Este artículo se enfoca en estudios preclínicos y clínicos que muestran que la administración de N-acetilcisteína restaura la captación de glutamato sináptico por los transportadores de glutamato astroglial y de ese modo inhibe los pensamientos invasores. Se postula que debido a que los pensamientos invasores constituyen un endofenotipo que es compartido por muchos trastornos, la N-acetilcisteína tiene efectos positivos en ensayos clínicos para una variedad de trastornos neuropsiquiátricos incluyendo la adicción a drogas, el juego patológico, la tricotilomanía y la depresión.

Les pensées intrusives déclenchent des symptômes cliniques dans de nombreux troubles neuropsychiatriques. En utilisant la toxicomanie comme modèle de trouble maintenu en partie par des pensées intrusives, nous analysons des études démontrant que des troubles des circuits corticaux-striataux contribuent fortement aux pensées intrusives. Des études de neuro-imagerie ont longtemps impliqué cette projection dans les envies irrésistibles de drogue induites par un signal. Des modèles précliniques montrent que des modifications notables sont générées au niveau des synapses cortico-striatales dans les noyaux accumbens pendant un épisode de rechute. Nous décrivons un microcircuit des noyaux accumbens, qui joue un rôle de médiateur dans la recherche de la drogue provoquée par un signal, devenant alors un événement intrusif. Ce microcircuit héberge de nombreuses cibles thérapeutiques potentielles. Nous analysons des études précliniques et cliniques montrant que la N-acétyIcystéine rétablit la capture du glutamate synaptique par des transporteurs du glutamate astroglial, inhibant ainsi les pensées intrusives. Selon ces études cliniques, les pensées intrusives étant un endophénotype partagé dans de nombreux troubles, la N-acétylcystéine a des effets positifs pour de multiples troubles neuropsychiatriques, dont la toxicomanie, l'addiction aux jeux, la trichotillomanie et la dépression.

The effect of N-acetylcysteine in the nucleus accumbens on neurotransmission and relapse to cocaine.

BACKGROUND: Relapse to cocaine seeking has been linked with low glutamate in the nucleus accumbens core (NAcore) causing potentiation of synaptic glutamate transmission from prefrontal cortex (PFC) afferents. Systemic N-acetylcysteine (NAC) has been shown to restore glutamate homeostasis, reduce relapse to cocaine seeking, and depotentiate PFC-NAcore synapses. Here, we examine the effects of NAC applied directly to the NAcore on relapse and neurotransmission in PFC-NAcore synapses, as well as the involvement of the metabotropic glutamate receptors 2/3 (mGluR2/3) and 5 (mGluR5). METHODS: Rats were trained to self-administer cocaine for 2 weeks and following extinction received either intra-accumbens NAC or systemic NAC 30 or 120 minutes, respectively, before inducing reinstatement with a conditioned cue or a combined cue and cocaine injection. We also recorded postsynaptic currents using in vitro whole cell recordings in acute slices and measured cystine and glutamate uptake in primary glial cultures. RESULTS: NAC microinjection into the NAcore inhibited the reinstatement of cocaine seeking. In slices, a low concentration of NAC reduced the amplitude of evoked glutamatergic synaptic currents in the NAcore in an mGluR2/3-dependent manner, while high doses of NAC increased amplitude in an mGluR5-dependent manner. Both effects depended on NAC uptake through cysteine transporters and activity of the cysteine/glutamate exchanger. Finally, we showed that by blocking mGluR5 the inhibition of cocaine seeking by NAC was potentiated. CONCLUSIONS: The effect of NAC on relapse to cocaine seeking depends on the balance between stimulating mGluR2/3 and mGluR5 in the NAcore, and the efficacy of NAC can be improved by simultaneously inhibiting mGluR5.