David Garcia Nuñez

Attempted Suicide by Self-Immolation is a Powerful Predictive Variable for Survival of Burn Injuries

Up to 9% of all burn victims in western countries are reported to have been caused by self-immolation with suicidal intent and usually involve extensive injuries. The authors sought to identify differences between suicide burn victims as opposed to those who sustained their injuries accidentally with regard to injury severity and mortality and determine the possible impact of suicide as a prognostic variable in the context of a scoring system such as the Abbreviated Burns Severity Index (ABSI). The data of all burns patients treated at the Specialist Burns Intensive Care Unit, University Hospital Zürich, between 1968 and 2008 were analyzed retrospectively. Of the 2813 patients included in the study, 191 were identified as attempted suicides, most commonly involving the use of accelerants. Thirty percent of all suicide victims had preexisting psychiatric diagnoses. Suicide victims presented with significantly more extensive burns (53.7%, ±0.98 SEM vs 21.4 %, ±0.36 SEM, P < .0001), had higher total ABSI scores (8.4, ±0.23 SEM vs 6.6, ±0.05 SEM, P < .0001), and had higher mortality rates (42.9% [83/191] vs 16.3% [426/2622]) than accident victims. Furthermore, logistic regression revealed suicide to be a significant predictor of mortality as inhalation injury (odds ratio 2.2, 95% confidence interval 1.4–3.5, P < .0003 and odds ratio 2.4, 95% confidence interval 1.4–4.0, P < .0009, respectively). The odds of dying from an attempted suicide are twice as high compared with those of accident patients in the same ABSI category, making suicide a powerful predictor of mortality. The authors therefore suggest including it as a fixed variable in scoring systems for estimating a patient’s mortality after burn injuries such as the widely used ABSI.

Subsyndromal delirium in the intensive care setting: Phenomenological characteristics and discrimination of subsyndromal delirium versus no and full-syndromal delirium

OBJECTIVE Similar to delirium, its subsyndromal form has been recognized as the cause of diverse adverse outcomes. Nonetheless, the nature of this subsyndromal delirium remains vastly understudied. Therefore, in the following, we evaluate the phenomenological characteristics of this syndrome versus no and full-syndromal delirium. METHOD In this prospective cohort study, we evaluated the Delirium Rating Scale-Revised, 1998 (DRS-R-98) versus the Diagnostic and Statistical Manual of Mental Disorders, 4th ed., Text Revision (DSM-IV-TR) diagnostic criteria and examined the diagnosis of delirium with respect to phenomenological distinctions in the intensive care setting. RESULTS Out of 289 patients, 36 with subsyndromal delirium versus 86 with full-syndromal and 167 without delirium were identified. Agreement with respect to the DSM-IV-TR diagnosis of delirium was perfect. The most common subtype in those with subsyndromal delirium was hypoactive, in contrast to mixed subtype in those with full-syndromal delirium versus no motor alterations in those without delirium. By presence and severity of delirium symptoms, subsyndromal delirium was intermediate. The ability of the DRS-R-98 items to discriminate between either form of delirium was substantial. Between subsyndromal and no delirium, the cognitive domain and sleep-wake cycle were more impaired and allowed a distinction with no delirium. Further, between full- and subsyndromal delirium, the prevalence and severity of individual DRS-R-98 items were greater. Although the differences between these two forms of delirium was substantial, the items were not very specific, indicating that the phenomenology of subsyndromal delirium is closer to full-syndromal delirium. SIGNIFICANCE OF RESULTS Phenomenologically, subsyndromal delirium was found to be distinct from and intermediate between no delirium and full-syndromal delirium. Moreover, the greater proximity to full-syndromal delirium indicated that subsyndromal delirium represents an identifiable subform of full-syndromal delirium.

Delirium in the intensive care setting and the Richmond Agitation and Sedation Scale (RASS): Drowsiness increases the risk and is subthreshold for delirium

INTRODUCTION Sedation is a core concept in the intensive care setting, however, the impact of sedation on delirium has not yet been studied to date. METHODS In this prospective cohort study, 225 patients with Richmond Agitation and Sedation (RASS) scores of -1 - drowsiness and 0 - alert- and calmness were assessed with the Delirium Rating Scale-Revised 1998 (DRS-R-98) and DSM-IV-TR-determined diagnosis of delirium assessing drowsiness versus alertness. RESULTS By itself, drowsiness increased the odds for developing delirium eightfold (OR 7.88 p<0.001) and rates of delirium were 68.2 and 21.4%, respectively. Further, in the drowsy patient, delirium was more severe. In the presence of drowsiness, delirium was characterized by sleep-wake cycle disturbances and language abnormalities. These two features, in addition to psychomotor retardation, allowed the correct classification of delirium at RASS-1. The same features, in addition to thought abnormalities and the impairment in the cognitive domain, orientation, attention, short- and long-term memory representing the core domains of delirium, or the temporal onset were very sensitive towards delirium, however lacked specificity. Conversely, delusions, perceptual abnormalities and lability of affect representing the non-core domain were very specific for delirium in the drowsy, however, not very sensitive. In the absence of delirium, drowsiness caused attentional impairment and language abnormalities. CONCLUSION Drowsiness increased the odds for developing delirium eightfold and caused more severe delirium, which was characterized by sleep-wake cycle and language abnormalities. Further, drowsiness by itself caused attentional impairment and language abnormalities, thus, with its disturbance in consciousness was subthreshold for delirium.

Brief assessment of delirium subtypes: Psychometric evaluation of the Delirium Motor Subtype Scale (DMSS)-4 in the intensive care setting.

OBJECTIVE The management of and prognosis for delirium are affected by its subtype: hypoactive, hyperactive, mixed, and none. The DMSS-4, an abbreviated version of the Delirium Motor Symptom Scale, is a brief instrument for the assessment of delirium subtypes. However, it has not yet been evaluated in an intensive care setting. METHOD We performed a prospective/descriptive cohort study in order to determine the internal consistency, reliability, and validity of the relevant items of the DMSS-4 versus the Delirium Rating Scale-Revised-98 (DRS-R-98) and the original DMSS in a surgical intensive care setting. RESULTS A total of 289 elderly, predominantly male patients were screened for delirium, and 122 were included in our sample. The internal consistency of the DMSS-4 items was excellent (Cronbachs α = 0.92), and between the DMSS-4 and DRS-R-98 the overall concurrent validity was substantial (Cramers V = 0.67). Within individual motor subtypes, concurrent validity remained at least substantial (Cohens κ = 0.65-0.81) and sensitivity high (69.8 to 82.2%), in contrast to those of the no-motor subtype, with less validity and sensitivity (κ = 0.28, 22%). Similarly, total concurrent validity between the DMSS-4 and the original DMSS reached perfection (Cramers V = 0.83), as did agreement between the subtypes (κ = 0.83-0.92), while sensitivity remained high (88.2-100%). Only in those with delirium with no-motor subtype was agreement moderate (κ = 0.56) and sensitivity lower (67%). Specificity was high across all subtypes (91.2-99.1%). The DMSS-4 yielded very sensitive ratings, particularly for hypoactive and hyperactive motor symptoms, and interrater agreement was excellent (Fleisss κ = 0.83). SIGNIFICANCE OF RESULTS We found the DMSS-4 to be a most reliable and valid brief assessment of delirium in characterizing the subtypes of delirium in an intensive care setting, with increased sensitivity to hypoactive and hyperactive motor alterations.

Pipamperone and delirium: a preliminary evaluation of its effectiveness in the management of delirium and its subtypes

INTRODUCTION Delirium has been recognised as an underdiagnosed and undermanaged syndrome with substantial prevalence rates and potentially deleterious consequences in the medically ill population. Despite its frequent administration in the management of delirium, the effectiveness of pipamperone has not yet been evaluated. METHODS In this retrospective, descriptive cohort study of 192 patients, pipamperone as monotherapy and as an adjunct to haloperidol, haloperidol alone, or atypical antipsychotics were compared with respect to their effectiveness in the management of delirium and its subtypes over the course of 20 days. RESULTS In this elderly patient population, pipamperone alone and as an adjunct to haloperidol was as effective as haloperidol or atypical antipsychotics in the management of delirium. Management with low-dose pipamperone monotherapy achieved delirium resolution in 70% of patients, over a mean of 6.4 (2-20) days. With pipamperone as an adjunct to haloperidol, delirium resolved in 59% of patients, over a mean of 7.4 (2-20) days. When haloperidol or atypical antipsychotics (risperidone, olanzapine or quetiapine) were used, the delirium resolution rates were 72 and 67%, over a mean of 5.2 (2-11) and 6.4 (2-20) days, respectively. The addition of pipamperone to haloperidol decreased the requirement for lorazepam. Pipamperone proved to be equally effective in all delirium subtypes - hypoactive, hyperactive and mixed. Nonetheless, potential bias could not be excluded in this observational design. CONCLUSION From these initial results, low-dose pipamperone was as effective as haloperidol or atypical antipsychotics in the management of delirium and its subtypes, and was benzodiazepine-sparing when used as an adjunct to haloperidol.

Screening for delirium with the Intensive Care Delirium Screening Checklist (ICDSC): a re-evaluation of the threshold for delirium

BACKGROUND With its high incidence and subsequent adverse consequences in the intensive care setting, several instruments have been developed to screen for and detect delirium. One of the more commonly used is the Intensive Care Delirium Screening Checklist (ICDSC); however, the optimal cut-off score indicating delirium has been debated. METHODS In this prospective cohort study, the ICDSC threshold for delirium set at ≥3, ≥4, or ≥5 was compared with the DSM-IV-TR-determined diagnosis of delirium (used as standard), and with the Confusion Assessment Method for the ICU (CAM-ICU), with respect to their concurrent validity. RESULTS In total, 289 patients were assessed, including 122 with delirium. The cut-off score of ≥4 had several shortcomings: although 90% of patients with delirium were correctly classified, 23% remained undetected. The agreement with the DSM-IV-TR diagnosis of delirium was only moderate (Cohens κ 0.59) and the sensitivity was only 62%. In contrast, when the cut-off was ≥3, 83% of patients with delirium were correctly classified and only 14.5% remained undetected. The agreement with DSM-IV-TR was substantial (Cohens κ 0.68) and the sensitivity increased to 83%. The benefit of setting the cut-off at ≥5 was not convincing: although 90% of patients with delirium were correctly classified, 30% remained undetected. The concurrent validity was only moderate (Cohens κ 0.44), and the sensitivity reached only 44%. Changing the ICDSC cut-off score did not strengthen the moderate agreement with the CAM-ICU (Cohens κ 0.45-0.56). CONCLUSION In clinical routine, decreasing the ICDSC threshold for delirium to ≥3 increased the accuracy in detecting delirium at the cost of over-identification and is therefore recommended as the optimal threshold. Increasing the cut-off score to ≥5 decreased the concurrent validity and sensitivity; in addition, the under-detection of delirium was substantial.

Gender Minority Stress and Depressive Symptoms in Transitioned Swiss Transpersons

Compared to the general population, transpersons are exposed to higher levels of discrimination and violence. The stigmatization of transpersons can lead to physical and psychological problems. In particular, transindividuals exhibit a higher prevalence of depression compared to the cispopulation. The gender minority stress model (GMSM) provides a comprehensive theoretical basis to interpret these biopsychosocial interactions. Using the GMSM, this study aimed to identify associations between experience of stigmatization and the mental health of transitioned transpersons using correlational analyses and multiple regression models. In total, 143 transpersons were recruited. Multivariate analyses identified three variables (i.e., unemployment, nonaffirmation of gender identity, and internalized transphobia) to explain variance of depressive symptoms. Furthermore, a mediation of the proximal factors between distal factors and depressive symptoms was found. However, the moderating effect of resilience factors was not demonstrated. The results confirmed the importance of distal and proximal minority stressors for the mental health of transpersons. At the same time, the protective influence of resilience factors seemed to be surprisingly minor. In the treatment of transpersons, practitioners should not only focus on somatic aspects, but also consider the persons previous experiences of stigmatization.

Quality of Life in Transitioned Trans Persons: A Retrospective Cross-Sectional Cohort Study

Background Medical gender-affirming interventions (GAI) are important in the transition process of many trans persons. The aim of this study was to examine the associations between GAI and quality of life (QoL) of transitioned trans individuals. Methods 143 trans persons were recruited from a multicenter outpatient Swiss population as well as a web-based survey. The QoL was assessed using the Short Form (36) Health Survey questionnaire (SF-36). Depressive symptoms were examined using the Short Form of the Center for Epidemiologic Studies-Depression Scale (ADS-K). Multiple interferential analyses and a regression analysis were performed. Results Both transfeminine and transmasculine individuals reported a lower QoL compared to the general population. Within the trans group, nonbinary individuals showed the lowest QoL scores and significantly more depressive symptoms. A detailed analysis identified sociodemographic and transition-specific influencing factors. Conclusions Medical GAI are associated with better mental wellbeing but even after successful medical transition, trans people remain a population at risk for low QoL and mental health, and the nonbinary group shows the greatest vulnerability.

Validation and Psychometric Properties of the German Version of the Delirium Motor Subtype Scale (DMSS)

Objective: Delirium has been characterized into its subtypes—hypoactive, hyperactive, mixed, or no motor subtype—along with the use of the Delirium Motor Symptom Scale (DMSS). The German version of this scale (DMSS-G), however, has not yet been validated. Method: We determined internal consistency, reliability, and validity of the DMSS-G in the surgical intensive care unit, using DSM-IV-TR criteria and the Delirium Rating Scale–Revised–98. Results: In total, 289 patients were included, and out of these, 122 were delirious. The DMSS-G showed excellent internal consistency (Cronbach’s α = 0.92) and interrater reliability (Fleiss κ = 0.83). Additionally, the overall concurrent validity was substantial (Cramer’s V = 0.69); within subtypes, hyperactive, hypoactive, or mixed, the concurrent validity remained at least substantial (Cohen’s κ = 0.73-0.82) and the sensitivity ranged from 60% to 97%. In contrast, in those with no motor subtype, we found the concurrent validity (Cohen’s κ = 0.31) and sensitivity to be low (22%). Overall, specificity for all individual subtypes was high (82% to 100%). The DMSS was very sensitive in both rating hyperactive and hypoactive motor symptoms of delirium. Conclusion: The DMSS-G is a highly reliable and valid instrument for detecting motor symptoms in delirium, which provides an accurate instrument to classify the motor subtypes of delirium.