OBJECTIVE: to detect the incidence of postoperative delirium in critically ill patients admitted to a surgical intensive care unit and to evaluate the predisposing and precipitating factors associated with postoperative delirium in critically ill patients admitted to a surgical intensive care unit.
METHODS: this is a prospective cohort study of 157 critically ill surgical patients. Fisher\'s exact test and Chi-square test were used for the association between factors and the occurrence of delirium, the Wilcoxon test for numerical variables, and the logistic regression model for the analysis of predisposing and precipitating factors.
RESULTS: the incidence of delirium was 28% (n=44). Age was a significant predisposing factor (p=0.001), followed by the length of surgery (p<0.001), blood transfusion (p=0.043), administration of crystalloids (p=0.008), and anti-inflammatory drugs (p=0.037), which were the precipitating factors identified. The best-adjusted models were: age, length of surgery, non-administration of anti-emetics, use of sufentanil, and blood transfusion.
CONCLUSIONS: delirium is a frequent condition in critically ill adults undergoing surgery and the existence of precipitating and predisposing factors is relevant to the outcome, with the anesthetic-surgical procedure as the catalyst event.

•Thrombotic thrombocytopenic purpura (TTP) may relapse after surgery.•In a systematic review, we assessed preoperative TTP prophylaxis.•Pre-emptive ADAMTS-13 activity measurement prior to surgery may improve relapse risk.•Preoperative TTP prophylaxis may lower surgical relapse risk.

Sodium-glucose cotransporter 2 (SGLT-2) inhibitors are highly selective, effective, and generally well-tolerated antihyperglycemic agents targeting the SGLT-2 transmembrane protein. Despite being primarily registered for diabetes treatment, due to their cardiorenal protective properties, SGLT-2 inhibitors caused a paradigm shift in the treatment of other diseases on the cardiorenal spectrum, becoming a fundamental part of heart failure and chronic kidney disease management. With their rapidly increasing use, there are also increased reports of a rare, often under-recognised and potentially deadly side effect, SGLT-2-inhibitor-induced euglycemic diabetic ketoacidosis (EDKA). The primary pathophysiological process behind its multifactorial aetiology comprises glucosuria and osmotic diuresis, which produce a significant carbohydrate deficit, leading to an increase in the glucagon-insulin ratio, thus resulting in accelerated ketogenesis. Although EDKA has a similar clinical presentation as diabetic ketoacidosis (DKA), the absence of the high glucose levels typically expected for DKA and the presence of urine ketone reabsorption contribute to a significant delay in its recognition and timely diagnosis. Given the broad use of SGLT-2 inhibitors, increased awareness, early recognition, and prompt identification of precipitating factors are essential. In this narrative review, we comprehensively explore the pathophysiological mechanisms of SGLT-2-inhibitor-induced EDKA, analyse its clinical manifestation, and identify the most common triggers for its development. We also discuss EDKA management and preventive strategies.

OBJECTIVE: Kleine-Levin syndrome (KLS) is a rare sleep disorder characterized by recurrent episodes of severe hypersomnolence in association with various degrees of cognitive impairment, perceptive abnormalities, apathy, behavioral disturbances. Some of these symptoms, hypersomnolence, compulsive eating and increased sexual drive may be replaced by their opposites or alternate with them. Remarkably enough, these « atypical symptoms » have never been enlighted nor compared in frequency with corresponding typical symptoms. Besides, KLS is more frequent in males than in females but no review has ever compared the frequency of precipitating factors and symptoms in males and females.
METHODS: To uncover these as yet uninvestigated aspects of KLS, a predesigned template was used to extract precipitating factors and symptoms, in 475 case reports of KLS, comprising 364 males and 111 females.
RESULTS: Precipitating factors were more frequently recorded in males (67.31 %) than in females (49.55 %). Recurrent episodes of hypersomnolencee were present in 94.32 % of cases, recurrent insomnia in 1.05 % and alternation of hypersomnolence and insomnia in 4.63 %. Cognitive impairment was present in 67.37 % of cases and absent in 6.95 %. Derealization/altered perception was present in 38.32 % of cases and absent in 1.68 %. Severe apathy was present in 44.63 % of cases. Compulsive eating was present in 59.58 % of cases, absent in 13.26 %, replaced by anorexia in 9.05 %, alternation of compulsive eating and anorexia in 5.68 % and alternation of compulsive eating and no compulsive eating in 8.42 %. Increased sexual drive was present in 33.68 % of cases, absent in 22.74 %, replaced by decreased sexual drive in 1.47 %, alternation of increased sexual drive and no increased sexual drive in 2.95 %. Odd behaviors were present in 45.05 % of cases. Psychiatric features were present in 71.58 % of cases, absent in 2.95 %. Finally, the percentages of precipitating factors and of sleep disorder, apathy, sexual disorder, irritability/agressivity, were higher in males than in females.
CONCLUSIONS: The frequency of the opposites of hypersomnolence, compulsive eating and increased sexual drive appears to be quite significant. In addition, a systematic comparison of precipitating factors and symptoms in males and females has shown limited differences between sexes.

BACKGROUND: Diabetic ketoacidosis (DKA) is an acute metabolic, life-threatening complication of diabetes mellitus with a mortality rate that now stand at less than 1%. Although mortality is coupled with the etiology of DKA, literature on the influence of DKA etiology on patient outcome is scarce.
OBJECTIVE: To study different triggers for DKA and their effect on outcomes.
METHODS: We conducted a retrospective study that include 385 DKA patients from 2004 to 2017. The study compared demographics, clinical presentation, and mortality rates by different precipitating factors.
RESULTS: Patients with DKA due to infections had a higher risk to develop in-hospital mortality after controlling for age and sex (odds ratio 4.40, 95% confidence interval 1.35-14.30), had a higher Charlson Comorbidity Index score, a higher risk of being mechanical ventilated (14% vs. 3%, P < 0.01), and a longer duration of hospitalization (5 days vs. 3 days, P < 0.001).
CONCLUSIONS: It is crucial to find the triggers that precipitate DKA and start the treatment as early as possible in addition to the metabolic aspect of the treatment especially when the trigger is an infectious disease.

This paper focuses on studying the optimization problem of multi-agent systems (MAS) under undirected graph. To reduce the communication frequency among agents, a zero-gradient-sum (ZGS) algorithm based on dynamic event-triggered (DET) mechanism is investigated. The event-triggered condition of each agent only uses its own state information and the neighbor\'s state information at the previous triggering instants, without requiring continuous state information from the neighbor. In addition, the designed algorithm allows for the sampling period to be arbitrarily large. The Lyapunov method is utilized to derive the sufficient conditions that incorporate time delay and parameters. As the event is only checked at the periodic moment, zeno behavior can be directly excluded. Finally, numerical simulations demonstrate the effectiveness of the theoretical results.

When de-novo immune-mediated thrombotic thrombocytopenic purpura (TTP) is diagnosed following an invasive procedure, clinical presentation patterns and outcomes are poorly defined. Therefore, in a systematic literature review of patients diagnosed with TTP following an invasive surgical or non-surgical procedure, we identified 19 studies reporting data on 25 patients. These data suggest that 1) TTP pathogenesis likely begins prior to the invasive procedure, 2) patients experience significant diagnostic delays, and 3) there is a high incidence of renal replacement therapy. Although invasive procedures may trigger TTP, further studies are needed to clarify the mechanisms underlying this association.

OBJECTIVE: In this narrative review, we aim to summarize recent insights into the complex interplay between environmental and genetic factors affecting the etiology, development, and progression of chronic migraine (CM).
RESULTS: Environmental factors such as stress, sleep dysfunction, fasting, hormonal changes, weather patterns, dietary compounds, and sensory stimuli are critical triggers that can contribute to the evolution of episodic migraine into CM. These triggers are particularly influential in genetically predisposed individuals. Concurrently, genome-wide association studies (GWAS) have revealed over 100 genetic loci linked to migraine, emphasizing a significant genetic basis for migraine susceptibility. In CM, environmental and genetic factors are of equal importance and contribute to the pathophysiology of the condition. Understanding the bidirectional interactions between these elements is crucial for advancing therapeutic approaches and preventive strategies. This balanced perspective encourages continued research into the complex gene-environment nexus to improve our understanding and management of CM.

The aim of the study was to determine the most common precipitating factors and symptoms of diabetic ketoacidosis and the possible difference according to age, gender and severity of diabetic ketoacidosis. Medical records from January 1, 2017 until December 31, 2019 were reviewed and patients diagnosed with diabetic ketoacidosis were selected. The study included 52 patients, median age 34 (interquartile range 21-56) years. There was no statistically significant difference between male and female gender. The severity of diabetic ketoacidosis was moderate in the majority of cases (65.4%; p=0.005). The most common precipitating factor was infection (61.7%). In patients with moderate diabetic ketoacidosis, respiratory infections were more common, while gastrointestinal infections were more common in severe diabetic ketoacidosis (33% and 25%, respectively; p=0.03). Nausea (median age 32 years; p=0.004) and vomiting (median age 31 years; p=0.01) were more common in younger age groups, while altered mental status was more common in the older age group (median age 61 years; p=0.001). Infection was the most common precipitating factor. The most common symptoms in younger age groups were nausea and vomiting, and altered mental status in the older age group.

Background: An early prediction of infection is challenging in diabetic ketoacidosis (DKA). Methods: This prospective cohort study aimed to assess effectiveness of various sepsis screening tools in predicting infections and prognosis in DKA. Results: Among 141 cases, infection (44.0%) was the commonest precipitating factor. A Sequential Organ Failure Assessment score ≥4 showed high specificity (82.28%) and high positive likelihood ratio (2.64) but limited sensitivity (46.77%). Conversely, Systemic Inflammatory Response Syndrome ≥2 exhibited good sensitivity (95.16%) but a high false-positive rate (84.28%). National Early Warning Score ≥7 and Quick Sequential Organ Failure Assessment ≥2 had low sensitivity and specificity. These sepsis tools also demonstrated low prognostic accuracy for mortality. Conclusion: Sepsis screening tools have limited predictive accuracy for infections and mortality in DKA.
Various clinical tools, including the Sequential Organ Failure Assessment score, Quick Sequential Organ Failure Assessment score, Systemic Inflammatory Response Syndrome criteria and the National Early Warning Score, are used to identify serious infections. This study examined the effectiveness of these tools in patients with diabetic ketoacidosis (DKA), a serious diabetes complication. The study involved 141 patients from north India, and nearly half of them had infections such as pneumonia and urinary tract infections. The researchers found that these tools were not highly effective in identifying infections or predicting deaths among DKA patients at the time of hospital admission. The study suggests that doctors need better ways to diagnose infections in DKA, including more thorough clinical evaluations and advanced tests.