Pain, and Not Opioids, Is Associated With Delirium in Older Emergency Department Patients
Notice bibliographique
Résumé
In Reply: We thank Dr. Meaden and collaborators for their interest in our study, their queries are interesting and deserve attention. It is true that the sample size for our cohort was previously calculated by Émond et al.1 to determine the incidence of delirium. However, the logistic regression analysis used in our study included the total 338 patients and not only the 41 patients with delirium. In addition, we reported a power calculation showing that with 338 patients, we had 80% chance of finding an odds ratio (OR) of at least 1.7 for a predictor of delirium, considering a baseline probability of 0.12 of delirium (41 cases). According to Chen et al.2 an OR of 1.7 is considered a small effect size by Cohen references, so we had sufficient power in our study to detect even a small effect size. It is also true that we did not have the power to examine the relationship between diagnoses and delirium in our study. However, in an ED setting, this relationship has not been clearly established. There was a significant association between patients who received opioids and patients with pain ≥ 65 (p ≤ 0.001), but not between opioids and delirium. Nevertheless, we agree with the comment that it was not possible with our data to know precisely how pain was managed during the study period. The level of pain was evaluated at the initial interview only and we do not know how the pain changes throughout the study, something that was acknowledged in the study’s limitations. We also agree that clinicians learn quickly that opioids cause delirium. However, this is based on low-quality data and maybe this teaching should change. The systematic review from Swart et al.,3 in 2017 cited by Dr. Meaden and colleagues to support this statement, reported that "there are some indications that meperidine and tramadol increase the risk of delirium […] The quality of existing research is limited." Moreover, pain was rarely controlled in the six studies included in the meta-analysis and the same authors state in the discussion section that "delirium as a result of pain, not as a result of opioid use, might play an important role in the included studies." Finally, they also state that “This review also suggests a protective effect of hydromorphone and fentanyl on delirium.”3 Our study provides more data to support the hypothesis that pain and not opioids is associated with delirium.
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Comment cette classification a été obtenuedéplier
Prédiction machine sur la base complète
Imitation des enseignantsNi prévalence calibrée, ni vérité terrain. Validation humaine à venir. Le volet Gemma est une étiquette directe du modèle pour chaque travail de la base, lue sur la notice réduite au titre. Le volet Codex est un classifieur appris des 10 348 étiquettes directes de Codex et calibré sur les taux pondérés de l'échantillon; les champs sans appui suffisant ne portent aucun appel Codex. Le mode candidate est l'union des deux volets; le consensus est leur intersection. Ces sorties portent le statut machine_predicted_unvalidated et ne sont pas des étiquettes humaines.
Scores du classifieur distillé par catégorie (deux têtes)
| Catégorie | Codex | Gemma |
|---|---|---|
| Métarecherche | 0,009 | 0,106 |
| Méta-épidémiologie (sens strict) | 0,001 | 0,001 |
| Méta-épidémiologie (sens large) | 0,002 | 0,002 |
| Bibliométrie | 0,002 | 0,001 |
| Études des sciences et des technologies | 0,001 | 0,002 |
| Communication savante | 0,002 | 0,004 |
| Science ouverte | 0,002 | 0,002 |
| Intégrité de la recherche | 0,012 | 0,015 |
| Charge utile insuffisante (le modèle a refusé de juger) | 0,006 | 0,003 |
Scores machine (provisoires)
Les deux têtes enseignantes du modèle étudiant, lues sur ce travail. Un score ordonne la base pour la relecture; il n'affirme jamais une catégorie, et le statut de validation accompagne chaque rangée tel quel.
Scores de référence d'un modèle non mature (critères de maturité non atteints, 7 itérations). Un score ordonne; il n'affirme jamais une catégorie.
score_only:v0-immature-baseline · tel quel depuis la passe de notation : score_only signifie que le nombre peut ordonner les travaux, et qu'aucune étiquette de catégorie n'en découleClassification
machine, non validéePrédiction automatique; un appel candidat d’une seule source (Gemma direct ou Codex distillé), pas un consensus.
Le détail, modèle par modèle et score par score, se trouve en fin de page sous « Comment cette classification a été obtenue ».