[Influence of Family in the Patient with Neurological Pathology and Acute Confusional Syndrome]

SUMMARY

Given the type of pathology and age of patients in the inpatient unit of Neurology, Hospital de Cabueñes (Gijon), acute confusional syndrome (ACS) is very common in this service.

OBJECTIVE

To determine the influence of the family, within the limits of the hospital, in patients with neurological disease suffering from SCA.

METHODOLOGY

A prospective, observational, descriptive study of 53 patients with neurological disease that suffered from SCA was performed. The study variables were: disorientation, agitation, medication, effectiveness, and body grip on each shift with and without family. All those patients suffering from any dementia or psychiatric problem before entering were discarded.

RESULTS

The mean age of the patients was 83 years old. The most common pathology was ICTUS. The patients with family were 47.4% versus 52.6% without family in three shifts. 70.3% of the patients became disoriented with family; for patients without family the percentage increased up to 83.8%. As far as nervousness is concerned, 11.4% of the patients with family experienced this behaviour in the three shifts; no-family patients suffering from nervousness were 29.4%. Medication was administered to 33% of the patients with family, and to 44% of no-family patients. The effectiveness was 66.5% for patients with family and 48% for no-family patients. The use of body grip in the three shifts was 7.6% for patients with family and 64.5% for no-family patients.

CONCLUSIONS

Family has a beneficial effect on neurological patients with ACS, specially by reducing the use of mechanical restraint, helping to preserve the dignity of elderly patients in an adverse environment such as a hospital.

Manic espisode, confusional syndrome and reversible splenial lesion after abrupt withdrawal of oxcarbazepine

BACKGROUND

Anticonvulsants are considered a second line option for bipolar disorder, it is known that the abrupt withdrawal is rarely related with demyelinated lesions of the splenium of the corpus callosum. Oxcarbazepine is used in bipolar disorder although it is not stated in the data sheet.

CLINICAL CASE

We presented a case of a 50 years old woman with bipolar disorder who is treated with lithium and oxcarbazepine, she presented a manic episode and a confusional syndrome after she stopped taking the medication. The magnetic resonance showed a restricted diffusion area at the splenium of the corpus callosum and bifrontal hygromas that disappear two weeks later.

CONCLUSIONS

The results of this study suggest that for a patient presenting with a mild encephalopathy and reversible splenial lesion, one should consider whether it is related to withdrawal of oxcarbazepine.

Clinical and Biochemical Characteristics of Exertional Heat Stroke among Paratroopers in Agra, India

OBJECTIVE

The purpose of this study was to assess the clinical profile, biochemical parameters and outcome in a series of 78 patients of heat stroke admitted and treated in a military hospital in India.

METHODS

This was a prospective study in a military hospital. A total of 78 patients of exertional heat stroke admitted and treated over more than 2 years are reported. Cooling measures started immediately on site of occurrence, carried on during evacuation and in hospital, IV normal saline initiated, clinical symptoms and signs were noted. Blood was collected and sent for hematological, biochemical and coagulation parameters.

RESULTS

Clinical features noted were violent behavior( 20.51%), confusional state (58.97%),coma (29.48%), seizure (33.33%),and vomiting (26.92%).Vital parameters were recorded and laboratory parameters revealed hypophosphatemia, hyponatremia, hypokalemia along with raised transaminases, creatinine kinase and lactic dehydrogenase. Patients were managed with cooling measures, IV fluids and supportive measures. All of them survived to be discharged in a mean of 8.34 days.

CONCLUSIONS

Timely diagnosis, prompt intervention in form of effective cooling measures to reduce the temperature to acceptable levels within 30 mins, volume resuscitation, judicious use of ionotropes after adequate volume replacement and effective supportive care resulted in a favourable outcome.

Paroxysmal Hypertension Induced by an Insulinoma

Insulinoma is a rare, usually benign, pancreatic neuroendocrine tumor. The clinical features of an insulinoma are fasting hypoglycemia with neuroglycopenic symptoms including confusion and unusual behavior, while hypertension is usually not associated with the disease. We herein report a patient with insulinoma who manifested paroxysmal hypertension and neuroglycopenic symptoms. The possible etiology of hypertension induced by an insulinoma is catecholamine release in response to hypoglycemia, which may cause acute hypertension through activation of the sympatho-adrenal system. This case implies that sustained hyperinsulinemia due to insulinoma can be functionally linked to the induction of paroxysmal hypertension.

ECG of the Month: Confusion and a Slow Heart Rate

Police found a confused 93-year-old woman wandering the streets and brought her to the hospital where an electrocardiogram (ECG) was recorded.

Cybersickness without the wobble: Experimental results speak against postural instability theory

It has been suggested that postural instability is necessary for cybersickness to occur. Seated and standing subjects used a head-mounted display to view a virtual tunnel that rotated about their line of sight. We found that the offset direction of perceived vertical settings matched the direction of the tunnel's rotation, so replicating earlier findings. Increasing rotation speed caused cybersickness to increase, but had no significant impact on perceived vertical settings. Postural sway during rotation was similar to postural sway during rest. While a minority of subjects exhibited postural sway in response to the onset of tunnel rotation, the majority did not. Furthermore, cybersickness increased with rotation speed similarly for the seated and standing conditions. Finally, subjects with greater levels of cybersickness exhibited less variation in postural sway. These results lead us to conclude that the link between postural instability and cybersickness is a weak one in the present experiment.

Dexmedetomidine for prevention of delirium in elderly patients after non-cardiac surgery: a randomised, double-blind, placebo-controlled trial

BACKGROUND

Delirium is a postoperative complication that occurs frequently in patients older than 65 years, and presages adverse outcomes. We investigated whether prophylactic low-dose dexmedetomidine, a highly selective α₂ adrenoceptor agonist, could safely decrease the incidence of delirium in elderly patients after non-cardiac surgery.

METHODS

We did this randomised, double-blind, placebo-controlled trial in two tertiary-care hospitals in Beijing, China. We enrolled patients aged 65 years or older, who were admitted to intensive care units after non-cardiac surgery, with informed consent. We used a computer-generated randomisation sequence (in a 1:1 ratio) to randomly assign patients to receive either intravenous dexmedetomidine (0·1 μg/kg per h, from intensive care unit admission on the day of surgery until 0800 h on postoperative day 1), or placebo (intravenous normal saline). Participants, care providers, and investigators were all masked to group assignment. The primary endpoint was the incidence of delirium, assessed twice daily with the Confusion Assessment Method for intensive care units during the first 7 postoperative days. Analyses were done by intention-to-treat and safety populations. This study is registered with Chinese Clinical Trial Registry, www.chictr.org.cn, number ChiCTR-TRC-10000802.

FINDINGS

Between Aug 17, 2011, and Nov 20, 2013, of 2016 patients assessed, 700 were randomly assigned to receive either placebo (n=350) or dexmedetomidine (n=350). The incidence of postoperative delirium was significantly lower in the dexmedetomidine group (32 [9%] of 350 patients) than in the placebo group (79 [23%] of 350 patients; odds ratio [OR] 0·35, 95% CI 0·22-0·54; p<0·0001). Regarding safety, the incidence of hypertension was higher with placebo (62 [18%] of 350 patients) than with dexmedetomidine (34 [10%] of 350 patients; 0·50, 0·32-0·78; p=0·002). Tachycardia was also higher in patients given placebo (48 [14%] of 350 patients) than in patients given dexmedetomidine (23 [7%] of 350 patients; 0·44, 0·26-0·75; p=0·002). Occurrence of hypotension and bradycardia did not differ between groups.

INTERPRETATION

For patients aged over 65 years who are admitted to the intensive care unit after non-cardiac surgery, prophylactic low-dose dexmedetomidine significantly decreases the occurrence of delirium during the first 7 days after surgery. The therapy is safe.

FUNDING

Braun Anaesthesia Scientific Research Fund and Wu Jieping Medical Foundation, Beijing, China. Study drugs were manufactured and supplied by Jiangsu Hengrui Medicine Co, Ltd, Jiangsu, China.

Clinical Case of the Month: A 64 Year-Old Woman Presenting With Fever, Confusion, Ophthalmoplegia and Pneumonia

Legionella pneumophila is a major cause of atypical community-acquired pneumonia, which is commonly severe enough to require hospitalization. Though primarily a respiratory infection, Legionellosis involves the central nervous system (CNS) in up to 50% of patients, and diagnosis can be obscured by the absence of obvious respiratory symptomatology. A reversible diffuse encephalopathy is the most common neurologic complication, but focal CNS involvement can sometimes be the initial presentation. We report a case of a woman infected with Legionella pneumophila presenting with vague symptomatology and focal neurologic findings. This report highlights the challenges of early recognition of Legionella infection when neurologic symptoms predominate.

Risk for Acute Confusion in Sensory-Impaired, Rural, Long-Term-Care Elders

Acute confusion is a common geriatric syndrome in long-term care (LTC) elders with prevalence rates of 10% to 39%. Sensory impairment, specifically vision and hearing impairment, is even more common in LTC, with prevalence rates of 40% to 90%. The purpose of this study was to investigate the risk relationship between sensory impairment and the development of acute confusion in LTC elders. Each resident (N = 114) underwent sensory screening and then was followed for 28 days to monitor for the onset of acute confusion. Twenty residents (17.5%) developed acute confusion, 60 residents (52.6%) were found to be visually impaired, 49 (44.1%) were hearing impaired, and 28 (24.6%) were found to be dually impaired. Significant relationships between vision impairment, odds ratio (OR) = 3.67, confidence interval (CI) (1.13, 11.92), and dual sensory impairment, OR = 2.88, CI (1.04, 8.26), with the development of acute confusion were identified.

Recovery Symptoms and Mood States in Thai CABG patients

Recovery symptoms and related mood states during early recovery after coronary artery bypass graft surgery (CABG) have never been assessed in Thailand. This cross-sectional descriptive correlational study was to identify the relationships between frequency of recovery symptoms and mood states of a convenience sample of 91 Thai CABG patients during 2 weeks after discharge. Standardized tools/procedures were used to measure the variables of interest. The most common recovery symptoms were chest and leg incision pain, having trouble sleeping, and neck and shoulder or back discomfort. The most common mood states were confusion, anxiety, and anger, respectively. In addition, Thai CABG patients who had more frequent recovery symptoms also had greater negative mood disturbance. These findings provide a beginning explanation about the phenomena of recovery symptoms and mood states in a specific culture, Thai CABG patients.

Can Alcohol Intoxication be Excluded as the Cause of Confusion following Head Injury?

Objective: To assess whether there is a breath alcohol level (BrAC) below which confusion in the head injured patient should not be attributed solely to the acute effects of alcohol Method: Based in the Accident and Emergency Ward in Glasgow Royal Infirmary, a prospective observational study was carried out over a five month period. Patients admitted to the ward were recruited for the study if they had a primary diagnosis of head injury. The outcome measures recorded and analysed were sequential 2 hrly BrAC readings (mg/L) and Glasgow Coma Scale findings (Eye opening, motor and verbal responses). The relationship between these was investigated, which revealed additional relevant factors affecting level of consciousness. Results: The breath alcohol analyser was found to be a useful non-invasive, quick and easy to use tool. The results obtained were consistent with the expected pattern of reducing BrAC levels over a 6 hour period. Within this group of patients, a poor correlation was found between each of the three responses of the Glasgow Coma Scale and BrAC readings. For those patients who remained confused, when their BrAC reading was less than 1 mg/L, other causes of a lowered level of consciousness were identified. Conclusion: Confusion in the head injured patient with a BrAC of less than 1 mg/L, should alert one to the likelihood of causes other than alcohol intoxication.

Progressive Multifocal Leukoencephalopathy: A Case Study

Progressive multifocal leukoencephalopathy is a rare, highly fatal demyelinating brain infection caused by the JC virus. This infection is associated with immunosuppressive agents and is emerging in the transplant population. There has never been a documented case of progressive multifocal leukoencephalopathy in a transplant recipient receiving sirolimus. We present a study, in which the JC virus was found in a 68-year-old man who had received a postorthotopic heart transplant 3 years earlier and who was receiving sirolimus and prednisone for immunosuppression. We review the clinical presentation, diagnosis, current treatment options, and the outcomes of progressive multifocal leukoencephalopathy in transplant recipients.

Intrusion and Confusion—The Impact of Medication and Health Professionals after Acute Myocardial Infarction

Background: Secondary prevention is important in preventing new cardiovascular events after acute myocardial infarction (AMI).

Aim: To explore patients' experiences of secondary prevention after a first AMI.

Methods: A qualitative approach with hermeneutical analysis of in depth interviews was used.

Results: Twenty patients (12 men and 8 women, aged 34–79 years) were interviewed. None of the patients was previously treated for cardiovascular disease except one that had a history of angina pectoris. Two main themes emerged from the analysis. 1) Impact of medication: patients interpreted bodily sensations as a consequence of being medicated rather than as a result of their heart attack. The medication led to feelings of being intruded upon but also to positive feelings of security. 2) Impact of health professionals: communication with health professionals resulted in confusion about both treatment and the severity of the coronary disease. Patients expressed a need of being reassured by their physician regarding their physical status.

Conclusions: Health professionals need to consider the impact of pharmacological treatment on patients' life, at least in patients who suffer from a first AMI. The point of departure in secondary preventive work must be patients' beliefs about their condition and the treatment they receive. Nurses and physicians must be aware of the information each patient has been given, and from this starting point, they have to be in concordance with one another. From the patients' perspective it is deemed necessary for the physicians to discuss the disease and the consequences it may have, both in the near future and in the long run, as soon as possible.

Palliative and supportive care in head and neck cancer: United Kingdom National Multidisciplinary Guidelines

This is the official guideline endorsed by the specialty associations involved in the care of head and neck cancer patients in the UK. It provides recommendations on the assessments and interventions for this group of patients receiving palliative and supportive care. Recommendations • Palliative and supportive care must be multidisciplinary. (G) • All core team members should have training in advanced communication skills. (G) • Palliative surgery should be considered in selected cases. (R) • Hypofractionated or short course radiotherapy should be considered for local pain control and for painful bony metastases. (R) • All palliative patients should have a functional endoscopic evaluation of swallowing (FEES) assessment of swallow to assess for risk of aspiration. (G) • Pain relief should be based on the World Health Organization pain ladder. (R) • Specialist pain management service involvement should be considered early for those with refractory pain. (G) • Constipation should be avoided by the judicious use of prophylactic laxatives and the correction of systemic causes such as dehydration, hypercalcaemia and hypothyroidism. (G) • Organic causes of confusion should be identified and corrected where appropriate, failing this, treatment with benzodiazepines or antipsychotics should be considered. (G) • Patients with symptoms suggestive of spinal metastases or metastatic cord compression must be managed in accordance with the National Institute for Health and Care Excellence guidance. (R) • Cardiopulmonary resuscitation is inappropriate in the palliative dying patient. (R) • 'Do not attempt cardiopulmonary resuscitation' orders should be completed and discussed with the patient and/or the family unless good reasons exist not to do so where appropriate. This is absolutely necessary when a patient's care is to be managed at home. (G).

An Unusual Cause of Altered Mental Status in Multiple Myeloma: An Extraosseous Manifestation

Multiple myeloma typically presents as lytic bony lesions, hypercalcemia, anemia, and renal failure. Extraosseous manifestations are rare. We report on a patient who was recently diagnosed with multiple myeloma and completed the first cycle of bortezomib, dexamethasone, and palliative radiation therapy with good response. Two weeks after discharge, she became confused and was re-admitted. Despite treatment with lactulose and rifaximin, altered mental status worsened. Computer tomographic scan of abdomen showed hepatomegaly and numerous ill-defined small hyperdense nodules scattered throughout the liver. Liver biopsy demonstrated aggregation of plasma cell myeloma. Magnetic resonance imaging of brain revealed dural thickening. Patient's altered mental status was likely from leptomeningeal myelomatosis and hyperammonemic encephalopathy. Although extraosseous manifestations in multiple myeloma including liver and leptomeningeal involvement are rare, its incidence has increased. This condition portends a poor prognosis. The non-specific manifestations of extraosseous myeloma can be confused with complications of multiple sclerosis and lead to incorrect management, thus clinicians should be aware of these pathologies and perform proper diagnostic tests including imaging and tissue pathology. The most effective treatment is unknown, however bortezomib and thalidomide show promise.