BACKGROUND:

In older individuals, acute medical illnesses and admission to hospital are often associated with a deterioration of cognitive status, also in the absence of dementia and full-blown delirium. We evaluated the prevalence of subsyndromal delirium (SSD) and its correlates in a sample of elderly medical inpatients.

METHODS:

From 763 consecutive inpatients, 325 participants with known dementia or delirium were excluded, whereas 438 (mean age: 80.6 years; female participants: 60.1%) were enrolled. SSD was diagnosed within 48 hour from admission, when at least two DSM-IV delirium criteria including disorientation, attention or memory deficit, altered level of consciousness, or perceptual disturbances were present. Cognitive performance was evaluated by Mini Mental Status Examination (MMSE). General, clinical, and laboratory parameters were also registered.

RESULTS:

One hundred and sixty-six patients (37%) had SSD. Compared with controls, SSD patients were older individuals, had less formal education, higher comorbidity, lower hemoglobin/lymphocytes counts, and higher creatinine levels. A trend toward higher prevalence of previous stroke and widowhood was observed. A MMSE score of less than 24/30 identified SSD with 88% sensitivity and 78% specificity. In SSD patients, MMSE independently correlated with years of education, high-sensitivity C reactive protein levels, and O2 arterial saturation (model adjusted r (2) = 0.30, p = .001); conversely, only years of education were associated with MMSE in controls (adjusted r (2) = 0.06, p = .01).

CONCLUSIONS:

Our data suggest that SSD is common in hospitalized older medical inpatients, and low MMSE score might be useful for identification of participants at risk of SSD. Current inflammatory response and reduced O2 arterial saturation were the only independent determinants of cognitive performance in SSD patients.

Associations between large cavum septum pellucidum and functional psychosis disorders, especially schizophrenia, have been reported. We report a case of late-onset catatonia associated with enlarged CSP and cavum vergae. A 66-year-old woman was presented with altered mental status and stereotypic movement. She was initially treated with aripiprazole and lorazepam. After 4 weeks, she was treated with electroconvulsive therapy. By 10 treatments, echolalia vanished, and catatonic behavior was alleviated. Developmental anomalies in the midline structure may increase susceptibility to psychosis, even in the elderly.

OBJECTIVE:

To prospectively analyze the prognostic factors for neurological complications of childhood bacterial meningitis.

METHODS:

This prospective study enrolled 77 children from 1 month until 16 years of age, treated for bacterial meningitis during the period of January 1, 2009 through December 31, 2010. 16 relevant predictors were chosen to analyze their association with the incidence of neurological complications. p-values < 0.05 were considered statistically significant.

RESULTS:

Of the 77 children treated for bacterial meningitis, 33 patients developed neurological complications (43%), and two children died (2.6%). The etiology of bacterial meningitis cases was proven in 57/77 (74%) cases: 32 meningococci, eight pneumococci, six Gram-negative bacilli, five H. influenzae, five staphylococci, and one S. viridans isolates were found. Factors found to be associated with increased risk of development of neurological complications were age < 12 months, altered mental status, seizures prior to admission, initial therapy with two antibiotics, dexamethasone use, presence of focal neurological deficit on admission and increased proteins in cerebrospinal fluid (CSF) (p < 0.05). Initial pleocytosis > 5,000 cells/mm(3), pleocytosis > 5,000 cells/mm(3) after 48hours, CSF/blood glucose ratio < 0.20, female gender, previous treatment with antibiotics, community-acquired infection, duration of illness > 48hours, presence of comorbidity, and primary focus of infection were not associated with increased risk for the development of neurological complications.

CONCLUSION:

Age < 12 months and severity of clinical presentation at admission were identified as the strongest predictors of neurological complications and may be of value in selecting patients for more intensive care and treatment.

Electrolyte disorders are frequently encountered by doctors working in a variety of hospital specialties. Abnormalities of potassium, sodium and calcium are usually treated promptly owing to the well- recognized consequences of cardiac arrhythmias and altered mental status that develop from delayed treatment, as well as familiarity with their management.

Incidence of brain metastases (BM) from breast cancer (BC) is increasing. However, prognostic evaluation and treatment strategies are still a matter of debate. Aim: To describe the clinical outcome of BM from BC treated by neurosurgical resection and to identify the actual prognostic factors in this specific population.We retrospectively reviewed all patients (n=49) with BM from BC treated at our institutions by surgical resection, between December 2001 and July 2011. Patient, tumor and treatment characteristics were recorded.Median cerebral progression-free survival (CPFS) was 11.3 months (95% Confidence Interval (CI)=6.0-16.6 months) and median overall survival (OS) was 19.4 months (95% CI=16.1-22.7 months). By multivariate analyses, altered Mini Mental Status (MMS) (CPFS: p=0.012, OS: p=0.009), multiple systemic metastases (CPFS: p=0.020, OS: p<0.001) and absence of post-operative chemotherapy (CPFS: p=0.013, OS: p=0.006) had independent adverse prognostic values. Hormonal receptors, Human epidermal growth factor-2 (HER2) and molecular subtype were not significantly correlated to survival.Surgical resection is an effective treatment in selected patients with BM from BC. MMS, number of systemic metastases and the use of postoperative systemic treatment are associated with better outcome.

BACKGROUND:

Acute encephalitis syndrome (AES) is a constellation of symptoms that includes fever and altered mental status. Most cases are attributed to viral encephalitis (VE), occurring either in outbreaks or sporadically. We conducted hospital-based surveillance for sporadic adult-AES in rural Central India in order to describe its incidence, spatial and temporal distribution, clinical profile, etiology and predictors of mortality.

METHODS:

All consecutive hospital admissions during the study period were screened to identify adult-AES cases and were followed until 30-days of hospitalization. We estimated incidence by administrative sub-division of residence and described the temporal distribution of cases. We performed viral diagnostic studies on cerebrospinal fluid (CSF) samples to determine the etiology of AES. The diagnostic tests included RT-PCR (for enteroviruses, HSV 1 and 2), conventional PCR (for flaviviruses), CSF IgM capture ELISA (for Japanese encephalitis virus, dengue, West Nile virus, Varicella zoster virus, measles, and mumps). We compared demographic and clinical variables across etiologic subtypes and estimated predictors of 30-day mortality.

RESULTS:

A total of 183 AES cases were identified between January and October 2007, representing 2.38% of all admissions. The incidence of adult AES in the administrative subdivisions closest to the hospital was 16 per 100,000. Of the 183 cases, a non-viral etiology was confirmed in 31 (16.9%) and the remaining 152 were considered as VE suspects. Of the VE suspects, we could confirm a viral etiology in 31 cases: 17 (11.2%) enterovirus; 8 (5.2%) flavivirus; 3 (1.9%) Varicella zoster; 1 (0.6%) herpesvirus; and 2 (1.3%) mixed etiology); the etiology remained unknown in remaining 121 (79.6%) cases. 53 (36%) of the AES patients died; the case fatality proportion was similar in patients with a confirmed and unknown viral etiology (45.1 and 33.6% respectively). A requirement for assisted ventilation significantly increased mortality (HR 2.14 (95% CI 1.0-4.77)), while a high Glasgow coma score (HR 0.76 (95% CI 0.69-0.83)), and longer duration of hospitalization (HR 0.88 (95% CI 0.83-0.94)) were protective.

CONCLUSION:

This study is the first description of the etiology of adult-AES in India, and provides a framework for future surveillance programs in India.

BACKGROUND:

EMR for the treatment of duodenal adenomas is challenging due to a thin wall and rich vascularity.

OBJECTIVE:

To evaluate a novel technique of "underwater" EMR without prior submucosal injection for the removal of large (≥2 cm) laterally spreading nonampullary duodenal adenomas.

DESIGN:

Prospective, observational study.

SETTING:

Tertiary academic referral center.

PATIENTS:

Twelve patients (median age, 60 years) meeting the inclusion criteria.

INTERVENTIONS:

Piecemeal EMR technique after sterile water submersion when using a double-channel endoscope. MAIN OUTCOME

MEASUREMENTS:

Technical success, adverse events, completeness of resection on follow-up endoscopy.

RESULTS:

Median adenoma size was 35 mm (25% greater than one-half circumference, 50% equal to one-third to one-half circumference, and 25% less than one-third circumference). Median procedure time was 65 minutes (range, 32-151). Final histology was tubular adenoma (7), tubulovillous adenoma (1), villous adenoma (3), and high-grade dysplasia (1). Eleven patients (92%) met the primary endpoint (technical success) and all patients met the secondary endpoint (completeness of resection). Median interval until follow-up endoscopy was 16 weeks (range, 11-56). Adverse events were as follows: delayed bleeding (3 patients, of whom 2 required transfusions), water intoxication syndrome manifested by altered mental status and hyponatremia (1), and stricture formation (1) that responded to balloon dilation. No perforation or postresection abdominal pain was found.

LIMITATIONS:

Single operator, single center, small sample size, limited follow-up.

CONCLUSION:

Underwater EMR for large sessile duodenal adenomas has high success rates for complete removal. The risk of delayed bleeding is significant, and precautions are needed when infusing a large volume of fluid into the GI tract.

The case of a patient who developed toxic epidermal necrolysis (TEN) after treatment with rifaximin for hepatic encephalopathy is reported.A 62-year-old Caucasian woman with a history of alcohol abuse arrived at the emergency room with complaints of abdominal pain and acute onset of jaundice, likely secondary to alcoholic hepatitis. Laboratory tests and multiple imaging studies conducted in the emergency department revealed signs of chronic liver disease and common bile duct dilation with ascites. At admission, she had low concentrations of serum sodium, serum chloride, serum creatinine, and serum albumin and elevated liver function test values. On hospital day 7, the patient developed an altered mental status, which was diagnosed as toxic metabolic encephalopathy, primarily hepatic in origin. The patient was given lactulose 20 g via nasogastric tube every 12 hours and rifaximin 400 mg orally every 8 hours. The patient received only two doses of the rifaximin before it was discontinued. On hospital day 27, oral rifaximin 550 mg twice daily was initiated. After 12 days of rifaximin therapy, the patient developed a diffuse, erythematous, maculopapular, and desquamating cutaneous reaction on her chest, arms, and legs. The suspected diagnosis was determined to be a severe cutaneous adverse drug reaction, possibly TEN. Use of the Naranjo et al. scale revealed that rifaximin was a possible cause of the reaction. Rifaximin was discontinued, and antihistamines and i.v. corticosteroids were initiated. The reaction completely resolved after one week.A 62-year-old woman developed possible TEN after receiving rifaximin to treat hepatic encephalopathy.

Acute lumbosacral plexus injury from gluteal compartment syndrome is extremely rare. Physicians should be aware of this diagnosis when examining patients with altered mental status, prolonged immobilization, and gluteal muscle compression. This case report presents a patient with acute complete left lumbosacral plexus paralysis and acute renal failure after gluteal compartment syndrome secondary to prolonged immobilization from drug abuse. Clinical examination, imaging of the pelvis, renal function, creatine phosphokinase, and urine myoglobin were indicative of gluteal compartment syndrome and rhabdomyolysis. Electrodiagnostic studies showed complete limb paralysis. Medical treatment and rehabilitation was administered. Renal function recovered within the 1st week; function at the proximal muscles of the left lower limb improved within 6 months, with mild discomfort on sitting at the buttock, foot drop, and sensory deficits at the leg and dorsum of foot.