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Crucial differential diagnosis of rapidly progressive dementia: A case of leptomeningeal metastasis.PCN Reports : Psychiatry and Clinical... Sep 2023Dementia that advances subacutely without accompanying neurological symptoms can often be misdiagnosed as a psychiatric condition. Leptomeningeal metastasis (LM), caused...
BACKGROUND
Dementia that advances subacutely without accompanying neurological symptoms can often be misdiagnosed as a psychiatric condition. Leptomeningeal metastasis (LM), caused by the spread of malignant cells to the leptomeninges and the subarachnoid space, is a relatively unfamiliar condition to psychiatrists in this context. The diagnosis of LM remains challenging due to the scarcity of diagnostic tools possessing high sensitivity and specificity.
CASE PRESENTATION
We present the clinical presentation of a male in his seventies with LM secondary to gastric ring cell carcinoma. The patient exhibited an acute confusional state, visual hallucinations, irritability, and cognitive impairments over a 3-week period. Initially, the patient was misdiagnosed with several conditions, including alcohol withdrawal syndrome, psychosis, and delirium associated with dementia, as there were no noteworthy findings on neurological examination or the head magnetic resonance imaging (MRI). Given the rapidly progressive cognitive decline, we maintained vigilance for potential neurological conditions, and a repeat investigation using head MRI and cerebrospinal fluid analysis led to the diagnosis of LM.
CONCLUSION
This critical case report underscores the rarity of psychiatric-onset LM originating from gastric cancer and highlights the importance of comprehensive neurological evaluations.
PubMed: 38867838
DOI: 10.1002/pcn5.137 -
Cureus Jun 2024Introduction Urosepsis is a systemic, dysregulated, inflammatory reaction to a urinary tract infection and can have severe effects on all systems, which can often...
Introduction Urosepsis is a systemic, dysregulated, inflammatory reaction to a urinary tract infection and can have severe effects on all systems, which can often lead to multi-organ failure and death. Sepsis-associated delirium is a common complication in critically ill patients, contributing to adverse outcomes and prolonged hospital stays. The neutrophil-to-lymphocyte ratio (NLR) has emerged as a potential biomarker for sepsis severity and prognosis. Material and methods Our study investigates the utility of NLR in the diagnostic strategies for urosepsis-associated delirium in a cohort of 76 patients with sepsis and septic shock admitted to the Intensive Care Unit (ICU). We performed a single-centre retrospective observational study in the Craiova Clinical Emergency Hospital between June and October 2023. Results Patients with urological conditions that were diagnosed with urosepsis included 76 patients. These patients were clustered as follows: a group with delirium (37 patients, 48.7%) and another group without delirium (39 patients, 51.3%). Complete blood count parameters were obtained upon admission, and delirium was assessed using standardized diagnostic criteria. We identified a strong significant positive correlation between elevated NLR values on ICU admission and the development of delirium during hospitalization in urosepsis patients. Receiver operating characteristic (ROC) analysis showed similar diagnostic performance for NLR score. Conclusions The findings suggest that NLR may serve as a valuable biomarker for early detection, risk stratification, and guiding therapeutic interventions in urosepsis-associated delirium, thus improving outcomes in critically ill patients.
PubMed: 38863776
DOI: 10.7759/cureus.62110 -
International Journal of General... 2024This study aims to investigate whether dexmedetomidine could prevent postoperative cognitive dysfunction and delirium in patients with lobectomy.
Intraoperative Dexmedetomidine for Prevention of Postoperative Cognitive Dysfunction and Delirium in Elderly Patients with Lobectomy: A Propensity Score-Matched, Retrospective Study.
PURPOSE
This study aims to investigate whether dexmedetomidine could prevent postoperative cognitive dysfunction and delirium in patients with lobectomy.
PATIENTS AND METHODS
Patients with lung cancer who underwent thoracoscopic lobectomy under general anesthesia were enrolled in this study and divided into dexmedetomidine group or control group. Propensity-score match (PSM) was used to reduce the bias and imbalance of confounding variables. After PSM, 87 patients in each group were included. Primary outcomes were postoperative cognitive function and delirium. Secondary outcomes include plasma TNF-α, IL-6, and S100 β protein concentrations. Adverse events were also collected.
RESULTS
There were no significant differences in the demographic characteristics and hemodynamic parameters between the two groups. Compared with the control group, the MoCA scores were significantly higher (<0.01), while the incidence of delirium (<0.01) and the plasma TNF-α (<0.01), IL-6 (<0.01), and S100 β protein (<0.01) concentrations were significantly lower in the dexmedetomidine group at 7 days post-operatively. The incidences of adverse events were similar between the two groups.
CONCLUSION
Dexmedetomidine could prevent postoperative cognitive dysfunction and delirium in patients with lobectomy by decreasing neuroinflammation.
PubMed: 38863738
DOI: 10.2147/IJGM.S456762 -
Acute and Critical Care May 2024Post-intensive care syndrome (PICS) refers to persistent or new onset physical, mental, and neurocognitive complications that can occur following a stay in the intensive...
Post-intensive care syndrome (PICS) refers to persistent or new onset physical, mental, and neurocognitive complications that can occur following a stay in the intensive care unit. PICS encompasses muscle weakness; neuropathy; cognitive deficits including memory, executive, and attention impairments; post-traumatic stress disorder; and other mood disorders. PICS can last long after hospital admission and can cause significant physical, emotional, and financial stress for patients and their families. Several modifiable risk factors, such as duration of sepsis, delirium, and mechanical ventilation, are associated with PICS. However, due to limited awareness about PICS, these factors are often overlooked. The objective of this paper is to highlight the pathophysiology, clinical features, diagnostic methods, and available preventive and treatment options for PICS.
PubMed: 38863353
DOI: 10.4266/acc.2023.01158 -
Ulusal Travma Ve Acil Cerrahi Dergisi =... Jun 2024Effective pain management is vital in critical care settings, particularly post-surgery. Clinicians should maintain objective and efficient standards to assess pain in a... (Randomized Controlled Trial)
Randomized Controlled Trial
BACKGROUND
Effective pain management is vital in critical care settings, particularly post-surgery. Clinicians should maintain objective and efficient standards to assess pain in a patient-centered manner, in order to effectively manage this complex issue. A newer technology, the nociception level (NOL) index, shows promise in achieving this task through its multi-parameter evaluation.
METHODS
This study was a prospective, controlled, randomized trial involving two groups of patients (n=30 each) in a diverse intensive care unit. Participants were over 18 years old with American Society of Anesthesiology scores ranging from I to III and were scheduled for critical care follow-up after general anesthesia. All subjects followed a standard analgesia protocol that included rescue analgesia. Drug administration was guided by a numeric rating scale and the critical care pain observation tool in the Control Group, while it was guided by nociception level index monitoring in the NOL Group.
RESULTS
Pain scores between the two groups did not significantly differ. However, within the NOL Group, pain scores and noci-ception values displayed a strong positive correlation. Notably, total analgesic consumption was significantly lower in the NOL Group (p=0.036).
CONCLUSION
Monitoring pain using the nociception level index is an effective method for detecting pain compared to standard pain scores utilized in critical care. Its guidance facilitates personalized analgesic titration. Additionally, the potential of nociception level index guidance to reduce the duration of intensive care and hospital stays may be linked to its effects on delirium, a connection that awaits further exploration in future studies.
Topics: Humans; Double-Blind Method; Male; Female; Pain Measurement; Prospective Studies; Middle Aged; Nociception; Critical Care; Adult; Pain Management; Prognosis; Intensive Care Units; Aged; Pain, Postoperative; Analgesics
PubMed: 38863294
DOI: 10.14744/tjtes.2024.95533 -
Trials Jun 2024Intensive care medicine continues to improve, with advances in technology and care provision leading to improved patient survival. However, this has not been matched by...
BACKGROUND
Intensive care medicine continues to improve, with advances in technology and care provision leading to improved patient survival. However, this has not been matched by similar advances in ICU bedspace design. Environmental factors including excessive noise, suboptimal lighting, and lack of natural lights and views can adversely impact staff wellbeing and short- and long-term patient outcomes. The personal, social, and economic costs associated with this are potentially large. The ICU of the Future project was conceived to address these issues. This is a mixed-method project, aiming to improve the ICU bedspace environment and assess impact on patient outcomes. Two innovative and adaptive ICU bedspaces capable of being individualised to patients' personal and changing needs were co-designed and implemented. The aim of this study is to evaluate the effect of an improved ICU bedspace environment on patient outcomes and operational impact.
METHODS
This is a prospective multi-component, mixed methods study including a randomised controlled trial. Over a 2-year study period, the two upgraded bedspaces will serve as intervention beds, while the remaining 25 bedspaces in the study ICU function as control beds. Study components encompass (1) an objective environmental assessment; (2) a qualitative investigation of the ICU environment and its impact from the perspective of patients, families, and staff; (3) sleep investigations; (4) circadian rhythm investigations; (5) delirium measurements; (6) assessment of medium-term patient outcomes; and (7) a health economic evaluation.
DISCUSSION
Despite growing evidence of the negative impact the ICU environment can have on patient recovery, this is an area of critical care medicine that is understudied and commonly not considered when ICUs are being designed. This study will provide new information on how an improved ICU environment impact holistic patient recovery and outcomes, potentially influencing ICU design worldwide.
TRIAL REGISTRATION
ACTRN12623000541606. Registered on May 22, 2023. https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=385845&isReview=true .
Topics: Humans; Intensive Care Units; Prospective Studies; Randomized Controlled Trials as Topic; Time Factors; Beds; Critical Care Outcomes; Health Facility Environment; Hospital Design and Construction; Critical Care
PubMed: 38863018
DOI: 10.1186/s13063-024-08222-6 -
International Journal of Surgery Case... Jul 2024Cleft lip and palate (CLP) are congenital anomalies of the craniofacial region, commonly found in low- and middle-income countries, including Indonesia. Surgical...
INTRODUCTION AND IMPORTANCE
Cleft lip and palate (CLP) are congenital anomalies of the craniofacial region, commonly found in low- and middle-income countries, including Indonesia. Surgical correction of clefts typically begins at around three months of age to support infant growth. An infraorbital nerve block is an option for regional anesthesia in CLP surgery. This case series aims to determine the effectiveness of infraorbital nerve block in pain management for pediatric CLP surgery.
CASE PRESENTATION
This case series includes five patients who fulfilled the Millard criteria for CLP surgery. All patients received general anesthesia followed by an infraorbital nerve block with 0.2 % ropivacaine in the infraorbital foramen area using the intraoral approach. Data were collected preoperatively, intraoperatively, and postoperatively.
DISCUSSION
The combination of general anesthesia and infraorbital nerve block resulted in stable hemodynamics, low delirium scores, low pain intensity, and adequate oral intake postoperatively.
CONCLUSION
Infraorbital nerve block with ropivacaine provides intraoperative hemodynamic stability, decreased delirium, and effective postoperative pain management in pediatric patients undergoing CLP surgery.
PubMed: 38861814
DOI: 10.1016/j.ijscr.2024.109893 -
Interactive Journal of Medical Research Jun 2024The COVID-19 pandemic led to behavioral exacerbations in people with dementia. Increased hospitalizations and lack of bed availability in specialized dementia wards at a...
The COVID-19 pandemic led to behavioral exacerbations in people with dementia. Increased hospitalizations and lack of bed availability in specialized dementia wards at a tertiary psychiatric hospital in Singapore resulted in lodging people with dementia in the High Dependency Psychiatric Unit (HDPCU). Customizations to create a dementia-friendly environment at the HDPCU included: (1) environmental modifications to facilitate orientation and engender familiarity; (2) person-centered care to promote attachment, inclusion, identity, occupation, and comfort; (3) risk management for delirium; and (4) training core competencies. Such practical solutions can also be implemented elsewhere to help overcome resource constraints and repurpose services to accommodate increasing populations of people living with dementia.
PubMed: 38861715
DOI: 10.2196/49618 -
JAMA Network Open Jun 2024
Topics: Humans; Delirium; Emergency Service, Hospital; Male; Female; Aged; Psychomotor Agitation; Middle Aged; Inpatients; Length of Stay; Aged, 80 and over; Hospitalization; Time Factors
PubMed: 38861262
DOI: 10.1001/jamanetworkopen.2024.16343 -
Trauma Surgery & Acute Care Open 2024Traumatic rib fractures present a considerable risk to patient well-being, contributing to morbidity and mortality in trauma patients. To address the risks associated...
INTRODUCTION
Traumatic rib fractures present a considerable risk to patient well-being, contributing to morbidity and mortality in trauma patients. To address the risks associated with rib fractures, evidence-based interventions have been implemented, including effective pain management, pulmonary hygiene, and early walking. Vancouver General Hospital, a level 1 trauma center in British Columbia, Canada, developed a comprehensive multidisciplinary chest trauma clinical practice guideline (CTCPG) to optimize the management of patients with rib fractures. This prospective cohort study aimed to assess the impact of the CTCPG on pain management interventions and patient outcomes.
METHODS
The study involved patients admitted between January 1, 2021 and December 31, 2021 (post-CTCPG cohort) and a historical control group admitted between November 1, 2018 and December 31, 2019 (pre-CTCPG cohort). Patient data were collected from patient charts and the British Columbia Trauma Registry, including demographics, injury characteristics, pain management interventions, and relevant outcomes.
RESULTS
Implementation of the CTCPG resulted in an increased use of multimodal pain therapy (99.4% vs 96.1%; p=0.03) and a significant reduction in the incidence of delirium in the post-CTCPG cohort (OR 0.43, 95% CI 0.21 to 0.80, p=0.0099). There were no significant differences in hospital length of stay, ICU (intensive care unit) days, non-invasive positive pressure ventilation requirement, ventilator days, pneumonia incidence, or mortality between the two cohorts.
DISCUSSION
Adoption of a CTCPG improved chest trauma management by enhancing pain management and reducing the incidence of delirium. Further research, including multicenter studies, is warranted to validate these findings and explore additional potential benefits of the CTCPG in the management of chest trauma patients.
LEVEL OF EVIDENCE
IIb.
PubMed: 38860116
DOI: 10.1136/tsaco-2023-001323