Development of the AL-O-A Score for Delirium Screening in Acute Internal Medicine: a Monocentric Prospective Study.

BACKGROUND: Delirium occurs frequently in acute internal medicine wards and may worsen the patient's prognosis; it deserves a fast, systematic screening tool. OBJECTIVE: Develop a delirium screening score for inpatients admitted to acute internal medicine wards. DESIGN: A monocentric prospective study between November 2019 and January 2020. PARTICIPANTS: Two hundred and seventeen adult inpatients. MAIN MEASURES: Within 48 h of hospital admission, physicians administered an index test to participants which explored potential predictors associated with the fluctuation of mental state, inattention, disorganised thinking and altered level of consciousness. On the same day, patients underwent a neuropsychological evaluation (reference standard) to assess for delirium. The score was constructed using a backward stepwise logistic regression strategy. Areas under the receiver operating curves (AUC) and calibration curves were drawn to calculate the score's performance. The score was tested on subgroups determined by age, sex and cognitive status. RESULTS: The AL-O-A score ("abnormal or fluctuating ALertness, temporospatial Orientation and off-target Answers") showed excellent apparent (AUC 0.95 (95% CI 0.91-0.99)) and optimism-corrected discrimination (AUC 0.92 (95% CI 0.89-0.96)). It performed equally well in subgroups with and without cognitive impairment (AUC 0.93 (95% CI 0.88-0.99) vs 0.92 (95% CI 0.80-0.99)); in men and women (AUC 0.96 (95% CI 0.94-0.99) vs 0.95 (95% CI 0.89-0.99)); and in patients younger and older than 75 years old (AUC 0.98 (95% CI 0.95-0.99) vs 0.93 (95% CI 0.87-0.99)). CONCLUSIONS: A simple, 1-min screening test (AL-O-A score), even administered by an untrained professional, can identify delirium in internal medicine patients.

Acute cytokine release syndrome after a first dose of pembrolizumab as second-line treatment for metastatic, programmed death-ligand 1-positive, non-small-cell lung cancer.

INTRODUCTION: The use of programmed death-ligand 1 (PD-L1) checkpoint inhibitor therapy is expanding, although its adverse effects are not completely known. We report on a rare case of acute cytokine release syndrome related to pembrolizumab use in a patient with lung cancer. CASE REPORT: A 79-year-old man with metastatic, PD-L1-positive, non-small-cell lung cancer developed a febrile condition associated with a systemic inflammatory response syndrome and suffered haemodynamic compromise four hours after the first intravenous administration of pembrolizumab. A thorough medical workup found no alternative cause and a grade 2 cytokine release syndrome (CRS) was diagnosed.Management and outcome: Aggressive fluid resuscitation and supportive therapy led to restitutio ad integrum. DISCUSSION: Acute CRS after the administration of a PD-L1 inhibitor is infrequent but could be a fatal condition. Supportive treatment and, if necessary, corticosteroids should be considered.

[Intensive care unit treatment for patients suffering from COVID-19: The second wave Neuchâtel experience]. / Traitement des patients souffrant de Covid-19 aux soins intensifs†: l'expérience neuchâteloise de la deuxième vague.

Between mid-October 2020 and mid-January 2021, during the second wave of COVID-19 pandemia, 125 patients have been admitted in the intensive care units of Neuchâtel network hospitals. To manage this flow, the bed capacity of intensive care unit increased by 240%. Each patient received corticosteroids, an increased prophylactic anticoagulation and an antibiotic. Similarly to the first wave, 51% patients received mechanical ventilation, 55% of which in prone position. Concerning the drug treatments, 16 patients were treated with tocilizumab and 4 with remdesivir. Despite an unprecedented rise in the number of ventilated beds, 15 patients were transferred out of the region of Neuchâtel in order to prevent a saturation point of the system. The mortality rate in the intensive care unit reached 16% of the admitted and non-transported patients.

Entre mi-octobre 2020 et mi-janvier 2021, durant la deuxième vague de pandémie de Covid-19, 125 patients ont séjourné aux soins intensifs du Réseau hospitalier neuchâtelois. Pour pouvoir recevoir cet afflux, la capacité d'accueil a augmenté de 240 %. Tous les patients ont bénéficié d'un traitement par glucocorticoïdes ainsi que d'une anticoagulation prophylactique majorée et d'une antibiothérapie. Similairement à la première vague, 51 % des patients ont nécessité une ventilation mécanique, dont 55 % ont bénéficié d'une ventilation en décubitus ventral. Par ailleurs, 16 patients ont bénéficié du tocilizumab et 4 du remdésivir. Malgré une augmentation hors norme du nombre de lits ventilés, 15 patients ont dû être transférés hors canton afin de prévenir une saturation du système. Le taux de mortalité des patients non transférés admis aux soins intensifs s'est élevé à 16 %.

[Intensive care unit treatment for patients suffering from COVID-19: the Neuchâtel experience]. / Traitement des patients souffrant de Covid-19 aux soins intensifs : l'expérience neuchâteloise.

SARS-CoV-2 appeared in Switzerland in February 2020 and reached Neuchâtel in March. During 2 months, 43 patients were admitted in the intensive care unit. 55% of ICU admitted patients received mechanical ventilation, 66% of which in prone position. All patients were treated with hydroxychloroquine. The majority of patients received antiretrovirals. One patient was treated with remdesivir. Near half the patients were treated with tocilizumab. One patient received a convalescent plasma obtained from patients who had recovered from COVID-19. The mortality rate was 17%. These results are in line with those from university intensive care units in Switzerland.

Le SARS-CoV-2 est apparu en Suisse en février 2020, avec les premiers cas déclarés dans le canton de Neuchâtel en mars. 43 patients ont été admis aux soins intensifs du Réseau hospitalier neuchâtelois sur une période de 2 mois. 55 % ont été intubés et ventilés, dont 66 % ont bénéficié d'une ventilation en décubitus ventral. Tous les patients ont été traités par hydroxychloroquine. Les traitements antirétroviraux ont été introduits dans la majorité des cas. Une patiente a bénéficié de remdésivir. Près de la moitié des patients ont été traités par tocilizumab. Un patient a bénéficié de la transfusion de plasma de patients convalescents. Le taux de mortalité a atteint 17 %. Ces résultats sont comparables à ceux des centres universitaires de soins intensifs en Suisse.

Neurological diagnostic tests for patients with and without delirium: a prospective observational study.

Since most of the precipitating factors of delirium are not due to neurological disorders, neurological diagnostic tests (NDTs) may be of limited value. We hypothesized that delirium has a high burden of NDTs with a low diagnostic yield. All patients admitted to the internal medicine wards of a single secondary teaching hospital between November 2019 and January 2020 were eligible. Within the first 48 h of their admission, they had a formal evaluation by a neuropsychologist to screen for presence of delirium. NDTs (brain MRI, brain CT, electroencephalography (EEG), and lumbar puncture) performed during the hospital stay were compared between patients with and without delirium using a logistic regression model stratified by a propensity score. The proportions of diagnostic yield (acute anomalies that changed the treatment management) provided by each type of examination were compared. Of 217 patients included, 19/32 patients (61%) with delirium had one or more NDTs, compared to 48/185 (26%) without delirium (adjusted OR 2.7; 95%CI 1.1-6.7; p = 0.027). The proportions of NDT results affecting management for patients with and without delirium were 13 and 20% for brain CT scans (p = 0.71), 29 and 38% for brain MRI (p = 0.99), and 20 and 10% for EEGs (p = 0.99), respectively. The higher proportion of NDTs performed on patients with delirium was associated with a low diagnostic yield, although not statistically different from those performed among inpatients without delirium. There is a need for restrictive, evidence-based guidelines to help with the work-up for patients with delirium.

Fatal fulminant hepatitis in a patient taking abiraterone acetate: a case report.

Abiraterone acetate is a steroidal inhibitor of cytochrome P450 17A1 indicated in the treatment of metastatic prostate cancer. This report examines the case of a 66-year-old patient diagnosed with prostate adenocarcinoma that had metastasized to the bones and lymph nodes. Treatment with abiraterone acetate and corticosteroid co-administration as well as LH-RH analog hormone therapy was initiated. Four and a half months later, the patient consulted for deterioration of general condition. Biologically, he developed a fulminant hepatitis of which he eventually died. An infectious or metabolic origin was ruled out. Oncological cause by either disease progression or second neoplastic process was eliminated by means of imaging. Hepatic toxicity was imputed to the treatment with abiraterone acetate. This case suggests that fulminant hepatitis on abiraterone acetate may be underestimated, and underscores the importance of regular monitoring of liver tests on this therapy.

[Adult severe community-acquired pneumonia: from diagnosis to intensive care]. / Pneumonie communautaire sévère de l'adulte: du diagnostic aux soins intensifs.

Severe community-acquired pneumonia is defined as a pneumonia acquired in an extra-hospital setting requiring intensive care. Clinical scores such as the ATS modified rule can help the clinician to recognize quickly the patients needing ICU. Evidence based interventions decreasing mortality consist of rapid administration of antibiotics, by probably privileging an association containing a macrolide, as well as fast and specialized care of shock and respiratory failure. Severe community-acquired pneumonia is burdened by a short and long-term important mortality.

Rare case of bilateral pleural effusion caused by pancreaticopleural fistula.

A 51-year-old man presented with dyspnoea and basithoracic pain. Chest X-ray revealed bilateral pleural effusion, which was managed by bilateral chest drain placement. The pleural fluid analysis showed elevated lipase. Subsequent endoscopic retrograde cholangiopancreatography (ERCP) demonstrated a large fistula from the tail of the main pancreatic duct to the left pleural space. Definitive treatment was accomplished with ERCP guided large pancreatic stents placement.

Toxic epidermal necrolysis after topical intranasal application of mupirocin.

We describe a case of toxic epidermal necrolysis after intranasal application of mupirocin in a 76-year-old woman. The drug was given for eradication of methicillin-resistant Staphylococcus aureus.

Life-threatening pulmonary embolism associated with a thrombus straddling a patent foramen ovale: report of a case.

BACKGROUND AND AIM: A biatrial thrombus straddling a patent foramen ovale (PFO) is rare. The optimal management is controversial. This report offers an additional report and brief review of the literature. CASE REPORT: A 72-year-old female presented with paroxysmal dyspnea. Transthoracic echocardiography showed distended right heart cavities, pulmonary artery hypertension, and a thrombus in the right atrium passing through the PFO into the left atrium. Urgent surgical embolectomy confirmed an 11.5 cm serpentine biatrial thrombus and allowed PFO closure and bilateral pulmonary embolectomy. Postoperative recovery was uneventful. CONCLUSIONS: The risk of systemic embolization during thrombolytic or heparin treatment for biatrial thrombus makes most authors recommend surgical or interventional thrombectomy and PFO closure. Given the limited number of cases, there is no evidence that any of the treatment strategies provide a better survival.