Accuracy of oncologist assessments of psychiatric problems in cancer inpatients.

OBJECTIVE: Our objective was to examine the accuracy of non-psychiatrist assessments of psychiatric problems in cancer patients. METHOD: We conducted a retrospective chart review of cancer patients who were admitted and referred to the consultation-liaison (C-L) team between January of 2011 and December of 2012. The agreement between non-psychiatrist assessments and final diagnoses by attending C-L psychiatrists was estimated for every category of referral assessment using codes from the International Classification of Mental and Behavioral Disorders (10th revision). The data were obtained from the consultation records of 240 cancer inpatients who were referred to the C-L service at a tertiary care center in Tokyo. RESULTS: The agreement ratio between referring oncologists and psychiatrists differed according to the evaluation categories. The degrees of agreement for the categories of "delirious," "depressive," "dyssomnia," "anxious," "demented," "psychotic," and "other" were 0.87, 0.43, 0.51, 0.50, 0.27, 0.55, and 0.57, respectively. The agreement for all patients was 0.65. Significant differences were observed among seven categories (chi-squared value = 42.454 at p < 0.001 and df = 6). The analysis of means for proportions showed that the degree of agreement for the "delirious" category was significantly higher and that that for the "depressive" category was lower than that for all patients, while for the "demented" category it was close to the lower decision limit but barely significant. One half of the 20 cases who were referred as depressive were diagnosed with delirium, with one quarter of those having continuously impaired consciousness. Some 7 of the 11 cases who were referred as demented were diagnosed as having delirium. SIGNIFICANCE OF RESULTS: The accuracy of non-psychiatrist assessments for psychiatric problems in cancer patients differs by presumed diagnosis. Oncologists should consider unrecognized delirium in cancer inpatients who appear depressed or demented.

How can we identify patients with delirium in the emergency department?: A review of available screening and diagnostic tools.

Delirium is a widespread and serious but under-recognized problem. Increasing evidence argues that emergency health care providers need to assess the mental status of the patient as the "sixth vital sign". A simple, sensitive, time-efficient, and cost-effective tool is needed to identify delirium in patients in the emergency department (ED); however, a stand-alone measurement has not yet been established despite previous studies partly because the differential diagnosis of dementia and delirium superimposed on dementia (DSD) is too difficult to achieve using a single indicator. To fill up the gap, multiple aspects of a case should be assessed including inattention and arousal. For instance, we proposed the 100 countdown test as an effective means of detecting inattention. Further dedicated studies are warranted to shed light on the pathophysiology and better management of dementia, delirium and/or "altered mental status". We reviewed herein the clinical questions and controversies concerning delirium in an ED setting.

One-year follow up after admission to an emergency department for drug overdose in Japan.

AIM: The aim of the study was to investigate the incidence of and risk factors for repetition of suicidal behavior within a year after admission for drug overdose in Japan. METHODS: Patients admitted to the emergency department of a general public hospital in Tokyo for drug overdose of prescribed medicine and/or over-the-counter drugs between March 2008 and February 2009 were followed up after 1 year. Demographic characteristics, previous suicide attempts, and mental health state were examined by self-report questionnaire and interview at recovery from the initial attempt. Information about suicidal behavior during the follow-up period was obtained from the outpatient psychiatrists by postal questionnaire 1 year after discharge. RESULTS: Of 190 patients admitted to the emergency department, 132 patients answered the questionnaire and had the interview. Information about thefollow-up period for 66 patients was obtained. Of the 66 patients, 28 patients attempted suicide again and two patients committed suicide during the 1-year follow-up period. Psychiatric diagnosis of personality disorder and denial of suicidal intent at the time of recovery were associated with increased risk for another suicide attempt. Lethality levels of suicidal behaviors before and after admission were associated with each other. CONCLUSION: The rate of fatal and non-fatal suicide attempt within a year after admission for self-poisoning was substantial. Psychiatric diagnosis of personality disorder was a risk factor for repetition of suicide attempt. Clinicians should pay attention to the means of previous suicide attempts even though the patient denies suicidal intent at recovery.

Periodic Slow Waves Presenting as Ictal Electroencephalography Findings in Complex Partial Status Epilepticus.

The diagnosis of nonconvulsive status epilepticus (NCSE) largely relies on electroencephalography (EEG) findings, but the existing diagnostic criteria for EEG results are sometimes inconsistent. Much debate has centered on periodic epileptic discharges (PEDs) and their relationship with seizures. The recently published Salzburg Consensus Criteria for diagnosis of NCSE, which consider PEDs to be ictal findings under several conditions, have been proven to have high diagnostic accuracy. However, the criteria do not include periodic slow waves (PSWs) and do not consider these as overall ictal electrographic changes. Here, we report 2 cases of complex partial status epilepticus in which routine EEG showed PSWs without epileptiform activity during the clinical ictal phase. Both patients were elderly males who had histories of seizures and presented with impaired consciousness and signs such as aphasia or tongue automatism that indicated a temporal lobe origin. After we administered antiepileptic drugs (AED), the clinical signs and periodic EEG slow waves disappeared. These cases show that PSWs may appear as ictal electrographic changes in NCSE. When PSWs accompany clinical signs suggestive of NCSE, they should be considered ictal findings, and physicians should administer AED.