Bilateral acute non-obstructive pyelonephritis presenting as acute kidney injury requiring haemodialysis.

A 54-year-old female patient with hypothyroidism and diabetes mellitus type 2 was brought to emergency room by the family members for acute change in mental status. The laboratory evaluation demonstrated findings consistent with acute renal failure (normal renal function 3 months prior to presentation). She was initiated on hemodialysis due to lack of improvement in renal function. Urine culture done prior to initiation of antibiotics was positive for Escherichia coli, which was later confirmed by renal biopsy. Extensive workup for the cause of renal failure including for connective tissue disease, plasmacytoma, obstruction was negative. She was treated with 6 week course of antibiotics with eventual recovery of her renal function in 4 months.

Supraventricular tachycardia and acute confusion following ingestion of e-cigarette fluid containing AB-FUBINACA and ADB-FUBINACA: a case report with quantitative analysis of serum drug concentrations.

BACKGROUND: AB-FUBINACA and ADB-FUBINACA are structurally similar synthetic cannabinoids with potent CB1 receptor agonistic effects. Very little is known about their pharmacology and toxicology. OBJECTIVE: To report a case of supraventricular tachycardia and acute confusion after ingestion of e-cigarette fluid containing AB-FUBINACA and ADB-FUBINACA, with quantitative analysis of the serum drug concentrations. CASE REPORT: A healthy 24-year-old man ingested two drops of e-cigarette fluid which were later found to contain AB-FUBINACA and ADB-FUBINACA. Within 30 min of ingestion, he became somnolent, confused, and agitated, with palpitation and vomiting. On arrival to the emergency department, a short run of supraventricular tachycardia was noted, which resolved spontaneously. Bedside urine immunoassay failed to detect recreational drugs. Laboratory blood tests showed mild hypokalemia. Exposure to AB-FUBINACA and ADB-FUBINACA was confirmed analytically, with serum concentrations of 5.6 ng/mL and 15.6 ng/mL, respectively, in the blood sample collected on presentation. The patient recovered uneventfully with supportive treatment and was discharged 22 h after admission. DISCUSSION: AB-FUBINACA and ADB-FUBINACA are orally bioavailable with rapid onset of toxicity after ingestion. In this case, supraventricular tachycardia was likely the result of exposure to AB-FUBINACA and ADB-FUBINACA. The serum concentrations of AB-FUBINACA and ADB-FUBINACA were higher than those previously reported in fatal cases. CONCLUSION: In the context of acute poisoning, the presence of unexplained tachyarrhythmias, confusion, and a negative recreational drug screen should prompt clinicians to consider synthetic cannabinoid toxicity as a differential diagnosis.

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).

LGI1 encephalitis: a disease of jerks and confusion.

Limbic encephalitis is a group of immune-mediated disorders that includes the classic paraneoplastic encephalitic syndrome and the recently described non-paraneoplastic autoimmune encephalitis most of which target the extracellular antigens. We present a case of 70-year-old man who presented with rapidly progressive cognitive decline and refractory faciobrachial dystonic seizures and demonstrated seropositivity for leucine-rich, glioma-inactivated protein 1 antibodies. After immunomodulation, the patient had dramatic improvement in the cognitive functioning and in seizure control.

[Psychiatric disorders in palliative care and at the end of life]. / Les troubles psychiatriques en soins palliatifs et en fin de vie.

Patients confronted to advanced organic diseases at a palliative stage can present psychological distress that might announce the occurrence of genuine psychiatric disorders. Some frequent and comprehensible symptoms such as sadness, mild agitation, anxiety or more disturbing such as hallucinations, delusions or suicidal ideations must alert the clinician who should not minimize them by attributing them in a reactive way to the consequences of the evolution of physical disease or treatment's side effects. Literature data regarding psychiatric disorders (mainly anxiety disorders, delirium and depressive disorders) in palliative care are emerging and can guide clinicians in their role to detect them and providing early and efficient management. Occurrence of warning symptoms of psychiatric disorders can impaired quality of life and impact the prognosis of patients already weakened by the context of an advanced physical disease. The clinician will have to be careful to any psychiatric prodromic symptom and not hesitate to treat and to refer if necessary to a heath mental professional.

[Dyspnea, hypoxia and a confusional state--a post-recovery diagnosis].

We present a case of a 48 year old female, with a medical history significant for paraplegia due to a cervical cord injury and a history of transitional cell carcinoma, which necessitated a urinary bladder ileal reconstruction. The patient was hospitalized due to an acute confusional state, severe respiratory distress and hemolytic anemia. One day prior to hospitalization, she was involved in a minor motor vehicle accident, yet she and her family denied any injuries due to the accident and the patient did not complain of pain. During the course of her hospitalization the patient was febrile, yet we did not find any evidence of an infectious cause for her symptoms. Notably, lumbar puncture and MRI scan were relatively contraindicated, hence a CNS infection was not completely ruled out. We also thoroughly investigated her respiratory symptoms, but could not reach a conclusive diagnosis. Nevertheless, after approximately 14 days of diagnostic efforts, empirical antibiotic treatment and supportive care, all clinical and laboratory abnormalities had resolved. The patient was discharged with a presumed diagnosis of a poorly understood infectious process. However, not long after, she returned to the emergency department complaining of a red, painful, swollen right knee. Imaging studies demonstrated a right supracondylar as well as a tibial plateau fracture. Consequently, a post-recovery diagnosis of fat emboli syndrome was made.

Bortezomib-induced thrombotic thrombocytopaenic purpura.

Thrombotic thrombocytopaenic purpura (TTP) is a thrombotic microangiopathy characterised by haemolytic anaemia, schistocytes on peripheral blood smear and thrombocytopaenia that can additionally present with fever, renal insufficiency and/or neurological abnormalities. While our understanding of idiopathic TTP has significantly advanced, there are still many unanswered questions regarding the pathophysiology of secondary TTP, which can be associated with malignancy, pregnancy, HIV infection, bone marrow transplantation and exposure to certain drugs including several chemotherapeutic agents. Here we present a case of bortezomib-associated TTP. Our patient developed microangiopathic haemolytic anaemia, thrombocytopaenia and altered mental status after her ninth dose of bortezomib. The drug was subsequently discontinued and the patient underwent one session of plasma exchange with clinical improvement and recovery of her platelet counts, disappearance of schistocytes and resolution of both neurological symptoms and haemolysis in 2 days.

What is special about patients with lung cancer and pulmonary metastases in palliative care? Results from a nationwide survey.

BACKGROUND: Patients with advanced lung cancer constitute a special focus in palliative care not only for epidemiological or prognostic reasons, but also because their symptom burden is felt to be widespread and difficult to treat. This study describes disease-specific characteristics and the symptom burden of patients with advanced incurable lung cancer, comparing them with patients suffering from other diseaseentities. METHODS: A secondary analysis of the nationwide Hospice and Palliative Care Evaluation (HOPE) was performed, by focussing on inpatient hospice and palliative care unit patients and by using descriptive methods. RESULTS: From 2006 to 2008, 5487 inpatients were registered, 874 of which were diagnosed with lung cancer and 1884 with pulmonary metastases. Symptoms such as weakness, tiredness, or pain were most prevalent in all subgroups. Dyspnea was significantly more prevalent in all patients with different kinds of pulmonary tumor manifestations; confusion was significantly more prevalent in patients with lung cancer. Dyspnea could not be treated as effectively as pain or nausea. Confusion and nursing problems worsened during the observation period. Dyspnea and confusion were associated with increased risk of death during the observational period. CONCLUSION: The symptom pattern of patients with lung cancer is characterized by dyspnea and confusion--symptoms that are difficult to treat until discharge and that imply a worse prognosis. Therefore, increased research on the pathophysiology and treatment of dyspnea and confusion is required, and efforts in advance care planning and anticipation of dyspnea and confusion as a critical symptom in patients with lung cancer should be reinforced.

Supportive care in neurooncology.

The quality of life of patients treated for brain tumor is, in all cases, deeply altered by the tumor and the treatments. Optimizing the symptomatic management is a key objective for all care givers. We present in this paper a very pragmatic focus concerning the management of intracranial hypertension (and/or neurological deficits), venous thromboembolism, confusion, epilepsy and symptoms more directly associated with the end of life.

A randomized study of the effectiveness of a brief psychosocial intervention for women attending a gynecologic cancer clinic.

OBJECTIVES: While there are many psychosocial interventions for cancer patients, few are brief in nature. The aim of this study was to investigate the usefulness of a single-visit psychosocial intervention for gynecologic cancer patients. METHODS: One hundred women attending a gynecologic cancer clinic as new patients were randomized to receive no intervention or a one-time meeting with a psychologist who discussed issues and concerns the woman might have about her cancer diagnosis. Thirty-eight of the women had a current or previous cancer. The women were given questionnaires measuring mood and quality of life at baseline, two weeks and three months after the intervention. RESULTS: At baseline, 43 of the women in the control group completed questionnaires, as did 45 women randomized to the intervention. 21 of these women received the intervention. Women who received the intervention had greater decreases in anxiety, depression and overall distress over time. The control group also had decreases in anxiety and overall distress over time, but had an increase in depression. The women in the intervention group increased in physical, emotional, functional, and overall well being, while the control group only had a slight increase in overall well being over time. The difference between the groups in emotional well being at Time 2 approached significance (p=.08). The intervention group had increases in positive coping at Time 2, while the control group decreased (p's ranged from .02-.10). Three month follow-up data were available for 23 women in the control group and 15 in the intervention group. At Time 3 functional well being was significantly higher in the intervention group (p=.04). Information seeking and affect regulation remained higher in the intervention than the control group (p's=.002 and .02, respectively). When the women with cancer or previous cancer were examined, significant differences were seen for affect regulation at baseline (p=.0007), and anger two weeks later (p=.04), with the women in the control group being more angry. Utilization of other cancer resources was low with 12% of the women reporting that they used the Cancer Resource Center. CONCLUSIONS: The results of this study show that there was a positive effect towards coping and quality of life for a one-time psychosocial intervention after the first visit to a gynecologic oncology practice. Women who were randomized to the intervention but did not go were more distressed at baseline than the women who did go. This suggests that incorporating psychosocial services as an integrated part of the new patient consultation may be very important to address patient's distress. Future studies with larger sample sizes may reveal more significant differences. Strategies to overcome the poor utilization of the cancer resource center are also clearly needed to improve awareness of these resources.

An unusual intracranial tumour presenting in pregnancy.

We describe a patient who presented in late pregnancy with deteriorating neurological status due to an intracranial capillary haemangioma causing mass effect and raised intracranial pressure. She became confused and uncooperative leading to practical difficulties in performing adequate radiological imaging. Decision regarding timing of delivery and craniotomy was not straightforward and required discussion between the neurosurgeon, obstetrician and anaesthetist based on assessment of fetal maturity and the need to perform a craniotomy to excise what was initially thought to be a meningioma. Caesarean section was performed under general anaesthesia. The tumour was resected three weeks later. Management of obstetric patients with brain tumours is complex, requiring knowledge of the physiological effects of pregnancy on tumour size and labour on intracranial pressure. Both of these may influence the choice of labour analgesia or anaesthesia for caesarean section. Anaesthetists must be aware of the difficulties of radiological imaging during pregnancy, particularly in confused patients. The conflicting requirements of general anaesthesia for craniotomy and caesarean section should be considered.

Acute myocardial infarction as the presenting symptom of acute myeloblastic leukemia with extreme hyperleukocytosis.

This case report deals with an unusual leukostatic complication in a 56-year-old woman with acute myeloblastic leukemia (AML) and extreme hyperleukocytosis (316 x 10(9)/L) who presented with acute myocardial infarction (MI). After leukopheresis the patient achieved hemodynamic stabilization and rapid neurologic recovery of encephalopathy that had also developed after the infarction. Considering the central role of WBC in the remodeling of post MI myocardial tissue, it was obvious that administration of chemotherapy with its subsequent inevitable pancytopenia could impose an increased risk for further cardiac complications including myocardial rupture. Nevertheless, cytarabine-based induction chemotherapy was initiated 3 days after admission, and she achieved prolonged complete remission. Coronary angiography disclosed segmental atherosclerosis, but the only significant obstruction was in the right coronary artery. The patient died with relapsed leukemia 7 years later without recurrence of any cardiac symptoms or signs. Autopsy disclosed segmental coronary atherosclerosis involving the LAD (60% obstruction), suggesting that atherosclerosis was a predisposing risk factor. Additional compromise to blood perfusion due to leukostasis had led to this unusual complication of AML involving a major vessel. This is the first documented case of leukostasis causing coronary artery occlusion as well as the first report of successful induction chemotherapy for AML during a myocardial infarction.

Non-convulsive status epilepticus: a treatable cause of confusion in pituitary apoplexy.

Confusion occurring in pituitary apoplexy is well described. We describe a case of pituitary apoplexy associated with confusion, occurring as a result of non-convulsive status epilepticus. Electroencephalography should be performed in pituitary apoplexy associated with confusion if this treatable and potentially serious complication is not to be missed.

Treatment of agitation in dementia.

Behavioral and psychological signs and symptoms associated with dementia are common and often confusing because they do not meet criteria for typical discrete psychiatric disorders. Although the symptoms tend to occur in clusters, the clusters often vary with time and between patients. Recognizing the behavioral pathology associated with dementia is important because it can be distressing to the patient, lead to dangerous interactions with others or the environment, and result in the use of inappropriate psychotropic medications. A practical, general approach to the evaluation and management of agitation in dementia for psychiatric consultants confronted with such problems is proposed.