Too Much of a Good Thing: Severe Hypercalcemia Presenting with Lethargy and Kidney Failure.

INTRODUCTION: We present a case of a 58-year-old man with a history of laryngo-pharyngectomy including bilateral thyroidectomy due to hypopharyngeal cancer presenting with lethargy, acute kidney failure, and hypercalcemia. Milk alkali syndrome was diagnosed given the history of high-dose calcium / vitamin D supplementation after ruling out other causes of hypercalcemia. After initial treatment with normal saline, furosemide and denosumab, the patient developed severe symptomatic hypocalcemia as a rare adverse effect of denosumab.

Evaluation of short-term adverse events of COVID-19 vaccines: An observational study.

Coronavirus disease 2019 (COVID-19) vaccines are the most effective tools in managing the pandemic. However, the concern about these vaccines is the occurrence of unwanted adverse events (AEs). This study aimed to evaluate the short-term AEs of COVID-19 vaccines (Sputnik V, Astrazenka, and Sinopharm). A cross-sectional study using an online questionnaire was conducted among 321 vaccinated individuals. Demographic information, history of drug use, prior infection with COVID-19, the type of vaccine, vaccination stage, local injection site complication, systemic complication, and allergic reactions were collected and evaluated. Local complications, including pain and swelling at the injection site, and systemic complications, including fever, fatigue, lethargy, lymphadenopathy, and diarrhea, were reported after the injection of the AstraZeneca vaccine was more than the other 2 vaccines; The prevalence of fatigue and lethargy was higher than other systemic complications. The least reported complication was due to lymphadenopathy. The Sinopharm vaccine showed a lower prevalence of AEs than the other 2. The rare AEs, such as facial paralysis, nasal bleeding, and urticarial, were further reported after injection of the AstraZeneca vaccine. In general, the severity of systemic complications after the second dose of the vaccine was also higher than the first dose. All 3 vaccines were safe and tolerable. The most commonly reported AEs were injection site pain (local) and fatigue and lethargy (systemic). These expected AEs occurred shortly after vaccination and indicated an early immune response after vaccination.

Management of Choroid Plexus Tumors and the Benefit of Preoperative Embolization in Pediatric Patients: Report of 46 Cases from a Single Institution.

OBJECTIVE: Optimal choroid plexus tumor (CPT) treatment involves gross total resection; however, intraoperative hemorrhage risk remains significant given tumor vascularity. This study describes pediatric CPT management and identifies patients most likely to benefit from preoperative embolization. METHODS: CPTs resected from 1997 to 2021 were included. The characteristics of embolized patients were compared to nonembolized patients; nonembolized patients were further stratified based on open vascular control-pedicle feeder ligation versus no pedicle ligation prior to tumor debulking. Statistical analyses identified factors associated with estimated blood loss (EBL), transfusion, length of stay, and complications. RESULTS: Among the 46 CPT cases identified, 98% achieved gross total resection, and 15% received embolization. Embolized patients were younger, smaller, and had larger tumors compared to nonembolized patients (median: 0.8 vs. 2.1 years; 9.3 vs. 14.4 kg; 91.08 vs. 5.5 cm3). Transfused patients were similarly younger and smaller (P < 0.05) than nontransfused patients. Among nonembolized patients, open vascular control was achieved in smaller tumors (<13 cm3) with significantly lower EBL (P = 0.002). Higher EBL was observed in patients with larger tumors, hydrocephalus, transependymal edema, vomiting, lethargy, and developmental regression (all P < 0.05). Patients with lethargy had longer hospital stays and a higher likelihood of postoperative complications (P < 0.05). There were no significant differences in complication rates between the embolization and nonembolization groups. CONCLUSIONS: Despite higher surgical risk profiles, embolized patients had similar complication rates and postoperative hydrocephalus management as nonembolized patients. Embolization was particularly beneficial in patients at high risk for surgical morbidity, such as those <2 years, weighing <10 kg, and with a tumor volume >15 cm3.

Changes in depression symptom profile with gender-affirming hormone use in transgender persons.

BACKGROUND: Women show higher prevalence of depression and different symptomatology than men, possibly influenced by sex hormones. Many transgender persons, who face a high risk of depression, use Gender-Affirming Hormone Therapy (GAHT), but the impact of GAHT on depressive symptom profiles is unknown. METHODS: This study examined depressive symptoms in transgender persons before GAHT and after 3- and 12 months of GAHT. We used the Inventory of Depressive Symptomatology-Self Report to assess depressive symptoms, exploratory factor analysis (EFA) to assess symptom clusters, and linear mixed models to assess changes in symptom clusters. RESULTS: This study included 110 transmasculine (TM) and 89 transfeminine (TF) participants. EFA revealed four symptom clusters: mood, anxiety, lethargy, and somatic symptoms. Changes in total depressive symptoms significantly differed between TM and TF groups. After 3 months of GAHT, TM participants reported improvement in lethargy (-16 %; 95%CI: -29 %; -2 %), and after 12 months TF participants reported worsening in low mood (24 %; 95%CI: 3 %; 51 %), but absolute score changes were modest. Neither group showed changes in anxiety or somatic symptoms. LIMITATIONS: This study had limited sample sizes at 12 months follow-up and did not include relevant biological or psychosocial covariates. DISCUSSION: Changes in depressive symptoms after GAHT use differ in TM and TF persons: TM persons report slight improvements in lethargy, whereas TF persons report a slight increase in low mood. Starting GAHT represents a significant life event with profound social and physical effects, and further research should assess social and biological effects of GAHT on mood-related symptoms.

A 44-Year-Old Woman With Prolonged Fever and Mediastinal "Lymphadenopathy".

CASE PRESENTATION: A 44-year-old woman with a history of dyslipidemia and chronic anemia from uterine fibroids was admitted to the general medicine department of a tertiary hospital for a prolonged fever of 2 months' duration. The patient reported multiple visits to her local general practitioner, with tympanic temperatures up to 38.2 °C, where she was treated with 2 courses of broad-spectrum antibiotics in view of associated sore throat, nonproductive cough, and generalized lethargy. Although her respiratory symptoms abated within a few days of her initial presentation, her fever and lethargy persisted. Initial chest radiograph was unremarkable. Subsequent CT scan of the thorax, abdomen, and pelvis detected an enlarged subcarinal lymph node measuring 3.7 cm × 1.7 cm and a mildly enlarged pre-carinal lymph node measuring 2.0 × 1.5 cm, with a mean attenuation of 66-77 Hounsfield Units (HU), and no central necrosis or calcification. No significant abnormalities were detected in the abdomen or pelvis. The patient was then referred to the respiratory department for further evaluation.

Occurrence and risk factors of feline immunodeficiency virus (FIV) and feline leukaemia virus (FeLV) in cats of Lebanon.

A cross-sectional study was carried out between April 2020 and August 2021. Blood samples were collected from 260 household cats recruited in different clinics in North and Mount Lebanon, with the aim of determining the seroprevalence of feline immunodeficiency virus (FIV) and feline leukaemia virus (FeLV). The seroprevalence reported reached 18.84% (95% CI 0.14-0.24) and 13.84% (95% CI 0.09-0.18) for FIV and FeLV, respectively. FIV seropositivity was associated with a younger age, health and neuter status, lymphoma, lethargy, and vomiting. Furthermore, male sex, neuter status, lymphoma, anaemia, lethargy, and vomiting were significantly associated with FeLV seropositivity. This first data from Lebanon emphasizes the need for implementing preventive programmes to cope with FIV- and FeLV-associated morbidity and mortality among cats.

Brainstem ADCYAP1+ neurons control multiple aspects of sickness behaviour.

Infections induce a set of pleiotropic responses in animals, including anorexia, adipsia, lethargy and changes in temperature, collectively termed sickness behaviours1. Although these responses have been shown to be adaptive, the underlying neural mechanisms have not been elucidated2-4. Here we use of a set of unbiased methodologies to show that a specific subpopulation of neurons in the brainstem can control the diverse responses to a bacterial endotoxin (lipopolysaccharide (LPS)) that potently induces sickness behaviour. Whole-brain activity mapping revealed that subsets of neurons in the nucleus of the solitary tract (NTS) and the area postrema (AP) acutely express FOS after LPS treatment, and we found that subsequent reactivation of these specific neurons in FOS2A-iCreERT2 (also known as TRAP2) mice replicates the behavioural and thermal component of sickness. In addition, inhibition of LPS-activated neurons diminished all of the behavioural responses to LPS. Single-nucleus RNA sequencing of the NTS-AP was used to identify LPS-activated neural populations, and we found that activation of ADCYAP1+ neurons in the NTS-AP fully recapitulates the responses elicited by LPS. Furthermore, inhibition of these neurons significantly diminished the anorexia, adipsia and locomotor cessation seen after LPS injection. Together these studies map the pleiotropic effects of LPS to a neural population that is both necessary and sufficient for canonical elements of the sickness response, thus establishing a critical link between the brain and the response to infection.

Systemic calcinosis in a Quarter Horse gelding homozygous for a myosin heavy chain 1 mutation.

CASE DESCRIPTION: A 9-year-old Quarter Horse gelding was presented for lethargy, decreased appetite, polyuria and polydipsia (PU/PD), and severe muscle wasting suggestive of immune-mediated myositis. CLINICAL FINDINGS: The horse displayed lethargy, fever, tachyarrhythmia, inappetence, PU/PD, and severe epaxial and gluteal muscle wasting. Clinicopathologic findings were consistent with previously reported cases of systemic calcinosis in horses, including increased muscle enzyme activity, hyperphosphatemia, increased calcium-phosphorus product, hypoproteinemia, and an inflammatory leukogram. A diagnosis of systemic calcinosis was established by histopathologic evaluation of biopsy specimens from skeletal muscle, lung, and kidney. TREATMENT AND OUTCOME: Symptomatic treatment was complemented by IV treatment with sodium thiosulfate to reverse calcium-phosphate precipitation in soft tissue and PO aluminum hydroxide to decrease intestinal phosphorus absorption and serum phosphorus concentration. CLINICAL RELEVANCE: This is the first report in the veterinary literature of an antemortem diagnosis of systemic calcinosis in the horse that was successfully treated and had favorable long-term outcome.

[Clinical application of orofacial myofunctional therapy combined with muscle functionnal appliance in postoperative rehabilitation of children with OSA].

Objective:To explore the clinical significance of orofacial myofunctional therapy combined with muscle functional appliance in postoperative rehabilitation of children with OSA. Methods:Sixty children were diagnosed as moderate-to-severe OSA with AHI≥5 and underwent adenoid and/or tonsillar surgery. Children were divided into two groups based on whether they were willing to receive orofacial myofunctional therapy and muscle functional appliance after surgery. Lateral cephalogram and portable polysomnography were performed, and the pediatric OSA-18 scale was filled under the guidance of medical staff. The treatment group received combined treatment with orofacial myofunctional therapy and muscle functional appliance. Results:①General condition and subjective symptoms: The total score of OSA-18 in the treatment group was 65.15±11.25 preoperatively and 49.83±7.09 1-month postoperatively, while the score in the control group was 64.69±10.23 preoperatively and 48.07±6.87 1-month postoperatively. The results showed that postoperative sleep, physical symptoms, emotional status, daytime lethargy and energy status of patients, and their influence on their guardians were significantly improved in both groups（P<0.01）. The improvement of sleep disturbance, physical condition, daytime lethargy, the influence on their guardians were greater in the treatment group than in the control group 6-month and 12-month post-operatively（P<0.05）. These findings suggested that oral and facial muscle functional training combined with muscle functional appliance can provide greater improvement in general condition and subjective symptoms in the treatment group. ②PSG: Postoperative AHI and OAI were significantly decreased in both groups, while LSaO2 was significantly increased （P<0.01）, indicating that sleep respiratory function was significantly improved in both groups after treatment. Patients in treatment group showed greater AHI reduction and LSaO2 improvement 6-month and 12-month postoperatively（P<0.01）, indicating that oral and facial muscle functional training combined with muscle functional appliance can provide greater improvement in airway obstruction symptoms and sleep respiration. ③Radiological changes: SNB Angle was increased（P<0.05） and ANB Angle was decreased significantly（P<0.05）, while SPP-SPPW, U-MPW and TB-TPPW increased significantly in airway measurement 6-month and 12-month postoperatively （P<0.01）, indicating that after combined treatment with oral muscle functional training and muscle functional appliance, the mandible was moved forward and rotated clockwise. Conclusion:The combined treatment with oral muscle functional training and muscle functional appliance is more effective in improving oral breathing, upper airway sagittal structure and sleep breathing, and can correct oral habits of children. The long-term effect needs further investigation.

Canine and feline core vaccinations: US veterinarians' concerns and perceived impact of COVID-19 antivaccination views on veterinary medicine.

OBJECTIVE: Assess US veterinarians' perceptions regarding vaccine concerns (their own and owners') and the association between owners' vaccine concerns and COVID-19 antivaccination sentiments. SAMPLE: Members of the Veterinary Information Network. PROCEDURES: An electronic survey distributed via the Veterinary Information Network data collection portal. RESULTS: 1,341 US veterinarians completed the survey. Top veterinarian concerns for vaccinating a healthy adult dog were anaphylaxis, soreness at injection site, and lethargy; for cats, these concerns included vaccine-associated sarcoma, lethargy, and soreness at injection site. Veterinarians reported that the most common concerns mentioned by owners included that the pet does not go outside, that vaccinations are unnecessary, that vaccinations can lead to chronic or severe illness, and cost. Veterinarians reported an increased number of dog and cat owners reluctant about or resistant to the idea of rabies vaccines and core vaccines since the time that COVID-19 vaccines became widely available. There was an association between veterinarians' perceptions of local COVID-19 antivaccination sentiments and the increase in the number of vaccine-resistant or -concerned clients. CLINICAL RELEVANCE: There appears to be little overlap between veterinarians' primary concerns related to vaccinations and their perception of dog and cat owners' primary concerns. The fact that the number of resistant clients is positively associated with the presence of veterinarians' perceptions of a local COVID-19 antivaccination sentiment suggests that human antivaccination sentiments impact pet owners' views of companion animal vaccinations. A better understanding of the cognitive biases that impact owners' vaccine decisions can help veterinarians better communicate with vaccine-reluctant clients and increase vaccination compliance rates.

CT can identify characteristic features of hypaxial muscle abscesses in dogs due to presumed migrating vegetal foreign material as well as additional changes along the migratory tract in other anatomic regions.

Hypaxial muscle abscess is an important differential in dogs presenting for abdominal or back pain, lameness, and nonspecific signs like fever, lethargy, and hyporexia. It can occur concurrently with intrathoracic disease such as pyothorax secondary to migrating vegetal foreign material. Twelve dogs that underwent CT of the lumbar spine or abdomen and had a diagnosed hypaxial abscess on surgical and/or microbiological examination were included in this retrospective, descriptive case series. Computed tomography findings and findings from other imaging modalities employed were described. Eleven dogs were hunting breeds. Clinical signs included lethargy, fever, increased respiratory effort, and abdominal or back pain. Radiography and/or ultrasonography were employed during preliminary work up at clinician discretion and respectively revealed changes consistent with osteomyelitis in the cranial lumbar vertebrae and heterogenous, hypoechoic areas in the hypaxial musculature consistent with abscesses. Computed tomography findings included enlargement of hypaxial muscles with well-defined fluid attenuating noncontrast enhancing areas with a contrast-enhancing rim consistent with abscesses, periosteal reaction and lysis of vertebrae, and retroperitoneal effusion. Four of the 12 cases in this series had material identified and removed at surgery. The other eight cases were presumed to be the same disease process based on compatible signalment, imaging findings, and microbiological results. Migrating vegetal foreign bodies are a common problem at the authors' institution. Computed tomography provided expedient, thorough visualization of the relevant hypaxial lesions for diagnostic and surgical planning purposes and also characterized intrathoracic components of this disease.

COVID-19 associated multisystemic inflammatory syndrome in 614 children with and without overlap with Kawasaki disease-Turk MIS-C study group.

Multisystemic inflammatory syndrome (MIS-C) diagnosis remains difficult because the clinical features overlap with Kawasaki disease (KD). The study aims to highlight the clinical and laboratory features and outcomes of patients with MISC whose clinical manifestations overlap with or without KD. This study is a retrospective analysis of a case series designed for patients aged 1 month to 18 years in 28 hospitals between November 1, 2020, and June 9, 2021. Patient demographics, complaints, laboratory results, echocardiographic results, system involvement, and outcomes were recorded. A total of 614 patients were enrolled; the median age was 7.4 years (interquartile range (IQR) 3.9-12 years). A total of 277 (45.1%) patients with MIS-C had manifestations that overlapped with KD, including 92 (33.3%) patients with complete KD and 185 (66.7%) with incomplete KD. Lymphocyte and platelet counts were significantly lower in patients with MISC, overlapped with KD (lymphocyte count 1080 vs. 1280 cells × µL, p = 0.028; platelet count 166 vs. 216 cells × 103/µL, p < 0.001). The median serum procalcitonin levels were statistically higher in patients overlapped with KD (3.18 vs. 1.68 µg/L, p = 0.001). Coronary artery dilatation was statistically significant in patients with overlap with KD (13.4% vs. 6.8%, p = 0.007), while myocarditis was significantly more common in patients without overlap with KD features (2.6% vs 7.4%, p = 0.009). The association between clinical and laboratory findings and overlap with KD was investigated. Age > 12 years reduced the risk of overlap with KD by 66% (p < 0.001, 95% CI 0.217-0.550), lethargy increased the risk of overlap with KD by 2.6-fold (p = 0.011, 95% CI 1.244-5.439), and each unit more albumin (g/dl) reduced the risk of overlap with KD by 60% (p < 0.001, 95% CI 0.298-0.559). CONCLUSION: Almost half of the patients with MISC had clinical features that overlapped with KD; in particular, incomplete KD was present. The median age was lower in patients with KD-like features. Lymphocyte and platelet counts were lower, and ferritin and procalcitonin levels were significantly higher in patients with overlap with KD. WHAT IS KNOWN: • In some cases of MIS-C, the clinical symptoms overlap with Kawasaki disease. • Compared to Kawasaki disease, lymphopenia was an independent predictor of MIS-C. WHAT IS NEW: • Half of the patients had clinical features that overlapped with Kawasaki disease. • In patients whose clinical features overlapped with KD, procalcitonin levels were almost 15 times higher than normal. • Lethargy increased the risk of overlap with KD by 2.6-fold in MIS-C patients. • Transient bradycardia was noted in approximately 10% of our patients after initiation of treatment.

Anaplasma phagocytophilum in domestic cats from Germany, Austria and Switzerland and clinical/laboratory findings in 18 PCR-positive cats (2008-2020).

OBJECTIVES: Anaplasma phagocytophilum is considered the most significant rickettsial pathogen affecting cats. The organism is transmitted by ticks of the species Ixodes ricinus in Central Europe and can cause granulocytic anaplasmosis in pets, wildlife and humans. The aims of this study were to assess the frequency of positive test results for A phagocytophilum in cats in Germany, Austria and Switzerland, as well as to evaluate clinical and laboratory findings in cats with positive PCR results. METHODS: This study included the results of direct (PCR) and indirect detection methods (immunofluorescence antibody tests [IFAT]) requested by veterinarians in Germany, Austria and Switzerland between 2008 and 2020 from the LABOKLIN laboratory (Bad Kissingen, Germany). The veterinarians treating the PCR-positive cats were contacted by telephone to enquire about their clinical signs, laboratory findings, management and outcomes. RESULTS: In total, 244/1636 cats (15%) tested positive by direct (PCR: n = 27/725 [4%]) and/or indirect detection methods (IFAT: n = 221/956 [23%]). In 18/26 cats with PCR results positive for A phagocytophilum, additional information about clinical signs, laboratory findings, treatment and outcome was obtained. Of these 18 cats, five had comorbidities independent of their infection with A phagocytophilum. The most common clinical signs in PCR-positive cats (total/without comorbidities) were lethargy (83%/92%), fever (83%/85%) and thrombocytopenia (61%/62%). Overall, more than half (57%) of the cats with and without comorbidities recovered clinically. CONCLUSIONS AND RELEVANCE: Infections with A phagocytophilum should be considered as differential diagnoses in cats with tick infestation, lethargy, fever and thrombocytopenia. The clinical signs and laboratory findings are consistent with published case reports in cats. Ectoparasite prophylaxis in cats is recommended throughout the entire year.

Síndrome de enterocolite induzida por proteína alimentar como diagnóstico diferencial das alergias alimentares: relato de caso / Food protein-induced enterocolitis syndrome as a differential diagnosis for food allergies: a case report

A síndrome da enteropatia induzida por proteína alimentar, aguda ou crônica, é um tipo de alergia alimentar não mediada por IgE, que surge entre os 5 e 9 meses de idade, e é caracterizada por episódios de vômitos que começam aproximadamente 1 a 4 horas após a ingestão do alérgeno, algumas vezes acompanhados de letargia, palidez cutânea e diarreia com sangue, resultando em instabilidade hemodinâmica e choque em 15% dos casos. Sua epidemiologia em larga escala é desconhecida, assim como o mecanismo imunopatológico, no entanto, sugere-se um papel importante das células T no processo inflamatório. As manifestações e a gravidade dependem da frequência e da dose do alimento desencadeante, bem como do fenótipo e da idade de cada paciente. A suspeita se dá com base principalmente na história clínica e nos sintomas característicos da doença, que tendem a melhorar após a retirada do alimento suspeito. O teste de provocação oral é o padrão ouro para o diagnóstico, mas deve ser reservado para os casos em que a história é confusa e a hipótese incerta. A abordagem de primeira linha no tratamento visa corrigir a desidratação ou estabilizar o choque quando presente, e interromper imediatamente a oferta de alimentos com potencial indutor de reação alérgica. Relatamos o caso de uma lactente de 2 meses de idade com diagnóstico da síndrome, cujo objetivo é atentar o leitor quanto as suas particularidades, auxiliando-o no diagnóstico precoce e adequado a fim de evitar a depleção progressiva e a evolução para sua forma potencialmente grave.

Acute or chronic food protein-induced enteropathy syndrome is a type of non-IgE-mediated food allergy occurring between 5 and 9 months of age. It is characterized by episodes of vomiting that begin approximately 1 to 4 hours after allergen intake, sometimes accompanied by lethargy, skin pallor, and bloody diarrhea, leading to hemodynamic instability and shock in 15% of cases. Its epidemiology is largely unknown, as well as its immunopathological mechanism; however, an important role of T cells in the inflammatory process is observed. Manifestations and severity depend on the frequency and dose of the triggering food, as well as the phenotype and age of each patient. Suspicion is based mainly on clinical history and characteristic symptoms of the disease, which tend to improve after the removal of the suspect food. Oral provocation testing is the gold standard for diagnosis, but it should be reserved for cases whose history is confusing and hypothesis is uncertain. The first-line treatment approach seeks to correct dehydration or to stabilize shock, if present, and to immediately stop the supply of food that potentially induce an allergic reaction. We report the case of a 2-month-old infant diagnosed with the syndrome, with the aim of drawing the readers' attention to its particularities, thus assisting in early and adequate diagnosis in order to avoid progressive depletion and deterioration to its potentially severe form.

Isolated second-phase diabetes insipidus post-transsphenoidal surgery.

A 57-year-old woman presented with severe lethargy, dizziness and nausea 1 week after transsphenoidal resection of a growth hormone secreting pituitary adenoma. She was found to have severe hyponatremia of 115 mmol/L. Importantly, she was neurologically intact and clinically euvolaemic. Her fluid intake was restricted and her sodium levels increased to 131 mmol/L over 4 days. She made a full recovery.She was diagnosed with isolated second-phase diabetes insipidus, a state of symptomatic hypoosmolar hyponatremia that usually occurs 7-10 days after transsphenoidal surgery. The sodium levels improve with fluid restriction.

Tobacco smoke exposure as a risk factor for obstructive sleep apnea in children.

BACKGROUND: The most common respiratory disturbance in sleeping children is obstructive sleep apnea syndrome (OSAS). Passive smoking is one of factors predisposing to OSAS. The aim of this study was to determine the correlations between exposure to tobacco smoke (passive smoking) and development of respiratory disorders in children during sleep. METHODS: One hundred and sixty school-aged children (6-18 years) were included in the study. The inclusion criterion was exposure to tobacco smoke at home (n = 90). The control group were school-aged children who had had no contact with tobacco smoke at home (n = 70). Exclusion criteria were obesity and children with impaired patency of the nose. Each child had a polygraphic examination performed at home. The children and their parents completed a questionnaire to assess the level of child's exposure to tobacco smoke. The study ran from December 15, 2012 to February 26, 2016. RESULTS: OSAS was observed in 12% of children with an apnea-hypopnea index >1.5 (<13 years of age) and an apnea-hypopnea index >5 (for children >13 years), and with diurnal and nocturnal symptoms. Children exposed to tobacco smoke presented more apnea-hypopnea events (n = 17) than the control group (n = 3; P < 0.001). In the group exposed to tobacco smoke the following issues were noted: concentration problems (38.9%), tiredness/lethargy (46.7%), and irritability/hyperactivity (36.7%). No statistically significant differences were found in waking up, snoring, or sleep apnea. CONCLUSIONS: OSAS occurs more often in children exposed to tobacco smoke and these children demonstrate concentration problems, tiredness, and irritability/hyperactivity to a greater extent than control group.

Clozapine toxicity: a cautionary palliative care tale.

OBJECTIVE: This case report presents an unusual case of clozapine toxicity secondary to reduced smoking habit mimicking a patient approaching end of life. METHODS: It is a cautionary tale for palliative care specialists, perhaps unaware of the effect of cigarette smoke on metabolism of this antipsychotic, to be aware of. RESULTS: Following specialist advice and change of antipsychotic medication, this patient's condition improved to the point that he was discharged from the hospice. CONCLUSION: Palliative care specialists should be aware that reducing cigarette consumption can alter metabolism of clozapine, potentially causing drug accumulation and toxicity with features which mimic deterioration towards end of life. Specialist advice should be sought in such a situation.