The Effects of Hand Massage on Stress and Agitation Among People with Dementia in a Hospital Setting: A Pilot Study.

Agitation in people with dementia is a growing concern as it causes distress for both patients and their nurses and may contribute to relational disorders. Previous studies involving patients with dementia living in long-term care facilities have reported decreased agitation following massage. The objective of this pilot study was to investigate the effect of hand massage on agitation and biological markers of stress in patients with dementia hospitalized in an acute geriatric psychiatry service. In this randomized controlled trial we included 40 agitated patients with dementia with an intervention group and a control group. The study is designed to test the effect of seven hand massages over three continuous weeks on agitation and levels of salivary cortisol (sC) and alpha-amylase (sAA). Compared to the control group, the intervention group exhibited larger increases in sC and sAA at week 1 from before to after the massage, but larger decreases at week 2 and 3, with a significant group effect for sAA at week 2. Agitation scores were not significantly different between the groups but tended to decrease more in the intervention group than the control group. This study provides first encouraging results suggesting that hand massage might have beneficial effects on stress and agitation in hospitalized patients with dementia. It also highlights the challenges associated with conducting such studies with this complex patient population. Further studies are needed to confirm these findings and the benefits of hand massage as part of routine care for patients with dementia.

A Randomized Controlled Trial Examining the Effect of Acupressure on Agitation and Salivary Cortisol in Nursing Home Residents with Dementia.

BACKGROUND: Acupressure has been used to manage agitation in people with dementia because it is safe and inexpensive. However, its effect on agitation and at the biochemical level is uncertain. METHODS: This randomized controlled trial examined the effect of acupressure on agitation, as measured by the Cohen-Mansfield Agitation Inventory (CMAI); and on salivary cortisol, as measured at baseline (T0) and in the 3rd (T1), 5th (T2), and 8th (T3) weeks. There were 119 agitated residents with dementia randomized into 3 groups: acupressure (n = 39), sham (n = 41), and usual-care group (n = 39). RESULTS: A downward trend in agitation over time was noted in the acupressure group, which almost reached a level of significance in interaction effects between groups and time points (p = 0.052). Post hoc pairwise tests in the acupressure group showed that acupressure significantly reduced agitation at T2 (mean difference -6.84, 95% CI -10.60, -3.08) compared to baseline. Significant interaction effects between groups and time points were observed on the level of salivary cortisol (p = 0.022). CONCLUSION: Acupressure is a multicomponent intervention that can reduce agitation. Acupoint activation may not be a significant component in reducing agitation, although this result may have been limited by the inadequate sample size. Acupressure is effective in reducing salivary cortisol in people with dementia.

Emergence agitation after orthognathic surgery: a randomised controlled comparison between sevoflurane and desflurane.

BACKGROUND: This study aimed to compare emergence agitation following sevoflurane and desflurane anaesthesia in adults undergoing orthognathic surgery. The hypothesis was that there might be a difference in the incidence of emergence agitation following sevoflurane and desflurane anaesthesia considering the difference in blood solubility and speed of recovery between the two. METHODS: In this prospective randomised double-blind study, 144 adults undergoing orthognathic surgery were randomly allocated to either sevoflurane or desflurane anaesthesia. The incidence of emergence agitation and possible causative factors were then compared between the groups. RESULTS: The incidence of emergence agitation was lower in the desflurane group than in the sevoflurane group (24% vs. 71%, P < 0.001). In addition, the time intervals between the discontinuation of anaesthetics and the first response, extubation, and discharge from post-anaesthesia care unit were significantly shorter in the desflurane group (P = 0.002, P < 0.001 and P = 0.003, respectively). The other variables were similar in the two groups. CONCLUSIONS: In adults undergoing orthognathic surgery, desflurane anaesthesia was associated with less emergence agitation than was sevoflurane anaesthesia.

A prospective study of anxiety, depression, and behavioral changes in the first year after a diagnosis of childhood acute lymphoblastic leukemia: a report from the Children's Oncology Group.

BACKGROUND: The authors prospectively assessed anxiety, depression, and behavior in children with standard-risk acute lymphoblastic leukemia (SR-ALL) during the first year of therapy and identified associated risk factors. METHODS: A cohort study was performed of 159 children (aged 2 years-9.99 years) with SR-ALL who were enrolled on Children's Oncology Group protocol AALL0331 at 31 sites. Parents completed the Behavior Assessment System for Children, the General Functioning Scale of the Family Assessment Device, and the Coping Health Inventory for Parents at approximately 1, 6, and 12 months after diagnosis. RESULTS: Overall, mean scores for anxiety, depression, aggression, and hyperactivity were similar to population norms. However, more children scored in the at-risk/clinical range for depression than the expected 15% at 1 month (21.7%; P= .022), 6 months (28.6%; P< .001), and 12 months (21.1%; P= .032). For anxiety, more children scored in the at-risk/clinical range at 1 month (25.2% vs 15%; P= .001), but then reverted to expected levels. On adjusted analysis, unhealthy family functioning was found to be predictive of anxiety (odds ratio [OR], 2.24; P= .033) and depression (OR, 2.40; P= .008). Hispanic ethnicity was associated with anxiety (OR, 3.35; P= .009). Worse physical functioning (P= .049), unmarried parents (P= .017), and less reliance on social support (P= .004) were found to be associated with depression. Emotional distress at 1 month predicted anxiety (OR, 7.11; P= .002) and depression (OR, 3.31; P= .023) at 12 months. CONCLUSIONS: Anxiety is a significant problem in a subpopulation of patients with SR-ALL immediately after diagnosis, whereas depression remains a significant problem for at least 1 year. Children of Hispanic ethnicity or those with unhealthy family functioning may be particularly vulnerable. These data suggest that clinicians should screen for anxiety and depression throughout the first year of therapy.

Dexmedetomidine does not reduce emergence agitation in adults following orthognathic surgery.

BACKGROUND: Patients undergoing orthognathic surgery are at high risk of developing emergence agitation. We hypothesised that a single-dose of dexmedetomidine would reduce emergence agitation in adults with nasotracheal intubation after orthognathic surgery. METHODS: Seventy adults (20-45 years old) undergoing orthognathic surgery were randomly assigned to two groups. Patients received intravenous dexmedetomidine 1 µg/kg (dex group) or normal saline (control group) for 10 min at the end of surgery. Remifentanil was infused at 0.02 µg/kg/min during emergence in both groups. The severity of emergence agitation was assessed with the Richmond agitation-sedation scale. Cough, haemodynamic and respiratory profiles, pain, and time to eye opening were evaluated. RESULTS: The incidence of emergence agitation was not different between dex group and control group (38% vs. 47%, P = 0.45). However, severe cough during emergence was reduced in the dex group (P = 0.04). Tachycardia during emergence and recovery phases was attenuated in the dex group. The verbal numeric rating of pain was lower in the dex group. There were no differences in respiratory rate between the two groups. Time to eye opening was prolonged in the dex group. CONCLUSION: The addition of a single dose of dexmedetomidine (1 µg/kg) to low-dose remifentanil infusion did not attenuate emergence agitation in intubated patients after orthognathic surgery compared with low-dose remifentanil infusion alone. However, single-dose dexmedetomidine suppressed coughing, haemodynamic changes, and pain during emergence and recovery phases, without respiratory depression. Delayed awakening might be associated with this treatment.

The Comparison of the Efficacy of Early versus Late Administration of Dexmedetomidine on Postoperative Emergence Agitation in Children Undergoing Oral Surgeries: A Randomized Clinical Trial.

BACKGROUND: Emergence Agitation (EA) is a dissociated state of consciousness characterized by irritability, uncompromising stance, and inconsolability. The etiology of EA is not completely understood. Dexmedetomidine is a highly selective α2-adrenoreceptor agonist with sedative and analgesic properties, which has been used to reduce the incidence of EA. We aimed to assess the efficacy of early versus late administration of dexmedetomidine on EA in children undergoing oral surgery. METHODS: A randomized, parallel, double-blind clinical trial was conducted at Mofid Children's Hospital affiliated to Shahid Beheshti University of Medical Sciences (Tehran, Iran) from November 2016 to March 2017. A total of 81 children, who underwent adenotonsillectomy or cleft palate repair surgery were enrolled in the study. Based on simple randomization, the children were assigned to two groups, namely early (group A, n=41) and late (group B, n=40) administration of dexmedetomidine. Intra-operative and postoperative hemodynamic variables, extubation time, post-anesthesia care unit (PACU) length of stay, and the scores on Ramsay sedation scale and FLACC pain scale were measured and compared. The data were analyzed using SPSS software (version 20.0), and P<0.05 were considered statistically significant. RESULTS: The mean FLACC score was lower in the late group than in the early group (2.0±1.5 vs. 4.2±1.6, P<0.001). The mean Ramsay sedation score was higher in the late group than in the early group (3.5±1.4 vs. 1.8±0.8, P<0.001). CONCLUSION: Late administration of dexmedetomidine 1 µg/kg reduced the incidence of EA and PACU length of stay and improved postoperative pain management. TRIAL REGISTRATION NUMBER: IRCT 2016122031497N1.

Safety of intravenous sedation administered by the operating oral surgeon: the second 7 years of office practice.

PURPOSE: This follow-up study provides an additional 7 years of data (December 2001 through November 2008) pertaining to complications that occurred in patients who received intravenous sedation in the practice of a single board-certified oral and maxillofacial surgeon. Together with the previously published 7 years of data (December 1994 through November 2001), this study summarizes the frequency of various complications encountered in patients sedated intravenously by the surgeon over a 14-year period. MATERIALS AND METHODS: The files of intravenous sedation cases from the second 7-year period were reviewed for complications. These data were then compared, contrasted, and combined with the previously published sedation cases from the first 7 years. RESULTS: A total of 3,320 sedations were performed by the surgeon during this second 7-year period, with only 1.57% of patients having complications (52 patients having 60 adverse events). These results showed a slight decline in the frequency of complications. Over the entire 14-year period of study, a total of 6,209 sedations were performed by the surgeon, with 1.96% of patients having complications (122 patients having 137 adverse events). There were no deaths, and no patients required emergency transport to a hospital. CONCLUSIONS: The results of this follow-up study confirm the previous findings. The administration of intravenous sedation by the operating surgeon for outpatient oral surgery is safe, with a low frequency of complications. Numerous patients were also made aware of previously undiagnosed medical problems, improving overall patient health.

The safety and efficacy of using a concentrated intranasal midazolam formulation for paediatric dental sedation.

AIM: To add to the evidence base for safe and effective paediatric conscious sedation techniques in primary dental care. OBJECTIVE: To consider the safety and effectiveness of an alternative sedation technique for facilitating dental treatment in anxious children, thereby avoiding dental general anaesthetic. SETTING: Leagrave Dental Sedation Clinic. A primary care-based general and referral clinic for anxious patients, special care dentistry and oral surgery. SUBJECTS, MATERIALS AND METHODS: This is a prospective service evaluation of 114 selected anxious children requiring invasive dental treatment. Each child was administered 0.25 mg/kg intranasal midazolam using a concentrated 40 mg/ml midazolam (INM) in 2% lignocaine solution. MAIN OUTCOME MEASURES: Successful completion of intended dental treatment with a child who is co-operative and who meets the UK accepted definition of conscious sedation. RESULTS: 57% of the children found the administration of the new formulation acceptable. Of the 114 patients who received INM, 104 completed the treatment (91%). The 10 children who could not complete the treatment with INM were converted to intravenous sedation and treatment was completed successfully at the same appointment. During treatment there was no desaturation and only one patient desaturated briefly in the recovery area. Parents rated the technique acceptable in 76% of cases and would have the procedure repeated in 83% of cases. Parents rated this technique as having 8.3 out of 10 with only 5 parents awarding a score of less than 7 out of 10. Side effects included blurred vision, sneezing, headaches, restlessness with one patient having post-operative nausea and vomiting. CONCLUSION: In selected cases intranasal sedation provides a safe and effective alternative for dental GA in short invasive procedures limited to one or two quadrants in children. Other techniques, e.g., oral and intravenous sedation, appear to have a much higher acceptability of administration. This technique may be useful if inhalation sedation, oral sedation or intravenous sedation is considered and the child is still unco-operative, either as a technique on its own or to facilitate cannulation for intravenous sedation. It is recommended that this technique should only be used by dentists skilled in intravenous paediatric sedation with midazolam with the appropriate staff training and equipment at their disposal.

Hypnotic depth and the incidence of emergence agitation and negative postoperative behavioral changes.

BACKGROUND: Emergence agitation (EA) and negative postoperative behavioral changes (NPOBC) are common in children, although the etiology remains unclear. We investigated whether longer times under deep hypnosis as measured by Bispectral Index (BIS) monitoring would positively correlate with a greater incidence of EA in the PACU and a greater occurrence of NPOBC in children after discharge. METHODS: We enrolled 400 children, 1-12 years old, scheduled for dental procedures under general anesthesia. All children were induced with high concentration sevoflurane, and BIS monitoring was continuous from induction through recovery in the PACU. A BIS reading <45 was considered deep hypnosis. The presence of EA was assessed in the PACU using the Pediatric Anesthesia Emergence Delirium scale. NPOBC were assessed using the Post-Hospital Behavior Questionnaire, completed by parents 3-5 days postoperatively. Data were analyzed using logistic regression, with a P < 0.05 considered statistically significant. RESULTS: The incidence of EA was 27% (99/369), and the incidence of NPOBC was 8.8% (28/318). No significant differences in the incidence of EA or NPOBC were seen with respect to length of time under deep hypnosis as measured by a BIS value of <45. CONCLUSION: Our data revealed no significant correlation between the length of time under deep hypnosis (BIS < 45) and the incidence of EA or NPOBC. Within this population, these behavioral disturbances do not appear to be related to the length of time under a deep hypnotic state as measured by the BIS.

Sevoflurane-emergence agitation: effect of supplementary low-dose oral ketamine premedication in preschool children undergoing dental surgery.

BACKGROUND AND OBJECTIVE: The use of sevoflurane in paediatric anaesthesia which could enable rapid recovery is complicated by the frequent occurrence of emergence agitation. The aim of this study was to test the efficacy of supplementing midazolam-based oral premedication with low-dose oral ketamine in reducing sevoflurane-related emergence agitation. METHODS: Ninety-two healthy preschool children who have been scheduled for elective dental procedures under general anaesthesia were allocated into two groups (46 patients for each): group M received oral midazolam 0.5 mg kg(-1), whereas group KM received similar premedication in addition to ketamine 2 mg kg(-1). Acceptance of drug mixture and onset of action were monitored over the next 30 min. Induction of anaesthesia was carried out using sevoflurane 8 vol% in 100% oxygen via face mask. Anaesthesia was maintained with sevoflurane 1.5-2 vol% in oxygen-nitrous oxide mixture. Following extubation, standard scoring scale was used for assessing quality of emergence. Agitation parameters were measured using a five-point scale. Agitated children were managed by giving intravenous increments of fentanyl 1 microg kg(-1). The time of hospital discharge allowance was recorded. RESULTS: Vast majority of children accepted the premedication. There were no significant differences between both groups regarding recovery from sevoflurane and allowance of hospital discharge. Onset of action of premedication was shorter in group KM. Similarly, postoperative agitation score and rescue fentanyl consumption were markedly lower in group KM upon admission to the postanaesthesia care unit (P<0.01). CONCLUSION: Adding a low dose of oral ketamine to midazolam-based oral premedication in preschool children undergoing dental surgery reduced emergence agitation without delaying hospital discharge.

Involuntary movements in an adolescent: what are the causes?

Involuntary movements can be a troublesome condition and represent a real challenge for emergency doctors, particularly for patients of paediatric age. We report a case of a 17-year-old boy with painful involuntary movements mostly affecting his mouth and lower limbs, but also the trunk. After reviewing the patient's history, it was revealed that the adolescent had had acute alcohol intoxication with severe acute agitation and therefore was given a single dose of 10 mg intravenous haloperidol. The concealment of the recent event posed serious difficulties in reaching the diagnosis. When the diagnosis of haloperidol-induced acute dystonia was made, 3 mg of intravenous biperiden was promptly administered with complete clinical resolution in 15 min.

Induction and emergence behavior of children undergoing general anesthesia correlates with maternal salivary amylase activity before the anesthesia.

BACKGROUND: The parents of the children who undergo surgery experience stress during the pre-anesthetic period. Such stress influences the mental status of their children, thereby inducing their pre-anesthetic anxiety and problematic behavior at emergence. Recently, measurement of salivary biomarkers was evaluated as stress biomarkers. Especially, alpha-amylase is utilized as an excellent index for psychological stress. In the present study, we tested whether salivary amylase activity of mothers before the surgery of their children correlates with the peri-operative children's behaviors. METHODS: A total of 22 pairs of mothers and children were analyzed. Maternal salivary amylase activity was evaluated at the entrance of the operation room. The children underwent minor plastic surgery under general anesthesia, and induction and emergence behaviors were assessed. RESULTS: The higher the maternal salivary amylase activity, the severer the children's induction anxiety (r(s)=-0.667, n=22, P<0.0001), and the higher the maternal amylase activity, the severer the children's emergence agitation (r(s)=0.705, n=22, P<0.0001). CONCLUSION: Induction and emergence behaviors of children undergoing general anesthesia significantly correlated with their respective maternal salivary amylase activity during the pre-anesthetic period.

The clinical efficacy of reflexology in nursing home residents with dementia.

OBJECTIVE: This experimental, repeated-measures, crossover design study with nursing home residents examined the efficacy of reflexology in individuals with mild-to-moderate stage dementia. Specifically, the study tested whether a weekly reflexology intervention contributed to the resident outcomes of reduced physiologic distress, reduced pain, and improved affect. SETTING: The study was conducted at a large nursing home in suburban Philadelphia. SAMPLE: The sample included 21 nursing home residents with mild-to-moderate stage dementia randomly assigned to two groups. INTERVENTIONS: The first group received 4 weeks of weekly reflexology treatments followed by 4 weeks of a control condition of friendly visits. The second group received 4 weeks of friendly visits followed by 4 weeks of weekly reflexology. OUTCOME MEASURES: The primary efficacy endpoint was reduction of physiologic distress as measured by salivary alpha-amylase. The secondary outcomes were observed pain (Checklist of Nonverbal Pain Indicators) and observed affect (Apparent Affect Rating Scale). RESULTS: The findings demonstrate that when receiving the reflexology treatment condition, as compared to the control condition, the residents demonstrated significant reduction in observed pain and salivary alpha-amylase. No adverse events were recorded during the study period. CONCLUSIONS: This study provides preliminary support for the efficacy of reflexology as a treatment of stress in nursing home residents with mild-to-moderate stage dementia.

Postoperative pain and other sequelae of dental rehabilitations performed on children under general anesthesia.

PURPOSE: The purpose of this study was to determine the prevalence, severity and variables influencing postoperative pain and other sequelae in children undergoing dental rehabilitation under general anesthesia. METHODS: Healthy children scheduled for dental rehabilitation having treatment on only primary teeth were included in the study. General anesthesia protocol was standardized, and patients did not receive local anesthesia intraoperatively. Pain and other postoperative sequelae were recorded for 7 days postoperatively. RESULTS: Ninety-five percent of the 90 children had postoperative pain which was moderate in intensity and highest immediately postoperatively. Children who had extractions or were at least 4 years old and had more than 12 procedures experienced increased postoperative pain. The most common postoperative symptoms other than pain were agitation, need for analgesics, and sleepiness. Longer operative times resulted in increased postoperative sleepiness. Children whose tracheal intubations were traumatic were more likely to report sore throats. Children who were at least 4 years old required more analgesics, experienced more postoperative sleepiness, and had nausea more frequently. All postoperative problems significantly decreased by postoperative day 2 and ceased by postoperative day 4 to 5. CONCLUSION: Children undergoing dental rehabilitations under general anesthesia commonly experience postoperative symptoms such as pain, agitation, need for analgesics, and sleepiness.

Evidence-Based Nonpharmacological Practices to Address Behavioral and Psychological Symptoms of Dementia.

Background and Objectives: To draw from systematic and other literature reviews to identify, describe, and critique nonpharmacological practices to address behavioral and psychological symptoms of dementia (BPSDs) and provide evidence-based recommendations for dementia care especially useful for potential adopters. Research Design and Methods: A search of systematic and other literature reviews published from January 2010 through January 2017. Nonpharmacological practices were summarized to describe the overall conceptual basis related to effectiveness, the practice itself, and the size and main conclusions of the evidence base. Each practice was also critically reviewed to determine acceptability, harmful effects, elements of effectiveness, and level of investment required, based on time needed for training/implementation, specialized care provider requirements, and equipment/capital requirements. Results: Nonpharmacological practices to address BPSDs include sensory practices (aromatherapy, massage, multi-sensory stimulation, bright light therapy), psychosocial practices (validation therapy, reminiscence therapy, music therapy, pet therapy, meaningful activities), and structured care protocols (bathing, mouth care). Most practices are acceptable, have no harmful effects, and require minimal to moderate investment. Discussion and Implications: Nonpharmacological practices are person-centered, and their selection can be informed by considering the cause and meaning of the individual's behavioral and psychological symptoms. Family caregivers and paid care providers can implement evidence-based practices in home or residential care settings, although some practices require the development of more specific protocols if they are to become widely used in an efficacious manner.

Cortisol and wake time in nursing home residents with behavioral symptoms of dementia.

Alterations in sleep and behavioral symptoms are consistently reported among nursing home residents with dementia. Disregulation in the hypothalamic-pituitary-adrenal axis (HPA), indexed by basal cortisol levels, offers one explanation. The purpose of this study is to examine the relationship between wake time and cortisol slope in residents with behavioral symptoms. The study included 27 residents aged 71 to 84 years with dementia and behavioral symptoms. Using a within-subject longitudinal design, the researchers documented wake time and collected saliva samples for 4 consecutive days upon waking and at 30 min, 6 hr, and 12 hr after waking. Within-person cortisol slopes were categorized into zero-positive and negative slopes. The zero-positives (35%) exhibited an earlier wake time than the negatives (65%). These preliminary results suggest both a relationship between wake time and HPA diurnal profile and an association between the sleep-wake cycle and cortisol secretion among nursing home residents with dementia.

Acute Agitation and Self-Injury in a 5-Year Old with Autism.

CASE: A 5-year-old nonverbal child with autism spectrum disorder (ASD) was admitted to inpatient pediatrics with new onset agitation and self-injurious behavior. His parents described him as a pleasant child without previous episodes of self-injury. Four days before admission, the parents noted new irritability followed by 2 days of self-injury to the face without clear precipitant. His hitting intensified with closed fist to face, and he required parental physical restraint to prevent further injury. Car rides and ibuprofen provided only temporary relief. He consumed minimal liquid and ate no solid food for 2 days. The parents denied any changes to the environment or routine and denied recent travel, sick contacts, fevers, cough, otalgia, vomiting, diarrhea, and constipation. The patient had been diagnosed with ASD at age 18 months old but had no other significant medical history.On examination, the child was alert but distressed and restless, wearing padded mitts as his parents attempted to calm him by pushing him in a stroller. He had multiple areas of severe bruising and facial swelling in the right periorbital area, cheek, and jaw. The rest of the physical examination was unremarkable. Laboratory results included a leukocytosis with left shift, a normal metabolic panel, and an elevated creatine kinase. Other investigations included a normal lumber puncture, chest radiograph, head and face computerized tomography without contrast, and brain magnetic resonance imaging. A dentist consultant examined him and noted an erupting molar but no decay or abscesses. A psychiatric evaluation was requested as there was no clear medical source for the patient's distress.

Delirium during intravenous sedation with midazolam alone and with propofol in dental treatment.

A 62-year-old man visited our clinic for dental implantation under intravenous sedation. He demonstrated increased psychomotor activity and incomprehensible verbal contact during intravenous sedation. Although delirium caused by midazolam or propofol in different patients has been reported, the present case represents a delirium that developed from both drugs in the same patient, possibly because of the patient's smaller tolerance to midazolam and propofol.

Acute Agitation and Self-Injury in a 5-Year Old with Autism.

CASE: A 5-year-old nonverbal child with autism spectrum disorder (ASD) was admitted to inpatient pediatrics with new onset agitation and self-injurious behavior. His parents described him as a pleasant child without previous episodes of self-injury. Four days before admission, the parents noted new irritability followed by 2 days of self-injury to the face without clear precipitant. His hitting intensified with closed fist to face, and he required parental physical restraint to prevent further injury. Car rides and ibuprofen provided only temporary relief. He consumed minimal liquid and ate no solid food for 2 days. The parents denied any changes to the environment or routine and denied recent travel, sick contacts, fevers, cough, otalgia, vomiting, diarrhea, and constipation. The patient had been diagnosed with ASD at age 18 months old but had no other significant medical history.On examination, the child was alert but distressed and restless, wearing padded mitts as his parents attempted to calm him by pushing him in a stroller. He had multiple areas of severe bruising and facial swelling in the right periorbital area, cheek, and jaw. The rest of the physical examination was unremarkable. Laboratory results included a leukocytosis with left shift, a normal metabolic panel, and an elevated creatine kinase. Other investigations included a normal lumber puncture, chest radiograph, head and face computerized tomography without contrast, and brain magnetic resonance imaging. A dentist consultant examined him and noted an erupting molar but no decay or abscesses. A psychiatric evaluation was requested as there was no clear medical source for the patient's distress.