A 73-Year-Old Woman With Confusion, Visual Field Disturbances, and Edematous White Matter Lesions: From the National Multiple Sclerosis Society Case Conference Proceedings.

We describe the case of a 73-year-old woman presenting with headaches, confusion, and vision disturbances. Brain MRI showed a large T2-hyperintense lesion in the right temporo-occipital region with vasogenic edema and leptomeningeal enhancement. A leptomeningeal biopsy was performed, which led to a definitive diagnosis.

A woman in her thirties with confusion. / En kvinne i 30-årene med forvirring.

Background: Coercion is rare in cancer treatment. We present a case where a young woman received gamma knife radiosurgery and immunochemotherapy under compulsory institutional care. Case presentation: A previously healthy patient in her thirties was admitted to hospital due to confusion, apathy, weight loss and sleep disturbance. She had difficulties expressing herself and spoke with considerable latency. A brain MRI revealed a tumour of 23 mm in the left-side centrum semiovale and perifocal oedema, while a CT scan showed a 5.6 cm tumour in the right upper lobe and enlarged mediastinal lymph nodes. She was diagnosed with non-small cell lung cancer, no actionable mutations, PD-L1 <75 %. When she did not wish to return to the hospital to undergo gamma knife radiosurgery, she was readmitted under a formal decision to use coercion, and remained under institutional care for over six months. Today she is fully recovered and has no cancer progression almost five years after diagnosis. Interpretation: This case report illustrates the challenges of brain metastases and use of coercion during cancer treatment, both for the patient and healthcare personnel. There is a need for thorough interdisciplinary discussions and to establish as early as possible a shared understanding of the intention and scope of the forced treatment.

Swimming, confusion, and plenty of brews: Negotiating ambivalence within Windermere's fragile waters.

Windermere is a complex and contested freshwater site which encounters fluctuating social and environmental pressures. Swimmers at Windermere regularly practice across all four seasons while negotiating social concerns such as access, conflicting user groups, public health communications, and swim safety, alongside environmental complications including extreme weather, wastewater, run-off, plastic pollution, algal blooms, biosecurity, and climate change. Simultaneously, these entangled pressures generate ongoing adaptation, ambivalence, and avoidance within the swim communities. Furthermore, they disrupt individualised and inwardly focused understandings of 'healthy' outdoor swimming practices. In contribution to the special issue (on outdoor swimming), this article reflects on how outdoor swimming researchers may methodologically attend to these social and environmental complexities within contested lacustrine environments through an immersive 12-month wet ethnographic approach, combining 'lake-hangouts' and 'swim-along interviews' with different swimmers at Windermere. The article discusses how these relational in-situ approaches can continue to broaden inwardly focused understandings of 'healthy' outdoor swimming practices towards the wider social and environmental relations for both the participants and researcher. The article also highlights senses of ambivalence and ethical tension while negotiating conflicting concerns of ill-health, in and out of Windermere's fragile waters.

Guía de tratamiento de la alteración aguda del estado mental. Academia Iberoamericana de Neurología Pediátrica / Guide for the treatment of acute altered mental status. Iberoamerican Academy of Pediatric Neurology

La alteración aguda del estado mental en pediatría se refiere a un cambio repentino y significativo en la función cerebral y el nivel de conciencia de un niño. Puede manifestarse como confusión, desorientación, agitación, letargo o incluso pérdida de la conciencia. Esta condición es una emergencia médica, y requiere una evaluación y una atención inmediatas. Existen diversas causas de alteración aguda del estado mental en niños, algunas de las cuales incluyen infecciones del sistema nervioso central, como la meningitis o la encefalitis, los traumatismos craneoencefálicos, los trastornos metabólicos, las convulsiones o las intoxicaciones, entre otras. Este estudio tuvo como objetivo analizar, preparar y calificar la bibliografía actual para determinar las mejores recomendaciones sobre el tratamiento ante casos de alteración aguda del estado mental en pediatría de diferentes causas. El estudio se basó en la calificación de expertos en el campo para poder determinar la calificación de las recomendaciones, además de ser sometido a la revisión por parte del comité científico de la Academia Iberoamericana de Neurología Pediátrica. Nuestra guía representa una ayuda para el tratamiento de este síntoma inespecífico desde un enfoque básico y avanzado, aplicable por cualquier neurólogo pediatra.(AU)

In pediatric patients, an acute altered mental status refers to a sudden and significant change in a child’s brain function and level of consciousness. It may manifest as confusion, disorientation, agitation, lethargy or even a loss of consciousness. This condition is a medical emergency, and requires immediate evaluation and attention. There are several causes of acute altered mental status in children, including infections of the central nervous system such as meningitis or encephalitis, traumatic brain injury, metabolic disorders, seizures and poisoning, among others. The aim of this study was to analyse, prepare and classify the current literature in order to determine the best recommendations for the treatment of cases of acute altered mental status with various causes in pediatric patients. The study was based on opinions from experts in the field in order to classify the recommendations, and was submitted to the scientific committee of the Iberoamerican Academy of Pediatric Neurology for review. Our guide is an aid for the treatment of this non-specific symptom based on a basic and advanced approach, which can be applied by any pediatric neurologist.(AU)

Galvanic Vestibular Stimulation Advancements for Spatial Disorientation Training.

INTRODUCTION: Spatial disorientation (SD) remains the leading contributor to Class A mishaps in the U.S. Navy, consistent with historical trends. Despite this, SD training for military aircrew is largely confined to the classroom and experiential training replicating SD illusions is limited and infrequent. Static flight simulators are most commonly used for training but offer no vestibular stimulation to the flight crew, omitting the source of vestibular-mediated SD.BACKGROUND: We first cover vestibular-mediated SD illusions which may be replicated through galvanic vestibular stimulation (GVS) in a static environment. GVS is a safe, reliable, low-cost avenue for providing vestibular sensory stimulation. We review the underlying mechanisms of GVS such as the excitement and inhibition of the afferent neurons innervating the vestibular system, particularly in the binaural bipolar electrode montage.APPLICATIONS: Two approaches for how GVS may be used to enhance SD training are examined. The first is a means for providing unreliable vestibular sensory perceptions to pilots, and the second details how GVS can be leveraged for replicating vestibular-mediated SD illusions.DISCUSSION: We recommend GVS be pursued as an enhancement to existing SD training. The ability to disorient aircrew in the safe training environment of a static flight simulator would allow for aircrew familiarization to SD, serving as an opportunity to practice life-saving checklist items to recover from SD. A repeatable training profile that could be worn by military aircrew in a static flight simulator may afford a low-cost training solution to the number one cause of fatalities in military aviation.Allred AR, Lippert AF, Wood SJ. Galvanic vestibular stimulation advancements for spatial disorientation training. Aerosp Med Hum Perform. 2024; 95(7):390-398.

Fahr's disease with neuropsychiatric symptoms and intermittent course: a case report.

Fahr's disease is a rare neurodegenerative disorder with brain calcifications and neuropsychiatric symptoms. It can have variable phenotypic expression and intermittent symptomatology, making diagnosis challenging. In this report, we describe a young female patient presenting with symptoms of psychosis and confusion, which could be indicative of a delirium superimposed on the cerebral vulnerability associated with Fahr's disease. Notably, about two years prior, she experienced multiple episodes of tonic-clonic seizures that spontaneously resolved without pharmacological intervention. She had no previous psychiatric history. Following comprehensive investigations, other organic causes were ruled out, and Fahr's disease was diagnosed based on bilateral symmetrical brain calcifications seen on a head CT scan. Her treatment regimen encompassed antipsychotics and anticonvulsants. This case highlights the importance of considering Fahr's disease as a differential diagnosis in patients with new-onset neuropsychiatric symptoms. The case also explores the atypical early onset and intermittent nature of symptoms in the absence of a positive family history, highlighting the complexity of Fahr's disease. A multidisciplinary approach and regular follow-up are crucial for optimizing patient care and monitoring disease progression. Further research is needed to enhance our understanding of Fahr's disease and develop standardized treatment strategies for this rare condition.

Ajuste de dosis según función renal en una paciente polimedicada incluida en el servicio de reacondicionamiento de medicamentos utilizando sistemas personalizados de dosificación (SPD) / Dose adjustment according to renal function in a polymedicated patient included in the medication reconditioning service using personalized dosing systems (SPD)

Paciente de 78 años, polimedicada e incluida en el servicio de Sistema Personalizado de Dosificación de Medicamentos (SPD). Al acudir a retirar su medicación nos informa que desde hace unos meses sufre cansancio, debilidad, mareos y confusión. Se realiza una revisión de la medicación, centrada en la dosificación de los medicamentos de metabolismo o eliminación renal, en función del valor de Filtrado Glomerular estimado de la paciente (FGe). Se realiza derivación al Médico de Atención Primaria (MAP) mediante un informe, en el que se recomienda la reducción de dosis de losartán y manidipino según el valor de FGe de la paciente. El MAP redujo la dosis de los antihipertensivos. Se efectuó seguimiento del caso, que permitió observar que la paciente dejó de presentar los síntomas descritos inicialmente.(AU)

[Guide for the treatment of acute altered mental status. Iberoamerican Academy of Pediatric Neurology]. / Guía de tratamiento de la alteración aguda del estado mental. Academia Iberoamericana de Neurología Pediátrica.

In pediatric patients, an acute altered mental status refers to a sudden and significant change in a child's brain function and level of consciousness. It may manifest as confusion, disorientation, agitation, lethargy or even a loss of consciousness. This condition is a medical emergency, and requires immediate evaluation and attention. There are several causes of acute altered mental status in children, including infections of the central nervous system such as meningitis or encephalitis, traumatic brain injury, metabolic disorders, seizures and poisoning, among others. The aim of this study was to analyse, prepare and classify the current literature in order to determine the best recommendations for the treatment of cases of acute altered mental status with various causes in pediatric patients. The study was based on opinions from experts in the field in order to classify the recommendations, and was submitted to the scientific committee of the Iberoamerican Academy of Pediatric Neurology for review. Our guide is an aid for the treatment of this non-specific symptom based on a basic and advanced approach, which can be applied by any pediatric neurologist.

TITLE: Guía de tratamiento de la alteración aguda del estado mental. Academia Iberoamericana de Neurología Pediátrica.La alteración aguda del estado mental en pediatría se refiere a un cambio repentino y significativo en la función cerebral y el nivel de conciencia de un niño. Puede manifestarse como confusión, desorientación, agitación, letargo o incluso pérdida de la conciencia. Esta condición es una emergencia médica, y requiere una evaluación y una atención inmediatas. Existen diversas causas de alteración aguda del estado mental en niños, algunas de las cuales incluyen infecciones del sistema nervioso central, como la meningitis o la encefalitis, los traumatismos craneoencefálicos, los trastornos metabólicos, las convulsiones o las intoxicaciones, entre otras. Este estudio tuvo como objetivo analizar, preparar y calificar la bibliografía actual para determinar las mejores recomendaciones sobre el tratamiento ante casos de alteración aguda del estado mental en pediatría de diferentes causas. El estudio se basó en la calificación de expertos en el campo para poder determinar la calificación de las recomendaciones, además de ser sometido a la revisión por parte del comité científico de la Academia Iberoamericana de Neurología Pediátrica. Nuestra guía representa una ayuda para el tratamiento de este síntoma inespecífico desde un enfoque básico y avanzado, aplicable por cualquier neurólogo pediatra.

Potential of GPT-4 for Detecting Errors in Radiology Reports: Implications for Reporting Accuracy.

Background Errors in radiology reports may occur because of resident-to-attending discrepancies, speech recognition inaccuracies, and large workload. Large language models, such as GPT-4 (ChatGPT; OpenAI), may assist in generating reports. Purpose To assess effectiveness of GPT-4 in identifying common errors in radiology reports, focusing on performance, time, and cost-efficiency. Materials and Methods In this retrospective study, 200 radiology reports (radiography and cross-sectional imaging [CT and MRI]) were compiled between June 2023 and December 2023 at one institution. There were 150 errors from five common error categories (omission, insertion, spelling, side confusion, and other) intentionally inserted into 100 of the reports and used as the reference standard. Six radiologists (two senior radiologists, two attending physicians, and two residents) and GPT-4 were tasked with detecting these errors. Overall error detection performance, error detection in the five error categories, and reading time were assessed using Wald χ2 tests and paired-sample t tests. Results GPT-4 (detection rate, 82.7%;124 of 150; 95% CI: 75.8, 87.9) matched the average detection performance of radiologists independent of their experience (senior radiologists, 89.3% [134 of 150; 95% CI: 83.4, 93.3]; attending physicians, 80.0% [120 of 150; 95% CI: 72.9, 85.6]; residents, 80.0% [120 of 150; 95% CI: 72.9, 85.6]; P value range, .522-.99). One senior radiologist outperformed GPT-4 (detection rate, 94.7%; 142 of 150; 95% CI: 89.8, 97.3; P = .006). GPT-4 required less processing time per radiology report than the fastest human reader in the study (mean reading time, 3.5 seconds ± 0.5 [SD] vs 25.1 seconds ± 20.1, respectively; P < .001; Cohen d = -1.08). The use of GPT-4 resulted in lower mean correction cost per report than the most cost-efficient radiologist ($0.03 ± 0.01 vs $0.42 ± 0.41; P < .001; Cohen d = -1.12). Conclusion The radiology report error detection rate of GPT-4 was comparable with that of radiologists, potentially reducing work hours and cost. © RSNA, 2024 See also the editorial by Forman in this issue.

Postoperative Delirium and the Older Adult: Untangling the Confusion.

Postoperative delirium is one of the most prevalent postoperative complications, affecting mostly older adults. Its incidence is expected to rise because of surgical advances, shifting demographics, and increased life expectancy. Although an acute alteration in brain function, postoperative delirium is associated with adverse outcomes, including progressive cognitive decline and dementia, that place significant burdens on patients' lives and healthcare systems. This has prompted efforts to understand the mechanisms of postoperative delirium to provide effective prevention and treatment. There are multiple mechanisms involved in the etiology of postoperative delirium that share similarities with the physiological changes associated with the aging brain. In addition, older patients often have multiple comorbidities including increased cognitive impairment that is also implicated in the genesis of delirium. These tangled connections pinpointed a shift toward creation of a holistic model of the pathophysiology of postoperative delirium. Scientific advancements integrating clinical risk factors, possible postoperative delirium biomarkers, genetic features, digital platforms, and other biotechnical and information technological innovations, will become available in the near future. Advances in artificial intelligence, for example, will aggregate cognitive testing platforms with patient-specific postoperative delirium risk stratification studies, panels of serum and cerebrospinal fluid molecules, electroencephalogram signatures, and gut microbiome features, along with the integration of novel polygenetic variants of sleep and cognition. These advances will allow for the enrollment of high-risk patients into prevention programs and help uncover new pharmacologic targets.

Detection method for unrecognized spatial disorientation based on optical flow stimuli.

BACKGROUND: Flight accidents caused by spatial disorientation (SD) greatly affect flight safety. OBJECTIVE: Few studies have been devoted to the evaluation of SD. METHODS: 10 pilots and 10 non-pilots were recruited for the experimental induction of SD. Videos for giving optical flow stimuli were played at two different flow speeds to induce SD. Subjective judgment and center of foot pressure (CoP) data were collected from the tests. The data were combined to determine the occurrence of SD and analyze the SD types. RESULTS: The number of self-reported SD events was slightly smaller in the pilots than in the non-pilots. The average upper bound of the confidence interval for the standard deviation of CoP was 0.32 ± 0.09 cm and 0.38 ± 0.12 cm in the pilots and non-pilots, respectively. This indicator was significantly lower in the pilots than in the non-pilots (P= 0.03). The success rate of the experimental induction of unrecognized SD was 26.7% and 45.0% in the pilots and non-pilots, respectively. CONCLUSION: The method offered a new to analyze unrecognized SD. We could determine the occurrence unrecognized SD. This is an essential means of reducing flight accidents caused by unrecognized SD.

The effect of participation in support groups on retirement syndrome in older adults.

BACKGROUND: Retirement and aging are phenomena that often occur simultaneously and lead to various physical and psychological changes in older adults. Retirement syndrome consists of symptoms such as feelings of emptiness, loneliness, uselessness, lack of clear understanding of future conditions and dissatisfaction with one's performance after retirement. This phenomenon requires interventions to adapt to these changes. Considering the supportive role of nurses, the formation of support groups as an effective intervention in adapting to transitional stages is emphasized. AIMS: This study aims to investigate the effect of older adults' participation in support groups on retirement syndrome. METHODS: This Quasi-experimental study recruited a total of 80 retired older adults meeting the inclusion criteria from three Retirement Associations (Retirement centers for social security retirees are among the institutions that have been set up by the government and this organization to provide face-to-face and offline services to social security retirees, as well as providing some facilities to this segment of the society). in Iran, Research samples were randomly assigned to two intervention and control groups. The demographic questionnaire and retirement syndrome questionnaire were completed by both groups at the beginning of the study. Then, four support group sessions lasting 60 to 90 min were held twice a week for the support group, and eight weeks after the end of the intervention, the questionnaires were completed for both groups. The data were analyzed using statistical tests in SPSS version 16. The significance level was set at p < 0.05 for all tests. RESULTS: The results of the covariance analysis showed that after the intervention, the feelings of helplessness and failure (p < 0.001), feelings of older and idleness (p = 0.027), and feelings of confusion and conflict (p = 0.002) were significantly less in the support group compared to the control group. In addition, the Feeling of trying and new direction (p < 0.001) was higher after the intervention. The paired t-test results showed that in the support group, the feelings of helplessness and failure (p < 0.001), feelings of older and idleness (p = 0.004), and feelings of confusion and conflict (p < 0.001) significantly decreased after the intervention compared to before it, while the feelings of trying and new direction (p = 0.004) significantly increased. Therefore, the results showed that after the intervention, there was a statistically significant difference between the two groups in all components of the retirement syndrome. CONCLUSION: The results of this study show that participation of retired older adults in support groups can significantly improve all components of retirement syndrome, leading to an improvement in their quality of life and satisfaction.

Functional brain networks in Developmental Topographical Disorientation.

Despite a decade-long study on Developmental Topographical Disorientation, the underlying mechanism behind this neurological condition remains unknown. This lifelong selective inability in orientation, which causes these individuals to get lost even in familiar surroundings, is present in the absence of any other neurological disorder or acquired brain damage. Herein, we report an analysis of the functional brain network of individuals with Developmental Topographical Disorientation ($n = 19$) compared against that of healthy controls ($n = 21$), all of whom underwent resting-state functional magnetic resonance imaging, to identify if and how their underlying functional brain network is altered. While the established resting-state networks (RSNs) are confirmed in both groups, there is, on average, a greater connectivity and connectivity strength, in addition to increased global and local efficiency in the overall functional network of the Developmental Topographical Disorientation group. In particular, there is an enhanced connectivity between some RSNs facilitated through indirect functional paths. We identify a handful of nodes that encode part of these differences. Overall, our findings provide strong evidence that the brain networks of individuals suffering from Developmental Topographical Disorientation are modified by compensatory mechanisms, which might open the door for new diagnostic tools.

Welfare of invertebrates: a pilot study on a new land snail stunning technique.

The almost complete absence of regulations to protect invertebrates is a common condition in legal systems, including the European one, especially when it comes to invertebrates intended for human consumption. Thus, in the vast majority of cases, edible invertebrates do not receive even the most basic protection at slaughter. Despite recent research indicating that invertebrates are capable of feeling pain and stress, the humane step of stunning is not used on them. This is also the case for land snails, which are gastropod invertebrates whose consumption has now reached significant levels, already involving tonnes and that is expected to increase significantly as edible snail farming becomes more popular as a relatively low-cost, easy-to-perform, and sustainable alternative animal husbandry, thereby making land snails an increasingly economically important species. This paper presents and investigates a proposed stunning method based on the immersion of mollusks in CO2-supplemented and refrigerated water that could be used in the snail meat production chain to reduce the slaughter suffering of millions of these invertebrates. To this end, body condition descriptors (hemolymph parameters) in snails were determined before and after CO2 treatment in cold water, while generating useful data for defining a preliminary set of reference intervals for basal values.

Reducing younger and older adults' spatial disorientation during indoor-outdoor transitions: Effects of route alignment and visual access on wayfinding.

Getting lost could lead to frustration, anxiety, and even fatal accidents. Previous research primarily focused on disorientation in indoor or outdoor environments separately. The indoor-outdoor transition received little attention, yet it is in this complex transition that individuals often lose their way. Therefore, the effects of indoor-outdoor route alignment, visual access, and age on wayfinding performance and spatial cognition were examined. Twenty older adults (aged 18-25) and twenty young adults (aged 65-82) participated in an experiment through desktop Virtual Reality (VR). They traversed indoor-outdoor environments and were informed within a building to quickly navigate an item inside another building. They also drew the route map. Participants repeated tasks in four different environments. Their spatial cognition and wayfinding performance were analyzed. Four main findings were derived. Firstly, the accuracy of global representation of the routes in the indoor-outdoor route alignment environment was higher than that in the non-aligned environment. Secondly, in environments with higher visual access, the accuracy of global representation of the routes for older adults was higher than that with lower visual access. Thirdly, enhancing visual access attenuated the negative impact of the non-aligned route on global representation of the routes. This effect is particularly beneficial for older adults. Fourthly, the younger adults outperformed the older adults in both wayfinding performance and global representation of the routes in indoor-outdoor environments. This difference could potentially be attributed to variations in education level, mental rotation ability, and digital experience. These findings provide valuable implications for urban design and wayfinding strategies.

EEG and acute confusional state at the emergency department.

OBJECTIVES: Acute confusional state (ACS) is a common cause of admission to the emergency department (ED). It can be related to numerous etiologies. Electroencephalography (EEG) can show specific abnormalities in cases of non-convulsive status epilepticus (NCSE), or metabolic or toxic encephalopathy. However, up to 80% of patients with a final diagnosis of NCSE have an ACS initially attributed to another cause. The exact place of EEG in the diagnostic work-up remains unclear. METHODS: Data of consecutive patients admitted to the ED for an ACS in a two-year period and who were referred for an EEG were collected. The initial working diagnosis was based on medical history, clinical, biological and imaging investigations allowing classification into four diagnostic categories. Comparison to the final diagnosis was performed after EEG recordings (and sometimes additional tests) were performed, which allowed the reclassification of some patients from one category to another. RESULTS: Seventy-five patients (mean age: 71.1 years) were included with the following suspected diagnoses: seizures for 8 (11%), encephalopathy for 14 (19%), other cause for 34 (45%) and unknown for 19 (25%). EEG was recorded after a mean of 1.5 days after symptom onset, and resulted in the reclassification of patients as follows: seizure for 15 (20%), encephalopathy for 15 (20%), other cause for 29 (39%) and unknown cause for 16 (21%). Moreover, ongoing epileptic activity (NCSE or seizure) and interictal epileptiform activity were found in eight (11%) patients initially diagnosed in another category. DISCUSSION: In our cohort, EEG was a key examination in the management strategy of ACS in 11% of patients admitted to the ED. It resulted in a diagnosis of epilepsy in these patients admitted with unusual confounding presentations.