A girl with headache, confusion and green urine.

The case of a 17-year-old girl with a history of headache, blurred vision, confusion, ataxia and syncope is presented. On admission, she had already recovered except for a slurring of speech. Her urine was found to be green. Screening for illegal drugs was negative, but gas chromatography with subsequent mass spectroscopy (GC-MS) revealed an extremely high concentration of flupirtine.

Hydration and acute confusion in long-term care residents.

Although it is generally appropriate for a healthy adult to consume 2000 to 2500 ml per day, the literature does not address evaluating any standard. The objective here was to develop a weight-based hydration management intervention and evaluate the impact of this on the incidence of acute confusion (AC) using an N = 98. The intervention consisted of a fluid intake goal based on 100 ml per kg for the first 10 kg, 50 ml/kg for the next 10 kg, and 15 ml for the remaining body weight. The treatment group received instruction and assistance on the fluid goal and the control group received routine care. Measurements included serum electrolytes, bioimpedance analysis, urinalysis, Mini-Mental State Exam, and the NEECHAM. There was no difference in the incidence of AC between treatment and controls, but those individuals with > or = 90% compliance demonstrated higher ECF volumes and also lower urine leukocyte counts.

Cognitive-behavioral stress management reduces distress and 24-hour urinary free cortisol output among symptomatic HIV-infected gay men.

BACKGROUND: Stress management interventions can reduce symptoms of distress as well as modulate certain immune system components in persons infected with human immunodeficiency virus (HIV). These effects may occur in parallel with reductions in hypothalamic-pituitary-adrenal (HPA) axis hormones such as cortisol, which has been related in other work to a down-regulation of immune system components relevant to HIV infection. The present study tested the effects of a multimodal cognitive-behavioral stress management (CBSM) intervention on 24-hour urinary free cortisol levels and distressed mood in symptomatic HIV+ gay men. METHODS: Symptomatic HIV-infected gay men who were randomized to either a 10-week group-based CBSM intervention or a 10-week wait-list period provided psychological responses and urine samples pre-post intervention. RESULTS: Of the 59 participants providing matched questionnaire data, men assigned to CBSM (n = 40) showed significantly lower posttreatment levels of self-reported depressed affect, anxiety, anger, and confusion than those in the wait-list control group (n = 19). Among the 47 men providing urine samples (34 CBSM, 13 controls), those assigned to CBSM revealed significantly less cortisol output as compared to controls. At the individual level, depressed mood decreases paralleled cortisol reductions over this period across the entire sample. CONCLUSION: A time-limited CBSM intervention reduced distress symptoms and urinary free cortisol output in symptomatic HIV+ gay men and greater reductions in some aspects of distress, especially depressed mood, paralleled greater decreases in cortisol over the intervention period. If persisting stressors and depressed mood contribute to chronic HPA axis activation in HIV-infected persons, then interventions such as CBSM, which teaches them to relax, alter cognitive appraisals, use new coping strategies, and access social support resources, may decrease distress and depressed mood and normalize HPA axis functioning.

The effectiveness of lumbar puncture in the evaluation of delirium and fever in the hospitalized elderly.

OBJECTIVE: To determine the value of the cerebrospinal fluid examination in the evaluation of hospitalized; elderly patients with delirium and fever. DESIGN: A retrospective case series of consecutive events during a 15-month period. SETTING: Tertiary care center. PARTICIPANTS: Elderly patients admitted to the University of Cincinnati (Ohio) Hospital between July 1, 1988, and October 1, 1989, who had a lumbar puncture and cerebrospinal fluid evaluation to evaluate fever and mental status changes. MAIN OUTCOME MEASURES: Primary intracranial causes and the clinical characteristics of delirium and fever. RESULTS: Eighty-one hospital admissions were reviewed. Fifty-seven (70%) of the lumbar punctures were performed as part of the admitting workup, and the remaining 24 (30%) were performed during the hospitalization. Eighty of the 81 cerebrospinal fluid cultures were negative for bacterial growth. The primary origins for fever and delirium included urinary tract infections (25%), pneumonia (22%), viral causes (17%), and metabolic causes/dehydration (14%). One case of bacterial meningitis was diagnosed in an alcoholic, 73-year-old man who was unresponsive in the emergency department. One case of presumed aseptic meningitis was diagnosed in a 65-year-old man who presented with fever and headaches and a blood pressure of 230/100 mm Hg. CONCLUSIONS: Most hospitalized, older patients with fever and delirium have primary causes of the confusion outside the central nervous system and may not require a routine evaluation of their cerebrospinal fluid.