C-L Case Conference: A 33-Year-Old Bhutanese Woman With Postpartum Hallucinations.

We describe the case of a 33-year-old pre-eclamptic Bhutanese woman who presented with postpartum hallucinations. We discuss our concern for postpartum psychosis versus a culturally appropriate phenomenon, with her diagnostic picture complicated by the use of interpreters and the intersection of culture and medicine. Top experts in the consultation-liaison (CL) field provide guidance for this clinical scenario based on their experience and a review of the available literature. This case highlights both the impact of language barriers and the challenges of interpreting psychiatric symptoms within a cultural context. Key teaching points include differential diagnoses for postpartum hallucinations, the importance of interpreting patient presentations within their unique cultural contexts and identities, and the impact of language interpretation on patient care. Specifically, we offer guidance on differentiating postpartum psychosis from a culturally appropriate phenomenon.

Top Ten Tips Palliative Care Clinicians Should Know About Medical Decision-Making Capacity Assessment.

Palliative care (PC) clinicians treat seriously ill patients who are at increased risk for compromised decision-making capacity (DMC). These patients face profound and complex questions about which treatments to accept and which to decline. PC clinicians, therefore, have the especially difficult task of performing thorough, fair, and accurate DMC assessments in the face of the complex effects of terminal illness, which may be complicated by fluctuating acute medical conditions, mental illness, or cognitive dysfunction. This study, written by a team of clinicians with expertise in PC, ethics, psychiatry, pediatrics, and geriatrics, aims to provide expert guidance to PC clinicians on best practice for complex DMC assessment.

Depressive symptoms and associated factors in systemic lupus erythematosus.

BACKGROUND: Depressive symptoms affect anywhere from 11% to 71% of patients with systemic lupus erythematosus (SLE), which may be related to SLE disease activity, other clinical variables, or sociodemographic factors. OBJECTIVE: We aimed to measure the rate of depressive symptoms in our cohort of patients with SLE and to identify modifiable factors associated with depressive symptoms. METHODS: Patients in our university-based SLE registry completed the Beck Depression Inventory-II (BDI-II), pain scores, and demographic information. Disease activity was measured using the physician's global assessment (PGA) and Selena-SLE disease activity index (Selena-systemic lupus erythematosus disease activity index (SLEDAI)). Patients were identified as having moderate or severe depressive symptoms (BDI-II ≥ 18) or not (BDI-II < 18). Nonparametric tests and χ(2) tests were used as appropriate to compare variables between groups. RESULTS: Fifty-three of 127 people (41.7%) were identified as having moderate or severe depressive symptoms, which were associated with higher pain levels and lower self-reported of current health status. Patients with moderate or severe depressive symptoms were more likely (49%) than those with no or mild depressive symptoms (18%) to have lupus arthritis (P < 0.01). Of the 53 patients with moderate or severe depressive symptoms, only 26 (49.0%) were prescribed antidepressants, and only 8/53 patients (15.0%) were prescribed the maximum dose of antidepressant. CONCLUSIONS: This study identified moderate or severe depressive symptoms in 41.7% of our cohort of patients with SLE. The most significant variable associated with these symptoms was pain; improved treatment of pain, and in particular from lupus arthritis, may result in alleviation of depressive symptoms in patients with SLE.

A case of delirium, motor disturbances, and autonomic dysfunction due to baclofen and tizanidine withdrawal: a review of the literature.

We report a case of delirium accompanied by extrapyramidal symptoms and autonomic dysfunction in a 59-year-old man following abrupt cessation of baclofen and tizanidine. An extensive search for the etiology was undertaken, but it was only after a careful history was taken that suspicion for baclofen and tizanidine withdrawal was raised. The delirium and motor disturbances resolved within 24 h of reintroduction of baclofen. Withdrawal from muscle relaxants requires a high index of suspicion but should be considered in patients who manifest signs and symptoms of withdrawal from the medications, particularly visual hallucinations, rigidity and autonomic dysfunction.

The case of H.S.: the ethics of reporting alcohol dependence in a bus driver.

The physician's duty to preserve patient confidentiality is challenged when doing so may endanger third parties. We present the case of a bus driver whose alcohol dependence raised concerns of a risk not only to his own health and safety, but to public safety as well. We first examine the legal and ethical obligations to report his alcohol use to his employer and then stress the importance of weighing the potential harm of violating patient-physician confidentiality against the severity of risk to the general public.