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1.
Acad Med ; 95(1): 145-150, 2020 01.
Artigo em Inglês | MEDLINE | ID: mdl-31425191

RESUMO

PURPOSE: Course evaluations by students are a standard tool that U.S. universities use to monitor the quality of their product. Here, the authors examine an alternative method of monitoring instructional quality that differs from traditional approaches in that it does not rely on students' ratings. The authors sought to glean relevant diagnostic information about course effectiveness from in-class exams used to assess students' learning progress (i.e., cognitively diagnostic assessments that explicitly target instructional content). METHOD: The authors used data from an end-of-course, cumulative exam given in 2015 and in 2016 to 200 first-year medical students. They mapped the exam questions to 4 attributes and analyzed the students' overall mastery of the content tested and the percentage of students mastering each attribute. RESULTS: Analyses of the cognitively diagnostic assessment data revealed the percentage of the cohort who achieved/failed to achieve mastery of each of the attributes, discreet mastery profiles that distinguish among students with similar scores, and the percentage of the cohort within each of the 16 attribute mastery profiles. Analysis allowed the authors to evaluate how well the course content was delivered. CONCLUSIONS: Cognitively diagnostic assessments enable in-class tests to appraise which skills specified in the curriculum have/have not been mastered by the students and how many students have mastered/failed to master which particular skills. Hence, if the learning goals have been well defined at the beginning of a course, then cognitively diagnostic assessments can show to what degree the instructional objectives have actually been accomplished.


Assuntos
Educação de Graduação em Medicina/métodos , Avaliação Educacional/métodos , Testes de Estado Mental e Demência/normas , Estudantes de Medicina/estatística & dados numéricos , Logro , Adulto , Algoritmos , Competência Clínica/estatística & dados numéricos , Confusão/diagnóstico , Confusão/etiologia , Currículo/normas , Confiabilidade dos Dados , Educação de Graduação em Medicina/estatística & dados numéricos , Inibidores Enzimáticos/toxicidade , Feminino , Febre/diagnóstico , Febre/etiologia , Humanos , Masculino , Pessoa de Meia-Idade , Consumo de Oxigênio/efeitos dos fármacos , Pentaclorofenol/toxicidade , Estados Unidos/epidemiologia , Universidades/normas
2.
BMJ Case Rep ; 12(11)2019 Nov 25.
Artigo em Inglês | MEDLINE | ID: mdl-31772134

RESUMO

A 26-year-old man presented at the emergency department with confusion and decreased consciousness after several days of vomiting. In the preceding 6 months, he had used a 2-litre tank of nitrous oxide (N2O) weekly. His metabolic encephalopathy was caused by hyperammonaemia which probably resulted from interference of N2O-induced vitamin B12 deficiency with ammonia degradation. A catabolic state might have contributed to the hyperammonaemia in this case. After treatment with vitamin B12 and lactulose, both his consciousness and hyperammonaemia improved. He reported no residual complaints after 3 months of follow-up. Since N2O is increasingly used as a recreational drug, we recommend considering hyperammonaemia as a cause of metabolic encephalopathy in cases of N2O use and altered mental status.


Assuntos
Encefalopatias Metabólicas/induzido quimicamente , Confusão/diagnóstico , Transtornos da Consciência/diagnóstico , Hiperamonemia/induzido quimicamente , Óxido Nitroso/efeitos adversos , Adulto , Encefalopatias Metabólicas/tratamento farmacológico , Confusão/etiologia , Transtornos da Consciência/etiologia , Diagnóstico Diferencial , Fármacos Gastrointestinais/administração & dosagem , Fármacos Gastrointestinais/uso terapêutico , Humanos , Hiperamonemia/complicações , Lactulose/administração & dosagem , Lactulose/uso terapêutico , Masculino , Resultado do Tratamento , Vitamina B 12/administração & dosagem , Vitamina B 12/uso terapêutico , Deficiência de Vitamina B 12/complicações , Complexo Vitamínico B/administração & dosagem , Complexo Vitamínico B/uso terapêutico , Vômito/diagnóstico
3.
BMJ Case Rep ; 12(8)2019 Aug 30.
Artigo em Inglês | MEDLINE | ID: mdl-31471356

RESUMO

A 47-year-old woman presented an episode of confusion and disorientation. According to remarkable psychiatric records, she had been treated for major depression and obsessive-compulsive disorder; however, no other relevant background was known. After preliminary examinations, blood analysis and neurological tests were unspecific and inconclusive. Therefore, the case was treated as a possible psychiatric episode related to her previous psychiatric disorders. However, due to the atypical presentation of the case, a cerebral MRI was performed, which demonstrated multiple central lesions of the corpus callosum ('snowball lesions'), as well as several supratentorial white matter lesions. As a result of the follow-up of the case, sensorineural hearing loss and branch retinal artery were detected, which concluded in the classic triad and the confirmation of the diagnosis of a Susac syndrome.


Assuntos
Confusão/diagnóstico , Transtornos Dissociativos/diagnóstico , Síndrome de Susac/diagnóstico , Confusão/psicologia , Diagnóstico Diferencial , Transtornos Dissociativos/psicologia , Feminino , Humanos , Pessoa de Meia-Idade , Síndrome de Susac/psicologia
4.
BMJ Case Rep ; 12(8)2019 Aug 26.
Artigo em Inglês | MEDLINE | ID: mdl-31451457

RESUMO

Kaposi sarcoma (KS) is an angioproliferative disorder that is commonly associated with human herpes virus 8 as well as the HIV. In fact, KS is one of the most common AIDS-defining illnesses. KS typically presents with diffuse, violaceous cutaneous nodules, and may have concomitant visceral involvement. However, visceral involvement rarely occurs without skin manifestations. A rare case of localised bronchopulmonary KS without skin involvement is described in a patient with previously undiagnosed HIV. This atypical presentation represents a challenge for modern-day physicians in developed countries where the prevalence of AIDS-related diseases is decreasing.


Assuntos
Síndrome de Imunodeficiência Adquirida , Infecções por HIV , Neoplasias Pulmonares , Oseltamivir/administração & dosagem , Sarcoma de Kaposi , Síndrome de Imunodeficiência Adquirida/diagnóstico , Síndrome de Imunodeficiência Adquirida/etiologia , Antivirais/administração & dosagem , Lavagem Broncoalveolar/métodos , Contagem de Linfócito CD4/métodos , Deterioração Clínica , Confusão/diagnóstico , Confusão/etiologia , Desidratação/complicações , Desidratação/diagnóstico , Desidratação/terapia , Diagnóstico Diferencial , Evolução Fatal , Hidratação/métodos , Infecções por HIV/complicações , Infecções por HIV/diagnóstico , Infecções por HIV/fisiopatologia , Infecções por HIV/terapia , Humanos , Neoplasias Pulmonares/patologia , Neoplasias Pulmonares/fisiopatologia , Masculino , Sarcoma de Kaposi/patologia , Sarcoma de Kaposi/fisiopatologia , Tomografia Computadorizada por Raios X/métodos , Carga Viral/métodos
5.
West Afr J Med ; 36(2): 183-188, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31385606

RESUMO

OBJECTIVE: There is paucity of information on delirium in sub-Saharan Africa (SSA) particularly in the older persons (>60 years of age), leaving questions about the burden of the disease in an environment with lower health care standards. In this article, we set out to determine the frequency, precipitants and symptomatology of delirium in elderly patients admitted into medical wards in a teaching hospital in South-West Nigeria. METHODS: This was a descriptive study involving a pre-planned sample of one hundred and fifty patients aged 60 years and over, assessed for cognitive impairment and delirium using the previously validated IDEA cognitive screen, and the Confusion Assessment Method (CAM) respectively. Diagnosis of delirium was made using the CAM and DSM-IV criteria. RESULTS: Delirium was diagnosed in 32 patients giving a frequency of 21.3% (95%CI: 14.7-30.0%). Patients with delirium were significantly older (p<0.05). A quarter of the patients had dementia. Hypertension was a notable co-morbid condition. All the patients had altered sleep wake cycle, inattention, disorientation, and altered consciousness. Neurological diseases were the most common precipitant. There was a good agreement between the DSM-IV and CAM diagnoses. CONCLUSION: Delirium is common in hospitalised elderly patients particularly those with neurological diseases. Co-morbidities like hypertension, dementia, and depression should be looked for in delirious elderly patients.


Assuntos
Disfunção Cognitiva/diagnóstico , Confusão/diagnóstico , Delírio/diagnóstico , Demência/diagnóstico , Idoso , Idoso de 80 Anos ou mais , Disfunção Cognitiva/epidemiologia , Comorbidade , Confusão/psicologia , Delírio/epidemiologia , Delírio/psicologia , Demência/epidemiologia , Manual Diagnóstico e Estatístico de Transtornos Mentais , Humanos , Hipertensão/epidemiologia , Entrevista Psiquiátrica Padronizada/estatística & dados numéricos , Pessoa de Meia-Idade , Doenças do Sistema Nervoso/epidemiologia , Testes Neuropsicológicos/estatística & dados numéricos , Nigéria/epidemiologia , Transtornos do Sono-Vigília/epidemiologia , Centros de Atenção Terciária
6.
BMC Med ; 17(1): 138, 2019 07 24.
Artigo em Inglês | MEDLINE | ID: mdl-31337404

RESUMO

BACKGROUND: Delirium affects > 15% of hospitalised patients but is grossly underdetected, contributing to poor care. The 4 'A's Test (4AT, www.the4AT.com ) is a short delirium assessment tool designed for routine use without special training. The primary objective was to assess the accuracy of the 4AT for delirium detection. The secondary objective was to compare the 4AT with another commonly used delirium assessment tool, the Confusion Assessment Method (CAM). METHODS: This was a prospective diagnostic test accuracy study set in emergency departments or acute medical wards involving acute medical patients aged ≥ 70. All those without acutely life-threatening illness or coma were eligible. Patients underwent (1) reference standard delirium assessment based on DSM-IV criteria and (2) were randomised to either the index test (4AT, scores 0-12; prespecified score of > 3 considered positive) or the comparator (CAM; scored positive or negative), in a random order, using computer-generated pseudo-random numbers, stratified by study site, with block allocation. Reference standard and 4AT or CAM assessments were performed by pairs of independent raters blinded to the results of the other assessment. RESULTS: Eight hundred forty-three individuals were randomised: 21 withdrew, 3 lost contact, 32 indeterminate diagnosis, 2 missing outcome, and 785 were included in the analysis. Mean age was 81.4 (SD 6.4) years. 12.1% (95/785) had delirium by reference standard assessment, 14.3% (56/392) by 4AT, and 4.7% (18/384) by CAM. The 4AT had an area under the receiver operating characteristic curve of 0.90 (95% CI 0.84-0.96). The 4AT had a sensitivity of 76% (95% CI 61-87%) and a specificity of 94% (95% CI 92-97%). The CAM had a sensitivity of 40% (95% CI 26-57%) and a specificity of 100% (95% CI 98-100%). CONCLUSIONS: The 4AT is a short, pragmatic tool which can help improving detection rates of delirium in routine clinical care. TRIAL REGISTRATION: International standard randomised controlled trial number (ISRCTN) 53388093 . Date applied 30/05/2014; date assigned 02/06/2014.


Assuntos
Confusão/diagnóstico , Delírio/diagnóstico , Testes Diagnósticos de Rotina , Testes Neuropsicológicos , Doença Aguda , Idoso , Idoso de 80 Anos ou mais , Algoritmos , Lista de Checagem/métodos , Lista de Checagem/normas , Testes Diagnósticos de Rotina/métodos , Testes Diagnósticos de Rotina/normas , Manual Diagnóstico e Estatístico de Transtornos Mentais , Serviço Hospitalar de Emergência , Feminino , Avaliação Geriátrica/métodos , Humanos , Pacientes Internados , Masculino , Testes Neuropsicológicos/normas , Valor Preditivo dos Testes , Reprodutibilidade dos Testes , Sensibilidade e Especificidade
7.
Geriatr Gerontol Int ; 19(8): 762-767, 2019 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-31237088

RESUMO

AIM: To evaluate the diagnostic performance of the Confusion Assessment Method for the intensive care unit (CAM-ICU) among postoperative older patients in non-ICU settings. METHODS: The CAM-ICU was used by trained staff to prospectively evaluate postoperative patients for delirium. The patients were aged ≥60 years, were in general wards and had no critical illnesses. The assessments occurred for 7 consecutive days after surgery. The results were compared with delirium diagnoses obtained by geriatricians using Diagnostic and Statistical Manual of Mental Disorders 5th edition criteria as the reference standard. RESULTS: The sensitivity of delirium detection for the CAM-ICU was 31.6% (95% confidence interval [CI] 12.6-56.6), while the specificity was 97.6% (95% CI 94.9-99.1), positive predictive value was 50.0% (95% CI 26.3-73.7) and negative predictive value was 95.0% (95% CI 93.3-96.3). Feature 4 (disorganized thinking) yielded the highest sensitivity (60%; 95% CI 14.7-94.7), whereas feature 2 (inattention) had low sensitivity (36.8%; 95% CI 16.3-61.6). Further analyses to explore the highest sensitive criteria showed that if CAM-ICU diagnoses were made by the presence of any two out of feature 1 (acute change or fluctuation of cognition), feature 3 (altered level of consciousness) or feature 4, the sensitivity increased substantially to 80.0% (95% CI 28.4-99.5), with a reasonably high specificity of 81.8% (95% CI 48.2-97.7). CONCLUSIONS: Modification of the flow of delirium diagnosis using the CAM-ICU appears to offer a better sensitivity for detecting delirium in non-ICU settings. Furthermore, changing feature 2 to evaluate patients' attention levels over a longer period of time might yield a better diagnostic performance. Geriatr Gerontol Int 2019; 19: 762-767.


Assuntos
Confusão , Delírio , Avaliação Geriátrica/métodos , Quartos de Pacientes , Complicações Cognitivas Pós-Operatórias/diagnóstico , Idoso , Confusão/diagnóstico , Confusão/etiologia , Cuidados Críticos/métodos , Delírio/diagnóstico , Delírio/etiologia , Manual Diagnóstico e Estatístico de Transtornos Mentais , Feminino , Humanos , Masculino , Valor Preditivo dos Testes , Padrões de Referência , Reprodutibilidade dos Testes , Sensibilidade e Especificidade
8.
BMJ Case Rep ; 12(6)2019 Jun 04.
Artigo em Inglês | MEDLINE | ID: mdl-31167766

RESUMO

New-onset paroxysmal events in patients over 60 years of age are often diagnostically challenging owing to atypical presentation. Recurrent falls and transient states of confusion are especially common in the elderly population, yet their causes often remain undiagnosed due to concomitant cognitive deficits and motor impairments. We present an elderly patient with newly occurring 'blackouts' without obvious triggers and transient states of confusion for which he was amnestic. All neurological exams including brain MRI scan and routine electroencephalography (EEG) were normal. Long-term ECG monitoring using an event recorder captured an asystole during a habitual episode, leading to the diagnosis of syncope and pacemaker implantation. A subsequent video EEG monitoring performed due to ongoing unexplained confusional states revealed both bradycardia and long-lasting confusional states to be caused by unrecognised temporal lobe seizures. Ictal video EEG monitoring may play a crucial role in establishing a diagnosis of atypical temporal lobe seizures in the elderly.


Assuntos
Amnésia/diagnóstico , Confusão/diagnóstico , Epilepsia do Lobo Temporal/complicações , Síncope/complicações , Acidentes por Quedas , Anticonvulsivantes/administração & dosagem , Anticonvulsivantes/uso terapêutico , Confusão/etiologia , Eletroencefalografia/métodos , Epilepsia do Lobo Temporal/tratamento farmacológico , Epilepsia do Lobo Temporal/fisiopatologia , Parada Cardíaca/complicações , Parada Cardíaca/fisiopatologia , Humanos , Masculino , Pessoa de Meia-Idade , Monitorização Fisiológica/métodos , Marca-Passo Artificial , Pregabalina/administração & dosagem , Pregabalina/uso terapêutico , Recidiva , Resultado do Tratamento , Gravação em Vídeo/instrumentação
10.
BMC Geriatr ; 19(1): 107, 2019 04 15.
Artigo em Inglês | MEDLINE | ID: mdl-30991945

RESUMO

BACKGROUND: Delirium occurs commonly in older adults and is associated with adverse outcomes. Multicentre clinical trials evaluating interventions to prevent delirium are needed. The Confusion Assessment Method (CAM) is a validated instrument for delirium detection. We hypothesised it would be possible for a large feasibility study to train a large number of research assistants, with varying experience levels, to conduct CAM assessments reliably in multiple hospital sites. METHODS: A standardised training programme was followed, incorporating structured training at a central location and at study sites. CAM practice sessions on both delirious and non-delirious patients by research assistants were conducted and, thereafter, there was ongoing inter-rater reliability assessment on the CAM between research assistant pairs at study sites. The setting was eight acute care hospitals in England and Wales. Participants were research assistants working on a multicentre feasibility study of delirium prevention. The measurement used was the Confusion Assessment Method. RESULTS: Thirty-seven research assistants were trained in CAM assessment and 33 returned training logs. The logs showed there was 100% overall agreement between research assistant pairs on 295 CAM assessments, of which 263 (89.2%) were negative for delirium and 32 (10.8%) were positive. In the course of the feasibility study, research assistants successfully completed 5065 (89.7%) of the 5645 expected CAM assessments, with minimal missing data. CONCLUSION: Using the training methods described in this study, it is possible to achieve high quality delirium assessments for large numbers of patients with little missing data across geographically dispersed sites in multicentre studies. The standardisation of multisite delirium assessments is an important contribution to research methodology, and provides a much-needed advance for the field. TRIAL REGISTRATION: ISRCT ISRCTN01187372 . Registered 13 March 2014.


Assuntos
Confusão/diagnóstico , Confusão/psicologia , Pessoal de Saúde/educação , Pessoal de Saúde/normas , Idoso , Idoso de 80 Anos ou mais , Confusão/epidemiologia , Delírio/diagnóstico , Delírio/epidemiologia , Delírio/psicologia , Inglaterra/epidemiologia , Estudos de Viabilidade , Feminino , Humanos , Masculino , Reprodutibilidade dos Testes , País de Gales/epidemiologia
12.
Ann Emerg Med ; 74(1): 60-68, 2019 07.
Artigo em Inglês | MEDLINE | ID: mdl-30078659

RESUMO

STUDY OBJECTIVE: Confusion, uremia, elevated respiratory rate, hypotension, and aged 65 years or older (CURB-65) is a clinical prediction rule intended to stratify patients with pneumonia by expected mortality. We assess the predictive performance of CURB-65 for the proximal endpoint of receipt of critical care intervention in emergency department (ED) patients admitted with community-acquired pneumonia. METHODS: We performed a retrospective analysis of electronic health records from a single tertiary center for ED patients admitted as inpatients with a primary diagnosis of pneumonia from 2010 to 2014. Patients with a history of malignancy, tuberculosis, bronchiectasis, HIV, or readmission within 14 days were excluded. We assessed the predictive accuracy of CURB-65 for receipt of critical care interventions (ie, vasopressors, large-volume intravenous fluids, invasive catheters, assisted ventilation, insulin infusions, or renal replacement therapy) and inhospital mortality. Logistic regression was performed to assess the increase in odds of critical care intervention or inhospital mortality by increasing CURB-65 score. RESULTS: There were 2,322 patients admitted with community-acquired pneumonia in the study cohort; 630 (27.1%) were admitted to the ICU within 48 hours of ED triage and 343 (14.8%) received a critical care intervention. Of patients with a CURB-65 score of 0 to 1, 181 (15.6%) were admitted to the ICU, 74 (6.4%) received a critical care intervention, and 7 (0.6%) died. Of patients with a CURB-65 score of 2, 223 (27.0%) were admitted to the ICU, 127 (15.4%) received a critical care intervention, and 47 (5.7%) died. Among patients with CURB-65 score greater than or equal to 3, 226 (67.0%) were admitted to the ICU, 142 (42.1%) received a critical care intervention, and 43 (12.8%) died. The areas under the receiver operating characteristic for CURB-65 as a predictor of critical care intervention and mortality were 0.73 and 0.77, whereas sensitivity of CURB-65 score greater than or equal to 2 in predicting critical care intervention was 78.4%; for mortality, 92.8%. CONCLUSION: Patients with CURB-65 score less than or equal to 2 were often admitted to the ICU and received critical care interventions. Given this finding and the relatively low sensitivity of CURB-65 for critical care intervention, clinicians should exercise caution when using CURB-65 to guide disposition. Future ED-based clinical prediction rules may benefit from calibration to proximal endpoints.


Assuntos
Infecções Comunitárias Adquiridas/diagnóstico , Infecções Comunitárias Adquiridas/epidemiologia , Cuidados Críticos/normas , Pneumonia/diagnóstico , Idoso , Idoso de 80 Anos ou mais , Regras de Decisão Clínica , Infecções Comunitárias Adquiridas/mortalidade , Confusão/diagnóstico , Confusão/etiologia , Serviço Hospitalar de Emergência/estatística & dados numéricos , Feminino , Mortalidade Hospitalar , Hospitalização/estatística & dados numéricos , Humanos , Hipotensão/diagnóstico , Hipotensão/etiologia , Unidades de Terapia Intensiva , Masculino , Pessoa de Meia-Idade , Avaliação de Resultados em Cuidados de Saúde , Pneumonia/mortalidade , Valor Preditivo dos Testes , Taxa Respiratória/fisiologia , Estudos Retrospectivos , Uremia/diagnóstico , Uremia/etiologia
14.
Acta Anaesthesiol Scand ; 63(3): 352-359, 2019 03.
Artigo em Inglês | MEDLINE | ID: mdl-30324653

RESUMO

BACKGROUND: Delirium is underinvestigated in the neuro-critically ill, although the harmful effect of delirium is well established in patients in medical and surgical intensive care units (ICU).To detect delirium, a valid tool is needed. We hypothesized that delirium screening would be feasible in patients with acute brain injury and we aimed to validate and compare the Confusion Assessment Method for the ICU and the Intensive Care Delirium Screening Checklist against clinical International Classification of Diseases-10 criteria as reference. METHODS: Nurses assessed delirium using the Confusion Assessment Method for the ICU and Intensive Care Delirium Screening Checklist in adult patients with acute brain injury admitted to the Neurointensive care unit (Neuro-ICU), Copenhagen University Hospital, if their Richmond agitation-sedation scale score was -2 or above. As the reference, a team of psychiatrist assessed patients using the International Classification of Diseases-10 criteria. RESULTS: We enrolled 74 patients, of whom 25 (34%) were deemed unable to assess by the psychiatrists, leaving 49 (66%) for final analysis. Sensitivity and specificity for the Confusion Assessment Method for the ICU was 59% (95% CI: 41-75) and 56% (95% CI: 32-78), respectively, and 85% (95% CI: 70-94) and 75% (95% CI: 51-92), respectively, for the Intensive Care Delirium Screening Checklist. CONCLUSIONS: Our findings suggest that the Intensive Care Delirium Screening Checklist may be a valid tool and the Confusion Assessment Method for the ICU is less suitable for delirium detection for patients in the Neuro-ICU. In the neuro-critically ill, delirium screening is challenged by limited feasibility.


Assuntos
Lista de Checagem , Estado Terminal/psicologia , Delírio/diagnóstico , Testes Neuropsicológicos , Adulto , Confusão/diagnóstico , Confusão/etiologia , Confusão/psicologia , Cuidados Críticos , Delírio/epidemiologia , Estudos de Viabilidade , Feminino , Humanos , Classificação Internacional de Doenças , Masculino , Programas de Rastreamento , Pessoa de Meia-Idade , Enfermeiras e Enfermeiros , Prevalência , Estudos Prospectivos , Agitação Psicomotora/diagnóstico , Reprodutibilidade dos Testes , Sensibilidade e Especificidade
15.
Ned Tijdschr Geneeskd ; 1632019 12 05.
Artigo em Holandês | MEDLINE | ID: mdl-32073794

RESUMO

BACKGROUND: Anti-NMDA-receptor-encephalitis is a progressive autoimmune disease with significant mortality if left untreated. CASE DESCRIPTION: A 58-year-old man without previous psychiatric or neurologic history presented at the emergency department after brief loss of consciousness at work. Within a few hours, the patient developed acute neuropsychiatric symptoms, including altered levels of consciousness, aggression, incoherence, change in behaviour, and psychomotor agitation. Initially, additional blood, cerebrospinal fluid and EEG tests showed no abnormalities. Over the course of the following days, catatonia, orofacial dyskinesia and autonomic-function disorder developed, eventually with respiratory insufficiency, necessitating transfer to the intensive-care unit. At this stage, the EEG did show abnormalities, and cerebrospinal fluid analysis showed marginal pleocytosis. The patient was treated with intravenous methylprednisolone and immunoglobins. Anti-NMDA-receptor antibodies were present in the blood and cerebrospinal fluid. Screening for malignancy identified small-cell lung carcinoma, for which the patient was treated with cytostatic agents. CONCLUSION: Acute neuropsychiatric symptoms in a middle-aged patient with no psychiatric medical history are suggestive of an underlying somatic cause. Timely recognition and treatment of anti-NMDA-receptor encephalitis is essential to improve the prognosis.


Assuntos
Encefalite Antirreceptor de N-Metil-D-Aspartato/complicações , Competência Clínica , Confusão/etiologia , Neuropsiquiatria/métodos , Médicos/psicologia , Doença Aguda , Encefalite Antirreceptor de N-Metil-D-Aspartato/diagnóstico , Confusão/diagnóstico , Diagnóstico Diferencial , Humanos , Masculino , Pessoa de Meia-Idade
16.
Klin Onkol ; 31(5): 371-375, 2018.
Artigo em Inglês | MEDLINE | ID: mdl-30541324

RESUMO

BACKGROUND: Brain metastases are one of the main causes of morbidity and mortality of patients with oncological disease. In non-small cell lung carcinoma (NSCLC), the risk of CNS secondary development is 30-50%. An unusual diagnostic and therapeutic problem is the finding of suspicious pituitary lesions. Obtaining a differential diagnosis relies on evaluating the clinical course of the disease (visual disturbances, diabetes insipidus (DI), weakness etc.), and performing endocrinological examinations and imaging analyses (CT, but mainly MRI). Sometimes, however, definitive resolution of the problem requires histological assessment of the tumor. CASE REPORT: A 65-year-old patient with a newly diagnosed metastatic lung adenocarcinoma was admitted to our department for a first cycle of chemotherapy consisting of cisplatin and navelbine. However, at the beginning of hospitalization, the patient developed qualitative disturbances in consciousness and disorientation. Emergency CT of the CNS revealed a tumor of the pituitary gland, and a subsequent MRI showed intraseller and suprasellar masses making contact with the optic chiasma. An endocrinological examination revealed panhypopituitarism. Pituitary metastasis of NSCLC was confirmed by tumor histology using the trans-sphenoid approach. CONCLUSION: Lung and breast carcinomas are among the most common cancers to metastasize to the pituitary gland. The incidence of pituitary metastases is reported to be 0.4-28.1%. Clinically, they are mostly silent, but may manifest as endocrine disorders, such as DI, hypothyroidism, and hypocorticism, or as visual disturbances due to compression of the optic nerve. Management depends on the establishment of a correct diagnosis. Key words: hypopituitarism - magnetic resonance imaging - pituitary neoplasm - radiosurgery - targeted therapy The authors declare they have no potential confl icts of interest concerning drugs, products, or services used in the study. The Editorial Board declares that the manuscript met the ICMJE recommendation for biomedical papers. Submitted: 26. 4. 2018 Accepted: 27. 6. 2018.


Assuntos
Adenocarcinoma de Pulmão/diagnóstico , Carcinoma Pulmonar de Células não Pequenas/diagnóstico , Confusão/diagnóstico , Transtornos da Consciência/diagnóstico , Hipopituitarismo/diagnóstico , Neoplasias Pulmonares/diagnóstico , Neoplasias Hipofisárias/diagnóstico , Adenocarcinoma de Pulmão/patologia , Idoso , Carcinoma Pulmonar de Células não Pequenas/patologia , Confusão/patologia , Transtornos da Consciência/patologia , Humanos , Hipopituitarismo/patologia , Neoplasias Pulmonares/patologia , Imagem por Ressonância Magnética , Neoplasias Hipofisárias/secundário
17.
Anasthesiol Intensivmed Notfallmed Schmerzther ; 53(11-12): 793-796, 2018 Nov.
Artigo em Alemão | MEDLINE | ID: mdl-30458577

RESUMO

Postoperative delirium (POD) is an acute change in the mental state with consciousness and attention deficits. It is a common complication after surgical procedures and can have serious consequences. Thus, the evidence- and consensus-based guidelines for POD appeals with the highest recommendation level that patients be regularly screened for delirium in the postoperative phase, from the recovery room to the fifth postoperative day and at least once per shift, using a validated test instrument for the detection of POD. In 2014, Marcantonio et al. published the 3D-CAM (3-Minute Diagnostic Interview for CAM-defined Delirium). In the 3D-CAM, the algorithm of the Confusion Assessment Method (CAM) is maintained by using individual elements that operationalize the evaluation of the criteria. Therefore, it requires less training, be faster to use, and, due to a standardized approach, has less interrater variability than the CAM, whereas the high sensitivity and specificity are maintained. Our goal was to translate the 3D-CAM from English to German, so as to make this instrument available to German-speaking countries. The translation of the 3D-CAM was based on the 2005 published guideline on Translation and Cultural Adaptation of Patient Reported Outcome Measures of the International Society for Pharmacoeconomics and Outcome Research. Three independent forward translations were harmonized to a preliminary translation, which then was translated back into the original language. Original authors reviewed the back translation. According to a cognitive debriefing, the translation was revised and in addition was adapted for use in the recovery room. Due to close contact with the original authors during the translation process, it was possible to ensure that the contents of the test instrument were remained intact during the translation process.


Assuntos
Anestesia Geral/efeitos adversos , Delírio do Despertar/diagnóstico , Entrevista Psicológica/métodos , Complicações Pós-Operatórias/diagnóstico , Idoso , Idoso de 80 Anos ou mais , Confusão/diagnóstico , Confusão/psicologia , Delírio do Despertar/etiologia , Humanos , Complicações Pós-Operatórias/psicologia , Complicações Pós-Operatórias/terapia , Reprodutibilidade dos Testes , Traduções
20.
Brain Behav ; 8(9): e01078, 2018 09.
Artigo em Inglês | MEDLINE | ID: mdl-30141244

RESUMO

INTRODUCTION: Topographical disorientation is defined as the inability to recognize familiar or unfamiliar environments. While its slowly progressive development is a common feature of neurodegenerative processes like Alzheimer's dementia, acute presentations are less frequent and mostly caused by strategic lesions within the cerebral navigation network. Depending on the lesion site, topographical disorientation can originate from deficits in landmark recognition and utilization for route planning (egocentric navigation deficit), or disturbance of an overarching cognitive map of the spatial environment (allocentric navigation deficit). However, objective measurements of spatial navigation performance over time are largely missing in patients with topographical disorientation. METHODS: We here report a 55-year-old patient with acute topographical disorientation as the single symptom of right-sided hippocampal hemorrhage and present quantitative gaze-monitoring head camera-based analyses of his path-finding strategy and visual exploration behavior in a real space navigation paradigm. RESULTS: The patient exhibited severe allocentric and also egocentric navigation deficits during the acute phase, shown by higher error rates at finding target items. In addition, he showed a more extensive use of search saccades toward, and fixations on, landmarks that could potentially serve as spatial cues. These deficits had been completely compensated for after four months, when the patient performed unremarkably in the real space navigation task, and used even more strongly allocentric path optimization strategies than age-matched controls. CONCLUSIONS: This case report highlights the integral function and right-sided dominance of the hippocampal formation in the cerebral navigation network in humans. It shows that the cognitive map can be restored completely despite a residual hippocampal lesion, which illustrates the enormous plasticity of the cerebral navigation network in humans.


Assuntos
Confusão/etiologia , Hipocampo/fisiopatologia , Hemorragias Intracranianas/complicações , Hemorragias Intracranianas/fisiopatologia , Confusão/diagnóstico , Hipocampo/diagnóstico por imagem , Humanos , Hemorragias Intracranianas/diagnóstico por imagem , Imagem por Ressonância Magnética , Masculino , Pessoa de Meia-Idade , Testes Neuropsicológicos , Navegação Espacial
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