Risk and clinical-outcome indicators of delirium in an emergency department intermediate care unit (EDIMCU): an observational prospective study.

BACKGROUND: Identification of delirium in emergency departments (ED) is often underestimated; within EDs, studies on delirium assessment and relation with patient outcome in Intermediate Care Units (IMCU) appear missing in European hospital settings. Here we aimed to determine delirium prevalence in an EDIMCU (Hospital de Braga, Braga, Portugal) and assessed routine biochemical parameters that might be delirium indicators. METHODS: The study was prospective and observational. Sedation level was assessed via the Richmond Agitation-Sedation Scale and delirium status by the Confusion Assessment Method for the ICU. Information collected included age and gender, admission type, Charlson Comorbidity Index combined condition score (Charlson score), systemic inflammatory response syndrome criteria (SIRS), biochemical parameters (blood concentration of urea nitrogen, creatinine, hemoglobin, sodium and potassium, arterial blood gases, and other parameters as needed depending on clinical diagnosis) and EDIMCU length of stay (LOS). Statistical analyses were performed as appropriate to determine if baseline features differed between the 'Delirium' and 'No Delirium' groups. Multivariate logistic regression was performed to assess the effect of delirium on the 1-month outcome. RESULTS: Inclusion and exclusion criteria were met in 283 patients; 238 were evaluated at 1-month for outcome follow-up after EDIMCU discharge ("good" recovery without complications requiring hospitalization or institutionalization; "poor" institutionalization in permanent care-units/assisted-living or death). Delirium was diagnosed in 20.1% patients and was significantly associated with longer EDIMCU LOS. At admission, Delirium patients were significantly older and had significantly higher blood urea, creatinine and osmolarity levels and significantly lower hemoglobin levels, when compared with No Delirium patients. Delirium was an independent predictor of increased EDIMCU LOS (odds ratio 3.65, 95% CI 1.97-6.75) and poor outcome at 1-month after discharge (odds ratio 3.51, CI 1.84-6.70), adjusted for age, gender, admission type, presence of SIRS criteria, Charlson score and osmolarity at admission. CONCLUSIONS: In an EDIMCU setting, delirium was associated with longer LOS and poor outcome at 1-month post-discharge. Altogether, findings support the need for delirium screening and management in emergency settings.

Obsessive-Compulsive Symptoms as a Manifestation of Homocystinuria.

Homocystinuria is a rare autosomal recessive metabolic disorder due to a defect in the cystathionine ß-synthase (CBS) that leads to high homocysteine plasma levels. Psychiatric symptoms secondary to homocystinuria have been described in the literature; however, there is a lack of information about obsessive-compulsive symptoms correlated to this disorder. We describe the case of a 39 years old man, diagnosed with homocystinuria in childhood, with no previous psychiatric history that presented obsessive-compulsive disorder (OCD) like symptoms, as a manifestation of homocystinuria. This case underlines the importance for a psychiatrist to explore medical nonpsychiatric history, especially when presentation is abrupt, atypical, or in treatment-resistant cases.

Wernicke-Korsakoff Syndrome: A Case Series in Liaison Psychiatry.

Wernicke-Korsakoff syndrome (WKS) is a life-threatening and underdiagnosed neuropsychiatric condition caused by thiamine deficiency that comprises Wernicke encephalopathy and Korsakoff syndrome. Although mainly associated with chronic alcoholism, WKS can arise from other circumstances. This report describes a series of cases of WKS that were clinically evaluated by liaison psychiatrists on a nonpsychiatric inpatient unit. The cases illustrate a deficit in the recognition and adequate treatment of WKS, demonstrating its clinical complexity and the need to improve physicians' knowledge.

Isoniazid-Induced Acute Psychosis in a Patient with Pleural Tuberculosis.

Tuberculosis is one of the top 10 causes of death and the leading cause from a single infectious agent (above HIV/AIDS). Isoniazid is highly bactericidal against replicating tubercle bacilli and is a component of all antituberculous chemotherapeutic regimens currently recommended by the World Health Organization (WHO). Several neuropsychiatric adverse effects, following both therapeutic and overdose use of isoniazid, have been described and isoniazid-induced psychosis, although uncommon, has been reported in the literature. We describe the case of a 21-year-old black woman, with no prior psychiatric history, who developed a psychotic episode four days after she was started on isoniazid. This case highlights psychosis arising as a possible adverse effect of isoniazid and the importance of remaining vigilant when antituberculous therapy is started.