Acute Altered Mental Status Research Articles

The role of Electroencephalography in children with Acute Altered Mental Status of unknown etiology: a prospective study.

Acute alterated mental status (AAMS) is often a challenge for clinicians, since the underlying etiologies cannot always easily be inferred based on the patient's clinical presentation, medical history or early examinations. The aim of this study is to evaluate the role of the electroencephalogram (EEG) as a diagnostic tool in AAMS of unknown etiology in children. We conducted a prospective study involving EEG assessments on children presenting with AAMS between May 2017 and October 2019. Inclusion criteria were age 1 month to 18 years and acute (<1 week) and persistent (>5 minutes) Altered mental status (AMS). Patients with a known etiology of AAMS were excluded. A literature review was also performed. Twenty patients (median age: 7.7 years, range: 0.5-15.4) were enrolled. EEG contributed to the diagnosis in 14/20 cases, and was classified as diagnostic in 9/20 and informative in 5/20. Specifically, EEG was able to identify nonconvulsive status epilepticus (NCSE) in 5 children and psychogenic events in 4. EEG proved to be a poorly informative diagnostic tool at AAMS onset in 6 children, however in 5 of them, it proved useful during follow-up. Limited data exist regarding the role of EEG in children with AAMS of unknown etiology. In our population EEG proved to be valuable tool, and was especially useful in the prompt identification of NCSE and psychogenic events.

A Family With Acute Altered Mental Status: Call for Action.

A Family With Acute Altered Mental Status: Call for Action.

Guide for the treatment of acute altered mental status. Iberoamerican Academy of Pediatric Neurology

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.

A Case of Congestive Heart Failure with Gastrointestinal Bleeding and Altered Mental Status

Congestive heart failure (CHF) is a common cardiovascular condition associated with significant morbidity and mortality. Complications of CHF such as gastrointestinal bleeding and acute altered mental status pose diagnostic and therapeutic challenges. We present the case of a 75-year-old male with history of hypertension and coronary artery disease who presented with chest pain, vomiting, melena and decreased consciousness. Workup revealed anemia, elevated cardiac markers, evidence of congestive heart failure and subarachnoid hemorrhage. Clinicians should maintain a high index of suspicion for life-threatening complications in CHF patients presenting with atypical manifestations. Prompt diagnosis and optimization of underlying conditions are key to improving outcomes.

Delayed malignant cerebellar posterior reversible encephalopathy syndrome secondary to (CLAG-M) and venetoclax regimen. (P12-13.006)

<h3>Objective:</h3> PRES (posterior reversible encephalopathy syndrome) is a heterogenous syndrome caused by multiple factors. Cerebellar PRES is commonly seen with autoimmune disease and rarely with chemotherapy. <h3>Background:</h3> Isolated cerebellar malignant posterior reversible encephalopathy syndrome (PRES) is rare. We report a case of delayed malignant cerebellar PRES triggered by cladribine, cytarabine, granulocyte colony-stimulating factor, mitoxantrone (CLAG-M) and venetoclax regimen. <h3>Design/Methods:</h3> A 73-year-old male presented with history of relapse after allogeneic stem cell transplantation for refractory myelodysplastic syndrome on maintenance tacrolimus. He was admitted for salvage therapy with (CLAG-M) + venetoclax regimen. Day 16^th post salvage therapy he developed acute onset altered mental status and headache followed by fever and hypotension. Brain MRI revealed posterior bilateral cerebellar, vermian edema with tiny petechial hemorrhages, ventriculomegaly, transependymal edema and mass effect on fourth ventricular effacement. Despite external ventricular drain placement, hyperosmolar therapy and steroids, day 19^th the patient suffered devastating neurological injury and family opted for hospice care. Of note, maintenance tacrolimus was held prior to admission and was started 4 days prior to onset of neurological symptoms with sub-therapeutic levels. <h3>Results:</h3> NA <h3>Conclusions:</h3> The potential role of (CLAG-M) and venetoclax regimen in the pathogenesis of PRES needs to be considered. Cerebellar PRES is rare and can be complicated by early hydrocephalus and 4^th ventricle compression. Although PRES is usually benign, prompt recognition of indicators of the malignant phenotype and aggressive management is crucial. <b>Disclosure:</b> Dr. Snehal has nothing to disclose. Dr. Mathew has nothing to disclose.

Distributive Shock in Erythrodermic Psoriasis Treated With Norepinephrine and Vasopressin: A Case Report

Distributive shock and hypothermia are two unusual and potentially fatal complications of erythroderma, a rare complication of psoriasis. Very few cases of erythrodermic psoriasis have been reported, particularly in the United States, which may pose a diagnostic challenge for internists. We present a case report of distributive hemodynamic instability and hypothermia in a 61-year-old female who initially presented with acute altered mental status thought to be related to an infectious etiology.

Diphenhydramine-induced delirium on top of HIV-associated neurocognitive disorder

IntroductionHIV-associated neurocognitive disorder has been less frequent in recent years due to the availability of anti-retrovials. However, in the Philippines, persons with HIV are diagnosed late resulting to cases of HIV-associated neurocognitive disorder. With higher incidence of depression and anxiety in this population, difficulty sleeping becomes a prominent symptom and diphenhydramine is a common non-prescription nighttime sleep aid being given.ObjectivesTo present a case of diphenhydramine-induced delirium after a patient with HIV-associated neurocognitive disorder.MethodsThis a case report.ResultsMr. JR., a 38-year-old person living with HIV and no past psychiatric history, presents with acute onset altered mental status, suicidal attempt, and jerking movements of the neck and extremities. He has been having bouts of diarrhea, fatigue, weight loss, and forgetfulness for a year before he was diagnosed with HIV-AIDS with CD4 count of 59 cells/mm3. At this time, he already had blurring of vision, poor sleep, weakness, poor concentration, and increasing severity of forgetfulness. He also started to have depressed mood and anhedonia but no suicidal ideations. He was eventually started on antiretroviral (ARVs) which are lamivudine, tenofovir, dolutegravir and antibiotics targeting opportunistic bacteria – Isoniazid, Moxifloxacin and Clindamycin. A few days after, he started to have jerking movements of the neck and extremities contributing further to poor sleep. Upon consult with a local clinic to address his sleep, he was prescribed with Diphenhydramine and after taking 50mg dose that evening, he started to have disorientation, paranoia, command auditory hallucinations resulting to a suicidal attempt, on top of the jerking movements, which prompted consult to the emergency room and subsequent admission. Initially assessed as central nervous system infection and focal seizure, CSF fluids studies and EEG were done showing normal findings. Started on Sodium Valproate + Valproic acid 500mg IV twice daily and Olanzapine 2.5mg twice a day, on top of his previously mentioned ARVs and antibiotics, the disorientation, auditory hallucinations, and myoclonic jerks mood resolved after five days. Five months on ARVs, he has no recurrence of myoclonic jerks, disorientation or psychosis, with memory and concentration improved, euthymic mood, and was able to resume work as an engineer.ConclusionsDiphenhydramine is a common nighttime sleep aid. Due to its anticholinergic effect, cases of delirium were reported for doses 300mg to 1,000mg per day. For Mr. JR, the mere 50mg dose of diphenhydramine caused disorientation and psychosis as his co-occurring HIV-associated neurocognitive disorder made his brain “delirium-ready”. Diphenhydramine is a relatively safe drug however not getting a thorough medical history may inadvertently cause harm to patients who are medically ill and frail.Disclosure of InterestNone Declared

A curious case of confusion

A curious case of confusion

Abruptly Stopping an Adamantane Management for Fatigue in an Elderly Multiple Sclerosis Patient Provoked Acute Withdrawal Symptoms (AWS); A Case Report

Introduction: Health care workers are continuously being burdened with acute conditions especially with the current pandemic of Covid-19. Staying home and feeling trapped can be particularly detrimental to patients with history of depression or psychotic as well as multiple sclerosis. We present a case of a 63-year-old patient with Multiple Sclerosis whose condition is being managed with mainly dopamine agonists. Withdrawal symptoms arose acutely after abrupt cessation of Amantadine; a dopamine agonist. Amantadine is thought to work by raising the amount of dopamine available to brain cells. The purpose of this research is to report a case of a 63-yearold Multiple Sclerosis patient who presented with Acute Withdrawal Syndrome (AWS) after being managed with Amantadine for two years and abruptly stopping the medication. Case Presentation: A 63-year-old woman with past medical history of stroke and multiple sclerosis reported symptoms of AWS after abruptly stopping amantadine use for multiple sclerosis. The patient was on cyclobenzaprine for spasticity, gabapentin and lamotrigine for neuropathic pain and seizure disorder respectively. She also had a history of hypertension and hyperlipidemia and presented with 1-week history of nausea and vomiting followed by visual hallucination, tremor, slurred speech and lethargy. On presentation, the patient was afebrile and hemodynamically stable. This patient denies blurred vision and severe fatigue with bathing or exercise. Upon further evaluation, patient did not report electrical sensation down her limbs or back especially with neck flexion. The initial labs were remarkable for hemoglobin of 8.5mg/dL and hypokalemia of 3.2mmol/L. We suspected vasculitis of CNS. One of the proposed pathophysiology for this is the extensive inflammatory damage to the blood brain barrier, allowing inflammatory cell recruitment into the CNS. The patient was admitted for acute altered mental status with waxing and wanning symptoms. Her acute delirium symptoms lead to the withdrawal of amantadine and cyclobenzaprine. Within about 48-70 hours later, patient developed severe agitation requiring emergent intubation. EEG showed generalized medium voltage delta, theta, and fast activity throughout indicative of diffuse cerebral dysfunction, but no lateralized or epileptic activity was seen. CT brain was negative for acute stroke or bleed. The patient underwent lumbar puncture, and was started on empiric coverage with IV acyclovir, vancomycin, and ceftriaxone for possible meningoencephalitis along with methylprednisolone for possible multiple sclerosis flare vs autoimmune encephalitis. MRI showed stable extensive white matter T2 hyperintense lesions. CSF was negative for infectious processes, and vancomycin, ceftriaxone, and acyclovir were discontinued. The patient continued to require sedation for severe agitation. The severe agitation was suspected to be due to discontinuation of her home medications, one of which was amantadine. The amantadine was resumed with improvement of her mental status within 24 hours. Patient was extubated within 48 hours of initiation of amantadine and was transferred to the floor for continuity of care and eventually discharged home after 15 days of hospitalization. Conclusion: Acute Withdrawal Syndrome (AWS) symptoms are often as a result of abrupt cessation of a medication(s) particularly central acting agents like clonidine, beta adrenergic antagonists as well as diuretics but Amantadine is starting to be a strong culprit since it is also thought to act centrally as a dopamine agonist. Clinicians should always be mindful of AWS especially from patients on long term central acting medications that have been abruptly stopped.

682: UNINTENTIONAL PEDIATRIC ORAL INGESTION OF BRIMONIDINE EYE DROPS

Introduction: Brimonidine is a central alpha-2 adrenergic agonist agent chemically similar to clonidine. When used for glaucoma treatment, activation of alpha-2 receptors in the ciliary musculature culminates in decreased intraocular pressure by reducing aqueous humor production and stimulating outflow. While intended use is intraocular, oral ingestion and associated neurological and cardiovascular toxicities are not robustly documented in pediatric literature. In this case report, we present the toxic oral ingestion of brimonidine eye drops in a pediatric patient. Description: A two year old, previously healthy female presented to the emergency department (ED) with acute altered mental status, found dizzy and unresponsive by her grandmother around 9pm; she was last known well before going to bed at 8pm. On arrival to the ED, the patient was crying, intermittently somnolent, and opening her eyes spontaneously. Her vital signs were as follows: temperature 97.2F, heart rate 79 beats per minute, respiratory rate 22 time per minute, blood pressure 126/86 mmHg. Venous blood gas showed respiratory alkalosis and lactate 2.1mmol/L. A urine toxicology screen was negative and serum acetaminophen, salicylate, alcohol, and tricyclic levels were undetectable. Head imaging and electrocardiograms were normal. Upon further review, the patient’s grandmother revealed she recently underwent kidney transplantation. She detailed that none of her oral medications were missing but had found an empty bottle of brimonidine eye drops under the couch. The grandmother was unable to share whether it was a 5mL or 15mL bottle of 0.1% or 0.2% eye drops. With concern that the patient may have ingested brimonidine, she received empiric intravenous naloxone 0.1mg/kg amounting to 1.5mg. Rapid improvement in wakefulness and mental status was observed. The child was admitted for monitoring in an intensive care unit, did not require any additional naloxone, and was discharged after approximately 36 hours. Discussion: Oral ingestion of brimonidine eye drops may cause somnolence and bradycardia in pediatric patients. Additionally, naloxone utilization may not elicit an appropriate response. This case describes the successful identification of toxicity and use of empiric naloxone for diagnostic and treatment purposes in a pediatric patient.

The Clinical Response of California Serogroup Virus Neuroinvasive Disease in a Pediatric Patient to Intravenous Immunoglobulin (IVIG) Therapy

Objective NA. Background California serogroup (CSG) viruses are commonly associated with neurologic disease. There are few cases of CSG viruses where IVIG has been proven to help. We report a young child with neuroinvasive CSG virus encephalitis treated with IVIG and associated outcome. Design/Methods A retrospective chart review. Results A 6 year old boy, previously healthy presented with fluctuating mental status with vomiting, fatigue, and fever starting six days prior to presentation. He began to have repetitive movements of rubbing his nose, and twisting movements of the upper extremities with mild eye deviation to the left with no EEG correlate. He required PICU admission for desaturations and altered mental status requiring intubation with sedation. He was found to have positive serum IgG and IgM antibody titers 1:128 of CSG viruses. IgG and IgM antibody titers of CSG viruses was negative (&lt;1:1) in CSF. Of note he was positive for human metapneumovirus IgM antibodies. His serum and CSF NMDA was negative suggesting California encephalitis is not likely associated with NMDA encephalitis. His MRI brain resulted with extensive diffusion restriction throughout the frontal, parietal, and temporal cortex as well as non-diffusion restricting signal abnormality involving the basal ganglia and brainstem, suggesting a para-infectious encephalitis. He received IVIG given his worsening mental status starting on day 14 of admission. Neurological symptoms gradually improved after IVIG treatment. Despite therapies he displayed difficulties with focus and attention. 6 months after initial presentation his routine EEG showed frequent, sleep activated, 1-3 seconds bursts of irregular generalized spikes-and-slow wave complexes. Patient was continued on levetiracetam with no seizures. Conclusions This report highlights a severe case of encephalitis with CSG viruses. Although it is not clear whether time or IVIG helped in this patient case, it seemed to have shortened his acute altered mental status although he still has long-term learning difficulties.

Head computed tomography for elderly patients with acute altered mental status in the emergency setting: value for decision-making and predictors of abnormal findings.

This study evaluated the impact of head computed tomography (CT) on clinical decision-making about older adults with acute altered mental status (AMS) in the emergency department in terms of CT's diagnostic yield, emergency department length of stay, and changes in medical strategy. It also attempted to find predictors of an acute imaging abnormality. This was a 1-year, retrospective, single-center observational study of patients aged ≥75 years who underwent noncontrast head CT because of an isolated episode of AMS. The acute positive CT findings were ischemic strokes, hemorrhages, tumors, demyelinating lesions, hydrocephalus, and intracranial infections. A total of 594 CTs were performed, of which 38 (6.4%) were positive. The main etiology of AMS was sepsis (29.1%). Changes in medical strategy were more common in patients with a positive CT, and the major changes were ordering additional neuro exams (odds ratio [OR], 95.3; 95% confidence interval [CI], 38.4-233.8; P<0.001), adjusting treatments (OR, 12.2; 95% CI, 5.0-29.5; P<0.001), and referral to a neurologic unit (OR, 7.3; 95% CI, 3.0-17.5; P<0.01). Three factors were significantly associated with a positive outcome: Glasgow Coma Scale <13 (OR, 8.5; 95% CI, 2.3-28.9; P<0.001), head wound (OR, 3.1; 95% CI, 1.1-8.2; P=0.025), and dehydration (OR, 0.3; 95% CI, 0.1-0.4; P=0.021). For elderly patients with a Glasgow Coma Scale ≥13 and no head wound or clinical dehydration, the probability of a positive CT was 0.02 (95% CI, 0.01-0.04). Considering only those patients, the diagnostic yield fell to 1.7%. In elderly patients, the causes of AMS are primarily extracerebral. Randomized clinical trials are needed to validate a clinical pathway for selecting patients who require emergent neuroimaging.

Use of Computed Tomography of the Head in Patients With Acute Atraumatic Altered Mental Status

The usefulness of computed tomography of the head (CTH) in patients with acute-onset atraumatic altered mental status (AMS) is poorly understood, but use in these patients remains high. To evaluate the use of CTH (event rate) in patients with AMS and the positive outcome event rate of the performed CTH studies. The PubMed/MEDLINE, PubMed Central, Embase, and CINAHL databases were searched using predefined Boolean parameters. All studies that met inclusion criteria until January 31, 2022, were included. Randomized clinical trials and observational, cohort, and case-control studies were included. Conference abstracts, reviews, letters, case reports, case series, systematic literature, and meta-analyses were excluded. The systematic literature review was performed per Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines. Data were independently extracted by 2 authors. Data were pooled using a random-effects method. Event rate of CTH use in patients with acute atraumatic AMS. The CTH event rates and positive CTH event rates were calculated with 95% CIs. Of 9338 studies identified, 26 qualified for the systematic review and 25 for the meta-analysis. The 25 studies in the meta-analysis included a total of 79 201 patients. The CTH event rate was 94% (proportion, 0.94; 95% CI, 0.76-1.00), and the positive CTH event rate was 11% (proportion, 0.11; 95% CI, 0.07-0.15). There was significant heterogeneity among the studies included (I2 > 50%, P < .001), for which a random-effects model was used. There was significant publication bias, as evident by an asymmetric funnel plot. There was no fluctuation of the results during the sensitivity analysis, which reassured the reliability of the data. In this meta-analysis, CTH use among patients with acute-onset atraumatic AMS was very high with a low yield. Large-scale studies are needed to guide clinical decision-making in such a situation.

A clinical study of artery of Percheron infarction

Artery of Percheron (AOP) infarction, a rare cause of acute altered mental status (AMS), is characterized by bilateral paramedian thalamic infarction. The aim of this study was to review the clinical manifestation, radiological patterns, treatment, and prognosis of patients with AOP infarction. This retrospective case series included patients with AOP infarction from 2009 to 2020 from a medical center in Taiwan. We defined AOP infarction as acute bilateral paramedian thalamic infarction from magnetic resonance imaging, and patients were further categorized by their additional AOP territorial involvements. We determined outcomes with the modified Rankin Scale at discharge. Among the 10 included patients, AMS was the most common presentation (90%). We identified two patients with bilateral vertebral artery (VA), five with unilateral posterior cerebral artery (PCA), and one with bilateral PCA occlusion. Atherosclerosis was the most common presumed etiology (60%). Two and eight patients had favorable and unfavorable prognoses, respectively. PCA occlusion, rather than VA and BA occlusion, was common in angiography. Residual symptoms often resulted in significant disability at discharge. Basilar tip syndrome may share indistinguishable thalamic infarct patterns with AOP infarction but could be differentiated by angiography and other infarcted territories.

COMMON PRESENTATION WITH AN UNCOMMON ETIOLOGY: THYMOMA-ASSOCIATED AUTOIMMUNE ENCEPHALITIS INDUCED BY COVID-19 BOOSTER VACCINE

COMMON PRESENTATION WITH AN UNCOMMON ETIOLOGY: THYMOMA-ASSOCIATED AUTOIMMUNE ENCEPHALITIS INDUCED BY COVID-19 BOOSTER VACCINE

A-58 Unusual Presentation of Anti-NMDAR Encephalitis in a Young Adult Male: A Case Study

Abstract Objective To illustrate an unusual presentation of anti-n-methyl-D-aspartate-receptor (anti-NMDAR) encephalitis in a young adult male. Anti-NMDAR encephalitis is an autoimmune-mediated disorder with psychiatric and neurological features that can have lasting impact on cognition. Unique presentation, diagnosis, and assessment are presented. Method Patient is a 28-year-old, Caucasian male with a history of bipolar disorder. Initial hospital presentation was characterized by headache, tremor, and acute altered mental status. Imaging revealed chronic meningitis with diffuse leptomeningeal enhancement/multiple cranial nerve enhancement, hydrocephalus, and Chiari I malformation. He underwent external ventricular drain (EVD) placement and was discharged upon stabilization. He presented 1 month later with symptom recurrence and interval development of hydrocephalus. CSF studies were positive for NMDAR antibody. He was treated with immunotherapy. His 3-month long hospitalization was complicated by acute respiratory failure and intracerebral and intraventricular hemorrhages. He was discharged to 1 month of inpatient rehabilitation. Results Neuropsychological assessment was completed 4 months following discharge from rehabilitation. Visual deficits due to grade 1 papilledema complicated testing. Results revealed frontal deficits (focused attention, processing, and executive functions), with intact verbal learning/memory. This deviates from previous literature that specify verbal memory dysfunction as a core long-term outcome of anti-NMDAR encephalitis. Conclusions This case highlights an unusual presentation and neuropsychological assessment of anti-NMDAR encephalitis. Rare presentations of anti-NMDAR encephalitis can preclude clinical diagnosis and compromise long-term cognitive outcomes if not rapidly and effectively treated. Additionally, mood symptoms may have been early manifestation of the patient’s disease process. Despite acute complications, he demonstrated remarkable functional and cognitive recovery.

Mucormycosis causing massive lower gastrointestinal bleeding: a case report

BackgroundLower gastrointestinal bleeding (LGIB) is very common in the hospital setting. Most bleedings stop spontaneously, but rare infectious causes of LGIB may lead to rapid and serious complications if left untreated and are sometimes very difficult to diagnose preoperatively.Case presentationWe described a young man with poorly controlled Type I diabetes mellitus and chronic alcohol abuse who presented with acute altered mental status. During his hospitalization for treatment of diabetic ketoacidosis, acute renal failure, and sepsis, he suddenly developed massive hematochezia of 1500 mL. Colonoscopy was performed and a deep ulcer covered with mucus with peripheral elevation was noted at the transverse colon. Biopsy of the ulcer later revealed nonpigmented, wide (5–20 µm in diameter), thin-walled, ribbon-like hyphae with few septations and right-angle branching suggestive of mucormycosis demonstrated by Periodic acid–Schiff stain. He received 2 months of antifungal treatment. Follow up colonoscopy post-treatment was normal with no ulcer visualized.ConclusionsEarly diagnosis and treatment of gastrointestinal (GI) mucormycosis infection is critical but can be challenging, especially in the setting of massive hematochezia. Therefore, clinical awareness for immunocompromised patients and prompt antifungal prophylaxis in cases with high suspicion of infection are essential.

Invasive Ductal Carcinoma of the Breast Presenting as Hypercalcemic Encephalopathy

We hereby present the case of a 68-year-old woman who presented to our emergency department with acute onset altered mental status. On evaluation, it was discovered that her serum calcium levels were elevated. The rest of the labs were normal. Through further testing and imaging studies, we found out that she had invasive ductal carcinoma leading to hypercalcemia which was causing her altered sensorium. The diagnosis of hypercalcemic encephalopathy was made with the primary culprit the ductal carcinoma of the breast. Herein, we would like to highlight hypercalcemia as an important cause of encephalopathy. With our report, we are trying to prove encephalopathy can be the first presentation of ductal carcinoma of the breast.

Continuous insulin therapy versus apheresis in patients with hypertriglyceridemia-associated pancreatitis.

The optimal treatment modality for lowering the triglyceride level in patients with hypertriglyceridemia (HTG)-associated acute pancreatitis is unknown. We evaluated the efficacy of continuous insulin infusion and apheresis procedures as triglyceride-lowering therapy. Clinical, demographic, and laboratory data were retrospectively evaluated for patients with HTG-associated pancreatitis who received continuous insulin infusion or apheresis in a single tertiary center. The endpoints were modality effectiveness and clinical outcomes. The study included 48 patients (mean age, 40.4 ± 9.9 years). Apheresis and insulin infusion were performed in 19 and 29 patients, respectively, in the first 24 h of hospital admission. Apheresis procedures included therapeutic plasma exchange in 10 patients and double filtration plasmapheresis in nine patients. Baseline mean triglyceride level was higher in the apheresis group. The two groups were similar in terms of other baseline clinical and demographic characteristics. Seventeen patients (58.6%) in the insulin group and nine patients (47.4%) in the apheresis group exhibited Balthazar grades D-E. There was a rapid reduction (78.5%) in triglyceride level after the first session of apheresis. Insulin infusion resulted in a 44.4% reduction in mean triglyceride level in the first 24 h. The durations of fasting and hospital stay, and the rates of respiratory failure and hypotension, were similar between groups. More patients in the apheresis group experienced acute renal failure or altered mental status. Prognosis did not significantly differ between groups. Although apheresis treatments are safe and effective, they provided no clear benefit over insulin infusion for HTG-associated pancreatitis.

The predictive value of variables measurable in the ambulance and the development of the Predict Sepsis screening tools: a prospective cohort study

BackgroundDespite sepsis being a time critical condition with a high mortality, it is often not identified in a timely fashion. The aim of the current study was to create a screening tool based on bedside measurable variables predictive of sepsis among ambulance patients with infection according to clinical judgment by ambulance personnel.MethodsProspective cohort study of 551 adult patients presenting with suspected infection, performed in the ambulance setting of Stockholm during 2017–2018. 18 variables were measured in the ambulance (8 keywords related to medical history, 6 vital signs, 4 point-of-care blood tests, in addition to age, gender, and comorbidity. Logistic regression, area under the curve (AUC) and classification trees were used to study the association with sepsis. The AUC, sensitivity, specificity, predictive values and likelihood ratios were used to evaluate the predictive ability of sepsis screening models.ResultsThe six variables with the strongest association with sepsis were: systolic blood pressure ≤ 100 mmHg, temperature > 38.5 °C, GCS < 15, lactate > 4 mmol/L, gastrointestinal symptoms, and a history of acute altered mental status. These were combined into the Predict Sepsis screening tool 1, with a sensitivity of 0.90, specificity 0.41, AUC 0.77; 95% confidence interval [CI] 0.73–0.81, PPV 0.52, and NPV 0.86. Combining a history of acute altered mental status with GCS < 15 and excluding lactate in the Predict Sepsis screening tool 2 did not noticeably affect the AUC. In addition, the AUCs of these models did not differ noticeably when compared to a model including vital signs alone, with novel calculated cut-offs; the Predict Sepsis screening tool 3.ConclusionsSystolic blood pressure ≤ 100 mmHg, temperature > 38.5 °C, GCS < 15, lactate > 4 mmol/L, gastrointestinal symptoms, and a history of acute altered mental status demonstrated the strongest association with sepsis. We present three screening tools to predict sepsis with similar sensitivity. The results indicated no noticeable increase of predictive ability by including symptom-variables and blood tests to a sepsis screening tool in the current study population.Trial registrationNCT03249597.