Mental Status Changes Research Articles

A - 75 Neuropsychological Consequences of Anoxic Encephalopathy Pursuant to Myocardial Infarction.

Myocardial infarctions (MI) often result in irreversible muscle damage to the heart and difficulty returning to daily activities. While the physical consequences of acute cardiac events are well documented in the medical literature (Lesperance et al., 1996), there is less research identifying the cognitive, emotional, and behavioral consequences of MI (Brink et al., 2008) particularly when complicated by anoxia and unresponsiveness. We present a case study of a 54-year-old right-handed male with 12years of education referred for neuropsychological assessment pursuant to mental status changes following a MI with an estimated 25-30minutes of unresponsiveness and subsequent diagnosis of anoxic encephalopathy, supported by neuroimaging, which is also positive for a 4mm pituitary tumor. Neuropsychological assessment revealed difficulties with cognitive efficiency, sequencing, language production, phonemic fluency, and memory. Performance was also inconsistent with age- and education-weighted norms, and therefore did not reflect a normal aging profile. An objective psychological inventory (PAI) revealed negative self-evaluation, a focus on health matters, acute stress, and substance concerns. Additionally, an endorsement of social isolation, discomfort in social interactions, and a readiness to express anger verbally was indicated. Findings supported diagnosis of cognitive impairment associated with anoxic brain injury from above noted MI. This case provides an example of the neuropsychological consequences of anoxic encephalopathy from MI on cognitive, emotional and behavioral functioning. It also supports the need for awareness of bodily health within the context of overall cognitive health. It emphasizes the benefits of integrating physiological and neurocognitive symptoms when conceptualizing patients with cardiac arrest.

A - 89 Cognitive Evaluation of Suspected Wernicke- Korsakoff's Encephalopathy in a Woman with Complicated Hyperemesis Gravidarum.

Wernicke-Korsakoff syndrome (WKS) is a neurological disorder caused by the lack of thiamine (vitamin B1) and includes Wernicke encephalopathy and the later stage of Korsakoff amnesic syndrome. WKS could be secondary to malnutrition, including Hyperemesis Gravidarum (HEG), which is characterized by severe vomiting during pregnancy. We present a case of HEG resulting in suspected WKS where neuropsychological evaluation clarified cognitive status with complex cultural, language, and educational factors. Repeat evaluations of a 29-year-old West-African* woman with mental status change, decreased verbal output, agitation, and inability to walk in the context of HEG. Initially referred for inpatient neuropsychological evaluation at 21weeks gestation. MRI demonstrated mild diffuse cerebral atrophy and symmetric foci of T2 FLAIR hyperintensities in periaqueductal gray matter, hypothalamus, bilateral thalami, perirolandic cortex, and bilateral mammillary bodies. Initial inpatient testing with a face-to-face language congruent interpreter demonstrated notable multidomain impairment. Possible Intellectual Disability was considered by the referring team and test performances. Attempts at re-evaluation were limited by medical complications and prolonged hospitalization. Repeat inpatient evaluation 5months later following birth of healthy child and initiation of stimulant medication, demonstrated profound memory impairment but otherwise improved cognitive capacity and engagement. Results aided in discharge planning including cognitive remediation with goal of improving functional independence. Wernicke-Korsakoff syndrome due to Hyperemesis Gravidarum is an uncommon but known complication that can have profound acute and long-term consequences. This case demonstrates that repeat neuropsychological evaluations can clarify cognitive status in complex medical/cultural/language situations. *(country of origin and primary language not provided for patient privacy).

FRI223 Ectopic ACTH Syndrome

Abstract Disclosure: S. Mallesara Sudhakar: None. E.S. Story: None. Introduction: Ectopic ACTH Syndrome (EAS) is caused by hypercortisolism from extra-hypophysial tumors. EAS accounts for 10-15 % of Cushing’s Syndrome. Case 1: A 36 year old male with recently diagnosed stage IV well differentiated grade 2 neuroendocrine tumor (NET) of the pancreas with liver metastases developed new hypertension, hyperglycemia, hypokalemia, metabolic alkalosis, fatigue and muscle weakness. There were no obvious signs of Cushing’s Syndrome. ACTH was 679 pg/ml, cortisol 120 ug/ml. MRI pituitary was normal. He required 4 antihypertensives, insulin, and metyrapone was initiated for hypercortisolism. Due to difficulty obtaining medications during the COVID pandemic, intolerance to therapies and lack of improvement in clinical symptoms, decision was made to perform laparoscopic bilateral adrenalectomy. He was started on hydrocortisone and fludrocortisone. Pathology revealed diffuse adrenal hyperplasia. Post-surgery he improved dramatically and was able to discontinue antihypertensives and insulin. Chemotherapy for the underlying tumor was discontinued due to cytopenias. His cancer progressed and he succumbed to disease 10 months from initial diagnosis. Case 2: A 60 year old female presented with severe hypokalemia, metabolic alkalosis, hypercalcemia, cytopenias, HTN, weight loss, muscle weakness, nausea and mental status changes. CT abdomen showed bilateral adrenal hyperplasia. ACTH was 489 pg/ml, cortisol 81 ug/ml. MRI pituitary was unremarkable. PET-CT additionally showed hypermetabolic mediastinal lymph nodes and right upper lobe nodular opacity, and widespread osseous lesions. She was started on ketoconazole and antihypertensives. Bilateral adrenalectomy was considered but could not be performed due to rapid clinical deterioration. Etomidate was initiated. Fine needle aspiration of a mediastinal lymph node showed small cell carcinoma. Patient became too frail to receive systemic chemotherapy and succumbed within 2 weeks of hospitalization. Discussion: Most Ectopic ACTH Syndrome cases are caused by NET of the lung, pancreas and thymus. In children, Ewing’s sarcoma has been reported. Small cell carcinoma of lung, malignant pancreatic NETs, and medullary carcinoma of thyroid often present with metastasis and carry an ominous prognosis. Not all patients have clinical features of classic Cushing's syndrome. The outcome of EAS correlates with tumor type. Optimum treatment is surgical resection of the tumor, often not possible with metastatic disease. Hypercortisolism may be controlled with adrenal enzyme inhibitors and receptor blockers. Bilateral surgical adrenalectomy may be needed when symptoms are not controlled by medical management. Early and rapid control of Cushing’s Syndrome is important to facilitate antineoplastic treatment of the underlying tumor. Presentation: Friday, June 16, 2023

FRI349 Atypical Timing: Transient Diabetes Insipidus After Pituitary Apoplexy

Abstract Disclosure: I.A. Rivera Nazario: None. A.M. Santiago Carrion: None. M.T. Torres: None. A. Figueroa Cruz: None. Y. Ortiz: None. A. Aponte Velez: None. A. Vazquez: None. E.J. Sola Sanchez: None. M.M. Mangual Garcia: None. Pituitary apoplexy results from acute hemorrhage or infarction of the pituitary gland. Also, an adenoma that can develop transient or permanent pituitary hormone deficiency. Posterior pituitary function is nearly always preserved due to alternate blood supply. Most cases presenting among the fifth or sixth decade. Few cases of transient Diabetes Insipidus (DI) have been described in literature, approximately 4% of patients, making this an uncommon complication of this condition. Hereby, we describe a young male with sudden onset headache due to pituitary apoplexy with transient DI. A 33-year-old man without past medical history, presented to the emergency room with the chief complain of sudden severe headache. Physical examination without altered consciousness, visual impairment or meningeal irritation. Initial head CT was negative, except for findings of muscle spasms. Patient was discharged home with muscle relaxant and NSAIDs. Ten days later, patient continued with worsening headache, not responding to medical therapy. On reevaluation, brain MRI identified a pituitary macroadenoma, measuring 2.2 cm, with mass effect, suprasellar extension impinging the pituitary stalk, prechiasmatic optic nerves and cavernous sinus extension. Blood tests showed Na 139 mEq/L, K 4.1 mmol/L and adequate renal function. Pituitary function test consistent for hypopituitarism with free T4 0.39 ng/dL, TSH 0.084 mIU/mL, cortisol 0.19 mcg/dL, ACTH 9.39 ng/mL, GH <0.1 ng/mL, IGF-1 22.8 ng/mL and prolactin 1.52 ng/mL; except normal FSH, LH and testosterone levels. After four months of apoplectic episode, he developed polyuria and polydipsia. Brain MRI with residual sellar mass of 1.2 cm with resolution of mass effect. Visual field charting was normal. Blood tests showed Na 139 mEq/L, K 4.1 mmol/L and adequate renal function. Started on hydrocortisone and levothyroxine replacement. Diagnosis of DI was suspected, but he refused water deprivation test or DDAVP therapy. During follow-up, patient was found with serum osmolality 288 mOsm/kg, urine osmolality 202 mOsm/kg and 4.6 L 24-hour urine collection. Three months later serum osmolality was 294 mOsm/kg, urine osmolality of 383 mOsm/kg with resolution of polyuria and polydipsia. This case presents a delayed onset of transient DI treated in a conservative way. In documented cases average onset was a period of 2 weeks with resolution in 2 months. Etiology most likely due to compression or destruction of the pituitary gland or stalk impeding transit of ADH from hypothalamus to the neurohypophysis. Transient impairment of the ADH secretion is rare in pituitary apoplexy deserving evaluation in this clinical scenario. When seen, it has been related to glucocorticoid use. This is an example of an atypical pituitary disorder requiring prompt recognition to prevent further complications. Presentation: Friday, June 16, 2023

Postoperative agitation or delirium in paediatric patients. What we know and how to avoid it.

Emergence delirium or postoperative agitation is the name given to the state of altered consciousness that occurs after surgery and especially affects pediatric patients. Its incidence is not negligible, reaching 80% of cases in certain studies. It is frequently confused with other clinical entities, for which reason a scale has been validated to facilitate its diagnosis. Risk factors include age under 5 years, the presence of pain after surgery and especially intense preoperative anxiety. Pediatric emergence delirium presents as an adverse event after surgery and influences patient safety by significantly increasing patient comorbidity. It is essential to recognize the entity, as well as its risk factors, in order to apply effective preventive measures to reduce its incidence and intensity when it occurs.

Screening Tool Risk Score Assessment in the Emergency Department for Geriatric (S-TRIAGE) in 28-day mortality

BackgroundThe number of older adults with a high risk of frailty and severe illness continues to increase. Moreover, physiological change and multiple comorbidities are challenging to triage in geriatrics. Therefore, we aimed to evaluate variables to predict 28-day mortality and develop a screening tool to predict mortality and lifesaving intervention among geriatric patients in the emergency department (ED).MethodsThis study was a retrospective, single-center, observational study at the ED of Ramathibodi Hospital, Bangkok. Patients aged ≥ 65 years who visited the ED between January 2018 and December 2019 were enrolled. In the development cohort, univariable logistic regression was used to identify predictors of 28-day mortality in older patients. A predictive model for mortality and the need for lifesaving intervention was developed by multivariable logistic regression. In addition, the score was validated with internal validation and compared between development and validation set by chi-square.ResultsWe enrolled 1393 patients. In the development cohort, among these 1002 patients, 103 (10.3%) of whom died within 28 days. Malignancy, shock index (SI), systolic blood pressure (SBP) < 100 mmHg, and altered mentation were independent risk factors of 28-day mortality. We developed new screening tools named the S-TRIAGE score, which has the respiratory rate (< 11, > 22 breaths/min), the ratio of pulse oximetric saturation to the fraction of inspired oxygen (< 420, 420–450), SI (> 1, 0.6–0.99), SBP < 100 mmHg, body temperature (< 36, > 37.5 °C), and mental change. The area under a receiver operating characteristic (ROC) curve of the S-TRIAGE score in the validation cohort was 0.826 [95% confidence interval (95%CI) 0.773–0.879] in predicting mortality and lifesaving intervention, and the clinical score classified patients into five groups.ConclusionThis study showed malignancy, hypotension, increased SI, and mental status change were predictive factors for 28-day mortality in older adults in the ED. The screening tool risk score for geriatrics used in this study is potentially a good predictor of mortality and lifesaving intervention in high-risk older patients in the ED.

Changes in the diagnosis of depression among nursing professionals during the COVID-19 pandemic: A longitudinal study.

To identify changes in mental health status among nursing professionals in a Brazilian municipality during the COVID-19 pandemic. An observational and longitudinal study. Using the Patient Health Questionnaire-9, the presence of depressive symptoms was evaluated among 690 nursing professionals in the city of Pelotas, Brazil, at two moments: June/July 2020 and June/July 2021. 13.0% incidence of depressive symptoms was identified; as well as 12.2% remission; 24.1% persistence and 50.7% absence. Among the factors associated with the worst prognoses we can mention female gender, greater workload, feeling of overload, illness of family members or friends due to COVID-19 and use of psychotropic drugs CONCLUSIONS: There was significant mobility in the diagnosis of depression among the professionals studied during the period analysed, with incidence of new cases of significant depression and greater than the number of remissions. In addition to sociodemographic aspects, traumatic experiences and exposure to continuous overload were associated with persistence and incidence of new cases. With the advent of the COVID-19 pandemic, several studies have shown an increase in depressive symptoms among nursing professionals; however, understanding the long-term effects of this scenario is still a challenge. What problem did the study address? This study investigates changes in the mental health status of nursing professionals working at different care levels, taking the prevalence of screening for depression as a proxy, during a period of a year during the COVID-19 pandemic. What were the main findings? Between both data collection moments, 2020 e 2021, there was a significant percentage of professionals with persistent depression, in addition to a significant proportion of incident cases that slightly exceeded the number of remissions and the factors associated with the worst prognoses were sociodemographic aspects such as gender and emotional stressors like illness of family members or close friends due to COVID-19, in addition to those related to the organisation and support provided by the services, such as workload and feeling of overload. Where and on whom will the research have an impact? This study will impact the nursing professionals and in role of the health services in order to establishing actions that contribute to minimising the deleterious effects of the pandemic on the mental health of their Nursing teams. The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines were adopted in this study. No Patient or Public Contribution.

Resource utilization among children presenting with cannabis poisonings in the emergency department

BackgroundExploratory pediatric cannabis poisonings are increasing. The aim of this study is to provide a national assessment of the frequency and trends of diagnostic testing and procedures in the evaluation of pediatric exploratory cannabis poisonings. MethodsThis is a retrospective cross-sectional study of the Pediatric Health Information Systems database involving all cases of cannabis poisoning for children age 0–10 years between 1/2016 and 12/2021. Cannabis poisoning trends were assessed using a negative binomial regression model. A new variable named “ancillary testing” was created to isolate testing that would not confirm the diagnosis of cannabis poisoning or be used to exclude co-ingestion of acetaminophen or aspirin. Ancillary testing was assessed with regression analyses, with ancillary testing as the outcomes and year as the predictor, to assess trends over time. ResultsA total of 2001 cannabis exposures among 1999 children were included. Cannabis exposures per 100,000 ED visits increased 68.7% (95% CI, 50.3, 89.3) annually. There was a median of 4 (IQR 2.0, 6.0) diagnostic tests performed per encounter. 64.5% of encounters received blood tests, 28.8% received a CT scan, and 2.4% received a lumbar puncture. Compared to White individuals, Black individuals were more likely to receive ancillary testing (OR 1.52 [95% CI, 1.23, 1.89]). Compared to those 2–6 years, those <2 years were more likely to receive ancillary testing (OR 1.55 [95% CI, 1.19, 2.02). We found no significant annual change in the odds of receiving ancillary testing (OR 1.04 [95% CI, 0.97, 1.12]). ConclusionsWe found no change in the proportion of encounters associated with ancillary testing, despite increases in exploratory cannabis poisonings over the study period. Given the increasing rate of pediatric cannabis poisonings, emergency providers should consider this diagnosis early in the evaluation of a pediatric patient with acute change in mental status. While earlier use of urine drug screening may reduce ancillary testing and invasive procedures, even a positive urine drug screen does not rule out alternative pathologies and should not replace a thoughtful evaluation.

A Case Report on the Toxicological Evaluation of Pyridaben from a Human Cadaver

Suicidal poisoning with pesticides in humans is common in India. Despite the interdiction or regulation of several pesticides, there are reported considerate poisoning cases in India. Pyridaben is a potentially fatal insecticide with extreme neurotoxicity in humans. Pyridaben toxicity reports in humans are uncommon. Here we describe a case of acute poisoning with Pyridaben in a minor girl who presented with severe nausea, vomiting, altered consciousness, body weakness, abdomen pain, and congestion of visceral organs. Soon after the poisoning, the patient was treated with life-saving mechanical ventilation. Forensic examination of the viscera of a minor victim enlightened that the death was assignable to Pyridaben intoxication. GC-MS analysis of viscera showed significant results in concern to the identification of Pyridaben. The present case study emphasized the misuse of readily accessible pesticides and identified a new pesticide that can exert a deleterious impact on human health deliberately (suicide) and unintentionally (accidental) exposure. The same needs to be communicated to the scientific community to explore this lethal pesticide for its all-possible detrimental impacts consequently gathering scientific evidence in this regard will abet to regulate it by legislative.

A hospital-based retrospective study: early recognition of neuronal surface antibodies by clinical manifestations and CSF inflammation indicators in patients with unexplained epilepsy

Background There is a lack of actual and comprehensive data on the detection rate of neuronal surface antibodies in patients with unexplained epilepsy in China. Thus, we attempted to analyze the differences in clinical manifestations, cerebrospinal fluid (CSF) characteristics, seizure types and other aspects of antibody-positive and negative patients, to identify suspected antibody-positive epilepsy patients. Methods In total, 137 inpatients with unexplained epilepsy were consecutively included, and neuronal surface antibodies (NSAbs) were detected by serological and/or CSF evaluations. The clinical features and seizure characteristics were analyzed between the NSAb-positive and negative patients. In addition, patients were divided into four groups based on CSF and blood antibody titers. CSF cell count and protein content were analyzed in relation to antibody titers. Results There were 45 (32.8%) patients tested positive for antibodies. Multivariate analyses revealed that age, mental status changes or memory deterioration, CSF protein, CSF cell count, treatment, days of hospitalization, outcome, duration of symptoms before hospitalization, status epilepticus, and number of antiepileptic drugs were significantly associated with the NSAb-positive group and changes in inflammatory indicators in routine CSF analysis were associated with antibody titers. Conclusions A relatively high proportion of patients with unexplained epilepsy have positive NSAbs. Patients with the above clinical characteristics need to be highly suspected of NSAbs positivity and should be tested for antibodies in time to assist treatment. The decrease of CSF cell count and protein content has suggestive value for the decrease of antibody titer, which should be evaluated in the follow-up.

Diagnosis and Acute Management of Hyperglycemic Hyperosmolar Syndrome in Children and Adolescents.

Hyperglycemic hyperosmolar syndrome (HHS) is an indolent process characterized by significantly increased levels of serum glucose, high osmolality, and electrolyte abnormalities. The incidence of HHS has steadily risen in the pediatric population over the past several years. Patients with HHS often present with profound dehydration, fatigue, and early mental status changes. Primary emergency management of HHS involves fluid replacement, hemodynamic support, correcting electrolyte derangements, and addressing complications and underlying illnesses. Insulin is not an initial therapy in HHS and should be considered only after the patient's fluids and electrolytes have been repleted. Unlike in diabetic ketoacidosis, HHS patients are not acidotic, although children may present with mixed HHS/diabetic ketoacidosis syndromes. Complications of HHS include thrombosis, rhabdomyolysis, and, rarely, malignant hyperthermia.

A Systematic Review on Outcomes of Patients with Heatstroke and Heat Exhaustion.

Heatstroke (HS) is a severe form of heat-related illness (HRI) associated with high morbidity and mortality, representing a condition that includes long-term multiorgan dysfunction and susceptibility to further heat illness. In a systematic review searching Medline PubMed from the studies conducted between 2009 and 2020, 16 papers were identified. A hallmark symptom of heat stroke is CNS dysfunction (a hallmark sign of HS) which manifests as mental status changes, including agitation, delirium, epilepsy, or coma at the time of the collapse. Acute kidney injury (AKI), gut ischemia, blood clots in the stomach and small intestine, cytoplasmic protein clumps in the spleen, and injury of skeletal muscle (rhabdomyolysis) are all characteristics of peripheral tissue damage. Severe heat stroke tends to be complicated by rhabdomyolysis, especially in patients with exertional heat stroke. Rhabdomyolysis may lead to systemic effects, including the local occurrence of compartment syndrome, hyperkalemic cardiac arrest, and/or lethal disseminated intravascular coagulopathy. Untreated heat stroke might exacerbate psychosis, lactic acidosis, consumptive coagulopathy, hematuria, pulmonary edema, renal failure, and other metabolic abnormalities. Core body temperature and level of consciousness are the most significant indicators to diagnose the severity of heat stroke and prevent unfavorable consequences. Heatstroke is a life-threatening illness if not promptly recognized and effectively treated. This review highlighted that core body temperature and white blood cell count are significant contributing factors affecting heat stroke outcomes. Other factors contributing to the poor outcome include old age, low GCS, and prolonged hospital stay. The prevalence of both classic and exertional heatstroke can be reduced by certain simple preventive measures, such as avoiding strenuous activity in hot environments and reducing exposure to heat stress.

Postpartum intracerebral hemorrhage unveiling moyamoya disease: A rare case report

Moyamoya disease (MMD) is an uncommon cerebrovascular disorder characterized by abnormal angiogenesis leading to progressive stenosis of the supraclinoid internal carotid artery. The resultant vascular pathology causes the formation of a compensatory collateral network, often visualized as a characteristic “puff of smoke” appearance on imaging. This report aims to present the case of a 36-year-old female patient who presented with altered consciousness and left hemiparesis two weeks after undergoing a cesarean section delivery, with moyamoya disease identified as the underlying cause of the stroke. The objective is to underscore the importance of considering moyamoya disease as a potential etiology in postpartum stroke cases and emphasize the significance of early diagnosis and appropriate management to improve patient outcomes. Timely imaging and appropriate treatment, such as revascularization surgery, can help prevent further neurological deterioration and potentially improve long-term prognosis for these patients.

Case of Hyperammonemia Due to Empyema.

A 91-year-old woman was brought to our hospital with altered consciousness. Blood tests showed an increased ammonia level of 468 μg/dL and a normal liver function. Chest computed tomography showed massive right pleural effusion with loculation. We immediately performed chest drainage using two drainage tubes. The pleural effusate pH was 8.5. We diagnosed her with right empyema leading to hyperammonemia and initiated ampicillin/sulbactam therapy. However, she developed progressive renal failure and died on the third day. Empyema caused by urease-producing bacteria can lead to hyperammonemia. This is the first report of hyperammonemia due to empyema in the English literature.

Analysis of 21 Patients With Alcoholic Marchiafava-Bignami Disease in Chongqing, China.

This study aimed to investigate the characteristics and prognosis of patients with alcoholic Marchiafava-Bignami disease (MBD), a rare neurological disorder commonly associated with chronic alcoholism, in Chongqing, China. We conducted a retrospective analysis of clinical data from 21 alcoholic MBD patients treated at the First Affiliated Hospital of Chongqing University between 2012 and 2022. The study included 21 patients with alcoholic MBD who had a mean age of 59 ± 9.86 years and an average drinking history of 35.48 ± 8.65 years. Acute onset was observed in 14 (66.7%) patients. The primary clinical signs observed were psychiatric disorders (66.7%), altered consciousness (61.9%), cognitive disorders (61.9%), and seizures (42.9%). Magnetic resonance imaging revealed long T1 and long T2 signal changes in the corpus callosum, with lesions predominantly found in the genu (76.2%) and splenium (71.4%) of the corpus callosum. The poor prognosis group demonstrated an increased incidence of altered consciousness (100% vs 50%, P = 0.044), pyramidal signs (80% vs 18.8%, P = 0.011), and pneumonia (100% vs 31.3%, P = 0.007). Patients with a longer drinking history (45.0 ± 10.0 years vs 32.69 ± 5.99 years, p = 0.008) and a lower thiamine dose (p = 0.035) had a poorer prognosis at 1 year. This study identified altered consciousness, pyramidal signs, and pneumonia as predictors of a poor prognosis in patients with alcoholic MBD. A longer duration of alcohol consumption and inadequate thiamine supplementation were associated with a poorer prognosis.

Brief case report: A case of FOLFIRI-Induced psychosis.

Key points Psychosis may occur due to the FOLFIRI chemotherapy regimen. An exhaustive approach to confounding elements of a patient's medical history should be taken to rule out competing causes of psychosis. Both 5‐FU and Irinotecan may be implicated in psychosis, though which agent in particular is the cause is unclear. Risperidone assisted in resolution of this patient's psychosis whilst Olanzapine and Quetiapine did not. Both 5‐FU and Irinotecan have pharmacologic traits that may induce changes in mental status.

Bradycardia symptomatic causes headache associated with frontal diffuse astrocytoma: a case report

Background: Headache is the most common symptom in patients with brain tumors, whereas a developing brain tumor generally increases intracranial pressure and brain edema. Brain tumors have symptoms including nausea, vomiting, seizures, neurological deficits, and mental status or consciousness changes. Heart rhythm disturbances can occur, including bradycardia (heart rate below 60x/minute), a common symptom in brain tumor patients. Case Presentation: In this case report, a young adult male patient was found with headache symptoms, a previous history of syncope, and sinus bradycardia on the EKG examination, but on physical examination, there were no symptoms of neurological deficits. Head CT scan with contrast found a tumor in the left frontal lobe associated with high intracranial pressure and brain edema that explained the symptoms. Conclusion: The relationship between headache and bradycardia, accompanied by a history of syncope, is close and can be regarded as an early sign of a brain tumor. In this case, a brain tumor found based on pathological examination is diffuse astrocytoma.

Predictor variables of abnormal imaging findings of syncope in the emergency department

Assessing diagnostic success of head CT in studied cases who present to emergency room with syncope. 117 studied cases presenting with syncopal event had no head CT results that had been clinically relevant, but those with competing indications for head CT—like those with history of trauma, seizures, changes in mental status, or studied cases with neurologic deficit on initial evaluation—were not included. Out of forty-four studied cases with syncope who received head CT on ED orders, 1 studied case had indications of an infarction. After removing studied cases with persistently changed mental status, drug-related or post-traumatic loss of consciousness, seizure, or hypoglycemia, diagnostic yield of five percent aberrant head CT findings is also required.

Posterior Reversible Encephalopathy Syndrome in a Patient with Septic Shock: A Case Report.

Posterior reversible encephalopathy syndrome (PRES) is a reversible condition with nonspecific neurologic and characteristic radiologic findings. Clinical presentation may include headache, nausea, vomiting, altered mental status, seizures, and vision changes. Diagnosis is confirmed through T2-weighted brain magnetic resonance imaging (MRI) showing bilateral hyperintensities in the white matter of posterior circulatory regions. We report a case of PRES in a patient suffering from complicated diverticulitis. Following medical management in the emergency department, the patient deteriorated, becoming hypotensive and altered. Bowel resection under general anesthesia was performed. Postoperative brain MRI demonstrated bilateral and symmetric T2 signal hyperintensities suggestive of PRES. Following supportive treatment, the patient was discharged from the surgical intensive care unit on postoperative day 21 with no residual deficits. It is important to recognize the nonspecific neurologic symptoms associated with PRES. Emergency physicians should suspect acute PRES when managing patients with prolonged or unexplained encephalopathy, while recognizing that hypertension need not be present.

Epidemiology and characteristics of emergency department utilization by patients with amyotrophic lateral sclerosis in Korea from 2016 to 2020: A nationwide study.

Patients with amyotrophic lateral sclerosis (ALS) inevitably visit the emergency department (ED) due to their increased risk of respiratory failure and mobility limitations. However, nationwide data on ED visits by patients with ALS are limited. This study investigated the characteristics of patients with ALS-related ED visits. We conducted a cross-sectional study from 2016 to 2020, utilizing a nationwide ED database. The total number of patients with ALS who visited the ED and their primary reasons for visiting/diagnoses were analyzed. In total, 6036 visits to the ED were made by patients with ALS. Of these, 41.8% arrived by ambulance and 27.7% spent >9 h in the ED. Following ED treatment, 57.4% were hospitalized, including 19.3% admitted to the intensive care unit (ICU) and 5.4% who died in the hospital. The primary reasons for ALS-related ED visits were dyspnea (35.2%), feeding tube problems (10.1%), fever (7.8%), and mental status changes (3.6%). The most common diagnoses were pneumonia (14.5%), respiratory failure (5.7%), dyspnea (5.5%), aspiration pneumonia (4.3%), and tracheostomy complications (3.4%). Reasons for ED visits for patients with ALS include acute respiratory distress, as well as concerns related to tube feeding and tracheostomy. To reduce the risk of patients with ALS requiring ED visits, it is essential to ensure the provision of timely respiratory support and high-quality home-based medical care teams that can support and address patients before their condition deteriorates.