Disoriented Patients Research Articles

TgF344-AD Rat Model of Alzheimer's Disease: Spatial Disorientation and Asymmetry in Hemispheric Neurodegeneration.

The TgF344-AD ratline represents a transgenic animal model of Alzheimer's disease. We previously reported spatial memory impairment in TgF344-AD rats, yet the underlying mechanism remained unknown. We, therefore, set out to determine if spatial memory impairment in TgF344-AD rats is attributed to spatial disorientation. Also, we aimed to investigate whether TgF344-AD rats exhibit signs of asymmetry in hemispheric neurodegeneration, similar to what is reported in spatially disoriented AD patients. Finally, we sought to examine how spatial disorientation correlates with working memory performance. TgF344-AD rats were divided into two groups balanced by sex and genotype. The first group underwent the delayed match-to-sample (DMS) task for the assessment of spatial orientation and working memory, while the second group underwent positron emission tomography (PET) for the assessment of glucose metabolism and microglial activity as in-vivo markers of neurodegeneration. Rats were 13 months old during DMS training and 14-16 months old during DMS testing and PET. In the DMS task, TgF344-AD rats were more likely than their wild-type littermates to display strong preference for one of the two levers, preventing working memory testing. Rats without lever-preference showed similar working memory, regardless of their genotype. PET revealed hemispherically asymmetric clusters of increased microglial activity and altered glucose metabolism in TgF344-AD rats. TgF344-AD rats display spatial disorientation and hemispherically asymmetrical neurodegeneration, suggesting a potential causal relationship consistent with past clinical research. In rats with preserved spatial orientation, working memory remains intact.

PATIENT SATISFACTION WITH THE QUALITY CARE PROVIDED BY NURSES AT THE BEDSIDE IN TERTIARY HEALTH INSTITUTE

to compare the level of patient satisfaction based on their socio-demographic characteristics in tertiary care institutes. This study was conducted at Nishtar Hospital after getting ethical approval from ERC. It was conducted from January 05, 2023, to May 05, 2023, between patients 20-50 years of age who had been admitted to the hospital for at least five days, and both genders were included. Disoriented patients or those who refused to participate were excluded from this study. Data was collected using PSNCQQ, a 19-emit questionnaire with 5 responses of each item from poor to fair, good, very good, and excellent. Then comparison was made between the socio-demographic and PSNCQQ total score. SPSS version.21 was employed for this purpose. Descriptive statistics were depicted in frequencies (%ages), mean & SD. The level of significance was <0.05. This study revealed no significant difference between patient’s age, gender & marital status, and level of satisfaction with quality care provided by nurses (p>0.05). But the nature of the patient's ward revealed a significant difference with p<0.05 and their satisfaction level with nursing care. It was concluded that the nature of the ward only affects the level of patient satisfaction by the nursing care they receive. And age, gender, and marital status do not affect their satisfaction level.

Methamphetamine-induced encephalopathy in the absence of hyperammonemia

BackgroundMethamphetamine is an addictive drug with various effects on the neurotransmitters in the central nervous system. Methamphetamine-induced encephalopathy in the absence of hyperammonemia presents a unique challenge in a clinical setting. Previously published cases of methamphetamine-induced encephalopathy suggested that methamphetamine-induced hepatotoxicity and subsequent hyperammonemia may be the cause of encephalopathy. However, the literature is limited on methamphetamine-induced encephalopathy without hyperammonemia.CaseThis case presents a disoriented patient with methamphetamine use disorder in acute toxicity, unable to ambulate independently, and poorly responsive to verbal stimuli. The patient was found to have normal ammonia levels.DiscussionThis patient’s presentation and laboratory findings, namely normal ammonia levels, suggest a different pathophysiological pathway for methamphetamine-induced encephalopathy. One potential pathway is through the direct action of methamphetamine on the central nervous system through acute disruption of neurotransmitter signaling and disruption of the blood-brain barrier.ConclusionFurther research should be conducted into the prevalence and pathophysiology of methamphetamine-induced encephalopathy in the absence of hyperammonemia.Key PointsMethamphetamine-induced encephalopathy (MIE) in the absence of hyperammonemia presents a unique challenge in a clinical setting.Previously published cases of MIE suggest that methamphetamine-induced hepatotoxicity and subsequent hyperammonemia may be the cause of encephalopathy.Further research should be conducted into the prevalence and pathophysiology of MIE in the absence of hyperammonemia.

Gallstone Ileus in the Absence of Gallbladder, Rare Etiology of Bowel Obstruction: A Case Report and Literature Review

Background: Gallstone ileus post-cholecystectomy is extremely rare surgical emergency causing mechanical bowel obstruction. This condition is usually misdiagnosed due to its non-specific clinical features. Radiological investigations are essential to evaluate and diagnose gallstone ileus cases. Case Presentation: A 92-year-old female patient, cholecystomized, presented to our hospital with a one-week history of an acute confusional state, generalized abdominal pain, and vomiting. The physical examination showed a disoriented patient with a distended abdomen and generalized tenderness, especially in the epigastric area. Hyperactive bowel sounds were audible. Laboratory investigations were non-specific. A plain abdominal X-ray was insignificant. The abdominal ultrasound showed marked abdominal gaseous distention. Then, an abdominal CT scan was performed, revealing an impression of gallstone ileus causing small bowel obstruction with no evidence of fistula formation. So, surgical intervention was decided, and an 8-gram gallstone was exteriorized through an enterolithotomy. The postoperative period was uneventful. Discussion: Gallstone ileus is an unusual entity that often affects elderly females. The clinical features of gallstone ileus include abdominal pain, abdominal distension, nausea, and vomiting. Diagnosis of gallstone ileus relies on imaging and physical examination. Abdominal CT with contrast provides a definitive diagnostic tool. The surgical options to manage the gallstone ileus can be either one or two-staged enterolithotomy. Conclusion: Due to the rare etiologic origin of the gallstone ileus in post-cholecystectomy cases, we report the case of a 92-year-old female with an acute confusional state and generalized abdominal pain, found to be caused by detected gallstone ileus, lacking evidence of fistula formation.

Chiari Malformation Type 1 and Syringomyelia: Why Do Patients Claim for International Guidelines? Commentary on the 2021 Chiari and Syringomyelia Consensus Document.

The diagnosis of Chiari malformation type 1 (CM1) and Syringomyelia (Syr) has become increasingly common during the past few years. Contemporarily, the body of literature on these topics is growing, although randomized controlled studies on significant case series to drive guidelines are missing in the pediatric and adult populations. As a result of the different opinions about surgical indications and techniques raised by CM1-Syr, an increasing number of well-informed but disoriented patients is emerging. To bridge this gap, an International Consensus Conference on CM1-Syr held in Milan in November 2019 aimed to find a consensus among international experts, to suggest some recommendations that, in the near future, could lead to guidelines. Here, we comment on the most relevant recommendations about the definition, diagnosis, surgical management, failures and re-intervention, and outcome. We also focus on some "wrong" indications or techniques that, although widely disapproved by the experts, and negatively experienced by many patients, are still largely in use.

Utility of Investigations, History, and Physical Examination in "Medical Clearance" of Psychiatric Patients: A Meta-Analysis.

Few reviews and no meta-analyses have explored the utility of investigations, such as laboratory tests, among patients presenting with psychiatric symptoms, and none has explored the yield of history and physical examination. A meta-analysis of studies exploring the utility of "medical clearance" among adult psychiatric patients was conducted. PubMed, PsycInfo, and Web of Science were systematically searched from inception until February 15, 2021. Primary outcome was detection by investigations (e.g., bloodwork and imaging), history, or physical examination of an illness that caused or aggravated psychiatric symptoms or was comorbid and that resulted in change in the patient's diagnosis or management ("yield"). A mixed-effects meta-analysis with inverse-variance weighting was used to pool results. Twenty-five cross-sectional studies were included. Pooled yield of investigations was 1.1% (95% confidence interval [CI]=0.5%-2.2%), although yield was relatively higher among disoriented, agitated, or older patients. Yield was higher in the inpatient setting, compared with the emergency room, with similar results by approach (protocolized versus nonprotocolized). Compared with investigations, yield of history and physical examination was higher (15.6%, 95% CI=9.1%-25.6%, and 14.9%, 95% CI=8.1%-25.9%, respectively), with nonsignificant differences by evaluator (psychiatrist versus nonpsychiatrist) for physical examination. Investigations were of relatively low yield, especially when weighed against cost and potential harm, and they should not be routinely conducted for patients presenting with primarily psychiatric complaints, although certain subgroups may benefit. History and physical examination, by contrast, should be undertaken for all patients, ideally with participation of the consulting psychiatrist.

'Excited Delirium', acute behavioural disturbance, death and diagnosis.

In the 1980s the traditional Hippocratic term excited delirium was transplanted from the bedsides of febrile, agitated and disoriented patients to the streets of Miami. Deaths in custody of young men who were intoxicated with cocaine and who were restrained by the police because of their erratic or violent behaviour were attributed to excited delirium. The blood concentrations of cocaine in these subjects were approximately ten times lower than the lethal level and other factors which might have contributed to the fatal outcome, such as the police use of neck-holds, choke-holds or 'hog-tying', were relegated to a minor role compared with the reframed 'diagnosis' of excited delirium. Over the course of the next few decades 'excited delirium' might be applied to virtually any highly agitated person behaving violently in a public place and who subsequently died in custody while being restrained or shortly afterwards. Expert witnesses, mainly forensic pathologists, testified that the deceased's death was probably inevitable given the perilous nature of excited delirium, even though this diagnostic entity lacked any consistent neuropathological basis and depended entirely on observed behaviour. This history of the rise and fall of this disputed diagnosis is a partial response to the sociologist Phil Brown's 1995 paper asking who benefits, or at least avoids trouble, by the identification and use of a diagnosis.

CHARACTERISTICS OF FIRST DAY COMPLICATIONS AFTER ODONTECTOMY OF IMPACTED MANDIBULAR THIRD MOLAR IN GENERAL ANESTHESIA

Introduction: Odontectomy is the most common procedure performed by oral and maxillofacial surgeons. The consideration of odontectomy cases in general anesthesia with certain factors, such as patient anxiety, mental or physical disorders, degree of difficulty in impacted teeth, disoriented patients, number of teeth performed odontectomy, and duration of surgery. Some complications after odontectomy, including swelling, trismus, and paresthesia often occur from the first day after odontectomy. The purpose of this study was to determine the characteristics of the complications on the first day after odontectomy of impacted mandibular third molar in general anesthesia at Dr. Hasan Sadikin General Hospital during January – June 2020. Methods: This study was a cross-sectional retrospective using medical record data of patients diagnosed with class I, II, and III mandibular molar impaction based on clinical and panoramic x-rays and performed odontectomy of mandibular third molar impaction in general anesthesia at Dr. Hasan Sadikin Hospital for the period January - June 2020. Results: The obtained data were 186 cases from 98 patients. Data were obtained from secondary data through medical records of mandibular third molar impaction odontectomy patients in general anesthesia who were treated at the inpatient installation of RSUP Dr. Hasan Sadikin for the period during January to June 2020 to determine the characteristics of complications on the first day after odontectomy of impacted mandibular third molar in general anesthesia based on age, gender, and the classification of mandibular third molar impactions. The percentage of complications on the first day after odontectomy of impacted mandibular M3 in general anesthesia at Dr. Hasan Sadikin General Hospital for the period during January - June 2020 showed that the largest number was found in complications of swelling as many as 41 people (54%), followed by trismus as many as 33 people (43%) and paresthesia were 2 patient (3%). Conclusion: The most common complications were swelling and trismus, where these complications were classified as mild and normal complications from odontectomy of impacted mandibular third molars. Meanwhile, the rarest complication was paresthesia. Keywords: Complications, Post-odontectomy, Impaction of mandibular third molar

Video calls to disoriented elderly persons during the COVID-19 health crisis

Maintaining an exchange between the disoriented elderly patient and his family circle is essential to help reduce patient anxiety. When visits are not possible, the implementation of video calls with highly disoriented individuals shows a benefit of these virtual exchanges. The introduction of new technologies, if accompanied, does not disturb the patient and does not alter the quality of the relationship.

Adverse events associated to the use of equipment and materials in nursing care of hospitalized patients.

To analyze the occurrence of adverse events associated to the use of equipment and materials in nursing care. Quantitative, descriptive study, using the electronic records of adverse events notifications in an accredited hospital. A total of 1,065 adverse events were reported, of which 180 (16.9%) were related to the use of equipment and materials. The most frequent events were: loss of feeding tube (45.0%), loss of central venous catheter (15.5%), skin injury (10.5%) and accidental extubation (10.0%). The main causes and immediate actions recorded were: loss of feeding tube - removal of the tube by the patient (53.1%) and reinsertion of the device (83.9%); loss of central venous catheter - agitated or disoriented patient (32.1%) and insertion of peripheral venous catheter (46.2%); skin injury - agitated or disoriented patient (26.3%) and application of occlusive dressing (73.7%); and accidental extubation - weaning from sedation, disconnected sedation or inadequate doses of sedation (50.0%) and reintubation (50.0%). The degrees of harm were: mild (23.3%), severe (62.2%), very severe (13.9%) and extremely severe (0.6%). The investigation of the occurrence of adverse events related to the use of equipment and materials in care can prevent and minimize harm to the patient.

Fiberoptic Endoscopic Evaluation of Swallow (FEES) in Intensive Care Unit Patients Post Extubation.

Intensive care unit patients frequently require prolonged intubation and ventilator support. Swallowing dysfunction often occurs in patients who receive prolonged mechanical ventilation. Intubation can cause transient injury to the larynx with a subsequent reduction in protective mechanism and increased incidence of oropharyngeal secretions once patient is extubated. Aim of this study was to evaluate the anatomical damage caused by intubation and the occurrence of aspiration/silent aspiration in patients following extubation, using fiberoptic endoscopic evaluation of swallow (FEES) as diagnostic and therapeutic tool. Participants in the study included all adult ICU patients who were intubated for ≥48h. Head injury patients, patients with abnormal neurological status, completely disoriented patients were excluded. We performed FEES in 41 patients. Duration of intubation was in the range of 2-9days. We studied 41 patients, among them 19(44%) patients had laryngeal injury and 6 (14%) had aspiration. we noticed that all patients who had aspiration had some laryngeal injury. All 6 patients who had aspiration initially recovered their swallowing function fully as noticed during repeat FEES done after swallow therapy. There is a significant impact of intubation on occurrence of aspiration (14%) and laryngeal abnormality (44%). We found in our study that there is a significant correlation to duration of intubation and occurrence of laryngeal injury.

Violent incidents within psychiatric settings

ObjectiveTo determine the frequency and types of aggressive and violent behaviors in acute psychiatric inpatient settings and potential interactions between staffing and patient mix and rates of the behaviours were explored.MethodsData on violent incidents were gathered prospectively in two acute psychiatric units in two general hospitals and two units in a psychiatric hospital in Isfahan, Iran. Staff recorded violent and aggressive incidents by using Morrison's hierarchy of aggressive and violent behavior. The classification ranged from level 1, inflicted serious harm to self or others requiring medical care, to level 8, exhibited low-grade hostility. They also completed weekly reports of staffing levels and patient mix. Regression analysis was used to calculate relative rates.ResultsA total of 400 violent incidents were recorded over a three-month period. Based on the scale, more than 50 percent of the incidents were serious. Seventy-eight percent were directed toward nursing staff. Complex relationships between staffing, patient mix, and violence were found. Relative risk increased with more nursing staff (of either sex), more non nursing staff on planned leave, more patients known to instigate violence, a greater number of disoriented patients, more patients detained compulsorily, and more use of seclusion. The relative risk decreased with more young staff (under 30 years old), more nursing staff with unplanned absenteeism, more admissions, and more patients with substance abuse or physical illness.ConclusionsViolent incidents within psychiatric facilities were frequent and serious, with great significance for occupational health. Some clues were found in the prediction of violence.Disclosure of interestThe authors have not supplied their declaration of competing interest.

Fall risk as a function of time after admission to sub-acute geriatric hospital units.

BackgroundThere is evidence about time-dependent fracture rates in different settings and situations. Lacking are data about underlying time-dependent fall risk patterns. The objective of the study was to analyse fall rates as a function of time after admission to sub-acute hospital units and to evaluate the time-dependent impact of clinical factors at baseline on fall risk.MethodsThis retrospective cohort study used data of 5,255 patients admitted to sub-acute units in a geriatric rehabilitation clinic in Germany between 2010 and 2014. Falls, personal characteristics and functional status at admission were extracted from the hospital information system. The rehabilitation stay was divided in 3-day time-intervals. The fall rate was calculated for each time-interval in all patients combined and in subgroups of patients. To analyse the influence of covariates on fall risk over time multivariate negative binomial regression models were applied for each of 5 time-intervals.ResultsThe overall fall rate was 10.2 falls/1,000 person-days with highest fall risks during the first week and decreasing risks within the following weeks. A particularly pronounced risk pattern with high fall risks during the first days and decreasing risks thereafter was observed in men, disoriented people, and people with a low functional status or impaired cognition. In disoriented patients, for example, the fall rate decreased from 24.6 falls/1,000 person-days in day 2–4 to about 13 falls/1,000 person-days 2 weeks later. The incidence rate ratio of baseline characteristics changed also over time.ConclusionsFall risk differs considerably over time during sub-acute hospitalisation. The strongest association between time and fall risk was observed in functionally limited patients with high risks during the first days after admission and declining risks thereafter. This should be considered in the planning and application of fall prevention measures.Electronic supplementary materialThe online version of this article (doi:10.1186/s12877-016-0346-7) contains supplementary material, which is available to authorized users.

Slow Regular Rhythm in a Disoriented Patient

A 65-year-old woman with a history of high blood pressure, diabetes mellitus, hyperlipidemia, chronic kidney disease, and stroke went to a walk-in clinic complaining of intermittent neck, left shoulder, and arm pain for several days. After being diagnosed with pneumonia and started on antibiotics, the patient went home. The pain became worse and constant 2 days later, and several hours thereafter her family found her disoriented and diaphoretic. An electrocardiogram on hospital admission showed atrial fibrillation, complete atrioventricular block, and a regular junctional escape rhythm at a rate of 37 beats/min (Figure). QRS, ST, and T changes indicated acute inferoposterolateral myocardial infarction, and the QT interval was long (604 msec; QTc 562). Figure. Electrocardiogram recorded on hospital admission. See text for explication. A survey of 11 studies of the culprit lesion sites in acute inferior myocardial infarction found right coronary artery to left circumflex coronary artery ratios that ranged from 2.2:1 to 7.0:1 with a mean of 4:1 (1). Furthermore, the artery to the AV node is a branch of the right 90% of the time and of the left circumflex only 10% of the time. Thus, there are good reasons for suspecting the right coronary artery as the culprit. Two findings, however, are common in left circumflex occlusions, but uncommon in right occlusions: ST depression in both leads V1 and V2 and ST depression ≥0.1 mV (1 mm) in lead aVR (1). Coronary arteriography, the ultimate clinical arbiter, demonstrated atherothrombotic occlusion in the middle portion of a dominant left circumflex coronary artery. This was treated with a bare metal stent, and a temporary transvenous electronic ventricular pacemaker increased the rate to 60 beats/min. Serum troponin I peaked at 75 ng/mL; reference, <0.04 ng/mL. Unfortunately, although atrioventricular block decreased to second and then first degree over 2 days, the patient remained poorly responsive for 6 days, suffered transient kidney failure requiring hemodialysis, and had acute respiratory distress syndrome requiring endotracheal ventilation for 12 days. The prolonged intubation caused dysphagia necessitating total parenteral nutrition via a percutaneous indwelling central catheter. Thrombocytopenia, seemingly induced by eptifibatide, abated after the drug was stopped. After 4 weeks of hospitalization, the patient was well enough to be transferred to an inpatient rehabilitation facility. The electrocardiographic lesson is that because a dominant left circumflex coronary artery supplies not only the usual distribution of the left circumflex, but also most of the usual distribution of the right, occlusion of a dominant circumflex usually causes a large infarct that has electrocardiographic features of both circumflex and right occlusions. The more important lesson is that failure to recognize an impending myocardial infarction often results in a clinical catastrophe.

Intravascular Large B-Cell Lymphoma: A Difficult Diagnostic Challenge.

Case Presentation. A 69-year-old Hispanic male, with a past history of diabetes and coronary disease, was admitted for fever, diarrhea, and confusion of 4 weeks duration. Physical examination showed a disoriented patient with multiple ecchymoses, possible ascites, and bilateral scrotal swelling. Hemoglobin was 6.7, prothrombin time (PT) 21.4 seconds with international normalized ratio 2.1, partial thromboplastin time (PTT) 55.6 seconds, fibrin split 10 µg/L, and lactate dehydrogenase (LDH) 1231 IU/L. Except for a positive DNA test for Epstein–Barr virus (EBV) infection, extensive diagnostic workup for infections, malignancy, or a neurological cause was negative. Mixing studies revealed a nonspecific inhibitor of PT and PTT but Factor VIII levels were normal. The patient was empirically treated with antibiotics but developed hypotension and died on day 27 of admission. At autopsy, patient was found to have intravascular diffuse large B-cell lymphoma involving skin, testes, lung, and muscles. The malignant cells were positive for CD20, CD791, Mum-1, and Pax-5 and negative for CD3, CD5, CD10, CD30, and Bcl-6. The malignant cells were 100% positive for Ki-67. Discussion. Intravascular large cell B-cell lymphoma (IVLBCL) is rare form of diffuse large B-cell lymphoma and tends to proliferate within small blood vessels, particularly capillaries and postcapillary venules. The cause of its affinity for vascular bed remains unknown. In many reports, IVLBCL was associated with HIV, HHV8, and EBV infections. The fact that our case showed evidence of EBV infection lends support to the association of this diagnosis to viral illness. The available literature on this subject is scant, and in many cases, the diagnosis was made only at autopsy. The typical presentation of this disorder is with B symptoms, progressive neurologic deficits, and skin findings. Bone marrow, spleen, and liver are involved in a minority of patients. Nearly all patients have elevated LDH, and about 65% are anemic. About 20% have hepatic and renal dysfunction. The treatment consists of systemic chemotherapy with cyclophosphamide, doxorubicin, vincristine, prednisone plus rituximab (CHOP-R) and central nervous system prophylaxis. Retrospective data suggests that, with treatment, 51% to 82% of the patients achieve a complete remission and 27% to 56% are alive at 2-year follow-up. Conclusion. IVLBCL is a difficult diagnosis to make as the disease remains confined to the vascular lumen. It may be associated with certain viral illnesses, and this association needs to be explored further. It is important to consider this diagnosis in the appropriate settings because patients may achieve durable remissions with therapy.

805 – Violence in clinical psychiatry

Objective To determine the frequency and types of aggressive and violent behaviors in acute psychiatric inpatient settings and potential interactions between staffing and patient mix and rates of the behaviors were explored. Methods Data on violent incidents were gathered prospectively in two acute psychiatric units in two general hospitals and two units in a psychiatric hospital in Isfahan, Iran. Staff recorded violent and aggressive incidents by using Morrison's hierarchy of aggressive and violent behavior. The classification ranged from level 1, inflicted serious harm to self or others requiring medical care, to level 8, exhibited low-grade hostility. They also completed weekly reports of staffing levels and patient mix. Results A total of 400 violent incidents were recorded over a three-month period. Based on the scale, more than 50 percent of the incidents were serious. Seventy-eight percent were directed toward nursing staff. Complex relationships between staffing, patient mix, and violence were found. Relative risk increased with more nursing staff (of either sex), more non nursing staff on planned leave, more patients known to instigate violence, a greater number of disoriented patients, more patients detained compulsorily, and more use of seclusion. The relative risk decreased with more young staff (under 30 years old), more nursing staff with unplanned absenteeism, more admissions, and more patients with substance abuse or physical illness. Conclusions Violent incidents within psychiatric facilities were frequent and serious, with great significance for occupational health. Some clues were found in the prediction of violence.

P-670 - Violence in psychiatric wards

Objective Violence in psychiatric wards is common, and it is on the rise. This study examined the frequency and types of aggressive and violent behaviors in acute psychiatric inpatient settings and focuses on the possible complex interaction between ward staffing, patient mix, and violence. Methods Data were gathered prospectively in two acute psychiatric units in two general hospitals and two units in a psychiatric hospital in Isfahan, Iran. Staff recorded violent and aggressive incidents by using Morrison's hierarchy of aggressive and violent behavior. They also completed weekly reports of Ward Activity Index (patient mix), and Staff Level Index were developed by the researcher. Regression analysis was used to calculate relative rates. Results A total of 429 violent incidents were recorded over a three-month period. Based on the scale, more than 50 percent of the incidents were serious. Seventy-eight percent were directed toward nursing staff. Complex relationships between staffing, patient mix, and violence were found. Relative risk increased with more nursing staff (of either sex), more non nursing staff on planned leave, more patients known to instigate violence, a greater number of disoriented patients, more patients detained compulsorily, and more use of seclusion. The relative risk decreased with more young staff (under 30 years old), more nursing staff with unplanned absenteeism, more admissions, and more patients with substance abuse or physical illness. Conclusions Violent incidents within psychiatric facilities were frequent and serious, with great significance for occupational health. Some clues were found in the prediction of violence.

In Reply

We welcome the comments by Livshits et al. They appropriately cite the need for effective diagnosis of delirium tremens. Neither the clinical institute withdrawal assessment (CIWA) nor the SHOT have been validated for patients in delirium tremens. However, the SHOT treatment protocol specifies that anyone who scores positive for hallucinations or orientation should be explicitly assessed and treated for delirium, regardless of the overall score. This is very different than the CIWA, in which orientation is just one of 10 categories and where it is quite possible that a disoriented patient may be missed if his or her total CIWA score is low. For brevity, the SHOT treatment protocol was not published in the journal article. However, referring to Table 1 (below) should clarify how the SHOT is appropriately used in the emergency department (ED) setting. Developed by emergency physicians (and other experts) for emergency physicians, we believe that the SHOT may provide a more efficient process for delivering safe and effective symptom-triggered therapy in the ED.

Predicting Neuropsychological Test Performance on the Basis of Temporal Orientation

ABSTRACT Temporal orientation is often disrupted in the context of psychiatric or neurological disease; tests assessing this function are included in most mental status examinations. The present study examined the relationship between scores on the Temporal Orientation Scale (TOS) and performance on a battery of tests that assess memory, language, and cognitive functioning in a sample of patients with Alzheimer's disease (N = 55). Pearson-product moment correlations showed that, in all but two instances, the TOS was significantly correlated with each neuropsychological measure, p values ≤ .05. Also, severely disoriented (i.e., TOS score ≤ −8) patients were consistently ‘impaired’ on memory tests but not on tests of language and general cognitive functioning.

Sidney Vogel: Spanish Civil War Surgeon

IN JULY 1936, THE democratically elected republican government of Spain was plunged into civil war when General Francisco Franco, with massive aid from Nazi Germany and fascist Italy, led an attempted coup d'etat.1 The republicans received aid from the Soviet Union and Mexico, but the Western democracies imposed an almost complete embargo on weapons and personnel. This was the context in which nearly 3000 Americans went against official US foreign policy and volunteered to fight on the side of the Spanish Republic, joining 35 000 other volunteers in a desperate and ultimately losing battle against the growing fascist menace.2 Among the US volunteers was Sidney Vogel, one of approximately 30 physician participants. Vogel was born April 28, 1904, in New York City. His father, an immigrant from Germany, was a physician. In 1927, Vogel received his medical degree from the University of Michigan and served an internship at Manhattan State Hospital, a psychiatric facility. In the 1930s, he practiced general medicine in New York City, at one point working for a large insurance company. Like many of his friends and family, he took progressive positions on the issues of the day, and like other idealistic physicians, he became caught up in the campaign led by the Medical Bureau of the Friends of Spanish Democracy to provide medical support to the republican forces.3–5 On May 29, 1937, Vogel arrived in Spain and was posted with the rank of captain to Murcia as director of the Casa Roja hospital. There he both supervised the work of the hospital and practiced surgery alongside his colleagues. As Franco's forces advanced, he was transferred to Mataro and other hospitals near Barcelona, always as director. Although the international brigades were withdrawn from combat in October 1938, medical staff members remained behind to supervise the transfer of the wounded out of Spain. In January 1939, Vogel left Spain for Paris and then New York, where he arrived in late February. Like many Spanish Civil War veterans, he volunteered again to fight fascism after Pearl Harbor, serving in the US Army's North African and Italian campaigns.6 As the only medical staff on his postings with any psychiatric experience, he was often assigned to care for shellshock victims and other disoriented patients. After the war, he used the GI Bill to retrain as a psychiatrist. He had a special interest in the then-novel fields of group therapy and alcoholism, topics on which he published several articles in the 1950s.7–9 He practiced psychiatry in New York City until his death on April 1, 1986. The document by Vogel printed here offers a contemporary first-hand description of medical practice during the Spanish Civil War. Previously unpublished, it was found in the American Lincoln Brigade Archives at New York University. Most likely dating from mid-1939, the manuscript's intended audience and publication venue are unknown. Because it is written in a popular rather than technical manner, it may have been meant to sensitize public opinion in preparation for the coming war.10 Throughout his text, Vogel emphasizes that organizational advances represent the main contribution made by medical staff in wartime. For example, this is the main significance of his vivid discussion of blood transfusion work during the Spanish Civil War. He expresses admiration for the system developed by Spanish personnel, but does not mention Norman Bethune, who subsequently received what now appears to be undeserved credit for these organizational innovations.11,12 Published accounts from the period by Spanish Civil War medical personnel can be counted on the fingers of one hand. In addition, Vogel is one of many Spanish Civil War volunteers whose participation has gone virtually unmentioned in the scholarly literature. Together, these factors make this article of special interest.