scholarly journals Delayed dyskinesia and prolonged psychosis in a patient presenting with profound hyponatraemia

2017 ◽  
Vol 2017 ◽  
Author(s):  
Victoria John ◽  
Philip Evans ◽  
Atul Kalhan
Keyword(s):  
Serum Sodium ◽  
Psychotic Symptoms ◽  
List Type ◽  
Close Monitoring ◽  
Focal Neurological Deficit ◽  
Neurological Sequelae ◽  
High Dependency ◽  
History Of ◽  
Learning Points

Summary A 65-year-old woman was admitted to the emergency unit with a 48 h history of generalised weakness and confusion. On examination, she had mild slurring of speech although there was no other focal neurological deficit. She had profound hyponatraemia (serum sodium level of 100 mmol/L) on admission with the rest of her metabolic parameters being within normal range. Subsequent investigations confirmed the diagnosis of small-cell lung cancer with paraneoplastic syndrome of inappropriate antidiuresis (SIAD). She was monitored closely in high-dependency unit with an attempt to cautiously correct her hyponatraemia to prevent sequelae associated with rapid correction. The patient developed prolonged psychosis (lasting over 2 weeks) and displayed delayed dyskinetic movements, even after a gradual increase in serum sodium levels close to 130 mmol/L. To our knowledge, delayed neurological recovery from profound hyponatraemia (without long-term neurological sequelae) has previously not been reported. This case should alert a clinician regarding the possibility of prolonged although reversible psychosis and dyskinetic movements in a patient presenting with profound symptomatic hyponatraemia. Learning points: Patients with profound hyponatraemia may develop altered sensorium, dyskinesia and psychotic behaviour. Full recovery from psychotic symptoms and dyskinesia may be delayed despite cautious correction of serum sodium levels. Careful and close monitoring of such patients can help avoid long-term neurological sequelae.

scholarly journals P044 Can an electronic prescribing system ensure clear anticoagulation discharge communication?

2019 ◽  
Vol 104 (7) ◽  
pp. e2.49-e2
Author(s):  
Susie Gage
Keyword(s):  
Patient Safety ◽  
Discharge Summary ◽  
Electronic Prescribing ◽  
List Type ◽  
Heparin Infusion ◽  
National Patient Safety Agency ◽  
High Dependency ◽  
National Patient ◽  
Discharge Summaries

AimThe National Patient Safety Agency (NPSA)1 identified heparin as a major cause of adverse events associated with adverse incidents, including some fatalities. By ensuring good communication, this should be associated with risk reduction.1 The aim of this study was to ensure there is clear anticoagulation communication on discharge, from the paediatric intensive care unit (PICU) electronic prescribing system (Philips), to the paediatric cardiac high dependency unit and paediatric cardiac ward. To investigate whether the heparin regimen complies with the hospital’s anticoagulant guidelines and if there is any deviation; that this is clearly documented. To find out if there is an indication documented for the heparin regimen chosen and if there is a clear long term plan documented for the patient, after heparin cessation.MethodsA report was generated for all patients who were prescribed a heparin infusion on PICU, between 1st January 2018 and 30th June 2018, from the Philips system. All discharge summaries from the PICU Philips system were reviewed. Only paediatric cardiac patients were included that had a heparin infusion prescribed on discharge, all other discharge summaries were excluded from the study. Each discharge summary was reviewed in the anticoagulant section; for the heparin regimen chosen, whether it complies with the hospital’s anticoagulant guidelines and if there was any deviation whether this was documented. The indication documented of which heparin regimen was chosen and whether a clear long term plan was documented after heparin cessation; for example if the patient is to be transferred onto aspirin, clopidogrel, warfarin or enoxaparin.Results82 discharge summaries were reviewed over the 6 month period between 1st January 2018 and 30th June 2018; 16 were excluded as were not paediatric cardiac, leaving 66 paediatric cardiac discharge summaries that were reviewed. 45 out of 66 (68%) complied with the hospital’s heparin anticoagulation guidelines. Of the 32% that deviated from the protocol; only 33% (7 out of 21) had a reason documented. Only 50% (33) of the summaries reviewed had an indication for anticoagulation noted on the discharge summary and 91% of discharge summaries had a long term anticoagulant plan documented.ConclusionThe electronic prescribing system can help to ensure a clear anticoagulation communication as shown by 91% of the anticoagulation long term plan being clearly documented; making it a more seamless patient transfer. On the Philips PICU electronic prescribing system there is an anticoagulant section on the discharge summary that has 3 boxes that need to be completed; heparin regimen, indication and anticoagulation long term plan. However, despite these boxes; deviations from the anticoagulant protocol were poorly documented as highlighted by only 33% having the reason highlighted in the discharge summary, only 50% of the indications were documented. Despite having prompts for this information on the discharge summary, the medical staffs needs to be aware to complete this information, in order to reduce potential medication errors and risk.ReferenceThe National Patient Safety Agency (NPSA). Actions that make anticoagulant therapy safer. NPSA; March 2007.

scholarly journals Cured primary hyperparathyroidism after fine-needle aspiration biopsy-induced parathyroid disappearance

2017 ◽  
Vol 2017 ◽  
Author(s):  
Elda Kara ◽  
Elisa Della Valle ◽  
Sara De Vincentis ◽  
Vincenzo Rochira ◽  
Bruno Madeo
Keyword(s):  
Primary Hyperparathyroidism ◽  
Fine Needle Aspiration ◽  
Needle Aspiration ◽  
Complete Disappearance ◽  
List Type ◽  
Fine Needle ◽  
Time Period ◽  
History Of

Summary Spontaneous or fine-needle aspiration (FNAB)-induced remission of primary hyperparathyroidism (PHPT) may occur, especially for cystic lesions. However, the disease generally relapses over a short time period. We present a case of PHPT due to an enlarged hyperfunctioning parathyroid that underwent long-term (almost 9 years) clinical and ultrasonographic remission after the disappearance of the lesion following ultrasound (US)-assisted FNAB. A 67-year-old woman with PHPT underwent biochemical and US examinations that confirmed the diagnosis and showed a lesion suggestive for parathyroid adenoma or hyperplasia. US-FNAB of the lesion confirmed its parathyroid nature by means of elevated levels of parathyroid hormone within the needle washing fluid. At the second visit, the patient referred slight neck swelling that resolved spontaneously in the days after the US-FNAB. At subsequent follow-up, the enlarged parathyroid was not found; it was visible neither with US nor with magnetic resonance imaging. Biochemical remission persists after 9 years. This is the first reported case of cure of PHPT after US-FNAB performed on a hyperfunctioning parathyroid resulting in its complete disappearance over a period of 9 years of negative biochemical and ultrasonographic follow-up. Learning points: Spontaneous or fine-needle aspiration-induced remission of primary hyperparathyroidism can occur. Both circumstances may present disease relapse over a variable time period, but definite remission is also possible even though long-term periodic follow-up should be performed. Parathyroid damage should be ruled out in case of neck symptomatology after parathyroid fine-needle aspiration or spontaneous symptomatology in patients with history of primary hyperparathyroidism.

scholarly journals Effective long-term temozolomide rechallenge in a macroprolactinoma

2018 ◽  
Vol 2018 ◽  
Author(s):  
Benedetta Zampetti ◽  
Giorgia Simonetti ◽  
Roberto Attanasio ◽  
Antonio Silvani ◽  
Renato Cozzi
Keyword(s):  
Aggressive Behavior ◽  
Acquired Resistance ◽  
Pituitary Tumors ◽  
List Type ◽  
Fractionated Radiotherapy ◽  
Resistance To Treatment ◽  
Aggressive Tumors ◽  
Learning Points ◽  
Treatment Surgery

Summary We describe the 20-year course of a 63-year-old male with a macroprolactinoma that acquired resistance to treatment and aggressive behavior after a 4-year successful treatment with cabergoline. He was submitted to multiple surgical resections by a skilled surgeon, fractionated radiotherapy and was eventually treated with temozolomide. After a first 6-month standard cycle, a relapse occurred and he was treated again successfully. Learning points: Prolactinomas are the most frequent type of pituitary adenoma. They usually have a benign course. In most cases dopamine-agonist drugs, mainly cabergoline, are first-line (and usually only) treatment. Occasionally prolactinomas can have or acquire resistance to treatment and/or aggressive behavior. Temozolomide (TMZ), an oral alkylating drug, can be effective in such aggressive tumors. Multimodal treatment (surgery, radiation, cabergoline and TMZ) is warranted in aggressive pituitary tumors. We describe here successful rechallenge with TMZ after relapse occurring 18 months after a first TMZ cycle.

scholarly journals Pasireotide in an insulin-requiring diabetic acromegalic patient without worsening of hyperglycemia

2017 ◽  
Vol 2017 ◽  
Author(s):  
Murray B Gordon ◽  
Kellie L Spiller
Keyword(s):  
Diabetes Mellitus ◽  
Type 2 Diabetes ◽  
Type 2 Diabetes Mellitus ◽  
List Type ◽  
Effective Treatment Option ◽  
Patients With Diabetes ◽  
Long Acting ◽  
Learning Points

Summary Long-acting pasireotide is an effective treatment option for acromegaly, but it is associated with hyperglycemia, which could impact its use in patients with diabetes. We present a case of a 53-year-old man with acromegaly and type 2 diabetes mellitus (glycated hemoglobin (HbA1c): 7.5%), who refused surgery to remove a pituitary macroadenoma and enrolled in a Phase 3 clinical trial comparing long-acting pasireotide and long-acting octreotide in acromegalic patients. The patient initially received octreotide, but insulin-like growth factor 1 (IGF-1) levels remained elevated after 12 months (383.9 ng/mL; 193.0 ng/mL; reference range: 86.5–223.8 ng/mL), indicating uncontrolled acromegaly. He switched to pasireotide 40 mg and subsequently increased to 60 mg. Within 6 months, IGF-1 levels normalized (193.0 ng/mL), and they were mostly normal for the next 62 months of treatment with pasireotide (median IGF-1: 190.7 ng/mL). Additionally, HbA1c levels remained similar to or lower than baseline levels (range, 6.7% to 7.8%) during treatment with pasireotide despite major changes to the patient’s antidiabetic regimen, which included insulin and metformin. Uncontrolled acromegaly can result in hyperglycemia due to an increase in insulin resistance. Despite having insulin-requiring type 2 diabetes, the patient presented here did not experience a long-term increase in HbA1c levels upon initiating pasireotide, likely because long-term control of acromegaly resulted in increased insulin sensitivity. This case highlights the utility of long-acting pasireotide to treat acromegaly in patients whose levels were uncontrolled after long-acting octreotide and who manage diabetes with insulin. Learning points Long-acting pasireotide provided adequate, long-term biochemical control of acromegaly in a patient with insulin-requiring type 2 diabetes mellitus who was unresponsive to long-acting octreotide. Glycemic levels initially increased after starting treatment with pasireotide but quickly stabilized as acromegaly became controlled. Long-acting pasireotide, along with an appropriate antidiabetic regimen, may be a suitable therapy for patients with acromegaly who also have insulin-requiring type 2 diabetes mellitus.

scholarly journals Acute milk-alkali syndrome

2018 ◽  
Vol 2018 ◽  
Author(s):  
Bidhya Timilsina ◽  
Niranjan Tachamo ◽  
Prem Raj Parajuli ◽  
Ilan Gabriely
Keyword(s):  
Renal Failure ◽  
Metabolic Alkalosis ◽  
List Type ◽  
Over The Counter ◽  
Excess Calcium ◽  
Severe Hypercalcemia ◽  
History Of ◽  
High Index Of Suspicion ◽  
Learning Points ◽  
Rule Out

Summary A 74-year-old woman presented with progressive lethargy, confusion, poor appetite and abdominal pain. She was found to have non-PTH-mediated severe hypercalcemia with renal failure and metabolic alkalosis. Extensive workup for hypercalcemia to rule out alternate etiology was unrevealing. Upon further questioning, she was taking excess calcium carbonate (Tums) for her worsening heartburn. She was diagnosed with milk-alkali syndrome (MAS). Her hypercalcemia and alkalosis recovered completely with aggressive hydration along with improvement in her renal function. High index of suspicion should be maintained and history of drug and supplements, especially calcium ingestion, should be routinely asked in patients presenting with hypercalcemia to timely diagnose MAS and prevent unnecessary tests and treatments. Learning points: Suspect milk-alkali syndrome in patients with hypercalcemia, metabolic alkalosis and renal failure, especially in context of ingestion of excess calcium-containing supplements. Careful history of over-the-counter medications, supplements and diet is crucial to diagnose milk-alkali syndrome. Milk-alkali syndrome may cause severe hypercalcemia in up to 25–30% of cases.

scholarly journals Phaeochromocytoma presenting with polyuria: an uncommon presentation of a rare tumour

2014 ◽  
Vol 2014 ◽  
Author(s):  
N Atapattu ◽  
K A C P Imalke ◽  
M Madarasinghe ◽  
A Lamahewage ◽  
K S H de Silva
Keyword(s):  
Correct Diagnosis ◽  
List Type ◽  
Rare Tumour ◽  
Uncommon Presentation ◽  
The Family ◽  
History Of ◽  
Associated Conditions ◽  
Complete Physical Examination ◽  
Learning Points

Summary Children rarely present with phaeochromocytoma. Their presentation differs from that of adults. The classic triad of sweating, headache and palpitation may not always present in children with phaeochromocytoma. In this study, we present a 6-year-old girl who came to us with polyuria and polydipsia for evaluation of suspected diabetes insipidus. She gave a clear history of increased sweating in the recent past. On clinical examination, she was noted to have high blood pressure. Subsequent investigations revealed a phaeochromocytoma. Her polyuria and hypertension resolved immediately after the surgery. We did not have the facilities to arrange for genetic tests; however, the patient and the family members are under follow-up for other associated conditions. Learning points Polyuria and polydipsia are rare symptoms of phaeochromocytoma. Complete physical examination prevented unnecessary investigations for polyuria and led to a correct diagnosis. Classic features are not always necessary for diagnostic evaluation of rare diseases.

scholarly journals Isolated hypophosphataemia as an early marker of primary hyperparathyroidism

2021 ◽  
Vol 2021 ◽  
Author(s):  
John Alexander ◽  
Dinesh Nagi
Keyword(s):  
Primary Hyperparathyroidism ◽  
List Type ◽  
Biochemical Abnormality ◽  
Common Presentation ◽  
Long Term Monitoring ◽  
Biochemical Testing ◽  
Term Monitoring ◽  
Learning Points ◽  
Biochemical Abnormalities

Summary Primary hyperparathyroidism (PHPT) is a disease caused by overactive parathyroid glands with consequent hypercalcaemia. The main cause in 85–90% of the cases is the presence of a solitary parathyroid adenoma. The most common presentation is with asymptomatic hypercalcaemia diagnosed on routine biochemical testing. Although low serum phosphate levels are an associated finding in primary hyperparathyroidism, the diagnostic criteria for PHPT remain to be hypercalcaemia, high or inappropriately normal PTH and hypercalciuria. This case report presents a patient who presented with low phosphate levels without any other biochemical evidence of PHPT, who returned several years later with overt primary hyperparathyroidism. This report intends to raise interest among the medical fraternity whether there is a need to consider hypophosphataemia as an early sign of PHPT. Learning points Primary hyperparathyroidism is a relatively common condition with varying clinical and biochemical presentation. The most common presentations still remain as an asymptomatic biochemical abnormality closely related to calcium, PTH and bone metabolism. Not much attention is usually given to associated biochemical abnormalities, and hence they are usually less investigated. Further research is needed to establish if patients need long-term monitoring when no obvious cause for isolated hypophosphataemia has been found.

scholarly journals Sirolimus therapy in a child with partially diazoxide-responsive hyperinsulinaemic hypoglycaemia

2016 ◽  
Vol 2016 ◽  
Author(s):  
Kah-Yin Loke ◽  
Andrew Sng Anjian ◽  
Yvonne Lim Yijuan ◽  
Cindy Ho Wei Li ◽  
Maria Güemes ◽  
...  
Keyword(s):  
Weight Gain ◽  
Side Effects ◽  
Viral Gastroenteritis ◽  
List Type ◽  
Hyperinsulinaemic Hypoglycaemia ◽  
Glucose Levels ◽  
Capillary Glucose ◽  
Clinically Significant ◽  
Learning Points

Summary Hyperinsulinaemic hypoglycaemia (HH), which causes persistent neonatal hypoglycaemia, can result in neurological damage and it’s management is challenging. Diazoxide is the first-line treatment, albeit not all patients will fully respond to it, as episodes of hypoglycaemia may persist and it entails unpleasant adverse effects. Sirolimus, an mTOR inhibitor, has reportedly been successful in treating children with severe diffuse HH, thus obviating the need for pancreatectomy. We report a girl with HH, with a novel heterozygous ABCC8 gene missense mutation (c.4154A>T/ p.Lys1385Thr), who was initially responsive to diazoxide therapy. After 11 months of diazoxide treatment, she developed intermittent, unpredictable breakthrough episodes of hypoglycaemia, in addition to generalized hypertrichosis and weight gain from enforced feeding to avoid hypoglycaemia. Sirolimus, which was commenced at 15 months of age, gradually replaced diazoxide, with significant reduction and abolition of hypoglycaemia. The hypertrichosis resolved and there was less weight gain given the reduced need for enforced feeding. Sirolimus, which was administered over the next 15 months, was well tolerated with no significant side effects and was gradually weaned off. After stopping sirolimus, apart from hypoglycaemia developing during an episode of severe viral gastroenteritis, the capillary glucose concentrations were maintained >3.5 mmol/L, even after a 10 h fast. Sirolimus may have a role in the treatment of partially diazoxide-responsive forms of HH who experience breakthrough hypoglycaemia, but the long-term safety and efficacy of sirolimus are not established. Learning points: Conventional treatment of diffuse HH with diazoxide is not always effective in controlling hypoglycaemia and can be associated with unpleasant side effects. Sirolimus was successfully used to abolish recurrent hypoglycaemia in partially diazoxide-responsive HH, with resolution of unacceptable diazoxide-associated side effects. Sirolimus was well tolerated with no clinically significant side effects. Shortly after stopping sirolimus, the capillary glucose levels remained normoglycemic.

scholarly journals Coming undone: a case of annuloplasty ring suture degeneration post mitral valve repair leading to recurrent severe MR

2020 ◽  
Vol 7 (1) ◽  
pp. K7-K10
Author(s):  
Patrick Savage ◽  
Michael Connolly
Keyword(s):  
Mitral Valve ◽  
Mitral Regurgitation ◽  
Mitral Valve Repair ◽  
Progressive Disease ◽  
List Type ◽  
Valve Repair ◽  
Annuloplasty Ring ◽  
2D And 3D ◽  
Learning Points

Summary Mitral valve repair is the gold standard treatment for degenerative mitral valve disease with superior perioperative and long-term morbidity and mortality outcomes vs mitral valve replacement. The 10 year survival freedom from redo valve repair varies from 72 to 90%. Often, failure of valve repair necessitating redo surgery is directly related to disease progression; however, rarely it can be attributed to technical complications such as annuloplasty dehiscence, leaflet suture rupture, incorrect artificial chord length or incorrect annuloplasty position. We report one such case of severe mitral regurgitation secondary to a degenerative annuloplasty ring suture occurring 1 year post valve repair. Learning points: Differentiation of causative pathology involved in recurrent mitral regurgitation following repair has important implications for patient outcomes. In the hands of an experienced practitioner echocardiography – in particular, integrated 2D- and 3D echocardiography – is a powerful tool for differentiating between progressive disease and procedural failure.

scholarly journals The effectiveness of long-term aripiprazole injections to a patient with paranoid schizophrenia: a case report

2020 ◽  
Vol 0 (0) ◽  
Author(s):  
Anna Maria Szota ◽  
Aleksander Araszkiewicz
Keyword(s):  
Case Report ◽  
Negative Symptoms ◽  
Social Withdrawal ◽  
Paranoid Schizophrenia ◽  
Psychotic Symptoms ◽  
Suicidal Thoughts ◽  
Duration Of Hospitalization ◽  
History Of ◽  
Long Acting

AbstractParanoid schizophrenia is a chronic, psychotic disorder which can be treated with long-acting injectable (LAI) antipsychotic drugs. There are risperidone (Risperdal Consta®), olanzapine (Zypadhera®), paliperidone (Xepilon®) and aripiprazole (Abilify Maintena®) currently available.The aim of this study was to present a case history of the patient to whom monthly injections of aripiprazole effectively prevented both relapses of psychotic symptoms and hospitalizations.Case report: A 55-year-old male patient with a 13-year history of paranoid schizophrenia has been effectively treated with aripiprazole (LAI) (400mg, every 4 weeks). During the last 8 years of treatment his mental state has been stabilized, without any acute psychotic symptoms and without any anxiety, or violent behaviours. Moreover, there have been no psychotic symptoms, or suicidal thoughts, or tendencies recordered. Therefore, no hospitalization has been required. However, despite the treatment, negative symptoms such as blunted affect, cognitive dysfunction and social withdrawal have been sustained.Discussion: The available articles on aripiprazole (LAI) treatment indicate that it was effective in reducing the positive and negative symptoms of schizophrenia, as well as reducing the frequency and duration of hospitalization. However, the case report of a patient who has not had relapses of psychotic symptoms and suicidal thoughts and has not been hospitalized during 8 years of treatment with aripiprazole (LAI) has not yet been reported.Conclusions: Regular, long-term injections of aripiprazole (LAI) are very effective at preventing positive symptoms of schizophrenia development and preventing both suicidal thoughts and hospitalizations. Therefore, treatment with this drug in everyday practice should be increased.

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