A Rare Case of Thiamine Deficiency Leading to Dry Beriberi, Peripheral Neuropathy, and Torsades De Pointes.

Thiamine (vitamin B1) is an essential nutrient and one of the eight B vitamins. As a water-soluble vitamin, thiamine is not stored; therefore, a balanced diet is required to ensure adequate intake of this essential vitamin. Thiamine deficiency is known to cause both wet and dry beriberi, but rarely in combination. Thiamine deficiency has also been known to cause QTc prolongation, but the mechanism remains unclear. In the most severe cases, this can lead to the lethal arrhythmia of torsades de pointes. This case describes a patient who became malnourished after a closed head injury and initially presented with seizure-like activity and syncopal episodes with nonspecific numbness. He was found to have prolonged QTc, leading to torsades de pointes requiring an implanted cardioverter defibrillator. With extensive workup, including genetic testing, the patient was found to have indetectable thiamine levels. With supplementation, the patient no longer had any recorded ventricular arrhythmias, and neurological function improved with only residual tingling in the hands. This case emphasizes the profound effects of thiamine deficiency and why this should be included in our differential diagnosis for patients presenting with the sequelae of the signs and symptoms discussed.

Risk factors, management, and outcomes in isolated parafalcine or tentorial subdural hematomas.

INTRODUCTION: Indications for hospitalization in patients with parafalcine or tentorial subdural hematomas (SDH) remain unclear. This study derived and validated a clinical decision rule to identify patients at low risk for complications such that hospitalization can be avoided. METHODS: A multicenter retrospective medical record review of adult patients with parafalcine or tentorial SDHs was completed. The primary outcome was significant injury, defined as injury that led to neurosurgery, discharge to another facility, or death. A multivariable logistic regression was performed to identify variables independently associated with the outcome in the derivation cohort. These variables were then validated on a separate cohort from a different institution abstracted without knowledge of the identified variables. RESULTS: In the derivation cohort, 134 patients with parafalcine/tentorial SDHs were identified. The mean age was 63 ± 19 years with 82 (61%) male. Seventy-one (53%) had significant injuries. Variables independently associated with significant injury included: age over 60, adjusted odds ratio (aOR) 3.46 (95% CI 1.24, 9.62), initial Glasgow Coma Scale score below 15, aOR =7.92 (95% CI 2.78, 22.5), and additional traumatic brain injuries (TBIs) on computerized tomography (CT), aOR =5.97 (95% CI 2.48, 14.4). These three variables had a sensitivity of 71/71 (100%, 95% CI 96, 100%) and specificity of 12/63 (19%, 95% CI 10, 31%). The validation cohort (n = 83) had a mean age of 62 ± 22 years with 50 (60%) male. The three variables had a sensitivity of 36/36 (100%, 95% CI 92, 100%) and specificity of 7/47 (15%, 95% CI 6.2, 28%). All 39 (100%, 95% CI 93, 100%) patients from both cohorts who underwent neurosurgery had additional TBI findings on their CT scan. CONCLUSIONS: Patients with parafalcine/tentorial SDHs who are under 60 years with initial GCS scores of 15 and no addition TBIs on CT are at low risk and may not need hospitalization. Furthermore, patients with isolated parafalcine/tentorial SDHs are unlikely to undergo neurosurgery. Prospective, external validation with a larger sample size is now recommended. STUDY TYPE: Retrospective Cohort Study.

An itchy rash and muscle weakness.

Dermatomyositis is a rare disease affecting primarily skin and muscles and is associated with malignancies, especially in at-risk patients. Clinical presentations vary widely but proximal muscle weakness and typical skin findings should prompt consideration of the diagnosis. Immunosuppressive therapy is required, as is continued screening for malignant disease during follow-up.

TRIAD IX: Can a Patient Testimonial Safely Help Ensure Prehospital Appropriate Critical Versus End-of-Life Care?

OBJECTIVE: The present study sought to assess the clarity of Physician Orders for Life-Sustaining Treatment (POLST) or Living Will (LW) documents alone or in combination with a video message/testimonial (VM). METHODS: Emergency medical services (EMS) personnel responded to survey questions about the meaning of stand-alone POLST and LW documents and those used in conjunction with emergent care scenarios. Personnel were randomized to receive documents only or documents with VM. Questions sought a code status for each scenario and a resuscitation decision. Code status responses were analyzed for consensus (95% response rate), resuscitation responses for correct treatment decisions. RESULTS: The survey response rate was 85%. Approximately half of emergency medical technician (EMT) respondents were EMT basic, and half EMT respondents were paramedic, with an average age of 42 years. Less than half had previous POLST/LW training averaging 2 hours. Consensus failed to be reached for stand-alone documents. For clinical scenarios, responses to POLST documents specifying do not resuscitate/comfort measures only or cardiopulmonary resuscitation/full treatment exceeded 80% for code status designation and correct resuscitation decisions. Other POLST resuscitation/treatment combinations showed more disparate responses, and most benefited from VM with changes in responses of 20% or more (P ≤ 0.025). Code status responses to LW-based scenarios evidenced a nonconsensus majority (79%-83%) that was significantly affected with VMs (≥12%, P ≤ 0.004); half evidenced large changes in resuscitation decisions (49%, P < 0.001). CONCLUSIONS: Document clarity, judged by consensus response, was rarely evidenced. video message/testimonial seems to be a helpful aid to both POLST and LWs. Standardized education and training reveal opportunities to improve patient safety to ensure patient wishes.

TRIAD XI: Utilizing simulation to evaluate the living will and POLST ability to achieve goal concordant care when critically ill or at end-of-life-The Realistic Interpretation of Advance Directives.

OBJECTIVE: Utilize simulation to evaluate if living wills (LW) or POLST achieves goal concordant Care (GCC) in a medical crisis. METHODS: Nurses and resident-physicians from a single center were randomized to a clinical scenario with a living will (LW), physician orders for life sustaining treatment (POLST) or no document. Primary outcomes were resuscitation decision and time to decision. Secondary outcome was the effect of education. RESULTS: Total enrollment was 57 and less than 30% received prior training. Types of directives were linked to resuscitation decisions (P = .019). Participants randomized to "No Document" or POLST specifying "CPR" performed resuscitation. If a terminal condition presented with a POLST/ do not resuscitate-comfort measures only (DNR-CMO), 73% resuscitated. The LW or POLST specifying DNR combined with medical support resulted in resuscitations in 29% or more of the scenarios. Documents did not significantly affect median time-to-decision (P = .402) but decisions for "No Document" and POLST/CPR were at least 10 s less than other scenarios. Scenarios involving POLST DNR/Limited Treatment had the highest median time of 43 s. Prior training in LWs and POLST exerted a 10% improvement in decision making (P = .537). CONCLUSION: GCC was not always achieved with a LW or POLST. This conclusion supports prior research identifying problems with the interpretation and discordance with LW's and POLST.

TRIAD XII: Are Patients Aware of and Agree With DNR or POLST Orders in Their Medical Records.

OBJECTIVE: The aim of the study was to determine (1) whether do-not-resuscitate (DNR) orders created upon hospital admission or Physician Orders for Life-Sustaining Treatment (POLST) are consistent patient preferences for treatment and (2) patient/health care agent (HCA) awareness and agreement of these orders. METHODS: We identified patients with DNR and/or POLST orders after hospital admission from September 1, 2017, to September 30, 2018, documented demographics, relevant medical information, evaluated frailty, and interviewed the patient and when indicated the HCA. RESULTS: Of 114 eligible cases, 101 met inclusion criteria. Patients on average were 76 years old, 55% were female, and most white (85%). Physicians (85%) commonly created the orders. A living will was present in the record for 22% of cases and a POLST in 8%. The median frailty score of "4" (interquartile range = 2.5) suggested patients who require minimal assistance. Thirty percent of patients requested cardiopulmonary resuscitation and 63% wanted a trial attempt of aggressive treatment if in improvement is deemed likely. In 25% of the cases, patients/HCAs were unaware of the DNR order, 50% were unsure of their prognosis, and another 40% felt their condition was not terminal. Overall, 44% of the time, the existing DNR, and POLST were discordant with patient wishes and 38% were rescinded. Of the 6% not rescinded, further clarifications were required. Discordant orders were associated with younger, slightly less-frail patients. CONCLUSIONS: Do-not-resuscitate and POLST orders can often be inaccurate, undisclosed, and discordant with patient wishes for medical care. Patient safety and quality initiatives should be adopted to prevent medical errors.