The development of pathways for responding to patient complexity in a liaison psychiatry setting.

OBJECTIVES: The aims were to develop and operationalise a method of identifying patients at increased risk of adverse outcomes due to clinical and systems complexity within consultation-liaison psychiatry (CLP), and to formalise escalation processes for enhanced input with targeted clinical and organisational support. METHODS: The literature pertaining to methods for identifying and responding to complexity in general hospital settings was reviewed. An Escalation Tool operationalising the identification of complexity and response pathways was devised and tested. Feedback on the face validity and utility guided refinement. RESULTS: Two established tools that assess complexity, INTERMED and the Patient-Centred Accreditation method (PCAM) and a novel 'episode complexity' screening method, were identified and informed the development of a tool for identifying and responding to complexity, which was then piloted. The tool was deemed useful, notwithstanding variability in scoring. CONCLUSIONS: The Escalation Tool combined elements of existing measures to identify complexity in general hospital inpatients and guide pathways for action. It was well received and considered feasible for implementation, with local adaptation according to available resources.

Acute Unilateral Oculomotor Nerve Palsy as the Initial Presenting Sign of Nonfunctioning Apoplectic Gonadotroph Adenoma.

Pituitary macroadenoma usually presents with visual field defects. Oculomotor nerve palsy is a rare presentation, and usually a sign of para-sellar growth and cavernous sinus extension. The oculomotor nerve is more susceptible to laterally transmitted pressure by pituitary mass expansion because of its anatomical location. A slow onset oculomotor nerve palsy results from either gradual compression of the nerve in the sinus wall or direct infiltration of the nerve by the pituitary tumor. We are reporting a unique case of a 68-year-old African American patient who presented to an ophthalmology clinic with left eye complete ptosis, blurry vision, and a progressive headache for a few weeks. He was found to have a nonfunctioning pituitary adenoma (NFPA) that required urgent transnasal transsphenoidal tumor resection. The patient's ocular movements significantly improved a few days postoperatively, and repeated computed tomography (CT) of the head showed complete resection of the pituitary adenoma. The postoperative morning cortisol level was significantly low, confirming the diagnosis of secondary adrenal insufficiency. The patient was treated with corticosteroid replacement therapy.

Rare Etiology of Renal Failure in a 25-Year-Old Caucasian Man: Fabry Disease With a Novel Mutation of GLA Gene.

Fabry disease (FD) is an X-linked recessive lysosomal storage disease caused by a mutation of the galactosidase alpha (GLA) gene, leading to deficiency of α-galactosidase A (alpha-Gal A). This deficiency results in a progressive, multiorgan accumulation of glycolipids, most notably globotriaosylceramide (Gb3), leading to multiorgan failure and subsequently premature death. Gb3 accumulation in the podocytes, epithelial, and mesangial cells of the glomeruli results in progressive renal disease and eventually renal failure and hemodialysis (HD). There are two types of FD: early-onset classical type 1 and late-onset type 2. Although nearly a thousand mutations of the GLA gene have been identified, the majority of them are of unknown significance. Herein we report the case of a 25-year-old Caucasian male with no significant medical history who presented with peripheral neuropathy and end-stage renal failure, requiring HD. He was diagnosed with FD based on the electron microscopy findings of renal biopsy and severely reduced alpha-Gal A activity (<0.4 nmol/mL/hour). A novel mutation of c.281G>T; p.Cys94Phe was identified. On discharge from our facility, he was referred to a renal transplant center and genetic counseling.

COVID-19 Fears May Be Worse Than the Virus: A Case of Cardiogenic Shock Secondary to Post-Myocardial Infarction Ventricular Septum Rupture.

Since the beginning of the coronavirus disease 2019 (COVID-19) pandemic, there has been a growing and justifiable fear of catching the virus from the emergency rooms, thus decreasing the hospital visits. With Virginia State slowly reopening and HCA local hospitals resuming elective procedures, the number of emergency room visits, are recovering and increasing. We report a sad and unfortunate case of an 87-year-old female who was experiencing pressure-like chest pain but presented to the emergency room five days later out of fear of catching COVID-19 from the hospital. On presentation to the ED, she was found to have an non-ST-elevation myocardial infarction, which required urgent stenting of the left anterior descending artery. Unfortunately, several hours later, she developed fatal cardiogenic shock due to ventricular septal rupture. We are reporting this case to highlight one of the many potential bad outcomes as a result of a delay in seeking necessary medical attention due to the fear of contracting the virus.

Routine clinical motion analysis: comparison of a bespoke real-time protocol to current clinical methods.

Motion analysis (MA) hardware has recently become more accessible; however, protocols have not developed in conjunction. Routine clinical assessment mostly relies on unreliable observational methods. This study aimed to develop an MA protocol for routine clinical use and compare kinematics and reliability to the gold-standard. Ten participants completed 10 over ground walks with a comprehensive marker set (bespoke and gold-standard). Inter/intra-assessor reliability was also compared. Results demonstrated comparable kinematics. Reliability of the bespoke model was lower than the gold standard but higher than observational methods. The bespoke model can be recommended for routine clinical use to assess patient progress and function.