Heart failure as a serious complication of iodinated contrast-induced hyperthyroidism: case-report.

BACKGROUND: exposure to iodinated contrast media (ICM) can cause hyperthyroidism, due to disruption of thyroid hormone regulation. Although rare, it can have severe consequences and can lead to fatal complications. Current guidelines do not recommend standard laboratory testing of the thyroid function prior to ICM exposure. Prophylactic treatment of patients at higher risk of hyperthyroidism is not advised. CASE PRESENTATION: we report the case of an 82-year-old woman who developed ICM induced hyperthyroidism after undergoing a chest computed tomography (CT). One month after ICM administration she presented with pneumonia at the emergency department. Hyperthyroidism was found with concomitant tachycardia, which was hard to control. As a result of hyperthyroidism and coincidental pneumonia the patient developed heart failure and died of myocardial ischemia. CONCLUSIONS: this case report underlines the importance of close monitoring of high-risk patients after ICM exposure. Clinicians should be aware of the risk of hyperthyroidism and potential severe complications. The use of ICM needs careful consideration, especially in the elderly who suffer more often from multinodular goitre.

The added value of clinical geriatric assessment prior to geriatric rehabilitation.

BACKGROUND: Community dwelling elderly who are temporarily unable to live independently due to functional decline can be referred for geriatric rehabilitation care at a nursing home. This referral is always preceded by a comprehensive geriatric assessment (CGA) by a geriatrician in hospital to rule out an indication for clinical admission and to evaluate geriatric multimorbidity. Because there is little evidence of the effectiveness of this procedure, we aimed to evaluate the results of this assessment and to elaborate on its relevance. METHODS: All patients who were referred by their general practitioner for a CGA in our hospital prior to geriatric rehabilitation care between March and December 2016 were included prospectively. Data were analysed retrospectively. Our primary aim was to describe the percentage of patients with an indication for hospital admission. Other outcomes included new diagnostic findings from the geriatric assessment and recommendations given to the elderly care physician in the geriatric rehabilitation facility. RESULTS: Of the 32 assessed patients, 25% required admission to hospital, either due to somatic illness, mainly infections or suspected neurological disorders, needing clinical treatment, or for further diagnostics. New findings by geriatric assessment mostly concerned vitamin deficiency and infection, for which treatment recommendations were given to the elderly care physician. CONCLUSION: Geriatric assessment prior to geriatric rehabilitation referral is essential as it identifies patients needing hospital care, which cannot be provided at a nursing home. Furthermore, the assessment results in important recommendations to the elderly care physician in the geriatric rehabilitation facility.

In-Hospital Haloperidol Use and Perioperative Changes in QTc-Duration.

OBJECTIVES: Haloperidol may prolong ECG QTc-duration but is often prescribed perioperatively to hip-fracture patients. We aimed to determine (1) how QTc-duration changes perioperatively, (2) whether low-dose haloperidol-use influences these changes, and (3) which clinical variables are associated with potentially dangerous perioperative QTc-prolongation (PD-QTc; increase >50 ms or to >500 ms). DESIGN: Prospective cohort study. SETTING: Tertiary university teaching-hospital. PARTICIPANTS: Patients enrolled in a randomized controlled clinical trial of melatonin versus placebo on occurrence of delirium in hip-fracture patients. MEASUREMENTS: Data from ECGs made before and after hip surgery (1-3 days and/or 4-6 days post-surgery) were analyzed. QTc-duration was measured by hand, blinded for haloperidol and pre/post-surgery status. Clinical variables were measured at baseline. Mixed model analysis was used to estimate changes in QTc-duration. Risk-factors for PD-QTc were estimated by logistic regression analysis. RESULTS: We included 89 patients (mean age 84 years, 24% male); 39 were treated with haloperidol. Patients with normal pre-surgery QTc-duration (male ≤430 ms, female ≤450 ms) had a significant increase (mean 12 ms, SD 28) in QTc-duration. A significant decrease (mean 19 ms, SD 34) occurred in patients with prolonged pre-surgery QTc-duration (male >450ms, female >470 ms). Haloperidol-use did not influence the perioperative course of the QTc-interval (p=0.351). PD-QTc (n=8) was not associated with any of the measured risk-factors. CONCLUSION: QTc-duration changed differentially, increasing in patients with normal, but decreasing in patients with abnormal baseline QTc-duration. PD-QTc was not associated with haloperidol-use or other risk-factors. Low-dose oral haloperidol did not affect perioperative QTc-interval.

Development of an abbreviated version of the delirium motor subtyping scale (DMSS-4).

BACKGROUND: Delirium is a common neuropsychiatric syndrome with considerable heterogeneity in clinical profile. Identification of clinical subtypes can allow for more targeted clinical and research efforts. We sought to develop a brief method for clinical subtyping in clinical and research settings. METHODS: A multi-site database, including motor symptom assessments conducted in 487 patients from palliative care, adult and old age consultation-liaison psychiatry services was used to document motor activity disturbances as per the Delirium Motor Checklist (DMC). Latent class analysis (LCA) was used to identify the class structure underpinning DMC data and also items for a brief subtyping scale. The concordance of the abbreviated scale was then compared with the original Delirium Motor Subtype Scale (DMSS) in 375 patients having delirium as per the American Psychiatric Association's Diagnostic and Statistical Manual (4th edition) criteria. RESULTS: Latent class analysis identified four classes that corresponded closely with the four recognized motor subtypes of delirium. Further, LCA of items (n = 15) that loaded >60% to the model identified four features that reliably identified the classes/subtypes, and these were combined as a brief motor subtyping scale (DMSS-4). There was good concordance for subtype attribution between the original DMSS and the DMSS-4 (κ = 0.63). CONCLUSIONS: The DMSS-4 allows for rapid assessment of clinical subtypes in delirium and has high concordance with the longer and well-validated DMSS. More consistent clinical subtyping in delirium can facilitate better delirium management and more focused research effort.

Polymorphisms in the melatonin receptor 1B gene and the risk of delirium.

BACKGROUND/AIMS: A disturbed sleep-wake rhythm cycle can be seen in delirium and as melatonin regulates this cycle via melatonin receptors, genetic variations in these receptors may contribute to susceptibility to delirium. The purpose of this study was to investigate whether genetic variants in the melatonin receptor 1B (MTNR1B) gene are associated with delirium. METHODS: Elderly medical and hip surgery patients were included in the study. Five single-nucleotide polymorphisms (SNPs) were determined in the MTNR1B gene, i.e. rs18030962, rs3781638, rs10830963, rs156244 and rs4753426. RESULTS: In total, 53% of 171 hip fracture patients and 33% of 699 medical patients were diagnosed with delirium. None of the polymorphisms were found to be associated with the occurrence of delirium. CONCLUSION: Future research could focus on sequencing this gene to look for other functional SNPs in relation to delirium.

Effectiveness of melatonin treatment on circadian rhythm disturbances in dementia. Are there implications for delirium? A systematic review.

OBJECTIVE: Circadian rhythm disturbances, like sundowning, are seen in dementia. Because the circadian rhythm is regulated by the biological clock, melatonin might be effective in the treatment of these disturbances. We systematically studied the effect of melatonin treatment in patients with dementia. In addition, we elaborate on the possible effects one might expect of melatonin treatment in patients with delirium, since dementia and delirium are strongly related. Moreover, some evidence exists that sundowning in patients with dementia and the alterations in the sleep/wake cycle, seen in patients with delirium both originate from circadian rhythm disturbances. DESIGN: A systematic search of the literature, published between 1985 and April 2009, was performed using PubMed and other databases. All papers on melatonin treatment in dementia were retrieved. Effects of melatonin on circadian rhythm disturbances were scored by means of scoring sundowning/agitated behaviour, sleep quality and daytime functioning. RESULTS: Nine papers, including four randomised controlled trials (RCTs) (n = 243), and five case series (n = 87) were reviewed. Two of the RCTs found a significant improvement on sundowning/agitated behaviour. All five case series found an improvement. The results on sleep quality and daytime functioning were inconclusive. CONCLUSION: Sundowning/agitated behaviour improves with melatonin treatment in patients with dementia. There are several arguments that sundowning in patients with dementia and the alterations in the sleep/wake cycle in patients with delirium have a common background, namely a disturbance of the circadian rhythm. This suggests that melatonin treatment could also have the same positive effects in patients with delirium.