Prevalence and risk factors of delirium in psychogeriatric outpatients.

BACKGROUND: Delirium is a serious neuropsychiatric syndrome, which requires timely treatment. However, it is easily missed, especially in older patients with premorbid cognitive disorders. OBJECTIVES: The aim of this study is to investigate the prevalence and risk factors of delirium in older outpatients with and without dementia. METHOD: We assessed 444 patients referred to the memory clinic of a psychiatric hospital between March 2013 and March 2014. Demographic information, medical history, impairments in daily living activities and referral information were registered. Patients underwent a psychiatric examination using the Delirium Rating Scale-Revised-98 and cognitive tests, a physical examination and laboratory tests. We recorded medication use and changes before and after the onset of symptoms. RESULTS: Among the 444 outpatients, 85 had probable delirium (prevalence of 19%), and 10 had subsyndromal delirium (2%). The most common triggers were infection (42%), drug-intoxication or withdrawal (22%), and metabolic/endocrine disturbance (12%). Age (OR 1.07, 95% CI 1.02-1.11) and prior delirium (OR 3.34, 95% CI 1.28-8.69) were independent non-modifiable factors associated with an increased risk of delirium. The only independent modifiable risk factor was infection (OR 17.31, 95% CI 8.44-35.49). CONCLUSIONS: A delirium was detected in one of five patients referred for dementia screening. Most patients could be treated at home. Age and prior delirium were predictive of an increased risk of delirium.

Can CT imaging improve targeting accuracy in clip-based proton therapy of ocular melanoma?

To evaluate the benefit of adding CT imaging to the simulation process of clip-based proton therapy of ocular melanomas. For thirty ocular melanoma cases, the clip position in the eye model was determined based on orthogonal radiographs as well as on a CT image set. The geometrical shift of the clips between the standard simulation process and standard simulation process with addition of CT imaging (CT-guided) was determined. The dosimetric impact was evaluated by developing treatment plans based on both the standard-process model and the CT-guided model. In 40% of the studied cases, the difference in clip position between eye models created with and without CT was less than 0.5 mm. This difference was more than 1 mm in 17% of cases. The dosimetric impact of shifts below 1 mm was low because these shifts did not exceed the planning margins. For the four cases with a shift of more than 1 mm a reduction in target coverage (ΔV99%) of -3% to -6% was observed. Changes in macula and optic-disc mean dose of up to 16% and 35% of the prescribed dose were seen when these structures abutted the target. Adding CT imaging to the simulation process is beneficial in select cases where discrepancies between the eye model and ophthalmology measurements occur or where a critical structure is located close to the target and improved localization accuracy is wanted. For the majority of patients, addition of CT imaging does not result in quantifiable changes in dosimetry. Nevertheless, CT imaging is a valuable tool in the quality control of the modeling and treatment-planning process of clip-based eye treatments.

Non-destructive mobile monitoring of microbial contaminations on meat surfaces using porphyrin fluorescence intensities.

A non-destructive mobile system for meat quality monitoring was developed and investigated for the possible application along the whole production chain of fresh meat. Pork and lamb meat was stored at 5 °C for up to 20 days post mortem and measured with a fluorescence spectrometer. Additionally, the bacterial influence on the fluorescence signals was evaluated by different experimental procedures. Fluorescence of NADH and different porphyrins could be correlated to the growth of diverse bacteria and hence used for contamination monitoring. The increase of porphyrin fluorescence started after 9 days p.m. for pork and after 2 days p.m. for lamb meat. Based on the results, a mobile fluorescence system was built and compared with the laboratory system. The corrected function of the meat slices showed a root mean square error of 1156.97 r.u. and a mean absolute percentage error of 12.59%; for lamb the values were 470.81 r.u. and 15.55%, respectively. A mobile and non-invasive measurement system would improve the microbial security of fresh meat.

Effects of different storage conditions on quality related porphyrin fluorescence signatures of pork slices.

This study evaluated the potential of fluorescence as an indicator of pork quality by determining the effects of various conditions on fluorescence signatures (excitation at 420 nm, emission at 550-750 nm). Storage of porcine musculus longissimus dorsi in PE bags led to a clear increase in porphyrin fluorescence intensity after approx. 10 d post mortem. Modified gas atmosphere (70% O(2), 30% CO(2)) inhibited the fluorescence emission of zinc protoporphyrin and protoporphyrin IX due to quenching by oxygen. Bleaching processes caused similar effects by halogen light exposure during meat storage. However, already formed signals could not be manipulated by oxygen or halogen light. Storage under vacuum reduced the quenching effects and resulted in increased fluorescence intensities. Freezing and thawing of meat samples delayed and reduced the increase in fluorescence intensity. Only minor effects could be detected at long-term frozen storage for two months. Consequently porphyrin fluorescence analysis is a potential means to indicate changes of pork quality and remaining shelf life.

Processing effects on physicochemical properties of creams formulated with modified milk fat.

Type of thermal process [high temperature, short time pasteurization (HTST) or ultra-high temperature pasteurization (UHT)] and homogenization sequence (before or after pasteurization) were examined for influence on the physicochemical properties of natural cream (20% milk fat) and creams formulated with 20% low-melt, fractionated butteroil emulsified with skim milk, or buttermilk and butter-derived aqueous phase. Homogenization sequence influenced physicochemical makeup of the creams. Creams homogenized before pasteurization contained more milk fat surface material, higher phospholipid levels, and less protein at the milk fat interface than creams homogenized after pasteurization. Phosphodiesterase I activity was higher (relative to protein on lipid globule surface) when cream was homogenized before pasteurization. Creams formulated with skim milk and modified milk fat had relatively more phospholipid adsorbed at the milk fat interface. Ultra-high-temperature-pasteurized natural and reformulated creams were higher in viscosity at all shear rates investigated compared with HTST-pasteurized creams. High-temperature, short time-pasteurized natural cream was more viscous than HTST-pasteurized reformulated creams at most shear rates investigated. High-temperature, short time-pasteurized creams had better emulsion stability than UHT-pasteurized creams. Cream formulated with buttermilk had creaming stability most comparable to natural cream, and cream formulated with skim milk and modified butteroil was least stable to creaming. Most creams feathered in a pH range of 5.00 to 5.20, indicating that they were moderately stable to slightly unstable emulsions. All processing sequences yielded creams within sensory specifications with the exception of treatments homogenized before UHT pasteurization and skim milk formulations homogenized after UHT pasteurization.

The antiphospholipid antibody syndrome.

Antiphospholipid syndrome includes elevation of either the lupus anticoagulant titer or the anticardiolipin antibody titer on two occasions, separated by 6 weeks in a patient with an episode of thrombosis. The eye is involved frequently in patients with antiphospholipid syndrome. Patients with retinal vascular disease and none of the usual risk factors for retinal vascular disease should be considered at risk for expressing this syndrome.

A case of bilateral optic neuropathy in a patient on tacrolimus (FK506) therapy after liver transplantation.

PURPOSE: To report a case of bilateral optic neuropathy in a patient receiving tacrolimus (FK 506, Prograf; Fujisawa USA, Inc, Deerfield, Illinois) for immunosuppression after orthotropic liver transplantation. METHOD: Case report. In a 58-year-old man receiving tacrolimus after orthotropic liver transplantation, serial neuro-ophthalmologic examinations and laboratory studies were performed. RESULTS: The patient had episodic deterioration of vision in both eyes, with clinical features resembling ischemic optic neuropathies. Deterioration of vision occurred despite discontinuation of the tacrolimus. CONCLUSION: Tacrolimus and other immunosuppressive agents may be associated with optic nerve toxicity.

Skeinoid fibers in mesectodermal leiomyoma of the ciliary body.

Unlike smooth muscle elsewhere in the body, the smooth muscle of the iris and ciliary body is derived from neuroectoderm (mesectoderm). Leiomyomas that arise from the ciliary body, and therefore are of mesectodermal origin, may resemble spindle cell neurogenic tumors by light microscopy. They show positive immunostaining for smooth muscle actin but negative staining for neural markers. Ultrastructurally, the cells have the features of smooth muscle cells. The authors report a typical case of mesectodermal leiomyoma in a 47-year-old woman in which skeinoid fibers, considered to be an ultrastructural marker of neurogenic spindle cell tumors, were frequent together with other ultrastructural features often seen in neuroglial cell tumors. The findings indicate that mesectodermal leiomyoma is unique in its histogenesis as well as in its morphology.

Tropicamide eyedrops cannot be used for reliable diagnosis of Alzheimer's disease.

OBJECTIVE: To evaluate the mydriatic effect of tropicamide eyedrops as a diagnostic test for Alzheimer's disease. MATERIAL AND METHODS: In a double-blind, placebo-controlled study, we assessed pupillary responses in 22 normal control subjects, 23 patients with probable Alzheimer's disease, 4 patients with isolated memory difficulty, and 6 patients with non-Alzheimer's dementia. Three separate studies were performed, the second and third on a subset of the original group. With use of infrared binocular pupillography, after 5 minutes of dark adaptation, we averaged pupil size during a 1-minute interval for baseline determinations. We then instilled 0.01% tropicamide into one eye. In the first two studies, we averaged pupil size for a 1-minute period at 5-minute intervals for 30 minutes, followed by a pupil light reflex test. In the third study, we measured pupil size every 5 minutes for 45 minutes and omitted the light reflex test. RESULTS: No significant difference was noted in pupil dilatation between normal subjects and patients with Alzheimer's disease and between patients with non-Alzheimer's dementias and the Alzheimer's disease group in all three studies. Furthermore, on reperformance of the test in the same patients, more than 50% changed from a group above or below 13% pupil dilatation (a cutoff reported to distinguish Alzheimer's disease from normal control subjects) to the opposite group. CONCLUSION: Results of this study indicate that pupil measurement after instillation of tropicamide cannot be used as a reliable diagnostic test for Alzheimer's disease. Moreover, test-retest reliability with use of dilute tropicamide eyedrops is questionable.

Clinical features and treatment of seven patients with carcinoid tumor metastatic to the eye and orbit.

PURPOSE: To understand better the clinical features, treatment, and outcome of patients with carcinoid tumors metastatic to the eye and orbit. METHODS: We studied seven patients with carcinoid tumors metastatic to the eye and orbit who were initially examined at the Mayo Clinic between 1974 and 1992. Carcinoid tumors metastasized to the choroid of six eyes of four patients and unilaterally to the orbit in three additional patients. RESULTS: Decreased vision was the most frequent initial symptom with choroidal metastases. Choroidal metastases were treated with brachytherapy only, with brachytherapy and chemotherapy, with external beam irradiation and chemotherapy, or with chemotherapy only. The duration of follow-up of these four patients ranged from seven to eight years after the diagnosis of choroidal metastases. Two of the four patients died from tumor complications 7 1/2 and seven years after the diagnosis of choroidal metastases. Proptosis and limitation of ocular motility were the most common initial signs with orbital metastases. Orbital metastases were treated with external beam irradiation and chemotherapy, with chemotherapy only, or with external beam irradiation only. Duration of follow-up of these three patients ranged from one-half to two years after the diagnosis of orbital metastases. All three patients died from tumor complications during the follow-up period. CONCLUSIONS: Because of the relatively good prospects for long-term survival in patients with carcinoid tumors metastatic to the choroid, early detection and treatment of the metastases are important.

Intravitreal large-cell lymphoma.

Large-cell (non-Hodgkin's) lymphoma may occur in the eye as a cellular infiltrate in the vitreous, uveal tract (choroid), retina, or optic nerve. Lymphomatous involvement may be limited to the eye but also is frequently associated with lesions of the central nervous system. Ocular involvement may precede involvement of the central nervous system by months or, in some cases, years. Ocular large-cell lymphoma is bilateral in approximately 80% of cases but often is asymmetric. The mean age of patients with ocular large-cell lymphoma is 60 years, and women are affected almost twice as often as men. Intravitreal large-cell lymphoma may manifest as an infiltrate of large glassy-gray cells or clusters of cells, and it may mimic uveitis or other inflammatory and infectious conditions of the eye. The diagnosis is based on cytologic and immunocytochemical studies of a vitreous biopsy specimen obtained by aspiration or by vitrectomy through the pars plana. Advances in irradiation of the eyes and the central nervous system, supplemented with corticosteroids and intrathecally and intravenously administered chemotherapeutic agents, have resulted in improvement of the dismal prognosis for patients with large-cell lymphoma.

Simultanagnosia as the initial sign of degenerative dementia.

In a study of 10 patients with degenerative brain disease that manifested as simultanagnosia, our aims were (1) to elucidate their clinical, neuropsychologic, and radiologic findings to determine whether these patients might represent a group distinguishable from those with typical Alzheimer's disease and (2) to help clinicians recognize this entity. All patients were initially examined by ophthalmologists because of visual difficulties, and the simultanagnosia remained undiagnosed until nonophthalmologic complaints developed. Optic ataxia developed in six patients, and all patients had mildly impaired eye movements. All 10 patients could identify colors appropriately. Nine patients had language deficits (anomia, decreased auditory comprehension, alexia, and agraphia) but were fluent and had relative preservation of sentence repetition, and four performed in the normal range on a test of associative fluency. Two patients scored in the normal range on memory tests, all had preserved insight, and nine had no family history of degenerative dementia. The mean age at onset of the disorder was 60 years (range, 50 to 69). Neuroimaging disclosed prominent bilateral occipitoparietal atrophy in nine patients and generalized atrophy in one. With this unusual but consistent clinical, neuropsychologic, and anatomic profile, these patients are clinically distinguishable from those with typical Alzheimer's disease, but until a specific cause has been found, we cannot be certain that they constitute a specific biologic entity. Clinicians should consider this diagnosis in relatively young patients who have slowly progressive nonocular visual complaints.

Varicella-zoster virus retinitis in a patient with AIDS-related complex: case report and brief review of the acute retinal necrosis syndrome.

Retinitis reminiscent of the acute retinal necrosis syndrome was recognized in a patient with AIDS-related complex after he had experienced several episodes of a sacral, dermatomic zosteriform eruption. Varicella-zoster virus (VZV) was subsequently recovered from cell culture of retinal tissue. The literature on VZV retinitis, including that on acute retinal necrosis, is reviewed. Dissemination of VZV infection in AIDS is also reviewed. Features that differentiate the findings and course of VZV retinitis in patients with AIDS from those in otherwise healthy adults are noted and related to potentially different pathogenic mechanisms. This unusual and recently recognized complication of herpesvirus infection may be promoted by AIDS-related immunosuppression. Acute retinal necrosis and other more-recently described forms of VZV retinitis, which have primarily been subjects of the ophthalmologic literature, merit the attention of clinicians and investigators of infectious diseases.

When do optic disc edema and peripheral neuropathy constitute poetry?

A patient with chronic, bilateral optic disc edema developed multiple systemic manifestations of POEMS syndrome (polyneuropathy, organomegaly, endocrinopathy, M-protein, skin changes). A serum immunoelectrophoresis showed an abnormal serum IgG lambda protein, and urine immunoelectrophoresis revealed a monoclonal lambda protein plus an IgG lambda fragment. Bone survey and MRI scan revealed a sclerotic lesion of the first lumbar vertebra, and lymph node biopsy showed changes consistent with Castleman's disease. Thus, his optic disc edema was the presenting feature of the POEMS syndrome and osteosclerotic myeloma.

Acquired retinal arteriovenous communications in occlusive disease of the carotid artery.

Retinal arteriovenous communications proximal to extensive areas of complete vascular closure developed in three patients with occlusive disease of the carotid arteries. In one case, the authors document the development of the arteriovenous communications through successive enlargement of small retinal vessels after progressive signs of retinal ischemia in the form of narrowed retinal arteries, venous dilation and beading, microaneurysms, retinal dot and blot hemorrhages, cotton-wool spots, and capillary nonperfusion. The development of arteriovenous communications in carotid occlusive disease has not been described previously.

Optic disk swelling with peripheral neuropathy, organomegaly, endocrinopathy, monoclonal gammopathy, and skin changes (POEMS syndrome).

We reviewed charts of patients seen at Mayo Clinic Rochester and Mayo Clinic Jacksonville to determine the importance and frequency of optic disk swelling in patients with peripheral neuropathy, organomegaly, endocrinopathy, monoclonal gammopathy, and skin changes (POEMS syndrome). A computer search identified 148 patients who were classified as having a monoclonal gammopathy and peripheral neuropathy. A review of the 148 charts disclosed that 11 patients had POEMS syndrome. Eight of these 11 patients had optic disk swelling identified by an ophthalmologist. In all eight patients, optic disk swelling was either the initial sign or was present the first time we saw the patient. Optic disk swelling may be an early sign in POEMS syndrome.

Combined gaze palsy of horizontal saccades and pursuit contralateral to a midbrain haemorrhage.

A midbrain haemorrhage, revealed by CT, caused a contralateral supranuclear horizontal gaze palsy of both saccades and foveal pursuit. These findings confirm the hypothesis that the supranuclear pathways for pursuit decussate to the contralateral midbrain and then decussate back before innervating the ipsilateral paramedian pontine reticular formation.

Open sky vitrectomy for total retinal detachment in retinopathy of prematurity.

Open sky vitrectomy was performed on 23 eyes in 18 children between 4 and 35 months of age with stage V retinopathy of prematurity (ROP). Postoperatively, the retina was reattached in the posterior pole in eight eyes (34.7%). Follow-up ranged between 7 and 55 months (average, 16 months). Prognostic factors based on preoperative findings and surgical observations are analyzed.

Conservative treatment of orbital roof blow-in fracture.

A two-year-old boy with orbital roof fracture had resolution of motility restriction without traditional surgical exploration. Orbital roof fractures may occur via a blow-in mechanism rather than by direct transmission of an outside force. As is the case with those caused by floor fractures, motility disturbances from roof fractures merit clinical observation before surgery is performed, since some motility defects will resolve spontaneously.