Ionised hypocalcaemia in emergency and acute medicine.

Acute hypocalcaemia can be life-threatening and must be diagnosed promptly. The gold-standard investigation is ionised calcium, which is measured on most blood gas analysers. Total calcium measurements are inaccurate in severe depletion even if 'corrected' or 'adjusted' for albumin. We present an illustrative case of a woman in her 30s with symptomatic hypocalcaemia and a very low ionised calcium on VBG analysis. Emergency calcium replacement was delayed due to a falsely reassuring corrected calcium result. Our discussion includes a systematic literature review on the use of ionised calcium in emergency and acute medical settings. We suggest cognitive biases that may explain clinical over-reliance on corrected calcium, and call for the inclusion of ionised calcium values in major treatment guidelines for acute hypocalcaemia.

Factitious disorder: a systematic review of 455 cases in the professional literature.

OBJECTIVE: Patients with factitious disorder (FD) fabricate illness, injury or impairment for psychological reasons and, as a result, misapply medical resources. The demographic and clinical profile of these patients has yet to be described in a sufficiently large sample, which has prevented clinicians from adopting an evidence-based approach to FD. The present study aimed to address this issue through a systematic review of cases reported in the professional literature. METHOD: A systematic search for case studies in the MEDLINE, Web of Science and EMBASE databases was conducted. A total of 4092 records were screened and 684 remaining papers were reviewed. A supplementary search was conducted via GoogleScholar, reference lists of eligible articles and key review papers. In total, 372 eligible studies yielded a sample of 455 cases. Information extracted included age, gender, reported occupation, comorbid psychopathology, presenting signs and symptoms, severity and factors leading to the diagnosis of FD. RESULTS: A total of 66.2% of patients in our sample were female. Mean age at presentation was 34.2 years. A healthcare or laboratory profession was reported most frequently (N=122). A current or past diagnosis of depression was described more frequently than personality disorder in cases reporting psychiatric comorbidity (41.8% versus 16.5%) and more patients elected to self-induce illness or injury (58.7%) than simulate or falsely report it. Patients were most likely to present with endocrinological, cardiological and dermatological problems. Differences among specialties were observed on demographic factors, severity and factors leading to diagnosis of FD. CONCLUSIONS: Based on the largest sample of patients with FD analyzed to date, our findings offer an important first step toward an evidence-based approach to the disorder. Future guidelines must be sensitive to differing methods used by specialists when diagnosing FD.