scholarly journals Serotonin syndrome due to duloxetine and tramadol use in an older patient

2020 ◽  
Vol 9 (7) ◽  
pp. 1124
Author(s):  
Olayinka A. Ogundipe
Keyword(s):  
Older Patients ◽  
Serotonin Syndrome ◽  
Case Review ◽  
Clinical Reminder ◽  
Concurrent Use ◽  
Underlying Causes ◽  
High Index Of Suspicion ◽  
Opiate Agonist ◽  
Symptoms And Signs ◽  
Suspected Adverse Drug Reactions

This case report describes a 92-year old woman presenting with acute confusion and agitation. She was initially diagnosed as having a hyperactive delirium. However, based on the presence of additional and evolving features of twitchiness, reduced coordination, palpitations and headaches, the diagnosis was re-evaluated. The clinical presentation was subsequently recognised as being that of the serotonin syndrome. In this instance, the serotonin syndrome was judged to have arisen from the concurrent use of duloxetine and tramadol. Duloxetine is an antidepressant with serotonergic properties. Tramadol is an analgesic agent with weak opiate agonist receptor effects, and also exerts reuptake inhibition of noradrenaline and serotonin. The patient’s polypharmacy was reviewed, and alongside other general supportive care measures, her symptoms and signs resolved within 48 hours. This report serves as a clinical reminder on the potential pitfalls of polypharmacy in older patients. Delirium is a common presentation in older patients, and on occasions, clearly establishing the underlying causes or risk factors may prove challenging or even elusive. The report prompts clinicians to bear in mind that the presentation and diagnosis of the serotonin syndrome requires a high index of suspicion, and that patients may present atypically. In support of pharmacovigilance reporting, two scales of causality assessment are employed in this case review. The application of these systems exemplifies their potential in promoting and enhancing objectivity when clinicians report suspected adverse drug reactions (ADRs) noted in routine clinical practice.

scholarly journals Atypical presentation of testicular torsion: a case series

2021 ◽  
Vol 27 (1) ◽  
Author(s):  
Uzodimma Ejike Onwuasoanya
Keyword(s):  
Physical Examination ◽  
Testicular Torsion ◽  
Age Groups ◽  
Case Series ◽  
Atypical Presentation ◽  
Testicular Pain ◽  
Future Fertility ◽  
Urological Emergency ◽  
High Index Of Suspicion ◽  
Symptoms And Signs

Abstract Background Testicular torsion is a urological emergency and needs urgent intervention to prevent testicular loss and impaired future fertility. It is commonly seen in the neonatal and adolescent age groups. Testicular torsion can also present outside these common age groups with uncommon symptoms and signs. We report case series of patients managed at Lily Hospitals Limited, Warri, Delta State, Nigeria with atypical presentation of testicular torsion. Case Presentation The first patient was a 35-year-old male that presented with recurrent right testicular pain of 1-year duration, described as dull aching with no constitutional symptoms, physical examination findings were not pathognomonic of testicular torsion, he had scrotal exploration with right orchidectomy and left orchidopexy. The second patient was a 39-year-old male who presented with recurrent right testicular pain of 4-days duration, described as dull aching with no constitutional symptoms. Physical examination findings were not classical for testicular torsion, he had scrotal exploration with bilateral orchidopexy. Conclusion Testicular torsion although common in neonatal and adolescent age groups can also present outside these age groups with uncommon symptoms and signs, a high index of suspicion is thus invaluable in any patient presenting with testicular pain despite the age and severity to avoid missing the diagnosis as this can lead to testicular loss.

Presentation of stroke in the older person

2020 ◽  
pp. 25-32
Author(s):  
Jagdish Sharma
Keyword(s):  
Older People ◽  
Ischaemic Stroke ◽  
Older Patients ◽  
Clinical Presentation ◽  
Cerebral Haemorrhage ◽  
Older Person ◽  
Younger Patients ◽  
Age Related ◽  
Atypical Presentations ◽  
Symptoms And Signs

‘Presentation of stroke in the older person’ outlines the varied patterns of clinical presentation of stroke in the older person, looking at common and the less common syndromes. Symptoms and signs in older people can be very subtle, often difficult to diagnose, and challenge even the most astute of clinicians. Most stroke presentations in older patients are similar to those in younger patients with respect to Oxford Community Stroke Project classification. However, atypical presentations can lead to diagnostic challenges in older patients due to the interaction between age-related cerebral and circulatory changes and comorbidities. The presentation of ischaemic stroke with its different vascular patterns, is discussed. Cerebral haemorrhage is explored in the context of its presentation patterns.

scholarly journals Sociodemographic, clinical and pharmacological profiles of medication misuse and dependence in hospitalised older patients in Norway: a prospective cross-sectional study

BMJ Open ◽  
2019 ◽  
Vol 9 (9) ◽  
pp. e031483 ◽  
Author(s):  
Socheat Cheng ◽  
Tahreem Ghazal Siddiqui ◽  
Michael Gossop ◽  
Espen Saxhaug Kristoffersen ◽  
Christofer Lundqvist
Keyword(s):  
Pain Intensity ◽  
Older Patients ◽  
Adverse Drug Events ◽  
Cross Sectional Study ◽  
University Hospital ◽  
Sectional Study ◽  
Cross Sectional ◽  
Medication Misuse ◽  
Factors Associated ◽  
Concurrent Use

ObjectivesTimely recognition of medication misuse and dependence is crucial to avoid both adverse drug events and increasing health expenditure. Yet the detection of these disorders in older people remains challenging due to the paucity of evidence on characteristics of patients at risk. This study investigates sociodemographic, pharmacological and clinical characteristics and factors associated with prolonged medication use, misuse and dependence in hospitalised older patients, focusing on three commonly prescribed central nervous system depressants (CNSDs): opioid analgesics, benzodiazepines and z-hypnotics.DesignA prospective, cross-sectional study complying with the Strengthening the Reporting of Observational Studies in Epidemiology guidelines.SettingSomatic departments of the Akershus University Hospital, Norway.Participants246 patients aged 65–90 were included.Outcome measuresProlonged use was defined as using CNSDs for ≥4 weeks. Misuse and dependence were assessed with the Diagnostic and Statistical Manual of Mental Disorders, 4th Edition criteria for substance abuse and dependence. We used descriptive statistics to report patients’ characteristics and logistic regression to demonstrate factors associated with prolonged use, and misuse or dependence.ResultsForty per cent of participants reported using CNSDs for ≥4 weeks. The odds of prolonged use were higher for patients aged 75–84 (OR=2.32, 95% CI 1.16 to 4.65) and ≥85 (OR=3.33, 95% CI 1.25 to 8.87) vs <75 years, for pain intensity (OR=1.02, 95% CI 1.01 to 1.04), and polypharmacy versus no polypharmacy (OR=5.16, 95% CI 2.13 to 12.55). The odds were lower for patients who completed secondary education (OR=0.33, 95% CI 0.13 to 0.83) compared with those with only basic education. Factors associated with misuse or dependence were pain intensity (OR=1.02, 95% CI 1.01 to 1.04) and concurrent use of ≥2 CNSDs (OR=3.99, 95% CI 1.34 to 11.88).ConclusionCNSD overuse is prevalent among hospitalised older patients, despite clear guidelines and recommendations. Our findings underline a need for stronger focus on responsible prescribing, timely detection and prevention of this issue, with special attention towards older patients, those with enhanced pain, polypharmacy and/or concurrent use of several CNSDs.Trial registration numberNCT03162081.

Spinal infections

2018 ◽  
Vol 11 (8) ◽  
pp. 448-451
Author(s):  
Shrijit Panikkar ◽  
Chitra V Nair
Keyword(s):  
Primary Care ◽  
Back Pain ◽  
Small Proportion ◽  
Delayed Diagnosis ◽  
Spinal Infection ◽  
Significant Morbidity ◽  
Presenting Symptoms ◽  
Underlying Causes ◽  
High Index Of Suspicion ◽  
Spinal Infections

Spinal infection is a rare cause of back pain that can have devastating consequences if left untreated. Since back pain can be the only symptom in early spinal infection diagnosing it is a major challenge in primary care, where back pain accounts for 6–9% of consultations. Most episodes of back pain, which has an annual incidence of 2–5%, are mechanical in nature and are self-limiting. Only a small proportion of back pain is due to serious underlying causes such as infection, neoplasia and fractures. GPs need to be aware of the presenting symptoms of spinal infection and who is at risk, as a high index of suspicion is needed to avoid the significant morbidity and mortality associated with delayed diagnosis.

Symptomatic Arnold-Chiari malformation: review of experience with 22 cases

1987 ◽  
Vol 66 (6) ◽  
pp. 812-816 ◽  
Author(s):  
William O. Bell ◽  
Edward B. Charney ◽  
Derek A. Bruce ◽  
Leslie N. Sutton ◽  
Luis Schut
Keyword(s):  
Chiari Malformation ◽  
Complete Resolution ◽  
Older Patients ◽  
Surgical Decompression ◽  
Complete Relief ◽  
Content Type ◽  
Arnold Chiari Malformation ◽  
Feeding Difficulty ◽  
Symptoms And Signs ◽  
Chiari Malformations

✓ Twenty-two patients with closed myelomeningoceles, shunted hydrocephalus, and symptomatic Arnold-Chiari malformations were studied retrospectively. Seventeen of the 22 patients were aged 6 months or younger; five patients were aged 3 to 23 years. Patients in the younger group presented with stridor, apnea, and/or feeding difficulty; those in the older group presented with hemiparesis, quadriparesis, oscillopsia, nystagmus, or opisthotonos. Fourteen of the 17 younger patients underwent surgical decompression of the Arnold-Chiari malformation: 10 within 18 days following the onset of symptoms and four on Day 19 or later. Of the 10 infants with early treatment, five eventually died secondary to continued symptoms and five survived. Of those surviving, three were asymptomatic and two had continuing symptoms but were improved over their preoperative state. Among the four patients undergoing surgery later, two died, one had lessening of stridor, and one had complete relief of symptoms. Of the three infants not undergoing decompression, two died and one eventually became asymptomatic. All five of the older patients underwent decompression and all had complete resolution of their preoperative symptoms and signs. The authors conclude that while decompression of a symptomatic Arnold-Chiari malformation may be effective in children and adults, this treatment does not always improve the clinical condition of infants. This may be the result of ischemic/hypoxic effects on the infant's brain stem, which may not be organized normally at birth.

CAPD and Pancreatitis: No Connection

1992 ◽  
Vol 12 (3) ◽  
pp. 309-316 ◽  
Author(s):  
Amit Gupta ◽  
Zheng Vuan ◽  
Elias V. Balaskas ◽  
Ramesh Khanna ◽  
Dimitrios G. Oreopoulos
Keyword(s):  
Acute Pancreatitis ◽  
Serum Amylase ◽  
Pancreatic Secretory Trypsin Inhibitor ◽  
Serum Lipase ◽  
High Index Of Suspicion ◽  
Acute And Chronic Pancreatitis ◽  
Symptoms And Signs ◽  
Capd Patient ◽  
Uncommon Complication

Autopsy studies have shown that approximately 56% of patients on long-term continuous ambulatory peritoneal dialysis (CAPD) develop various pancreatic abnormalities, such as acute and chronic pancreatitis, fibrosis, and acinar dilatation. This prevalence of anatomical abnormalities is similar to that observed in patients on hemodialysis and higher than that in those with normal renal function. However, clinical acute pancreatitis is an uncommon complication of CAPD (0.9%), and this prevalence is similar to that (1.7%) of patient son hemodialysis. We can attribute acute pancreatitis in CAPD patients to no single factor. Perhaps preexisting anatomical abnormalities of the pancreas make the CAPD patient susceptible to acute pancreatitis when exposed to a variety of physiological and non physiological influences. The diagnosis of acute pancreatitis in CAPD patients is difficult, because symptoms and signs are similar to those of dialysis-associated peritonitis. Serum amylase values three times greater than the upper limit of normal and effluent amylase greater than 100 U/L suggest the diagnosis of acute pancreatitis. Serum lipase, isoamylase, and pancreatic secretory trypsin inhibitor are not helpful. In confirming the diagnosis, a computed tomography (CT) scan is more helpful than ultrasound, although it is positive in only 50–60% of cases. One should harbor a high index of suspicion concerning acute pancreatitis if a CAPD patient presenting with suspected peritonitis has either a negative effluent culture or does not respond to antibiotic therapy.

Serotonin Syndrome Complicating Migraine Pharmacotherapy

Cephalalgia ◽  
1996 ◽  
Vol 16 (5) ◽  
pp. 323-327 ◽  
Author(s):  
NT Mathew ◽  
GE Tietjen ◽  
C Lucker
Keyword(s):  
Serotonin Receptors ◽  
Serotonin Receptor ◽  
Serotonin Syndrome ◽  
Behavioral Changes ◽  
Motor Weakness ◽  
Receptor Sites ◽  
Serotonin System ◽  
Subcutaneous Sumatriptan ◽  
Symptoms And Signs ◽  
Close Temporal Proximity

Serotonin syndrome, a condition with numerous clinical neurological manifestations, is the result of central serotonergic hyperstimulation. Features of the syndrome include mental status and behavioral changes (agitation, excitement, hypomania, obtuniation), motor system involvement (myoclonus, hemiballismus, tremor, hyperreflexia, motor weakness, dysarthria, ataxia) and autonomic symptoms (fever, chills, diarrhea). Serotonin syndrome has been reported exclusively in patients on medications for psychiatric illness and Parkinsonism, despite the fact that the putative action of many antimigraine agents also involves the serotonin system. We herein report six patients with migraine who developed symptoms suggestive of the serotonin syndrome. Five were taking one or more serotomimetic agents for migraine prophylaxis (sertraline, paroxetine, lithium, imipramine, amitriptyline). In each case the symptoms and signs developed in close temporal proximity with use of a migraine abortive agent known to interact with serotonin receptors. In three instances the agent was subcutaneous sumatriptan and, in three, intravenous dihydroergotamine. In each instance the symptoms were transiers and there was full recovery. With the ever increasing use of migraine medications active at serotonin receptor sites, cases of serotonin syndrome will likely occur more frequently. It is important that physicians creating migraine are aware of the serotonin syndrome and are able to recognize its varying presentations.

Statins Use Improves the Clinical Outcomes of Salvage Therapy in Relapsed/Refractory CLL

Blood ◽  
2012 ◽  
Vol 120 (21) ◽  
pp. 3931-3931
Author(s):  
Long Xuan Trinh ◽  
Young Kwang Chae ◽  
Preetesh Jain ◽  
Ohad Benjamini ◽  
Xuemei Wang ◽  
...  
Keyword(s):  
Overall Survival ◽  
Elderly Patients ◽  
Clinical Outcomes ◽  
Salvage Therapy ◽  
Older Patients ◽  
Conflicts Of Interest ◽  
Young Patients ◽  
The Other ◽  
Concurrent Use ◽  
The Impact

Abstract Abstract 3931 Introduction - Statins are a class of drugs used to lower cholesterol levels by inhibiting the enzyme HMG-CoA reductase. In addition, statins possess anti-inflammatory, immunomodulatory, antioxidant, and cell growth inhibitory properties. In B- CLL cells, statins induce in-vitro apoptosis (Daphne Chapman-Shimshon et-al), suggesting that statins might possess properties. We noticed a high prevalence of dyslipidemia in patients with chronic lymphocytic leukemia (CLL). However the impact of dyslipidemia and its modulation by statins on clinical outcomes of patients with CLL remains unclear. Therefore, we conducted a retrospective analysis to assess the effect of statins in patients with CLL who received salvage (fludarabine, cyclophosphamide and rituximab) FCR chemotherapy. Methods - We analyzed the clinical outcome of relapsed/refractory patients with CLL (n=284) who underwent FCR salvage therapy at our institution between 1999 and 2012. Patients who were uninterruptedly treated with statins at least one month prior to and during salvage therapy (n=35) were assigned to the statins arm, whereas the other arm consisted of 249 patients who were not treated with statins. The Cox proportional hazards regression model was used to assess the association between patient characteristics and progression-free survival (PFS) and overall survival (OS). Actual survival and PFS were estimated using the method of Kaplan-Meier, and OS and PFS were compared among two groups of patients using log-rank test. Results - All pretreatment characteristics of the patients with concurrent use of statins were similar to those who were not treated with statins except for their age. Patients in the statins arm were older: 21 patients (60%) were older than 65 compared to 74 patients of 249 (30%) in the other group (p<0.05). The median OS and PFS of all 284 patients were 3.9 years (95% CI: 3.4–4.5) and 1.74 years (95% CI: 1.6–2.3), respectively. PFS was significantly longer in patients treated with statins. Fifteen of the 35 statin-treated patients (43%) as opposed to only 36 of 249 (14%) in the non-statins group experience no disease progression. Concurrent use of statins significantly prolonged PFS. The median PFS for statin-treated v/s. untreated was 4.6 and 1.7 years, respectively (p<0.05). This significantly improved PFS was consistent in young and elderly patients. In young patients (age < 65) with statins, the median PFS was not reached whereas in patients who were not treated with statins it was 2 years (p<0.05). In older patients (age ≥ 65), PFS was significant longer with concurrent use of statins than without statins; estimated PFS were 2 and 1.6 years, respectively (p<0.05). With the median follow-up of 5 years, the median overall survival was significantly longer in patients treated with statins, with 17 of 35 (49%) patients of the statins group and 59 (24%) of 249 in patients who were not treated with statins alive at the end of study. Concurrent use of statins significantly prolonged OS with an estimated median OS for the two groups of 6.9 years and 3.9 years, respectively (p<0.05). This significantly improved OS was consistent in young and elderly patients. Young patients (age <65) with statins had a significant prolonged survival with an estimated OS of 8.6 years whereas estimated OS in young patients without statins (p<0.05) was only 4 years. In older patients (age ≥65) the median OS was significantly longer with the concurrent use of statins than without statins; estimated OS in the two subgroups were 6.9 and 2.6 years respectively, (p<0.05). Conclusions - In conclusion, concurrent use of statins significantly improved OS, PFS in relapsed/refractory CLL patients treated with salvage FCR therapy. Further studies to determine the role of statins and mechanism of action in patients with CLL are warranted. Disclosures: No relevant conflicts of interest to declare.

Pulmonary Aspiration Presenting with Generalised Convulsions

1983 ◽  
Vol 28 (4) ◽  
pp. 368-370 ◽  
Author(s):  
R. J. Northcote
Keyword(s):  
Foreign Body ◽  
Respiratory Distress ◽  
Case History ◽  
Pulmonary Aspiration ◽  
High Index ◽  
Grand Mal ◽  
High Index Of Suspicion ◽  
Epileptiform Seizures ◽  
Symptoms And Signs

Foreign body in the tracheobroncial tree is a relatively infrequent, but, potentially fatal event, requiring rapid and expert intervention. The symptoms and signs may be mistaken for asthma and pneumonia, — or, as in the case described, with grand mal epileptiform seizures. This emphasises the need to take a thorough case history, and to have a high index of suspicion in a case presenting with convulsion associated with cough, wheezing or respiratory distress.

scholarly journals Graves’ Disease

2021 ◽  
Author(s):  
Sanjay Saran
Keyword(s):  
Older Patients ◽  
Autoimmune Disorder ◽  
Organ System ◽  
Antithyroid Drugs ◽  
Graves Disease ◽  
Younger Patients ◽  
Skin Symptoms ◽  
Diffuse Goiter ◽  
Pretibial Myxedema ◽  
Symptoms And Signs

Graves’ disease (GD) is an autoimmune disorder characterized by presence of TSH receptor autoantibody. It is most common cause of hyperthyroidism worldwide. Though GD can occur any age but peak incidence is seen during adulthood in between 20 to 50 years of age. GD is more commonly seen in female. GD is primarily disease of thyroid gland but affects multi organ system i.e. heart, liver, muscle, eye and skin. Symptoms and signs are result from hyperthyroidism or a consequence of underlying autoimmunity. Weight loss, fatigue, heat intolerance, tremor, and palpitations are the most common symptoms. Diffuse goiter presents in most of younger patients with thyrotoxicosis but less common in older patients. Graves’ ophthalmopathy and pretibial myxedema are extrathyroidal manifestations of GD which results from action of TSHR autoantibodies on TSHR present onfibroblast, adipocyte and T cells in extrathyroidal tissue. Treatment of GD remains in between antithyroid drugs, radioiodine or surgery. In this review we discuss the diagnosis and management of GD.

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