Delayed neuropsychiatric syndrome after carbon monoxide poisoning: inclusion of hyperbaric oxygen therapy in the recovery protocol

The delayed neuropsychiatric syndrome can arise in the period from 4 days to 5 weeks following carbon monoxide poisoning, and is characterized by neuropsychological deficits, which in some cases become chronic. This case report describes an adult female who apparently suffered self-inflicted carbon monoxide poisoning. She was not treated with hyperbaric oxygen and developed delayed sequelae on day 20. The treatment started with 40 sessions of hyperbaric oxygen therapy and subsequently with neuropsychological rehabilitation and physiotherapy. The treatment resulted in a progressive and almost complete physical and psychological recovery as evidenced by neuropsychometric tests and diagnostic imaging performed in the follow-up. Recovery was attributed to hyperbaric oxygen therapy. Although further research is required, we propose hyperbaric oxygen therapy also in the recovery protocol in the treatment of delayed neuropsychiatric syndrome

Pneumococcal sepsis associated with adrenal apoplexy in a young woman with anorexia nervosa

BACKGROUND A crude rate of mortality of 5% has been quoted for anorexia nervosa in recent studies. Nowadays the mechanism of death is unclear and various authors recommend that any anorexia nervosa death be reported and that, where possible, an autopsy be performed. METHODS In this work we present a case of sudden death in anorexia nervosa with unexpected autopsy findings. A 21-years-old woman with long-standing anorexia nervosa, severely underweight with a body mass index of 14.47 kg/m2, has been taken to the Emergency Department in very critical conditions. Despite the attempts of resuscitation, she died shortly afterwards. Therefore an autopsy has been requested in order to clarify the causes of death. RESULTS The clinical picture, laboratory parameters, histology and microbiological investigations were consistent with pneumococcal sepsis associated adrenal apoplexy. CONCLUSIONS The cause of death in anorexia nervosa cannot reliably be established from antemortem clinical features. All anorexia nervosa deaths should be reported together with description of necropsy. This may lead to advances in the knowledge and treatment practices

Health-status outcomes with invasive or conservative care in coronary disease

BACKGROUND In the ISCHEMIA trial, an invasive strategy with angiographic assessment and revascularization did not reduce clinical events among patients with stable ischemic heart disease and moderate or severe ischemia. A secondary objective of the trial was to assess angina-related health status among these patients. METHODS We assessed angina-related symptoms, function, and quality of life with the Seattle Angina Questionnaire (SAQ) at randomization, at months 1.5, 3, and 6, and every 6 months thereafter in participants who had been randomly assigned to an invasive treatment strategy (2295 participants) or a conservative strategy (2322). Mixed-effects cumulative probability models within a Bayesian framework were used to estimate differences between the treatment groups. The primary outcome of this health-status analysis was the SAQ summary score (scores range from 0 to 100, with higher scores indicating better health status). All analyses were performed in the overall population and according to baseline angina frequency. RESULTS At baseline, 35% of patients reported having no angina in the previous month. SAQ summary scores increased in both treatment groups, with increases at 3, 12, and 36 months that were 4.1 points (95% credible interval, 3.2 to 5.0), 4.2 points (95% credible interval, 3.3 to 5.1), and 2.9 points (95% credible interval, 2.2 to 3.7) higher with the invasive strategy than with the conservative strategy. Differences were larger among participants who had more frequent angina at baseline (8.5 vs. 0.1 points at 3 months and 5.3 vs. 1.2 points at 36 months among participants with daily or weekly angina as compared with no angina). CONCLUSIONS In the overall trial population with moderate or severe ischemia, which included 35% of participants without angina at baseline, patients randomly assigned to the invasive strategy had greater improvement in angina-related health status than those assigned to the conservative strategy. The modest mean differences favoring the invasive strategy in the overall group reflected minimal differences among asymptomatic patients and larger differences among patients who had had angina at baseline

Initial invasive or conservative strategy for stable coronary disease

BACKGROUND Among patients with stable coronary disease and moderate or severe ischemia, whether clinical outcomes are better in those who receive an invasive intervention plus medical therapy than in those who receive medical therapy alone is uncertain. METHODS We randomly assigned 5179 patients with moderate or severe ischemia to an initial invasive strategy (angiography and revascularization when feasible) and medical therapy or to an initial conservative strategy of medical therapy alone and angiography if medical therapy failed. The primary outcome was a composite of death from cardiovascular causes, myocardial infarction, or hospitalization for unstable angina, heart failure, or resuscitated cardiac arrest. A key secondary outcome was death from cardiovascular causes or myocardial infarction. RESULTS Over a median of 3.2 years, 318 primary outcome events occurred in the invasive-strategy group and 352 occurred in the conservative-strategy group. At 6 months, the cumulative event rate was 5.3% in the invasive-strategy group and 3.4% in the conservative-strategy group (difference, 1.9 percentage points; 95% confidence interval [CI], 0.8 to 3.0); at 5 years, the cumulative event rate was 16.4% and 18.2%, respectively (difference, 121.8 percentage points; 95% CI, 124.7 to 1.0). Results were similar with respect to the key secondary outcome. The incidence of the primary outcome was sensitive to the definition of myocardial infarction; a secondary analysis yielded more procedural myocardial infarctions of uncertain clinical importance. There were 145 deaths in the invasive-strategy group and 144 deaths in the conservative-strategy group (hazard ratio, 1.05; 95% CI, 0.83 to 1.32). CONCLUSIONS Among patients with stable coronary disease and moderate or severe ischemia, we did not find evidence that an initial invasive strategy, as compared with an initial conservative strategy, reduced the risk of ischemic cardiovascular events or death from any cause over a median of 3.2 years. The trial findings were sensitive to the definition of myocardial infarction that was used