Valacyclovir-associated neurotoxicity (VAN) is a recognized adverse effect in elderly patients with renal impairment but remains underdiagnosed due to its nonspecific presentation and overlap with acute neurologic emergencies. We report a 78-year-old Filipino female with end-stage renal disease on maintenance hemodialysis who developed acute disorientation, agitation, vivid visual hallucinations and generalized weakness shortly after initiation of valacyclovir for herpes zoster. Given the abrupt onset of neuropsychiatric symptoms, viral encephalitis was initially considered. Magnetic resonance imaging of the brain showed no evidence of acute infarction or encephalitis, while electroencephalography demonstrated diffuse generalized slowing consistent with an encephalopathic process. Review of the medication history revealed valacyclovir dosing that exceeded recommendations for patients with end-stage renal disease. Valacyclovir was discontinued and emergent hemodialysis was initiated resulting in marked improvement in sensorium after the second session and complete resolution of symptoms after the third. This case shows VAN as an important diagnostic mimic of acute encephalopathy in elderly patients with renal failure and emphasizes the critical role of early medication review in preventing unnecessary investigations and enabling prompt, reversible management.

Human ; Female ; Aged: 65-79 Yrs Old ; Magnetic Resonance Imaging ; Kidney Failure, Chronic ; Magnetic Resonance Spectroscopy ; Electroencephalography ; Medication Review ; World Health Organization

We present a 66-year-old male presenting with sudden onset of headache. Medical decompression was done and neuroimaging of plain cranial CT angiogram (CTA) and CT venogram (CTV) showed components of subarachnoid hemorrhage, intracerebral hemorrhage and hyperdense appearance of the superior sagittal sinus and proximal left transverse sinus. The following were done to look for etiologic factors: 1. fungal swab to determine the cause of the intracerebral hemorrhage secondary to venous thrombosis as the patient presented with a chronic history of sinusitis, 2. coagulopathy workup to look for a hypercoagulable state, and 3. workup for systemic disease of autoimmune in etiology. Anticoagulation was safely initiated within several days given the regression of the intracerebral hemorrhage along with stable findings of subarachnoid hemorrhage. Here we report cerebral venous sinus thrombosis rarely presenting as acute subarachnoid hemorrhage and intracerebral hemorrhage.
Subarachnoid Hemorrhage ; Cerebral Hemorrhage

OBJECTIVE: To determine the efficacy and safety of risperidone compared to placebo and haloperidol in the treatment of behavioral and psychological symptoms of dementia. METHODOLOGY: In a systematic review of literature, all articles published from January 1990 - September 2005 that conducted double-blind, randomized controlled clinical trials evaluating the efficacy and safety of risperidone and haloperidol for the treatment of BPSD were selected. The search was performed by means of MEDLINE, PUBMED, Cochrane Library database limited to studies written in English from 1990 to 2005. Key journals and textbooks were also searched in addition to the electronic database search. References mentioned in these studies were likewise reviewed. Two reviewers independently did validity assessment. Analysis of data was done by statistical packs Revman 4.2.7 from Cochrane Collaboration and SPSS (statistical package for the social sciences) v 9.0. RESULTS: Five trials were included in this study. A total of 964 patients were evaluated. Risperidone was superior to placebo as evidenced by significant reduction in the scores of total BEHAVE-AD score (WMD = 2.97, 95% CI = 1.65 - 4.29), BEHAVE-AD aggression subscale (WMD = 1.40, 95% CI = 1.34 - 1.46), and CMAI total aggression subscale (WMD = 3.82, 95% CI = 3.04 - 4.60). Comparison of risperidone and haloperidol showed significant reduction in the total BEHAVE- AD score in patients receiving risperidone (WMD = 1.80, 95% CI = 0.43 - 3.18). Comparing the odds ratio of having an adverse effect, analysis revealed greater chance of developing somnolence (OR = 1.88, 95% CI = 1.27 - 2.77), peripheral edema (OR = 2.43, 95% CI = 1.29 - 4.59) and extrapyramidal symptoms (OR = 1.93, 95% CI = 1.04 - 3.61) with risperidone. CONCLUSION: Risperidone is effective and relatively safe in the treatment of behavioral and psychological symptoms of dementia. Higher incidence of somnolence, peripheral edema and extrapyramidal symptoms was noted with risperidone compared to placebo. Compared with haloperidol, risperidone was superior in the total BEHAVE- AD scale and showed more favorable results in the total CMAI scale, BEHAVE-AD aggression and CMAI total aggression subscales.

Human ; Male ; Female ; Aged 80 And Over ; Aged ; Middle Aged ; Patients ; Risperidone ; Haloperidol ; Dementia ; Meta-analysis

OBJECTIVE: To determine the prevalence of alcoholic use disorder among elderly non-psychiatric inpatients in a tertiary hospital and the ability of the medical staff to identify alcoholism among this specific population.
METHODOLOGY: This is a cross-sectional analytic study. Inpatients aged 65 and above were drawn from a tertiary general hospital. The Tagalog edition of the Short Michigan Alcoholism Screening Test-Geriatric version (SMAST-G) was administered to these subjects. The screened positive respondents were classified as non-hazardous, hazardous and harmful drinkers. They were also classified as either alcohol abusers or dependents based on DSM-IV-TR. The ability of the medical staff to identify alcoholism was assessed by interviewing the attending physician and reviewing the medical records of the patients.
RESULTS: The overall prevalence rate of alcoholic use disorder among elderly non-psychiatric inpatients was 18.5%, with male respondents comprising 83.3%. A strong association was observed between elderly alcohol use and male gender, higher educational attainment, age less than 75, married status, smoking status, current employment and past manual occupation. The identification rate of medical staff was computed at 41.7%, with internal medicine physicians detecting the most number of cases.
CONCLUSION: Approximately one-fifth of elderly inpatients has alcohol use disorder and has been neglected substantially by the medical staff.

Human ; Male ; Female ; Aged 80 And Over ; Aged ; Alcohol Drinking ; Alcohol-related Disorders ; Alcoholism ; Alcohols ; Diagnostic And Statistical Manual Of Mental Disorders ; Employment ; Hospitals, General ; Inpatients ; Internal Medicine ; Medical Records ; Prevalence ; Smoking ; Surveys And Questionnaires ; Tertiary Care Centers ; Aged

OBJECTIVES

To investigate and compare the morphologic effect at nerve terminals and muscle (extrafusal and intrafusal) following botulinum toxin type-A (BNTA) versus botulinum toxin-B (BNTB) among experimental rats.

METHODOLOGY

Thirty experimental rats were injected with either botulinum toxin type A (Dysport®) (n=10), Botulinum toxin B (Neurobloc®) (n=10) or placebo (n=10). The following parameters were obtained at two endpoints (Day 14 and Day 28): (a) histopathological studies that determined mean diameter and percentage of muscle fibers (type 1, 2A and 2B); (b) muscle atrophy; (c) intrafusal muscle fiber diameter (Bag 1, Bag 2, chains): (d) endplate lengths and (e) terminal innervation ratios (TIA).

RESULTS

Degeneration, necrosis, inflammatory cell infiltration, and nuclear abnormalities were not found on haematoxylin-eosin stain. On D28, a slight increase in fibrous connective tissues (using modified Gomori-trichrome stains) as well as few focal reductions in oxidative enzyme activities (seen in NADH-TA stains) were noted in both BNTA and BNTB groups. Extrafusal muscle fiber diameter measurements (using NADH-TA and ATPase stains) indicated the following changes: (a) whichever toxin is used, there was atrophy of muscle fibers on D14 and D28, compared to controls; (b) whichever toxin is used, there was prominent atrophy of muscle fibers on the injected side compared to the minimal atrophy on the non-injected side; (c) whichever toxin is used, there was more atrophy noted on D14 compared to D28; (d) whichever time point is taken, muscle fiber type 1, followed by muscle fiber type 2A showed more vulnerability to atrophy, and (e) BNTB tended to induce more muscle atrophy than BNTA at the two time points. With regard to intrafusal muscles, the following changes were found: (a) whichever is the toxin used, atrophy of intrafusal fibers on the injected side were noted at the two time points, compared to placebo; (b) whichever is the toxin used, no significant atrophy of intrafusal fibers was noted on the non-injected side at the two time points; (c) Bag1 fibers, followed by chain fibers are more vulnerable to atrophy, and (d) BNTA tended to induce more atrophy of intrafusal fibers than did BNTB at the two time points. With regard to terminal innervation patterns using silver-cholinesterase stains (SCE), BNTA and BNTB groups had higher TIA on D14 and D28, compared to placebo.

CONCLUSION

BNTA and BNTB produce neuromuscular changes comparable with one another. Both decrease the muscle strength and induce extrafusal and intrafusal muscle changes to varying degrees when compared to placebo. Spread to the opposite corresponding limb muscles occurred to a mild degree with both BTNA and BNTB, also to varying degrees.

Animals ; Botulinum Toxins ; Botulinum Toxins, Type A