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SUMMARYIn this overview we discuss the role of psychiatry in managing delirium in acute hospital admissions. We briefly discuss the role psychiatry can offer in four main domains: (a) assessment; (b) management; (c) recovery; and (d) paradigm, education and research. In the assessment section we discuss accurately detecting delirium in the context of comorbid mixed neuropsychiatric syndromes, including depression and dementia, and the clinical importance of delirium subtyping. The management section briefly outlines pharmacological and non-pharmacological approaches to delirium and their evidence-based rationale. The recovery section focuses on the effect delirium can have on cognitive decline, mental health and long-term health, including functional outcome and need for institutional care after hospital discharge. Finally, we outline the role of psychiatry in delirium research and education. We hope that this article will encourage clinicians to reflect on their current practice and consider holistic and evidence-based care for this vulnerable population in the acute hospital setting.

Objectives To describe the incidence of delirium recording before and after a diagnosis of dementia is established in patients with dementia with Lewy bodies (DLB) and compare findings to a matched cohort of patients with Alzheimer's disease (AD). Design Retrospective cohort study. Setting and participants A cohort of patients with dementia from a large mental health and dementia care database in South London, linked to hospitalization and mortality data. We identified 194 patients with DLB and 1:4 matched these with 776 patients diagnosed with AD on age, gender, and cognitive status. Measures We identified delirium episodes recorded in mental health and hospital records from 1 year before to 1 year after dementia diagnosis. Using dementia diagnosis as an index date we additionally followed patients until first episode of delirium, death or a censoring point without restricting the observation period. Results Patients with DLB had significantly more episodes of delirium recorded in the year before dementia diagnosis than patients with AD (incidence rate 17.6 vs 3.2 per 100 person-years; P < .001). Whereas the incidence of recording of delirium episodes reduced substantially in patients with DLB after dementia diagnosis, it remained significantly higher than in patients with AD (incidence rate 6.2 vs 2.3 per 100 person-years; P = .032). Cox regression models indicate that patients with DLB remain at a higher risk of delirium than patients with AD after a dementia diagnosis.Conclusions/Relevance Establishing a diagnosis of dementia reduces episodes classified as delirium in patients with DLB and might lead to fewer potentially harmful interventions such as hospitalization or use of antipsychotic medication.

Clinical motor subtypes have been long recognised in delirium and, despite a growing body of research, a lack of clarity exists regarding the importance of these motor subtypes. The aims of this review are to (1) examine how the concept of motor subtypes has evolved, (2) explore their relationship to the clinical context, (3) discuss the relationship between the phenomenology of delirium and motor activity, (4) discuss the application of neurobiology to the theory of delirium motor subtypes, and (5) identify methodological issues and provide solutions for further studies.The following databases were searched: PubMed, PsychInfo, EBSCO, Medline, BioMed central and Science Direct. Inclusion criteria specified peer-reviewed research assessing delirium motor subtypes published between 1990 and 2016.Sixty-one studies met the inclusion criteria. The majority of studies (n = 50) were found to use validated psychometric tools, while the remainder (n = 11) used clinical criteria. The majority of studies (n = 45) were conducted in the medical setting, while the remainder were in the ICU/post-operative setting (n = 17).Although host sensitivities (e.g. frailty) and exogenous factors (e.g. medication exposure) may determine the type of motor disturbance, it remains unclear to what extent motor subtypes are influenced by other features of delirium. The use of more specialised tools (e.g. delirium motor subtyping scale), may enable researchers to develop an approach to delirium that has a greater nosological consistency. Future studies investigating delirium motor subtypes may benefit from enhanced theoretical considerations of the dysfunctional neural substrate of the delirious state.

Identification of myocardial viability in hypokinetic segments is important in patients with ischemic cardiomyopathy because systolic dysfunction improves with revascularization. Positron emission tomography (PET) F-18 fluoro deoxyglucose (FDG) uptake has been demonstrated as an accurate indicator of metabolically active and thus viable myocardium. F-18 FDG single photon emission computed tomography (SPECT) has recently been introduced and offers a technically easier and less costly alternative to PET imaging for determination of myocardial viability. A body of literature demonstrates that F-18 FDG SPECT can reliably be performed with SPECT hardware equipped with 511-keV collimators, which provides an accurate assessment of myocardial viability. F-18 FDG SPECT offers data similar to those offered by F-18 FDG PET and compares favorably with other imaging modalities, including rest-redistribution and stress-reinjection thallium-201 myocardial perfusion imaging, gated technetium 99m SPECT, and low-dose dobutamine echocardiography.

Cardiac motion is likely to occur during long single photon emission computed tomography acquisitions or if there is considerable patient discomfort. Motion causes data misregistration and may decrease the accuracy of interpretation of cardiac single photon emission computed tomography by introducing image artifacts, such as smearing of counts around the ventricle (“hurricane sign”), distortion and discontinuities of the ventricular walls, nonanatomic defects, and hot spots. Although motion should be avoided during data acquisition, motion correction techniques have been developed to allow for manual or semiautomated compensation of cardiac displacement and should be used when motion cannot be eliminated.

Analysis of human tumour-derived cell lines has previously resulted in the identification of novel transformation-related elements and provided a useful tool for functional studies of different genes. To establish the utility of such cell lines as indicators of change relevant to urothelial cancer, we have characterised the expression of five genes (p53, MDM2, Rb, E-cadherin, APC) within a panel of human bladder carcinoma cell lines. Using single-strand conformation polymorphism (SSCP) and direct sequencing, p53 mutations were identified in 7/15 (47%) cell lines reflecting events reported in bladder tumours. Immunohistochemical analysis of p53 in cultured cells and in paraffin-embedded sections of xenografts from the cell line panel revealed discordant results. An absence of p53 nuclear staining was associated with an exon 5 mutation in EJ and with multiple p53 mutations found in J82. Two cell lines positive for p53 staining in the absence of detectable mutation displayed overexpression of MDM2 (PSI, HT1197) in Western blot analysis. Loss or aberrant Rb expression was recorded in 5/15 (TCCSUP, SCaBER, 5637, HT1376, J82) cell lines. Absence of E-cadherin was recorded in 5/15 cell lines (TCCSUP, EJ, KK47, UM-UC-3, J82) with loss of alpha-catenin in immunoprecipitated E-cadherin complexes of CUBIII. Western blot analysis of APC revealed a truncated protein in 1/15 (CUBIII) cell lines. The characterisation of oncogenic events within this panel of human bladder carcinoma cell lines establishes a representation of change observed in bladder tumours and better defines the genotypic background in these experimental human cell models of neoplastic progression. Images Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Figure 6

Background: Urinary cytology has long been used as a noninvasive screen for the detection of urinary tract cancer but is limited by the generation of false positive and false negative results. More recently, molecular changes associated with urothelial neoplastic progression have been identified in DNA from urine sediments, demonstrating an alternative approach for identifying neoplastic change in the bladder. Purpose: The purpose of this prospective study was to determine the value of detection of H-ras (also known as HRAS) mutations in urine sediment DNA as a clinical indicator of tumor presence, recurrence, and/or progression. Methods: Urine sediments were collected from 100 patients presenting with bladder tumors, with follow-up samples collected from 19 patients. DNA extracted from urine sediments was analyzed for changes in exon 1 of the H-ras gene, using single-strand conformation polymorphism (SSCP) analysis. A representative number of aberrant H-ras/SSCP migrating bands were excised and sequenced to confirm the presence of a mutation. Human bladder specimens were obtained from patients (93 of the 100 patients initially and 18 of the 19 patients studied by follow-up) and histologically evaluated for tumor content and grade. Results: Mutations in exon 1 of the H-ras gene were detected in urine sediments from 44% (44 of 100) of the patients; concordant results were obtained by cytologic analysis, where 33% (31 of 93) of the patients displayed positive cytology. Analysis of the distribution of abnormalities with tumor grade revealed greater detection of low-grade (1-2) lesions using ras analysis (47%) compared with cytology (16%). In contrast, cytology was more effective in identifying the presence of carcinoma in situ. Combined results from these two approaches substantially increased the sensitivity of tumor detection, resulting in the identification of tumors in 60% of patients. Conclusions: Identification of H-ras mutations in DNA from urine sediments facilitates the detection of low-grade bladder tumors and, in combination with cytology, increases the overall tumor detection from 33% to 60%. Preliminary results in patient follow-up suggest that detection of H-ras mutations may have some clinical utility in detecting the presence of abnormal cells in the absence of an overt lesion following cytoscopy or positive cytology

Renal cell carcinoma with extension into the inferior vena cava is a challenging clinical problem. Despite controversy about its management, improvements in surgical technique warrant aggressive surgical resection in select patients. Acceptable perioperative morbidity, operative mortality, and 5 and 10-year survival rates justify this treatment.lS2 We report a case of right radical nephrectomy with vena caval thrombectomy with cardiopulmonary bypass and circulatory arrest using a minimal access approach to the heart. CASE REPORT A 71-year-old man presented with a large right renal tumor extending into the inferior vena cava above the level of the diaphragm, which was discovered 3 months earlier when he underwent right colectomy for colon cancer elsewhere. Medical history was otherwise notable for coronary artery bypass surgery in 1984. Computerized tomography (CT) revealed a 13 cm. mass with probable extension into the inferior vena cava. Magnetic resonance imaging confirmed a vena caval thrombus extending into the supradiaphragmatic inferior vena cava. Chest x-ray, abdominal CT, head CT and bone scan were unremarkable. The patient was initially Accepted for publication September 5, 1997. treated with angioinfarction of the renal tumor before planned surgical intervention. An echocardiogram showed good left ventricular function with an ejection fraction of 55%, evidence of mild inferior hypokinesia, no valvular abnormalities and confirmed extension of the tumor thrombus into the supradiaphragmatic inferior vena cava to the level of the right atrial junction. Cardiac catheterization revealed the vein grafts and left internal mammary artery conduit to be patent. Elective surgery was scheduled in collaboration with the Cardiothoracic Surgery Service. At surgery a chevron incision was made and the right kidney with the tumor was freed. The vena cava was dissected up to the diaphragm, which was separated from the vena cava using a Langenbach maneuver. The patient was then prepared for cardiopulmonary bypass and circulatory arrest. We used a minimally invasive right parasternal incision to expose the right atrium. An 8 cm. skin incision was made over the heads of the 3rd and 4th ribs, which were removed. The pericardium was opened and the right atrium, aorta and right superior pulmonary vein were exposed. A second 5 cm. skin incision was made under the right clavicle to expose the right subclavian artery (figs. 1 and 2). The patient was then systemically heparinized. An arterial cannula was placed in the right subclavian artery for inflow. A 2-stage venous cannula was