Cognitive Functions After Traumatic Brain Injury. A 30-year Follow-up Study

Many cognitive deficits after TBI (traumatic brain injury) are well known, such as memory and concentration problems, as well as reduced information-processing speed. What happens to patients and cognitive functioning after immediate recovery is poorly known. Cognitive functioning is flexible and may be influenced by genetic, psychological and environmental factors decades after TBI. The general aim of this thesis was to describe the long-term cognitive course after TBI, to find variables that may contribute to it, and how the cognitive functions after TBI are associated with specific medical factors and reduced survival. The original study group consisted of 192 patients with TBI who were originally assessed with the Mild Deterioration Battery (MDB) on average two years after the injury, during the years 1966 – 1972. During a 30-year follow-up, we studied the risks for reduced survival, and the mortality of the patients was compared with the general population using the Standardized Mortality Ratio (SMR). Sixty-one patients were re-assessed during 1998-2000. These patients were evaluated with the MDB, computerized testing, and with various other neuropsychological methods for attention and executive functions. Apolipoprotein-E (ApoE) genotyping and magnetic resonance imaging (MRI) based on volumetric analysis of the hippocampus and lateral ventricles were performed. Depressive symptoms were evaluated with the short form of the Beck depression inventory. The cognitive performance at follow-up was compared with a control group that was similar to the study group in regard to age and education. The cognitive outcome of the patients with TBI varied after three decades. The majority of the patients showed a decline in their cognitive level, the rest either improved or stayed at the same level. Male gender and higher age at injury were significant risk factors for the decline. Whereas most cognitive domains declined during the follow-up, semantic memory behaved in the opposite way, showing recovery after TBI. In the follow-up assessment, the memory decline and impairments in the set-shifting domain of executive functions were associated with MRI-volumetric measures, whereas reduction in information-processing speed was not associated with the MRI measures. The presence of local contusions was only weakly associated with cognitive functions. Only few cognitive methods for attention were capable of discriminating TBI patients with and without depressive symptoms. On the other hand, most complex attentional tests were sensitive enough to discriminate TBI patients (non-depressive) from controls. This means that complex attention functions, mediated by the frontal lobes, are relatively independent of depressive symptoms post-TBI. The presence of ApoE4 was associated with different kinds of memory processes including verbal and visual episodic memory, semantic memory and verbal working memory, depending on the length of time since TBI. Many other cognitive processes were not affected by the presence of ApoE4. Age at injury and poor vocational outcome were independent risk factors for reduced survival in the multivariate analysis. Late mortality was higher among younger subjects (age < 40 years at death) compared with the general population which should be borne in mind when assessing the need for rehabilitation services and long-term follow-up after TBI.

"Dov'è la sinistra?" Hemispatial neglect in stroke

As long as the incidence of stroke continues to grow, patients with large right hemisphere lesions suffering from hemispatial neglect will require neuropsychological evaluation and rehabilitation. The inability to process information especially that coming from the left side accompanied by the magnetic orientation to the ipsilesional side represents a real challenge for rehabilitation. This dissertation is concerned with crucial aspects in the clinical neuropsychological practice of hemispatial neglect. In studying the convergence of the visual and behavioural test batteries in the assessment of neglect, nine of the seventeen patients, who completed both the conventional subtests of the Behavioural Inattention Test and the Catherine Bergego Scale assessments, showed a similar severity of neglect and thus good convergence in both tests. However, patients with neglect and hemianopia had poorer scores in the line bisection test and they displayed stronger neglect in behaviour than patients with pure neglect. The second study examined, whether arm activation, modified from the Constraint Induced Movement Therapy, could be applied as neglect rehabilitation alone without any visual training. Twelve acute- or subacute patients were randomized into two rehabilitation groups: arm activation training or traditional voluntary visual scanning training. Neglect was ameliorated significantly or almost significantly in both training groups due to rehabilitation with the effect being maintained for at least six months. In studying the reflections of hemispatial neglect on visual memory, the associations of severity of neglect and visual memory performances were explored. The performances of acute and subacute patients with hemispatial neglect were compared with the performances of matched healthy control subjects. As hypothesized, encoding from the left side and immediate recall of visual material were significantly compromised in patients with neglect. Another mechanism of neglect affecting visual memory processes is observed in delayed visual reproduction. Delayed recall demands that the individual must make a match helped by a cue or it requires a search for relevant material from long-term memory storage. In the case of representational neglect, the search may succeed but the left side of the recollected memory still fails to open. Visual and auditory evoked potentials were measured in 21 patients with hemispatial neglect. Stimuli coming from the left or right were processed differently in both sensory modalities in acute and subacute patients as compared with the chronic patients. The differences equalized during the course of recovery. Recovery from hemispatial neglect was strongly associated with early rehabilitation and with the severity of neglect. Extinction was common in patients with neglect and it did not ameliorate with the recovery of neglect. The presence of pusher symptom hampered amelioration of visual neglect in acute and subacute stroke patients, whereas depression did not have any significant effect in the early phases after the stroke. However, depression had an unfavourable effect on recovery in the chronic phase. In conclusion, the combination of neglect and hemianopia may explain part of the residual behavioural neglect that is no longer evident in visual testing. Further research is needed in order to determine which specific rehabilitation procedures would be most beneficial in patients suffering the combination of neglect and hemianopia. Arm activation should be included in the rehabilitation programs of neglect; this is a useful technique for patients who need bedside treatment in the acute phase. With respect to the deficit in visual memory in association with neglect, the possible mechanisms of lateralized deficit in delayed recall need to be further examined and clarified. Intensive treatment induced recovery in both severe and moderate visual neglect long after the first two to first three months after the stroke.

Trauma abdominal penetrante consecutivo à corrente elétrica industrial

The authors present a case report of a victim of high power electric shock. The main electric lesion was a penetrating abdominal wound with loss of substance of the abdominal wall and an electric lesion of the hepatic segment and of the gallbladder. The surgical treatment included hepatic segmentectomy, cholecystectomy, repair of the abdominal wall with Marlex prosthesis and skin graft, besides the debridment of the lesions of extremities. The postoperative evolution was satisfactory and the follow-up for 6 months didn't show any sequelae.

Complex pulmonary aspergilloma treated by cavernostomy

Objective: To evaluate the effectiveness of cavernostomy in patients with complex fungal balls.Methods: We analyzed the medical records of patients undergoing cavernostomy between January 2005 and May 2013, evaluating: age, gender, preoperative signs and symptoms, predisposing disease, preoperative tests, location of the aspergilloma, etiologic agent, cavernostomy indication, postoperative outcome.Results: Ten patients were male. The mean age was 42.9 years (34-56). The most frequent symptom was repeated pulmonary bleeding. Cavernostomy was proposed for patients at high risk for lung resection. It was performed in 17 patients and all of them had pulmonary tuberculosis sequelae, with cavitations. The indication in all cases was hemoptysis and elimination of phlegm. The cavernostomies were performed in a single surgical procedure. In all 17 patients the cavity was left open after the withdrawal of the mycetoma. In all patients hemoptysis ceased immediately. Operative mortality was 9.5% (1).Conclusion: cavernostomy is an effective treatment alternative in patients at high risk. It may be useful in some patients with complex aspergilloma, irrespective of lung function or bilateral disease. It is technically easy, has low-risk, saves parenchyma, and may be performed in a single operative time.

Prevalence of alterations in chest computerized tomography in patients with head and neck cancer

Objective: to assess the prevalence of abnormalities found by computed tomography (CT) of the chest in patients with squamous cell carcinoma of the head and neck. Methods: we retrospectively analyzed chest CT exams of 209 patients with squamous cell carcinoma of the head and neck. The CT findings were stratified as inflammatory / infectious, parenchymal, nodular uncharacteristic and nodular metastatic / tumoral Results: alterations were diagnosed in 66.6% of patients. Of these, 25.3% represented emphysema; 18.8%, uncharacteristic micronodules; 12.9%, metastases; 11.9%, thoracic lymph node enlargements; and in 6.6% we detected active pulmonary tuberculosis or its sequelae, pneumonia or inflammatory / infectious signs and pleural thickening or effusion. Conclusion: the prevalence of exams with alterations and the considerable rate of detected metastases indicate that chest CT should be required for diagnostic and / or staging in cases of head and neck cancer.

Medico-legal litigation in Obstetrics: a characterization analysis of a decade in Portugal

PURPOSE: It was to analyse the most critical areas in Obstetrics and to suggest measures to reduce or avoid the situations most often involved in these disputes. METHODS: Obstetrics cases submitted to the Medico-legal Council since the creation of the National Institute of Legal Medicine and Forensic Sciences in 2001 until 2011 were evaluated. A comprehensive characterization, determination of absolute/relative frequencies, hypothesis of a linear trend over the years and the association between each parameter was done. RESULTS: The analysis has shown no significantly linear trend. The most common reasons for disputes were perinatal asphyxia (50%), traumatic injuries of the newborn (24%), maternal sequelae (19%) and issues related to prenatal diagnosis and/or obstetric ultrasound (5.4%). Perinatal asphyxia showed no significantly linear trend (p=0.58) and was usually related to perinatal deaths or permanent neurologic sequelae in newborn children. Traumatic injuries of the newborn, mostly related to instrumented deliveries, shoulder dystocia or vaginal delivery in breech presentation, has shown a significantly increased linear trend (p<0.001), especially related to instrumented deliveries. The delay/absence of cesarean section was the clinical procedure questioned in a significantly higher number of cases of perinatal asphyxia (68.7%) and of traumatic lesions of the newborn due to instrumented deliveries (20.5%). CONCLUSION: It is important to improve and correct theoretical/practical daily clinical performance in these highlighted areas, in order to reduce or even avoid situations that could end up in medico-legal litigations.

Aivot ja stressi

Kirjallisuusarvostelu

Epidemiology, management and outcome of facial injuries

Dental injuries are common and the incidence of maxillofacial injuries has increased over the recent decades in Finland. Accidental injuries are the global leading cause of death among children over the age of one year and among adults under the age of 40 globally. Significant resources and costs are needed for the treatment of these patients. The prevention is the most economical way to reduce trauma rates and costs. For the prevention it is crucial to know the prevalences, incidences and risk factors related to injuries. To improve the quality of treatment, it is essential to explore the causes, trauma mechanisms and management of trauma. The above mentioned was the aim of this thesis. With a large epidemiological cohort study (5737 participants) it was possible to estimate lifetime prevalence of and risk factors for dental trauma in general population (Study I). The prevalence of dental fractures was 43% and the prevalence of dental luxations and avulsions was 14%. Male gender, a history of previous non-dental injuries, mental distress, overweight and high alcohol consumption were positively associated with the occurrence of dental injuries Study II was conducted to explore the differences in type and multiplicity of mandibular fractures in three different countries (Canada, Finland and Kuwait). This retrospective study showed that the differences in mandibular fracture multiplicity and location are based on different etiologies and demographic patterns. This data can be exploited for planning of measures to prevent traumatic facial fractures. The etiology, management and outcome of 63 pediatric skull base fracture (Study III) and 20 pediatric frontobasal fracture patients (Study IV) were explored. These retrospective studies showed that, both skull base fracture and frontobasa fracture are rare injuries in childhood and although intracranial injuries and morbidity are frequent, permanent neurological or neuropsychological deficits are infrequent. A systematic algorithm (Study V) for computer tomography (CT) image review was aimed at clinicians and radiologists to improve the assessment of patients with complex upper midface and cranial base trauma. The cohort study was cross sectional and data was collected in the Turku and Oulu University Hospitals. A novel image-reviewing algorithm was created to enhance the specificity of CT for the diagnosis of frontobasal fractures. The study showed that an image-viewing algorithm standardizes the frontobasal trauma detection procedure and leads to better control and assessment. The purpose of the retrospective subcranial craniotomy study (VI) was to review the types of frontobasal fractures and their management, complications and outcome when the fracture is approached subcranially. The subcranial approach appears to be successful and have a reasonably low complication rate. It may be recommended as the technique of choice in multiple and the most complicated frontal base fractures where the endoscopic endonasal approach is not feasible.

The cognitive subscale of the "Alzheimer's Disease Assessment Scale" in a Brazilian sample

The cognitive subscale of the "Alzheimer's Disease Assessment Scale" (ADAS-Cog) is widely used for the evaluation of dementia and is very popular in dementia drug trials because of the characteristics of the scale. The objective of the present study was to adapt the ADAS-Cog for use for the Brazilian population. A major problem is that education is variable, a fact that may influence performance in cognitive evaluation. This study was conducted on a control group (CG) of 96 subjects (25 males and 71 females aged 68 ± 8.6 years) and on 44 Alzheimer's disease (AD) patients (19 males and 25 females aged 72 ± 6.4 years) with mild dementia (Clinical Dementia Rating score 1). For statistical analysis groups were divided into three educational levels: I, 0-4 years of schooling (65 CG/20 AD); II, 5-11 years of schooling (19 CG/7 AD), and III, 12 or more years of schooling (12 CG/17 AD). The battery was applied according to original instructions. Total mean score for CG and AD was 10.9 and 22.9 for level I, 7.8 and 22.4 for level II, and 6.2 and 15.4 for level III, respectively. These results indicate that our version of the ADAS-Cog is useful to identify mild dementia, though there may be an overlapping when comparing high education demented with low education non-demented subjects.

Developmental norms for the Gardner Steadiness Test and the Purdue Pegboard: a study with children of a metropolitan school in Brazil

Norms for the Gardner Steadiness Test and the Purdue Pegboard were developed for the neuropsychological assessment of children in the metropolitan area of Rio de Janeiro. A computer-generated unbiased sample of 346 children with a mean age of 9.4 years (SD = 2.76), who were attending a large normal public school in this urban area, was the subject of this study. Two boys were removed from the study, one for refusing to participate and the other due to severe strabismus. Therefore, the final sample contained 344 children (173 boys and 171 girls). Sex and age of the child and hand preferred for writing, but not ethnic membership or social class, had significant effects on performance in the Gardner Steadiness Test and the Purdue Pegboard. Girls outperformed boys. Older children performed better than younger children. However, the predictive relationship between age of the child and neuropsychological performance included linear and curvilinear components. Comparison of the present results to data gathered in the United States revealed that the performance of this group of Brazilian children is equivalent to that of US children after Bonferroni's correction of the alpha level of significance. It is concluded that sex and age of the child and hand preferred for writing should be taken into account when using the normative data for the two instruments evaluated in the present study. Furthermore, the relevance of neurobehavioral antidotes for the obliteration of some of the probable neuropsychological effects of cultural deprivation in Brazilian public school children is hypothesized.

Category fluency test: effects of age, gender and education on total scores, clustering and switching in Brazilian Portuguese-speaking subjects

Verbal fluency tests are used as a measure of executive functions and language, and can also be used to evaluate semantic memory. We analyzed the influence of education, gender and age on scores in a verbal fluency test using the animal category, and on number of categories, clustering and switching. We examined 257 healthy participants (152 females and 105 males) with a mean age of 49.42 years (SD = 15.75) and having a mean educational level of 5.58 (SD = 4.25) years. We asked them to name as many animals as they could. Analysis of variance was performed to determine the effect of demographic variables. No significant effect of gender was observed for any of the measures. However, age seemed to influence the number of category changes, as expected for a sensitive frontal measure, after being controlled for the effect of education. Educational level had a statistically significant effect on all measures, except for clustering. Subject performance (mean number of animals named) according to schooling was: illiterates, 12.1; 1 to 4 years, 12.3; 5 to 8 years, 14.0; 9 to 11 years, 16.7, and more than 11 years, 17.8. We observed a decrease in performance in these five educational groups over time (more items recalled during the first 15 s, followed by a progressive reduction until the fourth interval). We conclude that education had the greatest effect on the category fluency test in this Brazilian sample. Therefore, we must take care in evaluating performance in lower educational subjects.

Evaluation of two experimental models of hepatic encephalopathy in rats

The serious neuropsychological repercussions of hepatic encephalopathy have led to the creation of several experimental models in order to better understand the pathogenesis of the disease. In the present investigation, two possible causes of hepatic encephalopathy, cholestasis and portal hypertension, were chosen to study the behavioral impairments caused by the disease using an object recognition task. This working memory test is based on a paradigm of spontaneous delayed non-matching to sample and was performed 60 days after surgery. Male Wistar rats (225-250 g) were divided into three groups: two experimental groups, microsurgical cholestasis (N = 20) and extrahepatic portal hypertension (N = 20), and a control group (N = 20). A mild alteration of the recognition memory occurred in rats with cholestasis compared to control rats and portal hypertensive rats. The latter group showed the poorest performance on the basis of the behavioral indexes tested. In particular, only the control group spent significantly more time exploring novel objects compared to familiar ones (P < 0.001). In addition, the portal hypertension group spent the shortest time exploring both the novel and familiar objects (P < 0.001). These results suggest that the existence of portosystemic collateral circulation per se may be responsible for subclinical encephalopathy.

Long-term loss of color vision after exposure to mercury vapor

We evaluated the color vision of 24 subjects (41.6 ± 6.5 years; 6 females) who worked in fluorescent lamp industries. They had been occupationally exposed to mercury vapor (10.6 ± 5.2 years) and had been away from the source of exposure for 6.4 ± 4.04 years. Mean urinary concentration of mercury was 40.6 ± 36.4 µg/g creatinine during or up to 1 year after exposure and 2.71 ± 1.19 µg/g creatinine at the time of color vision testing or up to 1 year thereafter. All patients were diagnosed with chronic mercury intoxication, characterized by clinical symptoms and neuropsychological alterations. A control group (N = 36, 48.6 ± 11.9 years, 10 females, 1.5 ± 0.47 µg mercury/g creatinine) was subjected to the same tests. Inclusion criteria for both groups were Snellen VA 20/30 or better and absence of known ophthalmologic pathologies. Color discrimination was assessed with the Farnsworth D-15 test (D-15) and with the Lanthony D-15d test (D-15d). Significant differences were found between the two eyes of the patients (P < 0.001) in both tests. Results for the worst eye were also different from controls for both tests: P = 0.014 for D-15 and P < 0.001 for D-15d. As shown in previous studies, the D-15d proved to be more sensitive than the D-15 for the screening and diagnosis of the color discrimination losses. Since color discrimination losses were still present many years after the end of exposure, they may be considered to be irreversible, at least under the conditions of the present study.

A Brazilian family with hereditary inclusion body myopathy associated with Paget disease of bone and frontotemporal dementia

Inclusion body myopathy associated with Paget disease and frontotemporal dementia (IBMPFD) is a progressive and usually misdiagnosed autosomal dominant disorder. It is clinically characterized by a triad of features: proximal and distal myopathy, early onset Paget disease of bone (PDB), and frontotemporal dementia (FTD). It is caused by missense mutations in the valosin-containing protein (VCP) gene. We describe here the clinical and molecular findings of the first Brazilian family identified with IBMPFD. Progressive myopathy affecting the limb girdles was detected by clinical examination followed by muscle biopsy and creatine kinase measurement. PDB was suggested after anatomopathological bone examination and FTD was diagnosed by clinical, neuropsychological and language evaluations. Brain magnetic resonance revealed severe atrophy of the anterior temporal lobes, including the hippocampi. A R93C mutation in VCP was detected by direct sequencing screening in subject W (age 62) and in his mother. Four more individuals diagnosed with "dementia" were reported in this family. We also present a comprehensive genotype-phenotype correlation analysis of mutations in VCP in 182 patients from 29 families described in the literature and show that while IBM is a conspicuously penetrant symptom, PDB has a lower penetrance when associated with mutations in the AAAD1 domain and FTD has a lower penetrance when associated with mutations in the Junction (L1-D1) domain. Furthermore, the R93C mutation is likely to be associated with the penetrance of all the clinical symptoms of the triad.

Averting the legacy of kidney disease - focus on childhood

World Kidney Day 2016 focuses on kidney disease in childhood and the antecedents of adult kidney disease that can begin in earliest childhood. Chronic kidney disease (CKD) in childhood differs from that in adults, in that the largest diagnostic group among children includes congenital anomalies and inherited disorders, with glomerulopathies and kidney disease as a consequence of diabetes being relatively uncommon. In addition, many children with acute kidney injury will ultimately develop sequelae that may lead to hypertension and CKD in later childhood or in adult life. Children born early or who are small-for-date newborns have relatively increased risk for the development of CKD later in life. Persons with a high-risk birth and early childhood history should be watched closely in order to help detect early signs of kidney disease in time to provide effective prevention or treatment. Successful therapy is feasible for advanced CKD in childhood; there is evidence that children fare better than adults, if they receive kidney replacement therapy including dialysis and transplantation, although only a minority of children may require this ultimate intervention. Because there are disparities in access to care, effort is needed so that children with kidney disease, wherever they live, may be treated effectively, irrespective of their geographic or economic circumstances. Our hope is that the World Kidney Day will inform the general public, policy makers and caregivers about the needs and possibilities surrounding kidney disease in childhood.