Case study Reduction of severe aggressive behaviour in acquired brain injury: case studies illustrating clinical use of the OAS-MNR in the management of challenging behaviours

Challenging behaviour, especially when this takes the form of aggression, may impede or prevent progress in neurorehabilitation. Despite its prevalence, the literature on management of aggression after brain injury is not extensive. It has been suggested that the 'Overt Aggression Scale-Modified for Neurorehabilitation' (OAS-MNR) could be used to help standardize future studies of aggressive behaviour. It was also suggested that this scale has sufficient properties to be useful in clinical work. In this paper, three case studies are described which attempt to illustrate the potential value of the OASMNR in neurorehabilitation. The use of the scale also provides evidence relating to the continued efficacy of the neurobehavioural model. In the first study, two cases are described in which reduction in aggression occurred through participation in individualized, needs-led holistic treatment programmes, which incorporated multiple interventions. These were based on neurobehavioural principles. In the second study, a further single case was presented which illustrated how the scale may be used to generate hypotheses regarding aggressive behaviour and to drive treatment. Causation and maintenance of aggression are discussed, especially with regard to cognitive impairment. Finally, practical points relating to the use of the OAS-MNR in clinical practice are reviewed.     

Measuring the relationship between overt aggression and expectations: a methodology for determining clinical outcomes

The presence of aggressive behaviour following traumatic brain injury imposes special challenges within rehabilitation centres. Survivors of traumatic brain injury constitute a heterogeneous population amongst whom problems with increased irritability and aggression are characteristic. There is a clear need to determine what treatment approaches might be helpful in reducing aggressive behaviour. Whilst single-case experimental methodologies including reversal and multiple baseline designs seem ideal for this purpose, the compelling need to minimize risk can compromise their deployment, especially when aggression takes the form of physical assaults on others. When this is the case, there are difficulties in assessing whether a change in aggressive behaviour represents a successful response to treatment or is simply a function of reduced demand in the environment. The contributions made to understanding the relationship between aggression and expectations made on patients participating within rehabilitation will be explored here. A possible means of quantifying demands using the Neurobehavioural Expectations Scale will be described. Three case studies are presented that suggest that a methodology that employs concurrent use of this tool with the Overt Aggression Scale — Modified for Neurorehabilitation, can enable objective evaluation to be made of the effects of rehabilitation on behaviour, without increasing risk.     

Testosteron und Psyche

Testosterone, like other steroid hormones, crosses the blood–brain barrier, and the androgen receptor is present in most parts of the human brain. Therefore, testosterone has many effects on the psyche, mainly in men but also in women. Most often discussed is its influence on sexuality, especially on desire and sexual fantasies, spontaneous nighttime erections, sexual activity, and the number of orgasms and ejaculations. Mood and energy are also testosterone related. Testosterone deficiency in male patients can lead to depressive disorders. In the past, elevated testosterone levels were seen as responsible for strongly aggressive behaviour. Some cognitive functions (spatial and mathematical sense, verbal skills) are, at least to a certain point, testosterone related. Due to the extremely complex functioning of the human brain, a scientifically exact statement regarding the true relationship between testosterone and human behaviour is not possible. On the one hand, the cause is definitively multifactorial, but on the other, testosterone is metabolised in the brain, and the metabolites act by themselves. Furthermore, a bidirectional relationship exists between hormones and human behaviour: Human behaviour is influenced by hormones, and human behaviour also has a direct influence on the levels of many hormones in the human body. Finally, much data in this field are derived from animal studies; studies on humans cannot be conducted because of ethical reasons or scientific and technical problems.     

Unusual variety of bladder urothelial carcinoma: "nest type" microlobular carcinoma: report of an anatomoclinical case and review of the literature

We report a case of nested cell carcinoma, an uncommon transitional tumor. These tumors are composed of regular cuboidal transitional cells forming small nests with minimal cytologic atypia. Despite the benign course, this tumor resembling proliferation of Brunn's nests or inverted papilloma, must be considered as an aggressive transitional tumor. Thus, morphologic criteria are needed to make the diagnosis. Because of its aggressive behaviour, the surgical therapy depends on the tumor's infiltration.     

Primary Management of Cutaneous Melanoma: Excision and Sentinel Node Biopsy

During the last decade, the treatment of primary cutaneous melanoma has considerably changed. The aggressive behaviour of this disease stimulated surgeons to perform extensive resections and manage the regional nodes in a radical way. However, numerous studies indicate that a less aggressive treatment with lesser cosmetic and functional injury is associated with a similar outcome. There is no doubt that the quality of life will be significantly improved by using narrower excision margins and by further refinements of the sentinel node technique.     

Primary management of cutaneous melanoma: excision and sentinel node biopsy

During the last decade, the treatment of primary cutaneous melanoma has considerably changed. The aggressive behaviour of this disease stimulated surgeons to perform extensive resections and manage the regional nodes in a radical way. However, numerous studies indicate that a less aggressive treatment with lesser cosmetic and functional injury is associated with a similar outcome. There is no doubt that the quality of life will be significantly improved by using narrower excision margins and by further refinements of the sentinel node technique.     

Low grade collecting duct carcinoma of the kidney. Presentation of one case and literature revision

Collecting duct renal cell carcinoma is an uncommon variant of renal carcinoma. Typically its behaviour is more aggressive than other forms of renal carcinoma and usually it is diagnosed at advanced stages. A 57-year-old man visited our hospital by right lumbar pain. Abdominal CT showed a enhanced mass on the right kidney. A right partial nephrectomy was done. Histological examination of the surgical specimen showed a low grade collecting duct carcinoma of the kidney. This is a new entity, with unknown behaviour but seems to be less aggressive than classical collecting duct carcinoma of the kidney. The clinical, radiological, pathological and immunohistochemical characteristics of this tumor are reported, and the literature is reviewed.     

Medical and legal involvement of the antisocial aggressive behaviour of the under-age person

The aggressive behaviour of the child, both the physical and the verbal one, appears due to the conflicts between the environments in which the child is incorporated, but also due to the difficulty of accommodation in a new one. The aggressive behaviour of the child could be a part of the normal way of the child development (for obtain the respect of the group or the autonomy in front of his parents or other persons), but also could be one of the elements, which denote the personality of the juvenile delinquent. The factors which are associated with the aggressive behaviour are: the disorganized family, with many children, the poor family, the alcoholism or drug-dependence of the parents, penal acts of the family members, but also factors which depends on the child: the age between 15 and 17 years old, male, sex head injuries, mental diseases. The facts produced by them could be: theft, burglary, robbery, arson, hitting, rape, sexual perversity, maiming, infanticide, murder.     

An XXYY male presenting with aggression: a case report

An abnormally tall 21-year-old Caucasoid male was referred for psychiatric assessment for pathological aggression and mental subnormality. He showed many of the phenotypic features of Klinefelter's syndrome. Cytogenetic studies revealed a 48,XXYY karyotype. The significance of the association of this karyotype with aggressive behaviour is discussed.     

Giant condyloma acuminatum (Buschke-Loewenstein tumour) of the scrotum

Summary A case of giant condyloma acuminatum of the scrotum is reported. It was initially diagnosed as a low grade squamous carcinoma. This neoplasm is closely related to Human Papillomavirus, mainly HPV 6 and HPV 11, and may be clinically indistinguishable from squamous carcinoma. The histological appearance is benign, however, its clinical behaviour is similar to verrucous carcinoma. A review of previously reported cases has been undertaken. The true significance of this lesion and management are discussed. Early aggressive therapy is recommended.     

Increased Number of Neurons Expressing Androgen Receptor in the Basolateral Amygdala of Pathologically Aggressive Dogs

The present study aimed to determine the extent to which the androgen receptor (AR) is directly involved in the hormonal modulation of pathological canine aggressive behaviour in the basolateral nuclear group (BNG) of the amygdaloid body. A stereological quantification of AR‐positive neurons was performed in the BNGs of normally behaving and aggressive male dogs. The BNG was selected because it is involved in sexual and behavioural activities that are influenced by androgens. In the aggressive dogs the BNG contained a significantly higher number of AR‐positive neurons compared with normally behaving dogs suggesting differences in androgen activity within the BNGs of both the groups. However, additional mechanisms are likely to be involved because the AR‐negative fraction of BNG neurons was also increased in the aggressive dogs. It was concluded that most of the AR was unliganded because a cytoplasmic staining pattern of AR positivity was observed in the canine BNG neurons. This indicates that genomic androgen actions, which are mediated through the AR are of minor importance in the testosterone modulation of canine aggression within the BNG. Other non‐genomic mechanisms through which androgens may exert their action in the BNG are discussed. The aromatase pathway is suggested to be the main mechanism through which testosterone exerts its action within the BNG.     

The use of lithium in the treatment of aggressive behaviours with two brain-injured individuals in a state psychiatric hospital

Brain-injured individuals often experience problems with aggression which can prevent full community reintegration. Two cases involving individuals (one 4 years, one 17 years post-injury) who had been placed in a state psychiatric hospital due to aggressive and/or self-injurious behaviours are discussed. Utilizing medication dosages and behavioural acuity indicators over a 2 year period, the authors demonstrate the efficacy of lithium carbonate in treating aggressive behaviours. Lithium, in concert with other medications, not only led to a decrease in the frequency of aggressive outbursts and in the need for restrictive and costly behaviour control techniques, but also allowed for a significant reduction in the use of neuroleptic medication in one case. The authors conclude that the use of lithium, within the context of an intensive, behavioural rehabilitation programme, may yield positive effects in the control of aggressive behaviour even in long-term post-injury cases.     

Micropapillary urothelial carcinoma of the bladder: case report and review of the literature

Micropapillary urothelial carcinoma (MCP) of the urinary bladder is an rare anatomopathology variant of aggressive behaviour. It is usually found as a high grade and stage carcinoma, and doesn't differ clinically from normal cell carcinoma of the bladder. Treatment should be early and aggressive, because radiotherapy and chemotherapy have shown limited results the therapy is surgically based. The diagnosis of this disease is required because its metastasic capacity is associate with a significantly increased mortality risk. In this study we report the case of a 64 years old man with a long development hematuria diagnosed of Micropapillary carcinoma infiltrating the bladder involving the ureter.     

Localized sarcomatoid renal carcinoma. Which factors may predict its course?

Sarcomatoid renal carcinoma constitutes an uncommon variant of renal carcinoma. Typically its behaviour is more aggressive than other forms of renal carcinoma and usually it is diagnosed at advanced stages. The main prognostic factor is the clinical stage at the time of the diagnosis. However, some cases initially are diagnosed at low stages having a poor prognosis, probably because there are other factors than the clinical stage which determinate its outcome. We report a case of sarcomatoid renal carcinoma confined inside the kidney capsule at the time of the diagnosis which had a rapidly bad progression. We review the characteristics of this tumour variant and analyse what factors, basically histological, could be helpful to predict its evolution.     

GIST (gastro-intestinal stromal tumour) of the gallbladder: a case report

The authors report a case of a gastrointestinal stromal tumour (GIST) of the gallbladder. GISTs are rare mesenchymal tumours of the gastrointestinal tract, mesentery and omentum. GISTs are characterized by the expression of the KIT protein, a transmembrane tyrosine kinase receptor for stem-cell factor. Only a few GISTs of the gallbladder have been described in the literature. The behaviour of these tumours is not fully understood but long-term survival is rare. Initial treatment consists of aggressive surgery. Radiotherapy and conventional chemotherapy have been mostly unsuccessful. More recently promising studies have been performed with Imatinib, an orally administered tyrosine kinase inhibitor, in patients with advanced disease.     

Personality and neurocognitive correlates of impulsive aggression in long-term survivors of severe traumatic brain injury

This study addresses a common outcome of severe traumatic brain injury (TBI), disinhibited aggressive behaviour. This behaviour has been classified in aggression literature as 'impulsive aggression' (IA). The purpose was to: (1) characterize those TBI patients who are likely to be an aggression risk, and (2) determine if TBI patients with IA demonstrate personality style and neurocognitive performance similar to that seen in other IA groups. Participants were 45 survivors of severe TBI (26 of whom had persisting problems with IA), who were clients of a residential brain injury treatment facility. IA participants had a higher incidence of pre-morbid aggressive behaviour, were younger, had a shorter tenure in the programine, and were more impulsive, irritable, and antisocial than the non-aggressive control participants. Unlike past research, no neurocognitive differences were found. The results are discussed in terms of the conceptualization, identification, and treatment of persisting IA in severe TBI.     

Response evaluation following neoadjuvant treatment of pancreatic cancer patients

Pancreatic ductal adenocarcinoma(PDAC) is one of the most aggressive human neoplastic entities,with a very poor prognosis characterized by a high mortality rate and short survival.This is due both to its aggressive biological behaviour and the high incidence of locally advanced stages at the time of the initial diagnosis.The limits of resectability and the role of neoadjuvant(radio) chemotherapy for PDAC management are still unclear.A recently published article by Kats et al compared the radiological,surgical and histopathological results of 129 patients with borderline resectable tumors undergoing neoadjuvant treatment followed by surgery.Although post-neoadjuvant treatment imaging implied a low response rate,a high rate of complete resections was achieved.This seems to confirm that,though radiology has made a significant progress in defining locally advanced PDAC,there is place for further improvement.In particular,the differentiation between radiotherapy-induced scarring/fibrosis and cancer-associated desmoplasia remains a clinical/radiological challenge.Though selection of patients with occult systemic disease is possible with neoadjuvant treatment,downstaging does not seem to occur frequently.Thus,development of novel,more aggressive(radio) chemotherapy regimens is required to improve prognosis of patients with locally unresectable but not systemically micro-metastasized tumors.     

GIST (Gastro-intestinal Stromal Tumour) of the Gallbladder: a Case Report

The authors report a case of a gastrointestin al stromal tumour (GIST) of the gallbladder. GlSTs are rare mesenchymal tumours of the gastrointestinal tract, mesemery and omentum. GISTs are characterized by the expression of the KIT protein, a transmembrane tyrosine kinase receptor for stem-cell factor.

Only a few GISTs of the gallbladder have been described in the literature.

The behaviour of these tumours is not fully understood but long-term survival is rare.

Initial treatment consists of aggressive surgery. Radiotherapy and conventional chemotherapy have been mostly unsuccessful. More recently promising studies have been performed with Imatinib, an orally administered tyrosine kinase inhibitor, in patients with advanced disease.