Bilateral impairment of somesthetically mediated object recognition in humans

Thirty adult patients (six in each of five groups--neurologically normal, lacunar infarct-related hemiparesis, unilateral thalamic lacunar infarction, right cortical infarction with mild left hemineglect, and extensive right cortical infarction with severe left hemineglect) were asked to perform various tasks that encompassed basic and intermediate somatosensory functions and tactile and visual object recognition. Patients with thalamic and cortical infarctions had severe impairment of contralateral hand-mediated somatosensory functions in all three categories of somesthetic tasks, although patients with cortical infarction were more impaired on the object recognition task than were patients with thalamic infarction. Patients with extensive damage to the right hemisphere and severe left hemineglect also had impairment of somesthetically mediated object recognition in the ipsilateral hand despite normal basic and intermediate somatosensory function and visually mediated object recognition analogous to unilateral tactile agnosia. All other groups had normal ipsilateral tactile object recognition.     

脑血管病患者失认症的神经心理学研究

为了解脑血管病患者失认症的类型与半球侧向性,对35例经影像学证实为单一病灶的脑血管病患者进行了汉语失语症检查法及自行设计的失认症检查法测试。结果显示：左半球组出现了物体、图画、色彩的失认,失认性失算,听失认,触觉失认,忽视,地理失定向,身体失认和病觉缺失;右半球组出现了色失认,忽视,地理失定向和病觉缺失。结论：大多数右利手患者的视觉、听觉、触觉、身体认知的优势半球位于左侧大脑半球;右半球可以产生色失认;忽视、病觉缺失在任何半球病变均可产生,右半球的机率高于左半球     

Behavioral Problems of Seniors in an Emergency Department

Background

Behavioral disorders are frequent in seniors with cognitive impairments. The ailment responsible for presentation to the Emergency Department (ED), in combination with preexisting conditions, can bring about a temporary cognitive disturbance or worsen an existing cognitive disturbance, thus increasing the frequency of behavioral disorders.

Study Objectives

The purpose of this research was to investigate whether there is any connection between pain, cognitive impairment, time in the ED, presence or absence of a supportive escort, and behavioral disorders exhibited by a senior.

Methods

The study sample consisted of 140 seniors aged 69 years and older who visited the ED. Data collected included personal data, presence or absence of an escort, length of stay in the ED, and formal reproducible evaluation of cognition, behavior, and pain.

Results

Behavioral disorders were found to be present in 18% of the total sample and in 25% of the group of seniors who suffered from cognitive impairment. The presence of cognitive impairment was found to increase by almost sevenfold the risk of a behavioral disorder. Presence of severe pain increased the risk of a behavioral disorder even more (odds ratio 63). Seniors with cognitive impairment who spent a longer-than-average time period in the ED exhibited behavioral disorders that were more severe than disorders in seniors without cognitive impairment. There was no moderating effect on behavioral disturbances by the presence of a supportive escort observed.

Conclusions

The findings of this study suggest that the risk of behavioral disorders in seniors attending the ED may be predicted by screening them for cognitive impairment and pain, and by monitoring the time period they are in the ED.     

Patterns of cortical reorganization parallel impaired tactile discrimination and pain intensity in complex regional pain syndrome

In the complex regional pain syndrome (CRPS), several theories proposed the existence of pathophysiological mechanisms of central origin. Recent studies highlighted a smaller representation of the CRPS-affected hand on the primary somatosensory cortex (SI) during non-painful stimulation of the affected side. We addressed the question whether reorganizational changes can also be found in the secondary somatosensory cortex (SII). Moreover, we investigated whether cortical changes might be accompanied by perceptual changes within associated skin territories. Seventeen patients with CRPS of one upper limb without the presence of peripheral nerve injuries (type I) were subjected to functional magnetic resonance imaging (fMRI) during electrical stimulation of both index fingers (IFs) in order to assess hemodynamic signals of the IF representation in SI and SII. As a marker of tactile perception, we tested 2-point discrimination thresholds on the tip of both IFs. Cortical signals within SI and SII were significantly reduced contralateral to the CRPS-affected IF as compared to the ipsilateral side and to the representation of age- and sex-matched healthy controls. In parallel, discrimination thresholds of the CRPS-affected IF were significantly higher, giving rise to an impairment of tactile perception within the corresponding skin territory. Mean sustained, but not current pain levels were correlated with the amount of sensory impairment and the reduction in signal strength. We conclude that patterns of cortical reorganization in SI and SII seem to parallel impaired tactile discrimination. Furthermore, the amount of reorganization and tactile impairment appeared to be linked to characteristics of CRPS pain.     

重症脑功能损伤并发多器官功能障碍及其预后

目的 :了解脑损伤并发多器官功能障碍的发生发展规律 ,为加强多器官系统功能的保护与治疗提供依据。方法 :急性脑功能损伤 189例 ,按格拉斯哥昏迷评分 (GCS)分为重症组 (131例 )和非重症组 (5 8例 ) ,对 2组进行各器官功能障碍的比较性研究。结果 :重症组 4个脑外器官功能障碍高于非重症组 (P<0 .0 5 )。重症组器官功能障碍率最高的是代谢功能紊乱 (高血糖 6 6 .3% ,低蛋白血症 2 8.3% )和肺功能障碍 (6 4 .9% ) ,其次是胃肠功能障碍 (49.6 % )和肾功能障碍 (16 .8% )。重症组并发严重感染的问题更加突出 (77.1% ) ,特别是下呼吸道感染。重症组符合多器官功能障碍综合征 (MODS)诊断标准的占 80 .1% ,脑外 2～ 4个器官损伤的例数最多 ,占 MODS的 85 .7% ,器官损伤数目越多 ,预后越差。结论 :重症脑功能损伤的监测与救治必须着眼于整个机体多器官系统。     

以听觉失认为首发症状的脑卒中康复4例报道

目的 分析卒中后听觉失认的临床特点、诊治和康复。方法 回顾性分析2016年1月至2018年8月4例以听觉失认为首发症状的脑卒中住院患者。结果 4例患者均以听觉障碍起病,并发肢体运动功能障碍、言语障碍等,既往有一次或多次脑血管病史,检查后确诊为卒中后听觉失认。经综合康复,所有患者运动功能恢复良好,可独立步行,日常生活活动能力改善,部分患者环境音辨别改善,但言语听理解能力改善不明显。结论 卒中后听觉失认临床少见,预后不良,应全面评估,有针对性地行言语感知训练,并加强非语言交流方式训练,提高交流实用性。     

Depression in painful chronic disorders: The role of pain and conflict about pain

Chronic pain severity, the responses of the significant other to the patient's pain, and social network relationships were investigated for their contributions to depression among patients with myofascial pain disorders (N= 67) and arthritis (N= 83). Interview data were gathered using the Beck Depression Inventory, McGill Pain Inventory, Multidimensional Pain Inventory, and Interpersonal Relationships Inventory. Patients with myofascial pain disorders reported significantly more severe depression and pain, more conflict about their pain, and more network conflict than those with arthritis. They also reported less network social support. After controlling for the type of painful chronic disorder, multiple linear regression analyses indicated that more severe depression was significantly associated with more severe pain, conflict about pain, and less network social support. Conflict about pain may increase the risk of depression for patients with chronic painful disorders. Patients with myofascial pain disorders, however, may experience more conflict about their pain because of the absence of objective physical findings that corroborate the report of pain.     

卒中后认知障碍程度对摄食-吞咽功能影响的临床研究

目的：研究脑卒中后认知障碍程度对摄食-吞咽功能的影响。方法：选取脑卒中后认知障碍患者60例,根据蒙特利尔认知评估量表（MOCA）将入组患者分为轻、中、重度3组。根据电视透视吞咽造影检查（VFSS）结果及24h入量,筛选并统计各组中存在摄食-吞咽障碍的患者,比较3组患者摄食-吞咽障碍发生率。同时,对三组患者进行认知-摄食训练,训练周期为8周,以24h入量、吞咽障碍造影评分量表（VDS）得分、口腔运送时间（OTT）,软腭上抬时间（SET）为评定标准,比较各组摄食-吞咽障碍患者训练前后的摄食-吞咽功能。结果：经统计学分析,3组患者摄食-吞咽障碍的发生率不同（P<0.05）,重度认知障碍患者更易发生摄食-吞咽障碍。训练后组内比较,中重度认知障碍患者的24h入量、VDS分值、OTT、SET均较前改善(P<0.05),轻度患者的24h入量、OTT也较前有所改善（P<0.05）;组间比较,训练前重度认知障碍患者的24h入量、VDS分值、OTT较轻、中度组差（P<0.05）,轻度患者的SET较中重度组好;训练后,轻度组相关摄食-吞咽功能指标结果最佳（P<0.05）;轻中度组较重度组指标改善更显著,差异有统计学意义（P<0.05）。结论：认知障碍程度对卒中后患者的摄食-吞咽功能及康复治疗效果存在显著影响。认知障碍程度越重,摄食-吞咽障碍发生率越高,且患者的摄食-吞咽功能越差;认知障碍程度越轻,摄食-吞咽功能改善越明显。     

脑卒中患者的知觉功能评测：附58例报告

根据目前国外常用的评测方法结合汉语习惯制定了一组评测表格,评测了58例住院脑卒中患者,结果发现知觉功能障碍发病率为41.38％:其中结构功能障碍24.14％,单侧忽略症5.17％,失用症3.45％,颜色失认症1.72％,面容失认症6.90％;时间、方向定向力障碍12.07％;知觉功能障碍同病变部位有明显关系;知觉功能障碍对日常生活活动能力有较大影响。     

重金属中毒所致周围神经损害的电生理研究

目的：探讨处于重金属环境中的作业工人急、慢性中毒性周围神经损害的电生理改变。方法：应用常规肌电图技术对30例重金属接触者进行肌电图(EMG)、神经传导速度(NCV)检测。结果：30例患者的电生理检查均呈周围神经损害．其中急性起病18例．以轴索损害为主；慢性蓄积性中毒12例，以脱髓鞘损害为主；电生理改变下肢较上肢明显．感觉神经传导异常重于运动神经传导。结论：电生理学检查对研究重金属中毒所致的周围神经损害提供了重要的客观依据。可作为临床诊断、鉴别诊断以及了解病损程度的动态随访指标。     

What vs. where in touch: an fMRI study

Two streams have been identified in cortical visual processing: a ventral stream for form, color, and features, and a dorsal stream for spatial characteristics and motion. We investigated whether similar "what" and "where" dissociations of function exist for human somatosensory processing. Using identical stimuli and hand movements, subjects either performed tactile object recognition (TOR) and ignored location or performed tactile object localization (LOC) and ignored identity. A matched-movement control task separated activation associated with sensorimotor input from higher-level cognitive contributions. Results confirmed separate processing streams for TOR and LOC. TOR activated the frontal pole as well as bilateral inferior parietal and left prefrontal regions involved in tactile feature integration and naming. LOC activated bilateral superior parietal areas involved in spatial processing. The dissociation of object and spatial processing streams appears to be a modality general organizational principle in the brain.     

不同脑半球损伤患者认知功能障碍的比较

目的探讨左、右大脑半球损伤患者在认知功能障碍方面的特点。方法用失语症筛查表、洛文斯顿作业疗法用认知评定成套测验 (LOTCA)对 5 5例左脑损伤患者和 43例右脑损伤患者的认知功能进行评定。结果右脑损伤患者组在地点定向、重叠图形识别、空间知觉、运用能力等方面的成绩明显高于左脑损伤患者组 (P <0 0 0 1— 0 0 0 5 ) ,而在形状视认、视运动组织等方面的成绩则明显低于左脑损伤患者组 (P <0 0 0 1— 0 0 2 ) ;右脑损伤后出现时间定向障碍、形状失认、图形背景分辨障碍、单侧忽略、注意力障碍的可能性明显多于左侧脑损伤 (P <0 0 0 5— 0 0 2 5 ) ,而出现失语、意念运动性失用的可能性明显少于左侧脑损伤 (P <0 0 0 5— 0 0 1) ;左右脑损伤后出现地点定向障碍、物体失认、颜色失认、空间失认、运用失用、结构性失用、思维障碍等方面的可能性无明显差异 (P >0 0 5 )。结论左右脑损伤后患者出现的认知功能障碍有其特征性表现     

睡眠节律紊乱与阿尔兹海默病研究进展

认知功能损害患者睡眠障碍患病率高,表现形式多样,主要包括：失眠、日间过度思睡、睡眠呼吸障碍、异态睡、不宁腿综合征、睡眠节律紊乱等。阿尔茨海默病(Alzheimer"s disease,AD)是最常见的认知损害类型,73%的中国汉族AD患者伴有睡眠障碍,其中53%伴有不同程度的睡眠节律紊乱。AD患者睡眠障碍在病程中后期较为突出,所以一直以来睡眠节律紊乱都被认为是AD相关神经退行性变的结果,例如“日落现象”,患者一到傍晚就焦虑不安、难以入睡,而白天则睡眠过多。但近期研究表明,睡眠节律紊乱很可能参与AD发生的始动环节。国外前瞻性的随访研究发现,睡眠节律紊乱的认知正常老年人群,在5-10年后更容易发生AD。目前,关于睡眠节律紊乱究竟通过何种途径促使神经系统退行性变发生的研究尚不深入,本文将回顾睡眠节律紊乱引发AD相关病理、生物标记物变化的研究报道。     

Thermal and tactile sensory deficits and allodynia in a nerve-injured patient: a multimodal psychophysical and functional magnetic resonance imaging study

OBJECTIVE: A case study was conducted to examine a patient with chronic neuropathic pain of the right foot following peripheral nerve injury and characterize associated sensory abnormalities. METHODS: Multimodal psychophysical examination of the patient's affected and nonaffected foot included thermal sensibility, dynamic touch, and directional sensibility. In addition, we used functional magnetic resonance imaging to study cortical representation of brush-evoked allodynia. RESULTS: Detailed psychophysical examination revealed substantial deficits in warm, cool, and tactile perception on the injured foot. These findings indicated severe dysfunction of perceptual processes mediated by A beta, A delta, and C fibers. Despite reduced tactile perception, light touch evoked a deep burning pain in the foot. Functional magnetic resonance imaging during brushing of the patient's injured foot showed that tactile allodynia led to activation of several cortical regions including secondary somatosensory cortex, anterior and posterior insular cortex, and anterior cingulate cortex. Brushing of the patient's nonaffected foot led to fewer activated regions. DISCUSSION: The profound sensory disturbances suggest a possible deafferentation type of tactile allodynia mediated by changes within the central nervous system, such as a disruption of normal tactile or thermal inhibition of nociception. The functional magnetic resonance imaging data suggest that tactile allodynia is represented in similar brain regions as experimental pain.     

Current termination of resuscitation (TOR) guidelines predict neurologically favorable outcome in Japan

Background

It is unclear whether the basic life support (BLS) and advanced life support (ALS) pre-hospital termination of resuscitation (TOR) rules developed in North America can be applied successfully to patients with out-of-hospital cardiac arrest (OHCA) in other countries.

Objectives

To assess the performance of the BLS and ALS TOR in Japan.

Methods

Retrospective nationwide, population-based, observational cohort study of consecutive OHCA patients with emergency responder resuscitation attempts from 1 January 2005 to 31 December 2009 in Japan. The BLS TOR rule has 3 criteria whereas the ALS TOR rule includes 2 additional criteria. We extracted OHCA patients meeting all criteria for each TOR rule, and calculated the specificity and positive predictive value (PPV) of each TOR rule for identifying OHCA patients who did not have neurologically favorable one-month survival.

Results

During the study-period, 151,152 cases were available to evaluate the BLS TOR rule, and 137,986 cases to evaluate the ALS TOR rule. Of 113,140 patients that satisfied all three criteria for the BLS TOR rule, 193 (0.2%) had a neurologically favorable one-month survival. The specificity of BLS TOR rule was 0.968 (95% CI: 0.963–0.972), and the PPV was 0.998 (95% CI: 0.998–0.999) for predicting lack of neurologically favorable one-month survival. Of 41,030 patients that satisfied all five criteria for the ALS TOR rule, just 37 (0.1%) had a neurologically favorable one-month survival. The specificity of ALS TOR rule was 0.981 (95% CI: 0.973–0.986), and the PPV was 0.999 (95% CI: 0.998–0.999) for predicting lack of neurologically favorable one-month survival.

Conclusions

The prehospital BLS and ALS TOR rules performed well in Japan with high specificity and PPV for predicting lack of neurologically favorable one-month survival in Japan. However, the specificity and PPV were not 1000 and we have to develop more specific TOR rules.     

High prevalence of vasomotor reflex impairment in newly diagnosed leprosy patients

BACKGROUND: Initial nerve damage in leprosy occurs in small myelinated and unmyelinated nerve fibers. Early detection of leprosy in the peripheral nervous system is challenging as extensive nerve damage may take place before clinical signs of leprosy become apparent. PATIENTS AND METHODS: In order to determine the prevalence of, and factors associated with, peripheral autonomic nerve dysfunction in newly diagnosed leprosy patients, 76 Brazilian patients were evaluated prior to treatment. Skin vasomotor reflex was tested by means of laser Doppler velocimetry. Blood perfusion and reflex vasoconstriction following an inspiratory gasp were registered on the second and fifth fingers. RESULTS: Vasomotor reflex was impaired in at least one finger in 33/76 (43%) patients. The fifth fingers were more frequently impaired and suffered more frequent bilateral alterations than the second fingers. Multivariate regression analysis showed that leprosy reaction (adjusted odds ratio = 8.11, 95% confidence interval: 1.4-48.2) was associated with overall impaired vasomotor reflex (average of the four fingers). In addition, palmar erythrocyanosis and an abnormal upper limb sensory score were associated with vasomotor reflex impairment in the second fingers, whereas anti-phenolic glycolipid-I antibodies, ulnar somatic neuropathy and a low finger skin temperature were associated with impairment in the fifth fingers. CONCLUSIONS: A high prevalence of peripheral autonomic dysfunction as measured by laser Doppler velocimetry was observed in newly diagnosed leprosy patients, which is clinically evident late in the disease. Autonomic nerve lesion was more frequent than somatic lesions and was strongly related to the immune-inflammatory reaction against M. leprae.     

Post-traumatic headache: facts and doubts

The International Classification of Headache Disorders does not separate the moderate from severe/very severe traumatic brain injury (TBI), since they are all defined by Glasgow coma scale (GCS) < 13. The distinction between the severe and very severe TBI (GCS < 8) should be made upon coma duration that in the latter may be longer than 15 days up to months in the case of vegetative state. Post-traumatic amnesia duration may double the coma duration itself. Therefore, the 3-month parameter proposed to define the occurrence or resolution of post-traumatic headache (PTH) appears inadequate. Following TBI, neuropathic pain, central pain, thalamic pain, combined pain are all possible and they call for proper pharmacological approaches. One more reason for having difficulties in obtaining information about headache in the early phase after regaining consciousness is the presence of concomitant medications that may affect pain perception. Post-traumatic stress disorder (PTSD) develops days or weeks after stress and tends to improve or disappear within 3 months after exposure; interestingly, this spontaneous timing resembles that of PTH. In our experience the number of TBI patients with PTH at 1-year follow-up is lower in those with longer coma duration and more severe TBI. Cognitive functioning evaluated after at least 12 months from TBI, showed mild or no impairment in these patients with severe TBI and PTH, whereas they have psychopathological changes, namely anxiety and depression. The majority of patients with PTH after severe/very severe TBI had skull fractures or dural lacerations and paroxystic EEG abnormalities. The combination of psychological changes (depression and anxiety) and organic features (skull fractures, dural lacerations, epileptic EEG abnormalities) in PTH may be inversely correlated with the severity of TBI, with prevalence of psychological disturbances in mild TBI and of organic lesions in severe TBI. On the other hand, only in severe TBI patients with good cognitive recovery the influence of the psychopathological disorders may play a role. In fact, the affective pain perception is probably related to the integrity of cognitive functions as in mild TBI and in severe TBI with good cognitive outcome.     

睡眠节律紊乱导致阿尔兹海默病相关机制的研究进展

认知功能损害患者睡眠障碍患病率高,表现形式多样,主要包括失眠、日间过度思睡、睡眠呼吸障碍、异态睡、不宁腿综合征、睡眠节律紊乱等。阿尔茨海默病(Alzheimer disease,AD)是最常见的认知损害类型。73%的中国汉族AD患者伴有睡眠障碍,其中53%伴有不同程度的睡眠节律紊乱。AD患者睡眠障碍在病程后期较为突出,因此睡眠节律紊乱一直被认为是AD相关神经退行性变的结果,如"日落现象"。但近期研究表明,睡眠节律紊乱很可能参与AD发生的始动环节。国外前瞻性随访研究发现,认知正常老年人群睡眠节律紊乱发生5年后更易发生AD。目前,关于睡眠节律紊乱通过何种途径促使神经系统退行性变发生的研究尚不深入。本文对睡眠节律紊乱引发AD相关病理、生物标志物变化进而导致AD发生的机制作一综述。     

抗N-甲基-D-天冬氨酸受体脑炎八例分析

目的：探讨抗N-甲基-D-天冬氨酸受体（NMDAR）脑炎患者的临床表现、辅助检查特点、治疗和预后。 方法：回顾性分析我院8例确诊为抗NMDAR脑炎患者的临床资料。结果：5例患者出现前驱症状;所有患者 临床症状均出现快速进展的精神行为异常、认知障碍,4例为首发症状,此外表现有言语障碍、癫痫发作、运 动障碍、意识水平下降及自主神经功能障碍等;8例患者脑脊液抗NMDAR抗体阳性,3例头MRI检查显示异 常病灶,位于大脑皮质、丘脑、海马、脑干等部位。6例患者脑电图异常,为弥漫性慢波或局灶性痫样放电。 所有患者均接受一线免疫治疗,延误诊治的1例患者对治疗反应差并出现复发。结论：抗NMDAR脑炎临床 表现复杂多样,但具有其特点,对于出现不明原因的精神行为异常或认知障碍的青年患者,及时行抗NMDAR抗体筛查十分必要,早期治疗预后良好。     

Evaluation of the Uptake of a Prehospital Cardiac Arrest Termination of Resuscitation Rule

BackgroundPrevious research has focused on creation and validation of a basic life support rule for termination of resuscitation (TOR) in nontraumatic out-of-hospital cardiac arrest (OHCA) to identify patients who will not be successfully resuscitated or will not have a favorable outcome. Although now widely implemented, translational research regarding in-field compliance with TOR criteria and barriers to use is scarce.ObjectivesThis project aimed to assess compliance rates, barriers to use, and effect on ambulance transport rates after implementing TOR criteria for OHCA.MethodsRetrospective chart review of patients ≥ 18 years with OHCA. Data from regional Emergency Medical Services agencies were collected to determine TOR rule compliance for patients meeting criteria, barriers to use, and effect of a TOR rule on ambulance transport.ResultsThere were 552 patients with OHCAs identified. Ninety-one patients met TOR criteria, with paramedics requesting TOR in 81 (89%) cases and physicians granting requests in 65 (80.2%) cases. Perceived barriers to TOR compliance included distraught families, nearby advanced-care paramedics, and unusual circumstances. Reasons for physician refusal of TOR requests included hospital proximity, patient not receiving epinephrine, and poor communication connection to paramedics. Total high priority transports decreased 15.6% after implementation of a TOR rule.ConclusionsThe study found high compliance after implementation of a TOR rule and identified potentially addressable barriers to TOR use. Appropriate application of a TOR rule led to reduction in high-priority ambulance transports, potentially reducing futile use of health care resources and risk of ambulance motor vehicle collisions.