Tuesday, February 28, 2012

Afib May Lead to Memory Trouble (CME/CE)

(MedPage Today) -- Atrial fibrillation seems to increase the risk of cognitive and functional decline, even in the absence of stroke, a post-hoc analysis of two randomized trials found.





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What Doctors Don't Understand About Anesthesia

Today anesthetics are considered as routine as a trip to the dentist. They have been around at least since the 18th century when a talented chemist named Humphry Davy discovered the mysterious effect of nitrous oxide (laughing gas). Davy, young and ambitious, set out to rigorously test the gas's effect, inhaling nitrous oxide daily for several months. Under slightly less rigorous conditions, Davy shared the gas with a distinguished group of friends including Samuel Taylor Coleridge, James Watt, and Robert Southey--who wrote in a letter that "the atmosphere of the highest of all possible heavens must be composed of this gas." These early trials laid the foundation for anesthesia's emergence in medicine today. Yet in the modern era, despite tremendous advances in the quality and selectivity of anesthetics, we still have a poor understanding of how anesthetics work in the brain.

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More Evidence Omega-3 Rich Diet May Protect Aging Brain

A study found that older adults with lower blood levels of omega-3 fatty acids had lower brain volumes and performed worse on certain cognitive tests than their peers with higher levels.
Medscape Medical News





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Traumatic brain injury: A risk factor for Alzheimer's disease

Publication year: 2012
Source: Neuroscience & Biobehavioral Reviews, Available online 27 February 2012
Thamil Mani Sivanandam, M.K. Thakur
Traumatic brain injury (TBI) constitutes a major global health and socio-economic problem with neurobehavioral sequelae contributing to long-term disability. It causes brain swelling, axonal injury and hypoxia, disrupts blood brain barrier function and increases inflammatory responses, oxidative stress, neurodegeneration and leads to cognitive impairment. Epidemiological studies show that 30% of patients, who die of TBI, have Aβ plaques which are pathological features of Alzheimer's disease (AD). Thus TBI acts as an important epigenetic risk factor for AD. This review focuses on AD related genes which are expressed during TBI and its relevance to progression of the disease. Such understanding will help to diagnose the risk of TBI patients to develop AD and design therapeutic interventions.

Highlights

► Traumatic brain injury (TBI) is an important epigenetic risk factor for the development of Alzheimer's disease ► Aβ plaques which are pathological features of Alzheimer's disease are seen in 30% patients who die of TBI ► Although many patients survive the initial insult, TBI initiates a chronic disease process ► As TBI affects many areas of the brain, a multiplicity of neurobehavioral symptoms is common after TBI.





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Bom, mas não excelente. Negado!

O nível de financiamento à pesquisa atende a minoria dos projetos apresentados. São rejeitados de 70 a 80% dos projetos apresentados na maioria das agências de financiamento. Ë esperado que o sistema resulte em muitas queixas.
"The system for funding scientific research is broken.

This declaration came to my mind after I experienced three separate occurrences. The first was my application for





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Clinical diagnoses and autopsy findings: Discrepancies in critically ill patients*

Objectives: To determine the proportion of clinical errors by comparing clinical and pathological diagnoses, and to evaluate changes of errors over time. Design: We conducted a prospective study of all consecutive autopsies performed on patients who died in the intensive care unit of the Hospital Universitario de Getafe, Madrid, Spain, between January 1982 and December 2007. The diagnostic errors were classified in two categories: class I errors that were major misdiagnoses with direct impact on therapy, and class II diagnostic errors which comprised major unexpected findings that probably would not have changed therapy. Main Results: Of 2,857 deaths during the study period, autopsies were performed in 866 patients (30.3%). Autopsy reports were available in 834 patients, of whom 63 (7.5%) had class I errors and 95 (11.4%) had type II errors. The most frequently missed diagnoses were pulmonary embolism, pneumonia, secondary peritonitis, invasive aspergillosis, endocarditis and myocardial infarction. The autopsy did not determine the cause of death in 22 patients (2.6%). Our rate of diagnostic discrepancy remained relatively constant over time, and the conditions leading to discrepancies have slightly changed, with pneumonia showing a decline in diagnostic accuracy in the last years. Conclusions: This study found significant discrepancies in 18.5% of patients who underwent autopsy, 7.5% of them were diagnoses with impact on therapy and outcome. This reinforces the importance of the postmortem examination in confirming diagnostic accuracy and improving the quality of care of critically ill patients.





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Monday, February 27, 2012

Understanding epileptogenesis in calcified neurocysticercosis with perfusion MRI

Objectives:

Calcified cysticercus larva with perilesional abnormality is thought to be responsible for seizures in patients with neurocysticercosis (NCC). However, it is not well understood why some calcified cysts are associated with seizures even without perilesional abnormality.

Methods:

The study group consists of 30 subjects from an ongoing survey for disease burden estimation of a swine farming community who had a single calcified lesion without any perilesional abnormality with or without presentation of seizures. Each group consisted of 15 patients with calcified cysts and was labeled as asymptomatic and symptomatic. We performed dynamic contrast-enhanced (DCE) MRI on all these subjects and determined serum matrix metalloproteinase-9 (MMP-9) levels and MMP-9 gene polymorphisms.

Results:

DCE-MRI–derived rate transfer constant (kep) and serum MMP-9 levels showed significant differences between symptomatic and asymptomatic subjects. We observed an increase in the MMP-9 levels, kep, and the volume transfer coefficient (ktrans) in these lesions. We also observed a significant increase in MMP-9 (R279Q) gene polymorphism in symptomatic subjects compared with asymptomatic and control subjects.

Conclusions:

Perilesional inflammation, which varies from symptomatic to asymptomatic subjects, can be quantified using DCE-MRI in calcified cysticercosis and may help distinguish these 2 groups with similar imaging findings. The observed increase in kep with serum MMP-9 levels suggests that the former may serve as a biomarker of MMP-9 levels in these subjects. The significant MMP-9 (R279Q) gene polymorphism in symptomatic subjects might explain the differences in the observed DCE-MRI indices between symptomatic and asymptomatic subjects.






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Epileptic seizures at initial presentation in patients with brain arteriovenous malformation

Objectives:

Brain arteriovenous malformations (AVMs) often present with epileptic seizures, but prospective data on the risk of seizures with respect to morphologic AVM characteristics are scarce.

Methods:

We studied 155 consecutive patients with AVMs from a prospective, single-center database using demographic and morphologic factors based on prospectively coded MRI and digital subtraction angiography (DSA) data. Univariate analysis and multivariate logistic regression models were used to test the effect of demographic (age and sex) and morphologic characteristics (AVM size, anatomic and arterial location, and venous drainage pattern) on seizures as initial presentation in patients with unruptured brain AVMs.

Results:

Overall, 45 patients with AVMs initially presented with seizures (29%). By univariate comparison, male sex (p = 0.02), increasing AVM size (p < 0,006), frontal lobe localization (p < 0.0001), arterial borderzone location (p < 0.0006), superficial venous drainage (p = 0.0002), and presence of venous ectasia (p = 0.003) were statistically associated with seizures. The multivariate analysis confirmed an independent effect of male sex, frontal lobe AVMs, and arterial borderzone location on seizure occurrence. All patients with seizures showed the presence of a superficial venous drainage component.

Conclusions:

Our study suggests that seizures mainly occur in AVMs with superficial drainage. Other predisposing factors include male sex, increasing AVM size, and frontal lobe and arterial borderzone location. Whether or not interventional treatment has an effect on the long-term risk of epilepsy remains to be determined.






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Prospective hemorrhage risk of intracerebral cavernous malformations

Objective:

Our goal was to describe the prospective risk and timing of symptomatic hemorrhage in a large cohort of followed patients with intracerebral cavernous malformations (ICMs).

Methods:

All patients between 1989 and 1999 with the radiographic diagnosis of intracerebral cavernous malformation were identified retrospectively. The records and radiographic data were reviewed, and follow-up after diagnosis was obtained. An incidence rate was used to calculate annual risk of symptomatic hemorrhage. Predictive factors for outcomes used univariate and multivariable analysis with p < 0.05.

Results:

A total of 292 patients were identified (47.3%male) with 2,035 patient years of follow-up. Seventy-four patients presented with hemorrhage, 108 with symptoms not related to hemorrhage (seizure or focal deficit), and 110 as asymptomatic. The overall annual rate of hemorrhage in those presenting initially with hemorrhage, with symptoms not related to hemorrhage, or as an incidental finding was 6.19%, 2.18%, and 0.33%, respectively. Patients who presented initially with symptomatic hemorrhage (hazard ratio 5.14; 95% confidence interval [CI] 2.54–10.4; p < 0.001) were at higher risk for future hemorrhage, and hemorrhage risk decreased with time. Male gender (hazard ratio 2.36; 95% CI 1.14–4.89; p = 0.02), and multiplicity of ICMs (hazard ratio 2.65; 95% CI 1.30–5.43; p = 0.01) also increased the risk of hemorrhage. The median time from first to second hemorrhage was 8 months.

Conclusions:

This study provides an estimate of prospective annual symptomatic hemorrhage risk in patients with ICMs stratified by initial presenting symptom. Prior hemorrhage, male gender, and multiplicity of ICMs may predict future hemorrhage. Hemorrhage risk decreases with time in those initially presenting with hemorrhage.






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Study: Opioid Deaths Linked to Specialty Care

(MedPage Today) -- PALM SPRINGS, Calif. -- Patients of pain medicine specialists may be at greater risk of opioid overdose death than those who get their medications from other clinicians, researchers said here.





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Social Cues in the Brain [Interactive]

Reading the emotions of others is essential for even the most basic social skills. Imagine someone without this ability; she might laugh at an angry coworker or try to comfort a delighted friend. But how do our brains pick up on what others are feeling? A face often fails to tell the whole story. We also use tone of voice, posture and even odor to solve the puzzle. (For more on the many ways we make use of sensory information, see Scientific American Mind's special report on the senses in March/April 2012.) Here's how our brain combines information from multiple senses to decode mood.

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Sunday, February 26, 2012

Medical ethics conference hears about professional responsibility, patient autonomy, and corporate p

Should a woman in a minimally conscious state have artificial nutrition and hydration withdrawn and be allowed to die? That was the stark question facing delegates at the BMA's "Morals and Medicine"...





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Prediction of time of death after withdrawal of life-sustaining treatment in potential donors after

Objective: Organ donation after cardiac death increases the number of donor organs. In controlled donation after cardiac death donors, the period between withdrawal of life-sustaining treatment and cardiac arrest is one of the parameters used to assess whether organs are suitable for transplantation. The objective of this study was to identify donation after cardiac death donor characteristics that affect the interval between withdrawal of life-sustaining treatment and cardiac death. Design: Prospective multicenter study of observational data. Patients: All potential donation after cardiac death donors in The Netherlands between May 2007 and June 2009 were identified. Interventions: None. Measurements and Main Results: Of the 242 potential donation after cardiac death donors, 211 entered analysis, 76% of them died within 60 mins, and 83% died within 120 mins after withdrawal of life-sustaining treatment. The median time to death was 20 mins (range 1 min to 3.8 days). Controlled mechanical ventilation, use of norepinephrine, absence of reflexes, neurologic deficit as cause of death, and absence of cardiovascular comorbidity were associated with death within 60 and 120 mins. The use of analgesics, sedatives, or extubation did not significantly influence the moment of death. In the multivariable logistic regression analysis, controlled mechanical ventilation remained a risk factor for death within 60 mins, and norepinephrine administration and absence of cardiovascular comorbidity remained risk factors for death within 120 mins. The clinical judgment of the intensivist predicted death within 60 and 120 mins with a sensitivity of 73% and 89%, respectively, and a specificity of 56% and 25%, respectively. Conclusion: Despite the identification of risk factors for early death and the additional value of the clinical judgment by the intensivist, it is not possible to reliably identify potential donation after cardiac death donors who will die within 1 or 2 hrs after life-sustaining treatment has been withdrawn. Consequently, a donation procedure should be initiated in every potential donor.





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Selective endovascular embolization for refractory idiopathic epistaxis is a safe and effective ther

Publication year: 2012
Source: Journal of Clinical Neuroscience, Available online 23 February 2012
José E. Cohen, Samuel Moscovici, John M. Gomori, Ron Eliashar, Jeffrey Weinberger, ...
Epistaxis generally responds to conservative management, but a more invasive approach, such as superselective embolization, is sometimes justified. We report our experience with endovascular procedures in 19 patients from 2002 to 2011 for the treatment of refractory idiopatic posterior epistaxis. The sphenopalatine artery and distal internal maxillary arteries were embolized in all patients. Unilateral embolization was performed in 12 patients (63%), bilateral embolization in seven (37%). Additional embolization of the descending palatine artery was performed in eight patients (42%) and embolization of the facial artery and palatine arteries in four (21%). In one patient the distal ophthalmic artery was embolized withn-butyl cyanoacrylate. No minor or major complications occurred in relation to the embolization procedures. The average hospital stay was 11.1 ± 8.6 days, including an average 5.2 ± 3.4 days after embolization. Average follow-up after discharge was 21.3 ± 25.7 months. Superselective endovascular embolization proved safe and effective in controlling idiopathic epistaxis, refractory to other maneuvers.





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Saturday, February 25, 2012

The Importance Of Nervous System Structure And Neural Wiring Evolution

A new study, in this week's online edition of the Proceedings of the National Academy of Sciences , shows an incredible degree of biological diversity in a surprising location, i.e. in a single neural connection in the body wall of flies. The finding opens up a new spectrum of interesting questions regarding the importance of the nervous system structure and the evolution of neural wiring...





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Mortality Risk Varies Between Antipsychotics in Dementia

A new study of elderly nursing home residents shows the mortality risk associated with various antipsychotics is not created equal.
Medscape Medical News





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Cognitive outcome after awake surgery for tumors in language areas

Abstract  
In surgery for tumors of the dominant hemisphere, the attention devoted to quality of resection and preservation of language function has not been accompanied by comparable interest in preservation of cognitive abilities which may affect quality of life. We studied 22 patients undergoing awake surgery for glioma removal in the language areas of the brain. Besides monitoring tumor variables (size, location, histology, edema), we used a multifaceted battery of tests to investigate mood, cognition, and language in an attempt to assess the burden of disease and treatment, and the relationships between these three dimensions. Baseline assessment showed that 45% of the patients were depressed and 23% anxious; some cognitive and language impairment was noted for 59 and 50%, respectively. A general decline in postoperative cognitive performance (significant for memory and attention only) and language function (significant for picture naming) was observed, whereas depression was unchanged and anxiety decreased. Tumor histology, but not demographic variables or extent of resection, correlated with postoperative cognitive changes: patients undergoing surgery for high-grade tumors were more likely to improve. No correlation was observed between scores for mood, cognition, and language function. A subset of patients with low-grade glioma was followed up for 3–6 months; although some improvement was observed they did not always regain their preoperative performance. In conclusion, we believe that cognitive assessment performed in conjunction with language testing is a necessary step in the global evaluation of brain tumor patients both before and after surgery.

  • Content Type Journal Article
  • Category Effects of Standard of Art Treatment
  • Pages 1-8
  • DOI 10.1007/s11060-012-0817-4
  • Authors
    • B. Santini, Department of Neuroscience, Section of Neurosurgery, University of Verona, Piazzale Stefani 1, 37126 Verona, Italy
    • A. Talacchi, Department of Neuroscience, Section of Neurosurgery, University of Verona, Verona, Italy
    • G. Squintani, Department Neurological Science, Neurology Unit, University Hospital, Verona, Italy
    • F. Casagrande, Department of Anesthesiology, Neurosurgical Intensive Care Unit, University Hospital, Verona, Italy
    • R. Capasso, CeRiN (Center for Neurocognitive Rehabilitation), CIMeC (Center for Mind/Brain Studies, University of Trento, Trento, Italy
    • G. Miceli, CeRiN (Center for Neurocognitive Rehabilitation), CIMeC (Center for Mind/Brain Studies, University of Trento, Trento, Italy





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Memory disorders in patients with cerebral tumors

Abstract  
In patients with cerebral tumors, deficits in declarative episodic memory typically result from damage to structures of the Papez circuit. These deficits can arise directly from the action of the tumor mass or indirectly from the surgical intervention. Memory deficits are also frequently seen in patients who show no direct involvement of the Papez circuit. In these patients, the memory impairment probably results from disruption of frontal lobe functioning (caused by localization of the tumor at this level or disconnection from subcortical afferents). Here, I review the neuropsychological tools used to differentiate amnesic syndromes resulting from lack of consolidation of new memory traces (as a consequence of damage to the Papez circuit) from amnesias resulting from reduced efficiency of elaborative encoding and/or strategic retrieval processes (as a consequence of frontal lobe damage). The clinical and rehabilitative implications of this distinction are briefly discussed.

  • Content Type Journal Article
  • Category Baseline Neuropsychological Investigations and Batteries
  • Pages 1-4
  • DOI 10.1007/s11060-012-0825-4
  • Authors
    • Giovanni A. Carlesimo, Clinica Neurologica, Università Tor Vergata, Rome, Italy





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Friday, February 24, 2012

Differential risk of death in older residents in nursing homes prescribed specific antipsychotic dru

Objective To assess risks of mortality associated with use of individual antipsychotic drugs in elderly residents in nursing homes.Design Population based cohort study with linked data from Medicaid,...





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Traumatic Brain Injury And Post-Traumatic Stress Disorder - A New Link

Mild traumatic brain injury (TBI) and posttraumatic stress disorder (PTSD) are cardinal injuries associated with combat stress, and TBI increases the risk of PTSD development. The reasons for this correlation have been unknown, in part because physical traumas often occur in highly emotional situations...





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Thursday, February 23, 2012

Computers Boost Brain Power in MS, Mental Illness (CME/CE)

(MedPage Today) -- Computer training is showing promise in improving cognitive abilities in patients with conditions as disparate as schizophrenia and multiple sclerosis, researchers reported.





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The Neglect of Mental Illness Exacts a Huge Toll, Human and Economic

Mental health care is one of the biggest unmet needs of our time. Nearly one in two people in the U.S. will suffer from depression, anxiety disorders or another mental health ailment at some point in their life, and about one in 17 Americans currently has a serious mental illness. Young people are especially prone to these troubles. Yet millions of people living with these conditions do not receive the care they require. In recent years the health system and state and federal governments have taken steps to right that wrong. Progress has been slow, and budget cuts and legal wrangling have now put many of these measures at risk. Doctors, insurers and politicians need to pick up the pace.

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Migraine Linked to Increased Risk of Depression in Women

Women with migraine history are 40 percent more likely to develop depression compared to women without a history of migraine





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AAN Publishes Guideline and Model Medical Policy on Intraoperative Monitoring

Intraoperative monitoring (IOM) of patients during spinal surgery and certain chest surgeries is the topic of an updated AAN evidence-based guideline.





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Reversible splenial lesion in the corpus callosum following rapid withdrawal of carbamazepine after

Publication year: 2012
Source: Journal of Clinical Neuroscience, Available online 18 February 2012
Harushi Mori, Masayuki Maeda, Jun-ichi Takanashi, Akira Kunimatsu, Nobuyoshi Matsushima, ...
Reversible splenial lesions (RSL) of the corpus callosum have been described in various clinical conditions, and some are attributed to the action of antiepileptic drugs (AED). Abrupt withdrawal of an AED in preparation for surgical treatment can result in RSL of the corpus callosum in patients with trigeminal neuralgia who do not have epilepsy. We report two patients who developed RSL following surgical treatment of trigeminal neuralgia. Since our two patients did not have epilepsy, it is strongly suggested that the AED, rather than convulsive status epilepticus, could be a contributing factor in RSL. The pathogenesis of AED-associated RSL is not clear. Similar RSL can appear under various circumstances, implying that factors other than AED can influence a common end-point mechanism that results in RSL. Nevertheless, delirium after surgery may be a cue for inquiring about RSL. This condition is transient and represents a clinicoradiological syndrome with an excellent prognosis. We should consider this phenomenon in the perioperative period after surgery for trigeminal neuralgia to avoid invasive diagnostic and therapeutic procedures.





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Analysis of Nonmodifiable Risk Factors for Intracranial Aneurysm Rupture in a Large, Retrospective C

BACKGROUND: The risk factors predictive of intracranial aneurysm rupture remain incompletely defined. OBJECTIVE: To examine the association between various nonmodifiable risk factors and aneurysm rupture in a large cohort of patients evaluated at a single institution. METHODS: A retrospective analysis of patients admitted to a cerebrovascular facility between January 2006 and 2010 with a primary diagnosis of cerebral aneurysm. Aneurysms were divided into 2 groups: unruptured or ruptured. The dome diameter, aspect ratio (AR), location, sidedness, neck morphology, and multiplicity were entered into a central database. A full model was constructed, and a systematic removal of the least significant variables was performed in a sequential fashion until only those variables reaching significance remained. RESULTS: We identified 2347 patients harboring 5134 individual aneurysms, of which 34.90% were ruptured and 65.09% were unruptured. On admission, 25.89% of aneurysms with a dome diameter <10 mm and 58.33% of aneurysms with a dome >10 mm were ruptured (P < .001). Of aneurysms with an AR >1.6, 52.44% presented following a rupture (P < .001). The highest incidence of rupture (69.21%) was observed in aneurysms with an AR >1.6, dome diameter <10 mm, and a deviated neck. Deviated neck-type aneurysms had a significantly greater incidence of rupture than classical neck-type aneurysms (P < .001). CONCLUSION: An AR >1.6, dome diameter >10 mm, a deviated neck, and right-sidedness are independently associated with aneurysm rupture.





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Back Pain: A Real Target for Spinal Cord Stimulation?

BACKGROUND: Failed back surgery syndrome represents one of the most frequent etiologies of chronic back pain and is a major public health issue. Neurostimulation has currently not been validated in the treatment of back pain because of technological limitations in implantable spinal cord stimulation (SCS) systems. New-generation leads using several columns of stimulation can generate longitudinal and/or transverse stimulation fields into the spinal cord. OBJECTIVE: To investigate, through extensive stimulation testing, the capacity of multicolumn tripolar leads to achieve back territory paresthesia coverage in refractory failed back surgery syndrome patients. METHODS: Eleven patients implanted with a 16-contact spinal cord stimulation lead (Specify 5-6-5, Medtronic Inc) were assessed with a systematic exploration of 43 selected stimulation configurations to generate bilateral back paresthesia in addition to leg territory coverage. RESULTS: The tripolar lead successfully generated paresthesia in both bilateral back and leg territories in 9 patients (81.8%). Success rates of multicolumn stimulation patterns were significantly higher than for longitudinal configurations for lombodorsal paresthesia coverage. Six months after implantation, significant pain relief was obtained compared with preoperative evaluation for global pain (Visual Analog Scale, 2.25 vs 8.2 preoperatively; P < .05), leg pain (Visual Analog Scale, 0.5 vs 7.6 preoperatively; P < .05), and back pain (Visual Analog Scale, 1.5 vs 7.8 preoperatively; P < .05). CONCLUSION: These results suggest that multicolumn leads can reliably generate back pain coverage and favor pain relief outcomes. This may lead physicians to reconsider new indications for spinal cord stimulation. Expanding neurostimulation perspectives to intractable back pain syndromes could become realistic in the near future.





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A modern approach to mental health

Does psychoanalysis have a place in modern medicine? Peter Fonagy and Alessandra Lemma do their best to make the case that it does. They argue that evidence of its usefulness is "on its way," that it...





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