[Infantile acquired brain injury, a personal experience. Demands from the socio-familial point of view]. / Daño cerebral sobrevenido infantil, una experiencia personal. Reclamaciones desde el punto de vista sociofamiliar.

We report on the experience of a family in which the youngest child has acquired brain injury and the struggle undertaken by the family to improve the neurorehabilitation resources in the public health service. The article outlines the main demands, from the socio-familial point of view, as regards the improvement of neurological rehabilitation and the resources needed to deliver it.

TITLE: Daño cerebral sobrevenido infantil, una experiencia personal. Reclamaciones desde el punto de vista sociofamiliar.Se describe la experiencia de una familia en la que el hijo menor tiene daño cerebral sobrevenido y la lucha emprendida por la familia para mejorar los recursos neurorrehabilitadores de la sanidad publica. Se recogen las principales reclamaciones, desde el punto de vista sociofamiliar, en cuanto a la mejora en la atencion neurorrehabilitadora y los recursos necesarios.

Assessment of Social Cognition and Theory of Mind: Initial Validation of the Geneva Social Cognition Scale.

BACKGROUND: Social cognition is widely studied in neurology. At present, such evaluations are designed for research or for specific diseases and simple general clinical tools are lacking. We propose a clinical evaluation tool for social cognition, the Geneva Social Cognition Scale (GeSoCS). METHODS: The GeSoCS is a 100-point scale composed of 6 subtests (theory of mind stories, recognition of social emotions, false beliefs, inferences, absurdity judgement and planning abilities) chosen from different validated tests of social and cognitive evaluation. Eighty-four patients with neurological disorders and 52 controls participated in the study. Evaluation duration lasted 20-60 min. RESULTS: Mean scores were 92.6 ± 4.5 for controls and 76.5 ± 15.3 for patients and differentiate patients and controls in all subtests. With a cut-off score of 84, the scale had a sensitivity of 62% and a specificity of 94%. In our stroke subgroup, right CVAs failed in cartoons, inferences, 'mind in the eyes', and in the temporal rule task while left CVAs were impaired in verbal/discourse tasks (social cognition, inferences, absurd stories, and cartoons. CONCLUSIONS: The GeSoCS is a medium duration assessment tool that appears to detect and characterize significant social impairment in neurological patients.

EXTENDING THE ASSESSMENT OF TECHNOLOGY-AIDED PROGRAMS TO SUPPORT LEISURE AND COMMUNICATION IN PEOPLE WITH ACQUIRED BRAIN INJURY AND EXTENSIVE MULTIPLE DISABILITIES.

Intervention programs for people with acquired brain injury and extensive motor and communication impairment need to be diversified according to their characteristics and environment. These two studies assessed two technology-aided programs for supporting leisure (i.e., access to songs and videos) and communication (i.e., expressing needs and feelings and making requests) in six of those people. The three people participating in Study 1 did not possess speech but were able to understand spoken and written sentences. Their program presented leisure and communication options through written phrases appearing on the computer screen. The three people participating in Study 2 did not possess any speech and were unable to understand spoken or written language. Their program presented leisure and communication options through pictorial images. All participants relied on a simple microswitch response to enter the options and activate songs, videos, and communication messages. The data showed that the participants of both studies learned to use the program available to them and to engage in leisure and communication independently. The importance of using programs adapted to the participants and their environment was discussed.

[Clinical profile in subjects with acquired brain injury in chronic phase in a social and health care center]. / Perfil del sujeto con daño cerebral adquirido en fase crónica en un recurso de atención sociosanitaria.

INTRODUCTION: There are few resources for acquired brain injury (ABI) in post-hospitalary phase in our country. At this level of carefulness, Personal Autonomy Promotion Center in Bergondo contemplates like a social and health care resource in order to facilitate community integration in subjects with ABI. AIMS. To describe clinical profile in the subjects admitted in our unit, and to assess intervention possibilities with clinico-functional recovery goals in the chronic phases in ABI. PATIENTS AND METHOD: . Sample of 105 subjects admitted in our center until December 2010. 86 men and 19 women, with a mean age of 32.16 years old and a most frequent evolution time of less than 5 years (64.76%). Variables collected were: sex, age, etiology, evolution time, personality changes diagnosis, admission FIM, previous participation in rehabilitation programmes and have recovery goals. RESULTS: The main etiology was traumatic brain injury (62.5%). The 54.28% of the subjects was taking physical rehabilitation at the moment of admission, while the 49.52% had participated in neuropsychological interventions. Physical recovery goals were identified in the 42.85% of the subjects and the 78.09% had goals in neuropsychology field. CONCLUSION: The clinical profile observed was young man with sequelae caused by a traumatic brain injury suffered in last five years, who has received poor neuropsychological care and that still takes physiotherapy treatment.

[Social impact of stroke due to atrial fibrillation]. / Impacto social del ictus producido por fibrilación auricular.

Atrial fibrillation (AF) is the most frequent heart arrhythmia and causes a substantial proportion of ischemic strokes. AF has a marked impact on stroke severity, as well as on morbidity and mortality in these patients. The importance of AF as an etiologic factor of stroke increases in the elderly and in the last few years its detection has increased. The presence of AF leads to more severe initial neurological involvement, longer hospitalization, greater disability and a lower probability of discharge to home. In addition, AF is an independent risk factor for mortality, especially in women and the elderly. All these factors lead to a higher social and economic impact among stroke patients with AF.

Promoting adaptive behavior in persons with acquired brain injury, extensive motor and communication disabilities, and consciousness disorders.

These two studies extended the evidence on the use of technology-based intervention packages to promote adaptive behavior in persons with acquired brain injury and multiple disabilities. Study I involved five participants in a minimally conscious state who were provided with intervention packages based on specific arrangements of optic, tilt, or pressure microswitches (linked to preferred environmental stimuli) and eyelid, toe and finger responses. Study II involved three participants who were emerging from a minimally conscious state and were provided with intervention packages based on computer presentations of stimulus options (i.e., preferred stimuli, functional caregiver's procedures, and non-preferred stimuli) and pressure microswitches to choose among them. Intervention data of Study I showed that the participants acquired relatively high levels of microswitch responding (thus engaging widely with preferred environmental stimuli) and kept that responding consistent except for one case. Intervention data of Study II showed that the participants were active in choosing among preferred stimuli and positive caregivers' procedures, but generally abstained from non-preferred stimuli. The results were discussed in terms of the successful use of fairly new/infrequent microswitch-response arrangements (Study I) and the profitable inclusion of functional caregiver's procedures among the options available to choice (Study II).

Errorless learning of functional life skills in an individual with three aetiologies of severe memory and executive function impairment.

Errorless learning (EL) procedures have been shown to be effective in teaching new information and new procedures to individuals with severe memory impairment. The published studies have been based on comparatively short-term interventions delivered to individuals with relatively circumscribed impairments. In this single case study, we explore the usefulness of errorless learning procedures used for seven years with an adult with profound and complicated memory and executive function impairments associated with three distinct aetiologies. In primary functional areas targeted by the intervention, outcome was documented by behavioural descriptions and a frequency rating scale. Caregiver burden was documented with qualitative descriptors. A financial cost-benefit analysis is also provided. In the absence of change in underlying neuropsychological impairments, DI's everyday functioning in critical areas improved substantially, with corresponding reduction in supports and improved quality of life. Caregiver burden was reduced to acceptable levels and cost-benefit analysis demonstrates substantial ongoing cost savings.

Economic games quantify diminished sense of guilt in patients with damage to the prefrontal cortex.

Damage to the ventromedial prefrontal cortex (VMPFC) impairs concern for other people, as reflected in the dysfunctional real-life social behavior of patients with such damage, as well as their abnormal performances on tasks ranging from moral judgment to economic games. Despite these convergent data, we lack a formal model of how, and to what degree, VMPFC lesions affect an individual's social decision-making. Here we provide a quantification of these effects using a formal economic model of choice that incorporates terms for the disutility of unequal payoffs, with parameters that index behaviors normally evoked by guilt and envy. Six patients with focal VMPFC lesions participated in a battery of economic games that measured concern about payoffs to themselves and to others: dictator, ultimatum, and trust games. We analyzed each task individually, but also derived estimates of the guilt and envy parameters from aggregate behavior across all of the tasks. Compared with control subjects, the patients donated significantly less and were less trustworthy, and overall our model found a significant insensitivity to guilt. Despite these abnormalities, the patients had normal expectations about what other people would do, and they also did not simply generate behavior that was more noisy. Instead, the findings argue for a specific insensitivity to guilt, an abnormality that we suggest characterizes a key contribution made by the VMPFC to social behavior.

Quality of life and brain damage after microsurgical clip occlusion or endovascular coil embolization for ruptured anterior communicating artery aneurysms: neuropsychological assessment.

OBJECT: For anterior communicating artery (ACoA) aneurysms, endovascular coil embolization constitutes a safe alternative therapeutic procedure to microsurgical clip occlusion. The authors' aim in this study was to evaluate the quality of life (QOL), cognitive function, and brain structure damage after the treatment of ruptured ACoA aneurysms in a group of patients who underwent microsurgical clipping (36 patients) compared with a reference group who underwent endovascular coiling (14 patients). METHODS: At 14 months posttreatment all patients underwent evaluations by independent observers. These observers evaluated global efficacy, executive functions using a frontal assessment battery of tests (Trail making test, Stroop tasks, dual task of Baddeley, verbal fluency, and Wisconsin Card Sorting test), behavior dysexecutive syndrome (the Inventaire du Syndrome Dysexécutif Comportemental questionnaire [ISDC]), and QOL by using the Reintegration To Normal Living Index. Brain damage was analyzed using MR imaging. RESULTS: In the microsurgical clipping and endovascular coiling groups, the distribution on the modified Rankin Scale (p = 0.19) and mean QOL score (85.4 vs 83.4, respectively) were similar. Moreover, the proportion of executive dysfunctions (19.4 vs 28.6%, respectively) and the mean score on the ISDC questionnaire (8.9 vs 8.5, respectively) were not significant, but verbal memory was more altered in the microsurgical clipping group (p = 0.055). Magnetic resonance imaging revealed that the incidence of local encephalomalacia and the median number of lesions per patient increased significantly in the microsurgical clipping group (p = 0.003). CONCLUSIONS: In the 2 groups, no significant difference was observed regarding QOL, executive functions, and behavior. Despite the significant decrease in verbal memory after microsurgical clipping, the interdisciplinary approach remains a safe and useful strategy.

Use of specific malingering measures in a Spanish sample.

There are an increasing number of tests available for detecting malingering. However, these tests have not been validated for using in Spanish speakers. The purpose of this study is to explore the value of three specific malingering tests in the Spanish population. This study used a known-groups design, together with a group of analog students. The results show that both the Victoria Symptom Validity Test and the b Test can be used to detect malingering in Spanish population. However, some restrictions must be applied when the Rey 15-Item Test is administered and interpreted.

Development and clinical trial of virtual reality-based cognitive assessment in people with stroke: preliminary study.

Stroke and traumatic brain injury affect an increasing number of people, many of whom retain permanent damage in cognitive functions. Conventionally, cognitive function has been assessed by a paper-based neuropsychological evaluation. However these test environments differ substantially from everyday life. This problem can be overcome by using virtual reality (VR) to objectively evaluate behaviors and cognitive function in simulated daily activities. With our virtual shopping simulation, we compared people who had undergone a stroke with control participants in an immersive VR program that used a head-mounted display (HMD). We evaluated user satisfaction with the tests, complications, and the user interface. Significant differences were consistently found between the stroke group and the control group for the following tasks: stage 1 performance index, interaction error; stage 2 delayed recognition memory score, attention index; and stage 3 executive index (p < 0.001). Perceptive dysfunction, visuospatial dysfunction, level of computer experience, and level of education affected the performance of the stroke group. The frequency of complications in the stroke group, calculated using the cut-off score for the Simulator Sickness Questionnaire, was 9.6% for nausea, 41.9% for oculomotor complications, and 25.8% for disorientation. The frequency of complications between the stroke and control groups was not significantly different. Thirty-five percent of participants in the stroke group and 13% in the control group reported difficulties with using the joystick. This computer-generated VR-based cognitive test shows promise in assessing cognitive function in patients with stroke. More refinements are needed in the user interface and the projection methods.

The validity of the Color Trail Test in the pre-driver assessment of individuals with acquired brain injury.

PRIMARY OBJECTIVE: To examine the validity of the Color Trails Test (CTT), a culture- fair analogue of the Trails Test, in the pre-driver assessment of individuals with acquired brain injury (ABI). RESEARCH DESIGN: Retrospective study. METHODS AND PROCEDURES: 30 participants with ABI completed the CTT and Useful Field of View (UFOV) in a driving rehabilitation clinic. Within the same week an on-road evaluation was conducted by a driving rehabilitation specialist, and a driving instructor. RESULTS: 50% of the participants passed the on-road evaluation and 50% failed. Individuals who passed the on-road test performed the CTT1 and CTT2 faster than those who failed, however the difference between the pass/fail groups was significant only for the CTT1. A correlation analysis between the CTT subtests (CTT1 and CTT2) and the UFOV subtests revealed significant, moderate correlations between these measures. CONCLUSIONS: The CTT1 may contribute to the pre-driving screening by rapidly identifying those individuals who are most at risk for unsafe driving behaviors. Further studies are required with a larger representative sample.

Approaches to neurodevelopmental assessment in congenital diaphragmatic hernia survivors.

BACKGROUND: Infants with congenital diaphragmatic hernia require complex surgical care and may have neurodevelopmental morbidity. We examined the performance of reports of motor functioning in 25 congenital diaphragmatic hernia survivors using the parent-completed Developmental Profile-II and a clinical evaluation by a neurodevelopmental pediatrician (MD) measured against the Bayley motor scale. METHODS: Bayley motor scores were dichotomized as normal or abnormal. Sensitivity and specificity were calculated for each test. RESULTS: The median age at assessment was 25 months. Bayley motor scores were abnormal in 77% of infants tested (10/13). The MD examinations detected motor problems in 92% (12/13). Sensitivity and specificity of the MD examination were 1.0 and 0.33, respectively. Developmental Profile-II physical scores were abnormal in 15% (2/13); sensitivity and specificity were 0.2 and 1.0, respectively. CONCLUSIONS: The high rate of abnormal motor findings in this study supports the need for ongoing screening and evaluation. The sensitivity of MD examinations was excellent, but hypotonia findings were not universally corroborated by the Bayley. Although specificity of parent-reported motor findings was high, parents underreported abnormal motor findings. Parental reports of neurodevelopmental problems should be heeded, and physicians should perform screening motor examinations. Bayley assessments may be warranted to determine the functional implications of observed abnormalities.

The use of the Color Trails Test in the assessment of driver competence: preliminary report of a culture-fair instrument.

Studies have shown that the Trail Making Test (TMT) predicts real-world driving performance in individuals who have cognitive deficits. However, because this test requires knowledge of the Latin alphabet, the TMT may not be appropriate for individuals who are illiterate or for those whom English is not their primary language. Because the Color Trails Test (CTT) is not influenced by knowledge of the alphabet, the CTT may be a culture-fair alternative to the TMT. To date, the utility of the CTT in the evaluation of driver competence has not been established. In the current study, individuals referred for a comprehensive driving assessment underwent testing with the TMT and CTT. The results suggest that the CTT and the TMT provide similar information regarding road-test outcome. Thus, the CTT may be a culture-fair alternative to the TMT in the assessment of driver competence.

[NeuroCogFX--a computer-based neuropsychological assessment battery for the follow-up examination of neurological patients]. / NeuroCogFX--eine computergestützte neuropsychologische Testbatterie für Verlaufsuntersuchungen bei neurologischen Erkrankungen.

Many neurological therapeutic trials require a longitudinal assessment of cognitive functions. An ideal instrument for that purpose should be in accordance to the criteria of classical testing theory and, furthermore, it should be repeatable and economic in administration and interpretation. We developed NeuroCogFX, a computerized assessment battery, according to these criteria. NeuroCogFX comprises subtests for short term memory, working memory, psychomotor speed, selective attention, verbal and figural memory and verbal fluency (mean duration: 25 minutes). Age-related normative data was obtained from 244 subjects without history of neurological or psychiatric disease (age range 16 - 75 years). Forty-two subjects were re-tested after an average of 8 weeks (range: 6 - 10 weeks) in order to assess retest reliability and training effects. Retest-reliabilities were middle-sized in all but one subtest, ranging from r (12) = 0.5 to r (12) = 0.7 (2-back Test: r (12) = 0.37). For construct validation NeuroCogFX was administered in addition to a comprehensive neuropsychological assessment battery in a group of 40 healthy subjects and in 42 patients with chronic epilepsy. The test allows a valid assessment of short-term memory, reaction speed, memory and verbal fluency. NeuroCogFX is an economic, sufficiently reliable and valid instrument for the neuropsychological follow-up examination in single patients and study groups which can be administered if a comprehensive neuropsychological assessment is unavailable.

The Brief Motor Scale (BMS) for the assessment of motor soft signs in schizophrenic psychoses and other psychiatric disorders.

Subtle motor impairment is an important aspect of neurological soft signs (NSS) which are frequently found in psychiatric patients-particularly schizophrenic patients. On the basis of data collected in previous studies using two different NSS scales, the most reliable and discriminative signs of motor impairment were identified to construct a brief 10-item rating scale. Subsequently, the new scale was applied to a sample of subacute patients with schizophrenic psychoses (N = 82) and healthy controls (N = 33). Factor analysis identified two factors which were labeled "motor coordination" and "motor sequencing". Both the total score and the subscores showed high internal consistency and test-retest reliability. There were highly significant group differences on the total score and the subscores as well as on each individual task. The scale has high sensitivity (84.1%) and specificity (87.9%) indicating that it may provide an effective instrument for the screening of subjects with neurodysfunction as well as for monitoring motor dysfunction in the clinical course of psychiatric disorders.

The benefits and risks of bacille Calmette-Guérin vaccination among infants at high risk for both tuberculosis and severe combined immunodeficiency: assessment by Markov model.

BACKGROUND: Bacille Calmette-Guérin (BCG) vaccine is given to Canadian Aboriginal neonates in selected communities. Severe reactions and deaths associated with BCG have been reported among infants born with immunodeficiency syndromes. The main objective of this study was to estimate threshold values for severe combined immunodeficiency (SCID) incidence, above which BCG is associated with greater risk than benefit. METHODS: A Markov model was developed to simulate the natural histories of tuberculosis (TB) and SCID in children from birth to 14 years. The annual risk of tuberculous infection (ARI) and SCID incidence were varied in analyses. The model compared a scenario of no vaccination to intervention with BCG. Appropriate variability and uncertainty analyses were conducted. Outcomes included TB incidence and quality-adjusted life years (QALYs). RESULTS: In sensitivity analyses, QALYs were lower among vaccinated infants if the ARI was 0.1% and the rate of SCID was higher than 4.2 per 100,000. Assuming an ARI of 1%, this threshold increased to 41 per 100,000. In uncertainty analyses (Monte Carlo simulations) which assumed an ARI of 0.1%, QALYs were not significantly increased by BCG unless SCID incidence is 0. With this ARI, QALYs were significantly decreased among vaccinated children if SCID incidence exceeds 23 per 100,000. BCG is associated with a significant increase in QALYs if the ARI is 1%, and SCID incidence is below 5 per 100,000. CONCLUSION: The possibility that Canadian Aboriginal children are at increased risk for SCID has serious implications for continued BCG use in this population. In this context, enhanced TB Control--including early detection and treatment of infection--may be a safer, more effective alternative.

Pre- and post-right middle cerebral artery stroke in a young adult: a case study examining the sensitivity of the Repeatable Battery for the Assessment of Neuropsychological Status (RBANS).

Right-hemisphere strokes are associated with a number of neurobehavioral deficits. The Repeatable Battery for the Assessment of Neuropsychological Status (RBANS) is a relatively new, but widely used screening battery; however, there is little published research in patients who have sustained strokes. We present a rare case of stroke in a 22-year-old psychiatric patient, who received neuropsychological evaluations before and after sustaining a right middle cerebral artery (MCA) stroke. The RBANS demonstrated sensitivity to post-stroke changes despite pre-stroke cognitive impairments and a complex psychiatric overlay, with the Visuospatial/Constructional index being one of the most sensitive indicators of right hemisphere dysfunction. Line Orientation fell from normal to defective levels; these findings were associated with decline in related standard neuropsychological measures.