Assessing patterns of delirium symptoms reveals a novel subtype among elective surgical patients with postoperative delirium.

OBJECTIVES: Prior studies reported incidence of hypoactive and hyperactive subtypes of postoperative delirium, but did not consider cognitive symptoms of delirium which are highlighted in the DSM-5 criteria for delirium. This study aims to address this gap in the literature by classifying cases of delirium according to their constellation of cognitive and motoric symptoms of delirium using a statistical technique called Latent Class Analysis (LCA). METHODS: Data were from five independent study cohorts (N = 1968) of patients who underwent elective spine, knee/hip, or elective gastrointestinal and thoracic procedures, between 2001 and 2017. Assessments of delirium symptoms were conducted using the long form of the Confusion Assessment Method (CAM) pre- and post-surgery. Latent class analyses of CAM data from the first 2 days after surgery were conducted to determine subtypes of delirium based on patterns of cognitive and motoric symptoms of delirium. We also determined perioperative patient characteristics associated with each latent class of delirium and assessed whether the length of delirium for each of the patterns of delirium symptoms identified by the latent class analysis. RESULTS: The latent class model from postoperative day 1 revealed three distinct patterns of delirium symptoms. One pattern of symptoms, denoted as the Hyperalert class, included patients whose predominant symptoms were being hyperalert or overly sensitive to environmental stimuli and having a low level of motor activity. Another pattern of symptoms, denoted as the Hypoalert class, included patients whose predominant symptom was being hypoalert (lethargic or drowsy). A third pattern of symptoms, denoted as the Cognitive Changes class, included patients who experienced new onset of disorganized thinking, memory impairment, and disorientation. Among 352 patients who met CAM criteria for delirium on postoperative day 1, 34% had symptoms that fit within the Hyperalert latent class, 39% had symptoms that fit within the Hypoalert latent class, and 27% had symptoms that fit within the Cognitive Changes latent class. Similar findings were found when latent class analysis was applied to those who met CAM criteria for delirium on postoperative day 2. Multinomial regression analyses revealed that ASA class, surgery type, and preoperative cognitive status as measured by the Telephone Interview for Cognitive Status (TICS) scores were associated with class membership. Length of delirium differed between the latent classes with the Cognitive Changes latent class having a longer duration compared to the other two classes. CONCLUSIONS: Older elective surgery patients who did not have acute events or illnesses or a diagnosis of dementia prior to surgery displayed varying symptoms of delirium after surgery. Compared to prior studies that described hypoactive and hyperactive subtypes of delirium, we identified a novel subtype of delirium that reflects cognitive symptoms of delirium. The three subtypes of delirium reveal distinct patterns of delirium symptoms which provide insight into varying risks and care needs of patients with delirium, indicating the necessity of future research on reducing risk for cognitive symptoms of delirium.

Detecting agitation and aggression in persons living with dementia: a systematic review of diagnostic accuracy.

OBJECTIVE: 40-60% of persons living with dementia (PLWD) experience agitation and/or aggression symptoms. There is a need to understand the best method to detect agitation and/or aggression in PLWD. We aimed to identify agitation and/or aggression tools that are validated against a reference standard within the context of PLWD. METHODS: Our study was registered on PROSPERO (CRD42020156708). We searched MEDLINE, Embase, and PsycINFO up to April 22, 2024. There were no language or date restrictions. Studies were included if they used any tools or questionnaires for detecting either agitation or aggression compared to a reference standard among PLWD, or any studies that compared two or more agitation and/or aggression tools in the population. All screening and data extraction were done in duplicates. Study quality was assessed using the Quality Assessment of Diagnostic Accuracy Studies 2 (QUADAS-2) tool. Data extraction was completed in duplicates by two independent authors. We extracted demographic information, prevalence of agitation and/or aggression, and diagnostic accuracy measures. We also reported studies comparing the correlation between two or more agitation and/or aggression tools. RESULTS: 6961 articles were screened across databases. Six articles reporting diagnostic accuracy measures compared to a reference standard and 30 articles reporting correlation measurements between tools were included. The agitation domain of the Spanish NPI demonstrated the highest sensitivity (100%) against the agitation subsection of the Spanish CAMDEX. Single-study evidence was found for the diagnostic accuracy of commonly used agitation scales (BEHAVE-AD, NPI and CMAI). CONCLUSIONS: The agitation domain of the Spanish NPI, the NBRS, and the PAS demonstrated high sensitivities, and may be reasonable for clinical implementation. However, a limitation to this finding is that despite an extensive search, few studies with diagnostic accuracy measurements were identified. Ultimately, more research is needed to understand the diagnostic accuracy of agitation and/or aggression detection tools among PLWD.

Use of actigraphy for monitoring agitation and rest-activity cycles in patients with acute traumatic brain injury in the ICU.

BACKGROUND: In traumatic brain injury patients (TBI) admitted to the intensive care unit (ICU), agitation can lead to accidental removal of catheters, devices as well as self-extubation and falls. Actigraphy could be a potential tool to continuously monitor agitation. The objectives of this study were to assess the feasibility of monitoring agitation with actigraphs and to compare activity levels in agitated and non-agitated critically ill TBI patients. METHODS: Actigraphs were placed on patients' wrists; 24-hour monitoring was continued until ICU discharge or limitation of therapeutic efforts. Feasibility was assessed by actigraphy recording duration and missing activity count per day. RESULTS: Data from 25 patients were analyzed. The mean number of completed day of actigraphy per patient was 6.5 ± 5.1. The mean missing activity count was 20.3 minutes (±81.7) per day. The mean level of activity measured by raw actigraphy counts per minute over 24 hours was higher in participants with agitation than without agitation. CONCLUSIONS: This study supports the feasibility of actigraphy use in TBI patients in the ICU. In the acute phase of TBI, agitated patients have higher levels of activity, confirming the potential of actigraphy to monitor agitation.

An automated ICU agitation monitoring system for video streaming using deep learning classification.

OBJECTIVE: To address the challenge of assessing sedation status in critically ill patients in the intensive care unit (ICU), we aimed to develop a non-contact automatic classifier of agitation using artificial intelligence and deep learning. METHODS: We collected the video recordings of ICU patients and cut them into 30-second (30-s) and 2-second (2-s) segments. All of the segments were annotated with the status of agitation as "Attention" and "Non-attention". After transforming the video segments into movement quantification, we constructed the models of agitation classifiers with Threshold, Random Forest, and LSTM and evaluated their performances. RESULTS: The video recording segmentation yielded 427 30-s and 6405 2-s segments from 61 patients for model construction. The LSTM model achieved remarkable accuracy (ACC 0.92, AUC 0.91), outperforming other methods. CONCLUSION: Our study proposes an advanced monitoring system combining LSTM and image processing to ensure mild patient sedation in ICU care. LSTM proves to be the optimal choice for accurate monitoring. Future efforts should prioritize expanding data collection and enhancing system integration for practical application.

Wrist-worn actigraphy in agitated late-stage dementia patients: A feasibility study on digital inclusion.

BACKGROUND: Wrist-worn actigraphy can be an objective tool to assess sleep and other behavioral and psychological symptoms in dementia (BPSD). We investigated the feasibility of using wearable actigraphy in agitated late-stage dementia patients. METHODS: Agitated, late-stage Alzheimer's dementia care home residents in Greater London area (n = 29; 14 females, mean age ± SD: 80.8 ± 8.2; 93.1% White) were recruited to wear an actigraphy watch for 4 weeks. Wearing time was extracted to evaluate compliance, and factors influencing compliance were explored. RESULTS: A high watch-acceptance (96.6%) and compliance rate (88.0%) was noted. Non-compliance was not associated with age or BPSD symptomatology. However, participants with "better" cognitive function (R = 0.42, p = 0.022) and during nightshift (F1.240, 33.475 = 8.075, p = 0.005) were less compliant. Female participants were also marginally less compliant (F1, 26 = 3.790, p = 0.062). DISCUSSIONS: Wrist-worn actigraphy appears acceptable and feasible in late-stage agitated dementia patients. Accommodating the needs of both the patients and their carers may further improve compliance.

Impact of the iWHELD digital person-centered care program on quality of life, agitation and psychotropic medications in people with dementia living in nursing homes during the COVID-19 pandemic: A randomized controlled trial.

INTRODUCTION: iWHELD is a digital person-centered care program for people with dementia in nursing homes adapted for remote delivery during the COVID-19 pandemic. METHODS: A 16-week two-arm cluster-randomized controlled trial in 149 UK nursing homes compared iWHELD with treatment as usual (TAU). Primary outcome was the overall quality of life with secondary outcomes of agitation and psychotropic use. RESULTS: iWHELD conferred benefit to quality of life on the primary (F = 4.3, p = 0.04) and secondary measures of quality of life (F = 6.45, p = 0.01) and reduced psychotropic medication use (χ2  = 4.08, p = 0.04) with no worsening of agitation. Benefit was seen in participants who contracted COVID-19, those with agitation at baseline, and those taking psychotropic medications. DISCUSSION: iWHELD confers benefits to quality of life and key measures of well-being, can be delivered during the challenging conditions of a pandemic, and should be considered for use alongside any emerging pharmacological treatment for neuropsychiatric symptoms. HIGHLIGHTS: iWHELD is the only remote, digital delivery nursing home training programme for dementia care iWHELD improved quality of life in people with dementia and reduced antipsychotic use without worsening of agitation Residents who contracted Covid-19 during the study also experienced benefits from iWHELD iWHELD offers a valuable, pandemic-safe tool for improving dementia care.

Brazilian guidelines for the management of psychomotor agitation. Part 1. Non-pharmacological approach

Objective: To present the essential guidelines for non-pharmacological management of patients with psychomotor agitation in Brazil. Methods: These guidelines were developed based on a systematic review of articles published from 1997 to 2017, retrieved from MEDLINE (PubMed), Cochrane Database of Systematic Review, and SciELO. Other relevant articles identified by searching the reference lists of included studies were also used to develop these guidelines. The search strategy used structured questions formulated using the PICO model, as recommended by the Guidelines Project of the Brazilian Medical Association. Recommendations were summarized according to their level of evidence, which was determined using the Oxford Centre for Evidence-based Medicine system and critical appraisal tools. Results: We initially selected 1,731 abstracts among 5,362 articles. The final sample included 104 articles that fulfilled all the inclusion criteria. The management of agitated patients should always start with the least coercive approach. The initial non-pharmacological measures include a verbal strategy and referral of the patient to the appropriate setting, preferably a facility designed for the care of psychiatric patients with controlled noise, lighting, and safety aspects. Verbal de-escalation techniques have been shown to decrease agitation and reduce the potential for associated violence in the emergency setting. The possibility of underlying medical etiologies must be considered first and foremost. Particular attention should be paid to the patient's appearance and behavior, physical signs, and mental state. If agitation is severe, rapid tranquilization with medications is recommended. Finally, if verbal measures fail to contain the patient, physical restraint should be performed as the ultimate measure for patient protection, and always be accompanied by rapid tranquilization. Healthcare teams must be thoroughly trained to use these techniques and overcome difficulties if the verbal approach fails. It is important that healthcare professionals be trained in non-pharmacological management of patients with psychomotor agitation as part of the requirements for a degree and graduate degree. Conclusion: The non-pharmacological management of agitated patients should follow the hierarchy of less invasive to more invasive and coercive measures, starting with referral of the patient to an appropriate environment, management by a trained team, use of verbal techniques, performance of physical and mental assessment, use of medications, and, if unavoidable, use of the mechanical restraint. Systematic review registry number: CRD42017054440.

Mood versus energy/activity symptoms in bipolar disorder: which cluster of Hamilton Depression Rating Scale better distinguishes between mania, depression, and euthymia? / Sintomas de humor versus sintomas de energia/atividade no transtorno bipolar: qual grupo da Escala de Depressão de Hamilton distingue melhor entre mania, depressão e eutimia?

Abstract Introduction Although bipolar disorder (BD) is traditionally included among mood disorders, some authors believe that changes in energy and motor activity, rather than mood changes, represent the true cardinal symptoms in mania and depression. The aim of the current study was to identify which cluster of the Hamilton Depression Rating Scale (HAM-D) better distinguishes between mania, depression and euthymia. Method A group of 106 patients with BD were followed for 13 years and repeatedly assessed with the HAM-D as well as with other clinical scales. To perform a comparison, HAM-D items were classified according to clinical criteria into three clusters: energy/activity symptoms, mood symptoms, and other symptoms. Item response theory (IRT) analyses were performed to provide a test information curve for those three clusters. We measured the prevalence of one cluster of symptoms over the other two throughout the latent trait. Results Considering HAM-D items individually, the IRT analysis revealed that there was a mixture of mood and energy/activity symptoms among the most discriminative items, both in depression and in euthymia. However, in mania, only energy/activity symptoms - i.e., general somatic symptoms and retardation - were among the most informative items. Considering the classification of items, both in depression as in mania, the energy/activity cluster was more informative than the mood cluster according to the IRT analysis. Conclusion Our data reinforce the view of hyperactivity and motor retardation as cardinal changes of mania and depression, respectively.

Resumo Introdução Embora o transtorno bipolar (TB) seja tradicionalmente incluído entre os transtornos do humor, alguns autores acreditam que as alterações na energia e na atividade motora, em vez das alterações no humor, representam os verdadeiros sintomas cardinais na mania e na depressão. O objetivo do presente estudo foi identificar qual grupo da Escala de Depressão de Hamilton (HAM-D) distingue melhor entre mania, depressão e eutimia. Método Um grupo de 106 pacientes com TB foram acompanhados por 13 anos e avaliados repetidamente com a HAM-D e com outras escalas clínicas. Para realizar uma comparação, os itens da HAM-D foram classificados de acordo com critérios clínicos em três grupos: sintomas de energia/atividade, sintomas de humor e outros sintomas. Foram realizadas análises da teoria da resposta ao item (TRI) para fornecer uma curva de informações de teste para esses três grupos. Medimos a prevalência de um grupo de sintomas em comparação aos outros dois através do traço latente. Resultados Considerando os itens da HAM-D individualmente, a análise da TRI revelou que havia uma mistura de sintomas de humor e de energia/atividade entre os itens mais discriminativos, tanto na depressão quanto na eutimia. No entanto, na mania, apenas os sintomas de energia/atividade - ou seja, sintomas somáticos gerais e retardo - estavam entre os itens mais informativos. Considerando a classificação dos itens, tanto na depressão quanto na mania, o grupo energia/atividade foi mais informativo que o grupo humor, de acordo com a análise da TRI. Conclusão Nossos dados reforçam a visão da hiperatividade e do retardo motor como as alterações cardinais de mania e depressão, respectivamente.

Brazilian guidelines for the management of psychomotor agitation. Part 2. Pharmacological approach

Objective: To present the essential guidelines for pharmacological management of patients with psychomotor agitation in Brazil. Methods: This is a systematic review of articles retrieved from the MEDLINE (PubMed), Cochrane Database of Systematic Reviews, and SciELO databases published from 1997 to 2017. Other relevant articles in the literature were also used to develop these guidelines. The search strategy used structured questions formulated using the PICO model, as recommended by the Guidelines Project of the Brazilian Medical Association. Recommendations were summarized according to their level of evidence, which was determined using the Oxford Centre for Evidence-based Medicine system and critical appraisal tools. Results: Of 5,362 articles retrieved, 1,731 abstracts were selected for further reading. The final sample included 74 articles that met all inclusion criteria. The evidence shows that pharmacologic treatment is indicated only after non-pharmacologic approaches have failed. The cause of the agitation, side effects of the medications, and contraindications must guide the medication choice. The oral route should be preferred for drug administration; IV administration must be avoided. All subjects must be monitored before and after medication administration. Conclusion: If non-pharmacological strategies fail, medications are needed to control agitation and violent behavior. Once medicated, the patient should be monitored until a tranquil state is possible without excessive sedation. Systematic review registry number: CRD42017054440.

The correlation among the Ramsay sedation scale, Richmond agitation sedation scale and Riker sedation agitation scale during midazolam-remifentanil sedation / Correlação entre a escala de sedação de Ramsay, escala de sedação-agitação de Richmond e escala de sedação-agitação de Riker durante sedação com midazolam-remifentanil

Abstract Background and objectives: Sedative and analgesic treatment administered to critically ill patients need to be regularly assessed to ensure that previously stated goals are well achieved as the risk of complications of oversedation is minimized. We revised and prospectively tested the Ramsay Sedation scale (RSS) for interrater reliability and compared it with the Sedation-Agitation Scale (SAS) and the Richmond Agitation Sedation Scale (RASS) to test construct validity during midazolam-remifentanil sedation. Methods: A convenience sample of ICU patients was simultaneously and independently examined by pairs of trained evaluators by using the revised SAS, RSS, and RASS. Ninety-two ICU patients were examined a total of 276 times by evaluator pairs. Results: The mean patient age was 61.32 ± 18.68 years, 45,7% were female (n = 42), 54.3% male (n = 50). Their APACHE values varied between 3 and 39 with an average of 13.27 ± 7.86 and 75% of the cases were under mechanical ventilation. When classified by using RSS (2.70 ± 1.28), 10.9% were anxious or agitated (RSS1), 68.5% were calm (RSS 2-3), and 20.6% were sedated (RSS 4-6). When classified by using RASS (-0.64 ± 1.58), 20.7% were anxious or agitated (RASS+1 to +4), 63.0% were calm (RASS 0 to -2), and 16.3% were sedated (RASS -3 to -5). When classified by using SAS (2.63 ± 1.00), 12% were anxious or agitated (SAS 5-7), 57.6% were calm (SAS 4), and 30.4% were sedated (SAS 1-3). RSS was correlated with the SAS (r = -0.656, p < 0.001) and RASS was correlated with the SAS (r = 0.565, p < 0.001). RSS was highly correlated with the RASS (r = -0.664, p < 0.001). Conclusions: Ramsay is both reliable and valid (high correlation with the RASS and SAS scales) in assessing agitation and sedation in adult ICU patients.

Resumo Justificativa e objetivos: O tratamento de pacientes em estado crítico com sedativos e analgésicos deve ser regularmente avaliado para garantir que as metas pré-definidas sejam atingidas, bem como minimizar o risco de complicações resultantes de sedação em excesso. Conduzimos uma revisão e testamos prospectivamente a Escala de Sedação de Ramsay (Ramsay Sedation Scale [RSS]) para a confiabilidade interavaliador e a comparamos com a Escala de Sedação e Agitação de Riker (Riker Sedation-Agitation Scale [RRSAS]) e a Escala de Sedação e Agitação de Richmond (Richmond Agitation Sedation Scale [RASS]) para testar a validade de construto durante a sedação com midazolam-remifentanil. Métodos: Uma amostra de conveniência de pacientes de UTI foi simultânea e independentemente examinada por pares de avaliadores treinados com o uso das escalas revisadas RRSAS, RSS e RASS. Foram examinados 92 pacientes de UTI por pares de avaliadores em 276 momentos. Resultados: A média dos pacientes foi de 61,32 ± 18,68 anos; 45,7% eram do sexo feminino (n = 42) e 54,3% do masculino (n = 50). Seus escores APACHE variaram entre 3-39, com média de 13,27 ± 7,86, e 75% dos casos receberam ventilação mecânica. Quando RSS foi usada para a classificação (2,70 ± 1,28), 10,9% dos pacientes estavam ansiosos ou agitados (RSS1), 68,5% estavam calmos (RSS 2 a 3) e 20,6% estavam sedados (RSS 4 a 6). Quando RASS foi usada para a classificação (-0,64 ± 1,58), 20,7% dos pacientes estavam ansiosos ou agitados (RASS +1 a +4), 63,0% estavam calmos (RASS 0 a -2) e 16,3% estavam sedados (RASS -3 a -5). Quando RSAS foi usada para a classificação (2,63 ± 1,00), 12% dos pacientes estavam ansiosos ou agitados (RSAS 5 a 7), 57,6% estavam calmos (RSAS 4) e 30,4% estavam sedados (RSAS 1 a 3). Houve correlação de RSS com RSAS (r = -0,656, p < 0,001) e de RASS com RSAS (r = 0,565, p < 0,001). Houve forte correlação de RSS com RASS (r = -0,664, p < 0,001). Conclusões: A RSS é confiável e válida (forte correlação com RASS e RSAS) para avaliar a sedação e agitação em pacientes adultos internados em UTI.

Validity, reliability and applicability of Portuguese versions of sedation-agitation scales among critically ill patients / Validade, confiabilidade e aplicabilidade das versões em português de escalas de sedação e agitação em pacientes críticos

CONTEXT AND OBJECTIVE: Sedation scales are used to guide sedation protocols in intensive care units (ICUs). However, no sedation scale in Portuguese has ever been evaluated. The aim of this study was to evaluate the validity and reliability of Portuguese translations of four sedation-agitation scales, among critically ill patients: Glasgow Coma Score, Ramsay, Richmond Agitation-Sedation Scale (RASS) and Sedation-Agitation Scale (SAS). DESIGN AND SETTING: Validation study in two mixed ICUs of a university hospital. METHODS: All scales were applied to 29 patients by four different critical care team members (nurse, physiotherapist, senior critical care physician and critical care resident). We tested each scale for interrater reliability and for validity, by correlations between them. Interrater agreement was measured using weighted kappa (k) and correlations used Spearman's test. RESULTS: 136 observations were made on 29 patients. All scales had at least substantial agreement (weighted k 0.68-0.90). RASS (weighted k 0.82-0.87) and SAS (weighted k 0.83-0.90) had the best agreement. All scales had a good and significant correlation with each other. CONCLUSIONS: All scales demonstrated good interrater reliability and were comparable. RASS and SAS showed the best correlations and the best agreement results in all professional categories. All these characteristics make RASS and SAS good scales for use at the bedside, to evaluate sedation-agitation among critically ill patients in terms of validity, reliability and applicability.

CONTEXTO E OBJETIVO: Escalas de sedação são usadas para guiar protocolos de sedação em unidades de terapia intensiva. Entretanto, nenhuma escala em português foi avaliada. O objetivo foi avaliar, quanto a validade e confiabilidade, quatro escalas de sedação/agitação (Glasgow, Ramsay, Richmond Agitation-Sedation Scale, RASS, e Sedation-Agitation Scale, SAS) traduzidas ao português em pacientes de terapia intensiva. TIPO DE ESTUDO E LOCAL: Estudo de validação em duas UTIs de hospital universitário. MÉTODOS: Todas as escalas foram aplicadas a 29 pacientes por quatro membros da equipe multiprofissional (uma enfermeira, um fisioterapeuta, um médico intensivista e um residente de medicina intensiva). Cada escala foi testada para confiabilidade interobservador e para validade, usando-se a correlação entre elas. A concordância foi medida pelo kappa ponderado e as correlações foram feitas pelo teste de Spearman. RESULTADOS: Todas as escalas tiveram uma concordância substancial (k ponderado 0,68-0,90). As escalas RASS (k ponderado 0,82-0,87) e SAS (k ponderado 0,83-0,90) tiveram a melhor concordância. Todas as escalas tiveram concordância boa e significante entre elas. CONCLUSÕES: Todas as escalas tiveram boa concordância interobservador e foram comparáveis entre elas. As escalas RASS e SAS tiveram a melhor correlação entre elas e os melhores resultados de concordância entre as categorias multiprofissionais. Estas características fazem com que as escalas RASS e SAS sejam boas para a avaliação de sedação e agitação de pacientes críticos em termos de validade, confiabilidade e aplicabilidade.

E449X mutation in the thyroid hormone receptor β associated with autoimmune thyroid disease and severe neuropsychomotor involvement / Mutação E449X no receptor β do hormônio tireoidiano associada com doença tireoidiana auto-imune e retardo neuropscicomotor grave

OBJECTIVE: To report the clinical and molecular aspects of a patient with a diagnosis of Resistance to Thyroid Hormone (RTH) harboring the E449X mutation associated with autoimmune thyroid disease and severe neuropsychomotor retardation. METHODS: We present a case report including clinical and laboratory findings, and molecular analysis of a Brazilian patient with RTH. RESULTS: A 23-year old male presented hyperactivity disorder, attention deficit, delayed neuropsychomotor development, and goiter. Since the age of 1 year and 8 months, his mother had sought medical care for her son for the investigation of delayed neuropsychomotor development associated with irritability, aggressiveness, recurrent headache, profuse sudoresis, intermittent diarrhea, polyphagia, goiter, and low weight. Laboratory tests revealed normal TSH, increased T3, T4, antithyroglobulin and antimicrosomal antibody titers. Increasing doses of levothyroxine were prescribed, reaching 200 µg/day, without significant changes in his clinical-laboratory picture. Increasing doses of tiratricol were introduced, with a clear clinical improvement of aggressiveness, hyperactivity, tremor of the extremities, and greater weight gain. Molecular study revealed a nonsense mutation in exon 10, in which a substitution of a guanine to tyrosine in nucleotide 1345 (codon 449) generates the stop codon TAA, confirming the diagnosis of RTH. CONCLUSION: This patient has severe neuropsychomotor retardation not observed in a single previous report with the same mutation. This may reflect the lack of a genotype-phenotype correlation in affected cases with this syndrome, suggesting that genetic variability of factors other than β receptor of thyroid hormone (TRβ) might modulate the phenotype of RTH.

OBJETIVOS: Descrever aspectos clínicos e moleculares de um paciente com resistência ao hormônio tireoidiano (RHT) portador da mutação E449X associada a doença tireoideana auto-imune e retardo neuropscicomotor grave. MÉTODOS: Relatamos um caso incluindo achados clínicos, laboratoriais e análise molecular de um paciente brasileiro com RHT. RESULTADOS: Paciente masculino, 23 anos de idade, apresentou-se com distúrbio de hiperatividade, déficit de atenção, retardo no desenvolvimento neuropsicomotor e bócio. Desde 1 ano e 8 meses de idade, sua mãe procurou assistência médica para investigação do retardo do desenvolvimento neuropsicomotor associado com irritabilidade, agressividade, cefaléia recorrente, sudorese profusa, diarréia intermitente, polifagia, bócio e perda de peso. Avaliação laboratorial evidenciou TSH normal e aumento do T3, T4 e anticorpos antimicrossomal e antitireoglobulina. Doses crescentes de levotiroxina foram prescritas, máximo de 200 µg/dia, sem significativas alterações em seu quadro clínico-laboratorial. Doses crescentes de tiratricol foram introduzidas com melhora clínica evidente da agressividade, da hiperatividade, do tremor de extremidades e maior ganho de peso. O estudo molecular revelou uma mutação nonsense no éxon 10, no qual a substituição da guanina pela tirosina no nucleotídeo 1345 (códon 449) gerou um stop códon TAA, confirmando o diagnóstico da RHT. CONCLUSÃO: Este paciente tem um grave retardo neuropiscomotor não observado em um relato único anterior com a mesma mutação. Isto pode refletir a falta de relação genotipo-fenótipo nos casos afetados com esta síndrome sugerindo que a variabilidade genética de outros fatores, além do receptor do hormônio tireoidiano (HT), possa modular o fenótipo da RHT.

A criança agitada nem sempre é um problema / The agitated child is not always a problem

O termo agitação pode englobar muitos comportamentos diferentes, geralmente associados a algum transtorno psiquiátrico, como transtorno de déficit de atenção e hiperatividade (TDAH), transtorno de conduta, transtorno afetivo bipolar (TAB). Uma dúvida frequente é quando considerar a agitação psicomotora parte do desenvolvimento normal infantil ou de alguma doença psiquiátrica. A patologia existe quando a fase de agitação persiste além do esperado para a idade e circunstância, há prejuízo funcional importante nas relações sociais dentro da família, com pares e no desempenho escolar, além da presença de outros sintomas. Apesar da influência genética, a grande capacidade de adaptação do cérebro na infância e adolescência permite que as experiências infantis tenham efeito duradouro nos circuitos neurais por toda a vida, reforçando a importância de um ambiente favorável e do tratamento medicamentoso e psicoterápico adequado, nesta faixa etária. O foco da intervenção deve ser ensinar comportamentos pró-sociais, para que a criança/adolescente lide adequadamente com as situações que anteriormente provocavam agitação, envolvendo a colaboração de pais, pares, escola e demais profissionais.

Reacción anafiláctica a la ocitocina utilizada para una operación cesárea: a propósito de un caso / Anaphilactic reaction to oxitocin used in a cesarean section. Case report

Se presenta el caso de una paciente sometida a operación cesárea bajo anestesia peridural que luego del nacimiento del niño desarrolla un cuadro brusco de excitación psicomotriz, dificultad respiratoria, caída de la Sat O 2 e hipotensión importante, desencadenado inmediatamente luego de la inyección de 10 UL de Ocitocina. Se discuten los diagnósticos alternativos por la similitud del cuadro clínico con la embolia de líquido amniótico, tromboembolismo pulmonar, broncoespasmo severo, crisis de pánico y bloqueo subdural

Uso da medicaçäo homeopática no tratamento de pacientes portadores de visäo subnormal associada à inquiataçäo motora, défiit de atençäo e impulsividade / Use of homeopathic medicine in the treatment of patients with low vision associated with motor uneasiness, attention deficit and impulsiveness

Resumo: Objetivo: Verificar a eficácia do tratamnto homeopático no controle da inquietaçäo motora, falta de atençäo e impulsividade nas crianças portadoras de visäo subnormal. Local: Departamento de Visäo Subnormal o Hospital Säo Geraldo da UFMG e Instituto Mineiro de Homeopatia. Metodo: Em um estudo piloto longitudinal e observacioal foram examinadas 4 crianças do sexo feminino, com idade que variava de um a nove anos, portadoras de visäo subnrmal de etiologias diversas. Quando suspeitava-se de inquietaçäo motora, falta de atençäo e impulsividade, discutia-se em equipe o diagnóstico e encaminhava-se a criança para consulta homeopática. Resultado: Todos os pacientes tiveram uma boa evoluçäo dos sintomas quando avaliados pela equipe multidisciplinar e pelo homeopata. Conclusäo: A hoeopatia pode contribuir para o tratamento dos pacientes com visäo subnormal à inquietaçäo motora, déficit de atençäo e impulsividade (au)

Agitação psicomotora / Psychomotor agitation

Pacientes agitados são presença constante na prática médica. Portanto, é fundamental que pessoas relacionadas a essa área tenham conhecimento acerca do tema. Nesse trabalho serão discutidos conceitos, etiologia, manejo e outras particularidades a respeito do tema. Os autores realizam uma revisão bibliográfica em livros textos e artigos recentes

El posoperatorio inmediato en neurocirugía craneana / Initial postoperative care after cranial neurosurgery

La valoración previa del riesgo anestésico quirúrgico y la prevención de las complicaciones constituyen estrategias claves de la anestesia. La primera hora del postoperatorio neuroquirúrgico representa un período crítico en el cual pueden desarrollarse complicaciones que comprometan la vida del paciente; la falta de recuperación de la conciencia, la hipotermia, alteraciones del medio interno y la dificultad respiratoria constituyen las principales. Se analiza la prevención, diagnóstico y tratamiento de las principales complicaciones postoperatorias en el paciente neuroquirúrgico. Se describen las causas anestésicas, quirúrgicas y fisiopatológicas de retraso en el despertar.

Acatisia: enfoque clínico-descritivo e aprofundamento diagnóstico / Akathisia a clinical-descriptive approach a contribution to a diagnosis

A acatisia se caracteriza por um sentimento subjetivo de intranquilidade de uma inquietaçäo motora. A interaçäo entre psiquismo e motricidade é enfocada: a acatisia é considerada um fenômeno neuropsiquiátrico com componenentes motores, afetivos e cognitivos. Após apresentaçäo de aspectos clínicos e descritivos é abordado o diagnóstico diferencial. Escalas neuropsiquiátricas para o acesso da acatisia säo comentadas