Ethical issues in end of life treatments for patients with dementia.

Dementia is a terminal disease, associated with great suffering and difficult decisions in the severe stage. The decision-making process is characterized by uncertainty because of lack of scientific evidence in treatments and by the need to reconcile conflicting points of view. In intercurrent diseases, aggressive interventions are used without consideration of its futility; in comparison with cancer, several consequences of physicians' attitude not to consider dementia as a terminal disease have been reported, especially concerning pain relief. Lack of evidence of artificial nutrition and hydration effectiveness makes advance care planning relevant.

Superficial siderosis of the central nervous system after brachial plexus injury. Case report.

Superficial siderosis is a rare condition characterized by deposition of hemosiderin in the leptomeninges and in the subpial layers of the brain and spinal cord. It is associated with cerebrospinal fluid abnormalities consistent with recurrent bleeding into the subarachnoid space. The usual symptoms are hearing loss, ataxia, spastic paraparesis, sensory and sphincter deficits, and mental deterioration. A case is presented of severe superficial siderosis of the central nervous system in a 51-year-old man who had suffered a brachial plexus injury at the age of 20 years. The diagnosis was made by means of magnetic resonance imaging 16 years after the initial symptoms, which comprised bilateral hearing loss and anosmia. Subarachnoid bleeding was due to traumatic pseudomeningocele of the brachial plexus, a very unusual cause of superficial siderosis. This case is interesting insofar as the surgical treatment prevented further bleeding and possibly progression of the disease.

Ethical questions in the treatment of subjects with dementia. Part I. Respecting autonomy: awareness, competence and behavioural disorders.

The document deals with some ethical issues raised by the treatment of demented people. In particular the conceptual and empirical aspects of the assessment of awareness and competence of these patients are analysed, as well as the dilemmas related to the treatment of behavioral disorders.

Left caloric vestibular stimulation ameliorates right hemianesthesia.

BACKGROUND: Left caloric vestibular stimulation (CVS) transiently reduces impairments of right-brain-damaged patients with left unilateral neglect, including left hemianesthesia, contralateral to the side of the lesion (contralesional). Conversely, no effect on right contralesional hemianesthesia in left-brain-damaged patients is seen with right CVS. This discrepancy is unexplained. METHODS: The authors explored the effect of CVS on right- and left-brain-damaged patients with hemianesthesia. One left-brain-damaged patient had an fMRI study during tactile stimulation before and after left CVS. The same fMRI touch study, without CVS, was performed in neurologically unimpaired subjects. RESULTS: A transient remission of right hemianesthesia associated with left brain damage was observed, provided that cold CVS was administered to the left ear. In the left-brain-damaged patient studied with fMRI, left CVS modulated the neural response to right hand tactile stimuli of a portion of the secondary somatosensory area (SII) of the right hemisphere. In neurologically unimpaired subjects, fMRI scans showed that the same part of area SII in the right hemisphere was activated by ipsilateral right-sided touches and to a larger extent than area SII in the left hemisphere by left-sided touches. CONCLUSIONS: Left caloric vestibular stimulation is effective on both left and right hemianesthesia because it modulates the hemisphere that has a more complete representation of, or is capable to attend to, the whole somatosensory surface of the body. These results suggest a hardwired hemispheric asymmetry in hand representation, starting from a somatotopically organized brain region such as area SII.

Diffuse cerebral cysticercosis: clinical and CT findings in a case.

A case of cerebral cysticercosis with both generalized and partial (multifocal) seizures is described. The diagnosis was not possible with traditional (pre-CT) procedures, but CT disclosed a very characteristic pattern. This disease, rare in our country, is very common elsewhere, particularly in South America, where epilepsy of recent onset in an adult or symptoms increased intracranial pressure always suggest this possible etiology.

[Progressive external ophthalmoplegia: clinical observations in two cases (author's transl)]. / Su due casi di oftalmoplegia esterna progressiva. Contributo clinico.

Two patients developed Progressive External Ophthalmoplegia at the age of 20 and 50 years respectively. There was no clinical invovlement of either skeletal muscles or the CNS. Electron microscopy of the lateral rectus muscle showed in one case regressive changes in the myofibrillary apparatus and in the mitochondria. Light microscopy of the quadriceps muscle in the other case showed only mild non-specific myopathic changes. EMG of the ocular muscles suggested a primary muscular damage in both cases.

Before M.A.S.T.-I: analysis of the population of a participating center.

Between 1 January 1989 and 31 December 1990 568 consecutive patients were admitted to our unit for ischemic stroke (defined on clinical criteria and with CT or MR evidence of ischemic areas or exclusion of hemorrhage or tumor). The interval between onset of symptoms and arrival in hospital was under 6 h in 270 cases (47.5%). We classified our population according to the clinical criteria proposed by Bamford et al. by subgroup as follows: LACI (27.5%); PACI (24.5%); TACI (30.6%); POCI (17.4%). The mortality in our population was 10.9%. The distribution of the risk factors considered was: hypertension in 387 cases (67%), diabetes in 158 cases (27.8%), NVAF in 95 cases (16.7%). Our data show that about a half of all patients with ischemic stroke can expect to receive treatment at the acute stage.

The effect of anticonvulsant drugs on blood levels of methotrexate.

The reduced bioavailability of chemotherapeutic agents is one of the reasons that explains the limited efficacy of adjuvant chemotherapy in high grade glioma patients. We report how even the results of high dose sequential chemotherapy can be influenced by antiepileptic drugs.

Prospective follow-up study of chronic polyneuropathy of undetermined cause.

Forty consecutive patients with chronic sensorimotor polyneuropathy of undetermined cause were followed to determine disease progression and prognosis. They had had neurological symptoms for at least 1 year before presentation. Neurophysiological examination in all patients showed chronic axonal degeneration, which was confirmed by sural nerve biopsy. Patients were reviewed every 3 months. Laboratory tests were performed every 6 months for the first 2 years and then annually. Neurophysiological examination was performed annually in all patients. Patients were followed up for at least 4 years. In no instance was a possible etiological factor detected during follow-up. The clinical and electrophysiological findings had a slowly progressive course. We suggest that patients with a chronic polyneuropathy of undetermined cause despite detailed investigations do not require further extensive and expensive laboratory tests and neurophysiological studies during follow-up.

Porphyric neuropathy: a clinical, neurophysiological and morphological study.

A case of neuropathy in the course of an attack of acute intermittent porphyria was studied from the neurophysiological and morphological points of view. The neurophysiological findings (acute neuropathy with almost complete denervation despite normal or slightly reduced conduction velocity) and the morphological findings (no segmental demyelination after teasing, conservation of the linear fiber diameter/internodal distance ratio, mainly axonal damage on ultrastructural study) seem to indicate that the disease process is chiefly an axonal neuropathy.

Atypical features and prognosis of Wallenberg syndrome: longitudinal study.

The lessons of a retrospective study of 24 consecutive cases of Wallenberg syndrome observed during a 6-year span are described: the high frequency of signs and symptoms not considered typical, such as headache, diplopia, supranuclear homolateral facial paresis and homolateral brachiocrural hemiparesis; the unfavorable short term course in a high percentage of cases, and the risk of sudden respiratory arrest.

Transient global amnesia: a clinical and EEG study.

33 cases of transient global amnesia are reported. An interaction between organic and functional factors in determining the syndrome is supposed.

Association between lupus anticoagulant and epilepsy.

Lupus anticoagulant associated with thrombocytopenia, thrombosis or recurrent abortions was diagnosed in 2 epileptic patients chronically treated with anticonvulsant drugs. The immunoglobulin fractions containing the anticoagulant activity were isolated and characterized. A search for lupus inhibitor was carried out in 96 consecutively examined patients, but no further cases were found. Although rarely, lupus anticoagulant and epilepsy may be associated. Whether lupus anticoagulant is causally related with epileptic seizures or secondary to the use of antiepileptic drugs remains to be established.