Discriminative value of different combinations of tests to detect unilateral neglect in patients with right hemisphere damage.

BACKGROUND AND PURPOSE: This study was undertaken to assess the most sensitive combination of tests to detect peripersonal unilateral neglect (UN) after stroke. METHODS: The present study is a secondary analysis of a previously reported multicentric study of 203 individuals with right hemisphere damage (RHD), mainly subacute stroke, 11 weeks postonset on average, and 307 healthy controls. A battery of seven tests, providing 19 age- and education-adjusted z-scores, were given: the bells test, line bisection, figure copying, clock drawing, overlapping figures test, and reading and writing. Statistical analyses used a logistic regression and a receiver operating characteristic (ROC) curve after adjustment on demographic variables. RESULTS: A combination of four z-scores based on the following three tests provided good discrimination of patients with RHD from matched healthy controls: the starting point and the difference between the number of omissions on left and right sides from the bells test, rightward deviation in bisection of long lines (20 cm), and left-sided omissions in a reading task. The area under the ROC curve was 0.865 (95% confidence interval = 0.83-0.901), with sensitivity = 0.68, specificity = 0.95, accuracy = 0.85, positive predictive value = 0.90, and negative predictive value = 0.82. CONCLUSIONS: The most sensitive and parsimonious combination of tests to detect UN after stroke relies on four scores from three simple tests (bells test, line bisection, and reading). Future study is warranted to assess its ability to account for the functional difficulties of UN in daily life in the patient's actual environment.

Care management of the agitation or aggressiveness crisis in patients with TBI. Systematic review of the literature and practice recommendations.

UNLABELLED: The agitation crisis in the awakening phase after traumatic brain injury (TBI) is one of the most difficult behavioral disorders to alleviate. Current treatment options are heterogeneous and may involve excessive sedation. Practice guidelines are required by professionals in charge of TBI patients. Few reviews were published but those are old and based on expert opinions. The purpose of this work is to propose evidence-based guidelines to treat the agitation crisis. METHODS: The elaboration of these guidelines followed the procedure validated by the French health authority for good practice recommendations, close to the Prisma statement. Guidelines were elaborated on the basis of a systematic and critical review of the literature. RESULTS: Twenty-eight articles concerning 376 patients were analyzed. Recommendations are: when faced with an agitation crisis, the management strategy implies to search for an underlying factor that should be treated such as pain, acute sepsis, and drug adverse effect (expert opinion). Physical restraints should be discarded when possible (expert opinion). Neuroleptic agent with a marketing authorization can be used in order to obtain a quick sedation so as to protect the patient from himself, closed ones or the healthcare team but the duration should be as short as possible (expert opinion). The efficacy of beta-blockers and antiepileptics with mood regulation effects like carbamazepine and valproate yield the most compelling evidence and should be preferably used when a background regimen is envisioned (grade B for beta-blocker and C for antiepileptics). Neuroleptics, antidepressants, benzodiazepines, buspirone may be prescribed but are considered second-line treatments (expert opinion). CONCLUSION: This study provides a strategy for treating the agitation crisis based on scientific data and expert opinion. The level of evidence remains low and published data are often old. New studies are essential to validate results from previous studies and test new drugs and non-pharmaceutical therapies.

Non pharmacological treatments for psychological and behavioural disorders following traumatic brain injury (TBI). A systematic literature review and expert opinion leading to recommendations.

INTRODUCTION: The non pharmacological approach is an important issue in the treatment of psychological and behavioural disorders in traumatic brain injury (TBI) patients. It remains nevertheless insufficiently known and defined. The objective of this work was to develop precise recommendations for caregivers and relatives. METHOD: The elaboration of these guidelines followed the procedure validated by the French health authority for good practice recommendations, close to the Prisma statement, involving a systematic, critical review of the literature and the expert opinions of the French Society of Physical Medicine and Rehabilitation (SOFMER) group. RESULTS: 458 articles were identified, among which 98 were selected for their relevance to the theme of the research. None of the studies reached the highest level of evidence. Fifteen controlled studies reached a relatively high level of evidence (level 2); other studies were case series or expert opinions, and other articles again were reviews of the literature and theoretical points of view. The holistic approach structured into programmes, cognitive-behavioural therapy, and family and systemic therapy, despite the low levels of proof, are recommended in first intention at all stages in the evolution of TBI. Relational and adaptive approaches, rehabilitation and vocational approaches, and psychoanalytical therapies may be useful, provided that therapists are familiar with and trained in traumatic brain injury. CONCLUSION: Despite the small number of publications and a low level of proof, a number of recommendations for the non-pharmacological approach to psychological and behavioural disorders in TBI is proposed by the consensus conference of experts. Scientific research in this domain is needed to confirm and complete these first recommendations.

Intravesical capsaicin versus resiniferatoxin for the treatment of detrusor hyperreflexia in spinal cord injured patients: a double-blind, randomized, controlled study.

PURPOSE: Chemical defunctionalization of C-fiber bladder afferents with intravesical vanilloids such as capsaicin (CAP) or resiniferatoxin (RTX) improves detrusor hyperreflexia in humans and animals. The little existing data comparing the efficacy and tolerance of these 2 vanilloid agents seem to favor RTX in 10% alcohol over CAP, which is usually diluted in 30% alcohol. We compared the efficacy and tolerability of the 2 vanilloid agonists in what to our knowledge is the first randomized, controlled study comparing nonalcohol CAP vs RTX in 10% alcohol in neurogenic patients with detrusor hyperreflexia. MATERIALS AND METHODS: This single center, randomized, double-blind, parallel groups study included 39 spinal cord injured adults with detrusor hyperreflexia. On day 0 patients were randomized to receive 1, 100 ml intravesical instillation of 100 nMol/l RTX diluted in 10% ethanol or 1 mmol/l CAP diluted in glucidic solvent. Efficacy (voiding chart and cystomanometry) and tolerability were evaluated during a 3-month followup. RESULTS: On day 30 clinical and urodynamical improvement was found in 78% and 83% of patients with CAP vs 80% and 60% with RTX, respectively, without a significant difference between the 2 treated groups. The benefit remained in two-thirds of the 2 groups on day 90. There were no significant differences in regard to the incidence, nature or duration of side effects in CAP vs RTX treated patients. CONCLUSIONS: Our results strongly argue for the importance of accounting for the role of vanilloid solute when interpreting the efficacy and tolerance of vesical vanilloid instillation in detrusor hyperreflexia cases. They suggest that a glucidic solute is a valuable solvent for vanilloid instillation.