Post-intensive care syndrome: Recent advances and future directions.

Post-intensive care syndrome comprises physical, cognitive, and mental impairments in patients treated in an intensive care unit (ICU). It occurs either during the ICU stay or following ICU discharge and is related to the patients' long-term prognosis. The same concept also applies to pediatric patients, and it can greatly affect the mental status of family members. In the 10 years since post-intensive care syndrome was first proposed, research has greatly expanded. Here, we summarize the recent evidence on post-intensive care syndrome regarding its pathophysiology, epidemiology, assessment, risk factors, prevention, and treatments. We highlight new topics, future directions, and strategies to overcome post-intensive care syndrome among people treated in an ICU. Clinical and basic research are still needed to elucidate the mechanistic insights and to discover therapeutic targets and new interventions for post-intensive care syndrome.

Patient-reported outcomes provide evidence for increased depressive symptoms and increased mental impairment in giant cell arteritis.

Objectives: The spectrum of giant cell arteritis (GCA) and polymyalgia rheumatica (PMR) represents highly inflammatory rheumatic diseases. Patients mostly report severe physical impairment. Possible consequences for mental health have been scarcely studied. The aim of this study was to investigate psychological well-being in the context of GCA and PMR. Methods: Cross-sectional study with N = 100 patients with GCA and/or PMR (GCA-PMR). Patient-reported outcomes (PROs) were measured using the Short Form 36 Version 2 (SF-36v2) and visual analog scale (VAS) assessment. Moreover, the Patient Health Questionnaire 9 (PHQ-9) was used in 35 of 100 patients to detect depression. To compare PROs with physician assessment, VAS was also rated from physician perspective. To assess a possible association with inflammation itself, serological parameters of inflammation (C-reactive protein [CRP], erythrocyte sedimentation rate [ESR]) were included. Results: In all scales of the SF-36v2 except General Health (GH) and in the physical and mental sum score (PCS, MCS), a significant impairment compared to the German reference collective was evident (MCS: d = 0.533, p < 0.001). In the PHQ-9 categorization, 14 of the 35 (40%) showed evidence of major depression disorder. VAS Patient correlated significantly with PHQ-9 and SF-36 in all categories, while VAS Physician showed only correlations to physical categories and not in the mental dimensions. Regarding inflammatory parameters, linear regression showed CRP to be a complementary significant positive predictor of mental health subscale score, independent of pain. Conclusion: PRO show a relevant impairment of mental health up to symptoms of major depression disorder. The degree of depressive symptoms is also distinctly associated with the serological inflammatory marker CRP.

An analysis of arguments for the retention of the defence of mental impairment.

This article summarises the main arguments for the retention of the defence of mental impairment presented in an online debate that took place in August 2021. It canvases the justifications for the defence, rebuts human rights arguments for its abolition and outlines why there is a lack of viable alternatives. It concludes that advances in knowledge should lead to the reform of the defence rather than its abolition.

Arguments for the abolition of the defence of mental impairment.

This article summarises arguments for abolishing the mental impairment defence, using the example of the defence in Victoria, taking a historical and comparative approach. It considers the defence in practice, its origins and stagnation in medieval and Victorian England, a better approach based on modern developments in the UK and Europe, its resistance to meaningful reform, and its failure to achieve its laudable, humane and principled aim of sparing vulnerable people with severe mental health problems from punishment. We conclude that the only way to actually achieve this aim is to abolish the mental impairment defence and replace it with an approach that allows for flexible mental health disposals for mentally disordered offenders based on clinical needs and, where necessary, the need for containment, incorporated in and aligned with mental health legislation, regardless of culpability, and with modern systems and services that bring Victoria out of the nineteenth century.

Seizures, Postictal States and Criminal Responsibility.

This column provides an overview of how courts have taken into account seizures and postictal states in terms of assigning criminal responsibility. In England, New Zealand and Australia, courts have generally treated evidence of epileptic seizures and postictal states as raising the defence of mental impairment which often results in indefinite detention. In comparison, there is a series of Canadian cases that have resulted in acquittals after evidence of seizures has been accepted as negating voluntariness or the fault element of the offence. It appears that policy issues have been influential in the Canadian cases, particularly a reluctance to equate epilepsy with "mental disorder".

Human Rights Law and the Defence of Mental Impairment.

This article provides an overview of recent scholarship calling for the defence of mental impairment to be abolished on the grounds that it breaches international human rights law. It outlines how differing interpretations of the United Nations Convention on the Rights of Persons with Disabilities (CRPD) suggest that arguments for abolition will continue to be contested. On a practical level, no Australasian law reform body has called for the abolition of the defence and it seems unlikely that government policy will shift towards this in the absence of such a recommendation from these bodies. However, highlighting the obligations on States Parties to the CRPD to ensure the right to equal treatment before the law necessitates a careful consideration of whether the defence of mental impairment is still fit for purpose.

Is there a higher risk of dislocation of hip hemiarthroplasty in patients with neuromuscular conditions? A clinical study of 3827 patients.

AIM OF THE STUDY: The aim of this study is to identify if there is any association between neuromuscular disorders and prosthetic dislocation in patients treated with hip hemiarthroplasty for neck of femur fractures. PATIENTS AND METHODS: Our study is a retrospective analysis of data collected over 34 years for patients with intracapsular neck of femur fracture who underwent hip hemiarthroplasty. Pathological fractures and patients treated with other treatment modalities were excluded. The study population is composed of four groups; patients with no neuromuscular disorders, patients with Parkinson's disease, patients with previous stroke, and patients with mental impairment. RESULTS: A total of 3827 patients were treated with hip hemiarthroplasty. For the 3371 patients with no neuromuscular condition (Group I) the dislocation rate was 1.1%. 219 patients had Parkinsonism (Group II) with a dislocation rate of 3.2%, 104 patients had a previous stroke with weakness on the fracture side with a dislocation rate of 1.0% (Group III), and 984 patients had severe mental impairment with a dislocation rate of 1.8% (Group IV). The increased dislocation rate for those with Parkinson's disease was statistically significant (p = 0.02) while none of the other neuromuscular conditions were statistically significant. CONCLUSION: Our study demonstrates an increased risk of dislocation after hemiarthroplasty for patients with Parkinson's disease in comparison to other groups. No increase was apparent for those with mental impairment or weakness from a previous stroke.

Cognitive changes in patients with epilepsy identified through the MoCA test during neurology outpatient consultation.

INTRODUCTION: Epilepsy is a chronic neurological disorder that may occur alongside cognitive changes, with effects on multiple cognitive domains. OBJECTIVE: To compare the cognitive performance of patients with epilepsy and healthy controls through Montreal Cognitive Assessment (MoCA) during outpatient consultation at a reference diagnostic center in Colombia and analyze and the influencing factors. MATERIALS AND METHODOLOGY: One-hundred and four patients during neurology outpatient consultation in the city of Cartagena, Colombia, were assessed with the (MoCA) test, i.e., 54 people who consulted for headache and have not been diagnosed with epilepsy (NEP) and 50 with a diagnosis of epilepsy (EPs) according to the diagnostic criteria of the International League Against Epilepsy (ILAE). RESULTS: Significant differences were found in the total mean scores of the (MoCA) between (EPs) and (NPE) groups (t = 4.72; p < 0.01), particularly in attention (t = 3.22; p < 0.02) and memory (t = 5.04; p < 0.01) dimensions. Additionally, a significant association was observed between years of schooling and (MoCA) scores (p = 0,019) but not between socioeconomic level (p = 0,510), age (p = 0,452) and the frequency of seizures (p = 0,471). DISCUSSION: Patients with epilepsy show lower scores in several cognitive domains in respect of the control group. The (MoCA) has proven its appropriateness for cognitive screening in the contexts of clinical neurology outpatient consultation.

A Systematic Review of Cognitive Function in Adults with Spina Bifida.

Background: Though much research has been done on the cognitive profiles of children, the abilities of patients with SBM as they age into adulthood are not well understood.Objective: Determine if adults with SBM have impairments in overall cognition, attention, executive function, and memory compared to typically developing adults or a standardized population mean.Methods: A medical librarian composed a search of spina bifida, adults, and cognitive function. 549 results were screened using title and abstract. Data were extracted using Covidence review software, including risk of bias assessments. 24 studies were included.Results: Memory impairments, notably working and prospective, have been reported. Results in other domains varied. Average VIQ or PIQ did not imply lack of impairment in other specific domains.Conclusion: Memory impairments should be accounted for and neuropsychological testing should be considered when providing care to adults with SBM. Future longitudinal cognitive aging and interventional studies are needed.

Sepsis Induces Physical and Mental Impairments in a Mouse Model of Post-Intensive Care Syndrome.

Post-intensive care syndrome (PICS) is a physical, cognitive, and mental impairment observed in intensive care unit (ICU) survivors. Although this is an emerging problem in the ICU, how sepsis induces the characteristic symptoms of PICS remains unclear. To develop a model of PICS, we induced sepsis in male C57/B6 mice via sublethal cecum slurry injection and subsequently treated them using ICU-like interventions. At 1-2 weeks post-sepsis induction, we simultaneously evaluated the abilities of the surviving mice using the following behavioral tests: (1) a grip strength test (GST) and a treadmill test for physical assessment, (2) a novel object recognition test (NORT) for cognitive assessment, and (3) an open field test (OFT) and a marble burying test (MBT) for mental assessment. The surviving mice showed a range of deficits, including muscle weakness with significantly decreased grip strength in the GST; decreased total mileage during the treadmill test; anxiety and decreased activity, with significantly decreased time in the central area, and increased duration of immobility in the OFT; and an increased number of buried marbles in the MBT. Given these physical and mental impairments in the surviving mice, our model has the potential to elucidate mechanistic insights and to discover therapeutic targets and new interventions for PICS.

Infiltrated regulatory T cells and Th2 cells in the brain contribute to attenuation of sepsis-associated encephalopathy and alleviation of mental impairments in mice with polymicrobial sepsis.

Sepsis-associated encephalopathy (SAE) increases not only morbidity and mortality but has been associated with long-lasting mental impairment after hospital discharge in septic patients. Recently, studies have shown that these mental impairments are caused by infection-induced neuroinflammation. However, the role of T cells in the pathogenesis of SAE and mental impairments remains unclear. Thus, in this study, we aimed to clarify how immune cells, especially T cells, influence the development and recovery of these disorders. In the cecal slurry (CS)-induced septic mouse model, we performed three different kinds of behavioral tests, open-field test, marble burying test, and forced swimming test, and observed anxiety-like behavior in septic mice. Additionally, increased interleukin (IL)-1ß and IL-6 expression levels, and infiltration of neutrophils and T cells were examined in the brain of septic mice, 10 days after sepsis onset. Twenty days after sepsis onset, the septic mice could recover the number of astrocytes. At day 30, expression levels of IL-1ß and tumor necrosis factor (TNF)-α returned to normal levels in the cerebral cortex of septic mice. Interestingly, resolution of neuroinflammation and alleviation of depression were delayed in septic mice treated with FTY720, which inhibits sphingosine-1-phosphate (S1P)-dependent lymphocyte egress from lymph nodes. On analyzing the brain T cells with or without FTY720 in septic mice, the FTY720 untreated mice presented increased regulatory T cells (Treg) and Th2 cells in the brain, whereas the FTY720 treated mice demonstrated increased Th17 in the brain at day 30. Furthermore, in FTY720 treated septic mice, the number of astrocytes in the cerebral cortex remained reduced at day 30. These results suggest that infiltrated Treg and Th2 cells contribute to the attenuation SAE and alleviate SAE-induce mental disorder by resolving neuroinflammation in the chronic phase of sepsis.

The Abolition or Reform of Mental Health Law: How Should the Law Recognise and Respond to the Vulnerability of Persons with Mental Impairment?

Vulnerability theory challenges the assumption that human beings are abstract and invulnerable liberal subjects and insists that any decent and just society must create law that takes into account and tries to ameliorate human vulnerability. In this article, I explore how vulnerability might apply in the context of the debate about the future of mental health law that has arisen since the entry into force of the Convention on the Rights of Persons with Disabilities (CRPD) in 2008; namely, whether mental health law should be abolished or reformed. In doing so, this article addresses three key issues: (i) how to conceptualise vulnerability; (ii) whether persons with mental impairments really are vulnerable and in what ways; and (iii) how the law should respond to the vulnerability of persons with mental impairments post-CRPD. It describes and compares three different approaches with respect to how well they address vulnerability: the Abolition with Support, Mental Capacity with Support, and the Support Except Where There is Harm Models. It argues that the law should try to accurately capture and ameliorate the vulnerability of those who are subject to it as much as possible. It also argues that from a vulnerability perspective, the reform of mental health law may be better than its abolition and that decreasing the vulnerability of persons with mental impairment requires systemic reform, resources, and cultural change.

Post-intensive care syndrome: its pathophysiology, prevention, and future directions.

Expanding elderly populations are a major social challenge in advanced countries worldwide and have led to a rapid increase in the number of elderly patients in intensive care units (ICUs). Innovative advances in medical technology have enabled lifesaving of patients in ICUs, but there remain various problems to improve their long-term prognoses. Post-intensive care syndrome (PICS) refers to physical, cognition, and mental impairments that occur during ICU stay, after ICU discharge or hospital discharge, as well as the long-term prognosis of ICU patients. Its concept also applies to pediatric patients (PICS-p) and the mental status of their family (PICS-F). Intensive care unit-acquired weakness, a syndrome characterized by acute symmetrical limb muscle weakness after ICU admission, belongs to physical impairments in three domains of PICS. Prevention of PICS requires performance of the ABCDEFGH bundle, which incorporates the prevention of delirium, early rehabilitation, family intervention, and follow-up from the time of ICU admission to the time of discharge. Diary, nutrition, nursing care, and environmental management for healing are also important in the prevention of PICS. This review outlines the pathophysiology, prevention, and future directions of PICS.

The Extension of the Crimes (Mental Impairment and Unfitness to be Tried) Act 1997 to the Children's Court: Opportunities and Shortfalls.

In 2014, the Crimes (Mental Impairment and Unfitness to be Tried) Act 1997 in Victoria was extended to the Children's Court of Victoria. This article describes the processes that preceded this change and the changes that occurred. The potential opportunities consequent to the changes are described, with their corresponding ethical implications. The decision not to resource some of the changes as recommended by the Victorian Law Reform Commission is described, with reference to the lack of establishment of an adolescent forensic mental health facility. The shortfalls currently occurring and their ethical implications are also discussed. We note the need for data regarding the number of children whose matters are being heard under the Crimes (Mental Impairment and Unfitness to be Tried) Act 1997, and the resourcing implications that flow from this.

Methamphetamine-induced Psychosis and Mental Impairment: A Challenge from New Zealand.

While knowledge about chronic amphetamine-induced psychosis and its similarity to schizophrenia is at an early stage, its incidence and ramifications are posing a serious issue for the criminal law. The condition has the potential in principle to result in findings of insanity/mental impairment and diminished responsibility, as well as to be significantly mitigating at the time of sentencing. However, difficult legal questions arise as to whether an ongoing (as against transient) chronic methamphetamine-induced psychosis constitutes a "disease of the mind" as well as complex public policy issues by reason of the condition being self-induced. This column reviews the law generally on the subject, as well as the ruling by Jagose J in R v Brackenridge [2019] NZHC 1004, and explores the ramifications of the reasoning in the ruling for decisions by courts outside New Zealand. It calls for further and more nuanced analysis of the ramifications of drug-induced psychoses being self-induced in the context of the law on criminal responsibility and culpability.

Sociocultural Factors Associated With Abuse of Mentally Impaired Persons in Imo State, Nigeria.

This study examined sociocultural factors associated with abuse of mentally impaired persons (MIP) in Imo state, Nigeria. A cross-sectional survey of 1,147 persons aged 10 years and above who had at least one MIP in their household was conducted. Six in-depth interviews and 21 focus group discussion (FGD) sessions with 160 study participants comprising adult male and female members of the communities, respectively, were conducted. The study established that a multitude of cultural and social factors shape the attitude of individuals toward mental impairment and MIPs. It was found that cultural perceptions of the cause of mental impairment as supernatural and evil forces were widespread within the study communities. Among those surveyed, 74.6% were aware that MIPs are victims of abuse. Perpetrators identified were mostly relatives and persons close to MIPs. The findings provide useful insights into gaps in conventional understanding of mental impairment and abuse of MIPs in Imo State.

Depressed but not legally mentally impaired.

This article examines the mental impairment (insanity) defense in the Australian state of Victoria and argues that the defense is successful only when offenders suffer from psychotic mental illnesses. This raises the question about how non-psychotic offenders are dealt with by the courts when they claim 'mental impairment' for serious acts of violence such as homicide, particularly when a relatively large number of perpetrators involved in homicide suffer from non-psychotic illnesses like depression. The analysis shows that depressive illnesses do not reach the threshold for mental impairment (legal insanity) such that they mitigate violent criminal behavior, although they can, arguably, diminish culpability. This article draws upon existing literature, qualitative analysis of two court cases and semi-structured interviews with four legal representatives to make its conclusions.

CHOA concussion consensus: establishing a uniform policy for academic accommodations.

Concussion research generally centers on physical challenges, though aspects such as social functioning and returning to school also warrant attention in pediatric populations. Restoring academic performance postconcussion remains a challenge. Here we provide recommendations addressing a uniform policy for pediatric concussion patients in academic institutions. Tools that may minimize difficulty with academic re-entry include independent educational evaluations, individualized educational programs (IEPs), student support teams (SSTs), letters of academic accommodation, time off, and 504 Plans. Recognition and treatment is crucial for symptom relief and prevention of functional disruption, as is specialist referral during the acute window. We recommend early intervention with a letter of academic accommodation and SST and suggest that 504 Plans and IEPs be reserved for protracted or medically complicated cases. Students with concussion should be observed for anxiety and depression because these symptoms can lead to prolonged recovery, decreased quality of life, and other social challenges.

Abnormal cystatin C levels in two patients with bardet-biedl syndrome.

Bardet-Biedl syndrome (BBS) is an autosomal recessive disorder characterized by central obesity, mental impairment, rod-cone dystrophy, polydactyly, hypogonadism in males, and renal abnormalities. The causative genes have been identified as BBS1-14. In the Western countries, the prevalence of this disease ranges from 1/13,500 to 1/160,000, while only a few Japanese patients have been reported in the English-language literature. The incidence of renal dysfunction or anomalies in previous reports varies considerably ranging from ∼20% to universal occurrence. We here report that two Japanese patients who had BBS with normal BUN and creatinine levels had elevated levels of cystatin C, a sensitive marker of glomerular filtration rate. A urine albumin level increased only in the elder patient. Thus, cystatin C may be useful for detecting renal abnormalities in patients with an apparent normal renal function. Because this disease is diagnosed by accumulation of symptoms, such a sensitive marker might help early diagnosis of BBS.