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1.
Pediatrics ; 146(Suppl 1): S66-S69, 2020 08.
Artigo em Inglês | MEDLINE | ID: mdl-32737235

RESUMO

In all of medicine, there is perhaps nothing so distressing as bearing witness to a patient's suffering, especially if that patient is a child. We want to do everything that we can to avoid or alleviate a child's suffering, yet what do clinicians, ethicists, lawyers, or family members mean when they use the term "suffering," and how should these claims of suffering factor into pediatric decision-making? This question of suffering and what to do about it has played a key role in several prominent pediatric cases over the past decade, including the cases of Charlie Gard, Alfie Evans, and Baby Joseph. These cases have become seminal cases precisely because there is no clear resolution, and the "suffering child" continues to challenge our moral ideals of what it means to live a good life. In this article, I explore the various ways in which the concept of suffering is used in these cases, and I offer new ways in which parents, providers, and all those who work with sick children can approach the suffering child.


Assuntos
Tomada de Decisão Clínica/ética , Doença de Leigh , Encefalomiopatias Mitocondriais , Doenças Neurodegenerativas , Terminologia como Assunto , Suspensão de Tratamento/ética , História do Século XXI , Humanos , Lactente , Doença de Leigh/diagnóstico , Doença de Leigh/psicologia , Doença de Leigh/terapia , Masculino , Encefalomiopatias Mitocondriais/terapia , Doenças Neurodegenerativas/diagnóstico , Doenças Neurodegenerativas/psicologia , Doenças Neurodegenerativas/terapia , Ontário , Pais/psicologia , Estado Vegetativo Persistente/psicologia , Estado Vegetativo Persistente/terapia , Qualidade de Vida , Respiração Artificial/ética , Estresse Psicológico/diagnóstico , Estresse Psicológico/psicologia , Estresse Psicológico/terapia , Traqueostomia/psicologia , Reino Unido , Suspensão de Tratamento/legislação & jurisprudência
2.
Medicine (Baltimore) ; 99(18): e19937, 2020 May.
Artigo em Inglês | MEDLINE | ID: mdl-32358365

RESUMO

RATIONALE: We report a stroke patient who showed increased thalamocortical connectivity to the medial prefrontal cortex (mPFC) with recovery of impaired consciousness that was demonstrated on diffusion tensor tractography (DTT) of the ascending reticular activating system (ARAS). PATIENTS CONCERNS: A 48-year-old male patient underwent craniectomy and hematoma removal for spontaneous intracerebral hemorrhage in the right basal ganglia and thalamus. When he started rehabilitation at 5 weeks after onset he was in a vegetative state with a Coma Recovery Scale-Revised score of 6. DIAGNOSES: The patient was diagnosed spontaneous intracerebral hemorrhage in the right basal ganglia and thalamus. INTERVENTIONS: He underwent comprehensive rehabilitation including neurotropic durgs, transcranial direct current stimulation, and repetitive transcranial magnetic stimulation of the left prefrontal lobe (Brodmann area 10). OUTCOMES: After 5 weeks of rehabilitation, the patient had recovered to a nearly normal conscious state with a Coma Recovery Scale-Revised score of 22. On 10-week DTT, thickening of the lower dorsal ARAS was observed on both sides compared with 5-week DTT. Decreased neural connectivity to the left PFC was observed on 5-week DTT whereas decreased neural connectivity to the left PFC was increased on 10-week DTT, especially the mPFC. LESSONS: Increased thalamocortical connectivity to the mPFC was demonstrated in a stroke patient who showed concomitant recovery from a vegetative state to a nearly normal conscious state. The results suggest that the increased neural connectivity to the mPMC contributed to recovery of consciousness in this patient.


Assuntos
Coma/fisiopatologia , Imagem de Tensor de Difusão/métodos , Estado Vegetativo Persistente/fisiopatologia , Córtex Pré-Frontal/fisiopatologia , Acidente Vascular Cerebral/fisiopatologia , Hemorragia Cerebral/complicações , Coma/diagnóstico por imagem , Coma/etiologia , Estado de Consciência , Craniotomia/métodos , Hematoma/cirurgia , Humanos , Masculino , Pessoa de Meia-Idade , Estado Vegetativo Persistente/diagnóstico por imagem , Estado Vegetativo Persistente/etiologia , Acidente Vascular Cerebral/complicações , Acidente Vascular Cerebral/diagnóstico por imagem , Reabilitação do Acidente Vascular Cerebral/métodos
3.
Nat Neurosci ; 23(6): 761-770, 2020 06.
Artigo em Inglês | MEDLINE | ID: mdl-32451482

RESUMO

Assessing residual consciousness and cognitive abilities in unresponsive patients is a major clinical concern and a challenge for cognitive neuroscience. Although neuroimaging studies have demonstrated a potential for informing diagnosis and prognosis in unresponsive patients, these methods involve sophisticated brain imaging technologies, which limit their clinical application. In this study, we adopted a new language paradigm that elicited rhythmic brain responses tracking the single-word, phrase and sentence rhythms in speech, to examine whether bedside electroencephalography (EEG) recordings can help inform diagnosis and prognosis. EEG-derived neural signals, including both speech-tracking responses and temporal dynamics of global brain states, were associated with behavioral diagnosis of consciousness. Crucially, multiple EEG measures in the language paradigm were robust to predict future outcomes in individual patients. Thus, EEG-based language assessment provides a new and reliable approach to objectively characterize and predict states of consciousness and to longitudinally track individual patients' language processing abilities at the bedside.


Assuntos
Idioma , Estado Vegetativo Persistente/diagnóstico , Avaliação de Sintomas/métodos , Inconsciência/diagnóstico , Estimulação Acústica , Adolescente , Adulto , Idoso , Estudos de Casos e Controles , Criança , Eletroencefalografia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estimulação Luminosa , Prognóstico , Fala , Adulto Jovem
4.
Nature ; 581(7809): 428-433, 2020 05.
Artigo em Inglês | MEDLINE | ID: mdl-32461641

RESUMO

After severe brain injury, it can be difficult to determine the state of consciousness of a patient, to determine whether the patient is unresponsive or perhaps minimally conscious1, and to predict whether they will recover. These diagnoses and prognoses are crucial, as they determine therapeutic strategies such as pain management, and can underlie end-of-life decisions2,3. Nevertheless, there is an error rate of up to 40% in determining the state of consciousness in patients with brain injuries4,5. Olfaction relies on brain structures that are involved in the basic mechanisms of arousal6, and we therefore hypothesized that it may serve as a biomarker for consciousness7. Here we use a non-verbal non-task-dependent measure known as the sniff response8-11 to determine consciousness in patients with brain injuries. By measuring odorant-dependent sniffing, we gain a sensitive measure of olfactory function10-15. We measured the sniff response repeatedly over time in patients with severe brain injuries and found that sniff responses significantly discriminated between unresponsive and minimally conscious states at the group level. Notably, at the single-patient level, if an unresponsive patient had a sniff response, this assured future regaining of consciousness. In addition, olfactory sniff responses were associated with long-term survival rates. These results highlight the importance of olfaction in human brain function, and provide an accessible tool that signals consciousness and recovery in patients with brain injuries.


Assuntos
Lesões Encefálicas/diagnóstico , Lesões Encefálicas/fisiopatologia , Estado de Consciência/fisiologia , Percepção Olfatória/fisiologia , Estado Vegetativo Persistente/diagnóstico , Estado Vegetativo Persistente/fisiopatologia , Olfato/fisiologia , Adulto , Nível de Alerta , Erros de Diagnóstico/prevenção & controle , Feminino , Humanos , Masculino , Odorantes/análise , Prognóstico , Recuperação de Função Fisiológica/fisiologia , Sensibilidade e Especificidade , Análise de Sobrevida
5.
Zhongguo Zhen Jiu ; 40(3): 234-8, 2020 Mar 12.
Artigo em Chinês | MEDLINE | ID: mdl-32270632

RESUMO

OBJECTIVE: To compare the clinical therapeutic effect of midnight-noon ebb-flow acupuncture combined with rehabilitation therapy and simple rehabilitation therapy in severe craniocerebral trauma patients with vegetative state. METHODS: A total of 100 patients were randomized into an observation group and a control group, 50 cases in each one. Basic treatment of medication, hyperbaric oxygen therapy and specialized nursing were given in both groups. In the control group, rehabilitation therapy was adopted for 30 min each time, once a day. On the basis of the control group, midnight-noon ebb-flow acupuncture was applied in the observation group, the needles were sustained for 30 min, once a day, 5 times a week. The treatment was for 30 days in both groups. Before treatment and after 10, 20, 30 days of treatment, scores of Glasgow coma scale (GCS) and coma recovery scale-revised (CRS-R) were observed, and the conscious rate after treatment was calculated in both groups. RESULTS: Compared before treatment, the GCS and CRS-R scores after 10, 20, 30 days of treatment were increased in both groups (P<0.01), and the scores in the observation group were superior to those in the control group (P<0.01). After treatment, the conscious rate was 20.0% (10/50) in the observation group, which was superior to 12.0% (6/50) in the control group (P<0.01). CONCLUSION: Midnight-noon ebb-flow acupuncture combined with rehabilitation therapy can effectively treat the severe craniocerebral trauma patients with vegetative state, improve the consciousness level, and have superior therapeutic effect compared with simple rehabilitation therapy.


Assuntos
Terapia por Acupuntura , Traumatismos Craniocerebrais/reabilitação , Estado Vegetativo Persistente/reabilitação , Estado de Consciência , Escala de Coma de Glasgow , Humanos , Resultado do Tratamento
6.
Zhen Ci Yan Jiu ; 45(3): 233-6, 2020 Mar 25.
Artigo em Chinês | MEDLINE | ID: mdl-32202716

RESUMO

OBJECTIVE: To observe the influence of Xiao's "xingnaofusu" needling (the technique for resuscitation) on regaining consciousness in the patients with persistent vegetative state (PVS). METHODS: A total of 50 patients of PVS were randomized into an observation group and a control group, 25 cases in each. The patients in the control group were treated by the routine western medicine, and those in the observation group treated by Xiao's "xingnaofusu" needling and routine western medicine. Baihui (GV20), Dingshen (Extra) to Shangen (Extra) (penetrating technique), Fengchi (GB20) to GB20 (penetrating technique), Neiguan (PC6) to Waiguan (TE5) (penetrating technique), Hegu (LI4) to Laogong (HT8) (penetrating technique) and Taichong (LR3) to Yongquan (KI1) (penetrating technique) were selected. The treatment was given once a day, 10 days as one treatment course, 3 courses in total. The coma recovery scale-revised (CRS-R) score, the modified Ashworth scale (MAS) score and the Glasgow coma scale (GCS) were separately compared before and after the treatment. Additionally, CT scanning was adopted to measure the width of the third ventricle before and after treatment so as to evaluate the clinical therapeutic effect. RESULTS: After the treatment, the CRS-R and GCS scores in the two groups increased remarkably, and MAS score reduced obviously as compared with that before the treatment(P<0.05); and the CRS-R and GCS scores were higher, and MAS score lower in the observation group than those in the control group(P<0.05). Compared with the control group, the width of the third ventricle reduced obviously in the observation group after the treatment(P<0.05). At the end of the treatment courses, the effective rate was 79.2%(19/24)in the observation group and was 47.8%(11/23) in the control group. The effective rate of the observation group was obviously higher than that of the control group (P<0.05). CONCLUSION: Xiao's "xingnaofusu" needling can remarkably improve the central nerve function, promote the recovery of brain function and the motor function of limbs, reduce the width of the third ventricle and improve the clinical therapeutic effect of regaining consciousness in the patients with PVS.


Assuntos
Terapia por Acupuntura , Estado Vegetativo Persistente/terapia , Terceiro Ventrículo , Estado de Consciência , Humanos , Resultado do Tratamento
8.
Medicina (B Aires) ; 80(1): 48-53, 2020.
Artigo em Espanhol | MEDLINE | ID: mdl-32044741

RESUMO

Patient relatives often request withdrawal of life support, especially artificial nutrition and hydration, in cases of permanent vegetative or minimally conscious state, and resort to court in case of disagreement. Two recent cases of withdrawal authorized by the courts concerned, one from abroad and one from Argentina, have been controversial. Although it may appear inhuman to stop feeding and hydrating such patients, to continue it only prolongs a state of irreversible biological subsistence. Families tend to increasingly accept withdrawal if the patient status remains unchanged. However, concern persists regarding the suffering that patients may undergo from onset of withdrawal till death, even though such suffering is little conceivable in the absence of cortical function and conscience content. While doctors and the layman consider ethical to withdraw life support, a nonnegligible proportion of doctors consider that vegetative state patients, even more minimally conscious state patients, do experience hunger, thirst and pain. In some countries, like the United Kingdom, strict withdrawal criteria were proposed, together with pharmacological treatment schemes for the distress arising during the withdrawal period, even though its benefit is controversial. In Argentina, two scientific societies have publicly advocated withdrawal, but not issued formal guidelines. In any case, both "dignified death" Law 26.742 and the Civil Code consent withdrawal of life support, if accompanied by appropriate relief of clinical symptoms indicating suffering.


Assuntos
Cuidados para Prolongar a Vida/legislação & jurisprudência , Estado Vegetativo Persistente , Direito a Morrer/legislação & jurisprudência , Suspensão de Tratamento/legislação & jurisprudência , Argentina , Humanos
9.
NeuroRehabilitation ; 46(1): 65-74, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32039868

RESUMO

BACKGROUND: Although emergence from the minimally conscious state (eMCS) is associated with symptoms including disorientation, memory and attention impairment, restlessness, and significant functional disability, the neurobehavioral profile of eMCS has not been empirically characterized. OBJECTIVE: Determine degree of cognitive impairment, presence of clinical symptoms and functional disability at time eMCS in patients with traumatic and non-traumatic brain injury (TBI, nTBI). METHODS: Retrospective observational study of 169 adults (median [interquartile range] age: 51 [29, 62] years; male: 116; TBI: 103) who emerged from MCS based on the Coma Recovery Scale-Revised while in an inpatient Disorders of Consciousness program. Outcome measures include the Confusion Assessment Protocol (CAP) and Disability Rating Scale (DRS). RESULTS: CAP administration was attempted in 54 subjects. Twenty-eight subjects had valid scores on all CAP items, with a median [interquartile range] of 4 [3-5] symptoms of confusion. Scores in 93% of this subsample were consistent with an acute confusional state. The most common symptoms were cognitive impairment (98% of subjects), disorientation (93%), and agitation (69%). The median DRS score upon emergence from MCS was 14.5 [13, 16], indicating severe disability (n = 140). CONCLUSIONS: eMCS is associated with an acute confusional state and severe disability. This finding may inform the lower boundary of confusion as well as approach to treatment and caregiver education.


Assuntos
Cognição , Estado Vegetativo Persistente/fisiopatologia , Adulto , Estado de Consciência , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estado Vegetativo Persistente/patologia , Estado Vegetativo Persistente/reabilitação , Recuperação de Função Fisiológica
10.
PLoS One ; 15(2): e0223812, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32053587

RESUMO

Recent evidence suggests that the quantity and quality of conscious experience may be a function of the complexity of activity in the brain and that consciousness emerges in a critical zone between low and high-entropy states. We propose fractal shapes as a measure of proximity to this critical point, as fractal dimension encodes information about complexity beyond simple entropy or randomness, and fractal structures are known to emerge in systems nearing a critical point. To validate this, we tested several measures of fractal dimension on the brain activity from healthy volunteers and patients with disorders of consciousness of varying severity. We used a Compact Box Burning algorithm to compute the fractal dimension of cortical functional connectivity networks as well as computing the fractal dimension of the associated adjacency matrices using a 2D box-counting algorithm. To test whether brain activity is fractal in time as well as space, we used the Higuchi temporal fractal dimension on BOLD time-series. We found significant decreases in the fractal dimension between healthy volunteers (n = 15), patients in a minimally conscious state (n = 10), and patients in a vegetative state (n = 8), regardless of the mechanism of injury. We also found significant decreases in adjacency matrix fractal dimension and Higuchi temporal fractal dimension, which correlated with decreasing level of consciousness. These results suggest that cortical functional connectivity networks display fractal character and that this is associated with level of consciousness in a clinically relevant population, with higher fractal dimensions (i.e. more complex) networks being associated with higher levels of consciousness. This supports the hypothesis that level of consciousness and system complexity are positively associated, and is consistent with previous EEG, MEG, and fMRI studies.


Assuntos
Lesões Encefálicas/fisiopatologia , Encéfalo/fisiopatologia , Modelos Neurológicos , Rede Nervosa/fisiopatologia , Estado Vegetativo Persistente/fisiopatologia , Adulto , Algoritmos , Encéfalo/diagnóstico por imagem , Lesões Encefálicas/diagnóstico , Estado de Consciência/fisiologia , Feminino , Fractais , Voluntários Saudáveis , Humanos , Imagem por Ressonância Magnética , Estado Vegetativo Persistente/diagnóstico , Índice de Gravidade de Doença
11.
World Neurosurg ; 136: 70-72, 2020 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-31931243

RESUMO

BACKGROUND: Although instrumented stabilization of pediatric atlanto-occipital dislocation (AOD) has been described in the literature, there is little evidence regarding instrumentation techniques in pediatric patients presenting with both AOD and a cervical fracture. We present a case of a 2-year-old male involved in a motor vehicle collision with an unstable C2 fracture and AOD, treated with an occiput-C4 posterior arthrodesis using a rod, crosslink, and cable construct. CASE DESCRIPTION: This patient suffered a type III C2 fracture and AOD with 4 mm craniocaudal and 3 mm anterior displacement. In the operating room, 2 cobalt chrome connecting rods (3.5 mm) were connected to 1 another with crosslinks at C2 and C4. These were affixed with suboccipital and sublaminar cables at C1, C2, and C4. At 14 months postoperatively, his spine is clinically and radiographically stable. He has spontaneous movement in all 4 extremities, and remains in a persistent vegetative state because of his underlying central nervous system injury. CONCLUSIONS: Although there is a breadth of literature investigating instrumentation approaches to pediatric AOD, there is minimal evidence on outcomes of patients presenting with both AOD and cervical fracture. The technique we describe has proven safe and effective for this patient.


Assuntos
Articulação Atlantoccipital/cirurgia , Vértebra Cervical Áxis/cirurgia , Vértebras Cervicais/cirurgia , Luxações Articulares/cirurgia , Fraturas da Coluna Vertebral/cirurgia , Acidentes de Trânsito , Artrodese , Articulação Atlantoccipital/diagnóstico por imagem , Articulação Atlantoccipital/lesões , Vértebra Cervical Áxis/diagnóstico por imagem , Vértebra Cervical Áxis/lesões , Vértebras Cervicais/diagnóstico por imagem , Vértebras Cervicais/lesões , Pré-Escolar , Humanos , Luxações Articulares/complicações , Luxações Articulares/diagnóstico por imagem , Masculino , Estado Vegetativo Persistente , Fraturas da Coluna Vertebral/complicações , Fraturas da Coluna Vertebral/diagnóstico por imagem
12.
BMC Neurol ; 20(1): 37, 2020 Jan 29.
Artigo em Inglês | MEDLINE | ID: mdl-31996169

RESUMO

BACKGROUND: We report on a stroke patient with disorder of consciousness (DOC) who underwent repetitive transcranial magnetic stimulation (rTMS) and showed recovery of an injured upper ascending reticular activating system (ARAS) injury, which was demonstrated by using serial diffusion tensor tractography (DTT). CASE PRESENTATION: A 45-year-old male patient was diagnosed as subarachnoid and intracerebral hemorrhages in the left fronto-parieto-temporal lobes. At 5 months after onset, the patient exhibited a persistent vegetative state, with a Coma Recovery Scale-Revised (CRS-R) score of 4. He underwent comprehensive rehabilitative therapy that included drugs for recovery of impaired consciousness and rTMS of the right dorsolateral prefrontal lobe. He recovered to a minimally conscious state (CRS-R: 13) at 7 months after onset and was transferred to a local rehabilitation hospital where he underwent similar rehabilitation but without rTMS. At 9 months after onset, his CRS-R score remained at 13. He was then readmitted to our hospital and underwent rehabilitation with rTMS until 10 months after onset. His CRS-R remained at 13, but his higher cognition had improved. The tract volume (TV) of the neural tract in the right prefrontal lobe in the upper ARAS on the 7-month DTT was higher than that on the 5-month DTT. However, compared to the 7-month DTT, the right prefrontal lobe TV was lower on the 9-month DTT. On the 10-month DTT, the TV of that neural tract had again increased. CONCLUSIONS: Increases in neural TV in the right prefrontal lobe of the upper ARAS that were associated with the periods of rTMS application were demonstrated in a stroke patient with DOC.


Assuntos
Encéfalo/fisiopatologia , Estado Vegetativo Persistente/terapia , Recuperação de Função Fisiológica , Estimulação Magnética Transcraniana/métodos , Imagem de Tensor de Difusão , Escala de Coma de Glasgow , Humanos , Masculino , Pessoa de Meia-Idade , Estado Vegetativo Persistente/etiologia , Estado Vegetativo Persistente/fisiopatologia , Acidente Vascular Cerebral/complicações
15.
Artigo em Russo | MEDLINE | ID: mdl-31793537

RESUMO

AIM: To study the prognostic value of magnetic resonance spectroscopy (MRS) in patients with vegetative state/unresponsive wakefulness syndrome (VS/UWS). MATERIAL AND METHODS: Thirty-four patients with VS/UWS underwent multi-voxel MRS (thalamus, globus pallidus, putamen, internal capsules, fornix, brainstem, temporal and frontal cortex). Subjects were grouped according to etiology: 22 patients with traumatic brain injury (TBI) (group 1) and 12 patients with a hypoxia (group 2). The groups were matched by age and duration of UWS (mean 2, 3 months). The CRS-R was used to identify the first signs of consciousness during hospitalization and 6-12 months later. Outcomes of the patients with TBI were as follows: chronic VS/UWS (n=6), minimally conscious state (MCS) plus (n=9), emergence from MCS (EMCS) (n=7). Outcomes of the patients with hypoxia were: chronic vegetative state (n=10), minimally conscious state (MCS) (n=2). RESULTS: The decrease in the NAA/Cr ratio in thalamus, capsula interna, temporal cortex are correlated with poor outcome in both groups. Higher rates of NAA/Cr in these structures are correlated with further recovery of consciousness. The decrease in the ratio of NAA Cr and NAA/NAA+Cho+Cr in the midbrain is correlated with poor outcome only in UWS with hypoxia. CONCLUSION: The results suggest that the MRS allows to more accurately predicting the outcome in VS/UWS patients with hypoxic brain damage, as well as in UWS patients with TBI, who have recovered consciousness to the level of EMCS.


Assuntos
Transtornos da Consciência , Estado de Consciência , Espectroscopia de Ressonância Magnética , Estado Vegetativo Persistente , Transtornos da Consciência/diagnóstico por imagem , Humanos , Imagem por Ressonância Magnética , Estado Vegetativo Persistente/diagnóstico por imagem , Prognóstico
16.
BMC Med Ethics ; 20(1): 91, 2019 12 30.
Artigo em Inglês | MEDLINE | ID: mdl-31884958

RESUMO

BACKGROUND: In the ruling in Y [2018], the UK Supreme Court has confirmed that there is no general requirement for the courts in England and Wales to authorise the withdrawal of clinically assisted nutrition and hydration from patients with prolonged disorders of consciousness. The perceived requirement, which originated in a court ruling in 1993, encompassed those in the vegetative state and those in the minimally conscious state. The ruling in Y confirms that the court may still be approached to decide difficult or contested cases, but there is otherwise no routine requirement that the judges be approached. MAIN BODY: There is much to welcome in this ruling, particularly as it means that these decisions for these patients are no longer (unusually) singled out for a judicial decision, with all the financial and emotional costs that court proceedings can entail. However, there is also a risk that the ruling might have unwelcome consequences. First, there is the possibility that patients might die too soon, particularly if doctors should now adopt the courts' previous reasoning, which has suggested that patients in the vegetative state lack interests, so treatment may - perhaps must - be withdrawn. Secondly, there is the converse possibility that patients might live too long, since empirical research suggests that - whether intentionally or not - patients' families, clinicians, and the health system appear to promote treatment-by-default. CONCLUSION: Rather than adopt general positions, which may be contestable and potentially risky, this article argues, on a pluralistic basis, that the individual patient should be the focus of any decision made in his or her 'best interests'. The existing legal framework in England and Wales, which is provided by the Mental Capacity Act 2005, already points in this direction, although more efforts may be needed to ensure that those involved in making these decisions are suitably educated and supported. Fortunately, new guidance from the British Medical Association could help clinicians and families to make decisions in the future, which are appropriate for the incapacitated individual patient in question.


Assuntos
Estado de Consciência , Dissidências e Disputas , Estado Vegetativo Persistente , Suspensão de Tratamento/ética , Suspensão de Tratamento/legislação & jurisprudência , Dissidências e Disputas/legislação & jurisprudência , Humanos , Cuidados para Prolongar a Vida , Reino Unido
17.
Acta Neurobiol Exp (Wars) ; 79(4): 421-431, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31885398

RESUMO

In the pursuit to clarify the concept of "BCI illiteracy", we investigated the possibilities of attaining basic binary (yes/no) communication via brain­computer interface (BCI). We tested four BCI paradigms: steady­state visual evoked potentials (SSVEP), tactile, visual, and auditory evoked potentials (P300). The proposed criterion for assessing for the possibility of communication are based on the number of correct choices obtained in a given BCI paradigm after a short calibration session, without prior training. In this study users answered 20 simple "yes/no" questions. Fourteen or more correct answers rejected the null hypothesis of random choices at P=0.05. All of the 30 healthy volunteers were able to attain above­chance choices in at least one of the four paradigms. Additionally, we tested the system in clinical settings on a patient recovering from disorders of consciousness, achieving successful communication in 2 out of 3 paradigms. In light of these facts, after a review of the sparse literature, and in the interest of motivating further research, we propose a paraphrase of de Finetti's provocative statement: "BCI illiteracy does not exist".


Assuntos
Mapeamento Encefálico , Potenciais Evocados/fisiologia , Interface Usuário-Computador , Adolescente , Adulto , Calibragem , Alfabetização Digital , Eletroencefalografia , Potencial Evocado P300/fisiologia , Potenciais Evocados Auditivos/fisiologia , Potenciais Evocados Visuais/fisiologia , Feminino , Humanos , Masculino , Estado Vegetativo Persistente/fisiopatologia , Tato/fisiologia , Vibração , Adulto Jovem
18.
PLoS One ; 14(10): e0222846, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31574106

RESUMO

OBJECTIVE: To investigate if animal-assisted therapy (AAT) leads to higher consciousness in patients in a minimally conscious state during a therapy session, measured via behavioral reactions, heart rate and heart rate variability. METHODS: In a randomized two treatment multi-period crossover trial, 10 patients in a minimally conscious state participated in eight AAT sessions and eight paralleled conventional therapy sessions, leading to 78 AAT and 73 analyzed control sessions. Patients' responses during sessions were assessed via behavioral video coding and the Basler Vegetative State Assessment (BAVESTA), heart rate and heart rate variability (SDNN, RMSSD, HF and LF). Data were analyzed with generalized linear mixed models. RESULTS: Patients showed more eye movements (IRR = 1.31, 95% CI: 1.23 to 1.40, p < 0.001) and active movements per tactile input during AAT compared to control sessions (IRR = 1.13, 95% CI: 1.02 to 1.25, p = 0.018). No difference was found for positive emotions. With BAVESTA, patients' overall behavioral reactions were rated higher during AAT (b = 0.11, 95% CI: 0.01 to 0.22, p = 0.038). AAT led to significantly higher LF (b = 5.82, 95% CI: 0.55 to 11.08, p = 0.031) and lower HF (b = -5.80, 95% CI: -11.06 to -0.57, p = 0.030), while heart rate, SDNN, RMSSD did not differ. CONCLUSIONS: Patients in a minimally conscious state showed more behavioral reactions and increased physiological arousal during AAT compared to control sessions. This might indicate increased consciousness during therapeutic sessions in the presence of an animal. TRIAL REGISTRATION: ClinicalTrials.gov NCT02629302.


Assuntos
Terapia Assistida com Animais , Estado de Consciência/fisiologia , Estado Vegetativo Persistente/terapia , Adolescente , Adulto , Idoso , Animais , Estudos Cross-Over , Feminino , Frequência Cardíaca/fisiologia , Humanos , Masculino , Pessoa de Meia-Idade , Estado Vegetativo Persistente/fisiopatologia
19.
J Neurol ; 266(12): 3144-3149, 2019 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-31541340

RESUMO

BACKGROUND: The vegetative state, also known as the unresponsive wakefulness syndrome, is one of the worst possible outcomes of acquired brain injury and confronts rehabilitation specialists with various challenges. Emergence to (minimal) consciousness is classically considered unlikely beyond 3-6 months after non-traumatic or 12 months after traumatic etiologies. A growing body of evidence suggests that these timeframes are too narrow, but evidence regarding chances of recovery is still limited. OBJECTIVE: To identify the moment of recovery of consciousness in documented cases of late emergence from a vegetative state. METHODS: Four cases of apparent late recovery of consciousness, identified within a prospective cohort study, were studied in-depth by analyzing medical, paramedical and nursing files and interviewing the patients' families about their account of the process of recovery. RESULTS: All patients were found to have shown signs of consciousness well within the expected time frame (5 weeks-2 months post-ictus). These behaviors, however, went unnoticed or were misinterpreted, leading to a diagnostic delay of several months to over 5 years. Absence of appropriate diagnostics, the use of erroneous terminology, sedative medication but also patient-related factors such as hydrocephalus, language barriers and performance fluctuations are hypothesized to have contributed to the delay. CONCLUSIONS: Delayed recognition of signs of consciousness in patients in a vegetative state may not only lead to suboptimal clinical care, but also to distorted prognostic figures. Discriminating late recovery from the delayed discovery of consciousness, therefore, is vital to both clinical practice and science.


Assuntos
Estado de Consciência/fisiologia , Estado Vegetativo Persistente/diagnóstico , Estado Vegetativo Persistente/fisiopatologia , Adulto , Lesões Encefálicas Traumáticas/complicações , Feminino , Parada Cardíaca/complicações , Humanos , Masculino , Pessoa de Meia-Idade , Estado Vegetativo Persistente/etiologia , Estudos Prospectivos , Hemorragia Subaracnóidea/complicações , Fatores de Tempo
20.
Brain ; 142(7): 1887-1893, 2019 07 01.
Artigo em Inglês | MEDLINE | ID: mdl-31505542

RESUMO

Dopaminergic stimulation has been proposed as a treatment strategy for post-traumatic brain injured patients in minimally conscious state based on a clinical trial using amantadine, a weak dopamine transporter blocker. However, a specific contribution of dopaminergic neuromodulation in minimally conscious state is undemonstrated. In a phase 0 clinical trial, we evaluated 13 normal volunteers and seven post-traumatic minimally conscious state patients using 11C-raclopride PET to estimate dopamine 2-like receptors occupancy in the striatum and central thalamus before and after dopamine transporter blockade with dextroamphetamine. If a presynaptic deficit was observed, a third and a fourth 11C-raclopride PET were acquired to evaluate changes in dopamine release induced by l-DOPA and l-DOPA+dextroamphetamine. Permutation analysis showed a significant reduction of dopamine release in patients, demonstrating a presynaptic deficit in the striatum and central thalamus that could not be reversed by blocking the dopamine transporter. However, administration of the dopamine precursor l-DOPA reversed the presynaptic deficit by restoring the biosynthesis of dopamine from both ventral tegmentum and substantia nigra. The advantages of alternative pharmacodynamic approaches in post-traumatic minimally conscious state patients should be tested in clinical trials, as patients currently refractory to amantadine might benefit from them.


Assuntos
Lesões Encefálicas Traumáticas/metabolismo , Dopamina/deficiência , Dopamina/metabolismo , Estado Vegetativo Persistente/metabolismo , Terminações Pré-Sinápticas/metabolismo , Adulto , Lesões Encefálicas Traumáticas/complicações , Corpo Estriado/metabolismo , Dextroanfetamina/farmacologia , Proteínas da Membrana Plasmática de Transporte de Dopamina/antagonistas & inibidores , Feminino , Humanos , Levodopa/farmacologia , Masculino , Estado Vegetativo Persistente/complicações , Tomografia por Emissão de Pósitrons , Terminações Pré-Sinápticas/efeitos dos fármacos , Racloprida/metabolismo , Receptores de Dopamina D2/metabolismo , Substância Negra/metabolismo , Tegmento Mesencefálico/metabolismo , Tálamo/metabolismo , Adulto Jovem
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