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Rituximab has been used to treat MS patients in Iceland for over a decade. However, long-term effect of rituximab on leukocyte populations has not yet been elucidated. By retrospective analysis of flow cytometric data from 349 patients visiting the neurological ward at The National University Hospital of Iceland from 2012 to 2023 for rituximab treatment, the long-term effect of rituximab and whether the effect was dose dependent (1000mg vs 500mg) was evaluated. No difference was detected in efficacy of B cell depletion in patients treated with 500mg as an initial dose of rituximab when compared to 1000mg. Long-term use of rituximab led to an increase in T cell count (p=0,0015) in patients receiving 3-8 doses of rituximab (1.5-8 years of treatment). The increase occurred in both CD4+ (p=0,0028) and CD8+ T cells (p=0,0015) and led to a decrease in the CD4/CD8 ratio (p=0,004). The most notable difference lies in reshaping the balance between näive and effector CD8+ T cells. The clinical implications of long-term treatment with rituximab and its effect on the T cell pool needs to be explored further. Since no difference in B cell depletion was detected between the two patient groups, 1000mg as an initial dose might be excessive, suggesting a personalized dosing regimen might have therapeutic and financial advantages.
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Esclerosis Múltiple , Rituximab , Humanos , Rituximab/administración & dosificación , Rituximab/uso terapéutico , Rituximab/efectos adversos , Masculino , Femenino , Adulto , Persona de Mediana Edad , Esclerosis Múltiple/tratamiento farmacológico , Esclerosis Múltiple/inmunología , Estudios Retrospectivos , Recuento de Linfocitos , Factores Inmunológicos/administración & dosificación , Factores Inmunológicos/uso terapéutico , Anciano , Relación CD4-CD8 , Linfocitos B/inmunología , Linfocitos B/efectos de los fármacos , Linfocitos T CD4-Positivos/inmunología , Linfocitos T CD4-Positivos/efectos de los fármacosRESUMEN
BACKGROUND: Transitioning to end-of-life care and thereby changing the focus of treatment directives from life-sustaining treatment to comfort care is important for neurological patients in advanced stages. Late transition to end-of-life care for neurological patients has been described previously. OBJECTIVE: To investigate whether previous treatment directives, primary medical diagnoses, and demographic factors predict the transition to end-of-life care and time to eventual death in patients with neurological diseases in an acute hospital setting. METHOD: All consecutive health records of patients diagnosed with stroke, amyotrophic lateral sclerosis (ALS), and Parkinson's disease or other extrapyramidal diseases (PDoed), who died in an acute neurological ward between January 2011 and August 2020 were retrieved retrospectively. Descriptive statistics and multivariate Cox regression were used to examine the timing of treatment directives and death in relation to medical diagnosis, age, gender, and marital status. RESULTS: A total of 271 records were involved in the analysis. Patients in all diagnostic categories had a treatment directive for end-of-life care, with patients with haemorrhagic stroke having the highest (92%) and patients with PDoed the lowest (73%) proportion. Cox regression identified that the likelihood of end-of-life care decision-making was related to advancing age (HR = 1.02, 95% CI: 1.007-1.039, P = 0.005), ischaemic stroke (HR = 1.64, 95% CI: 1.034-2.618, P = 0.036) and haemorrhagic stroke (HR = 2.04, 95% CI: 1.219-3.423, P = 0.007) diagnoses. End-of-life care decision occurred from four to twenty-two days after hospital admission. The time from end-of-life care decision to death was a median of two days. Treatment directives, demographic factors, and diagnostic categories did not increase the likelihood of death following an end-of-life care decision. CONCLUSIONS: Results show not only that neurological patients transit late to end-of-life care but that the timeframe of the decision differs between patients with acute neurological diseases and those with progressive neurological diseases, highlighting the particular significance of the short timeframe of patients with the progressive neurological diseases ALS and PDoed. Different trajectories of patients with neurological diseases at end-of-life should be further explored and clinical guidelines expanded to embrace the high diversity in neurological patients.
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Enfermedades del Sistema Nervioso , Cuidado Terminal , Humanos , Masculino , Cuidado Terminal/métodos , Cuidado Terminal/estadística & datos numéricos , Femenino , Anciano , Persona de Mediana Edad , Estudios Retrospectivos , Enfermedades del Sistema Nervioso/terapia , Enfermedades del Sistema Nervioso/diagnóstico , Enfermedades del Sistema Nervioso/epidemiología , Anciano de 80 o más Años , Esclerosis Amiotrófica Lateral/terapia , Esclerosis Amiotrófica Lateral/diagnóstico , Esclerosis Amiotrófica Lateral/mortalidadRESUMEN
INTRODUCTION: Research on healthy pregnant women's reflexes is almost unheard of, even if an estimation of reflexes is a conventional part of the physical examination of preeclamptic patients, and hyperreflexia is generally considered to be a warning sign of eclampsia. The aim of the present study was to investigate the possible impact of gestation on tendon reflexes and the Babinski response, as examined in a clinical bed-side manner. MATERIAL AND METHODS: A prospective, single-blind, cross-sectional study. Three study groups comprised non-pregnant (n = 20), 14-18 weeks (n = 16), and 34-38 weeks (n = 15) healthy pregnant women respectively. Two experienced neurologists examined separately each participant's patellar reflexes, Achilles reflexes, and Babinski response and rated them on two different scales, National Institute of Neurological Disorders and Stroke (NINDS) scale and Mayo Clinic Scale for Tendon Reflex Assessment. Inter-observer estimations between the patient groups and the neurologists were made by mixed effect model methodology. RESULTS: The patellar and Achilles reflexes´ strengths were rated similarly in all three groups (p > 0.05). The inter-observer difference was non-significant between the neurologists´ estimations (p > 0.05). The neurologists estimated the Babinski response in a few cases as neutral (0), otherwise down (normal). CONCLUSIONS: The patellar and Achilles reflex strengths are not affected in uncomplicated pregnancy. There is good concordance between neurologists´ estimations of tendon reflex strengths rated on the NINDS and Mayo scales.
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Tendón Calcáneo , Humanos , Femenino , Embarazo , Estudios Prospectivos , Estudios Transversales , Adulto , Método Simple CiegoRESUMEN
The association between age and language recovery in stroke remains unclear. Here, we used neuroimaging data to estimate brain age, a measure of structural integrity, and examined the extent to which brain age at stroke onset is associated with (i) cross-sectional language performance, and (ii) longitudinal recovery of language function, beyond chronological age alone. A total of 49 participants (age: 65.2 ± 12.2 years, 25 female) underwent routine clinical neuroimaging (T1) and a bedside evaluation of language performance (Bedside Evaluation Screening Test-2) at onset of left hemisphere stroke. Brain age was estimated from enantiomorphically reconstructed brain scans using a machine learning algorithm trained on a large sample of healthy adults. A subsample of 30 participants returned for follow-up language assessments at least 2 years after stroke onset. To account for variability in age at stroke, we calculated proportional brain age difference, i.e. the proportional difference between brain age and chronological age. Multiple regression models were constructed to test the effects of proportional brain age difference on language outcomes. Lesion volume and chronological age were included as covariates in all models. Accelerated brain age compared with age was associated with worse overall aphasia severity (F(1, 48) = 5.65, P = 0.022), naming (F(1, 48) = 5.13, P = 0.028), and speech repetition (F(1, 48) = 8.49, P = 0.006) at stroke onset. Follow-up assessments were carried out ≥2 years after onset; decelerated brain age relative to age was significantly associated with reduced overall aphasia severity (F(1, 26) = 5.45, P = 0.028) and marginally failed to reach statistical significance for auditory comprehension (F(1, 26) = 2.87, P = 0.103). Proportional brain age difference was not found to be associated with changes in naming (F(1, 26) = 0.23, P = 0.880) and speech repetition (F(1, 26) = 0.00, P = 0.978). Chronological age was only associated with naming performance at stroke onset (F(1, 48) = 4.18, P = 0.047). These results indicate that brain age as estimated based on routine clinical brain scans may be a strong biomarker for language function and recovery after stroke.
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INTRODUCTION: Fampridine is a drug for people with Multiple Sclerosis (MS). It is a broad-spectrum voltage-dependent potassium channel blocker that enhances synaptic transmission. The drug has been shown to be able to enhance conduction in demyelinated axons, thereby leading to improved gait in patients with MS. The purpose of this study was to examine the effect of fampridine on gait function in people with MS in the end of a 2 weeks trial drug period and to observe how many patients continued drug therapy. MATERIAL AND METHODS: Data from 41 individuals with MS was collected retrospectively for this study. Measurements were administered by physiotherapists and the results from the Timed 25-Foot Walk (T25FW) and 12-item Multiple Sclerosis Walking Scale (MSWS-12) were obtained from medical records from The National University Hospital of Iceland. RESULTS: The results showed a significant difference in walking speed before and at the end of trial period (p<0.0001). The average improvement in walking speed was 22%. Results also demonstrated a significant difference in MSWS-12 scores before and at the end of treatment (p<0.0001). The average improvement in MSWS-12 was 11.4 points. Eighteen individuals (43.9%) continued treatment after the trial period. CONCLUSION: Fampridine can have a positive effect on impaired gait function in people with MS and can be an important adjunct to treatment.
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Esclerosis Múltiple , 4-Aminopiridina/efectos adversos , Marcha , Humanos , Esclerosis Múltiple/diagnóstico , Esclerosis Múltiple/tratamiento farmacológico , Bloqueadores de los Canales de Potasio/efectos adversos , Estudios Retrospectivos , CaminataRESUMEN
PURPOSE: To explore facilitating and inhibiting factors in the inpatient care of patients with functional neurological disorders as experienced by interdisciplinary teams of healthcare professionals. METHOD: Qualitative focus group interviews were conducted with 18 healthcare professionals of various professions. Data were analyzed using qualitative content analysis with inductive coding of data. RESULTS: Two main categories were formulated: (a) Giving the diagnosis to patients - a moment of fragility and opportunities, and (b) Organization of care - ensuring the continuity and protecting patients' self-image. One overarching theme tied the two categories together: Establishing coherence in the inpatient trajectory - moving from stigmatization toward competent care. Coherence and steadiness in care was a prerequisite for transparency in goalsetting and for designating the responsibilities of individual healthcare professionals. Stigma and having clinical experience and knowledge of functional neurological disorders, as two counter-factors, influenced the extent to which this was achieved. Examples of facilitating factors for enhancing competent care were documentation of symptoms, effective ways of passing on clinical information, education, professional dialog, and organizational support. DISCUSSION: To nurture competent care, guidelines, structured educational initiatives and other supportive actions should be promoted. We provide ideas for the next logical steps for clinical practice and research.IMPLICATIONS FOR REHABILITATIONClose collaboration between interdisciplinary healthcare professionals plays an important role for reaching optimal results in the rehabilitation of inpatients with functional neurological disorder.There is currently limited knowledge regarding the facilitating and inhibiting features encountered by interdisciplinary healthcare professionals in the provision of care for patients with a functional neurological disorder.The findings show that a working environment that endorses a skillful culture of practice and which facilitates actions to reduce problems that hamper effective teamwork needs to be promoted.Solutions that help to solve many obstacles encountered by the team of healthcare professionals in the care provision of patients with functional neurological disorders include open dialog regarding symptoms, diagnosis and treatment, effective ways of documenting and reporting symptoms, and availability of guidelines and supporting educational material.
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Enfermedades del Sistema Nervioso , Estereotipo , Actitud del Personal de Salud , Grupos Focales , Personal de Salud , Humanos , Investigación CualitativaRESUMEN
INTRODUCTION: Multiple sclerosis (MS) is a chronic inflammatory disease of the central nervous system which affects young people, especially women. The aim of the study was to examine the disease profile of MS during pregnancy and postpartum as well as pregnancy outcomes in women with MS compared to a control group. Such a study has not been conducted in Iceland before. MATERIAL AND METHODS: A hospital based retrospective study with data from the Icelandic Medical Birth Register and medical records from Landspitali University Hospital including women with MS diagnosis during 2009-2018 and their deliveries through 1999-2018, a total of 91 women and 137 births. RESULTS: Relapse frequency decreased during pregnancy compared to the preceding year. Over half of the women received disease modifying drugs before pregnancy, all stopped treatment before or shortly after conception. Women in the study group underwent cesarean sections before labor more frequently than the control group. The gestational length was comparable between the groups when labor was spontaneous. The numbers of heavy- and lightweight newborns as well as Apgar scores were alike in both groups. CONCLUSION: We believe that our study reflects actual pregnancy outcome among Icelandic women with MS and our results show that their pregnancies and deliveries do not differ in any major aspect from the general population. Our findings agree with previous studies in that pregnancy protects against MS relapses although in our study this is confined to the first and second trimester.
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Esclerosis Múltiple/epidemiología , Adulto , Puntaje de Apgar , Peso al Nacer , Cesárea , Registros Electrónicos de Salud , Femenino , Humanos , Islandia/epidemiología , Recién Nacido , Esclerosis Múltiple/diagnóstico , Esclerosis Múltiple/tratamiento farmacológico , Embarazo , Resultado del Embarazo , Recurrencia , Sistema de Registros , Estudios Retrospectivos , Factores de TiempoRESUMEN
Autoimmune thyroid disease is the most common autoimmune disease and is highly heritable1. Here, by using a genome-wide association study of 30,234 cases and 725,172 controls from Iceland and the UK Biobank, we find 99 sequence variants at 93 loci, of which 84 variants are previously unreported2-7. A low-frequency (1.36%) intronic variant in FLT3 (rs76428106-C) has the largest effect on risk of autoimmune thyroid disease (odds ratio (OR) = 1.46, P = 2.37 × 10-24). rs76428106-C is also associated with systemic lupus erythematosus (OR = 1.90, P = 6.46 × 10-4), rheumatoid factor and/or anti-CCP-positive rheumatoid arthritis (OR = 1.41, P = 4.31 × 10-4) and coeliac disease (OR = 1.62, P = 1.20 × 10-4). FLT3 encodes fms-related tyrosine kinase 3, a receptor that regulates haematopoietic progenitor and dendritic cells. RNA sequencing revealed that rs76428106-C generates a cryptic splice site, which introduces a stop codon in 30% of transcripts that are predicted to encode a truncated protein, which lacks its tyrosine kinase domains. Each copy of rs76428106-C doubles the plasma levels of the FTL3 ligand. Activating somatic mutations in FLT3 are associated with acute myeloid leukaemia8 with a poor prognosis and rs76428106-C also predisposes individuals to acute myeloid leukaemia (OR = 1.90, P = 5.40 × 10-3). Thus, a predicted loss-of-function germline mutation in FLT3 causes a reduction in full-length FLT3, with a compensatory increase in the levels of its ligand and an increased disease risk, similar to that of a gain-of-function mutation.
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Codón sin Sentido/genética , Predisposición Genética a la Enfermedad/genética , Ligandos , Mutación , Tiroiditis Autoinmune/genética , Tirosina Quinasa 3 Similar a fms/genética , Tirosina Quinasa 3 Similar a fms/metabolismo , Alelos , Enfermedades Autoinmunes/genética , Bases de Datos Factuales , Estudio de Asociación del Genoma Completo , Mutación de Línea Germinal , Humanos , Islandia , Intrones/genética , Leucemia Mieloide Aguda , Mutación con Pérdida de Función , Sitios de Empalme de ARN/genética , Reino UnidoRESUMEN
Multiple sclerosis (MS) is the most common chronic inflammatory disease of the central nervous system and among the most com-mon causes of neurological disability in young and middle-aged adults. MS is an autoimmune disease caused by a complex interaction between genetic and environmental factors. During the last decades, great advances have been made in understanding the risk factors of MS and the diagnostic ability and treatment of the dis-ease have improved dramatically. It is of importance that doctors are made aware of the possibility of an early diagnosis and effective treatment. In this paper we discuss new knowledge regarding the etiology, diagnosis and treatment of MS.
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Esclerosis Múltiple , Diagnóstico Precoz , Predisposición Genética a la Enfermedad , Estado de Salud , Humanos , Incidencia , Esclerosis Múltiple/diagnóstico , Esclerosis Múltiple/epidemiología , Esclerosis Múltiple/terapia , Valor Predictivo de las Pruebas , Pronóstico , Factores de RiesgoRESUMEN
Left-hemisphere brain damage commonly affects patients' abilities to produce and comprehend syntactic structures, a condition typically referred to as "agrammatism." The neural correlates of agrammatism remain disputed in the literature, and distributed areas have been implicated as important predictors of performance, for example, Broca's area, anterior temporal areas, and temporo-parietal areas. We examined the association between damage to specific language-related ROIs and impaired syntactic processing in acute aphasia. We hypothesized that damage to the posterior middle temporal gyrus, and not Broca's area, would predict syntactic processing abilities. One hundred four individuals with acute aphasia (<20 days poststroke) were included in the study. Structural MRI scans were obtained, and all participants completed a 45-item sentence-picture matching task. We performed an ROI-based stepwise regression analyses to examine the relation between cortical brain damage and impaired comprehension of canonical and noncanonical sentences. Damage to the posterior middle temporal gyrus was the strongest predictor for overall task performance and performance on noncanonical sentences. Damage to the angular gyrus was the strongest predictor for performance on canonical sentences, and damage to the posterior superior temporal gyrus predicted noncanonical scores when performance on canonical sentences was included as a cofactor. Overall, our models showed that damage to temporo-parietal and posterior temporal areas was associated with impaired syntactic comprehension. Our results indicate that the temporo-parietal area is crucially implicated in complex syntactic processing, whereas the role of Broca's area may be complementary.
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Afasia/patología , Afasia/fisiopatología , Comprensión/fisiología , Reconocimiento Visual de Modelos/fisiología , Percepción del Habla/fisiología , Lóbulo Temporal/patología , Enfermedad Aguda , Anciano , Afasia/diagnóstico por imagen , Afasia/etiología , Femenino , Humanos , Imagen por Resonancia Magnética , Masculino , Persona de Mediana Edad , Psicolingüística , Accidente Cerebrovascular/complicacionesRESUMEN
The human leukocyte antigen (HLA) haplotype DRB1*15:01 is the major risk factor for multiple sclerosis (MS). Here, we find that DRB1*15:01 is hypomethylated and predominantly expressed in monocytes among carriers of DRB1*15:01. A differentially methylated region (DMR) encompassing HLA-DRB1 exon 2 is particularly affected and displays methylation-sensitive regulatory properties in vitro. Causal inference and Mendelian randomization provide evidence that HLA variants mediate risk for MS via changes in the HLA-DRB1 DMR that modify HLA-DRB1 expression. Meta-analysis of 14,259 cases and 171,347 controls confirms that these variants confer risk from DRB1*15:01 and also identifies a protective variant (rs9267649, p < 3.32 × 10-8, odds ratio = 0.86) after conditioning for all MS-associated variants in the region. rs9267649 is associated with increased DNA methylation at the HLA-DRB1 DMR and reduced expression of HLA-DRB1, suggesting a modulation of the DRB1*15:01 effect. Our integrative approach provides insights into the molecular mechanisms of MS susceptibility and suggests putative therapeutic strategies targeting a methylation-mediated regulation of the major risk gene.
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Metilación de ADN , Predisposición Genética a la Enfermedad/genética , Cadenas HLA-DRB1/genética , Esclerosis Múltiple/genética , Polimorfismo de Nucleótido Simple , Adulto , Anciano , Células Cultivadas , Estudios de Cohortes , Femenino , Regulación de la Expresión Génica , Humanos , Masculino , Metaanálisis como Asunto , Persona de Mediana Edad , Esclerosis Múltiple/inmunología , Esclerosis Múltiple/patología , Factores de Riesgo , Adulto JovenRESUMEN
PURPOSE: Structural and physiological abnormalities have been reported in the retina in patients with multiple sclerosis (MS). Retinal oximetry has recently detected changes in retinal oxygen metabolism in Alzheimer's disease and mild cognitive impairment. Our goal was to determine whether oxygen saturation in retinal blood vessels of patients with patients is different from that of a healthy population. METHODS: Oxygen saturation of haemoglobin was measured in retinal blood vessels, using imaging with spectrophotometric noninvasive retinal oximeter. Eight MS patients with history of optic neuritis were measured and compared to 22 healthy individuals matched in age and gender. RESULTS: Venular oxygen saturation was increased in patients with MS compared to healthy individuals (70.7 ± 3.4% versus 66.2 ± 4.7; p = 0.021, mean ± SD). The arteriovenous (AV) difference was lower in patients with MS compared to healthy (26.6 ± 3.6% versus 30.5 ± 4.8%; p = 0.049). There was no difference measured in arterioles when patients with MS (97.3 ± 1.7%) and healthy individuals (96.7 ± 2.8%) were compared. CONCLUSION: Increased venular oxygen saturation and lower AV difference in patients with MS may indicate reduced oxygen uptake. This may be due to less oxygen demand following atrophy and may be a useful objective biomarker for MS. Further studies are needed to confirm and expand these findings.
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Esclerosis Múltiple/diagnóstico , Neuritis Óptica/metabolismo , Oximetría/métodos , Consumo de Oxígeno/fisiología , Oxígeno/metabolismo , Vasos Retinianos/fisiología , Adulto , Arteriolas/fisiología , Femenino , Humanos , Masculino , Persona de Mediana Edad , Esclerosis Múltiple/complicaciones , Esclerosis Múltiple/metabolismo , Neuritis Óptica/diagnóstico , Neuritis Óptica/etiología , Estudios Prospectivos , Reproducibilidad de los Resultados , Vénulas/fisiologíaRESUMEN
Background Stroke patients with severe symptoms of hemispatial neglect (HN) are known to experience a weaker recovery than those less affected from the outset. Correct identification of HN is therefore important throughout the course of rehabilitation. Objectives To explore: (i) the course of clinical symptoms in stroke patients with moderate/severe HN from acute setting to home, (ii) changes in sensitivity of diagnostic tasks over time, and (iii) agreement between the researcher's and patients' HN assessments. Methods Out of 79 consecutive patients, we included 23 patients with moderate/severe HN following right hemisphere stroke. The Catherine Bergego Scale was used as a benchmark for HN and to measure the congruence between the researcher's and patients' HN assessments. Diagnostic tasks included star cancellation, line crossing, line bisection, m-fluff test, figure copying, and clock drawing. Data were collected at t1: sub-acute stroke (days: M ± SD = 10.3 ± 5.25), t2: during rehabilitation (days: M ± SD = 51 ± 8), and t3: following discharge (days: M ± SD = 141.5 ± 47.3). Results (i) 20 out of 23 patients had HN at t3. Associated stroke challenges included paralysis, sensory loss, visual deficits, and extinction. (ii) Combining the star cancellation and figure copying yielded the highest sensitivity at all time points, even in patients with mild HN at t3. (iii) Patients' HN scores differed from the researcher's at t1. The difference was insignificant at t3. Conclusions Joint consideration of stroke severity, functional difficulties, and patients' insight into neglect provides new knowledge to increase clinicians' recognition of HN. More extensive studies are needed to validate bedside screening with star cancellation and figure copying.
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Lateralidad Funcional/fisiología , Trastornos de la Percepción/diagnóstico , Trastornos de la Percepción/etiología , Accidente Cerebrovascular/complicaciones , Adulto , Anciano , Anciano de 80 o más Años , Femenino , Humanos , Masculino , Persona de Mediana Edad , Desempeño Psicomotor/fisiología , Estudios Retrospectivos , Sensibilidad y Especificidad , Factores de TiempoRESUMEN
A meta-analysis of publicly available summary statistics on multiple sclerosis combined with three Nordic multiple sclerosis cohorts (21,079 cases, 371,198 controls) revealed seven sequence variants associating with multiple sclerosis, not reported previously. Using polygenic risk scores based on public summary statistics of variants outside the major histocompatibility complex region we quantified genetic overlap between common autoimmune diseases in Icelanders and identified disease clusters characterized by autoantibody presence/absence. As multiple sclerosis-polygenic risk scores captures the risk of primary biliary cirrhosis and vice versa (P = 1.6 × 10-7, 4.3 × 10-9) we used primary biliary cirrhosis as a proxy-phenotype for multiple sclerosis, the idea being that variants conferring risk of primary biliary cirrhosis have a prior probability of conferring risk of multiple sclerosis. We tested 255 variants forming the primary biliary cirrhosis-polygenic risk score and found seven multiple sclerosis-associating variants not correlated with any previously established multiple sclerosis variants. Most of the variants discovered are close to or within immune-related genes. One is a low-frequency missense variant in TYK2, another is a missense variant in MTHFR that reduces the function of the encoded enzyme affecting methionine metabolism, reported to be dysregulated in multiple sclerosis brain.
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PURPOSE: To explore the usefulness of conventional tests for assessing spatial neglect and contrast these tests with daily challenges encountered by patients after discharge from rehabilitation to home. METHODS: A mixed method prospective study of 15 patients with neglect after a right hemisphere stroke, <1 month after discharge to home. Data were obtained from: (1) Catherine Bergego Scale (CBS), (2) star cancellation and figure copying and (3) observations and interviews. Qualitative data were analysed with content analysis and quantitative data with non-parametric statistics. The data were presented in a 'mixing matrix' and integrated by 'following threads'. Finally, a synthesis was written into a vignette. RESULTS: The CBS significantly underestimated fluctuations and did not capture important items of neglect. The star cancellation and figure copying did not identify neglect in mildly affected participants. Left starting point in the star cancellation and a characteristic process of drawing in figure copying were observed in all participants. CONCLUSION: Traditional numerical interpretations of paper-pencil tests inadequately confirmed mild neglect. Starting points of the star cancellation and observation of drawing should be incorporated into screening procedures. Assessment strategies need improvement to identify patients with subtle forms of neglect. Implications for Rehabilitation Findings demonstrate that identification of spatial neglect and the way symptoms of neglect impact on daily life functioning of stroke patients must be carefully pursued by health-care professionals working in stroke rehabilitation. Areas that should receive professional attention in the rehabilitation process include: preparing patients and their family for fluctuations related to neglect in the patient's own home, locating issues that might impact safety, and identifying unique factors that either enhance or diminish neglect within each patient's daily life context. The results of this study could be used to develop more wide-ranging assessment strategies to assist health-care professionals in identifying neglect after hospital discharge, for instance by expanding existing ecological assessment tools and including qualitative evaluation of test performance in paper-pencil tests, such as the star cancellation and figure copying.
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Infarto Cerebral , Alta del Paciente , Trastornos de la Percepción , Navegación Espacial/fisiología , Rehabilitación de Accidente Cerebrovascular/métodos , Anciano , Infarto Cerebral/complicaciones , Infarto Cerebral/psicología , Infarto Cerebral/rehabilitación , Femenino , Humanos , Masculino , Persona de Mediana Edad , Pruebas Neuropsicológicas , Trastornos de la Percepción/diagnóstico , Trastornos de la Percepción/etiología , Trastornos de la Percepción/rehabilitación , Estudios Prospectivos , Desempeño PsicomotorRESUMEN
OBJECTIVES: To identify rehabilitation interventions that can be integrated into ward-based nursing for patients with hemispatial neglect following stroke in the right brain hemisphere. DESIGN: A systematic review of interdisciplinary literature. DATA SOURCES: A preliminary literature search without time limits was conducted in the Cochrane Controlled Trials Register. We then searched the PubMed, CINAHL and PsychINFO databases for relevant articles published between January 2006 and June 2014. Selected journals were searched manually. Additional resources were explored by scrutinizing reference lists and tracking citations of the selected articles. REVIEW METHODS: Titles and abstracts were matched with the inclusion criteria. Articles were read in their entirety if the abstracts adhered to inclusion criteria or if there was any uncertainty. Two reviewers evaluated the risk of methodological bias independently by using quantitative appraisal forms from the Johanna Briggs Institute (JBI). Any disagreements were resolved by consensus. Authors of nine studies were contacted to acquire additional information. The JBI Reviewers' Manual was used to guide the overall procedure of the review. We used the PRISMA statement to ensure precise reporting of the results. The selected studies were graded according to the strength of their evidence (Levels 1-5); the proposed interventions were given recommendation grades (Grades A-D). RESULTS: Using 41 original studies, 11 interventions were identified. These comprise: (1) contralesional neck vibration (Grade C); (2) emotionally salient stimuli and reward (Grade D); (3) family participation and intensity of training (Grade C); (4) limb activation training (Grade C); (5) mental imagery training, (Grade D); (6) mirror therapy (Grade C); (7) music therapy (Grade D); (8) right half-field eye patching (Grade D); (9) smooth pursuit eye-movement training (Grade B); (10) virtual reality and computer-based training (Grade C); and (11) visual scanning training (Grade D). CONCLUSION: A total of 11 promising rehabilitation interventions were found. Encouraging results were, in particular, seen with smooth pursuit eye-movement training. It should be noted that the general low level of evidence and the diversity of interventions makes it difficult to endorse specific priorities and combinations for implementation. Instead, interventions should be applied after careful evaluation of each patient's unique capacities and problems. We include suggestions for operationalization into ward-based care in "Discussion" section. We also emphasize the need to integrate evidence-based interventions into nursing care to further stimulate rehabilitation outcomes and future research.
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Rehabilitación de Accidente Cerebrovascular , Humanos , Medición de Riesgo , Accidente Cerebrovascular/enfermería , Accidente Cerebrovascular/fisiopatologíaRESUMEN
We used a phenomenological approach to gain insight into the experiences of self, other, and world in patients with hemispatial neglect within the first month following stroke. Comprehensive descriptions of circumstances were conjoined with open-ended interviews of 12 participants. The neglect experience was captured in the overarching theme, "getting the left right," which encompasses the two subthemes of (a) surreal awareness of the left and (b) emergence of a different world. Patients had unclear perceptions of their own body and surroundings, their attention was brittle, and they encountered bewildering reactions from other people. They simultaneously pursued the ineffable neglected space and searched for coherence. The vulnerability, loss, and conflicting perceptions that patients with neglect face should be acknowledged and alleviation sought. Facilitating methods should provide additional opportunities for patients to communicate their experiences. We underscore the importance of readjusting the current approaches of neglect and emphasizing meaningfulness in professional guidance.
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Imagen Corporal/psicología , Trastornos de la Percepción/psicología , Accidente Cerebrovascular/psicología , Adulto , Anciano , Femenino , Humanos , Islandia , Entrevistas como Asunto , Masculino , Persona de Mediana Edad , Observación , Trastornos de la Percepción/etiología , Investigación Cualitativa , Índice de Severidad de la Enfermedad , Accidente Cerebrovascular/complicacionesRESUMEN
BACKGROUND AND PURPOSE: Atrial fibrillation (AF) has been associated with cognitive decline independent of stroke, suggesting additional effects of AF on the brain. We aimed to assess the association between AF and brain function and structure in a general elderly population. METHODS: This is a cross-sectional analysis of 4251 nondemented participants (mean age, 76 ± 5 years) in the population-based Age, Gene/Environment Susceptibility-Reykjavik Study. Medical record data were collected for the presence, subtype, and time from first diagnosis of AF; 330 participants had AF. Brain volume measurements, adjusted for intracranial volume, and presence of cerebral infarcts were determined with magnetic resonance imaging. Memory, speed of processing, and executive function composites were calculated from a cognitive test battery. In a multivariable linear regression model, adjustments were made for demographic factors, cardiovascular risk factors, and cerebral infarcts. RESULTS: Participants with AF had lower total brain volume compared with those without AF (P<0.001). The association was stronger with persistent/permanent than paroxysmal AF and with increased time from the first diagnosis of the disease. Of the brain tissue volumes, AF was associated with lower volume of gray and white matter hyperintensities (P<0.001 and P = 0.008, respectively), but not of white matter hyperintensities (P = 0.49). Participants with AF scored lower on tests of memory. CONCLUSIONS: AF is associated with smaller brain volume, and the association is stronger with increasing burden of the arrhythmia. These findings suggest that AF has a cumulative negative effect on the brain independent of cerebral infarcts.
Asunto(s)
Fibrilación Atrial/diagnóstico , Fibrilación Atrial/fisiopatología , Encéfalo/fisiología , Trastornos del Conocimiento/diagnóstico , Anciano , Anciano de 80 o más Años , Fibrilación Atrial/complicaciones , Encéfalo/patología , Infarto Cerebral/complicaciones , Infarto Cerebral/diagnóstico , Cognición , Trastornos del Conocimiento/complicaciones , Estudios de Cohortes , Estudios Transversales , Femenino , Predisposición Genética a la Enfermedad , Humanos , Imagen por Resonancia Magnética/métodos , Masculino , Evaluación de Resultado en la Atención de Salud , Análisis de Regresión , Factores de RiesgoRESUMEN
Following brain injury, many patients experience egocentric spatial neglect, where they fail to respond to stimuli on the contralesional side of their body. On the other hand, allocentric, object-based neglect refers to the symptom of ignoring the contralesional side of objects, regardless of the objects' egocentric position. There is an established tradition for considering these two phenomena as both behaviorally and anatomically dissociable. However, several studies and some theoretical work have suggested that these rather reflect two aspects of a unitary underlying disorder. Furthermore, in a recent large study Yue et al. [Archives of Physical Medicine and Rehabilitation 93 (2012) 156] reported that acute allocentric neglect is only observed in cases where substantial egocentric neglect is also present. In a new sample of right hemisphere stroke patients, we attempted to control for potential confounds by using a novel continuous measure for allocentric neglect (in addition to a recently developed continuous measure for egocentric neglect). Our findings suggest a strong association between egocentric and allocentric neglect. Consistent with the work of Yue et al. (2012), we found allocentric behavioral deficits only in conjunction with egocentric deficits as well as a large corresponding overlap for the anatomical regions associated with egocentric and with allocentric neglect. We discuss how different anatomical and behavioral findings can be explained in a unified physiologically plausible framework, whereby allocentric and egocentric effects interact.
Asunto(s)
Mapeo Encefálico , Trastornos del Conocimiento/fisiopatología , Lateralidad Funcional/fisiología , Trastornos de la Percepción/patología , Trastornos de la Percepción/fisiopatología , Percepción Espacial/fisiología , Anciano , Trastornos del Conocimiento/etiología , Femenino , Humanos , Procesamiento de Imagen Asistido por Computador , Imagen por Resonancia Magnética , Masculino , Persona de Mediana Edad , Pruebas Neuropsicológicas , Trastornos de la Percepción/psicología , Estimulación LuminosaRESUMEN
Patients with left hemisphere damage and concomitant aphasia usually have difficulty repeating others' speech. Although impaired speech repetition, the primary symptom of conduction aphasia, has been associated with involvement of the left arcuate fasciculus, its specific lesion correlate remains elusive. This research examined speech repetition among 45 stroke patients who underwent aphasia testing and MRI examination. Based on lesion-behavior mapping, the primary structural damage most closely associated with impaired speech repetition was found in the posterior portion of the left arcuate fasciculus. However, perfusion-weighted MRI revealed that tissue dysfunction, in the form of either frank damage or hypoperfusion, to the left inferior parietal lobe, rather than the underlying white matter, was associated with impaired speech repetition. This latter result suggests that integrity of the left inferior parietal lobe is important for speech repetition and, as importantly, highlights the importance of examining cerebral perfusion for the purpose of lesion-behavior mapping in acute stroke.