Delivering the diagnosis of Alzheimer's disease: bioethical considerations / Comunicación del diagnóstico de enfermedad de Alzheimer: reflexiones bioéticas.

Delivering the diagnosis of Alzheimer's disease to the patient can cause situations that do not meet the necessary ethical professional standards. We present two cases in which the rash way such a diagnosis was delivered did not respect the principle of nonmaleficence. In both cases the revelation worsened the situation prior to the consultation, causing unfortunate distress to the patient and family. The blunt use of the term "Alzheimer", together with the insufficient information on the characteristics of the affection, seems to have been the main factor that produced a negative emotional impact, revealing an arrogant professional attitude of 'absolute' and unquestionable knowledge, without the necessary equity. A diagnosis of Alzheimer´s should be not only truthful but delivered with caution, above all things avoiding a further damage than that already brought about by the disease.

Al comunicar al paciente el diagnóstico de enfermedad de Alzheimer, pueden originarse situaciones no acordes con la necesaria conducta ética profesional. Presentamos dos casos en los que, al actuarse con imprudencia, no se respetó el requisito de no maleficencia, En ambos casos la revelación diagnóstica empeoró la situación previa a la consulta, provocando en el paciente y su familia decisiones y consecuencias desafortunadas. El uso abrupto y cortante del término "Alzheimer", junto a la información insuficiente sobre las características de la afección, parece haber sido el factor principal de un impacto emotivo negativo, mostrando una actitud profesional dueña de un saber "absoluto" e inapelable, en un vínculo sin equidad. El acto de comunicar un diagnóstico debe ajustarse al criterio de prudencia, y no solamente al de veracidad o exactitud, evitando por sobre todas las cosas provocar un daño mayor al ya causado por la enfermedad.

[Cognitive impairment during the COVID-19- social isolation period]. / Restricción cognitiva durante la cuarentena por COVID-19.

The COVID-19 social isolation period entailed changes in daily habits and routines, testing the adjustment abilities of the population to address unusual situations. Given that the activities of daily living require a normally functioning cognitive system, the study of cognitive-functional interaction under social isolation is relevant. The object of this work was to obtain information on the cognitive-functional impact of social isolation, analyze the changes induced in daily routines and habits, and assess the cognitive adjustment of the adult population to the isolation requirements. We carried out an online adult population survey, that combined multiple choice or binary questions following a Likert ordinal scale, performing a percentage analysis as well as a principal component analysis of the results. We surveyed 1095 subjects, 68% of which were residents of the Buenos Aires Metropolitan Area (AMBA), of an average age of 52.7 ± 12.8 years, and 15.6 ± 2.2 years of education. All age groups reported attention and memory impairment, more significant in lower age groups and women. The principal component analysis showed an associated correlation of the functional challenge brought about by social isolation on the executive system, with the negative impact on cognitive functions such as attention and memory. Social isolation significantly impacted on the attentional, mnesic and executive cognitive systems, ratifying the role of cognitive abilities in the generation of means and strategies to overcome unusual situations, and highlighting the importance of cognitive-functional interaction.

El período de aislamiento social por COVID-19 generó cambios en los hábitos y rutinas, poniendo a prueba capacidades adaptativas para resolver situaciones infrecuentes. Dado que el sistema cognitivo es el sustrato de las actividades funcionales cotidianas, nuestro objetivo fue conocer el impacto cognitivofuncional del aislamiento, obtener información acerca de los cambios de hábitos y rutinas diarias y evaluar la modalidad de adaptación de la población adulta a la cuarentena. En el marco del Instituto de Salud Pública y Medicina Preventiva de la UBA, realizamos una encuesta online donde se incluyeron preguntas con respuesta de elección según escala ordinal Likert, de tipo binario y de elección múltiple. Se realizó un análisis porcentual de los resultados y un análisis de componentes principales. Encuestamos 1095 sujetos, el 68% fueron residentes en el Área metropolitana de Buenos Aires, edad 52.7 ± 12.8 años y 15.6 ± 2.2 años de instrucción. Todos los grupos de edad refirieron empeoramiento de la atención y memoria, siendo más significativo en las franjas de menor edad y en el género femenino. El análisis de componentes principales mostró una correlación asociada al efecto negativo de factores cognitivos previos como la memoria y la atención con la dificultad durante la cuarentena en el dominio ejecutivo. El aislamiento social impactó en el sistema atencional, mnésico y de funciones ejecutivas. Resultó corroborado el importante rol de las capacidades cognitivas en la generación de recursos y la aplicación de estrategias para adaptarse a situaciones poco habituales, poniendo de manifiesto la interacción cognitivo-funcional.

Restricción cognitiva durante la cuarentena por COVID-19 / Cognitive impairment during the COVID-19- social isolation period

Resumen El período de aislamiento social por COVID-19 generó cambios en los hábitos y rutinas, poniendo a prueba capacidades adaptativas para resolver situaciones infrecuentes. Dado que el sistema cog nitivo es el sustrato de las actividades funcionales cotidianas, nuestro objetivo fue conocer el impacto cognitivo-funcional del aislamiento, obtener información acerca de los cambios de hábitos y rutinas diarias y evaluar la modalidad de adaptación de la población adulta a la cuarentena. En el marco del Instituto de Salud Pública y Medicina Preventiva de la UBA, realizamos una encuesta online donde se incluyeron preguntas con respuesta de elección según escala ordinal Likert, de tipo binario y de elección múltiple. Se realizó un análisis porcentual de los resultados y un análisis de componentes principales. Encuestamos 1095 sujetos, el 68% fueron residentes en el Área metropolitana de Buenos Aires, edad 52.7 ± 12.8 años y 15.6 ± 2.2 años de instrucción. Todos los grupos de edad refirieron empeoramiento de la atención y memoria, siendo más significativo en las franjas de menor edad y en el género femenino. El análisis de componentes principales mostró una correlación asociada al efecto negativo de factores cognitivos previos como la memoria y la atención con la dificultad durante la cua rentena en el dominio ejecutivo. El aislamiento social impactó en el sistema atencional, mnésico y de funciones ejecutivas. Resultó corroborado el importante rol de las capacidades cognitivas en la generación de recursos y la aplicación de estrategias para adaptarse a situaciones poco habituales, poniendo de manifiesto la interacción cognitivo-funcional.

Abstract The COVID-19 social isolation period entailed changes in daily habits and routines, testing the adjustment abilities of the popula tion to address unusual situations. Given that the activities of daily living require a normally functioning cognitive system, the study of cognitive-functional interaction under social isolation is relevant. The object of this work was to obtain information on the cognitive-functional impact of social isolation, analyze the changes induced in daily routines and habits, and assess the cognitive adjustment of the adult population to the isolation requirements. We carried out an online adult population survey, that combined multiple choice or binary questions following a Likert ordinal scale, performing a percentage analysis as well as a principal component analysis of the results. We surveyed 1095 subjects, 68% of which were residents of the Buenos Aires Metropolitan Area (AMBA), of an average age of 52.7 ± 12.8 years, and 15.6 ± 2.2 years of education. All age groups reported attention and memory impairment, more significant in lower age groups and women. The principal component analysis showed an associated correlation of the functional challenge brought about by social isolation on the executive system, with the negative impact on cognitive functions such as attention and memory. Social isolation significantly impacted on the attentional, mnesic and executive cognitive systems, ratifying the role of cognitive abilities in the generation of means and strategies to overcome unusual situations, and highlighting the importance of cognitive-functional interaction.

[Withdrawal of life support in the permanent vegetative state, and a dignified death]. / Suspensión de soporte vital en el estado vegetativo permanente y muerte digna.

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.

Es frecuente que familiares directos soliciten la suspensión de soporte vital, en particular de la hidratación y nutrición asistidas, en pacientes con estado vegetativo o de mínima conciencia permanente, y que recurran a la justicia en caso de desacuerdo. Dos casos recientes de suspensión, uno del exterior y otro argentino, autorizados por los tribunales respectivos, han sido motivo de controversia. Si bien puede parecer inhumano dejar de alimentar e hidratar, continuar haciéndolo solo prolonga un estado de supervivencia biológica irreversible. Las familias tienden a aceptar la suspensión si el paciente se mantiene sin cambios. Sin embargo, persiste preocupación por el posible sufrimiento desde la suspensión hasta la muerte, aunque el mismo es poco concebible en ausencia de función cortical y de conciencia. Si bien médicos y profanos consideran ético suspender el soporte vital, una cierta proporción de médicos considera que en el estado vegetativo, o más aún, en mínima conciencia, efectivamente se experimenta hambre, sed y dolor. En países como el Reino Unido, se han propuesto criterios de suspensión de soporte vital, y esquemas de tratamiento para el malestar durante el período de suspensión, aunque su beneficio efectivo es controvertido. La Argentina cuenta con recomendaciones de dos sociedades científicas, pero no con criterios reglamentados. Pero tanto la Ley 26.742 de "muerte digna" como el Código Civil consienten la suspensión del soporte vital en el estado vegetativo o de mínima conciencia, si se acompaña de medidas de alivio de los síntomas clínicos que puedan significar sufrimiento.

Suspensión de soporte vital en el estado vegetativo permanente y muerte digna / Withdrawal of life support in the permanent vegetative state, and a dignified death

Es frecuente que familiares directos soliciten la suspensión de soporte vital, en particular de la hidratación y nutrición asistidas, en pacientes con estado vegetativo o de mínima conciencia permanente, y que recurran a la justicia en caso de desacuerdo. Dos casos recientes de suspensión, uno del exterior y otro argentino, autorizados por los tribunales respectivos, han sido motivo de controversia. Si bien puede parecer inhumano dejar de alimentar e hidratar, continuar haciéndolo solo prolonga un estado de supervivencia biológica irreversible. Las familias tienden a aceptar la suspensión si el paciente se mantiene sin cambios. Sin embargo, persiste preocupación por el posible sufrimiento desde la suspensión hasta la muerte, aunque el mismo es poco concebible en ausencia de función cortical y de conciencia. Si bien médicos y profanos consideran ético suspender el soporte vital, una cierta proporción de médicos considera que en el estado vegetativo, o más aún, en mínima conciencia, efectivamente se experimenta hambre, sed y dolor. En países como el Reino Unido, se han propuesto criterios de suspensión de soporte vital, y esquemas de tratamiento para el malestar durante el período de suspensión, aunque su beneficio efectivo es controvertido. La Argentina cuenta con recomendaciones de dos sociedades científicas, pero no con criterios reglamentados. Pero tanto la Ley 26.742 de "muerte digna" como el Código Civil consienten la suspensión del soporte vital en el estado vegetativo o de mínima conciencia, si se acompaña de medidas de alivio de los síntomas clínicos que puedan significar sufrimiento.

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.

Iatrogenic neurology.

Iatrogenic disease is one of the most frequent causes of hospital admissions and constitutes a growing public health problem. The most common type of iatrogenic neurologic disease is pharmacologic, and the central and peripheral nervous systems are particularly vulnerable. Despite this, iatrogenic disease is generally overlooked as a differential diagnosis among neurologic patients. The clinical picture of pharmacologically mediated iatrogenic neurologic disease can range from mild to fatal. Common and uncommon forms of drug toxicity are comprehensively addressed in this chapter. While the majority of neurologic adverse effects are listed and referenced in the tables, the most relevant issues are further discussed in the text.

Higher frequency of atrial fibrillation linked to colder seasons and air temperature on the day of ischemic stroke onset.

BACKGROUND: Whether a seasonal variation of atrial fibrillation among acute ischemic stroke (AIS) patients occurs is unknown. We studied the distribution of atrial fibrillation across seasons and air temperatures in a cohort of AIS patients. METHODS: We selected 899 AIS patients from the Argentinean Stroke Registry (ReNACer), who were admitted to 43 centers in the Province of Buenos Aires. We recorded the minimum and maximum temperatures at local weather centers on the day and the city where each stroke occurred. We used the goodness-of-fit χ(2) test to assess the distribution of atrial fibrillation across seasons and air temperatures and the Pearson correlation coefficient to assess the relationship between these variables. We developed a regression model for testing the association between seasons and atrial fibrillation. RESULTS: We found a seasonal variation in the occurrence of atrial fibrillation, with a peak in winter and a valley in summer (23.1% versus 14.0%, P < .001). The semester comprised by autumn and winter was associated with atrial fibrillation (Pearson P < .001). Atrial fibrillation showed a nonhomogeneous distribution across ranges of temperature (P < .001, goodness-of-fit test), with a peak between 5°C and 9°C, and was associated with minimum (Pearson P = .042) and maximum (Pearson P = .002) air temperature. After adjusting for significant covariates, there was a 2-fold risk of atrial fibrillation during autumn and winter. CONCLUSIONS: In this cohort of AIS patients, atrial fibrillation showed a seasonal variation and a nonhomogeneous distribution across air temperatures, with peaks in cold seasons and low temperatures on the day of stroke onset.

The case for an elderly targeted stroke management.

Stroke is a leading cause of death and disability worldwide. The elderly, in whom atrial fibrillation (AF) is most prevalent, carry the greatest risk, undergoing more recurrent, deadlier strokes, with bigger deficits, slower recoveries, and more comorbidities. Evidence-based data on advanced age stroke management are scarce. Age-related cerebral changes might undermine the benefit of established stroke treatments. Nevertheless, the elderly should probably also undergo thrombolysis for ischemic stroke: they do not bleed more, and die not because of hemorrhage but of concomitant illnesses. Beyond natural bleeding risks, AF in advanced age has a high embolic potential if not anticoagulated. Standard or lower intensity warfarin anticoagulation prevents embolic stroke in the elderly with a hemorrhage risk even lower than aspirin. In fact, adverse effects seem to occur more often with aspirin. Excess anticoagulation hazards are prevented with lower starting doses, stricter corrections, more frequent International Normalized Ratio monitoring, and longer adjustment intervals. Validated prognostic scores such as CHADS(2) help minimize bleeds. Direct inhibitors have recently shown a benefit similar to warfarin with fewer hemorrhages. Carefully tailoring antithrombotics to this age group is therefore useful. Antihypertensives probably help 80-plus stroke patients as well, but the risk/benefit of lowering blood pressure in secondary stroke prevention at that age is uncertain. Evidence-based data on diabetes management and use of lipid-lowering drugs are still lacking in this age group. In summary, emerging data suggest that stroke management should be specifically targeted to the elderly to better prevent its devastating consequences in the population at the highest risk.

Quality of ischemic stroke care in emerging countries: the Argentinian National Stroke Registry (ReNACer).

BACKGROUND AND PURPOSE: Limited information is available on stroke management in developing countries. An accurate monitoring of quality of stroke care will become crucial, particularly with the emerging paradigm of pay-for-performance. Our aim was to explore the feasibility of measuring standardized indicators of quality of ischemic stroke care in acute care facilities in Argentina. METHODS: ReNACer is a prospective, multicenter, countrywide, stroke registry comprising 74 academic and nonacademic institutions in Argentina. The registry includes patient-level information on demography, clinical characteristics, diagnostic procedures, treatment, and the selected key performance indicators of quality of ischemic stroke care (access to thrombolysis or aspirin use in the acute setting, admission to designated stroke units, length of stay, risk-adjusted in-hospital pneumonia, risk-adjusted in-hospital mortality, discharge on antithrombotics, and antihypertensive agents). RESULTS: We included 1991 patients with ischemic stroke from 74 institutions in Argentina between November 2004 and October 2006. Seventy-nine per cent of the patients were prescribed antithrombotic therapy within 48 hours of admission, but only 1% received thrombolytics. No more than 5.7% were admitted to stroke units. In-hospital pneumonia was diagnosed in 14.3% of the patients and was higher in nonacademic facilities (16.4% versus 11.4%, P<0.02). The overall adjusted in-hospital mortality was 9.1%, also higher in nonacademic hospitals (10.6% versus 7.1%, P<0.008). At discharge, antithrombotics were prescribed in 90.2% and antihypertensive agents in 63.6% of the patients. CONCLUSIONS: In ReNACer, there was a limited access to stroke units and thrombolytics, and a relatively high incidence of in-hospital pneumonia. Differences in stroke care were observed between academic and nonacademic institutions. There is an urgent need to develop national stroke programs in Argentina.