Generalized anosognosia, anosodiaphoria, and visual hallucinations with bilateral enucleation after severe bifrontal brain injury: a case report describing similarities with and differences from Anton syndrome.

Visual anosognosia, associated with confabulations and cortical blindness in the context of occipital lobe injury, is known as Anton syndrome. Patients with this syndrome strongly deny their vision loss and confabulate to compensate for both visual loss and memory impairments. In this article, we present a case of a patient with some similarities to Anton syndrome, however, with several differences in clinical presentation. Bifrontal brain injury, bilateral enucleation, affective indifference (anosodiaphoria), generalized anosognosia, and the conviction that vision will resume mark clear clinical differences with Anton syndrome. Differentiating these findings from Anton syndrome will help occupational therapists, neuropsychologists, speech-language pathologists, physical therapists, and physicians when assessing frontal lobe brain injury with total and partial visual loss. This case demonstrates that visual anosognosia and confabulations can occur without occipital lobe dysfunction or cortical blindness.

Virtual Reality During Brain Mapping for Awake-Patient Brain Tumor Surgery: Proposed Tasks and Domains to Test.

BACKGROUND: Virtual reality (VR) use in health care has increased over the past few decades, with its utility expanding from a teaching tool to a highly reliable neuro-technology adjunct in multiple fields including neurosurgery. Generally, brain tumor surgery with the patient awake has only been performed for mapping of language and motor areas. With the rise of VR and advancing surgical techniques, neurosurgical teams are developing an increased understanding of patients' anatomo-functional connectivity. Consequently, more specific cognitive tasks are being required for the mapping and preservation of deeper layers of cognition. METHODS: An extensive literature review was conducted with the inclusion criteria of manuscripts that described the use of VR during awake neurosurgery mapping. RESULTS: We identified 3 recent articles that met our inclusion criteria, yet none of them addressed the specific use of VR for cognition mapping. Consequently, a cognitive task phase was performed to search and craft the tasks and domains that better filled the spotted niche of this need inside the operating room. A proposed protocol was developed with 5 potential uses of VR for brain mapping during awake neurosurgery, each of them with a specific proposed example of use. CONCLUSIONS: The authors advocate for the use of a VR protocol as a feasible functional tool in awake-patient brain tumor surgery by using it as a complement during cognitive screening in addition to language testing.

Memory and Executive Dysfunction Predict Complex Activities of Daily Living Impairment in Amnestic Multi-Domain Mild Cognitive Impairment.

BACKGROUND: Specific cognitive alterations could be one of the predictors that lead to the complex activities of daily living (CADL) impairment in mild cognitive impairment (MCI) and, hence, help to explain the continuum between MCI and dementia. OBJECTIVE: We aimed to reevaluate the existing uncertainty regarding the impact of memory and executive functions on CADL in patients with MCI. METHODS: Caregivers of 161 patients with amnestic multi-domain MCI and of 150 patients with incipient Alzheimer's disease as well as 100 age-, sex-, and education-matched controls, completed the Interview for Deterioration in Daily Living Activities in Dementia, a suitable instrument for the description and discrimination of CADL. In addition, all patients and controls were assessed with a neuropsychological battery to measure explicit memory and executive functions performance. RESULTS: Multiple regression analyses showed that in the group of patients with amnestic multi-domain MCI, 67.4% of the variability of the CADL impairment was explained by worse performance on executive functions tests (p < 0.0001) and 41.8% by different explicit memory components impairment (p < 0.0001). Further, in patients with incipient AD, 44.0% of the variability of CADL impairment was explained by worse performance on executive functions tests (p < 0.0001) and 39.9% by different explicit memory components worsening (p < 0.0001). CONCLUSIONS: Memory and executive functions alterations impact similarly on the CADL in both amnestic multi-domain MCI and incipient Alzheimer's disease. Given the continuum that exists between both conditions, we conclude that CADL impairment may be an important early step in the evolution towards Alzheimer's disease from amnestic multi-domain MCI.

Structure of Enhanced Cued Recall Task in the 7 Minute Screen Test.

Episodic memory in the 7 Minute Screen is assessed by the Enhanced Cued Recall (ECR) test. The ECR test is composed of three phases, Identification, Immediate Recall, and Free and Cued Recall. However, just the last phase is considered for the total score. We believe that collecting the performance data of the Identification and Immediate Recall phases could provide information regarding possible difficulties or impairments in the different aspects involved in the temporal mnesic process of acquisition of new information, such as in working memory or visual identification. The objective was to assess the goodness of fit for the three phases of the ECR test using a Confirmatory Factor Analysis (CFA) to show if each phase is separated from each other as a different aspect that participates in the mnesic process. A total of 311 participants greater than 65 years were included in this study. Confirmatory factor analyses were conducted for each individual phase. The analyses show that the ECR test consists of three separate phases that identify different steps of the mnesic process. Individual scores for each phase could allow for investigation of patient performance in different aspects of the memory process and could help in further neuropsychological assessment.

Función ejecutiva en pacientes con trastorno bipolar tipo I durante la fase asintomática / Executive functions in patients with bipolar disorder type I during asymptomatic phase

La función ejecutiva se ve involucrada en la mayor parte de las actividades que realizamos a diario, repercutiendo en la calidad de vida de las personas. Los rendimientos ejecutivos en el trastorno bipolar tipo I pueden fluctuar en función de la fase clínica en la que se encuentra el paciente. El objetivo de este trabajo se centra en revisar los hallazgos encontrados respecto a la función ejecutiva durante la fase asintomática del trastorno bipolar tipo I. Se han analizado 37 artículos científicos que abordan el rendimiento ejecutivo de pacientes eutímicos con trastorno bipolar tipo I. Se puede concluir que la mayoría de los estudios reportan dificultades ejecutivas en estos pacientes, aunque no parece existir consenso en los diferentes trabajos al indicar el tipo de déficit. Esta falta de acuerdo podría ser debida a aspectos metodológicos de los estudios y a distintas variables clínicas y farmacológicas. Las alteraciones ejecutivas en la eutimia son menores que en las fases agudas del trastorno y afectan sobre todo a la velocidad de procesamiento de la información. Los déficits ejecutivos de los pacientes podrían estar vinculados a posibles alteraciones funcionales a nivel de la corteza prefrontal, así como al propio efecto de los psicofármacos utilizados. Sería de especial relevancia que el tratamiento de estos pacientes incorporase estas alteraciones, lo que podría conseguirse mediante un enfoque neurocognitivo dentro de un abordaje terapéutico integrado...

Executive function is present in most of dairy activities, so it influences in quality of life. Executive performances in bipolar disorder type I can change in function of clinical phase that patient is. The aim of this work is to review the studies that have investigated executive function during asymptomatic phase in bipolar disorder type I. It has been analyzed 37 scientific articles that examine executive performance in euthymic patients with bipolar disorder type I. It can be concluded that bipolar patients in asymptomatic phase suffer executive difficulties, but it doesn’t seem to exist consensus regarding the type of deficits. This lack of agreement could be due to methodological diversity in studies, as well as the influence of different clinical or pharmacological variables. Executive alterations in euthymic phase are lower than the acute phases in bipolar disorder and affect mainly to processing speed. Executive deficits in patients could be linked to possible functional alterations in prefrontal cortex, as well as the psychopharmacological effect. It would be specially relevant treatment in bipolar disorder keep in mind this alterations, which it can get it with a neurocognitive approach within integrate treatment...

Deterioro cognitivo y factores asociados. Estudio DERIVA / Cognitive impairment and associated factors. DERIVA study

Diversos factores sociodemográficos, funcionales y clínicos han sido asociados a la prevalencia de deterioro cognitivo (DC) en las personas mayores de 65 años. Objetivo: estudiar la relación entre la presencia de DC y factores sociodemográficos y clínicos en una población urbana de mayores de 65 años. Método: los 327 participantes del estudio DERIVA, mayores de 65 años, se clasificaron en participantes sin DC (n = 265) y con DC (n = 62). Se les aplicó el OARS MFAQ, el índice de Katz y el de comorbilidad de Charlson para obtener datos sociodemográficos, de funcionalidad y comorbilidad. Se realizó un análisis de regresión logística para conocer los factores de riesgo de DC. Resultados: la edad (odds ratio [OR] = 1,08; intervalo de confianza [IC] del 95 %, 1,03-1,12]; p < 0,01), la presencia de ansiedad-depresión (OR = 3,47; IC del 95 %, 1,61-7,51; p < 0,01) y la diabetes (OR = 2,07; IC del 95 %, 1,02-4,18; p = 0,04) se comportan como factores de riesgo, mientras que los años de estudio se muestran como un factor protector (OR = 0,79; IC del 95 %, 0,70-0,90; p < 0,01). Conclusión: sería conveniente realizar un seguimiento de los factores relacionados con la ansiedad-depresión y la diabetes, ya que aquellas personas mayores de 65 años que los presenten pueden tener mayor riesgo de desarrollar DC (AU)

Certain sociodemographic, functional and clinical factors have been associated to the prevalence of cognitive impairment (CI) among people older than 65 years old. Aim: To study the association between CI and sociodemographic and clinical factors in an urban sample older than 65 years old. Method: 327 participants from DERIVA Study older than 65 years old classified into the group without CI (n = 265) and with CI (n = 62). OARS-MFAQ, Katz Index and Charlson comorbidity Index to obtain sociodemographic, functional and comorbidity data. A logistic regression analysis to know risk factors of CI was performed. Results: Age (OR = 1.08; 95 % CI, 1.03-1.12; p < 0.01), anxiety-depression (OR = 3.47; 95 % CI, 1.61-7.51; p < 0.01) and diabetes (OR = 2.07; 95 % CI, 1.02-4.18; p = 0.04) were risk factors of CI, whereas years of education was a protector factor (OR = 0.79; 95 % IC, 0.70-0.90; p < 0.01). Conclusion: It’d be convenient to follow patients that present these factors related to anxietydepression and diabetes, since people older than 65 years old presenting them, can have more risk of developing CI (AU)

Deterioro cognitivo leve: detección temprana y nuevas perspectivas / Mild cognitive impairment: early detection and new perspectives

Introducción. En los últimos años ha habido un creciente interés en el estudio del deterioro cognitivo leve (DCL) y su detección temprana. A diferencia de las primeras teorías, tendencias actuales e internacionales de investigación nos sugieren que el DCL es un síndrome que se caracteriza por presentar alteración en una o más funciones cognitivas superiores, sin interferir en las habilidades funcionales de la vida diaria y acompañado de una preocupación por el cambio cognitivo producido. Aunque la detección temprana del DCL se suele realizar mediante tests de rastreo cognitivo, la mayoría de ellos no parecen detectar correctamente el DCL, a diferencia de la demencia. Objetivo. Exponer un análisis de las pruebas de rastreo cognitivo más recomendables para utilizar en la clínica habitual para la detección del DCL, basándose en las actuales tendencias de investigación. Desarrollo y conclusiones. Existen tres tipos de tests de rastreo cognitivo: los tests de rastreo generales, los de rastreo específico y los de rastreo de un subtipo de DCL. Observamos que la mayoría de los tests no se ajustan a los criterios de DCL actuales. En este sentido, proponemos la aplicación conjunta de tests, así como la necesidad de ser cautos en su elección, para poder detectar más eficazmente el DCL en la práctica clínica (AU)

Introduction. Along past years, interest in mild cognitive impairment (MCI) research and its early detection has been increased. Unlike first theories, international current proposals suggest that MCI is a syndrome characterized by an impairment in one or more cognitive functions without interfering in daily functional abilities and it is also accompanied by a concern because of the cognitive change. Although early MCI detection is usually made by cognitive screening tests, most of them do not seem to correctly detect MCI, but dementia. Aim. To expose an analysis of the cognitive screening tests more suitable for clinical MCI detection, according to current researches. Development and conclusions. There are three kind of cognitive screening tests: general cognitive screening tests, specific cognitive screening tests and MCI-subtype cognitive screening test. We observe that most of the tests don’t follow current MCI criteria. In this respect we propose to jointly apply tests, as well as the necessity of a carefully test choice to effectively detect MCI in clinical practice (AU)

Prevalence of cognitive impairment in individuals aged over 65 in an urban area: DERIVA study.

BACKGROUND: Few data are available on the prevalence of cognitive impairment (CI) in Spain, and the existing information shows important variations depending on the geographical setting and the methodology employed. The aim of this study was to determine the prevalence of CI in individuals aged over 65 in an urban area, and to analyze its associated risk factors. DESIGN: A descriptive, cross-sectional, home questionnaire-based study; SETTING: Populational, urban setting. PARTICIPANTS: The reference population comprised over-65s living in the city of Salamanca (Spain) in 2009. Randomized sampling stratified according to health district was carried out, and a total of 480 people were selected. In all, 327 patients were interviewed (68.10%), with a mean age of 76.35 years (SD: 7.33). Women accounted for 64.5% of the total. MEASUREMENTS: A home health questionnaire was used to obtain the following data: age, sex, educational level, family structure, morbidity and functionality. All participants completed a neuropsychological test battery. The prevalence data were compared with those of the European population, with direct adjustment for age and sex. Diagnoses were divided into three general categories: normal cognitive function, cognitive impairment - no dementia (CIND), and dementia. RESULTS: The prevalence of CI among these over-65s was 19% (14.7% CIND and 4.3% dementia). The age-and sex-adjusted global prevalence of CI was 14.9%. CI increased with age (p < 0.001) and decreased with increasing educational level (p < 0.001). Significant risk factors were found with the multivariate analyses: age (OR = 1.08, 95%CI: 1.03-1.12), anxiety-depression (OR = 3.47, 95%CI: 1.61-7.51) and diabetes (OR = 2.07, 95%CI: 1.02-4.18). In turn, years of education was found to be a protective factor (OR = 0.79, 95%CI: 0.70-0.90). Although CI was more frequent among women and in people living without a partner, these characteristics were not significantly associated with CI risk. CONCLUSIONS: The observed raw prevalence of CI was 19% (14.9% after adjusting for age and sex). Older age and the presence of diabetes and anxiety-depression increased the risk of CI, while higher educational level reduced the risk.

Detection of mild cognitive impairment in people older than 65 years of age and its relationship to cardiovascular risk factors (DECRIVAM).

BACKGROUND: Studies centered on the detection of cognitive impairment and its relationship to cardiovascular risk factors in elderly people have gained special relevance in recent years. Knowledge of the cardiovascular risk factors that may be associated to cognitive impairment could be very useful for introducing treatments in early stages - thereby possibly contributing to improve patient quality of life.The present study explores cognitive performance in people over 65 years of age in Salamanca (Spain), with special emphasis on the identification of early symptoms of cognitive impairment, with the purpose of detecting mild cognitive impairment and of studying the relationships between this clinical situation and cardiovascular risk factors. METHODS/DESIGN: A longitudinal study is contemplated. The reference population will consist of 420 people over 65 years of age enrolled through randomized sampling stratified by healthcare area, and who previously participated in another study. MEASUREMENT: a) Sociodemographic variables; b) Cardiovascular risk factors; c) Comorbidity; d) Functional level for daily life activities; and e) Study of higher cognitive functions based on a neuropsychological battery especially adapted to the evaluation of elderly people. DISCUSSION: We hope that this study will afford objective information on the representative prevalence of cognitive impairment in the population over 65 years of age in Salamanca. We also hope to obtain data on the relationship between cognitive impairment and cardiovascular risk factors in this specific population group. Based on the results obtained, we also will be able to establish the usefulness of some of the screening tests applied during the study, such as the Mini-Mental State Examination and the 7 Minute Screen test. TRIAL REGISTRATION: ClinicalTrials.gov: NCT01327196.

Does the combination of the MMSE and clock drawing test (mini-clock) improve the detection of mild Alzheimer's disease and mild cognitive impairment?

There is currently a need to develop tools to identify patients with mild AD and mild cognitive impairment (MCI). We determined the validity and reliability of a brief, easily administered cognitive screening battery consisting of fusion of two well-known brief tests (Mini-Mental Status Examination [MMSE] and Clock Drawing Test [CDT]) (Mini-clock) to differentiate between patients with mild AD, MCI, and healthy control subjects. 66 consecutive patients with mild AD, 21 with MCI, and 66 healthy controls seen in a memory clinic setting were compared. Receiver operating characteristic (ROC) curve analysis was used to calculate the cut-off value permitting discrimination between mild AD, MCI, and healthy control subjects. Interrater and test-retest reliability were also assessed. Mean cognitive scores for patients with AD, MCI, and control subjects on all two individual tests were significantly different (for each, p < 0.001). The mean area under the ROC curve for Mini-clock was higher than that obtained with MMSE or CDT in differentiating mild AD from controls (0.973 vs. 0.952 and 0.881, respectively) and MCI from controls (0.855 vs. 0.821 and 0.779, respectively). Test-retest reliability for the Mini-clock was 0.99, meanwhile interrater reliability was 0.87. The mean time to complete the test for all subjects was 8 min and 50 s. The Mini-clock is highly sensitive and specific in the detection of mild AD and reasonably accurate when attempting to separate MCI from health controls. It has a high interrater and test-retest reliability, can be quickly administered, and does not require major training.

Improvement pattern in the clock drawing test in early Alzheimer's disease.

OBJECTIVE: The aim of this paper was to compare the performance of a group of patients with early Alzheimer's disease (EAD) against a control group of healthy control (HC) subjects in the Clock Drawing Test (CDT), i.e. verbal command versus copying of a clock model presented to the subject. PATIENTS AND METHODS: The authors have studied 140 subjects; 70 patients with probable EAD, with a mean age of 76.4 +/- 7.64 years and a clinical dementia rating stage 1 (mild dementia), and 70 HC with a mean age of 75.16 +/- 6.34 years. RESULTS: Patients in the EAD group obtained significantly higher scores on the copy command mode than on the verbal command mode (Z = -7.129, p < 0.001)--improvement pattern of the CDT--whereas no statistically significant differences were found in the HC group (Z = -2.001, p < 0.080). Within the group of EAD patients, we have noticed that there is a correlation between the copy command mode and the visual-constructive functions of the Cambridge Cognitive Examination (CAMCOG) (r = 0.607, p < 0.01), while the memory functions of the CAMCOG correlate with the verbal command mode (r = 0.704, p < 0.01). CONCLUSIONS: In our study, the EAD patients show an improvement pattern in the execution of the CDT copy command in comparison with the execution of the CDT verbal command, which we did not observe in the HC group. Such results might be associated with a greater deterioration of the memory functions when compared with the visual-constructive ones in the patients with EAD.

Angioscopía periférica y coronaria: su correlación en procedimientos endovasculares / Coronary and peripheral angioscopy: its correlation with endovascular procedures

La eficacia de los métodos de angioplastía intraluminal han sido valorados mediante angiografía, la cual puede mostrar los resultados anatómicos mayores. Sin embargo, mediante angioscopía, es posible observar directamente los cambios morfológicos inducidos a la pared de los vasos tratados. Se estdiaron 5 arterias coronarias y 9 arterias periféricas; 7 con obstrucción del 100 por ciento de su lúmen y las 7 restantes con lesiones oclusivas superiores al 75 por ciento del diámetro vascular interno. A todas se les realizó exploración amgiográfica y angioscópica antes y después de los procedimientos de recanalización. A 11 de las arterias se aplicó ultrasonido. Se logró la recanalización en el 90 por ciento de los casos; en 6 de estos (55 por ciento), se encontró evidencia angioscópica de disección en grado variable. Dos casos fueron tratados exclusivamente mediante angioplastía con balón y la imagen angioscópica fue, asimismo, la disección. En el único caso tratado con energía láser, se observó una coloración café obscuro sugestiva de carbonización. El análisis angiográfico inicial no sugirió la presencia de complicaciones de las placas de ateroma. Sin embargo, la inspección angioscópica demostró en el 21 por ciento de los casos un tinte hemorrágico del endotelio y en el 29 por ciento trombosis in situ. No encontró correlación entre el aspecto angiográfico y el angioscópico en el 25 por ciento de los casos. Algunas alteraciones endoteliales en las placas de ateroma no son detectables mediante angiografía y pueden demostrarse a la inspección angioscópica. Estos cambios pueden mejorar la apreciación de los resultados de cualquier método de recanalización, y determinar sus posibles complicaciones inmediatas y tardías, en el sujeto vivo

Polimetilmetacrilato y antibióticos / Polimetilmetacrilate and antibiotics in rabits and dogs

Se hicieron determinaciones en sangre de antibióticos incluidos en polimetilmetacrilato (PMMA) en distintos modelos de experimentación animal a intervalos semanales. A ocho conejos, que se dividieron en dos grupos que se les colocó PMMA con Gentamicina, en la cavidad medular del fémur, de los cuales, en cuatro se usó Subiton y en otros cuatro Palacos R. A otros dos conejos se les aplicó Surgical SP Howmedical con cefalotina; finalmente a otros dos se les aplicó kanamicina, a uno en CMW y a otro en cemento Zimmer. En 12 perros se determinaron los valores de gentamicina en sangre, a los que se les había aplicado el antibiótico mezclado en Palacos a seis, en la cavidad intramedular del fémur. En todos los animales los niveles de antibiótico en sangre fueron inferiores a los mínimos requeridos para considerarse como terapeúticos. Se hicieron además 24 determinaciones de la temperatura del fraguado del PMMA con termómetro electrónico en conejos y 36 en perros a los que se les aplicó en la masa glútea. En todos los animales hubo termonucleósis (necrosis muscular) en la zona de contacto con el cemento y reacción inflamatoria crónica. El PMMA alcanzó temperaturas de 91 a 106 grados centígrados.