Clinical Decision on Disorders of Consciousness After Acquired Brain Injury: Stepping Forward / 神经科学通报·英文版

Major advances have been made over the past few decades in identifying and managing disorders of consciousness (DOC) in patients with acquired brain injury (ABI), bringing the transformation from a conceptualized definition to a complex clinical scenario worthy of scientific exploration. Given the continuously-evolving framework of precision medicine that integrates valuable behavioral assessment tools, sophisticated neuroimaging, and electrophysiological techniques, a considerably higher diagnostic accuracy rate of DOC may now be reached. During the treatment of patients with DOC, a variety of intervention methods are available, including amantadine and transcranial direct current stimulation, which have both provided class II evidence, zolpidem, which is also of high quality, and non-invasive stimulation, which appears to be more encouraging than pharmacological therapy. However, heterogeneity is profoundly ingrained in study designs, and only rare schemes have been recommended by authoritative institutions. There is still a lack of an effective clinical protocol for managing patients with DOC following ABI. To advance future clinical studies on DOC, we present a comprehensive review of the progress in clinical identification and management as well as some challenges in the pathophysiology of DOC. We propose a preliminary clinical decision protocol, which could serve as an ideal reference tool for many medical institutions.

Xingnao Kaiqiao acupuncture on promoting wake-up of consciousness disorder in children with early severe traumatic brain injury / 中国针灸

OBJECTIVE@#To observe the awakening effect and safety of Xingnao Kaiqiao (regaining consciousness and opening orifices) acupuncture on consciousness disorder in children with early severe traumatic brain injury (STBI) based on western medicine treatment.@*METHODS@#A total of 62 children with STBI were randomly divided into an observation group (31 cases,1 case dropped off) and a control group (31 cases, 1 case dropped off). The control group was treated with routine rehabilitation therapy (6 times a week for 30 days), and intravenous drip of cattle encephalon glycoside and ignotin injection (once a day for 28 days). On the basis of the treatment in the control group, the observation group was treated with Xingnao Kaiqiao acupuncture at Neiguan (PC 6), Shuigou (GV 26), Yintang (GV 24+), Baihui (GV 20), Sanyinjiao (SP 6), Zusanli (ST 36), etc., and supplementary acupoints according to clinical symptoms, once a day, 6 times a week for 30 days. The scores of Glasgow coma scale (GCS), coma recovery scale-revised (CRS-R) and modified Barthel index (MBI) were observed before treatment and 10, 20 and 30 d into treatment. Electroencephalogram (EEG) grading before and after treatment was observed in the two groups, and safety was evaluated.@*RESULTS@#After 10, 20 and 30 days of treatment, the scores of GCS, CRS-R and MBI in the two groups were increased compared before treatment (P<0.05), and those in the observation group were higher than the control group (P<0.05). After treatment, EEG grading of both groups was improved compared with that before treatment (P<0.05), and the observation group was better than the control group (P<0.05). There were no adverse events or adverse reactions in the two groups during treatment.@*CONCLUSION@#On the basis of western medicine treatment, Xingnao Kaiqiao acupuncture plays a remarkable role in wakening the early STBI children, can improve the level of consciousness disorder and daily living ability, and it is safe and effective.

Síndrome de embolismo graso en fractura de huesos largos, reporte de caso / Fat embolism syndrome in long bone fractures, case report

Introducción: El síndrome de embolismo graso es una complicación severa, aun-que poco frecuente de trauma grave. Es desencadenado por el paso de partículas de grasa hacia la microcirculación en varios órganos. La tríada característica: lesión pulmonar, hemorragia petequial y disfunción neurológica. Su prevalencia varía se-gún los criterios diagnósticos y la causa desencadenante, dificultando su detección temprana. Presentación del caso: Caso 1. Paciente 22 años, masculino, sufrió accidente automovilístico con fracturas abierta de fémur, tibia y peroné derechos, resueltas quirúrgicamente, a las 5 horas del evento sufre deterioro respiratorio, petequias conjuntivales, torácicas y en extremidades; posteriormente deterioro de concien-cia, estatus epiléptico y síndrome de hiperactividad simpática paroxística. Caso 2. Paciente 29 años, masculino, sufrió volcamiento del vehículo en el que viajaba, sufriendo fracturas cerradas de tibia, peroné y fémur izquierdas, luego de la cirugía traumatológica sufrió deterioro del estado de conciencia, petequias conjuntivales e hipoxemia.Diagnósticos e intervenciones: los dos pacientes fueron operados para resolución traumatológica dentro de las primeras 24 horas, luego del aparecimiento de síntomas neurológicos se sometieron a neuroimagen encontrándose el patrón de "campo de es-trellas" y recibieron corticoides.Resultados: Caso 1 el desenlace fue estado vegetativo, Caso 2 recuperación completa.Conclusión: La detección es imprescindible para establecer el tratamiento temprano, planificar la cirugía traumatológica o diferirla y estimar el pronóstico según la evolu-ción. El síndrome de embolia grasa cerebral es una causa rara del síndrome de hipe-ractividad simpática paroxística

Introduction: Fat embolism syndrome is a severe, although rare complication of major trauma. It is triggered by the passage of fat particles into the microcirculation in various organs. The characteristic triad: lung injury, petechial hemorrhage and neurological dysfunction. Its prevalence varies according to the diagnostic criteria and the triggering cause, making its early detection difficult. Case presentation: Case 1. Patient 22 years old, male, suffered a car accident with open fracture of the right femur, tibia and fibula, surgically resolved, 5 hours after the event he suffered respiratory impairment, conjunctival, thoracic and extre-mity petechiae; later impaired consciousness, status epilepticus and paroxysmal sympathetic hyperactivity syndrome. Case 2. Patient 29 years old, male, suffered overturning of the vehicle in which he was traveling, suffering closed fractures of the left tibia, fibula and femur, after trauma surgery he suffered impaired consciousness, conjunctival petechiae and hypoxemia.Diagnoses and interventions: Both patients underwent surgery for trauma reso-lution within 24 hours, after the appearance of neurological symptoms they un-derwent neuroimaging finding "star field" pattern, both received corticosteroids.Results: Case 1 the outcome was vegetative state, Case 2 complete recovery.Conclusion: Detection is essential to establish early treatment, to plan trauma sur-gery or to defer it and to estimate prognosis according to evolution. Cerebral fat em-bolism syndrome is a rare cause of paroxysmal sympathetic hyperactivity syndrome.

Neuromodulatory therapies for patients with prolonged disorders of consciousness / 中华医学杂志(英文版)

BACKGROUND@#Reviving patients with prolonged disorders of consciousness (DOCs) has always been focused and challenging in medical research. Owing to the limited effectiveness of available medicine, recent research has increasingly turned towards neuromodulatory therapies, involving the stimulation of neural circuits. We summarised the progression of research regarding neuromodulatory therapies in the field of DOCs, compared the differences among different studies, in an attempt to explore optimal stimulation patterns and parameters, and analyzed the major limitations of the relevant studies to facilitate future research.@*METHODS@#We performed a search in the PubMed database, using the concepts of DOCs and neuromodulation. Inclusion criteria were: articles in English, published after 2002, and reporting clinical trials of neuromodulatory therapies in human patients with DOCs.@*RESULTS@#Overall, 187 published articles met the search criteria, and 60 articles met the inclusion criteria. There are differences among these studies regarding the clinical efficacies of neurostimulation techniques for patients with DOCs, and large-sample studies are still lacking.@*CONCLUSIONS@#Neuromodulatory techniques were used as trial therapies for DOCs wherein their curative effects were controversial. The difficulties in detecting residual consciousness, the confounding effect between the natural course of the disease and therapeutic effect, and the heterogeneity across patients are the major limitations. Large-sample, well-designed studies, and innovations for both treatment and assessment are anticipated in future research.

Jahi McMath, a New Disorder of Consciousness / Jahi McMath, un nuevo trastorno de la conciencia / Jahi McMath, um novo transtorno da consciencia

Abstract: In this paper, I review the case of Jahi McMath, who was diagnosed with brain death (BD). Nonetheless, ancillary tests performed nine months after the initial brain insult showed conservation of intracranial structures, EEG activity, and autonomic reactivity to the "Mother Talks" stimulus. She was clinically in an unarousable and unresponsive state, without evidence of self-awareness or awareness of the environment. However, the total absence of brainstem reflexes and partial responsiveness rejected the possibility of a coma. Jahi did not have UWS because she was not in a wakefulness state and showed partial responsiveness. She could not be classified as a LIS patient either because LIS patients are wakeful and aware, and although quadriplegic, they fully or partially preserve brainstem reflexes, vertical eye movements or blinking, and respire on their own. She was not in an MCS because she did not preserve arousal and preserved awareness only partially. The CRS-R resulted in a very low score, incompatible with MCS patients. MCS patients fully or partially preserve brainstem reflexes and usually breathe on their own. MCS has always been described as a transitional state between a coma and UWS but never reported in a patient with all clinical BD findings. This case does not contradict the concept of BD but brings again the need to use ancillary tests in BD up for discussion. I concluded that Jahi represented a new disorder of consciousness, non-previously described, which I have termed "reponsive unawakefulness syndrome" (RUS).

Resumen: En este artículo, revisó el caso de Jahi McMath, quién fue diagnosticada con muerte encefálica (ME). No obstante, exámenes complementarios realizados nueve meses después de la lesión cerebral inicial mostraron conservación de las estructuras intracraneales, actividad en electroencefalografía EEG, y reactividad autonómica a estímulos llamados "Conversación de Madre". Ella estaba clínicamente en un estado sin respuesta a los estímulos, sin evidencia de autoconciencia o conciencia del ambiente. Sin embargo, la ausencia total de reflejos del tronco encefálico y la capacidad de respuesta parcial rechazaron la posibilidad de un coma. Jahi no tenía síndrome de vigilia sin respuesta SVSR porque no estaba en un estado de vigilia y mostró una capacidad de respuesta parcial. Tampoco pudo ser clasificada como paciente LIS porque los pacientes LIS están despiertos y conscientes, y aunque tetrapléjicos, conservan total o parcialmente los reflejos del tronco encefálico, los movimientos oculares verticales u el parpadeo, y respiran por sí mismos. Ella no estaba en un EMC porque no preservaba la excitación y preservaba la conciencia solo parcialmente. La CRS-R dio una puntuación muy baja, incompatible con pacientes de EMC. Los pacientes de EMC preservan total o parcialmente los reflejos del tronco encefálico y, por lo general, respirar por sí solos. El EMC siempre se ha descrito como un estado de transición entre un coma y SVSR pero nunca se ha reportado en paciente con todos los hallazgos clínicos de ME. Este caso no contradice el concepto de ME pero vuelve a plantear la discusión acerca de la necesidad de utilizar exámenes complementarios en ME. Llegué a la conclusión de que Jahi representaba un nuevo trastorno de la conciencia, no descrito anteriormente, que he denominado "síndrome de no despertar con respuesta" (SNDR).

Resumo: Neste artigo, foi revisado o caso Jahi McMath, que foi diagnosticada com morte encefálica (ME). Contudo, exames complementares realizados nove meses depois da lesão cerebral inicial mostraram conservação das estruturas intracranianas, atividade em eletroencefalografia (EEG) e reatividade autonômica a estímulos chamados "Conversación de Madre". Ela estava clinicamente em um estado sem resposta aos estímulos, sem evidência de autoconsciência ou consciência do ambiente. Contudo, a ausência total de reflexos do tronco encefálico e a capacidade de resposta parcial rejeitaram a possibilidade de um coma. Jahi não tinha síndrome de vigia sem resposta (SVSR), porque não estava em um estado de vigia e mostrou uma capacidade de resposta parcial. Também nao pode ser classificada como paciente LIS, porque estes estão acordados e conscientes, e ainda que tetraplégicos, conservam total ou parcialmente os reflexos do tronco encefálicos, os movimentos oculares verticais ou cintilação, e respiram por si próprios. Ela não estava em um EMC porque não preservava a excitação e preservava a consciencia somente parcialmente. A CRS-R deu uma pontuação muito baixa, incompatível com pacientes de EMC. Os pacientes de EMC preservam total ou parcialmente os reflexos do tronco encefálico e, em geral, respirar por si só. O EMC sempre foi descrito como um estado de transição entre coma e SVSR, mas nunca foi relatado em paciente com todos os achados clínicos de ME. Esse caso não contradiz o conceito de ME, mas volta a colocar a discussão sobre a necessidade de utilizar exames complementares em ME. Cheguei a conclusão de que Jahi representava um novo transtorno da consciencia, nao descrito anteriormente, que denominei "síndrome de resposta sem vigília" (SRSV)

Frequência Alfa na meditação Gurdjieff / Alpha Frequency in Gurdjieff Meditation

Introdução: a meditação é uma prática que visa regular o estado mental e as emoções, podendo induzir a estados alterados de consciência. Dentre inúmeras técnicas de meditação, o trabalho proposto por George I. Gurdjieff, inclui práticas voltadas para o recolhimento da atenção e o equilíbrio entre a atividade do corpo, da mente e do sentimento. Estudos realizados com eletroencefalografia (EEG), avaliando o estado meditativo em geral, demonstraram um padrão cerebral caracterizado pelo aumento da amplitude dos ritmos eletroencefalográficos alfa e teta, bem como diferenças na atividade alfa entre a meditação e o relaxamento. Entretanto, isto não está caracterizado em meditadores da linha de G.I. Gurdjieff, que praticam, além de meditações sentadas, exercícios corporais acompanhados de uma música própria e exercícios de atenção durante a vida diária. Objetivo: comparar a atividade cerebral da frequência alfa durante os estágios de meditação e relaxamento e avaliar as diferenças entre as regiões frontal, central e occipital nesses dois estados, em meditadores experientes do grupo Gurdjieff, de Salvador-Bahia-Brasil. Metodologia: a coleta da atividade cerebral dos 8 voluntários foi realizada através do EEG. O protocolo de coleta adotado foi de 6 minutos de relaxamento e 12 minutos de meditação. Resultados: foi encontrado aumento significativo da potência alfa durante a meditação, quando comparada ao relaxamento. As regiões frontal e central não apresentaram diferenças entre si para a potência alfa, enquanto a região occipital apresentou aumento da potência alfa em comparação com as regiões frontal e central. Existe um aumento da densidade de alfa durante a meditação em todas as regiões cerebrais testadas, com maior densidade na região occipital. Conclusão: A frequência alfa comporta-se de forma diferente durante a meditação, comparada ao relaxamento, com um aumento da densidade de potência durante o estado meditativo em todas as regiões avaliadas, sendo a região occipital a que apresentou maior potência.

Introduction: meditation is a practice that aims to regulate the mental state and emotions, and can induce altered states of consciousness. Among numerous meditation techniques, the work proposed by George I. Gurdjieff, includes an attempt to balance activities from the body, the mind and the feelings. Studies conducted with electroencephalography (EEG), evaluating the meditative tate, demonstrated a brain pattern characterized by increased alpha and theta amplitude, as well as differences in alpha activity between meditation and relaxation. However, this is not characterized in Gurdjieff meditators, which practice beyond sitted meditations, body exercises with music, and attentional exercises during everyday life. Objective: comparing the brain activity of the alpha power during the meditation and relaxation stages and evaluate the differences between the frontal, central and occipital regions in these two states, in experienced meditators from the Gurdjieff group, in Salvador-Bahia-Brazil. Methodology: the data collection of the brain activity from 8 volunteers was performed by EEG. The collection protocol adopted was 6 minutes of relaxation and 12 minutes of meditation. Results: a significant increase in alpha power was found during meditation, when compared to relaxation. The frontal and central regions showed no differences between them for alpha power, while the occipital region showed an increase in alpha power compared to the frontal and central regions. Conclusion: the alpha frequency behaves differently during meditation, compared to relaxation, with an increase in alpha density during the meditative state in all evaluated regions, with the occipital region being the most potent.

Alteraciones del Yo en las fases iniciales del espectro esquizofrénico / Self-disorders in Early Stages of the Schizophrenia Spectrum

RESUMEN El núcleo patogénico de la esquizofrenia ha variado de acuerdo con la época y la influencia de insignes investigadores. También se ha reconocido a las alteraciones del Yo como el eje de este trastorno, aunque están poco estudiadas debido a su naturaleza subjetiva. En los últimos arios, dado el creciente interés por las fases iniciales de la esquizofrenia, se ha retomado el estudio de las alteraciones del Yo. El modelo de las alteraciones del Yo en la esquizofrenia, desarrollado por Sass y Parnas, propone que en este trastorno la persona sufre pérdida de la perspectiva en primera persona y experimenta fenómenos de hiperreflexibilidad, el sentido disminuido del Yo y trastornos del campo de la conciencia. Por ello, experimenta sentimientos de extrañeza de sí mismo, dificultad para entender el sentido común de las cosas y problemas de interacción con el entorno. Con base en este modelo, se han elaborado instrumentos de evaluación de las alteraciones del Yo y se han conducido estudios empíricos para la evaluación de pacientes en riesgo de sufrir un trastorno del espectro esquizofrénico. Estos estudios muestran que las alteraciones del Yo se encuentran en estadios prepsicóticos y que su presencia puede predecir la transición a trastornos del espectro esquizofrénico. Estos resultados tienen importantes implicaciones clínicas, pues permiten identificar a personas en fases iniciales del trastorno y crean la oportunidad de aplicar intervenciones terapéuticas tempranas.

ABSTRACT The pathogenic nucleus of schizophrenia has varied according to the different eras and influences of distinguished clinical researchers. Self-disorders have also been recognised to be at the heart of this disorder, although they have seldom been studied due to their subjective nature. Recently, due to the growing interest in the study of the early stages of schizophrenia, the study of self-disorders has been resumed. The self-disorders in schizophrenia model, developed by Sass and Parnas, proposes that in this disorder the person suffers loss of the first-person perspective and experiences hyperreflexibility, diminished self-affection and disturbance of the field of awareness. Therefore, the person experiences feelings of strangeness about him/herself, difficulty in understanding the common sense of things and difficulty interacting with his/her environment. Based on this model, self-disorder evaluation instruments have been developed and empirical studies have been conducted to evaluate people at risk of developing a schizophrenia spectrum disorder. These studies show that self-disorders are found in prepsychotic stages and that their manifestation may predict the transition to schizophrenia spectrum disorders. These results have important clinical implications as they enable people in the early stages of the disorder to be identified and create the opportunity to apply early therapeutic interventions.

Aplicativo para avaliação do nível de consciência em adultos: produção tecnológica em enfermagem / Aplicación para evaluación del nível de consciencia en adultos: producción tecnológica en enfermería / App to evaluate the level of consciousness in adults: technological production in nursing

RESUMO Objetivo: desenvolver um aplicativo para a avaliação do nível de consciência em adultos. Método: produção tecnológica, estruturada a partir do referencial teórico da metodologia da aprendizagem baseada em problemas e desenvolvido considerando os passos do design instrucional contextualizado (análise, design, desenvolvimento, avaliação). Estudo realizado na Universidade Federal de Santa Catarina, de maio de 2014 a abril de 2015. Resultados: o aplicativo apresenta os conteúdos: escalas para avaliação do nível de consciência, avaliação pupilar, reflexos e padrão respiratório, apresentados aos usuários por meio de textos curtos com breves explicações, imagens e vídeos. Conclusão: o aplicativo pode facilitar o estudo sobre a temática em qualquer hora ou local, permitindo inclusive sua aplicação à beira do leito, contribuindo assim para melhorias do ensino, assistência e segurança de pacientes em estado crítico. O resultado da avaliação da tecnologia por docentes e estudantes será objeto de estudos futuros.

RESUMEN Objetivo: desarrollar una aplicación para analizar el nivel de consciencia en adultos. Método: producción tecnológica, estructurada por medio del referencial teórico de la metodología de aprendizaje basada en problemas, la cual se desarrolló considerándo los pasos del diseño educacional contextualizado (análisis, design, desarrollo, evaluación). Estudio que se realizó en la Universidad Federal de Santa Catarina, de mayo de 2014 a abril de 2015. Resultados: la aplicación presenta los contenidos: escalas para evaluación del nivel de consciencia, evaluación pupilar, reflejos y patrón respiratorio, presentados a los usuarios por medio de textos cortos con breves explicaciones, imágenes y videos. Conclusión: la aplicación puede facilitar el estudio acerca de la temática en cualquier hora o local, posibilitando incluso su uso en el lecho, lo que contribuye para mejorías de la enseñanza, asistencia y seguridad de pacientes en condición crítica. El resultado de la evaluación de la tecnología por docentes y estudiantes será objeto de estudios futuros.

ABSTRACT Objective: to develop an app for assessing the level of consciousness in adults. Method: technological production, structured from the theoretical framework of problem-based learning methodology and developed considering the steps of contextualized instructional design (analysis, design, development, evaluation). Study conducted at the Federal University of Santa Catarina, from May 2014 to April 2015. Results: the app presents the contents: scales for evaluation of the level of consciousness, pupillary evaluation, reflexes and breathing pattern, presented to the users through short texts with brief explanations, images and videos. Conclusion: the app can facilitate the study of the theme at any time or place, even allowing its application at the bedside, thus contributing to improvements in teaching, care and safety of critically ill patients. The results of the evaluation of the technology by teachers and students will be the object of future studies.

Updates on the Sedation for Gastrointestinal Endoscopy

Sedation, defined as the depressed level of consciousness, induced by drug administration, is widely used for gastrointestinal endoscopy to relieve a patient’s anxiety and discomfort. In addition, successful procedure is anticipated with control of unintended movements. Endoscopic sedation, however, cannot be free from the risk of serious adverse events, e.g., cardiopulmonary compromise. Therefore, principles on personnel, facility and equipment, as well as performance itself, should be followed to prevent unfavorable incidents. In this article, sedation guidelines for the Accreditation of Qualified Endoscopy Units, issued by the Korean Society of Gastrointestinal Endoscopy, are presented.

Adaptação transcultural e evidências de validade da escala Nociception Coma Scale-Revised: versão BR / Cross-cultural adaptation and validity evidence of Nociception Coma Scale - Revised: version BR

Introdução: O autorrelato é considerado padrão ouro para avaliação do paciente com dor. Em pacientes de Unidades de Terapia Intensiva existem barreiras de comunicação para avaliação da dor pelas disfunções neurológicas, alteração do nível de consciência secundária ao uso de sedativos, presença de cânula orotraqueal e outras condições impeditivas do autorrelato. Objetivo: Realizar a adaptação transcultural da NCS-R para a língua portuguesa e avaliar as evidências de validade brasileira da NCS-R em pacientes não comunicativos com desordens de consciência e distúrbios cognitivos. Método: Trata-se de um estudo metodológico para avaliação das evidências de validade da escala Nociception Coma Scale-Revised, dividido em duas etapas: adaptação transcultural e avaliação das evidências de validade do instrumento. O instrumento foi testado em 24 pacientes com desordens de consciência e distúrbios cognitivos das Unidades de Terapia Intensiva Geral e Cardiológica, Unidade Avançada de Insuficiência Cardíaca, Unidades Semicríticas e Unidades Clínicas do Hospital Sírio-Libanês em São Paulo. A fase de adaptação transcultural incluiu tradução inicial, síntese das traduções, retrotradução e comitê de especialistas. Na segunda fase foram avaliadas as evidências de validade quanto à validade de conteúdo e critério. A validade de critério foi verificada pelo teste de correlação da NCS- R entre a escala PAINAD; a NCS-R e o Questionário de Percepção do Profissional de Saúde sobre Indicadores Comportamentais de Dor. Para verificação da confiabilidade, foram avaliadas consistência interna, pelo alfa de Cronbach, e estabilidade, utilizando-se teste e reteste. Resultados: A escala NCS-R foi traduzida e adaptada do ponto de vista transcultural, apresentou evidências de validade de conteúdo (IVC 0,86) e validade de critério convergente moderada (r=0,65) com a escala PAINAD. A NCS-R apresentou resultados aceitáveis de confiabilidade, com alfa de Cronbach de 0,75, no teste-reteste, somente no item resposta motora, apresentou valor acima do aceitável (Kappa 0,61). A percepção dos profissionais sobre a presença de dor durante o estímulo apresentou diferença estatística significante. Conclusões: A NCS-R encontrase traduzida e adaptada, possui evidências de validade de conteúdo, critério e confiabilidade.

Introduction: Self-report is the gold standard for assessing patient pain. In intensive care unit patients, there are communication barriers for pain assessment due to neurological dysfunctions, altered level of consciousness secondary to sedative use, presence of orotracheal cannula and other conditions that impede self-report. Objective: To make the cross-cultural adaptation of NCS-R to the Portuguese language and to evaluate the evidences validity of the Brazilian version of NCS-R in non-communicative patients with consciousness disorders and cognitive disorders. Method: This is a methodological study to check the validity of the Nociception Coma Scale-Revised scale, divided into two stages: cross-cultural adaptation and evaluation of the evidence of instrument validity. The instrument was tested in 24 patients with consciousness and cognitive disorders of the General Intensive Care Units, Cardiac ICU, Advanced Heart Failure Unit, Stepdown Units and Clinical Units of the Hospital Sírio-Libanês in São Paulo. The cross-cultural adaptation phase included initial translation, synthesis of translations, back-translation and expert committee. In the second phase, evidences of validity regarding content validity and criterion validity were evaluated. Criterion validity was verified by the NCS-R correlation test between the PAINAD scale, the NCS-R and the Health Professional Perception Questionnaire on Behavioral Indicators of Pain. Reliability was checked by evaluating the internal consistency by Cronbachs alpha and stability by test and retest. Results: The NCS- R scale was translated and cross-culturally adapted, with evidence of content validity (CVI 0.86) and a moderate convergent criterion validity (r = 0.65) with the PAINAD scale. NCS-R presented acceptable reliability results, with Cronbachs alpha of 0.75; in the test-retest, only in the motor response item, it presented a result above the acceptable value (Kappa 0.61). The professionals perception of the presence of pain during the stimulus presented a statistically significant difference. Conclusions: NCS- R is translated and adapted, has good evidences of content, criterion validity moderate evidence of reliability.

Toxidrome sedante versus enfermedad cerebrovascular: a propósito de un caso / Sedative toxidrome versus cerebrovascular disease: A case report / Toxidrome sedante versus doença cerebrovascular: a propósito de um caso

Describimos el caso de una paciente femenina con signos y síntomas iniciales poco específicos, con alteración en el estado de conciencia. Se sospechó posible intoxicación, por nexo causal, probablemente por amitraz versus benzodiacepinas, sin embargo, sin confirmación de este. La paciente tenía alteración del sistema nervioso central con síntomas sugestivos de síndrome neurovascular, con posible compromiso de circulación posterior. La importancia de este caso es resaltar el amplio espectro de presentación clínica de las enfermedades neurológicas, la importancia de realizar diagnósticos diferenciales considerando los síntomas camaleónicos del accidente cerebrovascular, al igual que los "mimics stroke" y realizar enfoques clínicos integrales.

Description of the case of a female patient that presented non-specific initial signs and symptoms, with altered mental status, suggestive signs of neuro-vascular syndrome, and compromise of posterior circulation. Possible intoxication with amitraz or benzodiazepines was considered due to personal history and family reports. Given the chameleonic nature of the symptoms of cerebrovascular accidents and stroke mimics, this clinical case exposes the importance of a comprehensive approach and evaluation of possible differential diagnoses of neurological diseases.

Descrevemos o caso de uma paciente feminina com signos e sintomas iniciais pouco específicos, com alteração no estado de consciência. Se suspeitou possível intoxicação, por nexo causal, provavelmente por amitraz versus benzodiacepinas, mas, sem confirmação deste. A paciente tinha alteração do sistema nervoso central com sintomas sugestivos de síndrome neurovascular, com possível compromisso de circulação posterior. A importância deste caso é ressaltar o amplo espectro de apresentação clínica das doenças neurológicas, a importância de realizar diagnósticos diferenciais considerando os sintomas camaleónicos do acidente cerebrovascular, da mesma forma que os "mimics stroke" e realizar enfoques clínicos integrais.

Compromiso de conciencia y bradicardia / Unconciousness and bradycardia

Resumen: Mujer de 71 años, institucionalizada con antecedentes de esquizofrenia y tabaquismo. Consulta en el servicio de urgencias tras ser encontrada a la intemperie comprometida de conciencia. Al llegar la ambulancia se constata mal perfundida, bradipsíquica y bradicárdica, siendo trasladada al servicio de Urgencia. A su ingreso el ECG mostró bradicardia sinusal con trastorno de la conducción intraventricular y prolongación del intervalo QT. Los exámenes de laboratorio al ingreso resultaron dentro de límites normales. La historia clínica y los trazados electrocardiográficos son presentados, siendo discutidos junto al manejo médico.

Abstracts: A 71year old woman, institutionalized with a history of schizophrenia and smoking. She was transported to a local emergency room after being found laying outside unconscious. She was hypoperfused, bradypsychic and bradycardic, being transferred to the emergency service. On admission, the ECG showed sinus bradycardia with intraventricular conduction delay and QT prolongation. Laboratory tests were normal. Clinical history, physical examination and ECG tracings are presented and management is discussed.

Epidemiología de las intoxicaciones agudas por drogas de abuso en las urgencias de un hospital del Centro de España basada en datos de análisis toxicológico de orina / Epidemiology of acute poisonings for drugs of abuse in the emergency room of a hospital from the Center of Spain based on analysis data toxicological urine

Introducción: las intoxicaciones agudas son motivo de consulta cada vez más frecuente en los Servicios de Urgencia hospitalarios (SUH) debido a la mayor disponibilidad y acceso a productos químicos tóxicos. Se observan diferentes patrones en cada área sanitaria según el tipo de población, geografía y perfil epidemiológico de consumo. Material y métodos: el objetivo de nuestro estudio es realizar un perfil epidemiológico y describir el manejo del paciente que acude por clínica compatible con intoxicación aguda por drogas de abuso (IA) basado en la determinación de tóxicos en orina para seis sustancias (cannabis, opiáceos, cocaína, anfetaminas, benzodiazepinas y éxtasis) solicitados en el período de estudio 2010-2012. Resultados: se solicitaron 2755 peticiones, de las cuales fueron positivas 1429, y se estudiaron al azar 661 historias clínicas. El perfil de paciente intoxicado de nuestra área es el de varón de entre 30 y 40 años, consumidor preferentemente de cannabis y cocaína; las benzodiazepinas son el tóxico más frecuente en las mujeres, con clínica mayoritariamente neurológica, sin diferencias en cuanto a la franja horaria o el mes del año en que recibió el alta desde el propio SUH en casi el 60% de los casos. Discusión: las IA en los SUH representan casi el 1% de las consultas y tienen una escasa mortalidad. En algunos casos, el médico de urgencias comienza el tratamiento antes de conocer el resultado toxicológico, lo que nos hace plantearnos la utilidad real y el coste-efectividad de estas determinaciones en todos los pacientes con alteración del nivel de conciencia. (AU)

Introduction: acute intoxications are a rising and common query demand on the emergency rooms because of the easy access and disponibility to toxic substances, where we can observe different patterns attending to type of population, geography and epidemiologic consume profile. Material and methods: our objective is to analyze the epidemiology and patient handling coming to the Emergency Room (ER) with compatible symptoms of street drugs abuse, based on the determination of cannabis, cocaine, amphetamine, benzodiazepine, opiates and ectasy urine levels in the period 2010-2012. Results: the ER requested 2755 determinations being positive 1429 and randomly examined 661 clinical histories. The profile of intoxicated patient was male, 30 to 40 years old, preferently cannabis and cocaine consumer (benzodiazepine in women), mostly with neurological symptoms when arrive, without differences between months or day time and, almost 60% of them, discharged directly from the ER. Conclusions: acute intoxications barely represent 1% of ER demands and produce poor or scarce mortality. Sometimes, doctors in charge start with therapeutic measures before knowing the results of toxicology, what leads us to ask about actual usefulness and cost-efficiency of the toxicology assay to every patient with low conscious level. (AU)

Abnormal Effective Connectivity of the Anterior Forebrain Regions in Disorders of Consciousness / 神经科学通报·英文版

A number of studies have indicated that disorders of consciousness result from multifocal injuries as well as from the impaired functional and anatomical connectivity between various anterior forebrain regions. However, the specific causal mechanism linking these regions remains unclear. In this study, we used spectral dynamic causal modeling to assess how the effective connections (ECs) between various regions differ between individuals. Next, we used connectome-based predictive modeling to evaluate the performance of the ECs in predicting the clinical scores of DOC patients. We found increased ECs from the striatum to the globus pallidus as well as from the globus pallidus to the posterior cingulate cortex, and decreased ECs from the globus pallidus to the thalamus and from the medial prefrontal cortex to the striatum in DOC patients as compared to healthy controls. Prediction of the patients' outcome was effective using the negative ECs as features. In summary, the present study highlights a key role of the thalamo-basal ganglia-cortical loop in DOCs and supports the anterior forebrain mesocircuit hypothesis. Furthermore, EC could be potentially used to assess the consciousness level.

White Matter Deficits Underlying the Impaired Consciousness Level in Patients with Disorders of Consciousness / 神经科学通报·英文版

In this study, we aimed to (1) identify white matter (WM) deficits underlying the consciousness level in patients with disorders of consciousness (DOCs) using diffusion tensor imaging (DTI), and (2) evaluate the relationship between DTI metrics and clinical measures of the consciousness level in DOC patients. With a cohort of 8 comatose, 8 unresponsive wakefulness syndrome/vegetative state, and 14 minimally conscious state patients and 25 patient controls, we performed group comparisons of the DTI metrics in 48 core WM regions of interest (ROIs), and examined the clinical relevance using correlation analysis. We identified multiple abnormal WM ROIs in DOC patients compared with normal controls, and the DTI metrics in these ROIs were significantly correlated with clinical measures of the consciousness level. Therefore, our findings suggested that multiple WM tracts are involved in the impaired consciousness levels in DOC patients and demonstrated the clinical relevance of DTI for DOC patients.

Spinal Cord Stimulation Frequency Influences the Hemodynamic Response in Patients with Disorders of Consciousness / 神经科学通报·英文版

Spinal cord stimulation (SCS) is a promising technique for treating disorders of consciousness (DOCs). However, differences in the spatio-temporal responsiveness of the brain under varied SCS parameters remain unclear. In this pilot study, functional near-infrared spectroscopy was used to measure the hemodynamic responses of 10 DOC patients to different SCS frequencies (5 Hz, 10 Hz, 50 Hz, 70 Hz, and 100 Hz). In the prefrontal cortex, a key area in consciousness circuits, we found significantly increased hemodynamic responses at 70 Hz and 100 Hz, and significantly different hemodynamic responses between 50 Hz and 70 Hz/100 Hz. In addition, the functional connectivity between prefrontal and occipital areas was significantly improved with SCS at 70 Hz. These results demonstrated that SCS modulates the hemodynamic responses and long-range connectivity in a frequency-specific manner (with 70 Hz apparently better), perhaps by improving the cerebral blood volume and information transmission through the reticular formation-thalamus-cortex pathway.

Visual Fixation Assessment in Patients with Disorders of Consciousness Based on Brain-Computer Interface / 神经科学通报·英文版

Visual fixation is an item in the visual function subscale of the Coma Recovery Scale-Revised (CRS-R). Sometimes clinicians using the behavioral scales find it difficult to detect because of the motor impairment in patients with disorders of consciousness (DOCs). Brain-computer interface (BCI) can be used to improve clinical assessment because it directly detects the brain response to an external stimulus in the absence of behavioral expression. In this study, we designed a BCI system to assist the visual fixation assessment of DOC patients. The results from 15 patients indicated that three showed visual fixation in both CRS-R and BCI assessments and one did not show such behavior in the CRS-R assessment but achieved significant online accuracy in the BCI assessment. The results revealed that electroencephalography-based BCI can detect the brain response for visual fixation. Therefore, the proposed BCI may provide a promising method for assisting behavioral assessment using the CRS-R.

Responses of Patients with Disorders of Consciousness to Habit Stimulation: A Quantitative EEG Study / 神经科学通报·英文版

Whether habit stimulation is effective in DOC patient arousal has not been reported. In this paper, we analyzed the responses of DOC patients to habit stimulation. Nineteen DOC patients with alcohol consumption or smoking habits were recruited and 64-channel EEG signals were acquired both at the resting state and at three stimulation states. Wavelet transformation and nonlinear dynamics were used to extract the features of EEG signals and four brain lobes were selected to investigate the degree of EEG response to habit stimulation. Results showed that the highest degree of EEG response was from the call-name stimulation, followed by habit and music stimulations. Significant differences in EEG wavelet energy and response coefficient were found both between habit and music stimulation, and between habit and call-name stimulation. These findings prove that habit stimulation induces relatively more intense EEG responses in DOC patients than music stimulation, suggesting that it may be a relevant additional method for eliciting patient arousal.

Spatial Properties of Mismatch Negativity in Patients with Disorders of Consciousness / 神经科学通报·英文版

In recent decades, event-related potentials have been used for the clinical electrophysiological assessment of patients with disorders of consciousness (DOCs). In this paper, an oddball paradigm with two types of frequency-deviant stimulus (standard stimuli were pure tones of 1000 Hz; small deviant stimuli were pure tones of 1050 Hz; large deviant stimuli were pure tones of 1200 Hz) was applied to elicit mismatch negativity (MMN) in 30 patients with DOCs diagnosed using the JFK Coma Recovery Scale-Revised (CRS-R). The results showed that the peak amplitudes of MMN elicited by both large and small deviant stimuli were significantly different from baseline. In terms of the spatial properties of MMN, a significant interaction effect between conditions (small and large deviant stimuli) and electrode nodes was centered at the frontocentral area. Furthermore, correlation coefficients were calculated between MMN amplitudes and CRS-R scores for each electrode among all participants to generate topographic maps. Meanwhile, a significant negative correlation between the MMN amplitudes elicited by large deviant stimuli and the CRS-R scores was also found at the frontocentral area. In consequence, our results combine the above spatial properties of MMN in patients with DOCs, and provide a more precise location (frontocentral area) at which to evaluate the correlation between clinical electrophysiological assessment and the level of consciousness.