Effectiveness of the Japanese DOLOPLUS-2: a pain assessment scale for patients with moderate-to-severe dementia.

BACKGROUND: This study aimed to assess whether the Japanese DOLOPLUS-2 scale could effectively identify pain in elderly individuals with moderate-to-severe dementia. METHODS: This study used a pre-test/post-test design with purposive sampling to select an experimental group and a historical control group. The inclusion criteria were a Functional Assessment Staging score of 5 or 6, a diagnosis of an orthopaedic disease that typically involves pain, the ability to say 'I am currently in pain' (to prevent medication errors), and a total DOLOPLUS-2 scale score ≥5 at the first pain assessment. In the experimental group (n = 19), each patient was assessed by the DOLOPLUS-2 scale at 2PM and 9PM each day for 5 days. If a patient's total score was ≥5, analgesics were prescribed and the patient was re-assessed approximately 3 hours later. In the control group (n = 20), data were collected from medical records over a 1-year period, and we matched the characteristics of the control group to that of the experimental group. We also reviewed nursing records to determine the number of times analgesics had been administered over the 5 days after the nurses had first recorded that the patient had experienced pain. RESULTS: Among the 19 patients in the experimental group, 15 received pain medication because of a total pain score ≥5. Before treatment, their mean DOLOPLUS-2 scale score was 7.5 ± 3.2, and their score significantly decreased to 2.9 ± 2.1 (P < 0.001) after treatment. The experimental group also received significantly more treatments with analgesic medication than the control group (χ(2) = 16.033, P < 0.001, φ = 0.641). CONCLUSION: This study's findings suggested that the Japanese DOLOPLUS-2 scale could adequately identify pain in elderly individuals with moderate-to-severe dementia.

Early depressive symptoms after ischemic stroke are associated with a left lenticulocapsular area lesion.

BACKGROUND: Poststroke depression is one of the most frequent and important complications of stroke. Although many studies of depression after stroke have been reported, clinical association between the risk of depression after stroke and the lesion location remains unclear. The presence of depression after stroke reportedly confers a poor prognosis; however, early recognition of depressive symptoms may improve outcomes. We examined the relation between lesion location and presence of depressive symptoms 1 month after ischemic stroke, with a view toward early management of depressive symptoms. METHODS: In all, 134 consecutive patients with ischemic stroke were followed up to determine whether depression was present 1 month after stroke onset. Depressive symptoms were assessed by means of the Zung Self-rating Depression Scale. The lesion location was determined on magnetic resonance or computed tomography images. RESULTS: The incidence of depressive symptoms 1 month after stroke onset was 34.3%. Backward stepwise logistic regression analysis showed hypertension, education, and the presence of a left lenticulocapsular infarct, in particular, to be independent predictors of depressive symptoms. CONCLUSIONS: Patients with ischemic stroke, particularly in the left lenticulocapsular area, should be carefully evaluated for early detection and treatment of depressive symptoms, which may greatly influence outcome.

Neuromyelitis optica preceded by brain demyelinating episode.

Neuromyelitis optica (NMO) is considered a distinct disease from multiple sclerosis (MS) because of its pathogenesis. It is well accepted that NMO selectively affects the spinal cord and optic nerve and is not associated with brain lesions at the onset of the disease, unlike MS. We present a unique case where the patient's initial lesion was in the brain, and optic neuritis and myelitis were revealed 6 years after the brain lesion. In addition, the patient's serum antiaquaporin 4 (AQP4) antibody was positive. We consider the brain lesion to precede abnormal lesion of NMO, and the AQP4 measurement is important for diagnostics, even if it occurs with brain lesions.

Anti-apoptotic and neuroprotective effects of edaravone following transient focal ischemia in rats.

To investigate the effect of an antioxidant edaravone on the apoptotic process, we examined Bax and Bcl-2 immunohistochemical expression and terminal deoxynucleotidyl transferase-mediated dUTP-biotin nick end labeling (TUNEL) reactivity. Rat focal ischemia models were prepared by 2 h transient middle cerebral artery occlusion. Edaravone or physiological saline was intravenously administered after reperfusion. After 24 h of reperfusion, infarction volume assessments, Bax and Bcl-2 immunohistochemistry and TUNEL staining were performed as well as neurological evaluation. Cortical cerebral blood flow was not statistically different between the treatment-groups. Edaravone-treated animals showed significantly improved neurological outcome. Total and cortical infarct volumes in the edaravone group significantly decreased. In addition, edaravone-treatment provided a significant reduction in the number of TUNEL-positive apoptotic cells, a decrease in Bax immunoreactivity and an increase in Bcl-2 expression within the peri-infarct area. Edaravone shows an excellent neuroprotective effect against ischemia/reperfusion brain injury through a Bax/Bcl-2 dependent anti-apoptotic mechanism.

Differential effects of sublethal ischemia and chemical preconditioning with 3-nitropropionic acid on protein expression in gerbil hippocampus.

Pretreatment with a low dose of 3-nitropropionic acid (3-NPA) has been shown to induce ischemic tolerance in the gerbil hippocampus. It is well known that sublethal (2-min) ischemia also induces ischemic tolerance. To investigate the acquisition of ischemic tolerance with 3-NPA, we examined the protein expression after 3-NPA treatment in comparison with sublethal ischemia. Immunohistochemical studies revealed intense expression of Bcl-2 and Bcl-xL in the hippocampal CA1 area after 3-NPA treatment. Furthermore, the time course of the expression of Bcl-xL showed a similar pattern to the acquisition of ischemic tolerance by 3-NPA treatment. The induction of Bcl-xL occurred in the hippocampal CA1 area at 24 h after 3-NPA treatment, and significant induction was observed at 48 h. Western blot analysis of hippocampus harvested 48 h after the pretreatment, showed that the expression of Bcl-2 and Bcl-xL was significantly increased by either 3-NPA treatment or 2-min ischemia. However, PMCA1 and HSP70 protein expression increased only in the sublethal ischemia treated group. The difference between 3-NPA treated group and control group was not statistically significant. These results suggest that Bcl-2 and Bcl-xL are essential for acquisition of ischemic tolerance, while HSP70 and PMCA1 play important roles in the enhancement of ischemic tolerance.

Cerebral blood flow index: dynamic perfusion MRI delivers a simple and good predictor for the outcome of acute-stage ischemic lesion.

OBJECTIVES: To evaluate the feasibility of utilizing cerebral blood flow (CBF) index images, calculated automatically and quickly from dynamic perfusion imaging (DPI), to identify acute cerebral ischemia. We attempted to investigate (1) whether the CBF index has a threshold for assessing tissue outcome, (2) whether CBF index images can predict the resulting infracted area, and if so, (3) whether the predictive capacity of the CBF index image is comparable to the regional CBF (rCBF) image delivered from singular value decomposition (SVD) deconvolution methods, which are regarded as most accurate in predicting the final infarct area. METHODS: Diffusion-weighted images (DWI) and DPI were obtained in 17 patients within 12 hours of stroke onset and follow-up magnetic resonance imaging (MRI). On 3 DPI-delivered images, namely relative regional cerebral blood volume (rrCBV), uncorrected mean transit time (MTTu) and CBF index images, univariate discriminant analysis was done to estimate cut-off values to discriminate between infarcted and noninfarcted areas. Subsequently, correlations between the initial lesion volume of 3 images together with rCBF images delivered with SVD methods and the final infarct volume on follow-up T2-weighted MRI taken at the 8th to 20th day were determined. RESULTS: Among the 3 images, only the CBF index image was able reveal the threshold of the ischemic region. Lesion volume of CBF index images against follow-up infarct volume had the highest correlation (r = 0.995) to a linear fit and the slope was closest to 1.0 (0.91) among the 3 and had identical accuracy to the regression coefficient of rCBF images. CONCLUSIONS: CBF index images can predict final infarct volume. Evaluating CBF index images together with DWI can guide the initial assessment in the acute stage of cerebral ischemia.

Acute posterior leukoencephalopathy in a patient with nephrotic syndrome.

Reversible posterior leukoencephalopathy syndrome is one of the most serious complications of immunosuppressive therapy. The clinical features include headache, altered mental functioning, seizures, cortical blindness and other visual disturbances, with hypertension. The neuroimaging studies reveal predominant posterior leukoencephalopathy. Usually, antihypertensive therapy and reduction or withdrawal of immunosuppressive agents have been reported to resolve the neurological deficits and imaging abnormalities within a few weeks. We discuss here a 51-year-old woman with nephrotic syndrome who developed acute leukoencephalopathy during combination therapy with prednisolone and cyclosporine. She developed severe headache, visual disturbance, consciousness disturbance, and generalized tonic clonic convulsion. A computed tomography scan (CT) revealed low-density areas in the subcortices of the parietal and occipital lobes. Magnetic resonance imaging (MRI) disclosed a high signal intensity area on T2-weighted images and a low signal intensity area on T1-weighted images in the same lesions. Follow-up brain CT and MRI were performed several times. Three weeks after the first study, these lesions had completely resolved, but she had persistent altered consciousness for more than 1 year.