Pain affects the quality of life of neuropathic patients.

The aim of this study was to verify the extent to which the presence of pain affects the quality of life (QoL) of neuropathic patients. The patients were selected in our Department of Peripheral Nervous System Diseases. We enrolled 120 consecutive patients with chronic polyneuropathy who had not received continuous pain therapy during the two months preceding study entry, and administered them the Total Neuropathy Score (TNS), the official Italian version of the SF-36 and the Italian Pain Questionnaire (QUID). Our main finding was that the QoL is affected not only by the presence of neuropathy, but also by the presence and intensity of pain: the physical aspect of the QoL correlated only weakly with the TNS, but pain was closely related to a worsening in this parameter; moreover, the mental domains of the SF-36 were only correlated with pain. Pain per se worsens the QoL of neuropathic patients, regardless of disease severity.

Chronic deep brain stimulation of the subthalamic nucleus for Parkinson's disease: effects on cognition, mood, anxiety and personality traits.

OBJECTIVE: To evaluate modifications occurring in cognitive functions and behavioural aspects in a group of 72 consecutive patients with Parkinson's disease (PD) 15 months after bilateral deep brain stimulation (DBS) of the subthalamic nucleus (STN). METHODS: 72 consecutive PD patients bilaterally implanted for DBS of the STN were evaluated before and after surgery with a mean follow-up of 15 months. A neuropsychological assessment was performed to evaluate reasoning (Raven Colour Matrices), memory (Bisyllabic Word Repetition Test, Corsi's Block-Tapping Test, Paired-Associate Learning) and frontal executive functions (Trail Making Test Part B, Nelson Modified Card Sorting Test, phonemic and category verbal fluency tasks). Mood and suicidal ideation were evaluated using the Beck Depression Inventory (BDI). Anxiety was measured by means of the State-Trait Anxiety Inventory and personality traits were evaluated with the Structured Clinical Interview for the DSM-III-R Axis II Disorders (SCID-II). Assessment of thought disorders and apathy was based on subitems of the Unified Parkinson's Disease Rating Scale. RESULTS: The comparisons between pre- and postoperative neuropsychological test scores showed a significant worsening only in phonemic and semantic verbal fluency tasks, while fewer errors were found in the Nelson Modified Card Sorting Test. Globally, behavioural assessment evidenced a small improvement in mood, as assessed by the BDI, in obsessive-compulsive and paranoid personality traits (SCID-II). Thought disorders worsened while suicidal ideation, anxiety and apathy showed no postoperative modifications. The analysis of individual outcomes (+/-1 SD criterion) evidenced a relevant postoperative cognitive decline in 3 patients out of 65 (4.5%). Moreover, following implantation, 1 patients exhibited psychosis (1.5%), 2 patients experienced a clinically relevant worsening of depressive symptoms (3%), 7 patients showed an increase in anxiety (12%) and 3 patients a worsening in depression and anxiety symptoms (3%). On the contrary, 12 patients (20%) showed a relevant improvement in mood and 14 patients (23%) a relevant reduction of anxiety symptoms after the surgery. CONCLUSIONS: The present study confirms that STN DBS is cognitively safe since the only relevant change observed was a mild decrease in verbal fluency tasks. Globally, a small postoperative improvement was found in the BDI, and in two SCID-II subscales concerning obsessive-compulsive and paranoid personality traits, even though postoperative behavioural disturbances can occur in individual patients.

A further critical evaluation of requests for electrodiagnostic examinations.

The aim of this study was to evaluate the impact of electrophysiological (EDX) tests in the clinical management and diagnosis of patients, and the appropriateness of the referral diagnosis. A study was carried out in three electrodiagnostic services in the Torino area, over a 12-month period. In our study 3,900 individuals (2,340 females, 1,560 males) were evaluated. Patients underwent EDX examinations including nerve conduction study, electromyography and repetitive stimulation test. Most patients had been sent for EDX tests by specialists. Specialists suspected mainly polyneuropathy, whilst general practitioners suspected mainly carpal tunnel syndrome. Seventy-two percent of the requests were correctly formulated, 55% by general practitioners and 77% by specialists. There was a concordance between the results of the EDX tests and diagnostic hypothesis 40% of the time. This study confirms the usefulness and diagnostic impact of EDX examinations and evidences the amount of time and resources wasted as a result of incorrect or incomplete requests.

Attention in closed head injury: a critical review.

Closed head injury (CHI) is one of the commonest causes of physical disability and cognitive impairment in young people. In patients with CHI both in the acute and sub-acute phases it is possible to demonstrate a disturbance of cognitive functions that affects their performance in a wide variety of neuropsychological tasks. The most frequent deficits pertain to attention and memory. In reviewing the literature on attention in CHI patients it appears that a debate is still alive about how to interpret the cognitive attentional defect, i. e. whether it is due to a slowing of information processing, to a deficit of 'executive' frontal functions, to a reduction of arousal level, to deficits of selective or divided attention, or to a combination of factors. After a brief general explanation of the neuropsychological cognitive models of attention, an overview of the various studies on attention in CHI will be provided. For the purposes of the review, the studies are grouped according to the different theoretical interpretations in the literature concerning the nature of attentional deficits in CHI patients. Finally, a tentative general interpretation of attentional deficits in CHI, in light of the anatomo-pathological aspects of the brain of CHI patients and of some methodological considerations, is offered.

How can we evaluate interference in attentional tests? A study based on bi-variate non-parametric tolerance limits.

In attentional tasks a basic performance is often contrasted with the same task administered with some additional load, defined here as "interference". However, it is questionable how interference should be quantified. The raw difference between the interference-loaded ("complex") task and the basic task is marred by measurement artefacts. There are alternative ways, but the choice of which solution to employ appears arbitrary. Bivariate non-parametric tolerance limits were introduced as they retain the information linked to the bivariate nature of the observation, and in this study we compared the different approaches for evaluating interference using real data from 209 normal participants who performed Visual Reaction Times (basic and go / no-go) and the Stroop Test. Our analysis indicated that, among the univariate indices, the use of the complex score covaried for the basic score yields the most satisfactory evaluation of interference; however, its use can be decided only after data inspection. Bivariate non-parametric tolerance limits offer advantages in terms of generality of use.

The milan overall dementia assessment and the mini-mental state examination compared: an epidemiological investigation of dementia.

We assessed the validity of two screening tests [the Mini-Mental State Examination (MMSE) and the Milan Overall Dementia Assessment or (MODA)] in a population study on the prevalence of Alzheimer's disease, carried out in a small town in the north of Italy. A random sample of 1000 subjects aged 60 years or over entered the study. Subjects who scored below the cut-off points on MODA or on MMSE, or both, were further investigated with neuropsychological, laboratory and instrumental tests to ascertain a final diagnosis, which was considered as the gold standard. Our findings show that MODA has a higher sensitivity than MMSE in detecting subjects affected by dementing illnesses, while MMSE shows a higher specificity. MODA seems to be preferable to MMSE as a screening test for studies where a very high sensitivity is required.

Hypermnesia in unilateral neglect.

Thirteen right brain-damaged patients who were found to neglect pictures presented on the left of a display were presented the same stimuli, intermixed with foils, in a yes-no recognition test. Fifty per cent of patients claimed to have already seen one or more of the previously neglected pictures. This demonstrates that visual information that fails to access consciousness in neglect patients does retain the ability to surface as explicit memory at a later stage.

The 'preliminary neuropsychological battery'. An instrument to grade the cognitive level of minimally responsive patients.

An early, formalized cognitive evaluation of'minimally responsive' patients could be important in the planning of their care and rehabilitation as well as in providing a realistic prognosis and studying the modality of the cognitive recovery. A short, bedside, neuropsychologically-oriented test-battery, the Preliminary Neuropsychological Battery, a psychometric tool which enables the cognitive evaluation of these patients and of patients unable to give verbal or complex motor answers, has been devised. The BNP was administered to a sample of 40 head-injured patients and to a sample of 34 healthy subjects. The aim was (i) to evaluate its usefulness, and (ii) to study its correlation with cortical functions as assessed by a more extensive battery. The findings suggest that the BNP is useful for assessing the general cognitive level of head-injured post-comatose patients. It was able to detect patients deserving a wider, analytic, neuropsychological assessment. Attentional defects emerged as an important variable determining the BNP score.

Comparison of two scoring systems of the Mini-Mental State Examination as a screening test for dementia.

The difference in validity in detecting dementia of two different scoring systems (age- and education-adjusted versus raw scores) of the Mini-Mental State Examination (MMSE), was assessed in an epidemiological study on the prevalence of dementia. A second, independent, psychometric screening tool, the Milan Overall Dementia Assessment (MODA), was also used. A group of 829 subjects over age 59 took part in the study. Subjects scoring below the cut-off point of the MMSE and/or MODA were clinically evaluated. Clinical diagnoses were adopted as the gold standard. Sensitivity, specificity, positive, and negative predictive values of the two tests were calculated. Our findings show that the correction for age and education of the raw score of the MMSE causes the loss of the mildest demented patients and heavily reduces the sensitivity of the screening test (from 85.7% to 71.4%), while it accounts for a moderate improvement in the specificity (from 90.0% to 96.3%). A possible explanation for this seeming paradox is proposed.

Agreement in the clinical diagnosis of dementia: evaluation of a case series with mild cognitive impairment.

Interobserver agreement in the clinical diagnosis of dementia among four neurologists was evaluated. The physicians, masked to the original diagnoses, independently reviewed the clinical records of 50 outpatients consulting either the 1st University Neurology Department of Milan or the Neuropsychology Unit of the Medical Center of Veruno (Novara) for suspected cognitive impairment, during a 6-month period. The records contained patients' medical and neurological history, results of neuropsychological testing, laboratory tests, cerebral computed tomography and other investigations. For each patient, the raters had to provide both a diagnosis concerning the presence or absence of dementia and to assign an analytical diagnosis to all the dementia cases. The kappa statistic was used as a measure of interrater reliability. The level of agreement on the primary diagnosis of dementia was moderate (kappa = 0.49); with respect to the nosological diagnoses, the kappa values ranged from 0.16 for depression to 0.80 for multi-infarct dementia.

Selective visual attention in Alzheimer's and Parkinson's patients: memory- and data-driven control.

An automated visual search experiment was carried out on patients with incipient Alzheimer's disease, non-demented Parkinsonians and healthy controls to test for selective attention control within the framework of the Norman and Bobrow (1975) model. The performances of the Parkinsonians and healthy controls were consistent with the predictions of this model but those of the Alzheimer patients were not. These patients appeared to be no longer sensitive to the facilitation supplied by the stimulus context and to spend most of their residual resources on achieving accuracy. The reduction of their attentional resources possibly interferes with the control of the speed-accuracy trade-off.