Analysis of Italian regulations on pathways of care for patients in a vegetative or minimally conscious state.

Different rehabilitation models for persons diagnosed with disorders of consciousness have been proposed in Europe during the last decade. In Italy, the Ministry of Health has defined a national healthcare model, although, to date, there is a lack of information on how this has been implemented at regional level. The INCARICO project collected information on different regional regulations, analysing ethical aspects and mapping care facilities (numbers of beds and medical units) in eleven regional territories. The researchers found a total of 106 laws; differences emerged both between regions and versus the national model, showing that patients with the same diagnosis may follow different pathways of care. An ongoing cultural shift from a treatment-oriented medical approach towards a care-oriented integrated biopsychosocial approach was found in all the welfare and healthcare systems analysed. Future studies are needed to explore the relationship between healthcare systems and the quality of services provided.

Coma recovery scale-r: variability in the disorder of consciousness.

BACKGROUND: Despite evidence from neuroimaging research, diagnosis and early prognosis in the vegetative (VS/UWS) and minimally conscious (MCS) states still depend on the observation of clinical signs of responsiveness. Multiple testing has documented a systematic variability during the day in the incidence of established signs of responsiveness. Spontaneous fluctuations of the Coma Recovery Scale-revised (CRS-r) scores are conceivable. METHODS: We retrospectively analyzed the CRS-r repeatedly administered to 7 VS/UWS and 12 MCS subjects undergoing systematic observation during a conventional 13 weeks. rehabilitation plan. RESULTS: The CRS-r global, visual and auditory scores were found higher in the morning than at the afternoon administration in both VS/UWS and MCS subgroups over the entire period of observation. The probability for a VS/UWS subject of being classified as MCS at the morning testing at least once during the 13 weeks. observation was as high as 30%, i.e., compatible with the reported misdiagnosis rate between the two clinical conditions. CONCLUSIONS: Multiple CRS-r testing is advisable to minimize the risk of misclassification; estimates of spontaneous variability could be used to characterize with greater accuracy patients with disorder of consciousness and possibly help optimize the rehabilitation plan.

A study of the reliability of the Nociception Coma Scale.

OBJECTIVE: In this study, we investigated the reliability of the Nociception Coma Scale which has recently been developed to assess nociception in non-communicative, severely brain-injured patients. DESIGN: Prospective cross-sequential study. SETTING: Semi-intensive care unit and long-term brain injury care. SUBJECTS: Forty-four patients diagnosed as being in a vegetative state (n=26) or in a minimally conscious state (n=18). INTERVENTIONS: Patients were assessed by two experts (rater A and rater B) on two consecutive weeks to measure inter-rater agreement and test-retest reliability. MAIN MEASURES: Total scores and subscores of the Nociception Coma Scale. RESULTS: We performed a total of 176 assessments. The inter-rater agreement was moderate for the total scores (k = 0.57) and fair to substantial for the subscores (0.33 ≤ k ≤ 0.62) on week 2. The test-retest reliability was substantial for the total scores (k = 0.66) and moderate to almost perfect for the subscores (0.53 ≤ k ≤ 0.96) for rater A. The inter-rater agreement was weaker on week 1, whereas the test-retest reliability was lower for the least experienced rater (rater B). CONCLUSIONS: This study provides further evidence of the psychometric qualities of the Nociception Coma Scale. Future studies should assess the impact of practical experience and background on administration and scoring of the scale.

Ambient intelligence for monitoring and research in clinical neurophysiology and medicine: the MIMERICA* project and prototype.

Ambient Intelligence (AmI) provides extended but unobtrusive sensing and computing devices and ubiquitous networking for human/environment interaction. It is a new paradigm in information technology compliant with the international Integrating Healthcare Enterprise board (IHE) and eHealth HL7 technological standards in the functional integration of biomedical domotics and informatics in hospital and home care. AmI allows real-time automatic recording of biological/medical information and environmental data. It is extensively applicable to patient monitoring, medicine and neuroscience research, which require large biomedical data sets; for example, in the study of spontaneous or condition-dependent variability or chronobiology. In this respect, AML is equivalent to a traditional laboratory for data collection and processing, with minimal dedicated equipment, staff, and costs; it benefits from the integration of artificial intelligence technology with traditional/innovative sensors to monitor clinical or functional parameters. A prototype AmI platform (MIMERICA*) has been implemented and is operated in a semi-intensive unit for the vegetative and minimally conscious states, to investigate the spontaneous or environment-related fluctuations of physiological parameters in these conditions.

The vegetative state--a syndrome in search of a name.

In 2002, Bryan Jennett chose the caption "A syndrome in search of a name" for the first chapter of his book "The vegetative state--medical facts, ethical and legal dilemmas", which, in summary, can be taken as his legacy. Jennett coined the term "VegetativeState" (VS), which became the preferential name for the syndrome of wakeful unresponsiveness in the English literature, with the intention to specify the concern and dilemmas in connection with the naming "vegetative", "persistent" and "permanent". In Europe, Apallic Syndrome (AS) is still in use. The prevalence of VS/AS in hospital settings in Europe is 0.5-2/100.000 population year; one-third traumatic brain damage, 70% following intracranial haemorrhages, tumours, cerebral hypoxemia after cardiac arrest, and end stage of certain progressive neurological diseases. VS/AS reflects brain pathology of (a) consciousness, self-awareness, (b) behaviour, and (c) certain brain structures, so that patients are awake but total unresponsive. The ambiguity of the naming "vegetative" (meant to refer to the preserved vegetative (autonomous nervous system) can suggest that the patient is no more a human but "vegetable" like. And "apallic" does not mean being definitively and completely anatomically disconnected from neocortical structures. In 2009, having joined the International Task Force on the Vegetative State, we proposed the new term "Unresponsive Wakefulness Syndrome" (UWS) to enable (neuro-)scientists, the medical community, and the public to assess and define all stages accurately in a human way. The Unresponsive Wakefulness Syndrome (UWS) could replace the VS/AS nomenclature in science and public with social competence.

Heart rate variability: an index of brain processing in vegetative state? An artificial intelligence, data mining study.

OBJECTIVE: Brain processing at varying levels of functional complexity has been documented in vegetative state. In this study, data mining procedures are applied to identify significant changes in heart rate variability (an emerging objective descriptor of autonomic correlates of brain activation) in response to complex auditory stimuli with emotional value (music). METHODS: The heart rate of subjects in vegetative state from brain damage (n=6) or spontaneous hemorrhage (n=3) and 16 healthy controls was recorded while they passively listened to four pre-selected music samples by different authors (mean recording time: 3m and 36s±24s). The parametric and non-parametric frequency spectra were computed on the heart rate, spectra were compared within/across subjects and music authors, and the spectra descriptors were entered into a 1-R rules data mining procedure (WEKA software Leave One Out and Ten Fold Cross validation). The procedure independently classified the heart rate spectral patterns of both patients and controls and the emotions reported by healthy subjects as "positive" or "negative". RESULTS: In both healthy controls and vegetative state subjects, the power spectra while passively listening to music differed from baseline when compared irrespective of the music authorship and from each other when compared across music samples. Data mining sorted the nu_LF (normalized parameter unit of the spectrum low frequency range) as the significant descriptor of heart rate variability in the conditions of the study. The nu_LF classification of the healthy controls' HRV changes in response to music replicated that based on subjective reports with 75-93.7% accuracy. CONCLUSIONS: Although preliminary, these findings suggest that autonomic changes with possible emotional value can be induced by complex stimuli also in vegetative state, with implications on the residual responsiveness of these subjects. SIGNIFICANCE: Heart rate variability descriptors and data mining methods appear applicable to investigate brain function in the absence of consciousness.

Clinical signs and early prognosis in vegetative state: a decisional tree, data-mining study.

BACKGROUND AND PURPOSE: Residual brain function has been documented in vegetative state patients, yet early prognosis remains difficult. The purpose of this study was to identify by artificial intelligence procedures (classification and regression trees, data-mining) the significant neurological signs correlated to and predictive of outcome. METHODS: Three hundred and thirty-three patients in vegetative state of traumatic or non-traumatic aetiology referred to the S.Anna Institute were retrospectively studied. Twenty-two neurological signs were assessed according to criteria included in the UNI ENI ISO 9001 : 2000 quality standards at admission (Time(0)) and after 50, 100 or 180 days and entered into a CART (classification and regression tree) data-mining procedure with a decisional tree j48 (Weka software and 10-fold cross-validation). Outcome was conventionally rated by the Glasgow outcome scale. RESULTS AND CONCLUSIONS: Re-appearance with proper timing of spontaneous motility, eye tracking and oculo-cephalic reflex and disappearance of oral automatisms proved highly correlated to outcome and allowed early and reliable prognosis. These findings are consistent with the brain functional organization thought to sustain consciousness and warrant systematic investigation. Classification and regression trees and data-mining procedures proved applicable in neurology to sort out significant clinical signs also in clinical conditions characterized by paucity of signs such as the vegetative state. Extended application in clinical medicine is conceivable based on the approach peculiarities.

Cortical and cervical stimulation after hemispheric infarction.

Cortical and cervical stimulation has been performed in 20 patients with hemiparesis or hemiplegia due to hemispheric infarction and in 20 control subjects. The motor action potentials (MAPs) were recorded from biceps and thenar muscles. MAPs evoked by stimulation of the undamaged hemisphere were normal in 18 out of 20 patients and in two there was a slight increase of central conduction time (CCT). The stimulation of the motor cortex of the damaged hemisphere did not evoke any response in 15 patients; in two the MAPs were absent in one muscle and in the remaining three were delayed in one or both muscles. Cervical MAPs were normal in 18 patients and delayed in the thenar muscle in two patients.

[Visual and computerized analysis of EEG during transcendental meditation and sleep (author's transl)]. / Rechnerunterstützte Analyse des EEG während Transzendentaler Meditation und Schlaf.

Polygraphic records (EEG, EOG, heart rate) were obtained of 5 subjects during and after transcendental meditation (TM) as well as during night sleep. The records were analyzed twice. During TM the amplitude of the alpha-waves was higher as before TM and appeared continuously. Bilateral theta-bursts were also observed. The same EEG changes were seen during relaxation with closed eyes. The discriminance-analysis of 5 frequency-bands of the EEG recorded from C3 showed either no differences in dominant frequency, power and variancy. No differences were observed between the flat EEGs recorded during TM or sleep. The heart rate was significantly slower during meditation or light sleep - when a flat EEG (stage 1) was recorded - as when the recording showed an alpha-rhythm. The vigilosomnograms of all our subjects were normal. The subjects reported that they experienced an increased relaxation, alertness and floating consciousness. They were able to maintain themselves for unusually long time in a state of decreased alertness (stages W1;10).

Star-like display of EEG spectral values.

A new method of displaying the results of EEG spectral analysis is described. By means of Kiviat graphs some variables of two homologous derivations are represented by coplanar vectors beginning from a common centre. A symmetrical good system appears star-shaped. Successive evaluations are superimposed on the first one. The method allows a string right-left correlation and is particularly suitable for long term evaluations.

[Caudography with Dimer-X in the diagnosis of lumbar and sciatic pain syndromes of orthopedic interest. Report of 100 consecutive examinations]. / La caudografia con Dimer-X nella diagnostica delle sindromi lombosciatalgiche di interesse ortopedico. Consuntivo di 100 ingadini consecutive.

It was found that the employment of Dimer-X (methylglucamine jocarmate) as contrast medium greatly reduced the frequency of secondary phenomena in 100 caudographies performed in subjects with lumbar and sciatic pain syndromes of orthopaedic interest. Comparison between the clinical, caudographic and surgical findings showed how contrastography offered highly accurate information in support of the clinical diagnosis of disk compression in case of sufficiently severe lumbar and sciatic pain.