Therapeutic educational workshops for caregivers of patients with severe acquired brain injury.

Abstract: Severe acquired brain injury (sABI) leads to a wide range of functional limitations in cognitive, moto and behavioural abilities. These changes impact the patient's family in terms of the feeling of emotional and physical health, social life and financial condition. Caregivers are often intensely involved in the patient's management exposing them to negative effects of caregiving including stress, mood disorders and decreased quality of life. Implementing forms of active involvement of caregivers in the rehabilitative program could be useful. Thus, in the present study, therapeutic educational workshops (TEWs) for caregivers during the post-acute intensive hospitalization were organized during the post-acute intensive hospitalization of patients with sABI. The caregivers were asked to participate in the workshops to actively involve them in the patient's care and neurorehabilitation program. Each workshop session provided indications regarding the management of the patient with aphasia, neglect, behavioural and swallowing disorders. A questionnaire of 22 items has been designed in order to represent possible indicators of usefulness and effectiveness of the TEWs. The primary aim of this study was to develop a reliable and valid questionnaire able to assess the caregivers' satisfaction with the modalities of carrying out the TEW as a novel activity during the post-acute hospitalization of patients with sABI. The second aim was to assess the caregivers' satisfaction with the utility of the TEW as a tool to enhance their skills in the management of patients' disabilities. 100 caregivers of patients with sABI who attended at least one TEW session and completed the questionnaire were included in the analysis. In conclusion the administered questionnaire has proven to be a valid and reliable tool to evaluate sABI caregivers' satisfaction with TEW. Moreover, caregivers were satisfied with the organization of the TEW and with their usefulness in the management of the patients with sABI.

Is the patient able to watch TV or read the newspaper? A functional semi-structured scale to observe Hemineglect symptoms in Activities of Daily Living (H-ADL).

We developed a functional semi-structured scale to observe Hemineglect symptoms in Activities of Daily Living (H-ADL). The scale could assist clinicians in assessing rehabilitation priorities aimed at correcting any persisting errors or omissions. In addition, the scale could also be used by caregivers to observe patients' progress and improve their participation. Two groups of right brain-damaged patients (25 with hemineglect; 27 without hemineglect) were tested twice: at admission and before discharge from hospital. A control group of healthy individuals matched to patients for age and education and patients' caregivers also participated. Two raters (A; B), experts in neuropsychology, observed patients and healthy individuals using the H-ADL. We found that the H-ADL final scores correlated with the standard hemineglect tests. The three groups differed in performance and differences also emerged between the first and the second assessment, suggesting an improvement due to the remission of hemineglect as a consequence of the treatment. Raters A and B did not differ in their observations, but there were some discrepancies with caregivers' observations. Therefore, although caregivers could help clinicians in detecting persistent hemineglect behaviour, the assessment should be performed by experts in neuropsychology.

Retinotopic modulation of space misrepresentation in unilateral neglect: evidence from quadrantanopia.

A patient with right sided brain damage suffered contralesional neglect, inferior quadrantanopia (with 0 degrees sparing in the left eye and 13 degrees sparing in the right), and a visual field restriction (to 15 degrees ) in the upper contralesional quadrant of the left eye. In binocular vision, the patient showed underestimation of the horizontal size of contralesional line segments unless cued to localise their end points. When asked to reproduce, in monocular vision, 10 degrees and 20 degrees distances between two attentionally cued end points lying on the frontal vertical plane, the patient showed relative contralesional overextension and ipselesional underextension along the directions falling within the blind sectors of the neglected space. No asymmetry was present along the directions falling within the seeing sectors of the same space. These findings suggest precise retinotopic modulation of space misrepresentation in unilateral neglect.

Hypoxia combined with Escherichia coli produces irreversible gut mucosal injury characterized by increased intestinal cytokine production and DNA degradation.

The objective of the present study was to determine whether hypoxia/reoxygenation in the absence or presence of intestinal bacteria would affect the integrity of the gut mucosal epithelium (as evidenced by histologic changes) and increase the local production of cytokines (interleukin 6 [IL-6] and tumor necrosis factor [TNF]). Rat ileal mucosal membranes were harvested and their electrophysiologic properties and barrier function were measured ex vivo in the Ussing chamber system. Membranes were exposed to normoxia, normoxia + Escherichia coli, hypoxia for 40 min followed by normoxia, or hypoxia for 40 min + E. coli followed by normoxia for 3 h. IL-6 and TNF levels were measured using cytokine-dependent cellular assays. Morphological changes and the degree of DNA fragmentation were used as quantitative markers of gut mucosal injury. Mucosal integrity was maintained in the normoxia group. The addition of bacteria increased the IL-6 response and reduced mucosal integrity. During the hypoxic period, a transient decline in resistance (R) occurred and cytokine production was reduced. In the hypoxic ileal membranes not exposed to E coli, reoxygenation reversed the change in R and increased IL-6 production. The combination of hypoxia/reoxygenation plus E. coli bacterial challenge resulted in the greatest extent of gut mucosal injury and increase in TNF production. The results of this study support the hypothesis that the combination of increased intestinal bacterial levels superimposed on an ischemia/reperfusion injury increases the magnitude of gut mucosal injury and the production and subsequent release of proinflammatory cytokines.

Mesenteric lymph duct ligation provides long term protection against hemorrhagic shock-induced lung injury.

Recently we have shown that ligation of the main mesenteric lymph (MLN) duct prior to an episode of hemorrhagic shock (HS) prevents shock-induced lung injury. Yet, ligation or diversion of intestinal lymph immediately prior to injury is not clinically feasible. Diversion of intestinally derived lymph after injury to protect against secondary insults is possible, but it is not known how long the protective effects of lymph ligation would last. Thus, we tested whether ligation of the MLN duct seven days prior to HS would still be protective. Male Sprague-Dawley rats were subjected to laparotomy with or without MLN duct ligation. Seven days later, half of the sham and actual MLN duct ligated animals randomly were selected to undergo HS (30 mmHG for 90 min). The other half of the animals was subjected to sham shock. Lung permeability, pulmonary myeloperoxidase (MPO) activity, and bronchoalveolar fluid (BALF) protein content were used to determine lung injury. Lymphatic division 7 days prior to HS continued to prevent shock induced lung injury as assessed by a lower Evans Blue dye concentration, BALF protein and MPO activity. In addition, there was no evidence of Patent Blue dye in the previously ligated MLN duct. Since ligation of the main mesenteric lymphatic duct continues to protect against shock-induced lung injury 1 week after duct ligation, it is feasible that lymphatic ligation performed after an injury remains protective against certain secondary insults for at least 1 week.

Acute lung injury after hemorrhagic shock is dependent on gut injury and sex.

Recent studies have established gut-derived lymph rather than portal blood as the major source of toxic mediators after hemorrhagic shock that causes distant organ injury. Similarly, emerging data have identified sex as a major modifier of the response to injury and illness. Thus we tested the hypothesis that female rats would be more resistant to shock-induced lung injury than male rats because females are more resistant to shock-induced gut injury and produce mesenteric lymph that is less toxic to endothelial cells. Male and female rats were subjected to sham or hemorrhagic shock and lung permeability was quantitated by Evans blue dye and protein extravasation into the alveolar space. Next, mesenteric lymph collected from shocked and sham-shocked rats of both sexes was incubated with human umbilical vein endothelial cells (HUVECs) and assayed for toxicity. Trypan blue dye exclusion and the release of lactate dehydrogenase assessed HUVEC viability and injury respectively. Lastly, sections of the terminal ileum were histologically examined for evidence of shock-induced mucosal injury. Male rats but not female rats subjected to hemorrhagic shock had evidence of increased lung permeability and produced mesenteric lymph that was cytotoxic to HUVECs. Shock caused gut injury in the male rats whereas histological evidence of gut injury was not observed in the female rats. Hemorrhagic shock-induced lung injury depends on gut injury and mesenteric lymph appears to be the route by which gut-derived toxic factors exit the gut to cause lung injury. The resistance of female rats to shock-induced lung injury appears to be secondary to their resistance to shock-induced gut injury.

Gut-derived mesenteric lymph: a link between burn and lung injury.

BACKGROUND: Previously, we showed that mesenteric lymph generated following hemorrhagic shock increases endothelial cell permeability and contributes to lung injury. It has also been shown that lymph produced at the site of burn injury plays a role in altering pulmonary vascular hemodynamics. In addition, previous experimental work has suggested that organs and tissues distant from the injury site may contribute to pulmonary dysfunction. One explanation would be that gut-derived inflammatory factors (in addition to those produced locally at the site of injury) are reaching the pulmonary circulation, where they exert their effects via the gut lymphatics. HYPOTHESES: The 2 hypotheses herein were that (1) gut-derived factors carried in the mesenteric lymph of rats generated following thermal injury will contribute to lung injury and (2) intestinal bacterial overgrowth will potentiate the degree of burn-induced lung injury. These hypotheses were tested by examining the effect of mesenteric lymph flow interruption prior to thermal injury on burn-induced lung injury in rats with a normal intestinal bacterial flora and in rats with intestinal Escherichia coli overgrowth. These rats were termed E. coli-monoassociated rats. METHODS: Normal intestinal bacterial flora and monoassociated male Sprague-Dawley rats were subjected to sham burn, 40% total body surface area burn, or lymphatic division plus burn. After 3 hours, 10 mg of Evans blue was injected to measure lung permeability. After the rats were killed, a bronchoalveolar lavage was performed and the fluid analyzed spectrophotometrically. Bronchoalveolar lavage fluid protein content, pulmonary myeloperoxidase activity, and alveolar apoptosis served to further quantitate lung injury. RESULTS: Both normal intestinal bacterial flora and monoassociated-burned rats exhibited significant increases in lung permeability, bronchoalveolar lavage fluid protein content, myeloperoxidase activity, and alveolar apoptosis. The combination of monoassociation and thermal injury resulted in even further increases in lung injury over thermal injury alone. Lymphatic division prior to thermal injury ameliorated burn-induced increases in lung permeability, bronchoalveolar lavage fluid protein content, pulmonary myeloperoxidase accumulation, and alveolar apoptosis in both normal intestinal bacterial flora and monoassociated rats. CONCLUSIONS: The results of this study support the hypothesis that gut-derived factors carried in the mesenteric lymph contribute to burn-induced lung injury and may therefore play a role in postburn respiratory failure and suggest that intestinal bacterial overgrowth primes the host such that when animals are exposed to a second stimulus (such as thermal injury) an exaggerated response occurs.

Gut-derived mesenteric lymph but not portal blood increases endothelial cell permeability and promotes lung injury after hemorrhagic shock.

OBJECTIVE: To determine whether gut-derived factors leading to organ injury and increased endothelial cell permeability would be present in the mesenteric lymph at higher levels than in the portal blood of rats subjected to hemorrhagic shock. This hypothesis was tested by examining the effect of portal blood plasma and mesenteric lymph on endothelial cell monolayers and the interruption of mesenteric lymph flow on shock-induced lung injury. SUMMARY BACKGROUND DATA: The absence of detectable bacteremia or endotoxemia in the portal blood of trauma victims casts doubt on the role of the gut in the generation of multiple organ failure. Nevertheless, previous experimental work has clearly documented the connection between shock and gut injury as well as the concept of gut-induced sepsis and distant organ failure. One explanation for this apparent paradox would be that gut-derived inflammatory factors are reaching the lung and systemic circulation via the gut lymphatics rather than the portal circulation. METHODS: Human umbilical vein endothelial cell monolayers, grown in two-compartment systems, were exposed to media, sham-shock, or postshock portal blood plasma or lymph, and permeability to rhodamine (10K) was measured. Sprague-Dawley rats were subjected to 90 minutes of sham or actual shock and shock plus lymphatic division (before and after shock). Lung permeability, pulmonary myeloperoxidase levels, alveolar apoptosis, and bronchoalveolar fluid protein content were used to quantitate lung injury. RESULTS: Postshock lymph increased endothelial cell monolayer permeability but not postshock plasma, sham-shock lymph/plasma, or medium. Lymphatic division before hemorrhagic shock prevented shock-induced increases in lung permeability to Evans blue dye and alveolar apoptosis and reduced pulmonary MPO levels. In contrast, division of the mesenteric lymphatics at the end of the shock period but before reperfusion ameliorated but failed to prevent increased lung permeability, alveolar apoptosis, and MPO accumulation. CONCLUSIONS: Gut barrier failure after hemorrhagic shock may be involved in the pathogenesis of shock-induced distant organ injury via gut-derived factors carried in the mesenteric lymph rather than the portal circulation.

Dissociation between position sense and visual-spatial components of hemineglect through a specific rehabilitation treatment.

Current evidence suggests an association between contralesional extra-personal hemineglect, and deficits of arm position sense in patients with damage to the right cerebral hemisphere. A unitary deficit may produce both disorders, or this association may reflect the anatomical contiguity of relevant brain structures. A rehabilitation treatment, devised for visual-spatial hemineglect, was used to investigate these hypotheses in 8 patients with damage to the right cerebral hemisphere. The treatment improved hemineglect, but not the position sense deficit. The severity of the latter was however transiently reduced by optokinetic stimulation, with effects similar to those found in visual-spatial hemineglect. These effects of rehabilitation suggest that extra-personal hemineglect and the neglect-related component of the position sense disorder of the left forearm are independent, though frequently associated, deficits. Implications for the design of rehabilitation programs are discussed.

Facilitatory effect of neglect rehabilitation on the recovery of left hemiplegic stroke patients: a cross-over study.

A study of the effect of specific training for visual neglect on the recovery of motor and functional impairment in stroke patients is reported. Two groups of right hemisphere stroke patients with hemispatial neglect and one group without neglect were assessed by means of three functional and neurological scales (Rivermead Mobility Index, Barthel Index, Canadian Neurological Scale). Three evaluations were made at 0, 2 and 4 months from the beginning of physical rehabilitation. During the first 2 months of physical rehabilitation one of the two groups of neglect patients was randomly assigned to specific training for neglect, and the second group to a general cognitive intervention; during the final 2 months of rehabilitation the types of training were switched in the two groups. The non-neglect patients improved steadily during physical rehabilitation. In contrast, the functional recovery of the two neglect groups was time-locked to the period of the specific training for neglect. At the time of admission, the two neglect groups performed at the same level; after 2 months of rehabilitation, the group with neglect training showed higher functional recovery than the group with only general cognitive intervention. When the latter group received neglect training, there was no longer any difference between the two neglect groups. This pattern was present for both of the functional scales used but not for the neurological scale. Motor and functional recovery of stroke patients with neglect seems to be significantly improved by the simultaneous presence of a treatment specifically focused on neglect.

Transcutaneous electrical stimulation of the neck muscles and hemineglect rehabilitation.

In four patients with left visuo-spatial hemineglect and right brain- damage, the therapeutic effects of Transcutaneous Electrical Nervous Stimulation (TENS) of the left neck muscles, associated with a non-specific treatment, and of a specific rehabilitation paradigm were investigated. The two treatments were given for an 8-week period each. TENS had positive effects on hemineglect in two out of four patients, whereas the specific treatment produced a major improvement of the disorder in all four cases. The suggestion is made that an effective treatment of neglect requires a paradigm comprising a range of visuo-spatial exploratory tasks of increasing complexity and a systematic feedback as to the success of the patients' performance. This is the case of the specific treatment. By contrast a procedure confined to a sensory stimulation, which produces a short-term improvement in the range of minutes, does not have comparable long-term effects. © 1996 Elsevier Science Ireland Ltd. All rights reserved.

Optokinetic stimulation affects both vertical and horizontal deficits of position sense in unilateral neglect.

The effects of optokinetic stimulation on the disorders of position sense in the horizontal and vertical planes were assessed in 24 patients with unilateral cerebral lesions (eight right brain-damaged patients with visuo-spatial hemineglect, eight right brain-damaged patients without neglect, eight left brain-damaged patients without neglect). In neglect patients, the position sense disorder was more severe, and affected by optokinetic stimulation in a direction-specific fashion. In both the horizontal and the vertical plane, and in both arms, stimulation with a direction of the movement contralateral to the side of the lesion improved the disorder, whereas stimulation with an ipsilateral direction worsened the deficit. The suggestion is made that in patients with neglect the disorder of position sense is produced, at least in part, by an ipsilateral distortion of an egocentric co-ordinate system, comprising both the horizontal and the vertical dimension, which may be affected by direction-specific optokinetic stimuli.

Effectiveness of neglect rehabilitation in a randomized group study.

The effectiveness of neglect rehabilitation training has been studied in two randomly selected groups of right brain-damaged patients. All patients proved heminattentive on a standard battery 2 months or more after the CVA. One group received 2 months of treatment immediately after admission to a clinic, and the other group received only general cognitive stimulation for the same amount of time. At the end of this period a comparison showed significant improvement in the first group, based on a standard test battery and a functional scale. The second group was then given rehabilitation training for neglect for the same amount of time and obtained similar improvement. It is concluded that the rehabilitation program produces significant results, which generalize to situations similar to those of everyday life. The importance of the duration of training on the generalization of learning is briefly discussed with reference to previous negative reports in the literature.