Restoring consciousness with vagus nerve stimulation.

Patients lying in a vegetative state present severe impairments of consciousness [1] caused by lesions in the cortex, the brainstem, the thalamus and the white matter [2]. There is agreement that this condition may involve disconnections in long-range cortico-cortical and thalamo-cortical pathways [3]. Hence, in the vegetative state cortical activity is 'deafferented' from subcortical modulation and/or principally disrupted between fronto-parietal regions. Some patients in a vegetative state recover while others persistently remain in such a state. The neural signature of spontaneous recovery is linked to increased thalamo-cortical activity and improved fronto-parietal functional connectivity [3]. The likelihood of consciousness recovery depends on the extent of brain damage and patients' etiology, but after one year of unresponsive behavior, chances become low [1]. There is thus a need to explore novel ways of repairing lost consciousness. Here we report beneficial effects of vagus nerve stimulation on consciousness level of a single patient in a vegetative state, including improved behavioral responsiveness and enhanced brain connectivity patterns.

Care management of the agitation or aggressiveness crisis in patients with TBI. Systematic review of the literature and practice recommendations.

UNLABELLED: The agitation crisis in the awakening phase after traumatic brain injury (TBI) is one of the most difficult behavioral disorders to alleviate. Current treatment options are heterogeneous and may involve excessive sedation. Practice guidelines are required by professionals in charge of TBI patients. Few reviews were published but those are old and based on expert opinions. The purpose of this work is to propose evidence-based guidelines to treat the agitation crisis. METHODS: The elaboration of these guidelines followed the procedure validated by the French health authority for good practice recommendations, close to the Prisma statement. Guidelines were elaborated on the basis of a systematic and critical review of the literature. RESULTS: Twenty-eight articles concerning 376 patients were analyzed. Recommendations are: when faced with an agitation crisis, the management strategy implies to search for an underlying factor that should be treated such as pain, acute sepsis, and drug adverse effect (expert opinion). Physical restraints should be discarded when possible (expert opinion). Neuroleptic agent with a marketing authorization can be used in order to obtain a quick sedation so as to protect the patient from himself, closed ones or the healthcare team but the duration should be as short as possible (expert opinion). The efficacy of beta-blockers and antiepileptics with mood regulation effects like carbamazepine and valproate yield the most compelling evidence and should be preferably used when a background regimen is envisioned (grade B for beta-blocker and C for antiepileptics). Neuroleptics, antidepressants, benzodiazepines, buspirone may be prescribed but are considered second-line treatments (expert opinion). CONCLUSION: This study provides a strategy for treating the agitation crisis based on scientific data and expert opinion. The level of evidence remains low and published data are often old. New studies are essential to validate results from previous studies and test new drugs and non-pharmaceutical therapies.

[The organization of a post-intensive care rehabilitation unit]. / L'organisation d'un service de rééducation post-réanimation.

When a patient is admitted to a post-intensive care rehabilitation unit, the functional outcome is the main objective of the care. The motivation of the team relies on strong cohesion between professionals. Personalised support provides a heightened observation of the patient's progress. Listening and sharing favour a relationship of trust between the patient, the team and the families.

Let live or let die after traumatic coma: Scrutinizing somatosensory evoked potentials.

It is now firmly established that bilateral abolition of somatosensory evoked potentials (SEPs) after a nontraumatic coma has 100% specificity for nonawakening. In traumatic coma, a bilateral absence of the N20 components of SEPs does not implicate nonawareness. Comatose brain-injured patients should be systematically explored with auditory evoked potentials to check the functional integrity of another sensory pathway and the mesencephalic tegmento-tectal region on cerebral MRI should be carefully examined. Repeated evaluations during follow-up are also mandatory.

Degeneration of the Arnold's prefrontopontocerebellar tract in a case of locked-in syndrome over a 23-year period.

A 52-year-old woman has been under observation for a complete locked-in syndrome of vascular origin, since 1984. Her cognitive functions today are still normal. When first diagnosed, a CT-scan was made and 23 years later performed, a cerebral MRI was performed. A focal, bilateral and symmetric atrophy of the dorsomedial prefrontal gyri was clearly shown, contrasting with the non-atrophy of the precentral gyri (motor area), others prefrontal areas, frontopolar gyri and temporal cortices. Degeneration of the corticopontine projection, the first step in the corticopontocerebellar circuit, could explain this selective atrophy. This unique observation leads to the precise in vivo anatomical location of the Arnold tract.

Efficacy and tolerability of hyaluronan (ialuset) in the treatment of pressure ulcers: a multicentre, non-randomised, pilot study.

BACKGROUND: Pressure ulcers are complex chronic wounds and a frequent cause of morbidity in elderly subjects in hospitals and nursing homes. Local treatment is based on the use of dressings that protect the wound and provide a favourable environment for healing to occur. ialuset, a treatment based on hyaluronan (hyaluronic acid), is already available on the market and known to be an effective treatment for venous leg ulcers. However, no clinical trials of hyaluronan as a treatment option for pressure ulcers have been reported as yet. METHODS: The purpose of this review was to investigate the efficacy and tolerability of ialuset in the treatment of pressure ulcers. To this end, this article reports data from 21 predominantly elderly patients with National Pressure Ulcer Advisory Panel grade II, III or IV pressure ulcers treated with ialuset cream or gauze pads over a 3-week period in ten hospitals in France. RESULTS: A significant median decrease of 4cm2 in the surface area of treated wounds was observed after 3 weeks of ialuset use (p < 0.05 vs baseline). A >or=50% reduction in pressure ulcer surface area was seen in 65.0% of patients (95% CI 44.8, 84.3). Nine patients (45%) showed a >or=50% increase in epithelial surface compared with the initial lesion. Patient-reported pain appeared to decrease during the 3-week treatment period, although this decrease did not quite reach statistical significance (p = 0.07). Additionally, a significant decrease in the mean percentage of fibrous tissue in the wound was observed (p = 0.02), as was a non-significant increase in granulation tissue (p = 0.1). General efficacy was considered as good or very good for nearly all patients on review of the data (19/20 patients as assessed by clinicians). Overall tolerability was also considered good or very good in 12/15 assessments by patients at day 21. CONCLUSION: These preliminary findings suggest that ialuset is a promising option in the treatment of pressure ulcers; however, further investigation in the form of large, randomised clinical trials is required before firm conclusions can be drawn regarding the efficacy and tolerability of this treatment in this context.

Late auditory and event-related potentials can be useful to predict good functional outcome after coma.

OBJECTIVE: To investigate whether late auditory and event-related potentials, and in particular N100 and mismatch negativity, together with clinical parameters, can help to predict good functional outcome in comatose patients. DESIGN: Prospective cohort study. SETTING: Hospital. PARTICIPANTS: Consecutively sampled comatose patients (N=346) whose etiologies of coma were stroke (125 patients), brain injury (96 patients), anoxia (64 patients), complication of neurosurgery (54 patients), and encephalitis (7 patients). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Glasgow Outcome Scale score at 1 year postonset. Patients in a minimally conscious state and those who awoke and died during the follow-up period were classified separately. RESULTS: Univariate analysis showed that all variables studied, except brainstem auditory evoked potentials, correlated significantly with functional outcome. Mismatch negativity showed the highest positive predictive value for good outcome. A validated model was obtained with multivariate logistic analysis, including pupillary light reflex, N100, mismatch negativity, etiology, and age. CONCLUSIONS: Late auditory and event-related potentials, and particularly N100 and mismatch negativity, provide strong prognostic factors for good functional outcome. Furthermore, these components may enhance the accuracy of prognosis when associated with other clinical parameters available at the early stage of coma.