Loss of Personal Autonomy and Dignity-Related Distress in End-Of-Life Cancer Patients.

The objective of this cross-sectional study is to investigate Dignity-Related Loss of Personal Autonomy (DR-LPA) intended as loss of relational independence causing dignity-related distress. Moreover, it analyzes its possible relationships with demoralization, spirituality, quality of life, hope, and coping styles in a sample composed of 207 end-of-life cancer patients. These variables have been assessed through the following rating scales: Patient Dignity Inventory - Italian version, Demoralization Scale - Italian version, Functional Assessment of Cancer Therapy Scale - General Measure, Functional Assessment of Chronic Illness Therapy - Spiritual Well-Being, Brief Coping Orientation to Problem Experienced, and Herth Hope Index. The results have shown that most of the DR-LPA items were considered a problem by most patients. Functional, social, emotional, and spiritual wellbeing, disheartenment, age, and sex emerged as significant predictors of DR-LPA. In conclusion, this study showed that DR-LPA can be a relevant concern for patients at the end-of-life and for this reason it becomes necessary for psychosocial provides to consider it to deliver better dignity conserving care.

Re-learning mental representation of walking after a brain lesion. Effects of a cognitive-motor training with a robotic orthosis.

Introduction: Stroke-related deficits often include motor impairments and gait dysfunction, leading to a limitation of social activities and consequently affecting the quality of life of stroke survivors. Neurorehabilitation takes advantage of the contribution of different techniques in order to achieve more benefits for patients. Robotic devices help to improve the outcomes of physical rehabilitation. Moreover, motor imagery seems to play a role in neurological rehabilitation since it leads to the activation of the same brain areas as actual movements. This study investigates the use of a combined physical and cognitive protocol for gait rehabilitation in stroke patients. Methods: Specifically, we tested the efficacy of a 5-week training program using a robotic orthosis (P.I.G.R.O.) in conjunction with motor imagery training. Twelve chronic stroke patients participated in the study. We evaluated balance and gait performance before and after the training. Six of them underwent fMRI examination before and after the training to assess the effects of the protocol on brain plasticity mechanisms in motor and imagery tasks. Results: Our results show that the rehabilitation protocol can effectively improve gait performance and balance and reduce the risk of falls in stroke patients. Furthermore, the fMRI results suggest that rehabilitation is associated with cerebral plastic changes in motor networks. Discussion: The present findings, if confirmed by future research, have the potential to advance the development of new, more effective rehabilitation approaches for stroke patients, improving their quality of life and reducing the burden of stroke-related disability.

Alexithymia and Depression Affect Quality of Life in Patients With Chronic Pain: A Study on 205 Patients With Fibromyalgia.

Pain in fibromyalgia (FM) is accompanied by a heterogeneous series of other symptoms, which strongly affect patients' quality of life and interfere with social and work performance. The present study aimed to evaluate the effects of alexithymia on both the physical and the psychosocial components of the health-related quality of life (HRQoL) of FM patients, controlling for the concomitant effects of depression, anxiety, and pain. In particular, given the strong interconnection between depression and alexithymia, the relationship between alexithymia and HRQoL as mediated by depressive symptoms was further investigated. Data were collected on a consecutive sample of 205 female patients with a main diagnosis of FM. The results showed that about 26% of the patients showed the presence of alexithymia, as assessed by the Toronto Alexithymia Scale (TAS-20). Clinically relevant levels of depressive and anxiety symptoms were present in 61 and 60% of the patients, respectively. The results of the hierarchical multiple regression analyses showed that pain intensity (PI) and depressive symptoms explained the 45% of the variance of the physical component of HRQoL (p < 0.001). Regarding the mental component of HRQoL, depressive and anxiety symptoms, alexithymia, and PI significantly explained 61% of the variance (p < 0.001). The mediation analyses confirmed that alexithymia had a direct effect on the mental component of HRQoL and showed a statistically significant indirect effect on both the physical and the mental components, through the mediation of depressive symptoms. In conclusion, the results of the present study suggested the presence of both a direct and an indirect effect of alexithymia, in particular of the difficulty identifying feeling, on the HRQoL of patients with FM. Indeed, even though the concomitant presence of depressive symptoms is responsible of an indirect effect, alexithymia per se seems to directly contribute to worsen the impact that this chronic pain pathology has on the patients' quality of life, especially regarding the psychosocial functioning.

Concomitant Use of Transcranial Direct Current Stimulation and Computer-Assisted Training for the Rehabilitation of Attention in Traumatic Brain Injured Patients: Behavioral and Neuroimaging Results.

Divided attention (DA), the ability to distribute cognitive resources among two or more simultaneous tasks, may be severely compromised after traumatic brain injury (TBI), resulting in problems with numerous activities involved with daily living. So far, no research has investigated whether the use of non-invasive brain stimulation associated with neuropsychological rehabilitation might contribute to the recovery of such cognitive function. The main purpose of this study was to assess the effectiveness of 10 transcranial direct current stimulation (tDCS) sessions combined with computer-assisted training; it also intended to explore the neural modifications induced by the treatment. Thirty-two patients with severe TBI participated in the study: 16 were part of the experimental group, and 16 part of the control group. The treatment included 20' of tDCS, administered twice a day for 5 days. The electrodes were placed on the dorso-lateral prefrontal cortex. Their location varied across patients and it depended on each participant's specific area of damage. The control group received sham tDCS. After each tDCS session, the patient received computer-assisted cognitive training on DA for 40'. The results showed that the experimental group significantly improved in DA performance between pre- and post-treatment, showing faster reaction times (RTs), and fewer omissions. No improvement was detected between the baseline assessment (i.e., 1 month before treatment) and the pre-training assessment, or within the control group. Functional magnetic resonance imaging (fMRI) data, obtained on the experimental group during a DA task, showed post-treatment lower cerebral activations in the right superior temporal gyrus (BA 42), right and left middle frontal gyrus (BA 6), right postcentral gyrus (BA 3) and left inferior frontal gyrus (BA 9). We interpreted such neural changes as normalization of previously abnormal hyperactivations.

Are fibromyalgia patients cognitively impaired? Objective and subjective neuropsychological evidence.

OBJECTIVE: Patients with fibromyalgia (FM) syndrome often report a cluster of cognitive disorders that strongly interferes with their work and daily life, but the relationship between impaired cognitive function and self-reported dysfunction remains unclear. We aimed to investigate the presence of cognitive impairments in patients with FM and to analyze the relationship between the impairments and their evaluation by the patients through a comparison with a group of healthy controls. METHODS: In total, 30 FM patients and 30 healthy controls performed a neuropsychological and clinical evaluation of short-term, long-term, and working memory; executive function; and self-evaluation of cognitive impairment and depressive and anxiety symptoms. To thoroughly investigate executive function, we adopted the Miyake model that identifies 4 domains: shifting, inhibition, updating, and access. RESULTS: Our results confirmed the presence of impairments of attention, long-term memory, working memory, and shifting and updating executive functions in FM patients compared with healthy controls. These impairments are reflected in patient reports independently of depressive symptoms. CONCLUSION: The use of a self-reported questionnaire in clinical practice would provide a first and easy screen for the presence of cognitive impairment in FM patients and, in most cases, obviate the need for a time-consuming full neuropsychological test battery.

Once you feel it, you see it: insula and sensory-motor contribution to visual awareness for fearful bodies in parietal neglect.

The interplay between the neural mechanisms of visual awareness and those involved in emotion processing and the mapping of related somatic changes remains unclear. To address this issue we studied one patient with visual extinction following right parietal damage, in a combined behavioral, psychophysiological and neuroimaging experiment. Patient M.P. was presented with neutral and fearful bodily expressions, either unilaterally in the left (LVF) or right visual field (RVF), or in both visual fields simultaneously. Fearful expressions presented in the left visual field simultaneously with neutral bodies in the RVF were detected more often than left-side neutral bodies. Signal detection analysis showed that the preferential access of fearful bodies to visual awareness is related to higher perceptual sensitivity for these stimuli during attentional competition. Pupil dilation, which indexes autonomic arousal, increased for fearful more than for neutral bodies. Moreover, dilation for extinguished fearful bodies was bigger than for consciously perceived fearful bodies. This decoupling between (increased) arousal and (lack of) conscious visual experience argues against a direct relationship between visual awareness of emotional signals and peripheral changes. Neuroimaging results showed that fearful bodies activated the left amygdala and extrastriate cortex when consciously perceived as well as when extinguished. Critically, however, conscious perception of fearful bodies was uniquely associated with activity in the anterior insula, somatosensory, motor and premotor cortex (PMC), and the cerebellum. This suggests that the integration between peripheral arousal and the moment-to-moment mapping at the central neural level of these bodily changes is critical for the conscious visual experience of emotional signals.

Crossing the line of pain: FMRI correlates of crossed-hands analgesia.

UNLABELLED: Crossing the hands over the body midline reduces the perceived intensity of nociceptive stimuli applied to the hands by impairing the ability to localize somatosensory stimuli. The neural basis of this "crossed-hands analgesia" has not been investigated previously, although it has been proposed that the effect may be modulated by multimodal areas. We used functional magnetic resonance imaging to test the hypothesis that crossed-hands analgesia is mediated by higher-order multimodal areas rather than by specific somatosensory ones. Participants lay in the scanner while mechanical painful stimuli were applied to their hands held in either a crossed or uncrossed position. They reported significantly lower perceived intensity of pain when their hands were crossed. Although activations elicited by stimuli applied to the crossed hands revealed significantly greater blood oxygen level-dependent responses in the anterior cingulate cortex, the insula, and the medial frontal gyrus, the blood oxygen level-dependent responses in the superior parietal lobe were greater with the hands uncrossed. Our results provide evidence that crossed-hands analgesia is mediated by higher-order frontoparietal multimodal areas involved in sustaining and updating body and spatial representations. PERSPECTIVE: We found crossed-hands analgesia to be mediated by multimodal areas, such as the posterior parietal, cingulate, and insular cortices, implicated in space and body representation. Our findings highlight how the perceived intensity of painful stimuli is shaped by how we represent our body and the space surrounding it.

Unawareness of deficits in Alzheimer's disease: role of the cingulate cortex.

Unawareness of deficits is a symptom of Alzheimer's disease that can be observed even in the early stages of the disease. The frontal hypoperfusion associated with reduced awareness of deficits has led to suggestions of the existence of a hypofunctioning prefrontal pathway involving the right dorsolateral prefrontal cortex, inferior parietal lobe, anterior cingulate gyri and limbic structures. Since this network plays an important role in response inhibition competence and patients with Alzheimer's disease who are unaware of their deficits exhibit impaired performance in response inhibition tasks, we predicted a relationship between unawareness of deficits and cingulate hypofunctionality. We tested this hypothesis in a sample of 29 patients with Alzheimer's disease (15 aware and 14 unaware of their disturbances), rating unawareness according to the Awareness of Deficit Questionnaire-Dementia scale. The cognitive domain was investigated by means of a wide battery including tests on executive functioning, memory and language. Neuropsychiatric aspects were investigated using batteries on behavioural mood changes, such as apathy and disinhibition. Cingulate functionality was assessed with functional magnetic resonance imaging, while patients performed a go/no-go task. In accordance with our hypotheses, unaware patients showed reduced task-sensitive activity in the right anterior cingulate area (Brodmann area 24) and in the rostral prefrontal cortex (Brodmann area 10). Unaware patients also showed reduced activity in the right post-central gyrus (Brodmann area 2), in the associative cortical areas such as the right parietotemporal-occipital junction (Brodmann area 39) and the left temporal gyrus (Brodmann areas 21 and 38), in the striatum and in the cerebellum. These findings suggest that the unawareness of deficits in early Alzheimer's disease is associated with reduced functional recruitment of the cingulofrontal and parietotemporal regions. Furthermore, in line with previous findings, we also found apathy and disinhibition to be prominent features of the first behavioural changes in unaware patients.

Functional connectivity and coactivation of the nucleus accumbens: a combined functional connectivity and structure-based meta-analysis.

This article investigates the functional connectivity patterns of the nucleus accumbens (NAcc) in 18 healthy participants using a resting state functional connectivity (rsFC) protocol. Also, a meta-analytic connectivity modeling (MACM) was used to characterize patterns of functional coactivations involving NAcc: The results of a structure-based meta-analyses of 57 fMRI and PET studies were submitted to activation likelihood estimation analysis to estimate consistent activation patterns across the different imaging studies. The results of the combined rsFC and MACM analyses show that spontaneous activity in NAcc predicts activity in regions implicated in reward circuitries, including orbitomedial prefrontal cortex, globus pallidus, thalamus, midbrain, amygdala, and insula. This confirms the key role of NAcc in the mesocorticolimbic system, which integrates inputs from limbic and cortical regions. We also detected activity in brain regions having few or no direct anatomical connections with NAcc, such as sensorimotor cortex, cerebellum, medial and posterior parietal cortex, and medial/inferior temporal cortex, supporting the view that not all functional connections can be explained by anatomical connections but can also result from connections mediated by third areas. Our rsFC findings are in line with the results of the structure-based meta-analysis: MACM maps are superimposable with NAcc rsFC results, and the reward paradigm class is the one that most frequently generates activation in NAcc. Our results overlap considerably with recently proposed schemata of the main neuron systems in the limbic forebrain and in the anterior part of the limbic midbrain in rodents and nonhuman primates.

Altered resting state in diabetic neuropathic pain.

BACKGROUND: The spontaneous component of neuropathic pain (NP) has not been explored sufficiently with neuroimaging techniques, given the difficulty to coax out the brain components that sustain background ongoing pain. Here, we address for the first time the correlates of this component in an fMRI study of a group of eight patients suffering from diabetic neuropathic pain and eight healthy control subjects. Specifically, we studied the functional connectivity that is associated with spontaneous neuropathic pain with spatial independent component analysis (sICA). PRINCIPAL FINDINGS: Functional connectivity analyses revealed a cortical network consisting of two anti-correlated patterns: one includes the left fusiform gyrus, the left lingual gyrus, the left inferior temporal gyrus, the right inferior occipital gyrus, the dorsal anterior cingulate cortex bilaterally, the pre and postcentral gyrus bilaterally, in which its activity is correlated negatively with pain and positively with the controls; the other includes the left precuneus, dorsolateral prefrontal, frontopolar cortex (both bilaterally), right superior frontal gyrus, left inferior frontal gyrus, thalami, both insulae, inferior parietal lobuli, right mammillary body, and a small area in the left brainstem, in which its activity is correlated positively with pain and negatively with the controls. Furthermore, a power spectra analyses revealed group differences in the frequency bands wherein the sICA signal was decomposed: patients' spectra are shifted towards higher frequencies. CONCLUSION: In conclusion, we have characterized here for the first time a functional network of brain areas that mark the spontaneous component of NP. Pain is the result of aberrant default mode functional connectivity.