Electroencephalographic findings among inpatients with COVID-19 in a tertiary hospital from a middle-income country.

BACKGROUND: In 2019, the world witnessed the emergence of a new type of coronavirus - the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). The spectrum of coronavirus disease 2019 (COVID-19) is variable, and amongst its manifestations are neurological implications. OBJECTIVE: This report aimed to describe electroencephalographic findings in COVID-19 patients from a general tertiary hospital in São Paulo, Brazil. METHODS: It was a retrospective, observational, and non-interventional study. Data were collected anonymously, comprising inpatients from Mar 1 to Jun 30, 2020, either confirmed (positive RT-PCR) or probable cases (CO-RADS 4/5) who had performed EEG during hospitalization. RESULTS: Twenty-eight patients were enrolled, 17 (60.7%) women and 11 men, with a median age of 58 (minimum and maximum: 18-86; IQR 23.5). COVID-19 diagnosis was confirmed in 22 (78.5%). Twenty-one patients (75%) had severe disease, requiring mechanical ventilation due to acute respiratory distress syndrome (ARDS); 16 (57.1%) patients developed adjunct sepsis throughout hospitalization. There was no specific pattern found for COVID-19 in EEG. No patients presented with status epilepticus or electrographic events; most patients developed an encephalopathic pattern, as seen in most studies, with a high prevalence of altered mental status as an indication for EEG. Adjunct sepsis was associated with higher mortality. CONCLUSIONS: EEG presents as a useful tool in the context of COVID-19, as in other conditions, to differentiate nonconvulsive status epilepticus (NCSE) from encephalopathy and other causes of mental status alterations. Further studies are required to analyze whether there might be a specific EEG pattern to the disease.

Fields of Forel Brain Stimulation Improves Levodopa-Unresponsive Gait and Balance Disorders in Parkinson's Disease.

BACKGROUND: Gait and balance disturbance are challenging symptoms in advanced Parkinson's disease (PD). Anatomic and clinical data suggest that the fields of Forel may be a potential surgical target to treat these symptoms. OBJECTIVE: To test whether bilateral stimulation centered at the fields of Forel improves levodopa unresponsive freezing of gait (FOG), balance problems, postural instability, and falls in PD. METHODS: A total of 13 patients with levodopa-unresponsive gait disturbance (Hoehn and Yahr stage ≥3) were included. Patients were evaluated before (on-medication condition) and 1 yr after surgery (on-medication-on-stimulation condition). Motor symptoms and quality of life were assessed with the Unified Parkinson's Disease Rating scale (UPDRS III) and Quality of Life scale (PDQ-39). Clinical and instrumented analyses assessed gait, balance, postural instability, and falls. RESULTS: Surgery improved balance by 43% (95% confidence interval [CI]: 21.2-36.4 to 35.2-47.1; P = .0012), reduced FOG by 35% (95% CI: 15.1-20.3 to 8.1-15.3; P = .0021), and the monthly number of falls by 82.2% (95% CI: 2.2-6.9 to -0.2-1.7; P = .0039). Anticipatory postural adjustments, velocity to turn, and postural sway measurements also improved 1 yr after deep brain stimulation (DBS). UPDRS III motor scores were reduced by 27.2% postoperatively (95% CI: 42.6-54.3 to 30.2-40.5; P < .0001). Quality of life improved 27.5% (95% CI: 34.6-48.8 to 22.4-37.9; P = .0100). CONCLUSION: Our results suggest that DBS of the fields of Forel improved motor symptoms in PD, as well as the FOG, falls, balance, postural instability, and quality of life.

Subthalamic Nucleus Deep Brain Stimulation Lessens Acquired Dystonia: Report of Two Patients and Systematic Review of Published Cases.

INTRODUCTION: Deep brain stimulation (DBS) of the subthalamic nucleus (STN) is an efficient treatment of primary dystonia. Few studies have reported the effect of STN-DBS on secondary or acquired dystonia. METHODS: We reported 2 patients with acquired dystonia treated by subthalamic DBS and followed up for 24 months, besides providing a systematic review and meta-analysis of published series. RESULTS/CONCLUSIONS: Both patients had thalamic vascular or autoimmune lesions within the ventral and the pulvinar nuclei. A reduction of 67.2% on the Burke-Fahn-Marsden Dystonia Rating Scale and 90% improvement in disability scores were shown in the first patient, while the second patient showed a lower reduction in both dystonia symptoms (28.6%) and disability scores (44%). Both patients had a significant mean improvement in the quality of life (62.5% in the first and 57.9% in the second) and were free of drugs postoperatively. A systematic review showed a mean follow-up of 13 months in 19 patients, including our 2 patients. The review showed a significant Burke-Fahn-Marsden Dystonia Scale (BFMDRS) score median reduction of 19 points (52.4%; confidence interval [CI]: 11.0-25.0) and a significant median reduction of 6 points in disability scores (44.5%; 95% CI: 4.0-14.0), thereby improving quality of life. Age at surgery was inversely correlated with postoperative improvement (r = 0.63; p = 0.039). Hemidystonia had a nonsignificant better improvement than generalized dystonia (55.3 vs. 43.5%; p = 0.4433). No association between etiology and postoperative improvement and no serious complications were found. Although few data reported so far, subthalamic DBS is likely efficient for acquired dystonia.

Electroencephalographic findings among inpatients with COVID-19 in a tertiary hospital from a middle-income country / Achados eletroencefalográficos entre pacientes internados com COVID-19 em um hospital terciário de um país em desenvolvimento

ABSTRACT Background: In 2019, the world witnessed the emergence of a new type of coronavirus - the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). The spectrum of coronavirus disease 2019 (COVID-19) is variable, and amongst its manifestations are neurological implications. Objective: This report aimed to describe electroencephalographic findings in COVID-19 patients from a general tertiary hospital in São Paulo, Brazil. Methods: It was a retrospective, observational, and non-interventional study. Data were collected anonymously, comprising inpatients from Mar 1 to Jun 30, 2020, either confirmed (positive RT-PCR) or probable cases (CO-RADS 4/5) who had performed EEG during hospitalization. Results: Twenty-eight patients were enrolled, 17 (60.7%) women and 11 men, with a median age of 58 (minimum and maximum: 18-86; IQR 23.5). COVID-19 diagnosis was confirmed in 22 (78.5%). Twenty-one patients (75%) had severe disease, requiring mechanical ventilation due to acute respiratory distress syndrome (ARDS); 16 (57.1%) patients developed adjunct sepsis throughout hospitalization. There was no specific pattern found for COVID-19 in EEG. No patients presented with status epilepticus or electrographic events; most patients developed an encephalopathic pattern, as seen in most studies, with a high prevalence of altered mental status as an indication for EEG. Adjunct sepsis was associated with higher mortality. Conclusions: EEG presents as a useful tool in the context of COVID-19, as in other conditions, to differentiate nonconvulsive status epilepticus (NCSE) from encephalopathy and other causes of mental status alterations. Further studies are required to analyze whether there might be a specific EEG pattern to the disease.

RESUMO Antecedentes: Em 2019, testemunhou-se o surgimento de um novo tipo de coronavírus - o coronavírus associado à síndrome da angústia respiratória tipo 2 (SARS-CoV-2). O espectro da doença associada ao novo coronavírus, a COVID-19, é variável e, dentre suas manifestações, há implicações neurológicas. Objetivos: O presente estudo objetivou descrever achados eletroencefalográficos em pacientes com COVID-19 internados em um hospital terciário em São Paulo. Métodos: Tratou-se de estudo observacional, retrospectivo e não-intervencionista, realizado por meio de coleta anônima e retrospectiva de dados de prontuário médico de pacientes com diagnóstico confirmado (RT-PCR positivo) ou provável (CO-RADS 4 ou 5), que realizaram eletroencefalograma durante internação hospitalar. Resultados: Vinte e oito pacientes foram elencados, 17 (60,7%) mulheres e 11 homens. O diagnóstico de COVID-19 foi confirmado em 22 (78,5%) dos casos. Dos pacientes, 21 (75%) apresentaram a doença, requerendo suporte ventilatório, e 16 (57,1%) desenvolveram sepse sobreposta. Não houve padrão específico de EEG para COVID-19, e nenhum paciente apresentou estado de mal epiléptico ou crise eletrográfica; a maioria desenvolveu padrão de encefalopatia, com alentecimento da atividade cerebral, sendo a alta prevalência de alteração de estado mental a indicação para o exame. A sepse sobreposta foi associada a um pior desfecho, com maior mortalidade. Conclusão: No contexto da COVID-19, o EEG figura como ferramenta importante, auxiliando, como em outras condições, na diferenciação entre estado de mal epiléptico, encefalopatia e outras causas de alteração do estado mental. Estudos adicionais são necessários para avaliar a existência de padrão específico de alteração eletroencefalográfica na COVID-19.

Perspectives of organizational identity in a health higher education institution: a mixed-method analysis.

BACKGROUND: Among the processes to be experienced by any organization during its establishment is the formation of an organizational identity. This process can be understood as the activity and event through which an organization becomes unique in the mind of its members. An organizational identity leads to an identification and both are directly associated with the success of an institution. This study is about a public higher education institution in health in its early years, with distinctive characteristics in the country where it is situated. In spite of having been successful in the graduation of its students it has fragile institutional bases, lack of autonomy and internal problems common to other institutions of this type. Thus, this study was conducted to understand how this institution defined itself among its own members, the elements of its identity and what justified its relative success despite its weaknesses. METHODS: A mixed-method approach was used to evaluate how a representative portion of this organization identifies with it. For the qualitative study two focus groups were conducted with transcripts submitted to content analysis proposed by Bardin, culminating in results from which a Likert scale-based questionnaire was elaborated and applied to 297 subjects. RESULTS: There were six central elements of the organizational identity made evident by the focus groups: political / ideological conflict; active teaching and learning methodologies; location / separation of campuses; time of existence; teaching career; political-administrative transformations. The quantitative analysis revealed in more detail the general impressions raised in the focus groups. Most results were able to demonstrate distinct identifications of the same identity with its exposed weaknesses. CONCLUSIONS: Lack of autonomy, administrative and structural shortcomings and ideological or political conflicts presented themselves as problems capable of destabilizing the identity of a public higher education institution. On the other hand, one way to combat such problems is through the development of the institution itself, particularly by becoming more active and useful to the community and seeking in a common interest to the higher administration agencies.

Acute Disseminated Encephalomyelitis in COVID-19: presentation of two cases and review of the literature.

BACKGROUND: Neurological manifestations of COVID-19 are still incompletely understood. Neurological manifestations may be due to direct viral effect on neurons and glial cells, to an immune-mediated response to the virus, or to a hypercoagulable state and associated endothelial damage, as well as to severe systemic disease with prolonged intensive care unit stay. OBJECTIVE: To describe two patients with severe SARS-CoV-2 infection and delayed recovery of consciousness after sedation withdrawal, in whom MRI disclosed multifocal white matter brain lesions, compatible with the diagnosis of acute disseminated encephalomyelitis. METHODS: Observational report of two cases of severe COVID-19 infection in patients from two tertiary hospitals in São Paulo, Brazil. RESULTS: These patients underwent neurologic and systemic evaluation for delayed awakening after sedation withdrawal. MRI displayed multifocal centrum semiovale lesions, suggestive of demyelinating inflammation. Cerebrospinal fluid (CSF) polymerase chain reaction (PCR) for SARS-CoV-2 was negative in both cases. CONCLUSION: A recurrent pattern of multifocal white matter lesions can occur in COVID-19 patients, possibly associated with delayed awakening. Additional studies are necessary to elucidate the role of the viral infection and of inflammatory and immune-mediated associated changes in neurological manifestations of COVID-19.

Acute Disseminated Encephalomyelitis in COVID-19: presentation of two cases and review of the literature / Encefalomielite disseminada aguda associada a COVID-19: relato de dois casos e revisão de literatura

ABSTRACT Background: Neurological manifestations of COVID-19 are still incompletely understood. Neurological manifestations may be due to direct viral effect on neurons and glial cells, to an immune-mediated response to the virus, or to a hypercoagulable state and associated endothelial damage, as well as to severe systemic disease with prolonged intensive care unit stay. Objective: To describe two patients with severe SARS-CoV-2 infection and delayed recovery of consciousness after sedation withdrawal, in whom MRI disclosed multifocal white matter brain lesions, compatible with the diagnosis of acute disseminated encephalomyelitis. Methods: Observational report of two cases of severe COVID-19 infection in patients from two tertiary hospitals in São Paulo, Brazil. Results: These patients underwent neurologic and systemic evaluation for delayed awakening after sedation withdrawal. MRI displayed multifocal centrum semiovale lesions, suggestive of demyelinating inflammation. Cerebrospinal fluid (CSF) polymerase chain reaction (PCR) for SARS-CoV-2 was negative in both cases. Conclusion: A recurrent pattern of multifocal white matter lesions can occur in COVID-19 patients, possibly associated with delayed awakening. Additional studies are necessary to elucidate the role of the viral infection and of inflammatory and immune-mediated associated changes in neurological manifestations of COVID-19.

RESUMO Introdução: As manifestações neurológicas causadas pela COVID-19 ainda não estão completamente elucidadas. O comprometimento neurológico pode decorrer de um efeito viral direto em neurônios ou em células gliais, a efeito imunomediado em resposta à infecção viral, ou de um efeito secundário a estados de hipercoagulabilidade e danos endoteliais, assim como decorrente de complicações sistêmicas graves relacionadas a cuidados intensivos prolongados na unidade de terapia intensiva. Objetivo: Descrever dois pacientes com recuperação tardia do nível de consciência após a retirada da sedação associados à infecção grave pelo SARS-CoV-2, que apresentaram lesões multifocais de substância branca, compatíveis com o diagnóstico de encefalomielite disseminada aguda. Métodos: Estudo observacional, com relato de dois casos de infecção grave pela COVID-19, em dois hospitais terciários na cidade de São Paulo, Brasil. Resultados: Os pacientes foram submetidos à investigação sistêmica e neurológica para avaliação de estado alterado de consciência após retirada de sedação. A ressonância magnética de crânio evidenciou lesões multifocais no centro semioval, sugestivos de processo inflamatório desmielinizante. Análise liquórica evidenciou PCR negativo para SARS-CoV-2 em ambos os casos. Conclusão: Lesões multifocais de substância branca podem ocorrer em pacientes com COVID-19, possivelmente associadas a estados alterados de consciência. Estudos adicionais são necessários para determinar o processo fisiopatológico da infecção viral e dos estados inflamatórios e imunomediados na gênese das manifestações neurológicas causadas pela COVID-19.

Avaliação Critério-Referenciada em Medicina e Enfermagem: Diferentes Concepções de Docentes e Estudantes de uma Escola Pública de Saúde de Brasília, Brasil / Criterion-Referenced Measurement in Medicine and Nursery: Different Understandings of Teachers and Students at a Public College of Brasília, Brazil

RESUMO Introdução A avaliação critério-referenciada analisa o desempenho acadêmico sem comparar um estudante com outro, diferindo, assim, da avaliação normo-referenciada, que objetiva determinar os melhores e os piores desempenhos. A Escola Superior de Ciências da Saúde (ESCS) do Distrito Federal adota a avaliação critério-referenciada como único sistema avaliativo, buscando analisar o desempenho dos estudantes de forma integral e sem estimular a competitividade. Objetivo Analisar a concepção de docentes e estudantes de Medicina e Enfermagem acerca destes tipos avaliativos. Metodologia Estudo quali-quantitativo, descritivo, com delineamento transversal, por aplicação de questionários semiestruturados ao corpo acadêmico da primeira à quarta série da ESCS, realizado em 2013. Foram comparados estudantes, docentes e cursos utilizando-se o teste Qui-Quadrado. Resultados e Discussão: Obteve-se uma amostra de 413 participantes (n = 55,9%), totalizando 54 docentes e 344 estudantes. Observou-se fragilidade do conceito de avaliação critério-referenciada em todo o corpo acadêmico e insatisfação quanto aos critérios avaliativos adotados na escola (323 ou 79,6%). Entre os motivos apontados, destacam-se a subjetividade na correção dos exames empregados e dificuldades ao concorrer em concursos de residência. Outros autores relatam que o método critério-referenciado tende a inflacionar as menções dos estudantes, embora os avalie de maneira mais integral. Por isso, recomendam a adoção dos sistemas critério e normo-referenciado para, respectivamente, aferir melhor o desempenho dos estudantes e compará-los entre si. Conclusão A comparação entre estudantes é necessária para processos seletivos dentro e fora da instituição de ensino superior estudada. Por isso, a avaliação critério-referenciada isoladamente não supre as necessidades desta instituição, gerando problemas durante e após a formação acadêmica. Diante disso, propõe-se a adoção de ambos os modelos (normo e critério-referenciado), com a aplicação de padrões de desempenho. Os instrumentos avaliativos também necessitam de critérios mais objetivos para uma correção de testes mais uniforme e justa. Para isso, propõe-se o incremento na capacitação dos docentes com discussões sobre a elaboração de instrumentos avaliativos, como a Teoria de Resposta ao Item.

ABSTRACT Introduction Criterion-referenced tests measure academic performance without comparing one student to another, therefore differing from the norm-referenced tests, which are designed to determine the highest and the lowest scores. The Escola Superior de Ciências da Saúde (ESCS) of Federal District, Brazil, uses criterion-referenced measurement as its only evaluative method, attempting to assess students in a more integrative way and to avoid stimulating competitiveness among students. Objective To analyze the interpretation students and teachers of Medicine and Nursery courses about this measurement. Material and Methods Cross-sectional, descriptive, quali-quantitative study, performed by application of semi-structured questionnaires to teachers and students from first to fourth year of Medicine and Nursery courses. We compared courses, students and professors using the Chi-Square test. Results and Discussion: The sample size was of 413 subjects (n = 55.9%), composing 54 teachers and 344 students. We observed fragility in the concept of criterion-referenced measurement, as well as dissatisfaction regarding the method of evaluation adopted by the Institution (323 or 79,6%). Most answers point subjectivity in the correction of exams and difficulties in competing for residency programs after graduation as the major problems. Other authors state that criterion-referenced measurement tends to inflate grades of students, although it also evaluates them in a more integrative way. They recommend the adoption of both measurements (criterion and norm-referenced) in order to respectively: obtain best assessment and to compare students' performances. Conclusion Comparison of academic performance is necessary for selective processes inside and outside the studied institution. Therefore, criterion-referenced measurement alone cannot meet the needs of the institution, generating problems during and after graduation. We suggest the adoption of both methods (criterion and norm-referenced measurement) as well as the application of standard setting concepts for classification of students. Evaluative instruments also need objective criteria for correction of tests, in order to provide a uniform and fairer correction. For that, we propose an increase in teacher training by adding new discussions about elaboration of tests, like Item Response Theory.

Predictors of deep brain stimulation outcome in tremor patients.

BACKGROUND: Deep brain stimulation of the ventro-intermedius nucleus of the thalamus is an established treatment for tremor of differing etiologies but factors that may predict the short- and especially long-term outcome of surgery are still largely unknown. METHODS: We retrospectively investigated the clinical, pharmacological, electrophysiological and anatomical features that might predict the initial response and preservation of benefit in all patients who underwent deep brain stimulation for tremor. Data were collected at the following time points: baseline (preoperative), one-year post-surgery, and most recent visit. Tremor severity was recorded using the Fahn-Tolosa-Marin Tremor Rating Scale and/or the Unified Parkinson's Disease Rating Scale. RESULTS: A total of 52 patients were included in the final analysis: 31 with essential tremor, 15 with cerebellar tremor of different etiologies, and 6 with Parkinson's disease. Long-term success (mean follow-up duration 34.7 months, range 1.7-121.1 months) was reported in 63.5%. Predictors of long-term benefit were: underlying tremor etiology (best outcome in Parkinson's disease, worst outcome in cerebellar tremor); age at surgery (the older the better); baseline tremor severity (the greater the better); lack of response to benzodiazepines; a more anterior electrode placement and single-unit beta power (the greater the better). CONCLUSIONS: Specific patients' features (including single unit beta activity) and electrode locations may predict the short- and long-term benefit of thalamic stimulation for tremor. Future prospective studies enrolling a much larger sample of patients are needed to substantiate the associations detected by this retrospective study.