Demographic characteristics and delayed neurological sequelae risk factors in carbon monoxide poisoning.

AIM: Carbon monoxide (CO) is a colorless, odorless gas and tasteless. CO poisoning (COP) is one of the most frequently encountered inhalation poisonings. The most common cause of morbidity in COP is delayed neurological sequelae (DNS). DNS is the occurrence of neuropsychiatric findings within 2-240 days after discharge of patients with COP and there are no definitive diagnostic criteria. The aim of our study is; to determine the risk factors and incidence of DNS. METHOD: Our study is a retrospective, observational study. Patients with the diagnosis of COP in the emergency department between 2015 and 2016 were included in the study. Patients age, gender, findings in the initial physical examination (PE) and neurological examination (NE), blood carboxyhemoglobin (COHb) level, relation between hyperbaric oxygen (HBO) treatment and DNS were assessed. RESULTS: Total of 72 patients were included in the study. Mean age was 33.43 ±â€¯20.89. It was determined that pathological findings in the initial NE are a significant predictive factor for DNS (Odds ratio 18.600, p:0.004). Significant relation between NE and HBO treatment was present (p:00.1). There was no statistically significant relationship between initial COHb level and receiving HBO treatment (p:0.9). Median COHb level of patients with DNS was 30 (min:10, max: 43), median COHb level of patients without DNS was 25 (min:10, max:44) and there was no statistically significant relationship between the two groups according to COHb levels (p:0.7). CONCLUSION: Pathological findings in the initial neurological examination had a predictive value for delayed neurological sequelae in patients with carbon monoxide poisoning.

Responses to anterior and posterior perturbations in Parkinson's disease with early postural instability: role of axial and limb rigidity.

We studied 12 patients with Parkinson's disease (PD): 6 with postural instability (Hoehn and Yahr Stage 3) and 6 without (Stage 2 or 2.5), using a quantitative test based on the clinical pull test. Their findings were compared with those for 12 healthy controls. The patients on their usual medications were pulled either forwards or backwards at the level of the shoulders and asked not to take a step in a series of five trials. Acceleration was monitored for the upper trunk, sacrum, and both tibias. EMG was measured in soleus and tibialis anterior (TA) muscles in all and for thigh and truncal muscles in a subgroup. A target of 0.2 g trunk acceleration was used, but smaller perturbations were used in very unstable patients. All the Stage 3 patients lost balance in at least one trial for the posterior perturbations but none for the anterior ones. None of the Stage 2 patients lost balance. There was increased tonic EMG and agonist activity but no difference in EMG onset or initial force production compared to healthy controls. For posterior perturbations, there were two related disorders that separated the PD patients from controls. There was a significantly higher ratio of sacral-to-applied acceleration and both PD groups showed reduced knee acceleration and shortened latency, more so for the Stage 3 group. The increased sacral-to-C7 acceleration ratio was correlated with the tonic level of activation of the hamstrings (HS), quadriceps, and lumbar paraspinal muscles (PS), while the tibial acceleration latency was also correlated with the level of tonic PS activation. We also found that the size of balance responses, 0-200 ms post-perturbation, correlated significantly with the level of tonic activation in nearly all the muscles studied. We confirmed that PD patients show greater instability posteriorly than anteriorly to applied perturbations. Our findings support increasing axial and limb rigidity as the cause of the impaired pull test rather than postural bradykinesia and suggest that tonic truncal and thigh muscle activation may be an important underlying cause.

[Translation and validation of the Individualised Neuromuscular Quality of Life scale for the Spanish population: quality of life assessment for persons with neuromuscular diseases]. / Traduccion y validacion de la escala Individualized Neuromuscular Quality of Life para la poblacion española: evaluacion de la calidad de vida para personas afectas de enfermedades neuromusculares.

INTRODUCTION: The Individualized Neuromuscular Quality of Life (INQoL) is a questionnaire that evaluates the quality of life related to the health of adults with neuromuscular diseases. AIM: To validate and analyze the reliability of the Spanish version of the INQoL scale as an instrument for measuring quality of life related to health in individuals with neuromuscular diseases. PATIENTS AND METHODS: A translation-back translation of the INQoL in the Spanish population is performed and, subsequently, for the analysis of reliability, two measurements are carried out; test retest, with 50 patients aged between 19 and 67 years. In this way we assess the intraobserver concordance and assess the internal consistency of the scale. RESULTS: The study of the reliability of the intraobserver concordance index has a value of excellent in seven of the ten subdimensions as well as in the total score of the quality of life. It has a value of good in two and of moderate in one subdimension. The analysis of Cronbach's alpha for the subdimensions of the INQoL has a value of excellent (> 0.818) in seven of them, as well as in the total score of the quality of life related to health (0.928), a value of good internal consistency in three of the subdimensions, and of moderate in one. CONCLUSIONS: The Spanish version of the INQoL is a valid and reliable instrument as a tool for measuring quality of life in adult patients with neuromuscular diseases.

TITLE: Traduccion y validacion de la escala Individualized Neuromuscular Quality of Life para la poblacion española: evaluacion de la calidad de vida para personas afectas de enfermedades neuromusculares.Introduccion. La escala Individualized Neuromuscular Quality of Life (INQoL) es un cuestionario que valora la calidad de vida relacionada con la salud de personas adultas con enfermedades neuromusculares. Objetivo. Validar y analizar la fiabilidad de la version española de la INQoL, como instrumento de medicion de la calidad de vida relacionada con la salud en individuos con enfermedades neuromusculares. Pacientes y metodos. Se realiza una traduccion-retrotraduccion de la INQoL en la poblacion española y, posteriormente, para el analisis de fiabilidad se llevan a cabo dos mediciones, test-retest, a 50 pacientes de 19 a 67 años. De este modo se evalua la concordancia intraobservador y se evalua la consistencia interna de la escala. Resultados. El estudio de la fiabilidad del indice de concordancia intraobservador tiene un valor de excelente en siete de las diez subdimensiones y en la puntuacion total de la calidad de vida; de buena, en dos; y de moderada, en una. El analisis del alfa de Cronbach para las subdimensiones de la INQoL tiene un valor de excelente (> 0,818) en siete de ellas, asi como en la puntuacion total de la calidad de vida relacionada con la salud (0,928), un valor de buena consistencia interna en tres de las subdimensiones y de moderada en una. Conclusiones. La version española de la INQoL es un instrumento valido y fiable como herramienta de medicion de la calidad de vida en individuos adultos con enfermedades neuromusculares.

Default-mode network connectivity in cognitively unimpaired drug-naïve patients with rigidity-dominant Parkinson's disease.

Parkinson's disease (PD) with akinetic rigidity (PDAR) is more likely to develop cognitive deficits compared to PD with tremor-dominant symptoms (PDTD). The default mode network (DMN) is highly relevant for cognitive processes, so this study tested the functional connectivity (FC) of DMN in cognitively unimpaired PDAR patients. Resting-state fMRI data were collected in 21 cognitively unimpaired early stage drug-naïve patients with PDAR and 21 healthy controls (HC). PD patients were matched closely to HCs for demographic and cognitive variables. FC of DMN was evaluated by seed-based correlation approach. Compared to HCs, despite comparable cognitive performance and no statistically discernible GM volume differences, a disruption in the DMN of PDAR subjects was detected. A decreased FC of DMN was found, specifically prominent in the posterior DMN. We also found a significantly increased FC of the anterior DMN. Three parts of left medial prefrontal regions (anterior, ventral, and dorsal) had significantly increased FC with the cerebellum. In addition, increased FC values of the anterior and ventral parts were negatively correlated with cognitive scores. An evident decline of FC of posterior DMN and enhanced compensatory FC of anterior DMN suggested an early functional disruption of DMN in PDAR prior to clinical evidence of cognitive impairment. It could be hypothesized that the dysfunction of DMN connectivity may have a role in the development of cognitive decline in PD. However, further longitudinal studies are warranted to understand the underlying neural mechanisms and their relevance to clinical and cognitive outcomes in PDAR subtype.

Placebo effects induced by auditory cues decrease parkinsonian rigidity in patients with subthalamic stimulation.

Placebo effects are the consequence of an interaction between an organism and its surroundings and may be influenced by cues from the environment. Our study was designed to analyze if conditioned auditory cues could trigger placebo effects and affect parkinsonian rigidity as measured by viscoelastic properties of skeletal muscles in patients treated with subthalamic stimulation. We found that after repeatedly associating with the effect of deep brain stimulation on rigidity, a common dial phone signal itself was able to reduce the mean values of viscoelastic stiffness in the placebo stage (368.8±50.4Nm(-1)) as compared to the stimulation-off conditions (383.7±61.2Nm(-1)) (q=4.18; p<0.05) in ten patients with Parkinson's disease. Thus, it appears that due to associative learning processes environmental cues can acquire the capacity to trigger placebo effects affecting the clinical status of the patients.

The clinically important difference on the unified Parkinson's disease rating scale.

OBJECTIVE: To determine the estimates of minimal, moderate, and large clinically important differences (CIDs) for the Unified Parkinson's Disease Rating Scale (UPDRS). DESIGN: Cross-sectional analysis of the CIDs for UPDRS total and motor scores was performed on patients with Parkinson disease (PD) using distribution- and anchor-based approaches based on the following 3 external standards: disability (10% on the Schwab and England Activities of Daily Living Scale), disease stage (1 stage on the Hoehn and Yahr Scale), and quality of life (1 SD on the 12-Item Short Form Health Survey). SETTING: University of Maryland Parkinson Disease and Movement Disorders Center, Patients Six hundred fifty-three patients with PD. RESULTS: A minimal CID was 2.3 to 2.7 points on the UPDRS motor score and 4.1 to 4.5 on the UPDRS total score. A moderate CID was 4.5 to 6.7 points on the UPDRS motor score and 8.5 to 10.3 on the UPDRS total score. A large CID was 10.7 to 10.8 points on the UPDRS motor score and 16.4 to 17.8 on the UPDRS total score. CONCLUSIONS: Concordance among multiple approaches of analysis based on subjective and objective data show that reasonable estimates for the CID on the UPDRS motor score are 2.5 points for minimal, 5.2 for moderate, and 10.8 for large CIDs. Estimates for the UPDRS total score are 4.3 points for minimal, 9.1 for moderate, and 17.1 for large CIDs. These estimates will assist in determining clinically meaningful changes in PD progression and response to therapeutic interventions.

[Contribution to the study of painful and functional sequellae after breast reconstruction using latissimus dorsi flap. Investigation into 149 patients]. / Contribution à l'étude des séquelles douloureuses et fonctionnelles après reconstruction mammaire utilisant le lambeau dorsal. Enquête auprès de 149 patientes.

Latissimus dorsi flap is the most commonly used among tissues transfers for breast reconstruction. If its qualities and performances are well known, few papers have studied sequellae of this flap, particularly painful. The purpose of this paper is to provide a contribution about this subject. Postulating the complexity of this step, we limited ourselves initially to an evaluation based on analysis of concise questionnaire mailed to two pools of patients with different delays since their reconstruction using latissimus flap. In the two groups of patients, announced principal embarrassment - logically associated with a gestural limitation - is the feeling of axillo-dorsal rigidity, more pregnant than the pain itself. This one is marked during the 2 to 4 first months in the majority of the patients (68 and 66 %), and can persist several years in some among them (14 %). These after-effects did not prevent almost all of the patients to take again their domestic and professional activities and to express a high level of satisfaction with respect to their reconstruction. The addition of a prospective series studying the postoperative pain after reconstruction with or without latissimus flap tends to confirm that any oncologic breast surgery, ablative or reconstructive, expose to painful sequellae more linked to individual factors than to the technique implemented.

Globus pallidus stimulation improves both motor and nonmotor aspects of quality of life in advanced Parkinson's disease.

Our purpose was to measure the change in quality of life (QoL) following deep brain stimulation of the globus pallidus interna (GPi-DBS) in advanced Parkinson 's disease (PD), and identifies any associations with changes in motor features of the disease. Eleven patients (age range 54-69 years, 2 women) underwent GPi-DBS (4 unilateral, 7 bilateral). Outcome measures included assessment of PD-specific QoL (mean 8 months postsurgery) using the PDQ-39 questionnaire, and standard motor assessments. Off-period UPDRS III motor scores fell by (43 +/- 8)% (mean +/- SEM). Dyskinesia severity was reduced on the abnormal involuntary movement scale by (80 +/- 3)% and UPDRS IVa by (58 +/- 8)%. QoL as assessed by the PDQ39SI improved by (30 +/- 5)%, with significant improvements in mobility, activities of daily living, bodily discomfort, emotional wellbeing, communication, and cognitions subscales. Bilateral and unilateral groups demonstrated equivalent PDQ39SI improvement. QoL improvement was highly correlated with dyskinesia reduction but not reduction in UPDRS score or age at surgery. GPi-DBS markedly improves QoL in advanced PD. The impacts are broad and improve QoL domains not directly affected by the motor symptoms of the disease. Reduced dyskinesia plays a major role in the improvement of QoL in GPi-DBS treated patients.

Acute and reversible micrographia in a patient possibly due to cerebral ischaemia.

We report a patient who developed acute and reversible micrographia, presumably due to cerebral ischaemia, on a background of mutism following a pharyngo-laryngectomy 10 years earlier. Magnetic resonance (MR) imaging showed chronic small vessel disease without evidence of an acute ischaemic lesion on diffusion-weighted sequences. Our patient's micrographia improved significantly within 12 days of symptom onset. The MR imaging was performed within 5 days of symptom onset, suggesting that the lesion was either too small for detection or had resolved on diffusion-weighted sequences.

Behavioral disorder, dementia, ataxia, and rigidity in a large family with TATA box-binding protein mutation.

BACKGROUND: Spinocerebellar ataxia type 17 is an autosomal dominant cerebellar ataxia caused by a CAG repeat expansion in the TATA box-binding protein gene. Ataxia is typically the first sign whereas behavioral symptoms occur later. OBJECTIVE: To characterize the unusual phenotypic expression of a large spinocerebellar ataxia type 17 kindred. DESIGN: Clinical, neuropathological, and molecular genetic characterization of a 4-generation family with 16 affected patients. RESULTS: Behavioral symptoms and frontal impairment dominated the early stages preceding ataxia, rigidity, and dystonic movements. Neuropathological examination showed cortical, subcortical, and cerebellar atrophy. Purkinje cell loss and gliosis, pseudohypertrophic degeneration of the inferior olive, marked neuronal loss and gliosis in the caudate nucleus, and in the medial thalamic nuclei were salient features together with neuronal intranuclear inclusions stained with anti-TATA box-binding protein and antipolyglutamine antibodies. The disease was caused by a stable 52 CAG repeat expansion of the TATA box-binding protein gene, although there was apparent variability in the age of onset. CONCLUSION: The characteristics of this family broaden the clinical picture of spinocerebellar ataxia type 17: initial presenile dementia with behavioral symptoms should be added to ataxia, rigidity, and dystonic movements, which are more commonly encountered.

Pramipexole in routine clinical practice: a prospective observational trial in Parkinson's disease.

OBJECTIVE: The mixed dopamine D2/D3 receptor agonist pramipexole is effective as monotherapy in early Parkinson's disease and as adjunctive therapy in advanced disease. Clinical trials suggest that the benefits of pramipexole may extend beyond the relief of motor symptoms (akinesia, rigidity and tremor at rest) to amelioration of depressive symptoms in Parkinson's disease. The aim of this study was to confirm the beneficial effects of pramipexole on the core symptoms of Parkinson's disease (with a focus on tremor), as well as to assess its antidepressant activity, during routine clinical practice. The study also aimed to demonstrate the practicability of the Snaith-Hamilton Pleasure Scale (SHAPS-D), the Tremor Impact Scale (TIS) and the Short Parkinson's Evaluation Scale (SPES) under conditions of routine clinical practice. STUDY DESIGN: This was a prospective observational study. PATIENTS: Data for 657 outpatients with Parkinson's disease were collected from German hospitals and specialist practices. The majority of patients were in Hoehn & Yahr stage II or III and were receiving levodopa. METHODS: Pramipexole (Sifrol) was initiated at a dosage of 0.375 mg/day (using a three-times-daily schedule) and titrated upwards, as required, at weekly intervals over a 4-week period to a maximum dosage of 4.5 mg/day (three times daily). Clinical evaluation was performed at baseline, at the end of the titration phase and at the end of maintenance therapy. Patients were assessed via the German questionnaire versions of the physician-assessed SPES, the self-evaluated TIS and the SHAPS-D. Changes in scale scores were evaluated nonparametrically, using the Wilcoxon-matched pairs test. Cronbach's alpha was used as a measure for item consistency. RESULTS: Pramipexole significantly improved SPES subscores for motor symptoms, complications of therapy, psychological status and activities of daily living. Pramipexole also reduced the detrimental effect of tremor on activities of daily living and social interactions, as assessed by patients via the TIS. As indicated by the results of the SHAPS-D questionnaire, pramipexole significantly reduced anhedonia in patients who had associated depression. Internal consistency of SPES subscales was found to be unaltered between the initial evaluation and follow-up. Likewise, internal consistency for TIS and SHAPS-D was demonstrated. Pramipexole was well tolerated and accepted by the vast majority of physicians and patients. CONCLUSION: In addition to ameliorating the core symptoms of akinesia and rigidity in Parkinson's disease, pramipexole improves tremor and depressive symptoms in routine clinical practice. The SPES, TIS and SHAPS-D were found to be useful instruments with validity in this study.

Suppression of cocaine- and food-maintained behavior by the D2-like receptor partial agonist terguride in squirrel monkeys.

RATIONALE: The D2-like receptor partial agonist terguride has a profile of behavioral effects in rats that suggests potential benefit as a pharmacotherapy for cocaine addiction. OBJECTIVES: The present study investigated the effects of terguride on cocaine- and food-maintained behavior in squirrel monkeys. METHODS: Squirrel monkeys were trained to respond on a second-order schedule (FI 10 min, FR 10 or 30:S) of either i.v. cocaine injection or food pellet delivery. Additional monkeys were studied using quantitative observational techniques to construct side effect profiles. Under each procedure, the effects of terguride were compared with those of the reference D2-like receptor antagonist nemonapride and the D2-like receptor full agonist quinpirole. RESULTS: Terguride and nemonapride, but not quinpirole, dose-dependently reduced cocaine-maintained behavior. In animals self-administering food, terguride decreased response rates at doses lower than those required to suppress cocaine-maintained behavior. Effective doses of terguride had no systematic effect on motor activity or muscle rigidity, whereas effective doses of nemonapride virtually eliminated motor activity and induced severe catalepsy. The primary observable effects of terguride were a modest increase in self-directed behavior (a D2-receptor agonist-like effect) at intermediate doses and a small increase in static posture (a D2-receptor antagonist-like effect) at the highest dose tested. CONCLUSIONS: The results suggest that terguride has advantages over conventional D2-like receptor antagonists and agonists as a candidate pharmacotherapy for cocaine abuse; however, terguride significantly reduces food-maintained behavior at lower doses than those needed to decrease cocaine-maintained behavior suggesting limitations on the utility of terguride as a medication for cocaine addiction.

Discrimination of morphine- and haloperidol-induced muscular rigidity and akinesia/catalepsy in simple tests in rats.

The present study was conducted to establish a simple method for measuring muscular rigidity in rats, which could be used for screening and is able to discriminate between rigidity and akinesia/catalepsy. Therefore, we treated rats with morphine (30 mg/kg i.p.), since large doses of morphine lead to muscular rigidity and akinesia. We measured muscular rigidity with a new method by determining the resistance of the hindlimb to passive flexion in the 'balance test' and also checked haloperidol (3 mg/kg i.p.) treated rats for muscular rigidity. Furthermore, catalepsy was also tested after administration of each of these drugs. Then, the influence of D(1)-like and D(2)-like dopamine receptor stimulation on muscular rigidity and catalepsy was studied. Therefore, the partial D(1) agonist SKF 38393 (3 and 8 mg/kg s.c.), the D(2)/D(1) agonist pergolide (0.25 and 0.5 mg/kg i.p.) and the dopamine precursor L-DOPA (50 and 100 mg/kg i.p.) were administered up to 30 min before muscular rigidity was measured in morphine-treated rats. The results showed that morphine, but not haloperidol led to muscular rigidity, whereas both drugs led to positive scores in the catalepsy test. The dopaminergic drugs partly antagonized the morphine-induced muscular rigidity in the doses applied, but not the catalepsy. Apparently, rigidity, akinesia/catalepsy produced by morphine can be discriminated from that produced by haloperidol in simple and quick tests.

Clinical characteristics of neuroleptic-induced parkinsonism.

In order to characterize the clinical spectrum of neuroleptic-induced parkinsonism (NIP), we studied a population of consecutive psychiatric in-patients treated with neuroleptics for at least two weeks, who were diagnosed by their psychiatrist as having parkinsonism. Parkinsonism was confirmed by a movement disorders specialist who performed neurological assessment including the motor examination and the activities of daily living (ADL) sections of the Unified Parkinson's Disease Rating Scale (UPDRS), and the Hoehn and Yahr (H&Y) staging. Seventy-five patients (54 males), aged 46 +/- 13 years (range 21 to 73 years) were included in the analysis. The mean duration of neuroleptic therapy was 15 +/- 12 years, while 61% were treated for more than 10 years. Most of the patients (n = 66, 88%) were scored as H&Y stage 2.5 or less. Rest tremor was present in 44% of the patients, and usually persisted in action. Forty-one patients (61%) had symmetrical involvement. Parkinsonian signs were significantly more common and pronounced in the upper in comparison with the lower limbs (p = 0.0001). Gait disturbances were mild and freezing of gait was very rare (n = 2). Neither age nor duration of therapy or their interaction affected the total motor score or any of the motor sub-scores. In conclusion, NIP differs from PD for more bilateral involvement with relative symmetry, and by affecting upper limbs more often than the lower ones. NIP tends to be associated with the triad of bradykinesia, tremor and rigidity while PD tends to involve gait and posture more often. NIP develops unrelated to duration of neuroleptic treatment or age of the patient, suggesting an individual predisposition to blockage of the dopaminergic receptors.

Catatonia and other motor syndromes in a chronically hospitalized psychiatric population.

BACKGROUND: To determine the motor characteristics of chronic catatonia, catatonia and other motor disorders were systematically rated in a long-term hospitalized sample. METHOD: Chronically hospitalized psychiatric inpatients (N = 42) with a clinical diagnosis of catatonic schizophrenia (295.2X) were rated for catatonia with a novel 23-item catatonia rating scale, and for parkinsonism, dyskinesia and akathisia using standard rating scales with scale-based criteria for case definition. RESULTS: Catatonia was the sole motor syndrome in nine cases (21%), co-existed with parkinsonism in five (12%), tardive dyskinesia in four (10%), and both parkinsonism and tardive dyskinesia in 10 (24%). There was no correlation between total scores across the four rating scales. 'Rigidity' was the sole catatonic sign which overlapped with other scales. The symptom profile of catatonia in this chronic sample was similar to previous reports based on acutely ill patients. CONCLUSION: Catatonia is distinguishable from other motor disorders in chronic psychiatric patients using the 23-item catatonia rating scale. The features of chronic catatonia are described, and the distribution of catatonic signs is similar for chronic and acute catatonia.

Metaphor and meaning in conversion disorder: a brief active therapy.

The concept of conversion disorder as a change in somatic function that symbolically represents an unconscious conflict is currently challenged in the literature. In this article, the author elaborates on the psychodynamic concept of conversion and defines its characteristics and mode of diagnosis. The usefulness of this approach is demonstrated in a detailed case presentation of a brief, active psychodynamic psychotherapy of six sessions that led to the rapid disappearance of symptoms. In particular, the metaphoric meanings of the physical symptoms were interpreted and followed by an immediate disappearance of symptoms. The logic of this therapeutic approach and its implications as a transference cure are discussed in detail.