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Slomine B, Molteni E. Pediatric disorders of consciousness: Considerations, controversies, and caveats. NeuroRehabilitation 2024; 54:129-139. [PMID: 38251068 DOI: 10.3233/nre-230131] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2024]
Abstract
Pediatric disorders of consciousness (PedDOC) encompass conditions that may occur following very severe traumatic or other forms of acquired brain injury sustained during childhood. As in adults, PedDOC is described as a disturbance of awareness and/or responsiveness. PedDOC is a complex condition that requires specialized care, infrastructures, and technologies. PedDOC poses many challenges to healthcare providers and caregivers during recovery and throughout development. In this commentary, we intend to highlight some considerations, controversies, and caveats on the diagnosis, prognosis and treatment of PedDOC.
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Affiliation(s)
- Beth Slomine
- Kennedy Krieger Institute, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Erika Molteni
- School of Biomedical Engineering & Imaging Sciences, Faculty of Life Science & Medicine, King's College London, London, UK
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Hofmann A, Blum C, Single C, Adeyemi K, Schwarz P, Siokas V, Rattay TW, Häberle HA, Riessen R, Brendel B, Haug I, Bösel R, Zago M, Martus P, Ziemann U, Mengel A, Feil K. Amantadine for NeuroenhaNcement in acutE patients Study - a protocol for a prospective pilot proof of concept phase IIb study in intensive and intermediate care unit patients (ANNES). BMC Neurol 2023; 23:308. [PMID: 37608315 PMCID: PMC10464325 DOI: 10.1186/s12883-023-03345-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Accepted: 07/27/2023] [Indexed: 08/24/2023] Open
Abstract
BACKGROUND Persisting coma is a common complication in (neuro)intensive care in neurological disease such as acute ischemic stroke, intracerebral hemorrhage or subarachnoid hemorrhage. Amantadine acts as a nicotinic receptor antagonist, dopamine receptor agonist and non-competitive N-Methyl-D-aspartate receptor antagonist. Amantadine is a long-known drug, originally approved for treatment of influenza A and Parkinson`s Disease. It has been proven effective in improving vigilance after traumatic brain injury. The underlying mechanisms remain largely unknown, albeit anti-glutamatergic and dopaminergic effects might be most relevant. With limited evidence of amantadine efficacy in non-traumatic pathologies, the aim of our study is to assess the effects of amantadine for neuroenhancement in non-traumatic neurointensive patients with persisting coma. METHODS An investigator-initiated, monocenter, phase IIb proof of concept open-label pilot study will be carried out. Based on the Simon design, 43 adult (neuro)intensive care patients who meet the clinical criteria of persisting coma not otherwise explained and < 8 points on the Glasgow Coma Scale (GCS) will be recruited. Amantadine will be administered intravenously for five days at a dosage of 100 mg bid. The primary endpoint is an improvement of at least 3 points on the GCS. If participants present as non-responders (increase < 3 points or decrease on the GCS) within the first 48 h, the dosage will be doubled from day three to five. Secondary objectives aim to demonstrate that amantadine improves vigilance via alternative scales. Furthermore, the incidence of adverse events will be investigated and electroencephalography (EEG) will be recorded at baseline and end of treatment. DISCUSSION The results of our study will help to systematically assess the clinical utility of amantadine for treatment of persisting coma in non-traumatic brain injury. We expect that, in the face of only moderate treatment risk, a relevant number of patients will benefit from amantadine medication by improved vigilance (GCS increase of at least 3 points) finally leading to a better rehabilitation potential and improved functional neurological outcome. Further, the EEG data will allow evaluation of brain network states in relation to vigilance and potentially outcome prediction in this study cohort. TRIAL REGISTRATION NCT05479032.
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Affiliation(s)
- Anna Hofmann
- Department of Neurology/neurodegenerative diseases, University Hospital Tübingen, Tübingen, Germany
| | - Corinna Blum
- Department of Neurology & Stroke, University Hospital Tübingen, Tübingen, Germany
| | - Constanze Single
- Department of Neurology & Stroke, University Hospital Tübingen, Tübingen, Germany.
| | - Kamal Adeyemi
- Department of Neurology & Stroke, University Hospital Tübingen, Tübingen, Germany
| | - Patricia Schwarz
- Department of Neurology & Stroke, University Hospital Tübingen, Tübingen, Germany
| | - Vasileios Siokas
- Department of Neurology & Stroke, University Hospital Tübingen, Tübingen, Germany
- Department of Neurology, Faculty of Medicine, School of Health Sciences, University Hospital of Larissa, University of Thessaly, Larissa, 41100, Greece
| | - Tim W Rattay
- Department of Neurology/neurodegenerative diseases, University Hospital Tübingen, Tübingen, Germany
- Department of Neurology & Stroke, University Hospital Tübingen, Tübingen, Germany
| | - Helene A Häberle
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Tübingen, Tübingen, Germany
| | - Reimer Riessen
- Department of Medicine, Medical Intensive Care Unit, University Hospital Tübingen, Tübingen, Germany
| | - Bettina Brendel
- Institute for Clinical Epidemiology and Applied Biometry, Faculty of Medicine, Eberhard-Karls- University Tübingen, Tübingen, Germany
| | - Iris Haug
- Institute for Clinical Epidemiology and Applied Biometry, Faculty of Medicine, Eberhard-Karls- University Tübingen, Tübingen, Germany
| | - Ruth Bösel
- Institute for Clinical Epidemiology and Applied Biometry, Faculty of Medicine, Eberhard-Karls- University Tübingen, Tübingen, Germany
| | - Manola Zago
- Center for Clinical Studies ZKS Tübingen, University Hospital Tübingen, Tübingen, Germany
| | - Peter Martus
- Institute for Clinical Epidemiology and Applied Biometry, Faculty of Medicine, Eberhard-Karls- University Tübingen, Tübingen, Germany
| | - Ulf Ziemann
- Department of Neurology & Stroke, University Hospital Tübingen, Tübingen, Germany
- Hertie Institute for Clinical Brain Research, University of Tübingen, Tübingen, Germany
| | - Annerose Mengel
- Department of Neurology & Stroke, University Hospital Tübingen, Tübingen, Germany
- Hertie Institute for Clinical Brain Research, University of Tübingen, Tübingen, Germany
| | - Katharina Feil
- Department of Neurology & Stroke, University Hospital Tübingen, Tübingen, Germany
- Hertie Institute for Clinical Brain Research, University of Tübingen, Tübingen, Germany
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Medina JP, Nigri A, Stanziano M, D’Incerti L, Sattin D, Ferraro S, Rossi Sebastiano D, Pinardi C, Marotta G, Leonardi M, Bruzzone MG, Rosazza C. Resting-State fMRI in Chronic Patients with Disorders of Consciousness: The Role of Lower-Order Networks for Clinical Assessment. Brain Sci 2022; 12:brainsci12030355. [PMID: 35326311 PMCID: PMC8946756 DOI: 10.3390/brainsci12030355] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2021] [Revised: 02/24/2022] [Accepted: 02/28/2022] [Indexed: 01/27/2023] Open
Abstract
Resting-state fMRI (rs-fMRI) is a widely used technique to investigate the residual brain functions of patients with Disorders of Consciousness (DoC). Nonetheless, it is unclear how the networks that are more associated with primary functions, such as the sensory–motor, medial/lateral visual and auditory networks, contribute to clinical assessment. In this study, we examined the rs-fMRI lower-order networks alongside their structural MRI data to clarify the corresponding association with clinical assessment. We studied 109 chronic patients with DoC and emerged from DoC with structural MRI and rs-fMRI: 65 in vegetative state/unresponsive wakefulness state (VS/UWS), 34 in minimally conscious state (MCS) and 10 with severe disability. rs-fMRI data were analyzed with independent component analyses and seed-based analyses, in relation to structural MRI and clinical data. The results showed that VS/UWS had fewer networks than MCS patients and the rs-fMRI activity in each network was decreased. Visual networks were correlated to the clinical status, and in cases where no clinical response occurred, rs-fMRI indicated distinctive networks conveying information in a similar way to other techniques. The information provided by single networks was limited, whereas the four networks together yielded better classification results, particularly when the model included rs-fMRI and structural MRI data (AUC = 0.80). Both quantitative and qualitative rs-fMRI analyses yielded converging results; vascular etiology might confound the results, and disease duration generally reduced the number of networks observed. The lower-order rs-fMRI networks could be used clinically to support and corroborate visual function assessments in DoC.
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Affiliation(s)
- Jean Paul Medina
- Neuroradiology Unit, Diagnostic and Technology Department, Fondazione IRCCS Istituto Neurologico Carlo Besta, 20133 Milan, Italy; (J.P.M.); (M.S.); (L.D.); (S.F.); (C.P.); (M.G.B.)
| | - Anna Nigri
- Neuroradiology Unit, Diagnostic and Technology Department, Fondazione IRCCS Istituto Neurologico Carlo Besta, 20133 Milan, Italy; (J.P.M.); (M.S.); (L.D.); (S.F.); (C.P.); (M.G.B.)
- Correspondence: (A.N.); (C.R.)
| | - Mario Stanziano
- Neuroradiology Unit, Diagnostic and Technology Department, Fondazione IRCCS Istituto Neurologico Carlo Besta, 20133 Milan, Italy; (J.P.M.); (M.S.); (L.D.); (S.F.); (C.P.); (M.G.B.)
- Neurosciences Department “Rita Levi Montalcini”, University of Turin, 10126 Turin, Italy
| | - Ludovico D’Incerti
- Neuroradiology Unit, Diagnostic and Technology Department, Fondazione IRCCS Istituto Neurologico Carlo Besta, 20133 Milan, Italy; (J.P.M.); (M.S.); (L.D.); (S.F.); (C.P.); (M.G.B.)
- Neuroradiology Unit, Children’s Hospital A. Meyer—University of Florence, 50139 Florence, Italy
| | - Davide Sattin
- IRCCS Istituti Clinici Scientifici Maugeri di Milano, 20138 Milan, Italy;
| | - Stefania Ferraro
- Neuroradiology Unit, Diagnostic and Technology Department, Fondazione IRCCS Istituto Neurologico Carlo Besta, 20133 Milan, Italy; (J.P.M.); (M.S.); (L.D.); (S.F.); (C.P.); (M.G.B.)
- MOE Key Laboratory for Neuroinformation, School of Life Science and Technology, University of Electronic Science and Technology of China, Chengdu 611731, China
| | - Davide Rossi Sebastiano
- Epileptology Unit, Department of Neurophysiology and Diagnostic, Fondazione IRCCS Istituto Neurologico Carlo Besta, 20133 Milan, Italy;
| | - Chiara Pinardi
- Neuroradiology Unit, Diagnostic and Technology Department, Fondazione IRCCS Istituto Neurologico Carlo Besta, 20133 Milan, Italy; (J.P.M.); (M.S.); (L.D.); (S.F.); (C.P.); (M.G.B.)
- Medical Physics Unit, Asst Nord Milano, Sesto San Giovanni, 20099 Milan, Italy
| | - Giorgio Marotta
- Department of Nuclear Medicine, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy;
| | - Matilde Leonardi
- Neurology, Public Health, Disability Unit, Fondazione IRCCS Istituto Neurologico Carlo Besta, 20133 Milan, Italy;
| | - Maria Grazia Bruzzone
- Neuroradiology Unit, Diagnostic and Technology Department, Fondazione IRCCS Istituto Neurologico Carlo Besta, 20133 Milan, Italy; (J.P.M.); (M.S.); (L.D.); (S.F.); (C.P.); (M.G.B.)
| | - Cristina Rosazza
- Neuroradiology Unit, Diagnostic and Technology Department, Fondazione IRCCS Istituto Neurologico Carlo Besta, 20133 Milan, Italy; (J.P.M.); (M.S.); (L.D.); (S.F.); (C.P.); (M.G.B.)
- Department of Humanistic Studies, University of Urbino Carlo Bo, 61029 Urbino, Italy
- Correspondence: (A.N.); (C.R.)
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Irzan H, Pozzi M, Chikhladze N, Cebanu S, Tadevosyan A, Calcii C, Tsiskaridze A, Melbourne A, Strazzer S, Modat M, Molteni E. Emerging Treatments for Disorders of Consciousness in Paediatric Age. Brain Sci 2022; 12:198. [PMID: 35203961 PMCID: PMC8870410 DOI: 10.3390/brainsci12020198] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2021] [Revised: 01/28/2022] [Accepted: 01/29/2022] [Indexed: 11/17/2022] Open
Abstract
The number of paediatric patients living with a prolonged Disorder of Consciousness (DoC) is growing in high-income countries, thanks to substantial improvement in intensive care. Life expectancy is extending due to the clinical and nursing management achievements of chronic phase needs, including infections. However, long-known pharmacological therapies such as amantadine and zolpidem, as well as novel instrumental approaches using direct current stimulation and, more recently, stem cell transplantation, are applied in the absence of large paediatric clinical trials and rigorous age-balanced and dose-escalated validations. With evidence building up mainly through case reports and observational studies, there is a need for well-designed paediatric clinical trials and specific research on 0-4-year-old children. At such an early age, assessing residual and recovered abilities is most challenging due to the early developmental stage, incompletely learnt motor and cognitive skills, and unreliable communication; treatment options are also less explored in early age. In middle-income countries, the lack of rehabilitation services and professionals focusing on paediatric age hampers the overall good assistance provision. Young and fast-evolving health insurance systems prevent universal access to chronic care in some countries. In low-income countries, rescue networks are often inadequate, and there is a lack of specialised and intensive care, difficulty in providing specific pharmaceuticals, and lower compliance to intensive care hygiene standards. Despite this, paediatric cases with DoC are reported, albeit in fewer numbers than in countries with better-resourced healthcare systems. For patients with a poor prospect of recovery, withdrawal of care is inhomogeneous across countries and still heavily conditioned by treatment costs as well as ethical and cultural factors, rather than reliant on protocols for assessment and standardised treatments. In summary, there is a strong call for multicentric, international, and global health initiatives on DoC to devote resources to the paediatric age, as there is now scope for funders to invest in themes specific to DoC affecting the early years of the life course.
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Affiliation(s)
- Hassna Irzan
- School of Biomedical Engineering & Imaging Sciences, King’s College London, London WC2R 2LS, UK; (H.I.); (A.M.); (M.M.)
- Department of Medical Physics and Biomedical Engineering, University College London, London WC1E 7JE, UK
| | - Marco Pozzi
- Scientific Institute IRCCS E. Medea, Acquired Brain Injury Unit, 22040 Bosisio Parini, Italy; (M.P.); (S.S.)
| | - Nino Chikhladze
- Faculty of Medicine, Ivane Javakhishvili Tbilisi State University, Tbilisi 0179, Georgia; (N.C.); (A.T.)
| | - Serghei Cebanu
- Faculty of Medicine, Nicolae Testemitanu State University of Medicine and Pharmacy, MD-2004 Chišināu, Moldova; (S.C.); (C.C.)
| | - Artashes Tadevosyan
- Department of Public Health and Healthcare Organization, Yerevan State Medical University, Yerevan 0025, Armenia;
| | - Cornelia Calcii
- Faculty of Medicine, Nicolae Testemitanu State University of Medicine and Pharmacy, MD-2004 Chišināu, Moldova; (S.C.); (C.C.)
| | - Alexander Tsiskaridze
- Faculty of Medicine, Ivane Javakhishvili Tbilisi State University, Tbilisi 0179, Georgia; (N.C.); (A.T.)
| | - Andrew Melbourne
- School of Biomedical Engineering & Imaging Sciences, King’s College London, London WC2R 2LS, UK; (H.I.); (A.M.); (M.M.)
- Department of Medical Physics and Biomedical Engineering, University College London, London WC1E 7JE, UK
| | - Sandra Strazzer
- Scientific Institute IRCCS E. Medea, Acquired Brain Injury Unit, 22040 Bosisio Parini, Italy; (M.P.); (S.S.)
- Rehabilitation Service, “Usratuna” Health and Rehabilitation Centre, Juba, South Sudan
| | - Marc Modat
- School of Biomedical Engineering & Imaging Sciences, King’s College London, London WC2R 2LS, UK; (H.I.); (A.M.); (M.M.)
| | - Erika Molteni
- School of Biomedical Engineering & Imaging Sciences, King’s College London, London WC2R 2LS, UK; (H.I.); (A.M.); (M.M.)
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Driessen DMF, Utens CMA, Ribbers GM, van Erp WS, Heijenbrok-Kal MH. Outcome registry of early intensive neurorehabilitation in patients with disorders of consciousness: study protocol of a prospective cohort study. BMC Neurol 2021; 21:69. [PMID: 33579219 PMCID: PMC7879405 DOI: 10.1186/s12883-021-02099-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2020] [Accepted: 02/05/2021] [Indexed: 01/21/2023] Open
Abstract
BACKGROUND Prolonged disorders of consciousness (PDOC) may occur after severe brain injury. Two diagnostic entities are distinguished within PDOC: unresponsive wakefulness syndrome (UWS, previously known as vegetative state) and minimally conscious state (MCS). Patients with PDOC may benefit from early intensive neurorehabilitation (EIN). In the Netherlands, the EIN programme is provided by one designated expert rehabilitation centre and forms the starting point of a dedicated chain of specialised rehabilitation and care for this group. This study project, called DOCTOR: Disorders of Consciousness; Treatment and Outcomes Registry, sets up a registry and systematically investigates multiple short- and long-term outcomes of patients with PDOC who receive EIN. METHODS Single-centre prospective cohort study with a 2-year follow-up period. Patients with PDOC due to acute brain injury who receive EIN, aged 16 years and older are included. Measurements will take place at start EIN, in week 5, 10, and at discharge from the EIN programme (duration = max 14 weeks) and at week 28, 40, 52, and 104 after admission to the EIN programme, following patients through the health-care chain. Outcome measures are the changes over time in level of consciousness, using the Coma Recovery Scale-Revised; the frequency and type of medical complications; the mortality rate; level of disability, including the level of motor, cognitive, behavioural and emotional functioning; participation; and quality of life. Secondary outcomes include self-efficacy of caregivers, caregivers' strain and cost-effectiveness of the programme. DISCUSSION The DOCTOR study will provide insight in the recovery patterns and predictors of recovery for multiple outcomes in PDOC patients after following EIN. The results of the study will enable us to benchmark and improve EIN and the organisation of the health-care chain, both for patients with PDOC and for their families. TRIAL REGISTRATION Netherlands Trial Register, NL 8138 . Retrospectively registered 6 November 2019.
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Affiliation(s)
- Danielle M F Driessen
- Department of Rehabilitation Medicine, Erasmus MC, University Medical Centre Rotterdam, PO Box 2040, 3000, CA, Rotterdam, the Netherlands. .,Libra Rehabilitation & Audiology, PO Box 1355, 5022 KE, Tilburg, the Netherlands.
| | - Cecile M A Utens
- Department of Rehabilitation Medicine, Erasmus MC, University Medical Centre Rotterdam, PO Box 2040, 3000, CA, Rotterdam, the Netherlands.,Libra Rehabilitation & Audiology, PO Box 1355, 5022 KE, Tilburg, the Netherlands
| | - Gerard M Ribbers
- Department of Rehabilitation Medicine, Erasmus MC, University Medical Centre Rotterdam, PO Box 2040, 3000, CA, Rotterdam, the Netherlands.,Rijndam Rehabilitation, PO Box 23181, 3001 KD, Rotterdam, the Netherlands
| | - Willemijn S van Erp
- Libra Rehabilitation & Audiology, PO Box 1355, 5022 KE, Tilburg, the Netherlands.,Radboud University Medical Centre, Radboud Institute for Health Sciences, Department of Primary and Community Care, Nijmegen, the Netherlands.,Accolade Zorg, Zeist, the Netherlands
| | - Majanka H Heijenbrok-Kal
- Department of Rehabilitation Medicine, Erasmus MC, University Medical Centre Rotterdam, PO Box 2040, 3000, CA, Rotterdam, the Netherlands.,Rijndam Rehabilitation, PO Box 23181, 3001 KD, Rotterdam, the Netherlands
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Zhang X, Liu B, Li N, Li Y, Hou J, Duan G, Wu D. Transcranial Direct Current Stimulation Over Prefrontal Areas Improves Psychomotor Inhibition State in Patients With Traumatic Brain Injury: A Pilot Study. Front Neurosci 2020; 14:386. [PMID: 32508560 PMCID: PMC7251071 DOI: 10.3389/fnins.2020.00386] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2019] [Accepted: 03/30/2020] [Indexed: 01/10/2023] Open
Abstract
Objectives Many post-traumatic patients with minimally conscious state are complicated by psychomotor inhibition state (PIS), which impedes further rehabilitation. The treatment of PIS is not satisfactory. This pilot study aimed to investigate effects of anodal transcranial direct current stimulation (A-tDCS) on PIS in post-traumatic patients and examine the altered cortical activation after tDCS using non-linear electroencephalogram (EEG). Methods The study included 10 patients with post-traumatic PIS. An A–B design was used. The patients received 4 weeks of sham tDCS during Phase A, and they received A-tDCS over the prefrontal area and left dorsolateral prefrontal cortex (DLPFC) for 4 weeks (40 sessions) during Phase B. Conventional treatments were administered throughout both phases. JFK Coma Recovery Scale-Revised (CRS-R), apathy evaluation scale (AES), and the EEG non-linear indices of approximate entropy (ApEn) and cross approximate entropy (C-ApEn) were measured before Phase A, before Phase B, and after Phase B. Results After A-tDCS treatment, CRS-R and AES were improved significantly. ApEn and C-ApEn results showed that the local cortical connection of bilateral sensorimotor areas with their peripheral areas could be activated by affected painful stimuli, while bilateral cerebral hemispheres could be activated by the unaffected painful-stimuli condition. Linear regression analysis revealed that the affected sensorimotor cortex excitability and unaffected local and distant cortical networks connecting the sensorimotor area to the prefrontal area play a major role in AES improvement. Conclusion A-tDCS over the prefrontal area and left DLPFC improves PIS. The recovery might be related to increased excitability in local and distant cortical networks connecting the sensorimotor area to the prefrontal area. Thus, tDCS may be an alternative treatment for post-traumatic PIS.
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Affiliation(s)
- Xu Zhang
- Department of Rehabilitation, Wangjing Hospital of China Academy of Chinese Medical Sciences, Beijing, China
| | - Baohu Liu
- Department of Rehabilitation, Wangjing Hospital of China Academy of Chinese Medical Sciences, Beijing, China
| | - Nan Li
- Research Center of Clinical Epidemiology, Peking University Third Hospital, Beijing, China
| | - Yuanyuan Li
- Department of Rehabilitation, Wangjing Hospital of China Academy of Chinese Medical Sciences, Beijing, China
| | - Jun Hou
- Department of Rehabilitation, Wangjing Hospital of China Academy of Chinese Medical Sciences, Beijing, China
| | - Guoping Duan
- Department of Rehabilitation, Wangjing Hospital of China Academy of Chinese Medical Sciences, Beijing, China
| | - Dongyu Wu
- Department of Rehabilitation, Wangjing Hospital of China Academy of Chinese Medical Sciences, Beijing, China
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Sattin D, Leonardi M, Picozzi M. The autonomic nervous system and the brainstem: A fundamental role or the background actors for consciousness generation? Hypothesis, evidence, and future directions for rehabilitation and theoretical approaches. Brain Behav 2020; 10:e01474. [PMID: 31782916 PMCID: PMC6955833 DOI: 10.1002/brb3.1474] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2019] [Revised: 08/08/2019] [Accepted: 08/15/2019] [Indexed: 12/11/2022] Open
Abstract
INTRODUCTION One of the hardest challenges of the third century is to develop theories that could joint different results for a global explanation of human consciousness. Some important theories have been proposed, trying to explain the emergence of consciousness as the result of different progressive changes in the elaboration of information during brain processing, giving particular attention to the thalamocortical system. METHODS In this article, a summary review of results that highlighted as cerebral cortex could not be so fundamental for consciousness generation is proposed. In detail, three topics were analyzed: (a) studies using experimental approach (manipulating stimuli or brain areas), such as decorticated animals or subliminal presentation of stimuli; (b) studies using anatomo-clinical method (conscious inferenced from observed behaviors); and (c) data from neurostimulation of subcortical areas or of the autonomic nervous system. RESULTS We sketch two speculative hypothesis relative, firstly, to the possible independence from cortical areas of the on/off mechanism for consciousness generation and, secondly, to the possible role of information variability generated by the bottom-up exchange of information among neural systems as a switch for consciousness. CONCLUSIONS A broad range of evidence regarding the functional role of the brainstem and autonomic nervous system is reviewed for its bearing on a future hypothesis regarding the generation of consciousness experience.
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Affiliation(s)
- Davide Sattin
- Neurology, Public Health, Disability Unit and Coma Research Centre, Fondazione IRCCS Istituto Neurologico C.Besta, Milan, Italy.,Experimental Medicine and Medical Humanities-PhD Program, Biotechnology and Life Sciences Department and Center for Clinical Ethics, Insubria University, Varese, Italy
| | - Matilde Leonardi
- Neurology, Public Health, Disability Unit and Coma Research Centre, Fondazione IRCCS Istituto Neurologico C.Besta, Milan, Italy
| | - Mario Picozzi
- Biotechnology and Life Sciences Department and Center for Clinical Ethics, Insubria University, Varese, Italy
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Sattin D, Surya N, Pistarini C, Tonin P, Someshwar H, Caputo M, Leonardi M. Patients with Disorders of Consciousness in India: Preliminary Results from a Pilot Survey. Ann Indian Acad Neurol 2019; 22:485-487. [PMID: 31736576 PMCID: PMC6839285 DOI: 10.4103/aian.aian_355_18] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2018] [Revised: 10/22/2018] [Accepted: 11/08/2018] [Indexed: 11/18/2022] Open
Abstract
The epidemiological data of Indian patients with disorders of consciousness (DOC), specifically vegetative state and minimally conscious state, have not been investigated. The present study sought to explore the current state of the art in India for patients with DOC promoting a pilot survey. An ad hoc questionnaire was sent to a total of 400 Indian professionals who are affiliated to various centers; 59 professionals completed the questionnaire and 52 of them declared that their centers hospitalized patients with DOC in the last year for rehabilitation/medical treatments. The majority of the professionals were from Maharashtra region. The main preliminary findings showed that the prevalence rates of traumatic and nontraumatic etiologies were equally distributed, that the rate of use of the coma recovery scale-revised was low, and that the rehospitalization was always or frequently possible in neurological and rehabilitation units. The extrapolated estimated rate of patients with DOC hospitalized in the centers involved in 2017 was equal to 4 per million of population in Maharashtra region. More than 50% of the professionals declared that there were neither sufficient nor adequate services for caregivers’ support. Even if the present pilot survey has some limitations, the present article offers the first preliminary data on patients with DOC in Indian country.
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Affiliation(s)
- Davide Sattin
- Neurology, Public Health, Disability Unit - Coma Research Centre, Department of Scientific Directorate, Fondazione IRCCS Istituto Neurologico C. Besta Milan, Italy
| | - Nirmal Surya
- The World Federation for Neurolabirintite - RVP South Asia, Mumbai, Maharashtra, India
| | - Caterina Pistarini
- Department of Neurorehabilitation, Istituti Clinici Scientifici S. Maugeri -IRCCS, Pavia, Italy
| | - Paolo Tonin
- Department of Neurorehabilitation, Istituto S Anna, Crotone, Italy
| | - Hitav Someshwar
- The World Federation for Neurolabirintite - RVP South Asia, Mumbai, Maharashtra, India
| | - Milena Caputo
- Neurology, Public Health, Disability Unit - Coma Research Centre, Department of Scientific Directorate, Fondazione IRCCS Istituto Neurologico C. Besta Milan, Italy
| | - Matilde Leonardi
- Neurology, Public Health, Disability Unit - Coma Research Centre, Department of Scientific Directorate, Fondazione IRCCS Istituto Neurologico C. Besta Milan, Italy
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Sattin D, Leonardi M, Nelli B, Bramanti P, Marino S, Ferro S, Basaglia N, Guido D. Effect of Rehabilitation Treatments on Disability in Persons With Disorders of Consciousness: A Propensity Score Study. Arch Phys Med Rehabil 2019; 101:95-105. [PMID: 31465762 DOI: 10.1016/j.apmr.2019.07.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2019] [Revised: 05/17/2019] [Accepted: 07/02/2019] [Indexed: 11/20/2022]
Abstract
OBJECTIVE To evaluate the effects of rehabilitation (physical and cognitive) treatments on the diagnosis severity and Disability Rating Scale (DRS) scores, adjusted for a number of potential confounders measured at baseline, in a large cohort of patients with disorders of consciousness across time. DESIGN AND SETTING An observational, longitudinal (2 evaluations), multicenter project was made in 90 Italian centers. PARTICIPANTS Patients (N=364) with a diagnosis of disorders of consciousness. MAIN OUTCOME MEASURES Primary outcome was the severity of diagnosis, expressed on an ordinal scale (Other<MCS<VS<death). In the Other group were included patients who emerged from an MCS and recovered consciousness. The secondary outcome was the DRS score (range of 0-30 with 30 being the worst value). The DRS is a tool used to define the level of residual disability, commonly used to classify the level of functional impairment in patients with acquired brain injury. Both outcomes were measured for each wave. RESULTS A total of 364 subjects having a complete set of demographic, clinical, and pharmacologic data were included in the propensity score (PS) analysis. Results showed that the rehabilitation treatments (physical and cognitive) reduced the clinical worsening over time in both severity diagnosis and DRS (around 6.5 points) in patients with disorders of consciousness across different propensity score strategies (ie, PS matching, PS adjustment, and PS-weighted procedures). In addition, cognitive protocols seem to be limited to patients with a median value of DRS=23. CONCLUSIONS Our propensity score analysis suggests that rehabilitation treatment protocols seem effective and should be applied to a broader spectrum of patients with disorders of consciousness.
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Affiliation(s)
- Davide Sattin
- Neurology, Public Health, Disability Unit Scientific Department, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy.
| | - Matilde Leonardi
- Neurology, Public Health, Disability Unit Scientific Department, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
| | - Barbara Nelli
- Neurology, Public Health, Disability Unit Scientific Department, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
| | | | - Silvia Marino
- IRCCS Bonino Pulejo Neurolesi Center, Messina, Italy
| | - Salvatore Ferro
- Emilia Romagna Region, General Directorate for Personal Care, Health and Welfare, Bologna, Italy
| | - Nino Basaglia
- Emilia Romagna Region, General Directorate for Personal Care, Health and Welfare, Bologna, Italy
| | - Davide Guido
- Neurology, Public Health, Disability Unit Scientific Department, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
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Errante A, Saviola D, Fasano F, Basagni B, Alinovi S, Bosetti S, Chiari M, Minardi R, Pinardi C, Crisi G, Fogassi L, De Tanti A. Application of an Intensive Rehabilitation Program After Very Late Recovery of Consciousness: A Single-Case Neurorehabilitation and Neuroimaging Study. J Cent Nerv Syst Dis 2019; 11:1179573519843492. [PMID: 31037040 PMCID: PMC6475846 DOI: 10.1177/1179573519843492] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2018] [Accepted: 03/21/2019] [Indexed: 11/29/2022] Open
Abstract
Late recovery of consciousness in vegetative state is considered as an exceptional outcome and has been reported prevalently in patients who suffered a traumatic brain injury. In these patients, the benefits of prolonging the rehabilitation, aimed at the recovery of autonomy in basic everyday activities, has been demonstrated. Here, we describe the application of an intensive multi-professional rehabilitation program carried out on a young female patient, with exceptionally late recovery of consciousness, specifically, after 7 years of vegetative state due to severe brain hemorrhage. Neuropsychological and functional assessment was conducted before and after the end of the rehabilitation program. In addition, functional magnetic resonance imaging (fMRI) and diffusion tensor imaging (DTI)-based probabilistic tractography were performed. Two follow-up neuropsychological and functional assessments were also conducted 6 and 29 months after the conclusion of the program. Functional results showed an improvement, maintained over time, in walking with assistance, cognitive efficiency, visual acuity and visual field, dysarthria, and execution of activities of daily living. Moreover, functional and structural magnetic resonance imaging (MRI) data documented the existence of preserved neural networks involved in sensory, motor, and linguistic tasks, which in all likelihood support the recovery process. This report suggests the possibility of undertaking an intensive rehabilitation program in patients who remain for long periods in altered states of consciousness, in spite of early negative prognosis.
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Affiliation(s)
- Antonino Errante
- Department of Medicine and Surgery, University of Parma, Parma, Italy
| | - Donatella Saviola
- Cardinal Ferrari Rehabilitation Centre, S. Stefano Institute, Fontanellato, Italy
| | - Fabrizio Fasano
- Brain Research Imaging Centre, Cardiff University, Cardiff, UK
| | - Benedetta Basagni
- Cardinal Ferrari Rehabilitation Centre, S. Stefano Institute, Fontanellato, Italy
| | - Serena Alinovi
- Cardinal Ferrari Rehabilitation Centre, S. Stefano Institute, Fontanellato, Italy
| | - Sara Bosetti
- Cardinal Ferrari Rehabilitation Centre, S. Stefano Institute, Fontanellato, Italy
| | - Margherita Chiari
- Cardinal Ferrari Rehabilitation Centre, S. Stefano Institute, Fontanellato, Italy
| | - Rita Minardi
- Cardinal Ferrari Rehabilitation Centre, S. Stefano Institute, Fontanellato, Italy
| | - Chiara Pinardi
- Department of Medicine and Surgery, University of Parma, Parma, Italy
| | - Girolamo Crisi
- Neuroradiology Unit, Department of Diagnostic, Hospital and University of Parma, Parma, Italy
| | - Leonardo Fogassi
- Department of Medicine and Surgery, University of Parma, Parma, Italy
| | - Antonio De Tanti
- Cardinal Ferrari Rehabilitation Centre, S. Stefano Institute, Fontanellato, Italy
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11
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Yehene E, Zaksh Y, Davidian M, Bar-Nadav O, Elyashiv M. Locked-in your heart-shaped box: Familial-role and attachment orientation as predictors of grief in prolonged disorders of consciousness vs. death. DEATH STUDIES 2019; 44:510-520. [PMID: 30938582 DOI: 10.1080/07481187.2019.1586795] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
Death or prolonged disorders of consciousness (DOC) of a loved one are both considered relational-losses that severely disrupt attachment-bonds. Grief in both conditions was compared by exploring the impact of familial-role and attachment-orientation. In DOC, caregivers' grief was found significantly intensified relative to Death. Familial-role impacted grief in both conditions alike, with partners' heightened grief in DOC reflecting the complexity of their stagnant bonds. In Death, avoidance-attachment mitigated grief, while in DOC anxiety-attachment accentuated grief, we suggest that while physical-separation in death facilitates the modification of continuing attachment-schema, in DOC, modification may be required while the patient is still alive.
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Affiliation(s)
- Einat Yehene
- School of Behavioral Sciences, The Academic College of Tel Aviv - Yafo, Tel-Aviv-Yafo, Israel
| | - Yael Zaksh
- School of Behavioral Sciences, The Academic College of Tel Aviv - Yafo, Tel-Aviv-Yafo, Israel
| | - Meital Davidian
- School of Behavioral Sciences, The Academic College of Tel Aviv - Yafo, Tel-Aviv-Yafo, Israel
| | - Ofri Bar-Nadav
- International Center for the Study of Loss, Bereavement and Human Resilience, Department of Psychology, University of Haifa, Haifa, Israel
| | - Maya Elyashiv
- Respiratory Rehabilitation Division, Reut Medical-Rehabilitation Center, Tel-Aviv-Yafo, Israel
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Zaksh Y, Yehene E, Elyashiv M, Altman A. Partially dead, partially separated: establishing the mechanism between ambiguous loss and grief reaction among caregivers of patients with prolonged disorders of consciousness. Clin Rehabil 2018; 33:345-356. [PMID: 30255716 DOI: 10.1177/0269215518802339] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVES: To trace the psychological mechanism underlying caregivers' emotional experience in prolonged disorders of consciousness, by examining the mediating role of boundary ambiguity in the relationship between ambiguous loss and grief. DESIGN: Cross-sectional design. SETTING: The Respiratory Rehabilitation Division of a long-term medical and rehabilitation institute. SUBJECTS: A total of 64 primary caregivers (69% female) of patients in a vegetative state ( n = 49) or minimally conscious state ( n = 15), with a mean age of 55.5 (SD = 12.3) years. Participants were mostly the patient's children (62%) or partners (27%). The mean caregiving duration was 4.9 (SD = 5.1) years. MAIN MEASURES: The Boundary Ambiguity Scale, the Revised Need for Closure Scale, an adapted version of the multifactor Two-Track Bereavement Questionnaire, and a sociodemographic questionnaire, which included items regarding caregiving: frequency of visits and perception of the patient's psychological presence. RESULTS: (1) Caregivers' grief scores (total TTBQ: mean = 2.97; SD = 0.55) did not significantly differ from those exhibited by a normative bereavement sample. (2) Time since injury did not affect caregivers' grief scores (three-year cut-point; P > .05). (3) Mediation analyses revealed that boundary ambiguity (mean = 34.03; SD = 7.55) significantly mediates the relationship between need for closure ( B = .11; confidence interval (CI) = .04-.23) and grief; frequency of visits ( B = .05, CI = .02-.10) and grief and perception of psychological presence ( B = .26, CI = .00-.61) and grief in three separate models. CONCLUSION: Ambiguity concerning relational boundaries hinders caregivers' ongoing grief reaction and impedes their ability to integrate the loss. High frequency of visits, belief in the patient's psychological presence and difficulties in tolerating uncertainty are all clinical manifestations of caregivers' entangled experience.
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Affiliation(s)
- Yael Zaksh
- 1 School of Behavioral Sciences, The Academic College of Tel Aviv-Yaffo, Tel Aviv-Yaffo, Israel
| | - Einat Yehene
- 1 School of Behavioral Sciences, The Academic College of Tel Aviv-Yaffo, Tel Aviv-Yaffo, Israel
| | - Maya Elyashiv
- 2 Respiratory Rehabilitation Division, Reut Medical-Rehabilitation Center, Tel Aviv-Yaffo, Israel
| | - Arie Altman
- 2 Respiratory Rehabilitation Division, Reut Medical-Rehabilitation Center, Tel Aviv-Yaffo, Israel
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13
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Sattin D, De Torres L, Dolce G, Arcuri F, Estraneo A, Cardinale V, Piperno R, Zavatta E, Formisano R, D’Ippolito M, Vassallo C, Dessi B, Lamberti G, Antoniono E, Lanzillotti C, Navarro J, Bramanti P, Marino S, Zampolini M, Scarponi F, Avesani R, Salvi L, Ferro S, Mazza L, Fogar P, Feller S, De Nigris F, Martinuzzi A, Buffoni M, Pessina A, Corsico P, Leonardi M. Analysis of Italian regulations on pathways of care for patients in a vegetative or minimally conscious state. FUNCTIONAL NEUROLOGY 2018; 32:159-163. [PMID: 29042005 PMCID: PMC5726352 DOI: 10.11138/fneur/2017.32.3.159] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Different rehabilitation models for persons diagnosed with disorders of consciousness have been proposed in Europe during the last decade. In Italy, the Ministry of Health has defined a national healthcare model, although, to date, there is a lack of information on how this has been implemented at regional level. The INCARICO project collected information on different regional regulations, analysing ethical aspects and mapping care facilities (numbers of beds and medical units) in eleven regional territories. The researchers found a total of 106 laws; differences emerged both between regions and versus the national model, showing that patients with the same diagnosis may follow different pathways of care. An ongoing cultural shift from a treatment-oriented medical approach towards a care-oriented integrated biopsychosocial approach was found in all the welfare and healthcare systems analysed. Future studies are needed to explore the relationship between healthcare systems and the quality of services provided.
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Affiliation(s)
- Davide Sattin
- Neurology, Public Health, Disability Unit - Scientific Department, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
| | - Laura De Torres
- Neurology, Public Health, Disability Unit - Scientific Department, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
| | - Giuliano Dolce
- RAN (Research in Advanced Neurorehabilitation) - Istituto S. Anna, Crotone, Italy
| | - Francesco Arcuri
- RAN (Research in Advanced Neurorehabilitation) - Istituto S. Anna, Crotone, Italy
| | - Anna Estraneo
- Disorders of Consciousness Laboratory, Salvatore Maugeri Foundation, IRCCS, Scientific Institute of Telese Terme (BN), Italy
| | - Viviana Cardinale
- Disorders of Consciousness Laboratory, Salvatore Maugeri Foundation, IRCCS, Scientific Institute of Telese Terme (BN), Italy
| | - Roberto Piperno
- Neurorehabilitation Unit., Emergency Department., AUSL of Bologna, Italy
| | - Elena Zavatta
- Centro Studi per la Ricerca sul Coma - “Gli Amici di Luca” ONLUS. Casa dei Risvegli Luca De Nigris, Bologna, Italy
| | - Rita Formisano
- Unità Post-Coma, IRCCS Fondazione Santa Lucia, Roma, Italy
| | - Mariagrazia D’Ippolito
- Unità Post-Coma, IRCCS Fondazione Santa Lucia, Roma, Italy
- Dipartimento di Psicologia, “Sapienza” Università di Roma, Italy
| | - Claudio Vassallo
- Centro di Riabilitazione Ambulatoriale, Associazione Rinascita Vita ONLUS, Genova, Italy
| | - Barbara Dessi
- Centro di Riabilitazione Ambulatoriale, Associazione Rinascita Vita ONLUS, Genova, Italy
| | - Gianfranco Lamberti
- S.C. Neuroriabilitazione ASL CN1, Ospedale “SS. Trinità” - Fossano (CN), Italy
| | - Elena Antoniono
- S.C. Neuroriabilitazione ASL CN1, Ospedale “SS. Trinità” - Fossano (CN), Italy
| | | | - Jorge Navarro
- Fondazione San Raffaele - Presidio Ospedaliero di Ceglie Messapica (BR), Italy
| | | | - Silvia Marino
- IRCCS Centro Neurolesi “Bonino-Pulejo”, Messina, Italy
| | - Mauro Zampolini
- Neurorehabilitation Unit, “S.Giovanni Battista “ Hospital, Foligno (PG), Italy
| | - Federico Scarponi
- Neurorehabilitation Unit, “S.Giovanni Battista “ Hospital, Foligno (PG), Italy
| | - Renato Avesani
- Ospedale Sacro Cuore Don Calabria, Dipartimento di riabilitazione, Verona, Italy
| | - Luca Salvi
- Ospedale Sacro Cuore Don Calabria, Dipartimento di riabilitazione, Verona, Italy
| | - Salvatore Ferro
- Emilia Romagna Region, Direzione Generale Cura della Persona, Salute e Welfare, Bologna, Italy
| | - Luigi Mazza
- Emilia Romagna Region, Servizio Integrazione Sociosanitaria e politiche per la Non Autosufficienza, Bologna, Bologna, Italy
| | - Paolo Fogar
- Federazione Nazionale Associazioni Trauma cranico, Carnago (VA), Italy
| | - Sandro Feller
- Federazione Nazionale Associazioni Trauma cranico, Carnago (VA), Italy
| | | | | | - Mara Buffoni
- IRCCS Medea Conegliano Research Centre, Conegliano (TV), Italy
| | - Adriano Pessina
- Bioethics University Centre, Università Cattolica del Sacro Cuore, Milan, Italy
| | - Paolo Corsico
- Bioethics University Centre, Università Cattolica del Sacro Cuore, Milan, Italy
| | - Matilde Leonardi
- Neurology, Public Health, Disability Unit - Scientific Department, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
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14
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Wade DT. How many patients in a prolonged disorder of consciousness might need a best interests meeting about starting or continuing gastrostomy feeding? Clin Rehabil 2018; 32:1551-1564. [PMID: 29779405 DOI: 10.1177/0269215518777285] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE: To estimate the number of people in a prolonged disorder of consciousness (PDOC) who may need a formal best interests decision-making process to consider starting and/or continuing life-sustaining treatment each year in the population of a developed country. METHOD: Identification of studies on people with a PDOC giving information about incidence, and/or prevalence, and/or cause, and/or location of long-term care. Sources included systematic reviews, a new search of MEDLINE (April 2018), and a personal collection of papers. Validating information was sought from existing data on services. RESULTS: There are few epidemiologically sound studies, most having bias and/or missing information. The best estimate of incidence of PDOC due to acute onset disease is 2.6/100,000/year; the best estimate of prevalence is between 2.0 and 5.0/100,000. There is evidence that prevalence in the Netherlands is about 10% of that in other countries. The commonest documented causes are cerebral hypoxia, stroke, traumatic brain injury, and tumours. There is some evidence suggesting that dementia is a common cause, but PDOC due to progressive disorders has not been studied systematically. Most people receive long-term care in nursing homes, but a significant proportion (10%-15%) may be cared for at home. CONCLUSION: Each year, about 5/100,000 people will enter a prolonged state of unconsciousness from acute onset and progressive brain damage; and at any one time, there may be 5/100,000 people in that state. However, the evidence is very limited in quality and quantity. The numbers may be greater.
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Affiliation(s)
- Derick T Wade
- 1 OxINMAHR, and Movement Science Group, Faculty of Health and Life Sciences, Oxford Brookes University, Oxford, UK
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15
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Effects on the diagnosis change and on the disability level for individuals with disorder of consciousness: which predictors? Int Clin Psychopharmacol 2018; 33:163-171. [PMID: 29489493 DOI: 10.1097/yic.0000000000000214] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Prediction of the functional recovery in patients with disorders of consciousness (DOC) is still complex because of the different numbers of variables that influence the possibility of observing changes in clinical outcome. The aim of the present study is to identify the best set of predictors of the change in DOC diagnosis among different pharmacotherapy and nonpharmacotherapy indicators. This study analyzed data collected in a longitudinal, two-evaluation, multicenter project conducted in 90 centers. We analyzed the predictor effects of physical and cognitive treatments, duration of disease, etiology, age, and sex (nonpharmacological treatments) as well as the use of antiparkinson, psycholeptic, psychoanaleptic, and muscle-relaxant drugs (pharmacological variables). Ordered logistic models, linear regression models with bootstrap estimation, and model averaging procedures were used. The results showed that physical and cognitive treatments [best predictor: odds ratio (OR)=413.3, P<0.001], age (OR=0.964, P<0.001), and use of psycholeptic drugs (negative effect: OR=0.373, P=0.039) were the variables that contributed in general toward a change in diagnosis. Notably, the use of psycholeptic drugs seemed to impede the functional recovery in patients with DOC, so serious reflections on its use will be made.
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16
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Yousefzadeh-Chabok S, Emamhadi M, Alijani B, Cheragh Sepehr M, Khodadadi- Hassankiadeh N. Psychopathological Symptoms in Caregivers of Patients With Vegetative State. CASPIAN JOURNAL OF NEUROLOGICAL SCIENCES 2018. [DOI: 10.29252/cjns.4.13.57] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022] Open
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17
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Yang YM, Kim JI. Lived Experience of the Mother's Caring of Adult Children with Persistent Vegetative State. KOREAN JOURNAL OF WOMEN HEALTH NURSING 2017; 23:287-298. [PMID: 37684907 DOI: 10.4069/kjwhn.2017.23.4.287] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2017] [Revised: 12/11/2017] [Accepted: 12/13/2017] [Indexed: 09/10/2023] Open
Abstract
PURPOSE The purpose of this study was to deepen understanding the nature of the care experience by the mothers with adult children in persistent vegetative state. METHODS Participants were 7 mothers caring for their adult children in persistent vegetative state. Data were collected individually through in-depth interviews on their lived experiences. Also texts were included as data from literary works, novels, movies, essays, and arts containing on patients with persistent vegetative state and their mothers. Data were analyzed by van Manen's phenomenological methodology. RESULTS The essential themes of caring experiences of the mothers were as follows. The theme in relation to lived time has shown as back to the past and caring experience related lived body has emerged as locked the body in children. The theme related lived space was getting into the swamp and the theme in lived others was derived as lonely struggle into. CONCLUSION The nature of mothers' caring experiences for adult children in persistent vegetative state is summarized as 'Do not off hand of hope in a locked state'. This study suggests long-term supports are necessary for mothers to care persistent vegetative state children.
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Affiliation(s)
- Young Mi Yang
- Department of Nursing, Backsuk University, Cheonan, Korea
| | - Jeung Im Kim
- Department of Nursing, Backsuk University, Cheonan, Korea
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18
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Hauger SL, Olafsen K, Schnakers C, Andelic N, Nilsen KB, Helseth E, Funderud I, Andersson S, Schanke AK, Løvstad M. Cognitive Event-Related Potentials during the Sub-Acute Phase of Severe Traumatic Brain Injury and Their Relationship to Outcome. J Neurotrauma 2017; 34:3124-3133. [PMID: 28594285 DOI: 10.1089/neu.2017.5062] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
Predicting outcome in the early phase after severe traumatic brain injury (sTBI) is a major clinical challenge, particularly identifying patients with potential for good cognitive outcome. The current single-center prospective study aimed to explore presence and normalization of electroencephalography (EEG)-based event-related potentials (ERPs) in the early phase followings TBI, and their relationship to functional and cognitive outcome 6 months post-injury. Fourteen adult patients (eight males) with sTBI were recruited from the neurointensive care unit (mean age = 38.2 years [standard deviation (SD) = 14.7]; mean lowest Glasgow Coma Scale (GCS) score within first 24 h = 5.4, SD = 1.87). EEG recordings were conducted biweekly at three time-points applying an ERP paradigm encompassing a passive condition involving hearing their own name randomly interspersed between an unfamiliar name (UN), and an active condition with instruction to count their own name. Functional and cognitive outcome 6 months post-injury was measured with Glasgow Outcome Scale-Extended (GOSE) and neuropsychological tests of attention and memory. Ten patients demonstrated a significantly enhanced cognitive P3 in the active counting task compared with passive listening across recordings, and six presented with normalization of P3 in the counting task. Moreover, P3 amplitude to the counting task at the third time-point was positively correlated with both functional outcome (GOSE) and cognition (verbal learning, attentional set-shifting, and switching) 6 months post-injury. ERP can index cognitive capacities in the early phase following sTBI, and the cognitive P3 component in an active design is associated with functional and cognitive outcome, demonstrating that the cognitive P3 may yield valuable information of residual cognition and provide supplementary prognostic information.
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Affiliation(s)
- Solveig L Hauger
- 1 Department of Research, Sunnaas Rehabilitation Hospital , Nesoddtangen, Norway .,2 Department of Psychology, University of Oslo , Norway
| | - Kjell Olafsen
- 3 Department of Neurointensive Treatment, Oslo University Hospital , Norway
| | - Caroline Schnakers
- 4 Neurosurgery Department, University of California , Los Angeles.,5 Research Institute , Casa Colina Hospital and Centers of Healthcare, Pomona, California
| | - Nada Andelic
- 6 Department of Physical Medicine and Rehabilitation, Oslo University Hospital , Norway .,7 Institute of Health and Society, CHARM (Center for Habilitation and Rehabilitation Models and Services), Faculty of Medicine, University of Oslo , Norway
| | - Kristian Bernhard Nilsen
- 8 Department of Neurology, Oslo University Hospital , Norway .,9 Department of Neuroscience, Norwegian University of Science and Technology , Norway
| | - Eirik Helseth
- 10 Department of Neurosurgery, Oslo University Hospital , Norway .,11 Faculty of Medicine, University of Oslo , Norway
| | | | | | - Anne-Kristine Schanke
- 1 Department of Research, Sunnaas Rehabilitation Hospital , Nesoddtangen, Norway .,2 Department of Psychology, University of Oslo , Norway
| | - Marianne Løvstad
- 1 Department of Research, Sunnaas Rehabilitation Hospital , Nesoddtangen, Norway .,2 Department of Psychology, University of Oslo , Norway
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Emotional Burden, Quality of Life, and Coping Styles in Care Givers of Patients with Disorders of Consciousness Living in Italy: Preliminary Data. BRAIN IMPAIR 2016. [DOI: 10.1017/brimp.2016.26] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
The literature about the care givers of patients with Disorders of Consciousness (DOCs) has highlighted the impact on both mental and physical dimensions of quality of life. This study aimed to: (1) describe emotional burden, quality of life, and coping styles in care givers of hospitalized patients with DOCs, compared to Italian normative data; (2) explore the relationships between these variables and their associations with socio-demographic features; and (3) describe their changes over time.Fifteen care givers of patients with DOCs, mostly middle-aged women, were assessed using the Family Strain Questionnaire, the SF-36 Health Survey, and the Coping Orientation to Problems Experienced – Nuova Versione Italiana. Eleven subjects were also assessed after 6 and 12 months. Data were analysed through descriptive statistics, correlations, and nonparametric tests of group differences.Compared to the Italian normative data, our sample showed a worse outcome in mental health, social functioning, global mental component, and emotional role functioning. Furthermore, subjects with high emotional burden had more thoughts of death compared to subjects with low emotional burden. Follow-up analyses revealed no variables changed over time.These results highlight the need for psychological interventions and support, since care givers represent an important part of an all-embracing support and care network for patients with DOCs.
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20
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Covelli V, Sattin D, Giovannetti AM, Scaratti C, Willems M, Leonardi M. Caregiver's burden in disorders of consciousness: a longitudinal study. Acta Neurol Scand 2016; 134:352-359. [PMID: 26748540 DOI: 10.1111/ane.12550] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/30/2015] [Indexed: 11/30/2022]
Abstract
OBJECTIVES To study the changes in the burden of informal caregivers of patients with disorders of consciousness (DOC) over time. MATERIALS AND METHODS Short Form-12, Family Strain Questionnaire, Beck Depression Inventory and Coping Orientations to Problem Experiences were administered. RESULTS Data collected on 216 informal caregivers of patients with DOC (59.6% females, mean age 53.4 ± 12.7 years old) were analysed at two time-points (mean distance is 2.7 years). Results of the national study revealed that caregivers' mental health improved (T0: M = 41.1, SD = 11.8; T1: M = 45.8, SD = 11.7), whereas the emotional burden (T0: M = 7.4, SD = 3.6; T1: M = 6.6, SD = 3.9) and the presence of depressive symptoms (T0: M = 14.3, SD = 9.3; T1: M = 11.7, SD = 10.2) as well as the need for information about the disease (T0: M = 2.7, SD = 1.2; T1: M = 2.2, SD = 1.4), thoughts of death (T0: M = 3.6, SD = 1.5; T1: M = 3.1, SD = 1.6) and the use of avoiding coping strategy (T0: M = 7.8, SD = 1.0; T1: M = 6.0, SD = 1.3) decreased at T1. Furthermore, depressive symptoms positively correlated with the emotional burden (0.580) and negatively with the mental health component of caregivers' self-perceived health condition (-0.473). Physical (-0.308) and mental health (-0.444) negatively correlated with emotional burden. Finally, the acute event and patients' health condition still have a deep impact on the economic situation of the family. CONCLUSION Although high level of burden was observed, it tends to decrease over time, except for financial burden. Hence, this study suggests the importance to plan strategies or targeted interventions in order to reduce the psychosocial and financial burden associated with caregiving.
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Affiliation(s)
- V. Covelli
- Department of Psychology; e-Campus University; Milan Italy
| | - D. Sattin
- Neurology; Public Health and Disability Unit and Coma Research Centre - Scientific Directorate; Neurological Institute C. Besta IRCCS Foundation; Milan Italy
| | - A. M. Giovannetti
- Neuroimmunology Unit; Neurological Institute C. Besta IRCCS Foundation; Milan Italy
| | - C. Scaratti
- Neurology; Public Health and Disability Unit and Coma Research Centre - Scientific Directorate; Neurological Institute C. Besta IRCCS Foundation; Milan Italy
| | - M. Willems
- Neurology; Public Health and Disability Unit and Coma Research Centre - Scientific Directorate; Neurological Institute C. Besta IRCCS Foundation; Milan Italy
| | - M. Leonardi
- Neurology; Public Health and Disability Unit and Coma Research Centre - Scientific Directorate; Neurological Institute C. Besta IRCCS Foundation; Milan Italy
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Romaniello C, Bertoletti E, Matera N, Farinelli M, Pedone V. Morfeo Study II: Clinical Course and Complications in Patients With Long-Term Disorders of Consciousness. Am J Med Sci 2016; 351:563-9. [PMID: 27238917 DOI: 10.1016/j.amjms.2016.01.024] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2015] [Revised: 12/29/2015] [Accepted: 01/19/2016] [Indexed: 11/29/2022]
Abstract
BACKGROUND The life expectancy of patients with disorders of consciousness (DOCs) is ever-increasing, but little is known about their clinical course over late stages. Several issues (premorbid conditions, complications and pressure sores) are to be considered for their effect on clinical outcome, risk of death and recovery of functional performance. Unfortunately, in late stages of long-term rehabilitation, these aspects are still more neglected than in acute and postacute stages. The aim of this study was to investigate the clinical course and the complications of patients in the late stages of DOCs and to explore the relationship between mortality and specific biomarkers. MATERIALS AND METHODS A total of 112 patients, admitted over 10 years in a dedicated ward, were retrospectively studied. Sociodemographic data, preadmission and inpatient clinical features were collected. Disability Rating Scale scores, complications including pressure sores and blood markers were assessed monthly. Data were analyzed through descriptive statistics and correlations using SPSS. RESULTS Most patients were men older than 50 years with a nontraumatic etiology and a history of hypertension (42.86%). The most common complication was pneumonia (76.79%). No association was found between sex and mortality or between etiology and mortality (P > 0.05). Mortality correlated significantly with sepsis (ρ = 0.253), albumin (ρ = -0.558), hemoglobin (ρ = -0.354) and white blood cells (ρ = 0.243). Only 42% of patients remained unchanged at Disability Rating Scale evaluation. CONCLUSIONS These data confirmed that DOCs are not static conditions and they require ongoing monitoring and assessment of clinical status, level of consciousness and laboratory biomarkers.
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Affiliation(s)
| | | | | | - Marina Farinelli
- Clinical Psychology Service, Villa Bellombra Rehabilitation Hospital, Bologna, Italy
| | - Vincenzo Pedone
- Santa Viola Hospital, Bologna, Italy; Villa Bellombra Rehabilitation Hospital, Bologna, Italy
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22
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Rosazza C, Andronache A, Sattin D, Bruzzone MG, Marotta G, Nigri A, Ferraro S, Rossi Sebastiano D, Porcu L, Bersano A, Benti R, Leonardi M, D'Incerti L, Minati L. Multimodal study of default-mode network integrity in disorders of consciousness. Ann Neurol 2016; 79:841-853. [PMID: 26970235 DOI: 10.1002/ana.24634] [Citation(s) in RCA: 50] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2015] [Revised: 03/08/2016] [Accepted: 03/09/2016] [Indexed: 01/20/2023]
Abstract
OBJECTIVE Understanding residual brain function in disorders of consciousness poses extraordinary challenges, and imaging examinations are needed to complement clinical assessment. The default-mode network (DMN) is known to be dysfunctional, although correlation with level of consciousness remains controversial. We investigated DMN activity with resting-state functional magnetic resonance imaging (rs-fMRI), alongside its structural and metabolic integrity, aiming to elucidate the corresponding associations with clinical assessment. METHODS We enrolled 119 consecutive patients: 72 in a vegetative state/unresponsive wakefulness state (VS/UWS), 36 in a minimally conscious state (MCS), and 11 with severe disability. All underwent structural MRI and rs-fMRI, and a subset also underwent 18 F-fluorodeoxyglucose positron emission tomography (FDG-PET). Data were analyzed with manual and automatic approaches, in relation to diagnosis and clinical score. RESULTS Excluding the quartile with largest head movement, DMN activity was decreased in VS/UWS compared to MCS, and correlated with clinical score. Independent-component and seed-based analyses provided similar results, although the latter and their combination were most informative. Structural MRI and FDG-PET were less sensitive to head movement and had better diagnostic accuracy than rs-fMRI only when all cases were included. rs-fMRI indicated relatively preserved DMN activity in a small subset of VS/UWS patients, 2 of whom evolved to MCS. The integrity of the left hemisphere appears to be predictive of a better clinical status. INTERPRETATION rs-fMRI of the DMN is sensitive to clinical severity. The effect is consistent across data analysis approaches, but heavily dependent on head movement. rs-fMRI could be informative in detecting residual DMN activity for those patients who remain relatively still during scanning and whose diagnosis is uncertain. Ann Neurol 2016;79:841-853.
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Affiliation(s)
- Cristina Rosazza
- Neuroradiology Unit, Carlo Besta Institute of Hospitalization and Scientific Care Foundation Neurological Institute, Milan, Italy.,Scientific Department, Carlo Besta Institute of Hospitalization and Scientific Care Foundation Neurological Institute, Milan, Italy
| | - Adrian Andronache
- Neuroradiology Unit, Carlo Besta Institute of Hospitalization and Scientific Care Foundation Neurological Institute, Milan, Italy
| | - Davide Sattin
- Neurology, Public Health, Disability Unit, Fondazione IRCCS Istituto Neurologico "Carlo Besta", Milan, Italy
| | - Maria Grazia Bruzzone
- Neuroradiology Unit, Carlo Besta Institute of Hospitalization and Scientific Care Foundation Neurological Institute, Milan, Italy
| | - Giorgio Marotta
- Department of Nuclear Medicine, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Anna Nigri
- Neuroradiology Unit, Carlo Besta Institute of Hospitalization and Scientific Care Foundation Neurological Institute, Milan, Italy
| | - Stefania Ferraro
- Neuroradiology Unit, Carlo Besta Institute of Hospitalization and Scientific Care Foundation Neurological Institute, Milan, Italy
| | - Davide Rossi Sebastiano
- Department of Neurophysiology, Epilepsy Center, Fondazione IRCCS Istituto Neurologico "Carlo Besta", Milan, Italy
| | - Luca Porcu
- Laboratory of Methodology for Biomedical Research, Oncology Department, IRCCS - Istituto di Ricerche Farmacologiche "Mario Negri", Milan, Italy
| | - Anna Bersano
- Cerebrovascular Disease Unit, Fondazione IRCCS Istituto Neurologico "Carlo Besta", Milan, Italy
| | - Riccardo Benti
- Department of Nuclear Medicine, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Matilde Leonardi
- Neurology, Public Health, Disability Unit, Fondazione IRCCS Istituto Neurologico "Carlo Besta", Milan, Italy
| | - Ludovico D'Incerti
- Neuroradiology Unit, Carlo Besta Institute of Hospitalization and Scientific Care Foundation Neurological Institute, Milan, Italy
| | - Ludovico Minati
- Scientific Department, Carlo Besta Institute of Hospitalization and Scientific Care Foundation Neurological Institute, Milan, Italy
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Pichler G, Fazekas F. Cardiopulmonary arrest is the most frequent cause of the unresponsive wakefulness syndrome: A prospective population-based cohort study in Austria. Resuscitation 2016; 103:94-98. [PMID: 26980348 DOI: 10.1016/j.resuscitation.2016.02.023] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2015] [Revised: 02/11/2016] [Accepted: 02/26/2016] [Indexed: 12/21/2022]
Abstract
BACKGROUND The "Unresponsive wakefulness syndrome" (UWS) or previously termed vegetative state is a possible consequence of severe brain damage where individuals just open their eyes but show no conscious behavioural reaction. While head trauma has previously been considered the prevailing cause, clinical experience suggests shows that cardiopulmonary arrest plays an increasingly important role. We therefore attempted to study this hypothesis in a well-defined region of Austria. METHODS Prospective population-based cohort study to calculate the incidence and aetiologies of the UWS. All facilities in the state of Styria (n=38), which are involved in the medical care of patients with brain damage, participated. Among the adult population of Styria (n=1010,164) we identified all individuals who developed UWS over a one year period. The diagnosis was based on a formal neurologic evaluation at least 4 weeks after the brain damage and had to be in line with the criteria of the "Multi-society Task Force on Persistent Vegetative State". RESULTS We identified 19 individual with UWS which correspond to an annual incidence of 1.88/100,000 people. Male gender predominated (78.9%) and the mean age was 57.8 years (age range 18-78 years). The most frequent cause of UWS was cerebral hypoxia in the wake of cardiopulmonary resuscitation (63%), cerebral bleeding (21%) and brain trauma (16%). CONCLUSIONS Cardiopulmonary resuscitation has become the major cause of UWS which leads to an increasing incidence with age. These aspects may become even more prominent with the ageing of our population and need to be considered in the organisation of care.
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Affiliation(s)
- Gerald Pichler
- Department of Neurology, Albert-Schweitzer-Hospital Graz, Albert-Schweitzer-Gasse 36, 8020 Graz, Austria.
| | - Franz Fazekas
- Department of Neurology, Medical University of Graz, Auenbruggerplatz 22, 8036 Graz, Austria
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Neurophysiological Indicators of Residual Cognitive Capacity in the Minimally Conscious State. Behav Neurol 2015; 2015:145913. [PMID: 26504351 PMCID: PMC4609423 DOI: 10.1155/2015/145913] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2015] [Revised: 09/07/2015] [Accepted: 09/09/2015] [Indexed: 11/18/2022] Open
Abstract
Background. The diagnostic usefulness of electrophysiological methods in assessing disorders of consciousness (DoC) remains to be established on an individual patient level, and there is need to determine what constitutes robust experimental paradigm to elicit electrophysiological indices of covert cognitive capacity. Objectives. Two tasks encompassing active and passive conditions were explored in an event-related potentials (ERP) study. The task robustness was studied in healthy controls, and their utility to detect covert signs of command-following on an individual patient level was investigated in patients in a minimally conscious state (MCS). Methods. Twenty healthy controls and 20 MCS patients participated. The active tasks included (1) listening for a change of pitch in the subject's own name (SON) and (2) counting SON, both contrasted to passive conditions. Midline ERPs are reported. Results. A larger P3 response was detected in the counting task compared to active listening to pitch change in the healthy controls. On an individual level, the counting task revealed a higher rate of responders among both healthy subjects and MCS patients. Conclusion. ERP paradigms involving actively counting SON represent a robust paradigm in probing for volitional cognition in minimally conscious patients and add important diagnostic information in some patients.
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Giovannetti AM, Covelli V, Sattin D, Leonardi M. Caregivers of patients with disorder of consciousness: burden, quality of life and social support. Acta Neurol Scand 2015; 132:259-69. [PMID: 25808669 DOI: 10.1111/ane.12392] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/17/2015] [Indexed: 11/29/2022]
Abstract
OBJECTIVE To evaluate quality of life (QoL) and its predictors, psychological burden and level of perceived social support in caregivers of patients with disorder of consciousness. MATERIALS & METHODS World Health Organization Quality of Life-Bref (WHOQOL-BREF), State Trait Anxiety Inventory-Y (STAI-Y), Beck Depression Inventory (BDI-II), Prolonged Grief Disorder Questionnaire, Coping Orientations to Problem Experiences, State-Trait Anger Expression Inventory-2 (STAXI-2), and the Medical Outcome Study Social Support Survey (MOS-SSS) were administered. One-sample t-tests were performed to compare WHOQOL-BREF, STAI-Y and STAXI-2 mean scores to the respective normative sample (NS). Pearson correlation was calculated between time dedicated to patient's care, WHOQOL-BREF, BDI-II, STAI-Y and MOS-SSS scores. Hierarchical multiple regression analyses were performed to evaluate which variables have predictive power on QoL. RESULTS A total of 129 caregivers, 68.2% female, mean age 52.8 years, were enrolled. Three WHOQOL-BREF domains were significantly lower. Anxiety and anger were in line with NS. 28.7% of the sample reported high level of depressive symptoms; 20.9% satisfied the prolonged grief disorder criteria. No differences emerged between caregivers and chronic ill patients' scores at MOS-SSS. STAI-Y, BDI-II and WHOQOL-BREF scores positively correlated. MOS-SSS domains inversely correlate with BDI-II scores. BDI-II results the most relevant predictor of QoL. CONCLUSIONS Study results provided innovative information about caregivers' poor QoL, difficulties in social support and high levels of burden. Time dedicated to care is not strictly related to burden, while social support perceived is highly associated with caregivers' depressive symptoms that are strong predictor of poor QoL. Supportive intervention able to integrate psychological, social and environmental levels is needed.
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Affiliation(s)
- A. M. Giovannetti
- Neurology, Public Health and Disability Unit and Coma Research Centre; Scientific Directorate; Neurological Institute Carlo Besta IRCCS Foundation; Milan Italy
| | - V. Covelli
- Università degli Studi eCampus; Via Isimbardi; 10 - 22060 Novedrate (CO) Italy
| | - D. Sattin
- Neurology, Public Health and Disability Unit and Coma Research Centre; Scientific Directorate; Neurological Institute Carlo Besta IRCCS Foundation; Milan Italy
| | - M. Leonardi
- Neurology, Public Health and Disability Unit and Coma Research Centre; Scientific Directorate; Neurological Institute Carlo Besta IRCCS Foundation; Milan Italy
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26
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Bedini G, Bersano A, Sebastiano DR, Sattin D, Ciaraffa F, Tosetti V, Brenna G, Franceschetti S, Ciusani E, Leonardi M, Vela-Gomez J, Boncoraglio GB, Parati EA. Is Period3 Genotype Associated With Sleep and Recovery in Patients With Disorders of Consciousness? Neurorehabil Neural Repair 2015; 30:461-9. [PMID: 26359345 DOI: 10.1177/1545968315604398] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Background Sleep evaluation is increasingly being used as prognostic tool in patients with disorders of consciousness, but, surprisingly, the role of Period3 (Per3) gene polymorphism has never been evaluated. Objective The aim of this study was to investigate the contribution of Per3 genotype on sleep quantity and consciousness recovery level in patients with disorders of consciousness (DOC). Methods In this observational study, we evaluated 71 patients with DOC classified as vegetative state/unresponsive wakefulness syndrome or minimally conscious state. Demographic and clinical data were collected and a standardised diagnostic workup, including a polysomnographic record, was applied. After informed consent provided by proxy, genomic DNA was obtained and Per3 polymorphism was analysed by polymerase chain reaction to identify 5/5, 4/5, or 4/4 genotype. Results Per3(5/5) genotype was found in 12.7% of our DOC patients. The median total Coma Recovery Scale-revised score in Per3(5/5) carriers was significantly higher than 4/4 genotype (10, range 5-16 vs 7, range 4-11; post hoc P = .036). Moreover, total sleep time seemed to be higher in 5/5 genotype (5/5, 221 minutes, range 88-515 minutes; 4/4, 151.5 minutes, range 36-477 minutes; and 4/5, 188 minutes, range 44-422 minutes). Conclusion For the first time we have shown a possible association between Per3 polymorphism and consciousness recovery level in DOC patients. Even though the exact molecular mechanism has not been defined, we speculate that its effect is mediated by higher total sleep time and slow wave sleep, which would improve the preservation of main cerebral connections.
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Affiliation(s)
- Gloria Bedini
- Neurological Institute "C. Besta" IRCCS Foundation, Milan, Italy
| | - Anna Bersano
- Neurological Institute "C. Besta" IRCCS Foundation, Milan, Italy
| | | | - Davide Sattin
- Neurological Institute "C. Besta" IRCCS Foundation, Milan, Italy
| | | | | | - Greta Brenna
- Neurological Institute "C. Besta" IRCCS Foundation, Milan, Italy
| | | | - Emilio Ciusani
- Neurological Institute "C. Besta" IRCCS Foundation, Milan, Italy
| | - Matilde Leonardi
- Neurological Institute "C. Besta" IRCCS Foundation, Milan, Italy
| | - Jesus Vela-Gomez
- Neurological Institute "C. Besta" IRCCS Foundation, Milan, Italy
| | | | - Eugenio A Parati
- Neurological Institute "C. Besta" IRCCS Foundation, Milan, Italy
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Leonardi M, Covelli V, Giovannetti AM, Raggi A, Sattin D. ICF-DOC: the ICF dedicated checklist for evaluating functioning and disability in people with disorders of consciousness. Int J Rehabil Res 2015; 37:197-204. [PMID: 24463705 DOI: 10.1097/mrr.0000000000000051] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Clinicians need a comprehensive description of patients' functioning state to capture the complex interaction between symptoms and environmental factors, and to determine the actual level of functioning in patients in a vegetative state or a minimally conscious state. The aim of this study is to develop an International Classification of Functioning, Disability, and Health (ICF) checklist for patients with disorders of consciousness (DOC) so as to capture and describe, with a tailored list of categories, the most common health, disability, and functioning issues of adult patients with DOC. The WHO ICF checklist was used as a basis for collecting data. This was an observational, cross-sectional, multicenter study conducted in 69 Italian centers. Specific methodological procedures were used to identify the most appropriate categories for DOC patients to be added to or deleted from the ICF checklist so as to develop the ICF-DOC checklist. A total of 566 adult patients were enrolled: 398 in a vegetative state and 168 in a minimally conscious state. A total of 127 ICF categories reached the threshold of 20% concerning the presence of a problem: 37 categories from the body functions chapter, 13 from the body structures chapter, 46 from the activities and participations chapter, and 31 from the environmental factors chapter. ICF categories identified in this study can be useful guidelines for clinicians and researchers to collect data on functioning and disability of adult patients with DOC. The new ICF-DOC checklist allows monitoring of the effects of interventions on functional areas and possible changes in each patient in follow-up studies.
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Affiliation(s)
- Matilde Leonardi
- Neurology Public Health and Disability Unit, Scientific Directorate, Neurological Institute C. Besta, IRCCS Foundation, Milan, Italy
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Willems M, Sattin D, Vingerhoets AJJM, Leonardi M. Longitudinal changes in functioning and disability in patients with disorders of consciousness: the importance of environmental factors. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2015; 12:3707-30. [PMID: 25837348 PMCID: PMC4410211 DOI: 10.3390/ijerph120403707] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/30/2014] [Revised: 03/25/2015] [Accepted: 03/25/2015] [Indexed: 11/16/2022]
Abstract
Disorders of consciousness are neurological conditions associated with low levels of functioning which pose a serious challenge to public health systems. The current study aimed to examine longitudinal changes in functioning in patients with disorders of consciousness and to identify associated biopsychosocial factors using the International Classification of Functioning, Disability, and Health. An Italian sample of 248 patients was assessed longitudinally. Differences in relative variability (an index of change that controls for baseline levels) between acute and chronic patients and predictors of relative variability in "Activities & Participation" were examined. Results showed that there were subgroups of patients whose functioning improved over time. The number of problems in "Activities & Participation" decreased in acute patients over time, whereas in chronic patients, an increase was found. The significant difference in relative variability for the environmental factor "support and relationships" reflects the increase in facilitators in acute patients, whereas the number of facilitators in chronic patients remained unchanged over time. Age at event, time from event, and relative variability in "Environmental Factors" were significant predictors of relative variability in "Activities & Participation". It is of clinical relevance that patients with disorders of consciousness are kept in a supportive and facilitative environment, in order to prevent a decline in their functioning. Moreover, caregivers should receive tailored support in order to enhance and facilitate appropriate care of patients with disorders of consciousness.
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Affiliation(s)
- Michelle Willems
- Neurology, Public Health, Disability Unit-Scientific Directorate, Neurological Institute Carlo Besta Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Foundation, Via Celoria 11, Milan 20133, Italy.
- Department of Medical & Clinical Psychology, Tilburg University, P.O. Box 90153, Tilburg 5000 LE, The Netherlands.
| | - Davide Sattin
- Neurology, Public Health, Disability Unit-Scientific Directorate, Neurological Institute Carlo Besta Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Foundation, Via Celoria 11, Milan 20133, Italy.
| | - Ad J J M Vingerhoets
- Department of Medical & Clinical Psychology, Tilburg University, P.O. Box 90153, Tilburg 5000 LE, The Netherlands.
| | - Matilde Leonardi
- Neurology, Public Health, Disability Unit-Scientific Directorate, Neurological Institute Carlo Besta Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Foundation, Via Celoria 11, Milan 20133, Italy.
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Romaniello C, Farinelli M, Matera N, Bertoletti E, Pedone V, Northoff G. Anxious attachment style and hopelessness as predictors of burden in caregivers of patients with disorders of consciousness: A pilot study. Brain Inj 2014; 29:466-72. [DOI: 10.3109/02699052.2014.989402] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Covelli V, Cerniauskaite M, Leonardi M, Sattin D, Raggi A, Giovannetti AM. A qualitative study on perceptions of changes reported by caregivers of patients in vegetative state and minimally conscious state: the "time gap experience". ScientificWorldJournal 2014; 2014:657321. [PMID: 25431794 PMCID: PMC4241276 DOI: 10.1155/2014/657321] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2014] [Accepted: 09/15/2014] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVE Our purpose was to provide a comprehensive understanding of how women informal caregivers of patients in vegetative state (VS) or minimally conscious state (MCS) describe, represent, and experience changes that occurred in their life after the acute event of their family member. METHODS A qualitative study was conducted and fifteen women informal caregivers, mothers, or spouses of patients in VS or MCS were interviewed. RESULTS Caregivers' narratives revealed (1) important personal and interpersonal changes and (2) difficulties while facing the complex situation and integrating past, present, and future, defined as a "time gap experience." This difficulty is expressed in two ways. First, the reduction of variety of roles into one, caregiver's role. Second, the relationship with the relative is characterised by fluctuation in the relational style between caregiver and relative; it shifts from an adult to adult interaction to an adult to child one. Another fluctuation can be observed in the mixed use of present and past tenses when caregivers speak about their relatives. CONCLUSIONS Caregiving cause pervasive modifications in one's life. Targeted interventions aiming to empower the caregivers, to support them after the acute event in caregiving activities together with patient-focused interventions, and to promote their health should be implemented.
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Affiliation(s)
- Venusia Covelli
- Neurological Institute Carlo Besta IRCCS Foundation, Neurology, Public Health and Disability Unit, Via Celoria 11, 20133 Milan, Italy
| | - Milda Cerniauskaite
- Neurological Institute Carlo Besta IRCCS Foundation, Neurology, Public Health and Disability Unit, Via Celoria 11, 20133 Milan, Italy
| | - Matilde Leonardi
- Neurological Institute Carlo Besta IRCCS Foundation, Neurology, Public Health and Disability Unit, Via Celoria 11, 20133 Milan, Italy
| | - Davide Sattin
- Neurological Institute Carlo Besta IRCCS Foundation, Neurology, Public Health and Disability Unit, Via Celoria 11, 20133 Milan, Italy
| | - Alberto Raggi
- Neurological Institute Carlo Besta IRCCS Foundation, Neurology, Public Health and Disability Unit, Via Celoria 11, 20133 Milan, Italy
| | - Ambra Mara Giovannetti
- Neurological Institute Carlo Besta IRCCS Foundation, Neurology, Public Health and Disability Unit, Via Celoria 11, 20133 Milan, Italy
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Cipolletta S, Pasi M, Avesani R. Vita tua, mors mea: The experience of family caregivers of patients in a vegetative state. J Health Psychol 2014; 21:1197-206. [PMID: 25253627 DOI: 10.1177/1359105314550348] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
This study aims to understand whether, and possibly how, caregivers of patients in a vegetative state experience an emotional paradox between life and death. Individual semi-structured interviews were conducted with 24 (19 females and 5 males) caregivers of vegetative state patients living in northern Italy. Data were analysed using interpretative phenomenological analysis. Caregivers felt they were the only ones able to understand and give answer to patients' needs, but neglected their own lives in their total commitment to the patient. The findings highlight the importance for vegetative state caregivers in considering new possibilities of life that go beyond the assistance of vegetative state patients.
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32
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Assessment of patients with disorder of consciousness: do different Coma Recovery Scale scoring correlate with different settings? J Neurol 2014; 261:2378-86. [DOI: 10.1007/s00415-014-7478-5] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2014] [Revised: 08/20/2014] [Accepted: 08/21/2014] [Indexed: 12/11/2022]
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van Erp WS, Lavrijsen JCM, van de Laar FA, Vos PE, Laureys S, Koopmans RTCM. The vegetative state/unresponsive wakefulness syndrome: a systematic review of prevalence studies. Eur J Neurol 2014; 21:1361-8. [PMID: 25039901 DOI: 10.1111/ene.12483] [Citation(s) in RCA: 56] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2014] [Accepted: 05/05/2014] [Indexed: 12/21/2022]
Abstract
One of the worst outcomes of acquired brain injury is the vegetative state, recently renamed 'unresponsive wakefulness syndrome' (VS/UWS). A patient in VS/UWS shows reflexive behaviour such as spontaneous eye opening and breathing, but no signs of awareness of the self or the environment. We performed a systematic review of VS/UWS prevalence studies and assessed their reliability. Medline, Embase, the Cochrane Library, CINAHL and PsycINFO were searched in April 2013 for cross-sectional point or period prevalence studies explicitly stating the prevalence of VS/UWS due to acute causes within the general population. We additionally checked bibliographies and consulted experts in the field to obtain 'grey data' like government reports. Relevant publications underwent quality assessment and data-extraction. We retrieved 1032 papers out of which 14 met the inclusion criteria. Prevalence figures varied from 0.2 to 6.1 VS/UWS patients per 100 000 members of the population. However, the publications' methodological quality differed substantially, in particular with regards to inclusion criteria and diagnosis verification. The reliability of VS/UWS prevalence figures is poor. Methodological flaws in available prevalence studies, the fact that 5/14 of the studies predate the identification of the minimally conscious state (MCS) as a distinct entity in 2002, and insufficient verification of included cases may lead to both overestimation and underestimation of the actual number of patients in VS/UWS.
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Affiliation(s)
- W S van Erp
- Department of Primary and Community Care, Centre for Family Medicine, Geriatric Care and Public Health, Radboud University Medical Centre, Nijmegen, The Netherlands; Cyclotron Research Center & Neurology Department, Coma Science Group, University of Liège, Liège, Belgium
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Bastianelli A, Gius E, Cipolletta S. Changes over time in the quality of life, prolonged grief and family strain of family caregivers of patients in vegetative state: A pilot study. J Health Psychol 2014; 21:844-52. [DOI: 10.1177/1359105314539533] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
This study explored changes over time and in the internal standards of the quality of life, prolonged grief and family strain of informal caregivers of patients in vegetative state. Data obtained from 52 caregivers showed high levels of prolonged grief and family strain, and low quality of life. A decrease of caregivers’ quality of life and an increase of family strain were found by adopting a response shift procedure. Only prolonged grief did not change during time. Clinical intervention with the caregivers of vegetative state patients should be differentiated on the basis of the duration of the caring experience.
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Pagani M, Giovannetti AM, Covelli V, Sattin D, Leonardi M. Caregiving for Patients in Vegetative and Minimally Conscious States: Perceived Burden as a Mediator in Caregivers’ Expression of Needs and Symptoms of Depression and Anxiety. J Clin Psychol Med Settings 2014; 21:214-22. [DOI: 10.1007/s10880-014-9399-y] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Pagani M, Leonardi M, Covelli V, Giovannetti AM, Sattin D. Risk factors for mortality in 600 patients in vegetative and minimally conscious states. J Neurol 2014; 261:1144-52. [DOI: 10.1007/s00415-014-7309-8] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2013] [Revised: 03/03/2014] [Accepted: 03/04/2014] [Indexed: 10/25/2022]
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Pagani M, Giovannetti AM, Covelli V, Sattin D, Raggi A, Leonardi M. Physical and mental health, anxiety and depressive symptoms in caregivers of patients in vegetative state and minimally conscious state. Clin Psychol Psychother 2013; 21:420-6. [PMID: 23712507 DOI: 10.1002/cpp.1848] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2012] [Revised: 04/19/2013] [Accepted: 04/23/2013] [Indexed: 12/13/2022]
Abstract
UNLABELLED Caregivers of patients in vegetative state and minimally conscious state play a crucial role in the process of taking care and, as previous studies reported, they can suffer of high burden and negative health outcomes. The aim of this national cross-sectional study was to assess whether physical and mental health of caregivers, considering gender differences, is related to the presence of depressive symptoms, anxiety, age and patient's disease duration. Four-hundred and eighteen caregivers, 294 women and 124 men, completed the State Trait Anxiety Inventory-Y, Beck Depression Inventory, second version and Short Form-12. Hierarchical multiple regression analyses were performed to evaluate to which extent depressive and anxiety symptoms predict physical and mental health. Men reported higher levels of mental health state, whereas physical health was not different across gender. High levels of anxiety symptoms were associated to negative mental health outcomes in both genders, whereas depressive symptoms were found to impact on female's mental and physical health only. A comprehensive and cost-effective screening of anxiety and depressive symptoms may help to identify determinants of health worsening in order to plan, when necessary, caregivers' support. KEY PRACTITIONER MESSAGES Female caregivers of patients in vegetative state and minimally conscious state have poorer levels of mental health, whereas physical health is similar to men's. Anxiety symptoms are related to negative mental health outcomes in both male and female caregivers, whereas depressive symptoms are found to impact on female mental and physical health only. It is essential to consider and assess depressive and anxiety symptoms as they may contribute to caregivers' health worsening. This knowledge can lead to plan more comprehensive and tailored caregivers' supports and a better care for patients.
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Affiliation(s)
- M Pagani
- Neurology, Public Health and Disability Unit, Scientific Directorate, Neurological Institute Carlo Besta IRCCS Foundation, Milan, Italy
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