Recent advances in our understanding of neurodevelopmental outcomes in congenital heart disease

PURPOSE OF REVIEW

Patients with congenital heart disease (CHD) suffer from a pattern of neurodevelopmental abnormalities including deficits in language and executive function. In this review, we summarize recent studies that examine these outcomes, their risk factors, possible biomarkers, and attempts to develop therapeutic interventions.

RECENT FINDINGS

The latest literature has highlighted the role of genetics in determining neurologic prognosis, as we have increased our understanding of potentially modifiable perioperative risk factors. The role of potentially neurotoxic medical therapies has become more salient. One recent focus has been how neurodevelopment affects quality of life and leads to a high prevalence of mental illness. Neuroimaging advances have provided new insights into the pathogenesis of deficits.

SUMMARY

Although many risk factors in CHD are not modifiable, there is promise for interventions to improve neurodevelopmental outcomes in patients with CHD. Biomarkers are needed to better understand the timing and prognosis of injury and to direct therapy. Research into psychosocial interventions is urgently needed to benefit the many survivors with CHD.

Mini-Mental State Examination and Brain Age Quotient—Short Form: Relationship and Demographic Correlates

Modest intercorrelations between scores on the Mini-Mental State Examination and the Brain Age Quotient were obtained for 30 men in a VA medical program for alcoholic dependency. rs with age and education were small. As the two measures are reasonably different, they may be applied to advantage in studies of behavioral intervention.

Reanalysis of Halstead's Biological Intelligence Factor Matrix

A recent study by Russell did not duplicate Halstead's factors of biological intelligence. As an approach to understanding this finding, Hal-stead's original correlation matrix was subjected to the same orthogonal principal components analysis used in Russell's study as well as an orthogonal and an oblique factor analysis using communalities. All of Halstead's factors appeared in these analyses. The failure to duplicate Halstead's work was evidently not due to use of different factoring methods. In a second analysis which reduced the number of Halstead's variables to the number used by Russell, one of Halstead's factors (P) did not appear. This factor represented tests measuring the visual threshold, and so it appears to be primarily a perceptual factor.

[Meta-Cognitive Ability and Brain Damage in Autoimmune Encephalitis: A Case Report]

Autoimmune encephalitis is an important contributor to rapidly progressive cognitive and behavioral decline. The purpose of this work was to evaluate the effects of cognitive rehabilitation in a patient with autoimmune encephalitis. We also wanted to evaluate the effectiveness of rehabilitative treatment by monitoring the cognitive and metacognitive outcomes over a time interval. We reported a case of 22 year-old female patient with autoimmune encephalitis, cognitive behavioral impairments, and severe reduction in metarepresentational capacity. We performed an assessment of personality, neuropsychological, and meta-cognitive functions at the beginning of the rehabilitative training. The last evaluation was performed six months after the discharge from the rehabilitation unit. We applied a combination of remediation, psycho-educational treatment, and psychotherapy to improve the knowledge and the empathy of the patient, to promote the selfcontrol strategies, and to prompt better behavioral management. Our findings revealed an improvement in the performance of the individual tests after rehabilitative training.

Alphanumeric Sequencing: A Report on a Brief Measure of Information Processing Used among Persons with Multiple Sclerosis

Alphanumeric Sequencing involves the alternating recitation of counting and the alphabet. We report data on the use of this measure with two clinical samples of persons with multiple sclerosis, having either the chronic progressive (n = 23) or relapsing-remitting form (n = 52) of the disease. Patients were administered Alphanumeric Sequencing and several other tests of information-processing speed/capacity and short-term memory. Chronic progressive MS patients performed worse than 23 healthy controls on both the speed and error components of the test, while relapsing-remitting patients were worse than 35 controls only on the total time to complete the task. The time score was correlated with several measures of information processing and short-term memory.

The General Neuropsychological Deficit Scale and Halstead Impairment Index: Comparison of Severity

To examine how the severity of brain damage is evaluated by a summary neuropsychological measure, the General Neuropsychological Deficit Scale, 25 brain-damaged patients completed the Halstead-Reitan Neuropsychological Test Battery. From the test scores, both the General Neuropsychological Deficit Scale and the Halstead Impairment Index were calculated for each patient. Hit rates for agreement on severity were 60%, i.e., 15/25. Examination of the data suggested the General Neuropsychological Deficit Scale better reflects severity of brain damage at greater severity.

Assessment of Seizures and Related Symptomatology in Persons with Mental Retardation

Seizures can be debilitating across a number of physical, social, occupational, and personal variables. Given the deficits in all of these areas frequently present in persons with mental retardation, effective assessment and subsequent treatment of seizures is a primary goal for individuals with both mental retardation and epilepsy. To thoroughly address the behavioral domains related to seizures in persons with mental retardation and epilepsy, areas of assessment should include seizure behavior, triggering stimuli, reinforcing consequences, and antiepileptic medication side effects. Assessment of these areas in this population often deviates from methods typically used with persons of normal intelligence. Specifically, direct behavioral observation and third-party report with structured interviews are the most viable and accessible means of assessment, and efforts to establish reliable and valid protocols have been successful in some areas. This article reviews this assessment methodology and discusses the extant issues in establishing and proliferating such approaches.

A critical review of closing-in

When performing complex actions, like graphic copying or imitation of gestures, some patients may perform these actions very close to, or directly on the top of the model. This peculiar behavior, known as closing-in, is the focus of the present literature review, which will provide a critical picture of the research in this field, highlighting the difficulties in defining and assessing closing-in and the contrasting results about the nature and the characteristics of this phenomenon. Most importantly, we will discuss the 2 hypotheses proposed to explain closing-in, namely the compensation and the attraction account, in light of the most recent work. This critical review will provide substantial evidence that closing-in represent a primitive default tendency in which movements are attracted toward the focus of attention. On the other hand, the possibility that this interpretation might not be fully exhaustive and that different components of closing-in might exist will also be discussed. (PsycINFO Database Record

[The Value of Neuropsychological Legal Evaluations]

In the context of neurological assessment, neuropsychological deficits, in particular of attention and memory functions, usually require additional neuropsychological evaluation. Clinical neuropsychology also has at its disposal an inventory of validated and standardized tests for assessing symptom validity. Procedure, test selection, quality criteria and limitations of neuropsychological expert medical evaluations are presented. Independent expert evaluations should be conducted by a qualified clinical neuropsychologist.

A meta-analysis of working memory impairments in survivors of moderate-to-severe traumatic brain injury

OBJECTIVES

To establish the magnitude of deficits in working memory (WM) and short-term memory (STM) in those with moderate-to-severe traumatic brain injury (TBI) relative to age-matched, healthy controls and to explore the moderating effects of time since injury and age at injury on these impairments.

METHOD

Twenty-one studies that compared the WM and/or STM abilities of individuals with at least a moderate TBI relative to healthy controls were included in a random effects meta-analysis. Measures used to examine memory performance were categorized by modality (visuospatial, verbal) and memory system (WM, STM).

RESULTS

Individuals with TBI had significant deficits in verbal STM (Cohen's d = .41), visuospatial WM (Cohen's d = .69), and verbal WM (Cohen's d = .37) relative to controls. Greater decrements in verbal STM and verbal WM skills were associated with longer time postinjury. Larger deficits were observed in verbal WM abilities in individuals with older age at injury.

CONCLUSION

Evidence for WM impairments following TBI is consistent with previous research. Larger verbal STM and verbal WM deficits were related to a longer time postinjury, suggesting that these aspects of memory do not "recover" over time and instead, individuals might show increased rates of cognitive decline. Age at injury was associated with the severity of verbal WM impairments, with larger deficits evident for injuries that occurred later in life. Further research needs to chart the long-term effects of TBI on WM and to compare the effects of injury on verbal relative to visuospatial memory. (PsycINFO Database Record

[Minor Head Injury – a Silent Epidemic]

The vast majority out of the 20 000 patients annually hospitalized after sustaining a head injury belong to the minor head injury/cerebral concussion continuum. Fortunately, most of the patients show full recovery after days to weeks. However, about 15 % of these patients suffer from prolonged up to permanent sequels potentially impairing their quality of life to a considerable extent. This especially holds true for those who suffer from recurrent minor head injuries (i.e. victims from contact sport accidents). Unfortunately, many of these patients are never diagnosed in an appropriate way and therefore looked at as hypochondriacs or simulants. This prevents adequate rehabilitation and support. This review aims to present current knowledge about pathophysiology and clinical features of minor head injuries and to give some information about diagnostics and treatment according to current guidelines.

Neuroscience in forensic psychiatry: From responsibility to dangerousness. Ethical and legal implications of using neuroscience for dangerousness assessments

Neuroscientific evidence is increasingly being used in criminal trials as part of psychiatric testimony. Up to now, "neurolaw" literature remained focused on the use of neuroscience for assessments of criminal responsibility. However, in the field of forensic psychiatry, responsibility assessments are progressively being weakened, whereas dangerousness and risk assessment gain increasing importance. In this paper, we argue that the introduction of neuroscientific data by forensic experts in criminal trials will be mostly be used in the future as a means to evaluate or as an indication of an offender's dangerousness, rather than their responsibility. Judges confronted with the pressure to ensure public security may tend to interpret neuroscientific knowledge and data as an objective and reliable way of evaluating one's risk of reoffending. First, we aim to show how the current socio-legal context has reshaped the task of the forensic psychiatrist, with dangerousness assessments prevailing. In the second part, we examine from a critical point of view the promise of neuroscience to serve a better criminal justice system by offering new tools for risk assessment. Then we aim to explain why neuroscientific evidence is likely to be used as evidence of dangerousness of the defendants. On a theoretical level, the current tendency in criminal policies to focus on prognostics of dangerousness seems to be "justified" by a utilitarian approach to punishment, supposedly revealed by new neuroscientific discoveries that challenge the notions of free will and responsibility. Although often promoted as progressive and humane, we believe that this approach could lead to an instrumentalization of neuroscience in the interest of public safety and give rise to interventions which could entail ethical caveats and run counter to the interests of the offenders. The last part of this paper deals with some of these issues-the danger of stigmatization for brain damaged offenders because of adopting a purely therapeutic approach to crime, and the impact on their sentencing, in particular.

Diminished white matter injury over time in a cohort of premature newborns

OBJECTIVES

To determine the rate of magnetic resonance imaging (MRI)-detected noncystic white matter injury (WMI) in a prospective cohort of premature newborns, and to evaluate its associations with changes in clinical predictors of WMI over the study period.

STUDY DESIGN

A prospective cohort of premature newborns (<33 weeks gestational age) was studied with MRI within 4 weeks of birth and near term-equivalent age. A pediatric neuroradiologist scored the severity of WMI on T1-weighted MRI according to published criteria. WMI was classified as none/mild or moderate/severe. Subjects with severe cystic WMI, periventricular hemorrhagic infarction, or motion artifact on MRI were excluded. Changes in clinical characteristics and predictors of WMI over the study period (1998-2011) were evaluated. Predictors of moderate/severe WMI, including birth year, were evaluated using multivariate logistic regression.

RESULTS

Among 267 newborns, 45 (17%) had moderate/severe WMI. The rate of moderate/severe WMI decreased over the study period (P = .002, χ(2) test for trends). On multivariate logistic regression, the odds of moderate/severe WMI decreased by 11% for each birth year of the cohort (OR, 0.89; 95% CI, 0.81-0.98; P = .02). Prolonged exposure to indomethacin also was independently associated with reduced odds of moderate/severe WMI.

CONCLUSION

The decreasing burden of MRI-detected moderate/severe noncystic WMI in our cohort of premature newborns is independent over time of changes in the known clinical predictors of WMI. Prolonged exposure to indomethacin is associated with reduced WMI.

Common genetic variants and risk of brain injury after preterm birth

BACKGROUND

The role of heritable factors in determining the common neurologic deficits seen after preterm birth is unknown, but the characteristic phenotype of neurocognitive, neuroanatomical, and growth abnormalities allows principled selection of candidate genes to test the hypothesis that common genetic variation modulates the risk for brain injury.

METHODS

We collected an MRI-linked genomic DNA library from 83 preterm infants and genotyped tag single nucleotide polymorphisms in 13 relevant candidate genes. We used tract-based spatial statistics and deformation-based morphometry to examine the risks conferred by carriage of particular alleles at tag single nucleotide polymorphisms in a restricted number of genes and related these to the preterm cerebral endophenotype.

RESULTS

Carriage of the minor allele at rs2518824 in the armadillo repeat gene deleted in velocardiofacial syndrome (ARVCF) gene, which has been linked to neuronal migration and schizophrenia, and rs174576 in the fatty acid desaturase 2 gene, which encodes a rate-limiting enzyme for endogenous long chain polyunsaturated fatty acid synthesis and has been linked to intelligence, was associated with white matter abnormality measured in vivo using diffusion tensor imaging (P = .0009 and P = .0019, respectively).

CONCLUSIONS

These results suggest that genetic variants modulate white matter injury after preterm birth, and known susceptibilities to neurologic status in later life may be exposed by the stress of premature exposure to the extrauterine environment.

[Magnetic resonance imaging of premature infants with punctate white matter damage and short-term neurodevelopmental outcome]

OBJECTIVE

To investigate the early diagnosis with MRI changes, MRI types and short-term neurodevelopmental outcome of preterm infants with punctate white matter damage (PWMD).

METHOD

There were 44 preterm infants with PWMD (group A) from March 2009 to August 2010 at the neonatal ward of Shengjing Hospital of China Medical University, according to the number, shape and distribution of the lesions, group A was divided into dot injury group (A1), clusters group (A2) and linear group (A3), the first MRI and DWI scan of all cases were within 14 days after birth, and 17 subjects received re-examination with the MRI in the hospital. Twenty preterm infants with normal MRI (group B) received the follow-up, according to the age, 20 normal full-term infants were selected (group C) as the control group using paired design. Mental development index (MDI) and psychomotor development index (PDI) were determined using Bayley scales of infant development-II.

RESULT

First MRI scan:in 44 infants with PWMD, group A1, A2, A3 separately had, 10, and 9 infants. MRI follow up in 17 cases showed that in 4 cases of A1 group the dot lesions disappeared; in 3 of 4 cases in clusters group who received re-examination, the lesions disappeared, 1 case had periventricular leukomalacia (PVL); in 5 of the 9 cases who had re-examination in linear group the lesions disappeared, while in 4 cases the lesions evolved into PVL. MDI and PDI: Group A [MDI (102.9 ± 15.5) , PDI (107.7 ± 17.5) ] was lower than that of group B[MDI (114.0 ± 13.1) , PDI (120.8 ± 9.4) ], group C [MDI (114.2 ± 12.2) , PDI (119.5 ± 10.7) ] (P < 0.05) . There were no significant differences between group B and group C. Group A1 [MDI (112.2 ± 8.1) , PDI (116.4 ± 8.5) ] had no significant differences compared with group B and group C. Group A2 [MDI (100.8 ± 12.5) , PDI (105.0 ± 12.1) ] showed significantly reduced values compared with group B, Group C, Group A1 (P < 0.05) ,Group A3 [MDI (75.8 ± 11.6) , PDI (79.1 ± 16.2) ] had lower values than group B, Group C, Group A1, and Group A2 (P < 0.05) .

CONCLUSION

Premature infants with PWMD mainly showed dot-like and clustered injury that are easy to be absorbed and disappear, but the linear lesions are likely to evolve into PVL. In addition, the cluster-like and linear injury have an influence on short-term cognition and motion development, especially the outcome of linear injury was the worst.

[Neurological maturation retardation]

INTRODUCTION

The early years of life, more especially the first three, are dominated by a series of anatomical-functional facts that express the progressive enrichment of behaviour through the process of neurological maturation, which is expressed as reaching the maximum level of functioning at each stage of development as a result of a process of learning.

DEVELOPMENT

One's personal experience is used to address the main conceptual aspects that define neurological maturation both in its normal aspects, that is to say, its limits, and its pathological deviations, and there is a need for conceptual limits of the so-called maturation retardation. The concepts of 'risk child' and his or her neurodevelopmental control and prognostic factors are analysed.

CONCLUSIONS

The ultimate and primordial aim of any longitudinal study is the early detection of all the neurological anomalies, including maturation retardation, since this makes it possible to establish an early--either curative or palliative--treatment without producing 'false positives'. At the same time, if the neurological pathology is defined as residual, help can also be established for the patient and his or her family so that both of them can adapt to the situation in a suitable manner.

Psychiatric outcomes at age seven for very preterm children: rates and predictors

BACKGROUND

  Uncertainty remains about the rate of specific psychiatric disorders and associated predictive factors for very preterm (VPT) children. The aims of this study were to document rates of psychiatric disorders in VPT children aged 7 years compared with term born children, and to examine potential predictive factors for psychiatric diagnoses in VPT children.

METHODS

  Participants were 177 VPT and 65 term born children. Perinatal medical data were collected, which included brain abnormalities detected using magnetic resonance imaging. The Infant-Toddler Social-Emotional Assessment (ITSEA) and Strengths and Difficulties Questionnaire (SDQ) were administered at 2 and 5 years respectively. At 7 years of age, the Developmental and Well-being Assessment (DAWBA) was used to indicate psychiatric diagnoses.

RESULTS

  Compared with term born children, VPT children had three times the odds of meeting criteria for any psychiatric diagnosis at age 7 years (odds ratio 3.03; 95% confidence interval 1.23, 7.47, p = .02). The most common diagnoses were anxiety disorders (11% VPT, 8% term), attention-deficit/hyperactivity disorder (10% VPT, 3% term) and autism spectrum disorder (4.5% VPT, 0% term). For VPT children, those with severe global brain abnormalities (p = .02), those who displayed social-emotional problems at age 5 (p = .000) and those with higher social risk at age 7 (p = .001) were more likely to meet criteria for a psychiatric illness at age 7.

CONCLUSIONS

Compared with term born children, VPT children have higher rates of psychiatric diagnoses at early school age, predicted by neonatal brain abnormalities, prior social-emotional problems and social factors.

Child maltreatment: the neurobiological aspects of posttraumatic stress disorder

Childhood trauma due to physical abuse, neglect, or sexual abuse is a serious problem in the United States. Trauma can result in disruption or injury to the developing brain and lead to neurodevelopmental deficits that affect a child's functioning and can result in lifelong problems. Research has provided insight into how early childhood maltreatment affects brain development. This article examines the research on trauma, its effects on the brain, and evidence-based interventions. An overview of normal brain functioning and posttraumatic stress disorder is presented. Implications for social work practice with children who have experienced child maltreatment are discussed.

How do you know when your patient is "waking up": coma recovery assessment in a complex continuing care setting

Coma, vegetative state (VS) and minimally conscious state (MCS) are disastrous outcomes following severe traumatic brain injury. Due to the extent of the resultant neurological deficits including hemisphere damage, loss of cellular integrity, altered and abnormal movements such as flexor and extensor patterns, and alterations in cranial nerve function, it can become difficult for the interprofessional team to identify when a patient is emerging from their coma. The Glasgow Coma Scale (GCS), commonly used to assess patients with traumatic brain injury (TBI) is not comprehensive or sensitive enough to provide concrete evidence that a patient is emerging from VS to an MCS. The purpose of this paper is to present a case study of a patient who has emerged from a persistent VS to promote a deeper understanding of what is involved when working with this clientele. Challenges in assessment of cognitive functioning, the development of successful communication through the use of technology and the goals of therapy amongst the various health team members will be provided. Collaborative support with the family will also be discussed. Members of the interprofessional team explored the literature to determine coma recovery assessment tools and best evidence guidelines to direct their interventions with this patient.

Promoting adaptive behavior in persons with acquired brain injury, extensive motor and communication disabilities, and consciousness disorders

These two studies extended the evidence on the use of technology-based intervention packages to promote adaptive behavior in persons with acquired brain injury and multiple disabilities. Study I involved five participants in a minimally conscious state who were provided with intervention packages based on specific arrangements of optic, tilt, or pressure microswitches (linked to preferred environmental stimuli) and eyelid, toe and finger responses. Study II involved three participants who were emerging from a minimally conscious state and were provided with intervention packages based on computer presentations of stimulus options (i.e., preferred stimuli, functional caregiver's procedures, and non-preferred stimuli) and pressure microswitches to choose among them. Intervention data of Study I showed that the participants acquired relatively high levels of microswitch responding (thus engaging widely with preferred environmental stimuli) and kept that responding consistent except for one case. Intervention data of Study II showed that the participants were active in choosing among preferred stimuli and positive caregivers' procedures, but generally abstained from non-preferred stimuli. The results were discussed in terms of the successful use of fairly new/infrequent microswitch-response arrangements (Study I) and the profitable inclusion of functional caregiver's procedures among the options available to choice (Study II).

Homotopic language reorganization in the right hemisphere after early left hemisphere injury

To determine the areas involved in reorganization of language to the right hemisphere after early left hemisphere injury, we compared fMRI activation patterns during four production and comprehension tasks in post-surgical epilepsy patients with either left (LH) or right hemisphere (RH) speech dominance (determined by Wada testing) and healthy controls. Patient groups were carefully matched for IQ, lesion location and size. RH patients' activation across all tasks was greatest in right hemisphere areas homotopic to areas activated by LH and control participants. Differences in right vs. left dominant hemisphere activation were limited to homologous areas typically activated by language tasks, supporting the hypothesis that language localization following transfer to the RH is the mirror-image of localization in the absence of transfer. The similarity of these findings to those in patients with larger, peri-sylvian lesions suggests that these areas in both hemispheres may be uniquely predisposed to subserve various language functions.

Neurodevelopmental outcomes in children with congenital heart disease: evaluation and management: a scientific statement from the American Heart Association

BACKGROUND

The goal of this statement was to review the available literature on surveillance, screening, evaluation, and management strategies and put forward a scientific statement that would comprehensively review the literature and create recommendations to optimize neurodevelopmental outcome in the pediatric congenital heart disease (CHD) population.

METHODS AND RESULTS

A writing group appointed by the American Heart Association and American Academy of Pediatrics reviewed the available literature addressing developmental disorder and disability and developmental delay in the CHD population, with specific attention given to surveillance, screening, evaluation, and management strategies. MEDLINE and Google Scholar database searches from 1966 to 2011 were performed for English-language articles cross-referencing CHD with pertinent search terms. The reference lists of identified articles were also searched. The American College of Cardiology/American Heart Association classification of recommendations and levels of evidence for practice guidelines were used. A management algorithm was devised that stratified children with CHD on the basis of established risk factors. For those deemed to be at high risk for developmental disorder or disabilities or for developmental delay, formal, periodic developmental and medical evaluations are recommended. A CHD algorithm for surveillance, screening, evaluation, reevaluation, and management of developmental disorder or disability has been constructed to serve as a supplement to the 2006 American Academy of Pediatrics statement on developmental surveillance and screening. The proposed algorithm is designed to be carried out within the context of the medical home. This scientific statement is meant for medical providers within the medical home who care for patients with CHD.

CONCLUSIONS

Children with CHD are at increased risk of developmental disorder or disabilities or developmental delay. Periodic developmental surveillance, screening, evaluation, and reevaluation throughout childhood may enhance identification of significant deficits, allowing for appropriate therapies and education to enhance later academic, behavioral, psychosocial, and adaptive functioning.

Serum S100B and neuron-specific enolase levels in normothermic and hypothermic infants after perinatal asphyxia

AIM

Serum S100B and neuron-specific enolase (NSE) levels are elevated after perinatal asphyxia, but the influence of hypothermia on these proteins has not been previously reported. The aim of this study was to evaluate the effect of systemic hypothermia on these protein levels after perinatal asphyxia, time course, and association with perinatal factors and neurodevelopmental outcome at 2 years of age.

METHODS

Serum S100B and NSE levels were measured at fixed time points in asphyxiated infants treated with standard intensive care on hypothermia (HT: n = 13) or normothermia (NT: n = 11).

RESULTS

Serum S100B and NSE levels were grossly elevated in both HT and NT groups. Compared with the values at 6 h of age, S100B values decreased over time in both groups (NT: p = 0.002, HT: p = 0.04). Serum S100B values were lower in HT infants compared with those in NT infants (p = 0.047 at 48 h). Serum S100B and NSE values were significantly higher in infants who died or developed severe neurological impairment (S100B, p < 0.05 at all time points; NSE, p = 0.036 at 24 h of age).

CONCLUSION

Both NSE and S100B levels are highly elevated following asphyxia. Serum S100B levels were lower in the HT group and strongly correlated with the neurodevelopmental outcome.

Neuropsychological tests, MRI and SPECT in the evaluation of CNS involvement in SLE

OBJECTIVE

To assess the agreement between presence and location of central nervous system (CNS) structural damage and neuropsychological performance.

METHODS

21 unselected SLE patients underwent a 3 hours-long battery of neuropsychological tests sampling 15 cognitive functions. A neuropsychologist hypothesized for each SLE patient the most likely site of possible involvement, according to the neuropsychological performance. Patients underwent MRI scans within 6 months (3 months before or after) from neuropsychological tests and SPECT.

RESULTS

14 of the 21 SLE patients (66.6%) were impaired in at least 1 function; among these, 7 patients (33.3%) were mildly impaired and 7 (33.3%) had more than 3 functions impaired. 10 patients (48%) had abnormal MRI scan. Negative and positive agreements between neuropsychological performance and MRI scan were detected in 15 patients (71%; ?2 with Yates' correction 6.09, p 0.007, measure K for concordance 0.44, p 0.03). All the 6 negative agreements had no records of major neurologic or psychiatric events; among the 9 positive agreements, 6 presented previous major neurologic events and 2 minor neuropsychiatric symptoms. Among the subjects with disagreement, 1 was unimpaired with positive MRI and without neuropsychiatric symptoms, 5 were mildly impaired with negative MRI.

CONCLUSIONS

A detailed neuropsychological evaluation along with MRI arose as a valid method to exclude or to identify, localize and clinically interpret CNS involvement in SLE. Disagreement between MRI and neuropsychological tests was detected mainly for mild cognitive impairment that might be the expression of functional (inflammatory or ischemic) processes.

Ridiculous statements by mental health experts

When mental health experts express their opinions in testimony, reports, and articles in professional literature, it is expected that their statements will accurately reflect the current state of knowledge. Experts may disagree about the data that they collected. In some cases, however, disagreement occurs because an expert has employed a methodology that is far outside usual procedures or simply disregarded objective facts. When that occurs, the expert's opinions may be considered ridiculous. The author presents examples of ridiculous statements by mental health experts and provides suggestions for how a forensic practitioner might address ridiculous statements by mental health experts.

[Dissociation (conversion) - malingering - antisocial personality disorder: differential diagnostic reflection on the basis of a case study]

In this case report we refer to the big challenge of making a diagnosis in a deliberate malingering in the field of mental disorders. We specifically describe the difficulty regarding the differentiation between a conversion disorder and malingering of a serial delinquent. For such a person avoiding criminal persecution is one of the most frequent reason to deceitfully simulate a mental illness. In this field, symptoms of conversion disorders exceed the average; furthermore, a great number of organic-neurological illnesses may appear to be very similar to a conversion disorder or in many cases a neurological disorder can actually be detected in the course of a somatic examination. A further obstacle for the differential diagnosis can be seen in the difficulty to discern it from factitious disorders. However, it is quite possible to discern the deliberate malingering of a mental disorder from a conversion disorder by means of the diligent diagnosis of a competent and experienced doctor/assessor who specialises.

Münchhausen by Proxy Syndrome in Clinical Child Neuropsychology: A Case Presenting With Neuropsychological Symptoms

Münchhausen by proxy syndrome (MBPS) is a rare but dramatic variant of child abuse. In MBPS adults, mostly the mother, invent, manipulate, or produce the child's illness, and as a consequence the child has to undergo numerous diagnostic or treatment procedures. Typically, valid information about the etiology of the child's illness is withheld by the parents, and reversible symptoms vanish, when the child and the responsible adults are separated. Although valid statistical data about the epidemiology of MBPS are not available, MBPS should be considered more often than normally recognized. Neurological and neuropsychological presentations including developmental delays and learning problems appear to be common among MBPS cases so that clinical child neuropsychologists should be aware of this problem and consider MBPS at least in some of the mysterious cases that come to their attention. The present study describes a case of MBPS in which neurological and neuropsychological symptoms predominate. It presents a MBPS variant that is characterized by developmental delays and learning problems induced by unnecessary isolation at home, hospitalization, and treatment procedures. In the present case MBPS was at first suspected following neuropsychological assessment, since some of the main features of non-authenticity of symptom presentation gave cause for suspecting deceptive behavior on the mother's (and possibly also on the maternal grandmother's) side.

The Implications of Childhood Bacterial Meningitis for Language Development

Bacterial meningitis is a life threatening infection of the central nervous system. This illness is most prevalent early in life when the healthy child is rapidly acquiring language. This study investigated whether children with a history of bacterial meningitis were at risk for language difficulties post illness. Thirty post-meningitic children, aged between 9 years 0 months and 11 years 0 months, participated in this study. Each subject was administered a measure of non-verbal cognitive ability and a range of language tasks. These children performed poorly on applied language tasks, which tap skills used in effective discourse. These deficits occurred despite age appropriate performances on measures of linguistic/grammatical knowledge. These findings clearly illustrate that bacterial meningitis has implications for ongoing language development, which emphasises the importance of long term follow up. In developmental terms, this discrepancy between verbal knowledge and problem solving represents a dissociation between language skills which develop early in life and those which emerge later. This pattern of results suggests that bacterial meningitis may result in a delay in language development. A young age at illness was identified as an additional risk factor for adverse outcome. This study highlights the need to inform parents/guardians that post-meningitic children are at risk for experiencing language difficulties throughout childhood.

Using the Halstead–Reitan Battery to Diagnose Brain Damage: A Comparison of the Predictive Power of Traditional Techniques to Rohling’s Interpretive Method

The aim of this project was to validate an alternative global measure of neurocognitive impairment (Rohling Interpretive Method, or RIM) that could be generated from data gathered from a flexible battery approach. A critical step in this process is to establish the utility of the technique against current standards in the field. In this paper, we compared results from the Rohling Interpretive Method to those obtained from the General Neuropsychological Deficit Scale (GNDS; Reitan & Wolfson, 1988) and the Halstead-Russell Average Impairment Rating (AIR; Russell, Neuringer & Goldstein, 1970) on a large previously published sample of patients assessed with the Halstead-Reitan Battery (HRB). Findings support the use of the Rohling Interpretive Method in producing summary statistics similar in diagnostic sensitivity and specificity to the traditional HRB indices.

Event-Related Potential Findings in Healthy Extremely Pre-Term (< Week 29) Children at Age 10

Ten healthy extremely pre-term (EPT) children, born before gestational week 29, were tested at age 10 using mismatch negativity (MMN) and a three-tone odd-ball task; the results were then compared to age-matched full-term controls. We found no difference in MMN. By contrast, EPT children had generally shorter N1 latencies and larger P2 amplitudes, possibly indicating a more stimulus-driven response mode. However, P300 parameters, indicative of controlled attention, were unaffected.

Detecting Poor Effort and Malingering With an Expanded Version of the Auditory Verbal Learning Test (AVLTX): Validation With Clinical Samples

Three studies describe the development and validation of a new procedure (AVLTX) to detect inadequate effort or malingering by adding 60-min delayed recall/recognition trials and identifying "impaired" memory performances that are highly inconsistent with performances of brain-damaged (BD) individuals. In Study I, AVLTX performances of 25 probable malingerers (PMs) were compared with those of 43BD and 40 psychiatric patients (PSYs). Seven inconsistencies were identified and converted to scaled inconsistency scores, yielding the exaggeration index (EI). Study II reported cross-validation in an independent sample of 34 PM, 70BD and 89 PSY, showing sensitivity of 0.59 and specificities of 0.97 (BD) and 0.92 (PSY). Study III compared the diagnostic accuracy of the EI with two well-established effort assessment paradigms, exemplified by the RMTand DRT (a symptom validity test). The RMT showed excellent sensitivity and poor specificity; the DRT showed poor sensitivity and excellent specificity; the EI showed good sensitivity and excellent specificity. Adding a second delayed trial to list-learning tests can be a time-efficient procedure to detect inadequate effort.

Hyperdense middle cerebral artery sign is an ominous prognostic marker despite optimal workflow

OBJECTIVES

To evaluate the association between the hyperdense middle cerebral artery sign (HMCAS) and the functional outcome on one hand, and different predictors such as the National Institutes of Health Stroke Scale (NIHSS), infarct size, ASPECTS Score, intracerebral hemorrhage, and mortality on the other hand.

MATERIAL AND METHODS

Retrospective analysis of 120 patients with MCA-stroke treated with intravenous thrombolysis. We tested the association between HMCAS and NIHSS, infarct volume, ASPECTS, outcome, level of consciousness, different recorded time intervals, and the day/time of admission.

RESULTS

Seventy-four percentage of patients treated with thrombolysis developed cerebral infarction. All patients with HMCAS (n = 39) sustained infarction and only 31% showed favorable outcome compared with 62% and 60%, respectively among patients without HMCAS (P < 0.001 and P = 0.002). There was statistically significant association between functional outcome and HMCAS (P = 0.002), infarct volume, NIHSS, and ASPECTS (P < 0.001). The time to treatment was 12 min shorter in patients who developed infarction (P = 0.037). Independent predictors for outcome were NIHSS and the occurrence of cerebral infarction on computed tomography for the whole study population, and infarct volume for patients who sustained cerebral infarction.

CONCLUSIONS

Despite optimal workflow, patients with HMCAS showed poor outcome after intravenous thrombolysis. The results emphasize the urgent need for more effective revascularization therapies and neuroprotective treatment in this subgroup of stroke patients.

Split-brain syndrome after hepatic transplantation: a tacrolimus-related vasculitis?

An unusual case of inter-haemispheric disconnection syndrome occurring in a patient who had undergone hepatic transplantation is presented. The underlying disorder, at first wrongly interpreted as encephalitis, was found to be severe, diffuse cerebral vasculitis. The hypothesis that treatment with tacrolimus might have caused, or at least favoured the vascular damage is discussed.

[S100B protein and autoantibodies to S100B protein in diagnostics of brain damage in craniocerebral trauma in children]

Levels of antibodies AB (AB) to S100B and S100B protein were studied in the blood serum of children with different severity and outcomes of traumatic brain injury (TBI) from the 1st to 15-75th days after TBI. Severity and outcomes were assessed using the Glasgow Coma Scale (GCS). Patients were stratified by outcomes into the following groups: complete recovery (group 1), moderate disability (group 2), high disability (group 3), vegetative state (group 4) and fatal outcome (group 5). In patients of groups 1-3, the changes of S100B in the blood serum didn't depend on the severity of brain's damage; the significant increase of S100B protein levels in the 1st day was accompanied by the decrease to the normal range in the following 2-3 days. On the contrary, the levels of nAB in these groups increased starting from 3-5 days corresponding to the severity of brain's damage. The development of vegetative state was accompanied by low S100B and high AB to S100B levels in the blood serum. The maximal level of S100B protein and increased levels of AB were observed in patients with fatal outcome. In most patients with combined TBI, the levels of both parameters were higher compared to those with separate TBI.

Delayed encephalopathy and cognitive sequelae after acute carbon monoxide poisoning: report of a case and review of the literature

Serious delayed encephalopathy and cognitive sequelae following acute carbon monoxide intoxication constitutes a rare and a distinct entity. A case of delayed encephalopathy and cognitive sequelae after acute carbon monoxide poisoning is presented. The patient is a 50-year-old Thai female with a history of carbon monoxide poisoning during her vacation tour in Arizona in winter. She developed encephalopathy 4 weeks after recovery from the acute stage. Her MRI-brain found abnormal white matter change of cerebral hemispheres bilaterally and abnormal signal intensity at both putamens and caudate nuclei. She regained some improvement in her memory and other cognitive function after 4 weeks of treatment including hyperbaric oxygen therapy (HBOT).

Investigating whether adverse prenatal and perinatal events are associated with non-clinical psychotic symptoms at age 12 years in the ALSPAC birth cohort

BACKGROUND

Non-clinical psychosis-like symptoms (PLIKS) occur in about 15% of the population. It is not clear whether adverse events during early development alter the risk of developing PLIKS. We aimed to examine whether maternal infection, diabetes or pre-eclampsia during pregnancy, gestational age, perinatal cardiopulmonary resuscitation or 5-min Apgar score were associated with development of psychotic symptoms during early adolescence.

METHOD

A longitudinal study of 6356 12-year-old adolescents who completed a semi-structured interview for psychotic symptoms in the Avon Longitudinal Study of Parents and Children (ALSPAC) birth cohort. Prenatal and perinatal data were obtained from obstetric records and maternal questionnaires completed during pregnancy.

RESULTS

The presence of definite psychotic symptoms was associated with maternal infection during pregnancy [adjusted odds ratio (OR) 1.44, 95% confidence interval (CI) 1.11-1.86, p=0.006], maternal diabetes (adjusted OR 3.43, 95% CI 1.14-10.36, p=0.029), need for resuscitation (adjusted OR 1.50, 95% CI 0.97-2.31, p=0.065) and 5-min Apgar score (adjusted OR per unit decrease 1.30, 95% CI 1.12-1.50, p<0.001). None of these associations were mediated by childhood IQ score. Most associations persisted, but were less strong, when including suspected symptoms as part of the outcome. There was no association between PLIKS and gestational age or pre-eclampsia.

CONCLUSIONS

Adverse events during early development may lead to an increased risk of developing PLIKS. Although the status of PLIKS in relation to clinical disorders such as schizophrenia is not clear, the similarity between these results and findings reported for schizophrenia indicates that future studies of PLIKS may help us to understand how psychotic experiences and clinical disorders develop throughout the life-course.

[Mentoring system--performance optimization of treatment by formative case management]

The efficiency of the German public health system and its principle of adequate treatment are not up to the standards required by accident insurance companies. These have to be interested in realising optimal treatment, because the amount of pecuniary reparation essentially depends on (the quality of) the state of health of the injured person. To accomplish these objectives, their case management departments have to find a way to use the resources of the public health system and to improve considerably the quality of process und structure of the treatment. This is why case management is becoming increasingly important for insurance companies. Against this background, this case report describes the process of rehabilitation of a 72-year-old woman who had an accident and suffered a traumatic brain injury. This process was managed by AMB Generali Schadenmanagement GmbH in cooperation with the consulting firm Haase & Johanns Consulting, to develop approaches to rehabilitation management. It describes the mutual benefit for the injured person and of the insurer, which is defined by the success of treatment and saving of costs (care home, damages for pain and suffering) amounting to about 700,000 Euros.