Misdiagnosis of the vegetative state: retrospective study in a rehabilitation unit.

OBJECTIVE--To identify the number of patients who were misdiagnosed as being in the vegetative state and their characteristics. DESIGN--Retrospective study of the clinical records of the medical, occupational therapy, and clinical psychology departments. SETTING--20 bed unit specialising in the rehabilitation of patients with profound brain damage, including the vegetative state. SUBJECTS--40 patients admitted between 1992 and 1995 with a referral diagnosis of vegetative state. OUTCOME MEASURES--Patients who showed an ability to communicate consistently using eye pointing or a touch sensitive single switch buzzer. RESULTS--Of the 40 patients referred as being in the vegetative state, 17 (43%) were considered as having been misdiagnosed; seven of these had been presumed to be vegetative for longer than one year, including three for over four years. Most of the misdiagnosed patients were blind or severely visually impaired. All patients remained severely physically disabled, but nearly all were able to communicate their preference in quality of life issues-some to a high level. CONCLUSIONS--The vegetative state needs considerable skill to diagnose, requiring assessment over a period of time; diagnosis cannot be made, even by the most experienced clinician, from a bedside assessment. Accurate diagnosis is possible but requires the skills of a multidisciplinary team experienced in the management of people with complex disabilities. Recognition of awareness is essential if an optimal quality of life is to be achieved and to avoid inappropriate approaches to the courts for a declaration for withdrawal of tube feeding.     

The vegetative state as a manifestation of a stable pathological state

The results of comprehensive monitoring of the state of 25 patients in the vegetative state (prolonged coma) before and after compensating for the factors of secondary brain damage were analyzed and followed up for no less than six months. The primary results showed that the best recovery of consciousness and cognitive functions was observed if, according to the positron emission tomography data, a diffuse decrease in the glucose metabolism rate (GMR_glu), significantly exceeding the extent of the zones of morphological/anatomical lesions, was present in the brain before treatment, while the minimal improvement was observed if the GMR_glu was sufficiently intact. These and other paradoxical results can be explained if the vegetative state is regarded as a stable pathological state of the brain, which offers new approaches to the treatment of this group of patients.     

Patients in the persistent vegetative state: problems in their long term management.

Physicians responsible for the long term management of patients in the persistent vegetative state face several problems. These include deciding whether tube feeding is treatment or nutritional care, whether withdrawal of tube feeding is an appropriate form of management, what clinical advantage there is in active treatment; at what level of awareness can a patient be said to have a quality of life; and who should determine a patient''s right to die. These problems are determined more by social, legal, emotional, cultural, religious, and economic forces than by clinical facts.     

An ecological study of Caiman crocodilus crocodilus inhabiting savanna lagoons in the Venezuelan Guayana

Summary Mark and recapture studies were carried out for three and a half years on a population of Caiman c. crocodilus inhabiting a savanna lagoon system in the Venezuelan Guayana. Sub-adult and adult caimans migrated from permanent lagoon refuges to temporary lagoons during the wet season. A distinct homing response by artificially displaced caimans was observed.The wet season was the most significant time of the year for both feeding and growth. It was estimated that caimans take 6 years to reach a size of 97 cm. Thereafter the growth rate was variable. During a dry year there was little growth, but during a wet year a large caiman could increase in length by up to 10 cm.During the first 18 months of life, young caimans remained near the nest site. Older caimans dispersed and competed for territories which resulted in a high incidence of damage, particularly to the tails, as a result of intraspecific fighting.     

Functional neuroimaging of the vegetative state

A number of recent studies have demonstrated a role for state-of-the-art neuroimaging methods in the assessment of patients in the vegetative state and other so-called 'disorders of consciousness'. In several cases, functional MRI has been used to show that aspects of speech perception, emotional processing, language comprehension and even conscious awareness might be retained in some patients who behaviourally meet all of the criteria that define the vegetative state. This work has profound implications for clinical care, diagnosis, prognosis and medical-legal decision making (relating to the prolongation, or otherwise, of life after severe brain injury), as well as for more basic scientific questions about the nature of consciousness and the neural representation of our own thoughts and intentions.     

The Clinical Utility of fMRI for Identifying Covert Awareness in the Vegetative State: A Comparison of Sensitivity between 3T and 1.5T

In the last few years, mental imagery fMRI paradigms have been used successfully to identify covert command-following and awareness in some patients who are thought to be entirely vegetative. However, to date there is only evidence supporting their use at magnetic fields of 3T, which limits their applicability in clinical settings where lower field strengths are typically used. Here, we test the ‘gold standard’ fMRI paradigm for detecting residual awareness in non-responsive patients by comparing its sensitivity at 1.5T and 3T in the same group of healthy volunteers. We were able to successfully detect brain activity showing command-following in most participants at both 3T and 1.5T, with similar reliability. These results demonstrate that fMRI assessment of covert awareness is clinically viable and therefore justify a broader use of these methods in standard assessments in severely brain injured patients.     

Breast feeding,nutritional state,and child survival in rural Bangladesh

The effect of breast feeding on nutritional state, morbidity, and child survival was examined prospectively in a community in rural Bangladesh. Every month for six months health workers inquired about breast feeding and illness and measured arm circumference in an average of 4612 children aged 12-36 months. Data from children who died within one month of a visit were compared with those from children who survived. Roughly one third of the deaths in the age range 18-36 months were attributable to absence of breast feeding. Within this age range protection conferred by breast feeding was independent of age but was evident only in severely malnourished children.In communities with a high prevalence of malnutrition breast feeding may substantially enhance child survival up to 3 years of age.     

INITIATION AND ONTOGENY OF THE MICROSPORANGIATE CONE IN CUPRESSUS ARIZONICA IN RESPONSE TO GIBBERELLIN

Cupressus arizonica, a member of the Cupressaceae, was induced to produce pollen cones in response to gibberellin treatment. All apices remained vegetative during the first 17 days of treatment. At this time many lateral vegetative apices began to undergo a transition to the reproductive state. The transition was marked by changes in apical zonation characterized by increased mitotic activity primarily in the subapical mother-cell and peripheral zones. Also, precocious initiation of branch meristems occurred much higher on the shoot apex than before the transition period. About 22 days after the initial treatment, most apices became distinctly reproductive. The reproductive apex has a zonation pattern similar to the branching apex but is shorter and wider and quite distinct from the vegetative apex. The small subapical mother cells and cells of the peripheral zone form a continuous mantle of mitotically active cells with prominent nucleoli. This mantle encloses a very broad pith region which differentiates nearly to the summit of the apex. Microsporophyll and leaf initiation are similar and the protoderm of the apex remains discrete and does not contribute to deeper tissues. Sporangia do not originate from superficial cells of the microsporophyll. After all microsporophylls are initiated the reproductive apex becomes inactive. A discussion concerns the morphological implication in the origin of the foliar structures and of the similarity of C. arizonica to many angiosperms in the transition of the apex from vegetative to reproductive.     

An anatomofunctional brain database

This study proposes a closer look at the neuropsychological method defined as the study of the neural bases of the behavioural and cognitive functions using an organisation-representation model for current data and knowledge of the brain, and the application of an anatomofunctional database. A Centre of Cognitive Anatomy (CAC) was set up for the collection and processing of neuronatomical, neuropsychological, and psycho-behavioural data for patients presenting sequels of focal brain damage. Such a system would allow concurrent treatment of anatomical and functional data. We would expect the results from such a model to produce stable 'anatomofunctional laws' that would be independent of all inter-individual variations in the functioning of the brain and could be checked against the entire database of information. A direct application would be the improvement of cognitive and/or behavioural rehabilitation of patients with brain damage.     

Susceptibility-Weighted Imaging in Heat Stroke

Objective

To assess the role of susceptibility-weighted imaging in the detection of intracranial hemorrhage after heat stroke and in the prognosis.

Materials and Methods

The study group consisted of eight patients after heat stroke, with a score of 3 to 9 in Glasgow Coma Scale. The MR studies were performed with a 1.5 T scanner. Susceptibility-weighted imaging data were collected within 2–5 days after heat stroke. The study was approved by ethics committee, and written informed consents were obtained from family members of the patients.

Results

Punctate hemorrhages were detected in brain stem, corona radiata and frontal lobe by susceptibility-weighted imaging for three patients. Among the three cases, two patients came to death in the 5th day and the 25th day after heat stroke respectively. Another patient became a persistent vegetative state and died about 3 months later. Five patients with no hemorrhage detected gradually recovered and cerebellar dysfunction remained to various degrees.

Conclusions

Heat stroke is a life-threatening condition characterized by hyperthermia and accompanied by various complications such as disseminated intravascular coagulation. Susceptibility-weighted imaging is a very useful tool for detection of intracranial hemorrhage and may probably evaluate the prognosis after heat stroke.     

Life or death: prognostic value of a resting EEG with regards to survival in patients in vegetative and minimally conscious States

Objective

To investigate the potentially prognostic value of a resting state electroencephalogram (EEG) with regards to the clinical outcome from vegetative and minimally conscious states (VS and MCS) in terms of survival six months after a brain injury.

Methods

We quantified a dynamic repertoire of EEG oscillations in resting condition with eyes closed in patients in VS and MCS. The exact composition of EEG oscillations was assessed by analysing the probability-classification of short-term EEG spectral patterns.

Results

Results demonstrated that (a) the diversity and the variability of EEG for Non-Survivors were significantly lower than for Survivors; and (b) a higher probability of mostly delta and slow-theta oscillations occurring either alone or in combination were found during the first assessment for patients with a bad outcome (i.e., those who died) within six months of an injury compared to patients who survived. At the same time, patients with a good outcome (i.e., those who survived) after six months post-injury had a higher probability of mostly fast-theta and alpha oscillations occurring either alone or in combination during the first assessment when compared to patients who died within six months of an injury.

Conclusions

Resting state EEGs properly analysed may have a potentially prognostic value with regards to the outcome from VS or MCS in terms of survival six months after a brain injury.

Significance

This work may have implications for clinical care, rehabilitative programmes and medical–legal decisions for patients with impaired consciousness states after being in a coma due to acute brain injuries.     

Successful rehabilitation in conversion paralysis.

A rehabilitation programme for patients with conversion paralysis has been introduced in which they are offered physical rehabilitation. During an eight month period between October 1984 and May 1985 six patients who had been diagnosed as dependent on wheelchairs owing to conversion paralysis for a mean of 3 years (range 1-6 years) were entered into the inpatient neurorehabilitation programme. All six patients were able to walk within a mean of 41 days (range 10-70 days), and then relinquished a variety of aids and allowances as a result of their regained mobility. They continued to be independent at outpatient review for a mean of 10 months (range 8-15 months). Successful rehabilitation from wheelchair dependency can be achieved by a cost effective, prolonged, inpatient neurorehabilitation programme.     

Effect of Motor Imagery in Children with Unilateral Cerebral Palsy: fMRI Study

Background

Motor imagery is considered as a promising therapeutic tool for rehabilitation of motor planning problems in patients with cerebral palsy. However motor planning problems may lead to poor motor imagery ability.

Aim

The aim of this functional magnetic resonance imaging study was to examine and compare brain activation following motor imagery tasks in patients with hemiplegic cerebral palsy with left or right early brain lesions. We tested also the influence of the side of imagined hand movement.

Method

Twenty patients with clinical hemiplegic cerebral palsy (sixteen males, mean age 12 years and 10 months, aged 6 years 10 months to 20 years 10 months) participated in this study. Using block design, brain activations following motor imagery of a simple opening-closing hand movement performed by either the paretic or nonparetic hand was examined.

Results

During motor imagery tasks, patients with early right brain damages activated bilateral fronto-parietal network that comprise most of the nodes of the network well described in healthy subjects. Inversely, in patients with left early brain lesion brain activation following motor imagery tasks was reduced, compared to patients with right brain lesions. We found also a weak influence of the side of imagined hand movement.

Conclusion

Decreased activations following motor imagery in patients with right unilateral cerebral palsy highlight the dominance of the left hemisphere during motor imagery tasks. This study gives neuronal substrate to propose motor imagery tasks in unilateral cerebral palsy rehabilitation at least for patients with right brain lesions.     

Rapid declines in metabolism explain extended coral larval longevity

Lecithotrophic, or non-feeding, marine invertebrate larvae generally have shorter pelagic larval durations (PLDs) than planktotrophic larvae. However, non-feeding larvae of scleractinian corals have PLDs far exceeding those of feeding larvae of other organisms and predictions of PLD based on energy reserves and metabolic rates, raising questions about how such longevity is achieved. Here, we measured temporal changes in metabolic rates and total lipid content of non-feeding larvae of four species of reef corals to determine whether changes in energy utilization through time contribute to extended larval durations. The temporal dynamics of both metabolic rates and lipid content were highly consistent among species. Prior to fertilization, metabolic rates were low (2.73–8.63 nmol O₂ larva^?1 h^?1) before rapidly increasing to a peak during embryogenesis and early development 1–2 days after spawning. Metabolic rates remained high until shortly after larvae first became competent to metamorphose and then declined by up to two orders of magnitude to levels at or below rates seen in unfertilized eggs over the following week. Larvae remained in this state of low metabolic activity for up to 2 months. Consistent with temporal patterns in metabolic rates, depletion of lipids was extremely rapid during early development and then slowed dramatically from 1 week onward. Despite the very low metabolic rates in these species, larvae continued to swim and retained competence for at least 2 months. The capacity of non-feeding coral larvae to enter a state of low metabolism soon after becoming competent to metamorphose significantly extends dispersal potential, thereby accruing advantages typically associated with planktotrophy, notably enhanced population connectivity.     

Plasmapheresis in the initial treatment of insulin-dependent diabetes mellitus in children.

Several factors indicate that autoimmune mechanisms may play a part in the aetiology of insulin-dependent diabetes mellitus. At the onset of the disease in 10 children (aged 11-16 years) plasmapheresis was performed four times over one to two weeks. Seventeen age-matched children with the same clinical features served as controls. The C-peptide concentrations at onset were the same in the two groups, but after one month the children treated with plasmapheresis had significantly higher values. This difference became even more pronounced after three, nine, and 18 months, both during fasting and at the maximum response to a standardised meal. The study group also had a significantly more stable metabolism, longer partial remission, and no higher insulin requirement. Of the 10 treated children islet-cell cytoplasmic antibodies were present in seven before plasmapheresis and in nine during treatment. The antibodies remained detectable in five and six out of nine patients at one and six months respectively after plasmapheresis. Although the mechanisms are obscure, plasmapheresis performed at the onset of insulin-dependent diabetes mellitus may help to preserve beta-cell function.     

Changes in the content of endogenous auxins in apical buds ofchenopodium rubrum L. Induced with respect to the endogenous rhythm in capacity to flower

The content of endogenous auxins was examined in apical buds ofChenopodium rubrum plants induced by a photoperiodic cycle of 16h darkness and 8h light followed by a dark period of various duration so as to correspond with either maximal or minimal flowering response in the endogenous rhythm in capacity to flower initiated by the photoperiodic treatment. Apical buds of potentially generative plants contained less auxins than apical buds of plants which remained in the vegetative state. Apical buds from plants treated with kinetin (1. 10^-3 M) and therefore remaining in the vegetative state showed an auxin level comparable to that of untreated plants exhibiting minimal flowering response irrespective of the duration of the second dark period. Plants cultivated on a sucrose solution (0.6 M) during the second dark period became generative even at the normal minimum of flowering. The auxin content of the apical buds was low, similarly as in untreated plants induced for a period leading to maximal flowering response. On the other hand, apical buds from plants grown on sucrose solution during a dark period leading to the manifestation of maximal flowering response showed a relatively high auxin content comparable to that found in untreated plants which had obtained a more extended induction by three photoperiodic cycles. The results are discussed with respect to the possible role of endogenous auxins in the regulation of the changes in growth correlations occurring in the shoot apex during photoperiodic induction and in the expression of the competence to flower.     

Direct cost associated with acquired brain injury in Ontario

ABSTRACT: BACKGROUND: Acquired Brain Injury (ABI) from traumatic and non traumatic causes is a leading cause of disability worldwide yet there is limited research summarizing the health system economic burden associated with ABI. The objective of this study was to determine the direct cost of publicly funded health care services from the initial hospitalization to three years post-injury for individuals with traumatic (TBI) and non-traumatic brain injury (nTBI) in Ontario Canada. METHODS: A population-based cohort of patients discharged from acute hospital with an ABI code in any diagnosis position in 2004 through 2007 in Ontario was identified from administrative data. Publicly funded health care utilization was obtained from several Ontario administrative healthcare databases. Patients were stratified according to traumatic and non-traumatic causes of brain injury and whether or not they were discharged to an inpatient rehabilitation center. Health system costs were calculated across a continuum of institutional and community settings for up to three years after initial discharge. The continuum of settings included acute care emergency departments inpatient rehabilitation (IR) complex continuing care home care services and physician visits. All costs were calculated retrospectively assuming the government payer's perspective. RESULTS: Direct medical costs in an ABI population are substantial with mean cost in the first year post-injury per TBI and nTBI patient being $32132 and $38018 respectively. Among both TBI and nTBI patients those discharged to IR had significantly higher treatment costs than those not discharged to IR across all institutional and community settings. This tendency remained during the entire three-year follow-up period. Annual medical costs of patients hospitalized with a brain injury in Ontario in the first follow-up year were approximately $120.7 million for TBI and $368.7 million for nTBI. Acute care cost accounted for 46-65 % of the total treatment cost in the first year overwhelming all other cost components. CONCLUSIONS: The main finding of this study is that direct medical costs in ABI population are substantial and vary considerably by the injury cause. Although most expenses occur in the first follow-up year ABI patients continue to use variety of medical services in the second and third year with emphasis shifting over time from acute care and inpatient rehabilitation towards homecare physician services and long-term institutional care. More research is needed to capture economic costs for ABI patients not admitted to acute care.     

First record of the olive bud mite Oxycenus maxwelli (Keifer) (Acari: Eriophyidae) from Brazil

The mite Oxycenus maxwelli (Keifer) (Eriophyidae) is reported for the first time in Brazil infesting olive trees, Olea europaea. Specimens were found on seedlings at Maria da Fé, state of Minas Gerais, in 2007. Although minor symptoms were not noticed, significant damage to plants were observed. There is no reliable evidence of when the mite could have been introduced. It is believed that the mite occurs since the first introductions of olive trees, around 1820, through vegetative propagating material, but the mite remained unnoticed due to the lack of studies with olive trees in Brazil.     

RESTING CELLS OF PEDIASTRUM

Davis , Joseph S. (Southern Illinois U., Edwardsville.) Resting cells of Pediastrum. Amer. Jour. Bot. 49(5): 478–481. Illus. 1962.—After approximately 10 weeks in a partially defined mineral medium, cells of vegetative colonies of Pediastrum boryanum lost their chlorophyll and became orange resting cells. The resting cells were colored orange by carotenoid pigment dissolved in fat droplets within the cells. No cell wall thickening occurred during or after resting-cell formation. Starch was abundant in the resting cells. Dried resting cells remained viable for at least 4 years. When placed in the culture medium, 4-year-old dried resting cells became green and reproduced like vegetative cells.