Jorge Maurino

Spontaneous and reflex movements in brain death

Article abstract Spontaneous and reflex movements may be found in patients with brain death (BD). The authors prospectively evaluated their frequency using a standardized protocol. Among 38 patients who fulfilled criteria for BD, the authors found 15 (39%) with spontaneous or reflex movements. The most common movement was finger jerks. Undulating toe flexion sign, triple flexion response, Lazarus sign, pronation–extension reflex, and facial myokymia also were seen. These movements may be more common than reported and do not preclude the diagnosis of BD.

Suboptimal treatment adherence in bipolar disorder: impact on clinical outcomes and functioning

Background The primary aim of this study was to assess drug treatment adherence in patients with bipolar disorder and to identify factors associated with adherence. The secondary aim was to analyze the impact of suboptimal adherence on clinical and functional outcomes. Methods A cross-sectional study was conducted in a sample of outpatients receiving an oral antipsychotic drug. Medication adherence was assessed combining the 10-item Drug Attitude Inventory, the Morisky Green Adherence Questionnaire, and the Compliance Rating Scale. Logistic regression was used to determine significant variables associated with suboptimal adherence to medication. Results Three hundred and three patients were enrolled into the study. The mean age was 45.9 ± 12.8 years, and 59.7% were females. Sixty-nine percent of patients showed suboptimal adherence. Disease severity and functioning were significantly worse in the suboptimal group than in the adherent group. Multivariate analysis showed depressive polarity of the last acute episode, presence of subsyndromal symptoms, and substance abuse/dependence to be significantly associated with suboptimal treatment adherence (odds ratios 3.41, 2.13, and 1.95, respectively). Conclusion A high prevalence of nonadherence was found in an outpatient sample with bipolar disorder. Identification of factors related to treatment adherence would give clinicians the opportunity to select more adequately patients who are eligible for potential adherence-focused interventions.

Pupillary diameter assessment: Need for a graded scale

Assessment of pupillary diameter is useful for lesion location, a necessary step in diagnosing neurologic disorders.1,2 Recognition of pupillary changes can serve as an early warning of acute brain injury, and may, with prompt treatment, prevent further injury. However, not all pupillary changes are relevant, because size changes in various physiologic or pharmacologic conditions.1 A few studies have evaluated the reliability of nurses to assess pupils,3,4 but none evaluated the reliability of physicians. Because, in practice, physicians usually use their own impression to assess pupillary diameter, we questioned if such a practice is justified. In this study, the inter- and intrarater reliability of physicians assessing pupillary diameters using their own judgment or a graded scale was evaluated. Four third- and fourth-year neurology residents consecutively evaluated the pupil size of 100 subjects (60% men; median age, 41.5 years) in randomized order. Subjects gave informed consent. Raters assessed pupil diameter twice with a 20-minute difference between …

Impact of depressive symptoms on subjective well-being: the importance of patient-reported outcomes in schizophrenia

Objective The subjective experience of psychotic patients toward treatment is a key factor in medication adherence, quality of life, and clinical outcome. The aim of this study was to assess the subjective well-being in patients with schizophrenia and to examine its relationship with the presence and severity of depressive symptoms. Methods A multicenter, cross-sectional study was conducted with clinically stable outpatients diagnosed with schizophrenia. The Subjective Well-Being under Neuroleptic Scale – short version (SWN-K) and the Calgary Depression Scale for Schizophrenia (CDSS) were used to gather information on well-being and the presence and severity of depressive symptoms, respectively. Spearman’s rank correlation was used to assess the associations between the SWN-K total score, its five subscales, and the CDSS total score. Discriminative validity was evaluated against that criterion by analysing the area under the curve (AUC). Results Ninety-seven patients were included in the study. Mean age was 35 years (standard deviation = 10) and 72% were male. Both the total SWN-K scale and its five subscales correlated inversely and significantly with the CDSS total score (P < 0.0001). The highest correlation was observed for the total SWN-K (Spearman’s rank order correlation [rho] = −0.59), being the other correlations: mental functioning (−0.47), social integration (−0.46), emotional regulation (−0.51), physical functioning (−0.48), and self-control (−0.41). A total of 33 patients (34%) were classified as depressed. Total SWN-K showed the highest AUC when discriminating between depressive severity levels (0.84), followed by emotional regulation (0.80), social integration (0.78), physical functioning and self-control (0.77), and mental functioning (0.73). Total SWN-K and its five subscales showed a significant linear trend against CDSS severity levels (P < 0.001). Conclusion The presence of moderate to severe depressive symptoms was relatively high, and correlated inversely with patients’ subjective well-being. Routine assessment of patient-reported measures in patients with schizophrenia might reduce potential discrepancy between patient and physician assessment, increase therapeutic alliance, and improve outcome.

Short-term clinical stability and lack of insight are associated with a negative attitude towards antipsychotic treatment at discharge in patients with schizophrenia and bipolar disorder

Purpose The primary aim of this study was to assess the range of attitudes towards antipsychotic treatment at hospital discharge in patients with schizophrenia and bipolar disorder. The secondary aim was to analyze the relationship between patients’ attitudes and sociodemographic and clinical parameters. Patients and methods A cross-sectional study with a sample of patients admitted due to acute exacerbation of schizophrenia or a manic episode was conducted. Attitude towards pharmacological treatment at discharge was assessed with the 10-item Drug Attitude Inventory (DAI-10). Logistic regression was used to determine significant variables associated with attitude to medication. Results Eighty-six patients were included in the study. The mean age was 43.1 years (standard deviation [SD] 12.1), and 55.8% were males. Twenty-six percent of the patients presented a negative attitude towards antipsychotic treatment (mean DAI-10 score of −4.7, SD 2.7). Most of them had a diagnosis of schizophrenia. Multivariate analysis showed that poor insight into illness and a greater number of previous acute episodes was significantly associated with a negative attitude towards medication at discharge (odds ratio 1.68 and 1.18, respectively). Conclusion Insight and clinical stability prior to admission were related to patients’ attitude towards antipsychotic treatment at hospital discharge among patients with schizophrenia and bipolar disorder. The identification of factors related to the attitude towards medication would offer an improved opportunity for clinicians to select patients eligible for prophylactic adherence-focused interventions.

Undulating toe movements in brain death.

For many years, death implied immobility. Nevertheless, there are anecdotal reports of spontaneous or reflex movements (SRMs) in patients with Brain death (BD). The presence of some movements can preclude the diagnosis of BD, and consequently, the possibility of organ donation for transplantation. McNair and Meador [(1992) , Mov Dord7: 345–347] described the presence of undulating toe flexion movements (UTF) in BD patients. UTF consists in a sequential brief plantar flexion of the toes. Our aim was to determine the frequency, characteristics and predisposing factors of UTF movements in a prospective multicenter cohort study of patients with BD. Patients with confirmed diagnosis of BD were assessed to evaluate the presence of UTF using a standardized protocol. All patients had a routine laboratory evaluation, CT scan of the head, and EEG. Demographic, clinical, hemodynamic and blood gas concentration factors were analyzed. amongst 107 BD patients who fulfilled the AAN requirements, 47 patients (44%) had abnormal movements. UTF was observed in 25 (23%) being the most common movement (53%). Early evaluation (OR 4.3, CI95% 1.5–11.9) was a predictor of UTF in a multivariate regression model. The somato‐sensory evoked potential (SSEPs) as well as brainstem auditory evoked potentials (BAEPs) did not elicit a cortical response in studied patients with UTF. This spinal reflex is probably integrated in the L5 and S1 segments of the spinal cord. Abnormal movements are common in BD, being present in more than 40% of individuals. UTF was the most common spinal reflex. In our sample, early evaluation was a predictor of UTF. Health care professionals, especially those involved in organ procurement for transplantation, must be aware of this sign. The presence of this motor phenomenon does not preclude the diagnosis of BD.

Conjoint analysis to understand preferences of patients with multiple sclerosis for disease-modifying therapy attributes in Spain: a cross-sectional observational study

Objective To assess patients’ preferences for a range of disease-modifying therapy (DMT) attributes in multiple sclerosis (MS). Design A cross-sectional observational study. Setting The data reported were from 17 MS units throughout Spain. Participants Adult patients with relapsing-remitting MS. Main outcome A conjoint analysis was applied to assess preferences. A total of 221 patients completed a survey with 10 hypothetical DMT profiles developed using an orthogonal design and rating preferences from 1 (most acceptable) to 10 (least acceptable). Medication attributes included preventing relapse, preventing disease progression, side effect risk, route and frequency of administration. Results Patients placed the greatest relative importance on the side effect risk domain (32.9%), followed by route of administration (26.1%), frequency of administration (22.7%), prevention of disease progression (10.0%) and prevention of relapse (8.3%). These results were independent of the Expanded Disability Status Scale score. The importance assigned to side effect risk was highest for patients with a recent diagnosis. Patients who had previously received more than one DMT gave a higher importance to relapse rate reduction than patients receiving their first DMT. Conclusions Patient DMT preferences were mainly driven by risk minimisation, route of administration and treatment schedule. The risk–benefit spectrum of available DMT for MS is becoming increasingly complicated. Understanding which treatment characteristics are meaningful to patients may help to tailor information for them and facilitate shared decision-making in clinical practice.

Factors associated with the effectiveness of a telephone-based nursing strategy for enhancing medication adherence in schizophrenia.

A post hoc analysis was made to identify factors associated with success following a 4-month telephone-based strategy for enhancing adherence to antipsychotic treatment in schizophrenia. A total of 928 stable outpatients were randomized to receive a monthly telephone call provided by a nurse or routine clinical care. Logistic regression with a backward stepwise procedure was used. A higher percentage of patients in the intervention group (25.7%, n=109) improved adherence at the end of the study compared with the control group (16.8%, n=74) (p=0.0013). The intervention was significantly associated with adherence improvement in those patients with a previous negative attitude towards medication (OR=4.7, 95% CI =2.4-9.0, p<0.0001). A slight concordance was obtained between adherence improvement and improvement in patient perception of treatment (kappa=0.21; 95% CI=0.15-0.27). The identification of factors related to the effectiveness of a specific intervention would offer clinicians the opportunity to more adequately select patients who are eligible for such intervention.

The subjective well-being under neuroleptic scale - short version (SWN-K) and the SF-36 health survey as quality of life measures in patients with schizophrenia.

Purpose The desired outcome in schizophrenia treatment has evolved from symptom management to maximization of quality of life and functional recovery. The aim of this study was to assess the relationship between a specific well-being measure, the Subjective Well-being under Neuroleptic Scale – short version (SWN-K), and the SF-36 Health Survey as a generic quality of life measure. Patients and methods A multicenter, cross-sectional study was conducted with clinically stable outpatients diagnosed with schizophrenia. Spearman’s rank correlation was used to assess the associations between the SWN-K total score, its five subscales, and the SF-36 domains. Results Ninety-seven patients were included in the study. The mean age was 35 years (standard deviation = 10) and 72% were male. All correlations among domains were positive and most were statistically significant. The bodily pain domain of the SF-36 presented the lower correlations with the SWN-K (rho range 0.10–0.25), whereas the other seven domains correlated significantly (rho range 0.49–0.60, all P < 0.001). The largest correlations were obtained between the SWN-K and the SF-36 domains of general health (rho = 0.53), mental health (rho = 0.60), and vitality (rho = 0.54). Conclusion The positive but nevertheless moderate correlations observed between a specific well-being instrument and a generic quality of life scale supports the inclusion of diagnosis-specific tools for outcome assessment of patients with schizophrenia.

Facial myokymia in brain death

Background Brain death (BD) is the irreversible loss of all functions of the brain and brainstem. Spontaneous and reflex movements of the limbs have been described in this condition. However, facial myokymia (FM) in BD has not been previously reported. The origin of that motor phenomenon in alive patients is still uncertain, since supranuclear, nuclear and peripheral mechanisms have been proposed.