Reciprocal influences in individuals with traumatic brain injury (TBI) and their caregivers: neurocognitive status in TBI subjects, attachement style and burden in caregivers.

Traumatic Brain injury (TBI) in war veterans and civilians is a formidable health and socio- economic issue. Beyond the large number of deaths following a TBI, the survivors often live with physical, psychological, cognitive and social limitations related to the injury. The challenge faced by them is also shared by family members, friends, and even more specifically by the primary caregiver. In this context, it is necessary to include caregivers in the equation of the rehabilitation of TBI individuals. In a 40-year follow-up study of Vietnam War veterans, we were interested in the reciprocal relationship between these two partners: the TBI individual and his/her caregiver. The TBI patients we studied had suffered penetrating traumatic brain injuries (pTBI) and while they are rarer than blunt or blast head injuries, their lesions are much more focal and it is easier to interpret the effects of pTBI on particular functions. In the first study, we investigated the effects of TBI-related brain lesions on long-term caregiver burden in relation to dysexecutive syndrome. Burden was greater overall in caregivers of TBI individuals compared to healthy controls veterans. Also, caregivers of individuals with brain lesions located in areas affecting cognitive and behavioral indicators of a dysexecutive syndrome (i.e., left dorsolateral prefrontal and dorsal anterior cingulate cortices) showed greater long-term burden than caregivers of participants with lesion(s) elsewhere in the brain. In a second study, we investigated the role of the caregiver attachment style on the TBI individual's cognitive trajectory. After controlling for other factors, cognitive decline was more pronounced in TBI individuals with a highly fearful caregiver, compared to those with a caregiver who demonstrated low levels of fearfullness. Consequently, there is a long-lasting reciprocal influence between these two partners. First, some TBI-related brain lesions have a lasting effect on long-term caregiver burden due to cognitive and behavioral factors. Second, it seems that caregivers exercise a significant impact on TBI individuals' environments, sometimes negatively. These results, combined with compelling evidence in the literature about neural plasticity and cognitive reserve, lend support to the impact of the caregiver on the TBI individual; the caregiver can be a surrogate for the environment and provides key stimulation that can both modify and facilitate plasticity. Finally, we discuss potential intervention strategies based on these new findings. -- Le traumatisme crânio-cérébral (TCC) est un problème socio-économique et sanitaire important, voire dramatique, chez les militaires comme chez les civils. En plus de la haute prévalence de décès parmi les personnes présentant un TCC, les survivants sont souvent confrontés à des séquelles physiques, psychologiques et cognitives, associées à un possible isolement social. L'inévitable défi de vie imposé par ce TCC implique non seulement la personne elle-même, mais également l'entourage et, plus particulièrement, le proche-aidant. Dans ce contexte, il est nécessaire d'intégrer le proche-aidant dans l'équation de la prise en charge globale de la personne avec un TCC. Lors d'une étude de suivi prospectif sur 40 ans chez des vétérans de la guerre du Vietnam victimes d'un TCC, nous nous sommes intéressés à la relation réciproque entre les deux partenaires, à savoir la personne avec un TCC et son proche-aidant. Les TCC étudiés dans ce travail sont de type pénétrant. Alors qu'ils sont moins fréquents que les TCC fermés, les lésions sont plus focales, ce qui facilite l'interprétation de leur association avec des fonctions cognitives. Dans notre première étude, nous avons investigué les effets des lésions cérébrales du sujet avec un TCC sur le fardeau de son proche-aidant, 40 ans après le TCC. Comme nous l'avions prédit, le fardeau des proche-aidants des sujets avec un TCC est plus sévère que celui des proche-aidants des sujets du groupe contrôle (vétérans de la guerre du Vietnam sans TCC). Par ailleurs, les proche-aidants des sujets avec un TCC qui présentent une lésion dans les aires cérébrales principalement impliquées dans les fonctions exécutives (à savoir les cortex préfrontal dorsolatéral et cingulaire antérieur gauches) ont une valeur de fardeau significativement supérieure à celle des proche-aidants dont les sujets n'ont pas de lésion dans les régions cérébrales précitées. Dans notre seconde étude, nous avons exploré le rôle du style d'attachement du proche-aidant sur l'évolution cognitive du sujet avec un TCC. Après avoir contrôlé pour les autres facteurs, nous avons mis en évidence un déclin cognitif significativement supérieur chez les sujets avec un TCC dont le proche-aidant présente un style d'attachement anxieux. Par conséquent, il existe une influence réciproque entre ces deux partenaires avec, premièrement, un effet à long-terme de la localisation cérébrale des lésions du sujet avec un TCC sur le fardeau du proche-aidant, probablement dû à des facteurs cognitifs et comportementaux liés aux fonctions exécutives ; Deuxièmement, il semble que le proche- aidant exerce un effet important sur l'environnement du sujet avec un TCC, parfois négativement. Ces résultats sont interprétés à la lumière de la littérature existante sur la plasticité neuronale et la réserve cognitive et sont accompagnés d'une réflexion sur les interventions thérapeutiques potentielles

Tuberculose Pulmonar associada ao Tabagismo

Objetivos: Analisar a associação entre tabagismo e variáveis sócio demográficas, epidemiológicas e clínicas de pacientes com TB pulmonar encaminhados ao Centro de Pesquisa Clínica do Hospital Cassiano Moraes. Metodologia: Estudo descritivo analítico de corte transversal. Foi realizado no Hospital Universitário Cassiano Antônio de Moraes. A pesquisa foi realizada com analise de fichas de pacientes participantes de uma pesquisa multicêntrica, somente com pacientes de Vitória-ES, sendo o único polo no Brasil. Atendidos no Centro de Pesquisas Clínicas nos anos de 2003 a 2006. Resultados: Foram analisados fichas de 537 pacientes. Destes 225 (41,9%) eram não fumantes, 183 (34,1%) fumantes e 129 (24%) ex-fumantes. O sexo masculino foi o mais prevalente entre todos os grupos, sendo que entre os não fumantes eram 58,7% (132), entre os fumantes 73,2% (134) e entre ex-fumantes 66,7% (86). A maioria dos pacientes atendidos não possuiam nenhuma escolaridade. A presença de tosse, entre os não fumantes foi de 175 (78,1%) pessoas, já em fumantes foi 165 (90,2%) e no grupo de ex-fumantes 109 (84,5). A presença de escarro purulento, entre os não fumantes foi de 122 (54,2%) fumantes 142 (77,6%) e ex-fumantes 82 (63,6%). Quando analisado a ingestão de bebida alcoólica entre não fumantes eram 24 (10,7%), em fumantes 62 (33,9%) e em ex-fumantes 18 (14%) pacientes. A mediana em anos de tabagismo foi de 20 (IIQ: 20) entre fumantes, ex-fumantes 12 (IIQ:15). Em relação ao número de cigarros fumados por dia entre fumantes a mediana foi de 20 cigarros/dia (IIQ: 10), nos ex-fumantes de 10 cigarros/dia (IIQ: 16). Quanto a lesões cavitárias, não fumantes eram 110 (49,1%), fumantes 94 (51,9%) e ex-fumantes 79 (61,2%). Conclusão: Este estudo confirmou que há diferenças entre pacientes que possuem histórico de tabagismo e aqueles que nunca fumaram, principalmente no tempo de aparecimento dos sinais e sintomas clínicos comuns da TB, podendo se tornar um fator confundidor na detecção de casos da TB retardando o diagnóstico

SURGERY BY INFRARED VISION

This paper is about the development, uses and advantages of infrared thermography. Its principles had already been used by old civilizations as a manner of diseases diagnosis. The discovery of the infrared waves and its heating power happened on 1800, but its use in modern Medicine as a diagnosis method was only possible because of the scientific and technological development demanded by the Great Wars, in the 20th century. Here the authors present some news and promising surgery applications

Association Between Long-Term Cognitive Decline in Vietnam Veterans With TBI and Caregiver Attachment Style.

OBJECTIVE: To examine whether a caregiver's attachment style is associated with patient cognitive trajectory after traumatic brain injury (TBI). SETTING: National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, Maryland. PARTICIPANTS: Forty Vietnam War veterans with TBI and their caregivers. MAIN OUTCOME MEASURE: Cognitive performance, measured by the Armed Forces Qualification Test percentile score, completed at 2 time points: preinjury and 40 years postinjury. DESIGN: On the basis of caregivers' attachment style (secure, fearful, preoccupied, dismissing), participants with TBI were grouped into a high or low group. To examine the association between cognitive trajectory of participants with TBI and caregivers' attachment style, we ran four 2 × 2 analysis of covariance on cognitive performances. RESULTS: After controlling for other factors, cognitive decline was more pronounced in participants with TBI with a high fearful caregiver than among those with a low fearful caregiver. Other attachment styles were not associated with decline. CONCLUSION AND IMPLICATION: Caregiver fearful attachment style is associated with a significant decline in cognitive status after TBI. We interpret this result in the context of the neural plasticity and cognitive reserve literatures. Finally, we discuss its impact on patient demand for healthcare services and potential interventions

Reliability of the Multidimensional Pain Inventory and stability of the MPI classification system in chronic back pain

Contains fulltext : 109346.pdf (publisher's version ) (Open Access)ABSTRACT: BACKGROUND: This cross validation study examined the reliability of the Multidimensional Pain Inventory (MPI) and the stability of the Multidimensional Pain Inventory Classification System of the empirically derived subgroup classification obtained by cluster analysis in chronic musculoskeletal pain. Reliability of the German Multidimensional Pain Inventory was only examined once in the past in a small sample. Previous international studies mainly involving fibromyalgia patients showed that retest resulted in 33-38% of patients being assigned to a different Multidimensional Pain Inventory subgroup classification. METHODS: Participants were 204 persons with chronic musculoskeletal pain (82% chronic non-specific back pain). Subgroup classification was conducted by cluster analysis at 4 weeks before entry (=test) and at entry into the pain management program (=retest) using Multidimensional Pain Inventory scale scores. No therapeutic interventions in this period were conducted. Reliability was quantified by intraclass correlation coefficients (ICC) and stability by kappa coefficients (kappa). RESULTS: Reliability of the Multidimensional Pain Inventory scales was least with ICC = 0.57 for the scale life control and further ranged from ICC = 0.72 (negative mood) to 0.87 (solicitous responses) in the other scales. At retest, 82% of the patients in the Multidimensional Pain Inventory cluster interpersonally distressed (kappa = 0.69), 80% of the adaptive copers (kappa = 0.58), and 75% of the dysfunctional patients (kappa = 0.70) did not change classification. In total, 22% of the patients changed Multidimensional Pain Inventory cluster group, mainly into the adaptive copers subgroup. CONCLUSION: Test-retest reliability of the German Multidimensional Pain Inventory was moderate to good and comparable to other language versions. Multidimensional Pain Inventory subgroup classification is substantially stable in chronic back pain patients when compared to other diagnostic groups and other examiner-based subgroup Classification Systems. The MPI Classification System can be recommended for reliable and stable specification of subgroups in observational and interventional studies in patients with chronic musculoskeletal pain

In vivo acquisition and risk of inter-species spread of blaKPC-3-plasmid from Klebsiella pneumoniae to Serratia marcescens in the lower respiratory tract

In recent years, Serratia marcescens has emerged as an important agent of hospital-acquired infections, such as pneumonia, urinary tract infection, septicaemia and meningitis, particularly in vulnerable patients. Compared to Klebsiella pneumoniae and Escherichia coli, S. marcescens is less commonly associated with blaKPC genes, yet few cases of plasmid transmission at the gastrointestinal level from K. pneumoniae carbapenemase (KPC)-producing Enterobacterales to S. marcescens have been described. Here we report a case of in vivo acquisition, during a 3-month period of hospitalization in the intensive care unit, of a blaKPC-3 gene carried by a pKpQIL-IT plasmid, and its probable transmission at the bronchial level among different species of Enterobacterales, including K. pneumoniae and S. marcescens. By using whole genome sequence analyses we were able provide insight into the dynamics of carbapenem-resistance determinants acquisition in the lower respiratory tract, a novel anatomical region for such plasmid transmission events, that usually involve the gastrointestinal tract. The co-presence at the same time of both wild-type and resistant Enterobacterales could have been the critical factor leading to the spread of plasmids harbouring carbapenem-resistance genes, of particular importance during surveillance screenings. The possibility of such an event may have significant consequences in terms of antimicrobial treatment, with a potential limitation of therapeutic options, thereby further complicating the clinical management of high-risk critically ill patients

Frequency, characterisation and therapies of fatigue after stroke.

Post-stroke objective or subjective fatigue occurs in around 50% of patients and is frequent (30%) even after minor strokes. It can last more than one year after the event, and is characterised by a different quality from usual fatigue and good response to rest. Associated risk factors include age, single patients, female, disability, depression, attentional impairment and sometimes posterior strokes, but also inactivity, overweight, alcohol and sleep apnoea syndrome. There are few therapy studies, but treatment may include low-intensity training, cognitive therapy, treatment of associated depression, wakefulness-promoting agents like modafinil, correction of risk factors and adaptation of activities