A case of Balint syndrome: the importance of a specific neuropsychological appraisal in the clinical diagnosis of visuospatial disorders

Balint syndrome is characterized by a severe disturbance of visual spatial analysis including impaired oculomotor behaviour, optic ataxia, and simultanagnosia. The complete syndrome is relatively rare, and partial syndromes have been reported more frequently. The present study aims to describe a case of Balint syndrome who displayed all the three main neuropsychological features as a consequence of infarction in the watershed between the anterior and posterior cerebral artery territories. In this case report three days post stroke the clinical assessment showed a severe impairment in several visual spatial tasks (e.g. reading, writing, description of a visual scene, voluntary gaze-shift). Twelve weeks post-stroke the clinical assessment showed a significant improvement in reading, writing, as well as in verbal delayed recall processes, but only a mild improvement in visual spatial tasks like the description of a complex visual scene was registered. Balint’s syndrome is rare and is not easy to assess with standard clinical tools. The classical neurological examination evaluates in detail the senses, motility, balance, and to some extent language, but, sometimes, it is much less concerned with cognitive functions. The case discussed here is a good example of the need to emphasize that an acutely ill patient should also be accurately evaluated for the presence of cognitive and behavioural disturbances

Robot-assisted lung resection: outcomes and technical details

Robotic surgery has gained acceptance for surgical use but few data exist regarding its value in thoracic procedures. The aim of this study is to report our experience with totally robotic thoracic resections. From June 2001 to June 2009, 38 consecutive totally robotic lung resections were performed in two different hospitals by a single surgeon. All data was prospectively collected in a dedicated database, and reviewed retrospectively. A total of 32 lobectomies, three bilobectomies, and three pneumonectomies were performed. The indication was a malignant tumor in 28 cases. There were nine cases with benign pathology. Mean operating time was 209 min (range: 105-380 min). Six conversions were required (15.8%) and there was one postoperative death (2.6%). Four postoperative complications occurred (10.5%). Median hospital stay was 10 days (range: 3-24 days). After a median follow-up of 42 months, 80% of patients with stage I disease are alive without recurrence. Advanced thoracic procedures can be performed safely using the robotic system. In this heterogeneous series of lung resections, we report low mortality and morbidity. The robotic approach can achieve a good dissection in difficult to reach areas, making it particularly useful for oncologic resections

Marker elettrofisiologici e compiti cognitivi in pazienti con aMCI: analisi time-frequency dell’attività elettroencefalografica beta durante un compito attentivo

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Beta Responses in Healthy Elderly and in Patients With Amnestic Mild Cognitive Impairment During a Task of Temporal Orientation of Attention

Recent studies demonstrated that beta oscillations are elicited during cognitive processes. To investigate their potential as electrophysiological markers of amnestic mild cognitive impairment (aMCI), we recorded beta EEG activity during resting and during an omitted tone task in patients and healthy elderly. Thirty participants were enrolled (15 patients, 15 healthy controls). In particular, we investigated event-related spectral perturbation and intertrial coherence indices. Analyses showed that (a) healthy elderly presented greater beta power at rest than patients with aMCI patients; (b) during the task, healthy elderly were more accurate than aMCI patients and presented greater beta power than aMCI patients; (c) both groups showed qualitatively similar spectral perturbation responses during the task, but different spatiotemporal response patterns; and (d) aMCI patients presented greater beta phase locking than healthy elderly during the task. Results indicate that beta activity in healthy elderly differs from that of patients with aMCI. Furthermore, the analysis of task-related EEG activity extends evidences obtained during resting and suggests that during the prodromal phase of Alzheimer\u2019s disease there is a reduced efficiency in information exchange by large-scale neural networks. The study for the first time shows the potential of task-related beta responses as early markers of aMCI impairments

Memory-related EEG markers in aMCI: beta time-frequency activity during an omitted tone task

Objective Mild Cognitive Impairment (MCI) subclinical pictures are deemed as prodromal stages of Alzheimer\u2019s disease (AD) or other dementia. In particular, amnestic MCI (aMCI) shows the strongest association with AD and is primarily characterized by memory impairments, whose severity associate with the likelihood and steepness of progression to dementia. According to the attention deficit hypothesis, aMCI symptoms may ground on a global attention network and working memory decline. Monitoring those domains may then usefully help in tracking and predicting clinical development. The present study aims at investigating the potential of attention-related beta EEG activity as markers of aMCI. Participants To investigate task-related beta responses we designed an omitted tone task, where participants had to explicitly orient their attention to estimate repeated intervals in a series of tones and signal when a tone is omitted. 15 aMCI patients and 15 healthy controls took part in the study. Event-related spectral perturbation (ERSP) and inter-trial coherence (ITC) were computed to assess time-frequency beta EEG patterns collected during the task. Results Bootstrap statistics on processed electrophysiological data highlighted that both groups presented event-related desynchronization during the tone condition and event-related synchronization during the omitted tone condition, but their responses differed in terms of spatial-temporal pattern. Further, analyses highlighted peculiar coherence indices during both conditions in aMCI patients. Conclusion Given their functional correlates, ERSPs and ITC modulations may mark the alteration of cortical information processing and exchange in attention/working-memory networks accompanied by a pathological enhancement of sensory cortical excitability even in the prodromal stage of AD. Beta EEG responses measured during relevant cognitive tasks might then act as valuable clinical markers and might inform on the state of pathology-specific cognitive difficulties and of supporting cortical networks

Gastrectomia mini-invasiva robotica: fasi tecniche e vantaggi dell’approccio robotico

Aim of the study. To show the technical steps and advantages of robotic total/subtotal gastrectomy. Material & Methods. Between 2000 and 2009, 96 robotic gastric resections have been performed: 45 total gastrectomies, 48 subtotal gastrectomies and 3 partial resections. Patient is in supine position, with 10°-15° reverse-Trendelemburg. Five ports are placed in half concave line. Preliminary exploration, gastro-colic detachment and short gastric vessels section are performed in traditional laparoscopy. The robotic cart is then installed. Infra-pyloric lymphadenectomy and right gastroepiploic vessels section is completed before the transection of the duodenum with a linear endostapler. Lymphadenectomy is performed in a clockwise fashion along the hepatic proper, common hepatic, celiac trunk and splenic artery. The right gastric artery, the left gastric artery and vein are sectioned in the process. In total gastrectomy the distal oesophagus is mobilized after lymphadenectomy of pericardial stations and sectioned, then an anastomosis by circular stapler was performed. After subtotal gastrectomy, the gastro-intestinal anastomosis is performed by stapler or robotic hand-suturing. The specimen is retrieved through a mini-laparotomy in the right flank. Results. Average intra-operative time was 280 min (range:120-480). Conversion was necessary in eight patients: 2 cases to laparoscopy (one splenic injury, one robotic arm failure), 6 cases to open surgery (locally advanced or metastatic disease). The mean number of removed nodes in D2 was 32.2 (range 19-70). Postoperative morbidity and mortality were respectively 19.8% and 3.1%. Anastomotic and duodenal stump leakage occurred respectively in 11 and 3 cases (11.4% and 3.1%). A redo-surgery was necessary in 7 patients (7.3%). Mean postoperative hospital stay was 11.6 days.Conclusion. Robotic total/subtotal gastrectomy is a feasible, safe and oncologically adequate procedure

Marcatori EEG task-relati per quadri di aMCI: uno studio sul potenziale delle risposte beta durante un compito attentivo

Introduzione: Recenti evidenze hanno ricondotto i quadri di MCI (Mild Cognitive Impairment) a possibili stadi prodromici di diversi quadri di demenza (Petersen & Negash, 2008). Tali quadri clinici prodromici si presentano in persone anziane non affette da demenza che presentano un profilo cognitivo globalmente preservato e una buona funzionalita\u300 nella vita quotidiana. Si caratterizzano pero\u300 per la presenza di lievi difficolta\u300 specifiche in uno o piu\u300 domini cognitivi. Il quadro di MCI primariamente caratterizzato da deficit di memoria, definito aMCI (amnestic-MCI), mostra le piu\u300 forti associazioni con una successiva conversione in AD (Malattia di Alzheimer). La probabilita\u300 di conversione verso quadri di demenza cresce con la gravita\u300 di tali peculiari difficolta\u300 che, secondo l\u2019ipotesi del deficit di attenzione, rispecchierebbero il declino della funzionalita\u300 dei circuiti corticali che mediano i meccanismi attentivi e di memoria di lavoro. Il presente studio mira quindi a testare il potenziale delle modulazioni elettrofisiologiche della banda EEG beta associate ai processi attentivi come possibile marker diagnostico di profili aMCI, capitalizzando precedenti evidenze sulle modificazioni del profilo elettroencefalografico in pazienti con MCI e AD. Materiali e Metodi: 15 pazienti con aMCI e 15 partecipanti di controllo sani comparabili per eta\u300 hanno completato un compito di orientamento attentivo associato a una rilevazione elettroencefalografica. Al fine di indagare le competenze attentive dei partecipanti e le relative modulazioni del profilo EEG, e\u300 stato creato un compito di detezione di toni omessi, in cui i partecipanti devono consapevolmente orientare le loro risorse cognitive per stimare la cadenza di una serie di toni acustici e segnalare quando un tono viene omesso. I tracciati EEG sono stati analizzati con tecniche time-frequency per estrarre misure evento-relate di perturbazione spettrale (ERSP; Makeig, 1993) e di coerenza inter-trial (ITC; Pfurtscheller & Lopes da Silva, 1999) per la banda beta. Risultati: Le analisi statistiche delle misure EEG hanno evidenziato: (i) desincronizzazioni evento- relate durante la percezione di toni in entrambi i gruppi; (ii) sincronizzazioni evento-relate quando il tono viene omesso in entrambi i gruppi; (iii) differente pattern spazio-temporale delle risposte evento-relate tra i gruppi; (iv) peculiari misure di coerenza in risposta ai toni presenti/omessi nei pazienti che presentano aMCI. Discussione: In accordo con l\u2019ipotesi del deficit di attenzione, monitorare la funzionalita\u300 del dominio attentivo e della memoria di lavoro in pazienti con aMCI puo\u300 offrire utili strumenti per tracciare il decorso clinico e prevederne lo sviluppo. Le modulazioni delle misure di ERSP e ITC che abbiamo osservato possono rispettivamente indicare un\u2019alterazione dell\u2019attivita\u300 corticale e dello scambio d\u2019informazioni nei network attentivi e di memoria di lavoro e un parallelo aumento patologico dell\u2019eccitabilita\u300 dei network corticali sensoriali (che caratterizza anche gli stadi piu\u300 avanzati di AD). Le evidenze suggeriscono la potenzialita\u300 delle modulazioni dell\u2019attivita\u300 EEG beta associate a compiti cognitivi per la valutazione del declino cognitivo e funzionale di pazienti con aMCI, nonche\u301 come marker clinici aggiuntivi rispetto alle misure ottenute a riposo

The Impact of COVID-19 Quarantine on Patients With Dementia and Family Caregivers: A Nation-Wide Survey

Introduction: Previous studies showed that quarantine for pandemic diseases is associated with several psychological and medical effects. The consequences of quarantine for COVID-19 pandemic in patients with dementia are unknown. We investigated the clinical changes in patients with Alzheimer’s disease and other dementias, and evaluated caregivers’ distress during COVID-19 quarantine. Methods: The study involved 87 Italian Dementia Centers. Patients with Alzheimer’s Disease (AD), Dementia with Lewy Bodies (DLB), Frontotemporal Dementia (FTD), and Vascular Dementia (VD) were eligible for the study. Family caregivers of patients with dementia were interviewed by phone in April 2020, 45 days after quarantine declaration. Main outcomes were patients’ changes in cognitive, behavioral, and motor symptoms. Secondary outcomes were effects on caregivers’ psychological features. Results: 4913 patients (2934 females, 1979 males) fulfilled the inclusion criteria. Caregivers reported a worsening in cognitive functions in 55.1% of patients, mainly in subjects with DLB and AD. Aggravation of behavioral symptoms was observed in 51.9% of patients. In logistic regression analysis, previous physical independence was associated with both cognitive and behavioral worsening (odds ratio 1.85 [95% CI 1.42–2.39], 1.84 [95% CI 1.43–2.38], respectively). On the contrary, pandemic awareness was a protective factor for the worsening of cognitive and behavioral symptoms (odds ratio 0.74 [95% CI 0.65–0.85]; and 0.72 [95% CI 0.63–0.82], respectively). Approximately 25.9% of patients showed the onset of new behavioral symptoms. A worsening in motor function was reported by 36.7% of patients. Finally, caregivers reported a high increase in anxiety, depression, and distress. Conclusion: Our study shows that quarantine for COVID-19 is associated with an acute worsening of clinical symptoms in patients with dementia as well as increase of caregivers’ burden. Our findings emphasize the importance to implement new strategies to mitigate the effects of quarantine in patients with dementia