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A 80-year-old woman with a history of severe degenerative dementia, with behavioral and psychological symptoms of dementia (BPSD), COPD and hypertension, was admitted to our hospital (Geriatric Unit, University Hospital of Parma) for an acute change in her cognitive status, with stupor status. The clinical question was: 'What is the cause of this rapid worsening of cognitive and mental condition in a demented patient?' A diagnosis of Non-Convulsive Status Epilecticus (NCSE), defined by behavioral or cognitive changes from a patient's baseline state of functioning, with seizure activity on EEG, should be considered when patients with severe dementia are admitted to hospital. It is sufficient for the diagnosis of NCSE to be suspected and not strictly confirmed to start preliminary treatment with an antiepileptic drug. [ABSTRACT FROM AUTHOR]

Background: Rehabilitation is a crucial issue in the management of spinal cord injuries (SCI) but, in these patients, the primary treatment can bias the outcome of recovery protocols., Aim: Purpose of this paper is to review our case load in the treatment of surgical failures and to define the role of surgery in thoraco-lumbar injuries rehabilitation., Patients and Methods: Between 2000 and 2009 seventy patients with post-traumatic paraplegia were referred to Surgical Department as rehabilitation was unfeasible due to inadequate spine injury treatment. Forty-six had had surgery, 24 were treated conservatively Twenty-five patients had a thoracic lesion, 9 a lumbar lesion and 36 a lesion of the thoraco-lumbar junction. A total of 44 surgical procedures were performed (by anterior, posterior or anterior-posterior)., Results: On postoperative imaging sagittal alignment was found good in 93% of cases and acceptable in 7%. All patients regained the sitting position within 5 days after surgery. Wound healing problems requiring revision were observed in 4 cases. Major complications were a cerebro spinal fluid (CSF) leakage and a massive pulmonary embolism case in the early post-op., Conclusions: Wrong primary treatment frequently leads to demanding revision procedures with increased risks for the patient and more than double costs for the health care system. Whatever the technique a stable spine is the target in surgery of SCI allowing a quick and effective rehabilitation without external orthosis.

This case series investigates whether painful electrical stimulation increases the early prognostic value of both somatosensory-evoked potentials and functional magnetic resonance imaging in comatose patients after cardiac arrest. Three single cases with hypoxic-ischemic encephalopathy were considered. A neurophysiological evaluation with an electroencephalogram and somatosensory-evoked potentials during increased electrical stimulation in both median nerves was performed within five days of cardiac arrest. Each patient also underwent a functional magnetic resonance imaging evaluation with the same neurophysiological protocol one month after cardiac arrest. One patient, who completely recovered, showed a middle latency component at a high intensity of stimulation and the activation of all brain areas involved in cerebral pain processing. One patient in a minimally conscious state only showed the cortical somatosensory response and the activation of the primary somatosensory cortex. The last patient, who was in a vegetative state, did not show primary somatosensory evoked potentials; only the activation of subcortical brain areas occurred. These preliminary findings suggest that the pain-related somatosensory evoked potentials performed to increase the prognosis of comatose patients after cardiac arrest are associated with regional brain activity showed by functional magnetic resonance imaging during median nerves electrical stimulation. More importantly, this cases report also suggests that somatosensory evoked potentials and functional magnetic resonance imaging during painful electrical stimulation may be sensitive and complementary methods to predict the neurological outcome in the acute phase of coma. Thus, pain-related somatosensory-evoked potentials may be a reliable and a cost-effective tool for planning the early diagnostic evaluation of comatose patients.

PD is an age-related neurodegenerative disorder that affects as many as 1-2% of persons aged 60 years and older. In the latest decade, the approach to PD was dramatically changed. In fact, although for many years PD has been considered only "a disease that affects walking", with a key role of the neurotransmitter dopamine, recently the neurological approach has been substantially modified. The approach for this disease is not only a neurological issue. Given the complexity of its clinical aspects, such as depression, anxiety, dementia, sleep disorder, pneumonia dysfagia-related and malnutrition, a multidisciplinary evaluation and not just a neurological evaluation is needed. We suggest a n multidisciplinary approach for this old actor, underlying a subtle link between neurophatological stages of the disease (Braak's classification) and clinical aspects (Braak's stages 1 and 2 associated with the premotor phase; Braak's stages 3-4 associated with the motor symptoms and Braak's stages 5-6 associated with cognitive impairment). In addition, we emphasize the usefulness of geriatric evaluation for the identification of frail "in situ", frail, and disable status for improving care and treatment in this multifaceted disease., (Copyright © 2011 Elsevier Ireland Ltd. All rights reserved.)

Percutaneous endoscopic gastrostomy (PEG) has recently become a usual procedure for patients with prolonged disorders of consciousness after brain injuries. Despite a high rate of success and a very low procedure-related mortality, morbidity associated to PEG placement reaches 9.4% in a recent large meta-analysis. This case report describes an uncommon complication of PEG placement in a patient with vegetative state after traumatic brain injury: the development of prolonged duodenal paralysis. This patient was treated by placement of a transient jejunostomy until recovery of duodenal functional activity, to permit adequate nutrition. This procedure-related complication is previously unreported in scientific literature.

Aim: Stroke is the third highest cause of death and the leading cause of chronic disability in adults in Italy. More than half of patients who survive the first month after a stroke will require specialised rehabilitation. Rehabilitation is, however, an expensive and limited resource, and its success depends on careful selection of patients. The aim of this study was to identify the functional ability at discharge and after one-year of follow-up in a large sample of first-time stroke patients from a rehabilitation hospital according to the stroke Oxfordshire Community Stroke Project (OCSP) criteria., Methods: A multicenter observational study was conducted among 1023 first-time stroke patients who were admitted to 18 different Italian inpatient rehabilitation centres between February 1999 and November 2000. The study population consisted of 946 (92.4%) of the 1023 enrolled at baseline. Each patient has been first evaluated within 72 h after admission and, on a second occasion, within 72 h before discharge. From the 722 ischemic strokes evaluated at baseline, after one-year of follow-up 76 participants died. From the survived 646 patients, we had 513 (79.0%) participants both evaluated at baseline and after one-year of follow-up. Clinical data regarding stroke type and ischemic stroke clinical syndrome, according to the Oxfordshire Community Stroke Project (OCSP) criteria; the degree of impairment, both motor (assessed by Barthel Index [BI], Motricity Index, and Trunk Control Test) and neuropsychological (assessed by the Mini Mental State Examination, and the presence of aphasia or neglect); the extent of disability, as assessed by Functional Independence Scale (FIM) and the evidence of concomitant prespecified medical complications, as well as of dysphasia and of the need of indwelling urinary catheter. Other variables were taken into account, such as the time interval between stroke onset and admission to rehabilitation ward and the length of stay. To assess stroke outcome, two different indexes were selected: the frequency of home discharge and the extent of functional recovery., Results: There were 722 (76.3%) ischemic and 224 (23.7%) hemorrhagic strokes. Among ischemic strokes, the partial anterior circulation infarct was the most frequent syndrome, accounting for the 33.2% of cases. The posterior circulation infarct syndrome was the less frequent (14.1%). Lacunar anterior circulation infarct was present for the 29.5% and finally, the total anterior circulation infarct (TACI) was present for the 23.2%. According to the OCSP criteria, the TACI syndrome received 76.1±52.9 (mean±SD) days of rehabilitation, which were statistically different from the other three types of stroke. At discharge, the BI and the FIM of patients affected by TACI was significantly lower and higher, respectively, from the other three type of stroke. However, this difference disappear after one-year of follow-up., Conclusion: The TACI subtype of stroke required higher days of rehabilitation from the other type of stroke according to the OCSP criteria. Rehabilitation program is efficacious for improving functional ability of patients affected by stroke although the program should be tailored according to the stroke type.

Delirium, an acute confusional state characterized by decline in attention and cognition, is a common, life-threatening, but potentially preventable clinical syndrome among older persons. Deficits in cholinergic function have been postulated to cause delirium and cognitive decline. In particular, an imbalance between levels of acetylcholine and monoamine (such as dopamine) may cause delirium. We describe two cases of delirium in hospitalized older patients, supporting the "cholinergic deficiency hypothesis". In the first patient, hypo-reactive delirium developed a few hours after a dose of the long-acting opiate tramadol (a drug with anticholinergic effect) as analgesic for pain related to advanced peripheral artery disease. In the second patient, with vascular parkinsonism plus pre-frontal cortex vascular lesions, hyper-reactive delirium developed a few hours after a prescribed administration of L-dopa. These symptoms disappeared completely on the following day. These two "natural" experiments support the hypothesis that both hypo-reactive and hyper-active delirium may be caused by a reduction in cholinergic signaling.

Objectives: To assess how much of the excess risk of poor outcome from stroke in people aged 80 and older aging per se explains, independent of other prognostic determinants., Design: Cohort, observational., Setting: University hospital., Participants: One thousand five hundred fifty-five patients with first-ever ischemic stroke consecutively referred to an in-hospital Clinical Pathway program were studied., Measurements: The relationship between age and 1-month outcome (death, disability (modified Rankin Scale 3-5), and poor outcome (modified Rankin Scale 3-6)) was assessed, with adjustment for several prognostic factors., Results: Six hundred twelve patients aged 80 and older showed worse outcome after 1 month than those who were younger, in terms of mortality (19% vs 5%, hazard ratio (HR)=3.85, 95% confidence interval (CI)=2.8-5.4) and disability (51% vs 33%, odds ratio (OR)=3.16, 95% CI=2.5-4.0), although in multivariate models, the adjusted HR for mortality decreased to 1.47 (95% CI=1.0-2.16) and the ORs for disability and poor outcome decreased to 1.76 (95% CI=1.32-2.3.) and 1.83 (95% CI=137-2.43), respectively. Stroke severity, the occurrence of at least one medical complication, and premorbid disability explained most of the risk excess in the oldest-old., Conclusion: Stroke outcome is definitely worse in very old people, and most of the excess risk of death and disability is attributable to the higher occurrences of the most-severe clinical stroke syndromes and of medical complications in the acute phase. These represent potential targets for preventive and therapeutical strategies specifically for elderly people.

Aim: The assessment of major obstacles to community integration which may result from an acquired brain injury (ABI) is needed for rational planning and effective management of ABI patients' social adjustment. Currently, such a generally acceptable measure is not available for the Italian population. This paper reports the translation process, the internal consistency, and the inter-rater reliability data for the Italian version of the Mayo-Portland Adaptability Inventory-4 (MPAI-4), a useful measure with highly developed and well documented psychometric properties. The MPAI-4 is specifically designed to assess socially relevant aspects of physical status and cognitive-behavioural competence following ABI. It is a 29-item inventory which is divided into three subdomains (Abilities, Adjustment, and Participation indices) covering a reasonably representative range, Methods: Twenty ABI patients with at least one-year discharge from the rehabilitation facilities were submitted to the Italian MPAI-4. They were independently rated by two different rehabilitation professionals and a family member/significant other serving as informant (SO). Internal consistency was assessed by calculating the Cronbach's alpha values. Inter-rater agreement for individual items was statistically examined by determining the interclass correlation coefficient (ICC)., Results: In addition to the 8% of perfectly correspondent sentences, a clear prevalence (75.5%) of minor semantic variations and formal variations with no semantic value at the sentence-to-sentence matching was found. Full-scale Cronbach's alpha was 0.951 and 0.947 for the two professionals (rater #1 and rater #2, respectively), and was 0.957 for the family member serving as informant (rater #3). Full-Scale ICC (2.1) between professionals and SOs was 0.804 (CI=95%; lower-upper bound=0.688-0.901)., Conclusions: The Italian MPAI-4 shares many psychometric features with the original English version, demonstrates both good internal consistency and good inter-rater reliability. The MPAI-4 confirms to be suitable for research applications in postacute settings as an efficient, broad and inclusive outcome measure for adult subjects with ABI.

Objective: To evaluate the effect of training with ergometers on subjects with spinal cord injury (SCI) in the postacute phase., Design: Cohort study., Setting: A spinal unit at a physical medicine and rehabilitation institute., Participants: Twenty-one subjects with SCI in the postacute phase as a consecutive sample were chosen on a strict first-come, first-chosen basis. All patients completed the study., Interventions: A 6-week (5d/wk, 90 min/d) program consisting of exercises with the ergometers formulated (as intensity and duration) for each patient on the basis of the results obtained in specific cardiovascular tests., Main Outcome Measures: Parameters of workload levels, as well as hematologic and hormonal parameters, recorded during the first 6 weeks of training., Results: The workload performed during the training showed an initial increase, but it reached a plateau in week 4. No statistically meaningful variations in the workload emerged between the fourth and the sixth weeks of monitoring. There were no hematologic or hormonal signs of overtraining., Conclusions: Strengthening and aerobic rehabilitation programs for patients with subacute SCI should be limited to 4 weeks, followed by an independent maintenance exercise program. The strengthening program is safe for these patients.

Aim: This paper proposes an anthropomorphic model developed in a virtual context, useful to simulate the maintenance of the erect stance. Such a model can be built through a suitable software which can identify the geometry of the articular parts and place mechanical constraints (e.g. joints, spherical links, etc.) between the single elements., Methods: Our approach can be described as the assembly of rigid parts linked at the joints. The control is given by internal torques at the joints and driven by strategy for the balance aimed to the least amount of total muscular energy spent. The anthropomorphic model proposed underlines and solves the typical problems of a system characterized by a multiple number of degree of freedom placed in erect stance and perturbed by phenomena of endogenous and exogenous nature. This model is developed via the coupling of 2 separate bi-dimensional models, one representing the sagittal plane and the other the frontal plane. The numerical tests were validated through experimental tests in a group of healthy volunteers. For this purpose we employed a stabilometric platform (force-plate) to record the statokinesigram (SKG) on the rest surface., Results: The shapes of the stabilometric plots show a good spatial similarity between the experimental and simulated SKG. Both SKGs present a good range in the frontal plane with concentration of points in some areas (or attractors) in the experimental SKG, but not in the simulated one. The tests also showed a postural oscillation at low frequency (= 0.02Hz), probably due to the differential tiredness of groups of muscles or because of a delayed action of the neurological control., Conclusions: On the numerical simulations, we claim the suitability of the antropomorphic model for a general description of the maintenance of the erect stance. Despite the simplification, with our approach it is possible to simulate some of the main characteristics of the postural act. In particular, the length and the areas of the simulated SKG's are comparable with those of the experimental tests.

The aim of this study was the quantitative evaluation of the myotatic reflex in a group of 11 subjects affected by spastic paresis of the lower limbs (8 hemiplegic and 3 paraplegic patients) and, for comparison, in a group of 7 healthy subjects. The parameters taken into account were the gain of the reflex and the time delay between the input and the mechanical output. The gain was calculated as the ratio between: i) the peak value of the input force (FPH) measured by means of an instrumented hammer with which the patellar tendon was hit; and ii) the peak value of the corresponding reflex force of the quadriceps femoris (FPQ) measured by means of a load cell connected to the subject's ankle. The gain of the reflex (FPQ/FPH) was found to be 1.9 to 2.4 times larger in patients as compared to control subjects and, among the patients to be twice at low, as compared to high, levels of stimulation. Among the hemiplegic patients, significant differences were found in the time delay of the response between the affected and unaffected limbs. Since both the intensity of the reflex and its gain were found to depend on the mechanical energy input, both parameters must be taken in to account if a diagnosis of spasticity has to be made.