Abnormal Neurological Findings Research Articles

Neurological assessment

Neurological system assessment is an important skill for the orthopaedic nurse because the nervous system has such an overlap with the musculoskeletal system. Nurses whose scope of practice includes such advanced evaluation, e.g. nurse practitioners, may conduct the examination described here but the information will also be useful for nurses caring for patients who have abnormal neurological assessment findings. Within the context of orthopaedic physical assessment, possible neurological findings are evaluated as they complement the patient's history and the examiner's findings. Specific neurological assessment is integral to diagnosis of some orthopaedic conditions such as carpal tunnel syndrome. In other situations such as crushing injury to the extremities, there is high risk of associated neurological or neurovascular injury. These patients need anticipatory examination and monitoring to prevent complications. This article describes a basic neurological assessment; emphasis is on sensory and motor findings that may overlap with an orthopaedic presentation. The orthopaedic nurse may incorporate all the testing covered here or choose those parts that further elucidate specific diagnostic questions suggested by the patient's history, general evaluation and focused musculoskeletal examination. Abnormal findings help to suggest further testing, consultation with colleagues or referral to a specialist.

Early functional and morphological brain disturbances in late-onset intrauterine growth restriction

AimsTo determine whether the brain disturbances develop in late-onset intrauterine growth restriction (IUGR) before blood flow redistribution towards the fetal brain (detected by Doppler measurements in the middle cerebral artery and umbilical artery). Further, to evaluate predictive values of Doppler arterial indices and umbilical cord blood gases and pH for early functional and/or morphological brain disturbances in late-onset IUGR. Study designThis cohort study included 60 singleton term pregnancies with placental insufficiency caused late-onset IUGR (IUGR occurring after 34 gestational weeks). Umbilical artery resistance index (URI), middle cerebral artery resistance index (CRI), and cerebroumbilical (C/U) ratio (CRI/URI) were monitored once weekly. Umbilical blood cord samples (arterial and venous) were collected for the analysis of pO2, pCO2 and pH. Morphological neurological outcome was evaluated by cranial ultrasound (cUS), whereas functional neurological outcome by Amiel-Tison Neurological Assessment at Term (ATNAT). Results50 fetuses had C/U ratio>1, and 10 had C/U ratio≤1; among these 10 fetuses, 9 had abnormal neonatal cUS findings and all 10 had non-optimal ATNAT. However, the total number of abnormal neurological findings was much higher. 32 neonates had abnormal cUS (53.37%), and 42 (70.00%) had non-optimal ATNAT. Furthermore, Doppler indices had higher predictive validity for early brain disturbances than umbilical cord blood gases and pH. C/U ratio had the highest predictive validity with threshold for adverse neurological outcome at value 1.13 (ROC analysis), i.e., 1.18 (party machine learning algorithm). ConclusionAdverse neurological outcome at average values of C/U ratios>1 confirmed that early functional and/or structural brain disturbances in late-onset IUGR develop even before activation of fetal cardiovascular compensatory mechanisms, i.e., before Doppler signs of blood flow redistribution between the fetal brain and the placenta.

Analysis of related factors of extremely preterm infants'abnormal neurological findings

To observe the effect of intrapartum and postpartum factors on abnormal neurological findings in the extremely preterm infants. Clinical data of 62 premature infants (33 of male, 29 of female) were retrospectively analyzed. None of the premature infants had birth defect; their gestational ages were all less than 28 weeks (23(+ 6)-27(+ 6) weeks). They were hospitalized within 12 hours after birth in the neonatal intensive care unit (NICU) of BAYI Children's Hospital from November 2010 to June 2013. The blood gas, birth condition, complications, the mechanical ventilation and the ultrasonic encephalography were recorded. The 62 cases were divided into 2 groups, alive group and died group. Meanwhile, all cases of survial were divided into brain injuries group and normal brain group. Data were analyzed with t-test, Chi square test and Spearman correlation analysis. Fifty-six cases were alive, and 6 cases died (3 were during the treatment and 3 were after parents gave up). The average birth weight of brain injuries group was (954 ± 182) g; and that of the normal brain group was (1 071 ± 136) g. There were significant differences between the two groups in gender (χ(2) = 4.314, P = 0.038), gestational age (χ(2) = 11.622, P = 0.001), birth weight (t = 2.728, P = 0.009), which had significant correlation with neurological outcomes. The Spearman correlative coefficients were -0.278, 0.456 and 0.364 respectively. And P values were 0.038, 0.000 and 0.006. The rates of multiple pregnancy, lung hemorrhage and surgical operation in brain injuries group were 45%(9/20), 55%(11/20), 40%(8/20), which were significantly higher than those in normal brain group, 3%(1/36), 17%(6/36), 11%(4/36)(χ(2) = 12.800, 8.936, 4.773, P all < 0.05). These three factors were the high risk factors for adverse neurological outcomes, the odds ratios were 28.64, 6.11 and 5.33 respectively. There was no significant difference in delivery mode, amniotic fluid, maternal infection, asphyxia, necrotizing enterocolitis, patent ductus arteriosus, sepsis, mechanical ventilation, inhaled nitric oxide therapy, blood glucose, blood gas analysis, doses of dopamine between brain injuries group and normal brain group. The birth weight in alive group was (1 029 ± 163) g, which was significantly higher than those in died group (870 ± 144)g (r=0.29, P=0.022). There was no significant difference in other factors between alive group and died group(P all>0.05). Gender, gestational age and birth weight may have relation with the neurological outcomes of extremely preterm infants. Multiple pregnancy, pulmonary hemorrhage and surgical operation are the risk factors of brain injuries. Birth weight is related to the survival of extremely preterm infants.

A Case of Acute Suppurative Thyroiditis Accompanied by Transient Abducens Nerve Palsy

ABSTRACT Objective: This article reports the case of a 66-year-old female that developed right abducens nerve palsy 1 week after the onset of acute suppurative thyroiditis on her left side. Recurrent laryngeal nerve palsy has not been previously reported in a patient with acute suppurative thyroiditis and abducens nerve palsy. Methods: A medical examination of the patient revealed abnormal eye movements but no other abnormal neurological findings. Warmth, redness, and tenderness in the left anterior neck were noted along with right abducens nerve palsy. Laboratory data suggested a bacterial infection. Serum thyroid hormone and thyroglobulin concentrations were elevated. Computed tomography demonstrated unclear edematous changes together with the presence of air noted on the left side of the upper thyroid. Results: The patient was treated with an empiric broad-spectrum antibiotic and her suppurative thyroiditis improved. Two months after therapy, the right abducens nerve palsy improved without additional t...

Neurodevelopmental comorbidity profile in specific learning disorders

Background: Specific learning disorders (SLD) are the common reasons for referral of an otherwise healthy child from a main stream school. Although children do have difficulties even in early learning years in pre-primary and primary school; a significant number of preadolescent children from mainstream school do present with such disabilities. Primary objective was to study the differential distribution of various comorbidities across SLD spectrum. Secondary objective was to check for prevalence of abnormal neurological examination findings including soft signs. Methods: After approval of institutional ethics committee, 100 consecutive case records of children presenting to the center were studied. Diagnosis was confirmed as per DSM V criteria. The clinical, psychological and neurological information was derived from notes of pediatrician, after SLD certification. Details about history, ADHD and comorbidities if any were recorded from parents where documented information was not sufficient. The prevalence of comorbidities was expressed as a percentage of total cases studied. Results: ADD of combined type was the commonest comorbidity seen in 53% cases. Other occasional comorbidities noted were epilepsy, autism, cerebral palsy, history of meningitis and febrile seizures. Speech and visuospatial skills were affected 10% and 41% in children with SLD and all of these had ADD. Soft neurological signs like astereognosis, graphesthesia, dysdiadochokinesia, dysmetria were seen in more than 20% cases. Abnormal antenatal and perinatal history was more common in ADHD with SLD. Conclusions: SLD children from mainstream schools usually have ADHD as commonest comorbidity. Often they should be looked for various neurological comorbidites like autism, epilepsy, cerebral palsy. Soft signs and motor delay need not be overlooked in view of comprehensive management. A large multicentric study is needed to look for soft neurological signs; neuroimaging may be needed in SLD to understand the disorders in cognitive spectrum.

Neurological manifestations in HIV positive patients attending tertiary care teaching hospital in Western India

Background: Neurologic manifestations affecting the nervous system at all levels and stages of HIV infection are common and increasing with the extended survival of HIV-positive persons. Neurological manifestations occur due to either primary pathologic process of HIV or secondary to opportunistic infection. The neurological manifestations of HIV disease are likely to be different in Indian patients because of prevailing endemic infections, malnutrition, poverty and illiteracy. The present study was conducted to study various neurological manifestations in HIV positive patients presenting to tertiary care teaching institute. Methods: This was observational study of 100 HIV infected patients with clinical evidence of CNS involvement. A detailed clinical history and CNS examination was carried out. CD4 counts were measured and magnetic resonance imaging (MRI), brain/electromyography, nerve conduction studies and cerebrospinal fluid (CSF) examination were done as required for diagnosis. Results were analysed by using percentage and proportions whenever necessary. Results: HIV induced primary illness was present in about 27% cases, while 73% associated with secondary CNS manifestations were mainly due to opportunistic infection. The most common primary illness was distal symmetrical polyneuropathy (17%) followed by myopathy (6%). On the other hand, the most common secondary CNS infection was tuberculous meningitis (TBM; 30%), followed by cryptococcal meningitis (7%), and cerebral toxoplasmosis (4%). The commonest neurological presenting symptoms were headache (38%) whereas the commonest abnormal neurological finding was presence of signs of meningeal irritation (46.5%). The commonest abnormality found on neuroimaging was meningeal enhancement (32%). Conclusions: High index of suspicion of neurological involvement in HIV patients in all stages helps in early diagnosis and timely institution of specific therapeutic treatment which in turn may considerably reduce the morbidity and mortality due to the disease.

Effect of Zinc Supplementation on Early Outcome of Neonatal Sepsis - A Randomized Controlled Trial

To find the effect of zinc supplementation on the outcome of neonatal sepsis at one month of age. This randomized controlled trial was conducted in a tertiary care neonatal unit, enrolling neonates with clinical features of sepsis and positive blood culture or positive sepsis screening tests. The treatment group received 3 mg/kg/twice a day of zinc sulfate monohydrate orally for 10 d along with standard antibiotic therapy. The control group received standard antibiotic treatment without zinc. Samples were collected from both the groups before and after the treatment. Babies were monitored till discharge and followed up as out-patients till one month of age. Demographic characteristics were similar between the cases and controls. After 10 d of treatment, the mean serum zinc level between the two groups was 737.09 ± 219.97 vs. 801.26 ± 405.56, (p = 0.20). Outcome measures like days of hospital stay (15 vs. 15; p = 0.69) and mortality rate (4.5% vs. 13.6%; p = 0.27) were not found to be significantly different between the groups. At one month of age, more number of control neonates had abnormal neurological findings as compared to the zinc supplemented group [(P = 0.02); RR (95%CI) = 0.28 (0.11-0.73)]. Zinc supplementation in neonates with sepsis improves the neurological status at one month of age although the mortality reduction was not statistically significant.

Is MRI Necessary in the Evaluation of Pediatric Central Sleep Apnea?

(1) To determine the prevalence of central nervous system (CNS) pathology identified on head magnetic resonance imaging (MRI) scans in children with central sleep apnea (CSA); (2) to assess the yield of MRI in evaluation of CSA; and (3) to identify factors that predict CNS pathology in children with CSA. Case series with chart review. Tertiary children's hospital. A chart review was conducted over 12 years. Patients 6 months to 18 years of age who underwent head MRI for evaluation of CSA were included. CSA was diagnosed on polysomnogram as central apnea index >1. Forty children were included in the CSA group. Twenty-two patients were male, and the mean age was 60 ± 41.5 months. The mean central apnea index was 3.8 ± 1.9, while the mean obstructive apnea hypopnea index was 3.4 (interquartile range, 0.7-3.8). Eighteen percent (7 of 40) of children with CSA had evidence of CNS pathology on MRI, with the most common finding (n = 3) being arachnoid cyst. Children with CSA who had gastroesophageal reflux disease or abnormal neurologic examinations were more likely to have CNS pathology. Other factors, such as prematurity, did not improve the yield of MRI in children with CSA. While routine evaluation of children with elevated central apnea index by MRI is not indicated, providers should consider neuroimaging in children with CSA and abnormal neurologic examination findings or gastroesophageal reflux disease. Further research is necessary to identify other tests with improved diagnostic yield for evaluation of pediatric CSA.

The Case Files

The Case Files

Long-term neurological outcomes in West Nile virus-infected patients: an observational study.

The Houston West Nile Cohort (HWNC) was founded in 2002 when West Nile virus (WNV) reached Houston, TX. The long-term outcomes following WNV infection are still mostly unknown, though neurological abnormalities up to 1 year postinfection have been documented. We report an observational study of neurological abnormalities at 1–3 and 8–11 years following WNV infection in the HWNC. We conducted standard neurological examinations at two separate time points to assess changes in neurological status over time. The majority of patients (86%, 30/35) with encephalitis had abnormal neurological exam findings at the time of the first assessment compared with uncomplicated fever (27%, 3/11) and meningitis (36%, 5/14) cases. At the time of the second assessment, 57% (4/7) of West Nile fever (WNF), 33% (2/6) of West Nile meningitis (WNM), and 36% (5/14) of West Nile encephalitis (WNE) had developed new neurological complications. The most common abnormalities noted were tandem gait, hearing loss, abnormal reflexes, and muscle weakness. Long-term neurological abnormalities were most commonly found in patients who experienced primary WNV encephalitis. New abnormalities may develop over time regardless of initial clinical infection. Future studies should aim to differentiate neurological consequences due to WNV neuroinvasive infection versus neurological decline related to comorbid conditions.

Epilepsy in dogs five years of age and older: 99 cases (2006–2011)

To classify the etiology of epilepsy and evaluate use of abnormal neurologic examination findings to predict secondary epilepsy in dogs ≥ 5 years of age. Retrospective case series. 99 dogs with epilepsy. Medical records were reviewed to identify client-owned dogs evaluated for seizures at ≥ 5 years of age with a diagnosis of primary or secondary epilepsy. Dogs were stratified by age; prevalence of primary and secondary epilepsy and the proportion of dogs with secondary epilepsy that had a diagnosis of neoplasia (on the basis of MRI findings) versus other disease were evaluated. Sensitivity and specificity of abnormal neurologic findings to detect secondary epilepsy were determined. 7 of 30 (23%) dogs 5 to 7 years of age, 13 of 29 (45%) dogs 8 to 10 years of age, 13 of 33 (39%) dogs 11 to 13 years of age, and 2 of 7 dogs ≥ 14 years of age had primary epilepsy. Prevalence of primary vs secondary epilepsy did not differ among age groups. The proportion of dogs with neoplasia at 5 to 7 years of age was lower than that of dogs in other age groups. Abnormal neurologic examination results had 74% sensitivity and 62% specificity to predict secondary epilepsy. A substantial proportion of dogs ≥ 5 years of age had primary epilepsy. Results indicated that lack of abnormalities on neurologic examination does not exclude the possibility of intracranial lesions, and MRI with CSF analysis (when applicable) should be recommended for all dogs with onset of seizures at ≥ 5 years of age.

CT Imaging of Craniofacial Fibrous Dysplasia.

Fibrous dysplasia is a benign fibroosseous bone dysplasia that can involve single (monostotic) or multiple (polyostotic) bones. Monostotic form is more frequent in the jaws. It is termed as craniofacial fibrous dysplasia, when it involves, though rarely, adjacent craniofacial bones. A 16-year-old girl consulted for a painless swelling in the right posterior mandible for two years. Panoramic radiography revealed ground-glass ill-defined lesions in the three different regions of the maxilla and mandible. Axial CT scan (bone window) showed multiple lesions involving skull base and facial bones. Despite lesions in the skull base, the patient had no abnormal neurological findings. The lesion was diagnosed as fibrous dysplasia based on radiological and histopathological examination. In this paper, CT findings and differential diagnosis of CFD are discussed. CT is a useful imaging technique for CFD cases.

Community-acquired meningitis in older adults: clinical features, etiology, and prognostic factors.

To investigate the epidemiology and outcomes of community-acquired meningitis in older adults. Retrospective study. Participants adults in Houston, Texas, with community-acquired meningitis hospitalized between January 1, 2005, and January 1, 2010 (N = 619; n = 54, 8.7%, aged ≥65; n = 565 aged <65). An adverse clinical outcome was defined as a Glasgow Outcome Scale score of 4 or less. Older adults had higher rates of comorbidities, abnormal neurological and laboratory (serum white blood cell count >12,000/μL, and cerebrospinal fluid protein >100 mg/dL) findings (P < .001), abnormalities on computed tomography and magnetic resonance imaging of the head (P = .002), and adverse clinical outcomes (ACOs) (P < .001). The majority of participants (65.8%) had meningitis of unknown etiology. Bacterial meningitis was an infrequent cause of community-acquired meningitis (7.4%). Of the known causes, bacterial meningitis and West Nile virus were more common in older than younger adults; younger participants more frequently had cryptococcal and viral meningitis. On logistic regression, female sex was predictive of a poor outcome in the older participants (P = .002), whereas abnormal neurological examination (P < .001), fever (P = .01), and a cerebrospinal fluid glucose level less than 45 mg/dL (P = .002) were significant poor prognostic factors in younger participants. Most cases of community-acquired meningitis are of unknown origin. Older adults are more likely than younger adults to have bacterial meningitis and West Nile virus infection when a cause can be identified. They also have more neurological abnormalities, laboratory and imaging abnormalities, and adverse clinical outcomes.

PO-0431 Serum Vascular Endothelial Growth Factor (vegf) And Neonatal Encephalopathy

Background Pro-inflammatory cytokines in both cerebrospinal fluid (CSF) and serum have been associated with abnormal neurological findings following hypoxic-ischaemic injury. Vascular endothelial growth factor (VEGF) seems to have a neuroprotective effect in adult stroke and low levels correlate with poor outcomes. We aimed to establish a correlation between serum VEGF levels and the severity of Neonatal Encephalopathy (NE). Methods Multi-organ evaluation was carried out on infants with NE (n = 122) with a particular emphasis on neurological status and function including neuroimaging (MRI and Cranial Ultrasound) and placental pathology. Serial serum VEGF levels were measured by multiplex ELISA over the first week of life. Results Infants with NE (n = 73) had serum VEGF levels on days 1, 2 and 3 of life that decreased as the severity of NE increased (Grade 0: n = 9, Grade 1: n = 20, Grade 2: n = 37, Grade 3: n = 7). Infants with NE (n = 122) had an association between elevated serum VEGF levels on day 1 and histological chorioamnionitis (n = 24) (p = 0.025). The mean serum VEGF in those without chorioamnionitis was 570 ± 870pg/mL compared to 1144 ± 1129pg/mL in those with chorioamnionitis. Serial VEGF levels were significantly associated with cord anomalies (p Conclusions VEGF correlated with Histological Chorioamnionitis in NE and the severity of encephalopathy.

Evaluation of coronal shift as an indicator of neuroaxial abnormalities in adolescent idiopathic scoliosis: a prospective study.

BackgroundIn previous studies, many indicator factors have been proposed to select patients who need an MRI screening of the spinal canal. In current study, the clinical and radiologic factors including coronal parameters of the curve were evaluated to find out which indicator is more important.MethodsA prospective study included 143 consecutive patients with the diagnosis of adolescent idiopathic scoliosis who were treated between 2010 and 2013 at our spinal clinics. Only patients with normal or subtle neurologic findings were included. All patients were evaluated by a total spine MRI protocol for examination of neuroaxial abnormalities. Known indicators and also coronal shift were analysed in all patients with or without abnormal MRI.ResultsThe incidence of neuroaxial abnormalities was 11.9% (17 of 143); only 5 patients (3.5%) were operated to treat their neuroaxial problem. The significant indicators of the abnormalities in our patients were: younger age at onset, asymmetric superficial abdominal reflex and, coronal shift more than 15 mm (P = 0.03). Some previously known indicators like atypical curves, male gender, double curves and absence of thoracic lordosis were not different between two groups of the patients.ConclusionsA total spine MRI is recommended at presentation in patients with younger age, abnormal neurologic findings and severe coronal shift.

Central nervous system infections due to cryptococcus gattii: epidemiology and implications for management

The emergence of Cryptococcus gattii in temperate climates has challenged the assumption that this fungus is ‘tropical’. In Australia, C. gattii still largely causes infection in healthy hosts although a recent study identified 28% of patients with immuno-compromised/co-morbid conditions. In contrast, 40-76% of cases in the outbreaks in North America had predisposing conditions/ were immunosuppressed. Meningitis ± cerebral infection (≈85% cases) is common in Australia, whilst in the outbreaks lung infection predominated. Headache (59-88%) and neck stiffness (48%) are common. Abnormal neurological findings at presentation or arising during therapy occur in 31-58% of cases including seizures and cranial nerve deficits. Raised intracranial pressure affects 50-60% of patients and hydrocephalus 30%. Lumbar puncture, recording CSF pressure and cerebral imaging are mandatory in all patients as is fundoscopy to detect papilledema. Isolates are speciated routinely for genotyping and susceptibility testing. A new lateral flow assay has provided a valuable added resource for rapid diagnosis. Because CNS infection is severe with high morbidity, prolonged treatment is required. In Australia, physician practice often employs induction therapy with amphotericin B and 5-flucytosine for 6 weeks followed by eradication therapy with fluconazole for 18-24 months. Surgical intervention, e.g., resection of mass lesions or CSF shunting may be required. The emergence of Cryptococcus gattii in temperate climates has challenged the assumption that this fungus is ‘tropical’. In Australia, C. gattii still largely causes infection in healthy hosts although a recent study identified 28% of patients with immuno-compromised/co-morbid conditions. In contrast, 40-76% of cases in the outbreaks in North America had predisposing conditions/ were immunosuppressed. Meningitis ± cerebral infection (≈85% cases) is common in Australia, whilst in the outbreaks lung infection predominated. Headache (59-88%) and neck stiffness (48%) are common. Abnormal neurological findings at presentation or arising during therapy occur in 31-58% of cases including seizures and cranial nerve deficits. Raised intracranial pressure affects 50-60% of patients and hydrocephalus 30%. Lumbar puncture, recording CSF pressure and cerebral imaging are mandatory in all patients as is fundoscopy to detect papilledema. Isolates are speciated routinely for genotyping and susceptibility testing. A new lateral flow assay has provided a valuable added resource for rapid diagnosis. Because CNS infection is severe with high morbidity, prolonged treatment is required. In Australia, physician practice often employs induction therapy with amphotericin B and 5-flucytosine for 6 weeks followed by eradication therapy with fluconazole for 18-24 months. Surgical intervention, e.g., resection of mass lesions or CSF shunting may be required.

Lower extremity nerve entrapments in athletes.

Nerve entrapments are a potential cause of lower extremity pain in athletes. Signs and symptoms suggestive of nerve entrapment include anesthesia, dysesthesias, paresthesias, or weakness in the distribution of a peripheral nerve. The physical examination may reveal an abnormal neurologic examination finding in the distribution of a peripheral nerve, positive nerve provocative testing, and positive Tinel sign over the area of entrapment. Electrodiagnostic studies, radiographs, magnetic resonance imaging studies, and sonographic evaluation may assist with the diagnosis of these disorders. Initial treatment usually involves conservative measures, but surgical intervention may be required if conservative treatment fails. This article discusses the diagnosis and treatment of common lower extremity nerve entrapments in athletes. A high index of suspicion for nerve entrapments enables the clinician to identify these conditions in a timely manner and institute an appropriate management program, thus improving patient outcomes.

Postanesthesia Persistent Amnesia in a Patient With a Prior History of Dissociative Fugue State: The Case for the Two-Hit Hypothesis

The psychiatry service was called to evaluate a patient in the outpatient procedure unit who could not remember who she was or why she was there. “Ms. R” was a 36-yearold Hispanic woman with a history of morbid obesity who underwent an upper endoscopy for evaluation of nausea and inability to tolerate oral intake 1 month after a Roux-en-Y gastric bypass for her obesity. The endoscopy demonstrated moderate stenosis at the gastrojejunal anastomosis, which did not account for the severity of her nausea. The stenosis was dilated without incident. For the procedure, Ms. R received a total of 420 mg i.v. of propofol, 100 mg i.v. of lidocaine, and 0.2 mg i.v. of glycopyrrolate. She also received a total of 200 μg i.v. of phenylephrine for a transient decrease in blood pressure to 81/45. In the recovery room, when Ms. R awoke from her conscious sedation, she had no recollection of why she was in the hospital, was disoriented to place, and, most significantly, was unable to recall her identity. She was agitated, prompting the psychiatric consultation. Ms. R was visibly frightened when any person tried to approach her, including her boyfriend of 5 years. She repeatedly asked why she was there but was unable to retain the information received. She was given 2 mg of midazolam for agitation, after which a minor improvement in behavior was observed. A repeat dose of midazolam was administered, without further improvement. Forty-five minutes after the procedure, Ms. R was still unable to recall her date of birth. Her vital signs and general physical and neurological examination were within normal limits. Her mental status examination was significant for agitation, disorientation to person and place, and extensive memory loss, which continued for the rest of the day. She repeatedly expressed the delusion that the baby she had just delivered was taken from her. She had no evidence of hallucinations. A preprocedure pregnancy test was negative. Ms. R was on a liquid diet and taking a multivitamin once daily, 1,000 μg of vitamin B12 three times a week sublingually, and calcium citrate daily. Ms. R’s past medical history included a history of gallstones as well as the Roux-en-Y gastric bypass surgery 1 month earlier, at which time her body mass index (BMI) was 47. Ms. R had received 200 mg of propofol as part of the anesthesia during the 3-hour bariatric surgery without incident. Ursodiol was begun 3 weeks before the endoscopy for nausea that developed while she was consuming a postoperative liquid diet. When her diet was advanced to soft foods, she began vomiting. She returned to a liquid diet, and the endoscopy was scheduled. Ms. R’s past psychiatric history was significant for a dissociative fugue, which occurred at the same time as her divorce 7 years earlier and for which she was psychiatrically hospitalized. She continued in individual and group treatment for 2 years after that hospitalization. She had no history of traumatic events. Because of Ms. R’s persistent amnesia and agitation, she was admitted to amedical unit for further evaluation. Results of all testing, routine laboratory tests, urine drug screen, head CT, head MRI, and EEG were normal except for ketones in the urine. Ms. R’s BMI had decreased to 40.5. She was started on a clear liquid diet and had no further nausea. The neurology consultant agreed with the psychiatrist’s diagnosis of dissociative amnesia. During her hospitalization, Ms. R slowly regained some of her memory. She vaguely remembered that she had an adult son living in another state. Ms. R could not remember how to use her cell phone. She was afraid to take a shower without supervision as she was not sure she would know what to do. She also could not recall important historical events, such as the September 2001 attacks on the World Trade Center. There was no evidence of anterograde amnesia after the first hospital day. After showing some improvement over her 6-day hospitalization, she was discharged home with her boyfriend. Two weeks after hospital discharge, Ms. R continued to recover some of her memories and to increase her activities. It was unclear, however, whether her retrograde amnesia was improving or whether she was only retaining newly learned information. She began to cook on her own and reported increased comfort around her boyfriend and her family. Ms. R was afraid to return to work because she was concerned that she would not remember how to do her job. Within 2 months of the episode, Ms. R was retrained by her employer and successfully resumed her work as a secretary. Six months after the procedure, Ms. R’s retrograde amnesia had significantly improved and she continued to form new memories without difficulty.

Signs and symptoms of methylmercury contamination in a First Nations community in Northwestern Ontario, Canada

In 1970, fish caught in the English–Wabigoon River system in northwestern Ontario, Canada, were found to be contaminated with mercury coming from a chlor-alkali plant in the province. In the 1970s, patients exhibiting some of the symptoms of the Hunter–Russell syndrome (e.g. paresthesias, visual field constriction, ataxia, impaired hearing, and speech impairment) were reported by some researchers. However attempts to diagnose the patients as suffering from methylmercury poisoning proved to be controversial. In order to research the presence of methylmercury contamination, and show that the patients, through eating contaminated fish, were suffering from methylmercury poisoning, we studied the results of subjective complaints, neurological findings, and quantitative somatosensory measurements gathered in Grassy Narrows Indian Reservation, Ontario, in March, 2010. At that time, the population of the Grassy Narrows settlement was around 900. Ninety-one residents volunteered to be examined. From them, we selected 80 people who were older than 15years old, and divided them into two groups. Canadian Younger (CY): 36 residents who were from 16 to 45years old. Canadian Older (CO): 44 residents who were from 46 to 76years old. We compared them to Japanese Exposed (JE): 88 methylmercury exposed residents from the Minamata district in Japan, and Japanese Control (JC): 164 control residents from non-polluted areas in Japan. Complaints and abnormal neurological findings were more prevalent and quantitative sensory measurements were worse in the two Canadian groups and the Japanese Exposed group than in the Japanese Control group. Complaints, neurological findings and quantitative sensory measurements were similar in Canadian Older and Japanese Exposed. The results for Canadian Younger fell between those of Canadian Older and Japanese Control. These findings indicate that the clinical signs and symptoms of the residents of Grassy Narrows are almost the same as those recorded for Minamata disease in Japan.

Autism spectrum disorders associated to a deficiency of the enzymes of the mitochondrial respiratory chain

Autism spectrum disorder (ASD) is a group of neurodevelopmental disorders characterized by a combination of reciprocal social deficits, communication impairment, and rigid ritualistic interest and stereotypies. The etiology is generally multifactorial, including genetic, immunological and/or environmental factors. A group of ASD has been linked to mitochondrial dysfunction with subsequent deficiency in energy production. Patients with ASD and mitochondrial disease often show signs and symptoms uncommon to idiopathic ASD such as cardiac, pancreatic or liver dysfunction, cardiac, growth retardation, fatigability, but in some cases semiology is different. We show two clinical cases of ASD associated to a deficiency of the mitochondrial respiratory chain (complex I+III and IV) with different clinical presentations. In one case, signs and symptoms of mitochondrial disorder were mild and the second diagnosis was attained many years after that of ASD. These findings support the recent growing body of evidence that ASD can be associated with mitochondrial disorder. Children with ASD and abnormal neurologic or systemic findings should be evaluated for mitochondrial disorder.