Amnesia Research Articles

Transient Fever Response After ECT in a Patient with Catatonic Schizophrenia: A Case Report.

Electroconvulsive therapy (ECT) is an effective and safe treatment method for many psychiatric disorders. In general medical practice, ECT may cause side effects as most other treatment methods do. Headache, myalgia, nausea, vomiting, confusion, anterograde amnesia are common side effects of electroconvulsive therapy. Fever; in addition to general medical conditions such as infection, malignancy, connective tissue diseases, drug treatments, malignant hyperthermia, convulsions, it can also occur due to conditions such as neuroleptic malignant syndrome (NMS), serotonin syndrome, catatonia, malignant catatonia, which are frequently encountered in psychiatry clinics. In the literature, transient fever response due to electroconvulsive therapy application have been described, albeit rarely. Although there are many proposed mechanisms for the emergence of a fever response, regardless of its cause, it is still not understood why some fever responses occur. In this article, we present the differential diagnosis of the fever response, possible causes, and the mechanisms that may reveal the secondary fever response to electroconvulsive therapy in a case with a diagnosis of catatonic schizophrenia, who developed a fever response during electroconvulsive therapy sessions and no fever response was observed at times other than electroconvulsive therapy sessions. In this case, postictal benign fever response associated with electroconvulsive therapy was considered after excluding other medical conditions that may cause a fever response after electroconvulsive therapy. Keywords: ECT, Fever, Catatonia, NMS.

On the replicability of action-verb deficits in Parkinson's disease.

The case of JP, reported by Ackerly and Benton in 1948 with a detailed follow-up by Ackerly in 1964, stands as the index case of developmental prefrontal damage and its impact on social adaptation. Although the 1948 case report included findings from a 1933 pneumoencephalogram and exploratory craniotomy, a definitive cause was never established for JP's prefrontal damage. Etiologies were never determined for the left-sided seizures that occurred when JP was age four, nor for the progressive anterograde amnesia that JP developed in middle age.Given Ackerly's thoroughness and long-term follow-up of his patient, it was hoped that a brain cutting would have been done, though no report of a post-mortem examination was published. The lead author of this paper (SB) set out to discover what had happened to JP after Ackerly's 1964 report and whether a brain cutting had in fact occurred. Using a variety of investigative approaches, it was discovered that a post-mortem brain examination had taken place. Those present at the brain cutting were identified, and the still-living witnesses to the brain cutting were interviewed. Previously unpublished, relevant materials were uncovered from archival sources. A film of the brain cutting, as well as photos, were located. A film of Ackerly interviewing JP prior to JP's death at age sixty-four also was found.The authors studied autopsy findings in the newly discovered video and still images. These findings were judged consistent with massive perinatal hemorrhagic damage to both frontal lobes. JP's left-sided seizures were likely due to activation of a focus from his congenital brain damage. The anterograde amnesia that was documented when JP was twenty-five and that was noted to worsen when he was forty-nine remains unexplained but may have been related to slowly progressive hydrocephalus. This paper expands what is known about the case of JP, making it the only report of a person with congenital frontal injury followed for their entire life including post-mortem brain examination.

Safe sedation during diagnostic and therapeutic flexible bronchoscopy in Japan: A review of the literature.

We explored whether a combination of an opioid (fentanyl or pethidine) and midazolam could safely sedate Japanese patients undergoing bronchoscopic procedures. We searched the PubMed Medline and Igaku Chuo Zasshi (ICHUSHI) databases from 1980 to 2022 for papers on sedatives used during bronchoscopy, especially opioids (fentanyl and pethidine) and midazolam. The keywords were "bronchoscopy" and "sedation" ("kikanshikyo" and "chinsei", respectively, in Japanese). The results showed that midazolam was the preferred sedation agent during flexible bronchoscopy; with midazolam sedation is rapid, and the drug is associated with anterograde amnesia and decreased discomfort. A combination of an opioid (fentanyl or pethidine) and midazolam improved the patient tolerance and willingness to undergo a repeat procedure and also improved the working conditions for the physician. The British Thoracic Society guideline of 2013 suggested that a combination of an opioid (fentanyl or alfentanil) and midazolam should be considered to improve bronchoscopic tolerance. The American College of Chest Physicians Consensus Statement of 2011 suggested that fentanyl should be preferred; the onset of action and peak effect are rapid, and the effects are of relatively short duration. Emphasis has been placed on safety aspects, such as patient monitoring, the precautions that should be taken in patients with certain conditions, prevention and management of complications, adequate staffing, and optimal sedation and disinfection. In conclusion a combined opioid (fentanyl or pethidine) and midazolam sedation is optimal for diagnostic and therapeutic flexible bronchoscopy in Japanese patients.

Forensic Aspects of Zolpidem Use

Zolpidem is one of the most commonly prescribed hypnotic drugs for short-term treatment of insomnia. Zolpidem use or abuse was associated with an increased risk of driving accidents, inducing of suicide attempts and death. Its use or abuse associate with hallucinations and bizarre behaviors. Zolpidem induces anterograde amnesia, confusion and sedation and abused as a tool in drug-facilitated crimes. From this view, its analysis and interpretation in forensic cases has been important. In this article, we reviewed the some forensic aspects of zolpidem use or abuse.

Comparison Between Clonazepam and Bromazepam as Premedication Drugs to Reduce Anxiety in Patients Undergoing Elective Surgery Under General Anaesthesia

Background: The majority of patients admitted in hospital for elective surgery experience anxiety preoperatively which can adversely influence the surgical procedure as well as the patient’s recovery. Reduction of anxiety and fear during preoperative period in patients of elective surgery is an essential surgical preparation. Benzodiazepines are the most commonly used drugs for this purpose. Materials and Methods: The study was carried out in a series of 60 consecutive, randomly selected patients, aged 18-60 years, admitted for elective surgery under General Anaesthesia, in Combined Military Hospital, Chattogram during the period September 2021 to February 2022. Patients who received Clonazepam or Bromazepam as preoperative medication were included in the study. Anxiety was scored using VAS (Visual Analogue Scale), sedation was scored by using Ramsay Sedation Scale and anterograde amnesia by asking preoperative events after 24 hours of premedication. Results: While evaluating mean anxiety reduction, mean reduction is not significantly different between the two groups (P value 0.856). Sedation level was more achieved with Clonazepam but that was not statistically significant (mean 2.13 vs mean 2.0, P value 0.557). In the Clonazepam group, greater percentage of patients could not recall preoperative events but that was not statistically significant (average 51.10% vs 39.99%, P value>0.05). Incidence of adverse effects was more in the Bromazepam group (16.66% vs 6.66%). Conclusion: The standard administration of Clonazepam and Bromazepam before operation provides patients with a moderate reduction of periprocedural anxiety. Clonazepam produces more amnesia, sedation and less adverse effects.. Therefore, this study favors routine use of Clonazepam as premedication to reduce anxiety before surgery. KYAMC Journal Vol. 13, No. 03, October 2022: 139-144

Transient global amnesia - hippocampal lesions in magnetic resonance imaging

BackgroundTransient global amnesia is a benign syndrome characterized by a sudden onset loss of anterograde amnesia with full recovery. Magnetic resonance of the brain including diffusion–weighted imaging of patients with transient global amnesia revealed the presence of punctate hyperintense signal abnormalities in the hippocampus. ObjectiveAnalysis of the presence of hippocampal lesions in brain magnetic resonance imaging in patients with transient global amnesia and the possible influence of additional factors on their appearance. MethodsIn this retrospective, an observational study we assessed brain magnetic resonance imaging in 38 consecutive patients with transient global amnesia. The incidence of brain magnetic resonance imaging lesions was analyzed for the coexisting cardiovascular risk factors and precipitating events. ResultsHippocampal brain magnetic resonance imaging lesions were detected in 47% of patients with transient global amnesia. Of those, 65% had unilateral lesions, 82% were left-sided, and 28% were right-sided. Most lesions were located in the CA1 subfield. The incidence of hypertension in patients with transient global amnesia was higher than in the general population. Stress and exercise preceded the onset of transient global amnesia only in 13% and 16% of patients, respectively. There was no higher incidence of migraine in transient global amnesia patients (13%). ConclusionsWe found that nearly 50% of patients with transient global amnesia had hyperintense hippocampal brain magnetic resonance imaging lesions. In addition to hypertension, individuals with transient global amnesia had similar cardiovascular risk factors as the general population. We did not identify any precipitating events prior to the onset of transient global amnesia.

564 AN UNUSUAL PRESENTATION OF ICA DISSECTION. A CASE OF TRANSIENT GLOBAL AMNESIA IN A PATIENT WITH PAINLESS SPONTANEOUS INTERNAL CAROTID ARTERY DISSECTION

Abstract Image focus A 42-year-old woman was carried to emergency room lamenting sudden memory loss. Her husband witnessed the onset of the episode. No recent head trauma was reported, blood pressure was under control. Anterograde and retrograde memory loss was present and confirmed by a neurologist. No other neurological signs were elicitable. Blood exams and toxicological analysis were negative. ECG, chest radiography, and cerebral TC showed no abnormalities. At physical examination a carotid bruit could be appreciated. We performed an eco-color-Doppler of carotid artery that showed a left common and internal carotid artery dissection (figure 1). The diagnosis of ICA dissection was confirmed with a contrast CT. The coexistence of an aortic dissection was excluded with the same imaging technique. The anterograde amnesia resolved 15 h after the admission. A neurologist confirmed that the patient experimented an episode of transient global amnesia (TGA). After a vascular surgery consultation, a conservative treatment was deemed appropriate. After a 6 month follow up the patient didn't complain of any other neurological symptom or sign. Transient global amnesia (TGA) is characterized by reversible anterograde and retrograde amnesia of sudden onset. This amnesic syndrome resolves spontaneously within 24 h. Annual incidence rate for all ages of spontaneous ICA dissection is approximately of 2.6 per 100 000 inhabitants, however data are extremely variable among different studies. TGA has never been associated with a spontaneous ICA dissection. In order to not miss a spontaneous ICA dissection as a rare ethology of TGA, we suggest performing an eco-color-Doppler of the epi-aortic vessels in patient affected by such amnesic syndrome.

Comparative Study of the Effect of a DNA Methyltransferase Inhibitor and a Histone Deacetylase Inhibitor on Memory Formation Processes in Anterograde Amnesia.

The participation of DNA methylation and histone acetylation in the mechanisms of anterograde amnesia and memory recovery was studied on grape snails trained in conditioned food aversion. Anterograde amnesia developed 10 days after memory reconsolidation impairment with an NMDA glutamate receptor antagonist and was characterized by long-term memory formation impairment upon repeated training. DNA methyltransferase inhibitor injections to snails 1 h before repeated training, as well as 15 min or 4 h after repeated training, caused rapid formation of memory that persisted for at least 10 days. Injections of histone deacetylase inhibitor before repeated training also induced the formation of a stable long-term memory. However, administration of histone deacetylase inhibitor 15 min after repeated training initiated a temporary memory recovery. Injections of the inhibitor 4 h after repeated training were ineffective. These results indicate that histone-dependent chromatin remodeling and DNA methylation are selectively involved in the mechanisms of anterograde amnesia and memory recovery.

Effects of Chronic Oral Administration of Midazolam on Memory and Circadian Rhythms in Rats.

Studies have shown the ability of benzodiazepine drugs to cause memory loss in animals and humans. Midazolam is a benzodiazepine commonly administered intravenously during surgical procedures because it reacts rapidly, causes anterograde amnesia, and has few side effects. It has also been used in palliative medicine where, among others, an oral route has been employed for chronic administration of the drug. The current study evaluated the effects of chronic orally administered midazolam on spatial working memory and procedural memory in control and experimental female rats over a three-week experimental period utilizing the Morris water maze. Sample and test run times to a submerged platform in the maze were recorded daily. In addition, activity wheels attached to each cage were employed to monitor daily circadian activity of the animals. Spatial working memory was not impaired in either group. However, procedural memory amnesia occurred in animals receiving the drug indicative of a consolidation or retrieval problem. Concerning circadian rhythms, a phase-shift was noted in experimental animals possibly indicating that time of day of drug administration is important. The findings of the present study could shed insight into altered reactions observed in humans who have received midazolam as a component of treatment in palliative medicine.

A Case of Transient Global Amnesia Triggered by Sexual Intercourse

Transient global amnesia (TGA) is described as a sudden onset of anterograde and retrograde amnesia. In this case report, we present a case of a 52-year-old man who came to our hospital experiencing sudden-onset confusion and memory loss an hour after engaging in sexual activity with his wife. Before this, the patient had no previous medical history. Four hours following the event, a non-contrast computed tomography (CT) scan was performed and showed no signs of any intracranial pathology. In addition, T1-weighted and T2-weightedmagnetic resonance imaging (MRI) was performed13 hours following the incident and demonstrated punctate focus of restricted diffusion in the medial right temporal lobe in the region of the hippocampus. A diagnosis of transient global amnesia was made after other causes were ruled out. We present this rare case of transient global amnesia (TGA), highlighting sexual intercourse as a probable triggering component of the disease and demonstrating how crucial it is to rule out other severely morbid conditions before managing TGA.

Comparison between Bromazepam and Lorazepam as premedicant to reduce anxiety in patients undergoing elective surgery under General Anaesthesia

Background: The majority of patients admitted to the hospital for elective surgery experience anxiety preoperatively which can adversely influence the surgical procedure as well as the patient’s recovery. Reduction of anxiety and fear at the preoperative period in patients of elective surgery is essential for surgical preparation. Benzodiazepines are the most commonly used drugs for this purpose. Materials and Methods: The study was carried out on a series of 60 consecutivepatients, aged 18-60 years, admitted for elective surgery under General Anaesthesia, in Combined Military Hospital, Chattogram during the period September 2021 to February 2022. Patients receiving bromazepam or lorazepam as preoperative medication were selected. Anxiety was scored using VAS (Visual Analogue Scale), sedation was scored by using the Ramsay Sedation scale and anterograde amnesia by asking about preoperative events after 24 hours of premedication. Results: While evaluating mean anxiety reduction only, mean reduction is greater in the lorazepam group compared to that of bromazepam. Sedation level was less achieved with bromazepam. In the lorazepam group, a greater number of patients could not recall preoperative events but incidence of adverse effects was significantly more in this group. Conclusion: The standard administration of bromazepam before the procedure provides patients with a moderate reduction of periprocedural anxiety. Premedication of lorazepam is associated with a high incidence of adverse effects. Therefore, this study does not support the routine use of lorazepam as premedication to reduce anxiety before surgery. Bangladesh Crit Care J September 2022; 10(2): 110-115

DNA methylation inhibition participates in the anterograde amnesia key mechanism through the suppression of the transcription of genes involved in memory formation in grape snails

The study of the amnesia mechanisms is of both theoretical and practical importance. The mechanisms of anterograde amnesia are the least studied, due to the lack of an experimental model that allows studying this amnesia type molecular and cellular mechanisms. Previously, we found that conditional food aversion memory reconsolidation impairment in snails by NMDA glutamate receptor antagonists led to the amnesia induction, in the late stages of which (>10 days) repeated training did not cause long-term memory formation. In the same animals, long-term memory aversion to a new food type was formed. We characterized this amnesia as specific anterograde amnesia. In the present work we studied the role of epigenetic DNA methylation processes as well as protein and mRNA synthesis in the mechanisms of anterograde amnesia and memory recovery. DNMT methyltransferase inhibitors (iDNMT: zebularine, RG108 (N-Phthalyl-1-tryptophan), and 5-AZA (5-Aza-2'-deoxycytidine)) were used to alter DNA methylation. It was found that in amnesic animals the iDNMT administration before or after shortened repeated training led to the rapid long-term conditional food aversion formation (Ebbinghaus saving effect). This result suggests that amnestic animals retain a latent memory, which is the basis for accelerated memory formation during repeated training. Protein synthesis inhibitors administration (cycloheximide) before or immediately after repeated training or administration of RNA synthesis inhibitor (actinomycin D) after repeated training prevented memory formation under iDNMT action. The earlier protein synthesis inhibitor effect suggests that the proteins required for memory formation are translated from the pre-existing, translationally repressed mRNAs. Thus, we have shown for the first time that the anterograde amnesia key mechanism is DNMT-dependent suppression of the transcription of genes involved in memory mechanisms. Inhibition of DNMT during repeated training reversed these genes expression blockade, opening access to them by transcription factors synthesized during training from the pre-existing mRNAs.

Drug-facilitated crimes: Do not forget to test for GHB in hair!

The aim of this paper is to promote the determination of GHB in hair to better document drug-facilitated crimes. Over the past years, there has been a dramatic increase in media reports about drug-facilitated crimes (DFC) victims. These reports evoked systematically the presence of GHB, but forensic toxicologists perfectly know that real cases are rare, at least in France. As exogenous GHB is rapidly eliminated (t1/2 approx. 30–60 min) there is a need of sampling victim's blood and urine very precociously: unfortunately, that is most of the time not possible due to delayed police report. Hair analysis remains the only solution to investigate these cases. We present here two DFC cases where GHB determination in hair gave the proof of GHB administration. Two different offenders used the same modus operandi at two different times, purporting as taxi drivers, that facilitated the reception of the victims and offering to drink a bottle of water. Victims (2 men) became confused and slightly asleep then loss motor skills; they awaked at home the morning after, suffering an anterograde amnesia. They found that their watches and their money had been stolen. Hair samples of the victims were collected 3 and 4.5 months after the offense. A targeted screening for drugs usually used in DFC cases was performed by LC-MS/MS. Hair were then tested for GHB. For each, a total of 8 small 0.5-cm segments from either side of the section of interest (i.e. the segment corresponding to the offense) were analyzed according to a standardized procedure: GHB-D6 (i.s.) was added to 10 mg hair from each segment before a 2-hours sonication in water; extraction was performed with ethyl acetate under acidic conditions; BSTFA derivatization was performed after evaporation of the organic layer. Chromatographic conditions were the following on a GC-MS/MS Trace 1300/TSQ 8000 (ThermoFisher): injection volume 2 μL; column 5% phenyl-95% dimethylpolysiloxane; temperature: 80 °C to 310 °C @ 15 °C/min. Analyzes for the common DFC drugs remained negative in both cases. Results for GHB are summarized as follow: case#1 GHB baseline was 2 ng/mg, GHB segments around the offense were 5.8 and 7.7 ng/mg. Case#2 GHB baseline was 1.3 ng/mg, GHB segments around the offense were 6.4 and 7.2 ng/mg. In both case the 2 segments near the root were excluded to avoid misinterpretation due to sweat contamination. The results were significantly different between the baselines and the offense-segments to conclude to a criminal administration of GHB or GBL. Moreover, the description of the clinical symptoms and memory loss were very typical of GHB ingestion. Our positive results were sufficient arguments to help the judge to charge 4 different fake taxi drivers with theft by trickery and with administration of poison, and to continue the investigation in seizing different household products presumed to contain GHB/GBL. It is important to notice that the fake taxi driver is a new way for robbery that appeared in recent years, operating in front of nightclubs, waiting most of the time for women but also for men who wanted to go home. Among all the drugs used to commit DFC (including DFSA), GHB is one of the most difficult to deal with in term of interpretation of the results. Hair testing for GHB is currently not an analytical problem (neither in blood and urine), thus it is a valuable reason to encourage testing for GHB in a sufficient number (8) of small hair segments (0.5 cm) to document DFC cases.

EFFECT OF FENOFIBRATE AND GEMFIBROZIL IN SODIUM NITRITE-INDUCED ANTEROGRADE AMNESIA IN MALE WISTAR RATS

Objectives: The present study was planned to study the effect of fenofibrate and gemfibrozil on sodium nitrite-induced anterograde amnesia in male Wistar rats. Methods: Anterograde amnesia was induced by 75 mg/kg of sodium nitrite in six groups (eight in each group) of male Wistar rats (150–180 g). Fenofibrate (21 mg/kg and 18 mg/kg) and gemfibrozil (108 and 21 mg/kg) were used as test drugs. The paradigm used was Morris water maze, where a hidden platform was kept for the rat to escape from the water. Rats were trained to locate a hidden platform by releasing them into water for 4 times a day for 4 consecutive days. The acquisition of this task was measured by noting the time taken to escape to the platform. On the 6th day of the study, retrieval of this learnt task was measured by noting the time taken to search for the missing hidden platform. The time taken by the rats during the acquisition and retrieval tasks in fenofibrate and gemfibrozil treated groups were measured and compared with disease control group. On the 6th day (retrieval trial), only vehicle (distilled water oral) was administered to the groups. Results: Fenofibrate and gemfibrozil completely ameliorated the anterograde amnesia. The mean escape latency time of both fenofibrate and gemfibrozil administered rats was significantly reduced with respect to sodium nitrite group while, retrieval time increased significantly. However, the same group of rats showed significant retrieval of task memory. Conclusion: In the present study, fenofibrate and gemfibrozil ameliorated chemical hypoxia-induced anterograde amnesia. Both can potentially inhibit oxidative stress induced neurodegeneration at the commonly prescribed clinical doses. In addition to their hypolipidemic effect, they can also prevent modifiable risk factors of chronic neurodegenerative disorders. Further studies are needed to substantiate these findings.

Distorted time perception in patients with transient global amnesia: time perception task and imaging analysis.

Transient global amnesia (TGA) is defined as a sudden and transient episode of memory loss and accompanied by temporal disorientation. However, the mechanism by which time distortion occurs is not clearly elucidated yet. Between March 2019 and November 2020, we subjected 30 TGA patients to several time perception tasks and analyzed their magnetic resonance image (MRI) scans and compared the results with age- and sex-matched control group. Among the 60 recruited subjects (64.5 ± 6.3years), 70% were women. Fourteen patients had only anterograde amnesia. Furthermore, 46% of the patients with TGA (n = 14) had a history of Valsalva maneuver, and 70% of the patients (n = 21) had a pre-attack stress factor. The MRI scans of 14 patients (46.67%) showed hippocampal hyperintensity. With regard to the time production task, patients with TGA exhibited shorter times in all trials compared with their counterparts (5s, 4.90 ± 1.16 vs. 5.53 ± 0.87; p value = 0.02: 15s, 12.18 ± 4.55 vs. 14.42 ± 2.54; p value = 0.021). For the time comparison task, the number of correct answers given by patients with TGA was significantly lesser than that given by the control group (6.07 ± 1.23 vs. 6.90 ± 1.24; p value = 0.006). This is the first study to invesgating an altered time perception in patients with TGA. Although the exact neurophysiological mechanism remains unclear, our findings could aid in the elucidation of brain function across specific time frames.

Comparison between Diazepam and Midazolam as Premedicant to Reduce Anxiety in Patients underwent Elective Surgery Under General Anaesthesia

Background: The majority of patients admitted to hospital for elective surgery experience anxiety preoperatively which can adversely influence the surgical procedure as well as the patient’s recovery. Reduction of anxiety and fear at preoperative period in patients of elective surgery is essential for surgical preparation. Benzodiazepines are the most commonly used drugs for this purpose. The purpose of the study to evaluate the comparative efficacy of Diazepam and Midazolam regarding onset, duration and degree of antianxiety, sedation and amnesia during surgery under general anaesthesia. Materials and methods: The study was carried out in series of 60 consequetive, unselected patients, aged 18-60 years, admitted for the elective surgery under General Anaesthesia, in Combined Military Hospital (CMH) Chattogram during the period September 2019 to February 2020. Patients receiving diazepam or midazolam as preoperative medication were taken. Anxiety was scored using VAS, sedation was scored by using Ramsay Sedation scale and anterograde amnesia by asking preoperative events after 24 hours. Results: While evaluating mean anxiety reduction only, mean reduction is greater in the diazepam group compared to that of midazolam. Desired sedation level was less achieved with midazolam. In the diazepam group, greater number of patients could not recall preoperative events. Conclusion: The standard administration of diazepam before procedure provides patients with a moderate reduction of periprocedural anxiety. Routinely, administration of midazolam has a limited effects on the reduction of anxiety. Additionally, premedication of midazolam is associated with a high incidence of adverse effects. Therefore, this study does not support the routine use of midazolam as premedication to reduce anxiety. IAHS Medical Journal Vol 5(1), June 2022; 65-69

Forgetting the Unforgettable: Transient Global Amnesia Part II: A Clinical Road Map.

Transient global amnesia (TGA) is a clinical syndrome characterized by the sudden onset of a temporary memory disorder with profound anterograde amnesia and a variable impairment of the past memory. Usually, the attacks are preceded by a precipitating event, last up to 24 h and are not associated with other neurological deficits. Diagnosis can be challenging because the identification of TGA requires the exclusion of some acute amnestic syndromes that occur in emergency situations and share structural or functional alterations of memory circuits. Magnetic Resonance Imaging (MRI) studies performed 24–96 h after symptom onset can help to confirm the diagnosis by identifying lesions in the CA1 field of the hippocampal cornu ammonis, but their practical utility in changing the management of patients is a matter of discussion. In this review, we aim to provide a practical approach to early recognition of this condition in daily practice, highlighting both the lights and the shadows of the diagnostic criteria. For this purpose, we summarize current knowledge about the clinical presentation, diagnostic pathways, differential diagnosis, and the expected long-term outcome of TGA.

Healthcare choices following mild traumatic brain injury in Australia

BackgroundAccurate data on the types of healthcare people seek in the early stages following mild traumatic brain injury (mTBI) in Australia is lacking. We sought to investigate the types of healthcare people seek following mTBI, including seeking no care at all; ascertain the demographic, pre- and peri-injury factors, and symptom characteristics associated with the care that people access; and examine whether choice of care is associated with symptomatic recovery and quality of life.MethodsAn online retrospective survey of Australians aged 18 to 65 years who had experienced a self-reported ‘concussion’ (mTBI) within the previous 18 months. Types of healthcare accessed were investigated, as well as those who did not seek any care. Data were analysed using frequency and percentages, chi-squared tests and logistic regression models.ResultsA total of 201 respondents had experienced a self-reported ‘concussion’ but 21.4% of the respondents did not seek any care. Of the 183 respondents who sought healthcare, 52.5% attended a hospital Emergency Department, 41.0% attended a general practitioner and 6.6% accessed sports-based care. Compared to their counterparts, those who had a lower level of education (p = 0.001), had experienced previous mTBI (p = 0.045) or previous mental health issues (p = 0.009) were less likely to seek healthcare, whilst those who had experienced loss of consciousness (p = 0.014), anterograde (p = 0.044) or retrograde (p = 0.009) amnesia, and symptoms including drowsiness (p = 0.005), nausea (p = 0.040), and feeling slow (p = 0.031) were more likely to seek care. Those who did not seek care were more likely to recover within one month (AOR 4.90, 95%CI 1.51 – 15.89, p = 0.008), albeit the relatively large 95%CI warrants careful interpretation. Compared to seeking care, not seeking care was not found to be significantly associated with symptom resolution nor quality of life (p > 0.05).ConclusionsThis study provides unique insight into factors associated with healthcare utilisation in the early stages following mTBI, as well as outcomes associated with choice of care, including not seeking care. Delivering targeted community education on the signs and symptoms of mTBI, and the advantages of seeking care following injury is an important step forward in the management of this challenging condition.

Wernicke encephalopathy after chronic pancreatitis exacerbation. Case report

Wernicke encephalopathy (WE), is an emergency acute neuropsychiatric condition, which develops secondary to thiamine deficiency. According to data of multiple investigations, this disorder is greatly underdiagnosed. WE classically connected to chronic alcohol abuse, but also diagnosed in non‑alcoholic patients with different risk factors including severe vomiting, chronic malnutrition, systemic infections, malignancies, chemotherapy, HIV/AIDS, gastrointestinal surgeries or disease, and renal problems.
 We present a case of a 33‑year‑old woman with history of chronic pancreatitis exacerbation with prolonged vomiting, present to the neurological department with neurological symptoms consistent with WE. WE was suspected according to triad of symptoms, such as altered mental state, oculomotor disturbances and ataxia. Brain magnetic resonance imaging (MRI) and thiamine blood level aid us to confirm WE diagnosis. The patient was given thiamine, at the dosage of 200 mg 3 times per day intravenously for seven days, followed by oral thiamine. Gaze paresis disappeared at day 10, truncal ataxia noticeably improved after two weeks. The patient was left with some signs of anterograde amnesia, gaze‑provoked nystagmus at the two month follow‑up.
 Physicians should be familiar with clinical presentation of WE in non‑alcoholic patients with appropriate history and risk factors, like prolonged emesis, unbalanced diet, malignancies, etc. Presence of classic triad of clinical symptoms and pathological findings on brain MRI are the most important diagnostic tool, while the blood thiamine level may be within the normal range. Early diagnosis and therapy onset are crucial for patients to prevent further irreversible complications or death.

Wernicke’s Encephalopathy in the Setting of Severe Malnutrition and Alcohol Abuse

Wernicke’s encephalopathy is an acute, potentially fatal syndrome attributable to thiamine deficiency. Prompt identification and treatment is essential to prevent the development of Korsakoff syndrome, an irreversible memory disorder associated with both retrograde and anterograde amnesia. Here, we present a case of a 39-year-old woman admitted to the ICU with a diagnosis of alcohol withdrawal and severe malnutrition. On admission, the patient was noted to have horizontal nystagmus and underwent aggressive thiamine repletion resulting in resolution of her symptoms.