Premorbid Level Of Functioning Research Articles

E029 Intracranial haemorrhage in scleroderma renal crisis; an unusual presentation

Abstract Background/Aims Scleroderma renal crisis is a life-threatening complication of systemic sclerosis (SSc), which typically occurs in the first 5 years after disease onset. Several risk factors for development of renal crisis are well recognised, including diffuse skin involvement, presence of RNA polymerase 3 antibodies and preceding use of corticosteroids. Methods A 66 year old female 6 years post diagnosis of stable diffuse systemic sclerosis/ polymyositis overlap (PM Scl 100 positive) presented to her GP with a 1 week history of fatigue. She had been seen 2 months earlier by her rheumatologist with stable, mild skin involvement. She had no preceding history of hypertension or other significant co-morbidity. A month earlier she received antibiotics for a chest infection from which she made a slow but complete recovery. She was found to have shingles and started a course of oral acyclovir. Blood tests revealed acute kidney injury stage 3 (eGFR 10 from baseline 70). However, she deteriorated overnight, waking with headache and disturbed colour vision. This quickly deteriorated to bilateral blindness precipitating admission to the emergency department (ED). On arrival she was conscious but severely hypertensive with a BP of 240/105. She received ramipril, amlodipine and a GTN infusion with limited efficacy. CT head (CTH) showed a left occipitoparietal bleed. She then experienced a seizure in ED, which was terminated with lorazepam. She was intubated in the post ictal phase. Repeat CTH following the seizure showed a right frontal bleed extending into the subarachnoid space. Repeat CTH at 48 hours showed progression of the right frontal and left parieto-occipital intracerebral haemorrhages, with evidence of posterior reversible encephalopathy syndrome. Lumbar puncture was normal (VZV negative). Treatment was commenced with intravenous hydralazine. On day 2 of admission she required haemofiltration and subsequently regular renal dialysis. Results SSc was diagnosed in 2016, since when her main issue had been severe Raynaud’s phenomenon for which she took sildenafil. Her muscle disease had only ever manifested as a modestly raised CPK, which settled with a brief course of low dose prednisolone at diagnosis. She has never required DMARDs. She had mild reflux symptoms. Skin tightening was noted distally over her fingers, forearms, lower legs and feet. Annual echocardiography showed nothing to suggest developing pulmonary arterial hypertension. With supportive management she has made a remarkable neurological recovery and has returned to her pre-morbid level of function. She remains dialysis dependent at 4 months. Conclusion This lady lacked a single recognised risk factor for developing a renal crisis, and this occurred quite unexpectedly following a reassuring clinic visit just 2 months prior to presentation. As rheumatologists we must remain vigilant for features of a renal crisis and avoid being falsely reassured by a low risk profile. Disclosure L. Parker: None. N. Buchanan: None. E.L. Williams: None.

The Impact of Delirium on Recovery in Geriatric Rehabilitation after Acute Infection

ObjectivesDelirium is common during acute infection in older patients and is associated with functional decline. Geriatric rehabilitation (GR) can help older patients to return to their premorbid functional level. It is unknown whether delirium affects GR outcomes in patients with acute infection. We evaluated whether delirium affects trajectories of activities of daily living (ADL) and quality of life (QoL) recovery in GR after COVID-19 infection. DesignThis study was part of the EU-COGER study, a multicenter cohort study conducted between October 2020 and October 2021. Setting and ParticipantsParticipants were recruited after COVID-19 infection from 59 GR centers in 10 European countries. MethodsData were collected at GR admission, discharge, and at the 6-week and 6-month follow-ups. Trajectories of ADL [using the Barthel index (BI)] and QoL [using the EuroQol–5 Dimensions–5 Level (EQ-5D-5L)] recovery were examined using linear mixed models. ResultsOf the 723 patients included (mean age 75.5 ± 9.9 years; 52.4% male), 28.9% had delirium before or during GR admission. Participants with delirium recovered in ADL at approximately the same rate as those without (linear slope effect = −0.13, SE 0.16, P = .427) up to an estimated BI score of 16.1 at 6 months. Similarly, participants with delirium recovered in QoL at approximately the same rate as those without (linear slope effect = −0.017, SE 0.015, P = .248), up to an estimated EQ-5D-5L score of 0.8 at 6 months. Conclusions and ImplicationsPresence of delirium during the acute phase of infection or subsequent GR did not influence the recovery trajectory of ADL functioning and QoL.

Critical Care in Older People in Low and Middle-Countries (LMICs): Comprehensive Geriatric Assessment (CGA) Protocol in Andes Mountains

Background: The number of older adults in ICU care is increasing. Nowadays, at least fifty percent of ICU patients are aged 65 years and older. The most frequent pathologies to be admitted to the ICU in older people include acute diseases, long-term conditions, and acute or chronic disease exacerbations. Furthermore, new clinical phenotypes, and geriatric syndromes (falls, frailty, immobility) result from the interaction of age-associated conditions and comorbidity. Severity of index disease, multimorbidity, premorbid functional status, frailty, nutritional status, and cognitive level are more important determinants of long-term outcome than chronological age. Comprehensive geriatric assessment (CGA) is a recognized and useful instrument in the management of elderly patients. Methods: We present a protocol for a clinical trial on the application ofCGA in ICU in the Andes Mountains in Colombia, a Low and Middle-Income Country (LMIC). This protocol could provide valuable information for the integration of geriatrics into critical care and provide practical information on how to implement CGA in this context. Results: The selection criteria of the tools to be used during the assessment of the patients were based on the available literature review and on reviews about interdisciplinary team interventions in acute care services based on the CGA. Conclusion: The care of critically ill elderly patients in the ICU is challenging due to factors such as frailty, psychosocial vulnerability, cognitive impairment, dependence on activities of daily living, and the presence of geriatric syndromes which are important conditions for adverse health outcomes in the future. CGA technology could be considered an excellent tool for managing older people in ICU.

Distal Radius Plates With Coracoid Suture Anchors for the Fixation of Displaced Lateral End Clavicle Fractures.

Introduction Management of displaced fractures of the lateral end clavicle has always challenged orthopaedic surgeons, due to a high non-union rate, and difficulty achieving stable fixation allowing early mobilisation. Different methods of fixation have been utilised to provide stability and improve healing and functional outcomes. In this series, we evaluate the results of internal fixation using dorsal distal radius locking plates and coracoid suture anchors. Patients and methods We retrospectively reviewed the clinical notes and radiographs of eight consecutive patients with fractures of the lateral end of the clavicle presented to our hospital between January 2016 and December 2017. Patients were treated by open reduction and internal fixation using dorsal distal radius locking plates and coracoid suture anchors. Results All patients achieved full range of motion of the shoulder at eight weeks postoperatively. There were no intra-operative complications. Evidence of bone healing was noted in all cases within eight weeks post-operatively. There were no cases of wound complications, metal work irritation or fixation failures. The pre-morbid level of function was restored following the rehab protocol and physiotherapy. Conclusion Dorsal distal radius plates with suture anchor fixation appear to be a valuable alternative for the treatment of fractures of the lateral end of the clavicle. Coracoclavicular fixation provided and maintained the reduction of the fracture. Good clinical results can be achieved with a low risk of complications and without the need for metalwork removal.

29 Associations Between Social Support and Cognitive Performance Among Persons with MS

Objective:Social support is an emerging protective factor against cognitive decline. However, the relationship between social support and cognitive functioning in the multiple sclerosis (MS) population is not well understood. The present study aimed to investigate the associations between different aspects of social support and cognitive performance among persons with MS.Participants and Methods:A volunteer sample of 63 persons with MS (% female = 88.9, mean age = 48.16) completed measures assessing perceived levels of social support measured by the Medical Outcomes Study Support Social Survey 5-item short form (MSSS-5), and social network (social network diversity and total size of social network) measured by the Social Network Index (SNI). Cognitive functioning was assessed by a brief virtual examiner-administered neuropsychological test battery (using a teleconferencing platform), including the Rey Auditory Verbal Learning Test, Controlled Oral Word Association Test, animal naming, and the Symbol Digit Modalities Test. Participants also completed brief, self-paced, virtual cognitive tests through the testmybrain.org platform, which consisted of digit span and the Trail-Making Test. A principal component analysis (PCA) was carried out to reduce the number of neuropsychological outcomes into fewer dimensions. Multiple linear regressions were conducted to examine the associations between social support measures and cognitive performance. Regression models were adjusted by the levels of depressive symptoms (operationalized by the Chicago Multiscale Depression Inventory or the Hospital Anxiety and Depression Scale) and premorbid functioning (measured by the Test of Premorbid Functioning).Results:A PCA reduced neuropsychological outcomes into 3 components representing cognitive domains of 1) processing speed/executive functioning, 2) verbal memory, and 3) verbal fluency / simple attention. In the unadjusted models, both perceived social support (i.e., to what extent one receives assistance from their social network) as well as total size of social network (i.e., total number of people one regularly talks to) were significant predictors of the processing speed/executive functioning component score of moderate strength, where F(1, 59) = 11.93, p = .001, β = 0.41 and F(1, 59) = 11.57, p = .001, β = 0.41, respectively. These associations were maintained after adjusting for depressive symptoms and level of premorbid functioning (F(4, 55) = 3.31, p = .003 and F(4, 55) = 3.31, p = .006, respectively). On the other hand, social network diversity (i.e., number of different types of close social relationships one has) was not a significant predictor of the processing speed/executive functioning component score (p > 0.05). None of the social support measures were significantly associated with the verbal memory and verbal fluency/simple attention component scores.Conclusions:Greater social support (specifically, perceived levels of assistance and total size of social network) is associated with better performance on processing speed/executive functioning measures among persons with MS, independent of effects from depressive symptoms and premorbid functioning. Maintaining a strong social support network may be an important factor in optimizing cognitive health in MS.

51 Optimizing the Mapping out of Neurocognitive Functioning in Glioblastomas in the Era of Intraoperative Mapping in Surgical Resection

AbstarctObjective:Glioblastomas, Grade 4 astrocytomas, comprise about 60% of all astrocytomas and have a median survival rate between 14 and 16 months. The extent of resection impacts the prognosis, with an eloquent balance of preserving the patient's functional status. As preoperative imaging and intraoperative techniques improve to maximize safe operative resection, thorough neuropsychological evaluation can aid in assessing cognitive decline and quality of life pre- and post-treatment. In light of the tumors' progressive nature and potential presence in precarious brain locations, it is imperative that the functional burden of the various presentations of glioblastomas be understood. Given the limited data on cognitive presentations of glioblastomas, we present a case study describing a neuropsychological and neuroradiologic profile of a Grade 4 astrocytoma in a patient with a left temporal glioblastoma.Participants and Methods:The patient signed consent for clinical evaluation and research. At the time of evaluation, he was 68 years old with a master's degree and was working at multiple start-up companies. He began noticing subtle cognitive functioning changes approximately two months prior with difficulty understanding information. His challenges progressed to difficulty composing emails, word-finding issues, and some slurring and mispronunciations. He was diagnosed with a brain tumor after an emergency MRI was performed. He participated in a neuropsychological evaluation just prior to surgery. The evaluation included a battery of neuropsychological tests examining attention, processing speed, executive functioning, learning and memory, language functioning, visuospatial functioning, motor functioning, and mood.Results:The imaging results revealed a non-enhancing intra-axial mass in the left superior temporal lobe with surrounding edema. Also noted were rare scattered nonspecific T2 hyperintensities. The scores showed variable motor functioning and deficits within attention for complex information, executive functioning abilities (i.e., motor planning and sequencing, phonemic fluency), language functioning, visuospatial functioning, and learning and memory of information relative to his premorbid level of functioning, indicating total brain involvement consistent with imaging findings of edema.Conclusions:Taken together, the results of the evaluation and imaging were suggestive of a level of cognitive decline that is more than expected with normal aging. Moreover, there was a lack of evidence representative of a lateralized profile. Notably, the evaluation was conducted before resection surgery, and therefore, the patient continued to experience significant brain edema due to the tumor. Although medication may have contributed to dysfunction, particularly with motor and cognitive slowing, it is not likely that it explained his presentation entirely. As such, the evaluation results were suggestive of neurocognitive dysfunction, which was partially attributable to the tumor and edema displacing neuronal tissue. Given the potential for improvement following tumor resection and secondary decline resulting from recurrence or treatment, it is crucial to have a baseline and the ability to map out higher order functioning, including frontal and temporal lobe functioning. Ultimately, as the field continues to look toward long-term survival for patients with currently lethal brain tumors, the goal is to achieve maximum resection with minimal neurocognitive loss.

Associations between Social Support and Cognitive Performance among Persons with MS.

Social support is a protective factor against cognitive decline in the general population. However, the relationship between social support and cognitive functioning among persons with multiple sclerosis (MS) is not well understood. The present study aimed to investigate the associations between different aspects of social support and cognitive performance among persons with MS. A volunteer sample of 60 persons with MS completed the Medical Outcomes Study Support Social Survey 5-item short form (MSSS-5) and the Social Network Index (SNI). Cognitive functioning was assessed through a virtually-administered neuropsychological battery. Multiple linear regressions were conducted to examine the associations between social support measures and cognitive performance. In models adjusting for level of premorbid functioning, both perceived social support (i.e., to what extent one receives assistance from their social network; p=.002) and total size of social network (i.e., total number of people one regularly talks to; p=.002) were significant predictors of processing speed/executive functioning with moderate effect sizes. However, when we accounted for employment status in a post hoc analysis, the association between social network size and processing speed/executive functioning became statistically insignificant, while the relationship between perceived social support and processing speed/executive functioning remained significant (p = .002). Greater perceived social support is associated with better performance on processing speed/executive functioning measures among persons with MS, independent of effects from premorbid functioning and employment status. Maintaining a strong social support network may be an important factor in optimizing cognitive health in MS.

Cerebral microhaemorrhage count is related to processing speed, but not level of symptom reporting, independently of age, psychological status and premorbid functioning, after first-ever mild traumatic brain injury

Cerebral microhaemorrhage is a commonly identified neuropathological consequence of mild traumatic brain injury (mTBI) and can be identified in vivo using susceptibility weighted imaging (SWI). This study aimed to determine whether SWI-detected microhaemorrhages are more common in individuals after a single, first-ever, mTBI event relative to trauma controls (TC) and to investigate whether a linear relationship exists between microhaemorrhage numbers and cognition or symptom reporting in the post-acute period after injury, independently of age, psychological status and premorbid level of functioning. Microhaemorrhagic lesions were identified by expert clinical examination of SWI for 78 premorbidly healthy adult participants who were admitted to hospital after a traumatic injury and had suffered a first-ever mTBI (n = 47) or no head strike (n = 31). Participants underwent objective cognitive examination of processing speed, attention, memory, and executive function as well as self-reported post-concussion symptomatology. Bootstrapping analyses were used as data were not normally distributed. Analyses revealed that the mTBI group had significantly more microhaemorrhages than the TC group (Cohen’s d = 0.559). These lesions were only evident in 28% of individuals. The mTBI participants demonstrated a significant linear association between number of microhaemorrhages and processing speed, independently of age, psychological status, or premorbid level of functioning. This study shows that a single mTBI causes cerebral microhaemorrhages to occur in a minority of premorbidly healthy individuals. Greater microhaemorrhage count is independently associated with slower processing speed, but not symptom reporting, during the post-acute injury period.

Seizure burden and neuropsychological outcomes of new-onset refractory status epilepticus: Systematic review.

Long-term sequelae of the new onset refractory status epilepticus (NORSE) include the development of epilepsy, cognitive deficits, and behavioral disturbances. The prevalence of these complications has been previously highlighted in case reports and case series: however, their full scope has not been comprehensively assessed. We conducted a systematic review of the literature (PROSPERO ID CRD42022361142) regarding neurological and functional outcomes of NORSE at 30 days or longer following discharge from the hospital. A systematic review protocol was developed using guidance from the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). Of the 1,602 records for unique publications, 33 reports on adults and 52 reports on children met our inclusion criteria. They contained the description of 280 adults and 587 children of whom only 75.7 and 85% of patients, respectively had data on long-term follow-up. The mean age of adult and pediatric patients was 34.3 and 7.9 years, respectively; and the longest duration of follow up were 11 and 20 years, respectively. Seizure outcomes received major attention and were highlighted for 93.4 and 96.6% of the adult and pediatric NORSE patients, respectively. Seizures remained medically refractory in 41.1% of adults and 57.7% of children, while seizure freedom was achieved in only 26 and 23.3% of these patients, respectively. The long-term cognitive outcome data was provided for just 10.4% of the adult patients. In contrast, cognitive health data were supplied for 68.9% of the described children of whom 31.9% were moderately or severely disabled. Long-term functional outcomes assessed with various standardized scales were reported in 62.2 and 25.5% of the adults and children, respectively with majority of patients not being able to return to a pre-morbid level of functioning. New onset psychiatric disorders were reported in 3.3% of adults and 11.2% of children recovering from NORSE. These findings concur with previous observations that the majority of adult and pediatric patients continue to experience recurrent seizures and suffer from refractory epilepsy. Moderate to severe cognitive disability, loss of functional independence, and psychiatric disorders represent a hallmark of chronic NORSE signifying the major public health importance of this disorder.

COVID-19-Associated Schizophrenia-Like Psychosis

Background: COVID-19-associated psychoses are psychotic disorders that have developed during a new coronavirus infection. Criteria of these psychoses are the manifestation of psychosis simultaneously with infection with the SARS-CoV-2 virus and the presence of documented COVID-19 disease. Information about these diseases appears as brief reports of mental services or with rare clusters. The need to study COVID-19-associated psychoses is due to the relatively high risk of their development, reaching 2.8%. The aim of study was to analyse the identified cases of COVID-19-associated psychosis in comparison with the results presented in the scientific literature. Patients and methods: 50 cases of COVID-19-associated psychosis were analyzed using a clinical method, taking into account the results of physical examination from April 2020 to September 2021. Results: 27 women and 23 men aged 20 to 57 were examined. Common symptoms were revealed: simultaneously or immediately after infection and identification of the virus against the background of growing anxiety and dissomnia, delusional ideas were formed, which quickly turned into fantastic delusion with disturbing agitation and hallucinations and subsequent marked disorganization of behavior with possible confusion of consciousness at the peak of psychosis. Perceptual deceptions were the most common, auditory hallucinations were the most prevalent, and catatonia was relatively common. The cupping therapy led to reduction of psychotic symptoms, and returned patients to a pre-morbid level of functioning. In most cases, there was a critical resolution of the attack, which probably indicates a favorable outcome of the disorder. Such dynamics is consistent with scientific literature data. Conclusion: the question of the primary or secondary nature of COVID-19-associated psychoses remains unresolved. It is necessary to continue the study of COVID-19-associated psychosis with the identification of risk factors for the development of psychosis, manifestation features, psychopathological picture, outcome options to determine the optimal rehabilitation program.

The "Dutch Reading Test for Adults" has Been Used for 29 Years to Estimate the Premorbid Performance Level, does it Still Meet the Expectations?

To detect cognitive change after brain damage, it is important to know the level of premorbid intellectual functioning. A popular instrument in this context is the “Nederlandse Leestest voor Volwassenen” (NLV; Schmand et al., 1992). In this test, 50 words with irregular pronunciation must be read out loud. The score on this test used to be considered as a good estimate of someone’s premorbid IQ, due to high correlations with the Verbal and Full-Scale IQ estimates of the WAIS (Verbal IQ: r = .85, Full Scale IQ: r = .74; Schmand et al., 1992). Despite some updates of the normative data (e.g., Bouma et al., 2012), the validity of the test has not been re-evaluated since. The aim of the current study was to evaluate whether the NLV still correlates sufficiently with the WAIS-IV to warrant its proper use as a psychodiagnostic tool. In Study 1, 30 participants (age range: 20–29 year) were tested, and in Study 2, 51 participants (age range: 45–65 year). We checked whether the NLV-generated IQ-score estimates correlated with the different IQ indices of the WAIS-IV. In the younger group, no correlations were found between the NLV-generated IQ-score estimate and any of the WAIS-IV indices nor the Full-Scale IQ. In the older group, the NLV-generated IQ-score estimate correlated with Full scale IQ and the indices of Verbal Comprehension, Working Memory and Processing Speed. These correlations were all <.46 which is far below the typically hold standard in test development of >.70. Based on these findings we conclude the NLV in its current form is not appropriate anymore to estimate premorbid IQ in both young and older adults.

A-179 Association of Race and Cognitive Impairment in Retired NFL Athletes

Abstract Objective: The Baseline Assessment Program (BAP) provided neuropsychological assessment to determine cognitive and psychological impairment in retired National Football League (NFL) athletes. The objective of the current study was to examine if an association exists between race and cognitive impairment using traditional race-based norms. Method: This is a retrospective analysis of 56 retired NFL athletes with repetitive head trauma secondary to contact sports. Participants identified as Black (n = 45) and White (n = 11) with a mean age of 52.52 years and 16.04 years of education. Five domains of cognition were assessed: Complex Attention and Processing Speed, Learning and Memory, Visual-Perceptual Processing, Language, and Executive Functioning. We estimated level of premorbid functioning accounting for race, education, region, and highest occupation held. We calculated levels of impairment for each domain and overall cognitive functioning by comparing t-scores with expected level of premorbid functioning (0.0, 1.0, 1.5, and 2.0 standard deviations [SDs] below expected level). Results: Our trend test revealed no significant association between race and levels of impairment for any of the domains assessed. Conclusion(s): Race was not associated with level of cognitive impairment. Null results may be due to unbalanced groups and positively skewed data. Level of cognitive impairment as outlined by the NFL is restrictive and resulted in few individuals with one or more SDs below estimated level of premorbid functioning. Future work may examine if these criteria or race-based norms result in false negative estimates of impairment, as this has clinical implications for access to resources and compensation for injury.

Premorbid of depressive youth at clinical high-risk for psychosis

IntroductionEarly detection of psychosis is a promising area in preventive psychiatry. The use of early intervention can prevent the first episode psychosis and improve outcomes.ObjectivesIdentification of premorbid features of depressive patients at clinical high risk for psychosis (CHR) comparing with depressive patients without CHR in order to improve early recognition of the psychotic process.Methods219 young depressive in-patients with CHR criteria for SOPS with attenuated positive and attenuated negative symptoms and 52 young depressive in-patients without CHR were examined. Presence of obstetric complications, neurodevelopmental deviance, neurological and psychiatric signs at the premorbid stage, and the level of premorbid functioning on the PAS were examined.ResultsIt has been established that depressive patients at CHR and without CHR had some obstetric complications (57.5% and 40.4%, respectively). Neurodevelopmental deviance in the first year of live was in 57.5% patients with CHR. At the age of 3-5 sleep disorders, ADHD and phobias were more common in patients at CHR than without it (58.8% and 32.7%, p=0.014). In pubertal, patients at CHR were more likely to show depression symptoms, obsessions, and aggression - 90.4% versus 76.9% (p=0.029). On the PAS scale, a decrease of the level of premorbid functioning has been observed in two groups of patients with and without CHR from the age of 12: from 12 to 15 years, 0.4 and 0.3 (p=0.004), from 16 to 18 years, 0.47 and 0.37 (p 0.001).ConclusionsPremorbid functioning were worst in patients with CHR, which indicates the possibility of early clinical detection of psychosis.DisclosureNo significant relationships.

Estimation of premorbid intelligence: Demographical and current neurocognitive functioning based algorithms.

Establishing a premorbid level of intellectual functioning is crucial for determining the severity level of impairment and prognosis for patients in clinical setting. Therefore, the study aimed to develop a method to estimate premorbid IQ of Hindi speaking Indian population. A Hindi vocabulary test was developed (N=60) and standardized (N=100). The regression algorithm has been developed using VAIS, WAPIS, RPMT, and a newly developed Vocabulary test, and validated on 100 normal individuals and on 39 brain injury patients. The estimated premorbid Verbal IQ and performance IQ equation was developed by using demographic variables combine with Hindi vocabulary scores and Matrix Reasoning raw scores respectively. Both the estimated premorbid verbal and performance IQ were found to be significant and valid in estimating verbal and performance IQ in normal and brain injury population. These equations for estimating verbal and performance IQ were found significantly accurate in predicting verbal and performance IQ.

Targeted Osmotic Lysis of Advanced Carcinoma in Companion Animals

Targeted osmotic lysis (TOL) is a novel technology that involves the concomitant stimulation of voltage‐gated sodium channels (VGSCs) and pharmacological blockade of Na+, K+‐ATPase (sodium pumps) causing selective osmotic lysis of highly malignant cancer cells that may offer an option for treating advanced carcinomas in companion animals. We hypothesized, that as in experimental animals, TOL would be able to increase survival beyond that anticipated for animals with advance carcinoma without adversely affecting quality of life. Accordingly, we treated 2 feline and 3 canine companion animals in which TOL was used to safely treat advanced carcinoma. Based on available pre‐clinical evidence for safety, efficacy and lack of off‐target damage to normal tissue, companion animals diagnosed with advanced carcinomas that were experiencing impaired behavior and functionality were offered trial treatment with TOL. When practical, biopsy samples were obtained to determine the level of VGSC expression. Digoxin was administered to achieve steady‐state, therapeutic tissue levels. The animals were then exposed to pulsed electric field stimulation. Post‐treatment measurements of tumor size and assessments of behavior and functionality were compared to pre‐treatment observations made by the owners and by the treating veterinarian. The frequency of treatments and survival varied, based on the patient’s level of pre‐morbid functioning and response to treatment. In all five cases, TOL the animals survived beyond the prognosis. In 3 cases, owners reported behavioral improvement. The results support the hypothesis that TOL may provide a therapeutic option with broad application in veterinary practice as a safe, well‐tolerated and effective option for treating patients with advanced stage carcinoma.

Premorbid features of youth depression patients with attenuated schizophrenic symptoms

To establish the premorbid features in youth depression patients with attenuated symptoms of schizophrenia (ASS) and in a comparison group, with an analysis of the course of age crises, signs of personality disorders, level of premorbid functioning and their relationship with the level of functioning after five-year follow-up. Two hundred and nineteen youth depression patients with ASS (according to ICD-10: F32.1, F32.2, F32.28, F32.8) (main group) and 52 patients with «pure» adolescent depression without ASS (comparison group) were examined. A total of 124 patients from the main group and 27 patients from the comparison group were examined in 5-year follow-up. The Perceptual Awareness Scale (PAS) was used to assess premorbid functioning and the Personal and Social Performance (PSP) scale was used to determine function at the time of the follow-up. The method of χ2 was used to analyze qualitative data. The correlation analysis was performed with Spearman's rank correlation coefficient. Results are presented as median values [Q1; Q3]. The main group of patients with ASS have worse psychopathological symptoms compared with the comparison group (χ2=4.74; p=0.029). Premorbid functioning was also lower in the period 12-15 years (0.4 [0.33; 0.5]) and 16-18 years (0.47 [0.385; 0.585]) than in the comparison group (0.3 [0.23; 0.43] and 0.37 [0.23; 0.462], respectively, (p<0.05)). Negative correlation has been established between average PAS scores in the age of 12-15 and 16-18 years and the five-year follow-up on the PSP scale (r=-0.276, p<0.05 and r=-0.359, p<0.05 respectively). Similar characteristics of the premorbid period in childhood and an increase in differences starting from the pubertal period reflect the pathogenetic significance of the pubertal crisis and suggest compensatory mechanisms that, in patients with youth depression with ASS, are able to restrain the development of the endogenous process for a certain time, but subsequently become exhausted, which leads to persistence of psychopathological symptoms in intercrisis periods and serves as the first clinical marker of the onset of schizophrenia.

Chronic Achilles tendon rupture: a novel modification of surgical technique described by El Shewy.

Chronic Achilles tendon rupture is commonly defined as a rupture presenting 6 weeks after the time of injury and operative management is recommended. This research aims to describe a novel modified surgical technique in the repair of chronic Achilles tendon rupture and to report the result of this technique. This is a retrospective study performed between January 2007 and January 2017, and a novel modification of El Shewy et al.'s surgical technique is described. Fifteen patients with chronic rupture of Achilles tendon repaired with the technique by a single experienced surgeon were identified. Patients were contacted via phone call and questionnaires completed. Achilles Tendon Rupture Score and pain score were assessed via questionnaires. Thirteen patients were contacted and two patients were uncontactable. Ten patients were able to return to their premorbid level of function. Twelve patients were satisfied or very satisfied with the outcome. Only one patient was very dissatisfied with the outcome. The average Achilles Tendon Rupture score was 72 (n=7, 54%). The average pain score was 1.23 (n=13, 100%). This novel modified surgical technique demonstrated good functional outcomes and high levels of patient satisfaction in patient with chronic Achilles tendon rupture. It can be considered in the repair of chronic Achilles tendon rupture.

Health related quality of life in COVID-19 survivors discharged from acute hospitals: results of a short-form 36-item survey

Background: Health-related quality of life (HRQL) is important for evaluating the impact of a disease in the longer term across the physical and psychological domains of human functioning. The aim of this study is to evaluate HRQL in COVID-19 survivors in Italy using the short form 36-items questionnaire (SF-36). Methods: This is an observational study involving adults discharged home following a coronavirus disease 2019 (COVID-19)-related hospital admission. Baseline demographic and clinical data including the Cumulative Illness Rating Scale (CIRS) and the Hospital Anxiety and Depression Scale (HADS) were collected. The validated Italian version of SF-36 was administered cross-sectionally. The SF-36 contains eight scales measuring limitations in physical and social functioning, the impact on roles and activities, fatigue, emotional well-being, pain and general health perception. Results: A total of 35 patients, with a mean age of 60 years, completed the SF-36. The results showed difficulties across the physical and psychological domains, particularly affecting the return to previous roles and activities. A higher burden of co-morbidities as well as a more severe muscle weakness was associated to a lower physical functioning. Younger age, rather than older, correlated to a perceived greater limitation in physical functioning and vitality. Conclusions: COVID-19 survivors particularly the ones of working age may need support for resuming their premorbid level of functioning and returning to work.

Cognitive dysfunction in ulcerative colitis patients in remission and its comparison with patients with irritable bowel syndrome and healthy controls.

There is a paucity of research concerning cognitive impairments in Inflammatory bowel disease - ulcerative colitis (IBD-UC) and irritable bowel syndrome (IBS). Studies on cognitive dysfunction in patients with IBD-UC have either been small or have shown conflicting results. This study is conducted to examine the evidence of cognitive dysfunction in IBD-UC patients in remission and compare the evident cognitive deficit with IBS patients and healthy controls. This single-centre cross-sectional observational study enrolled a total of 90 participants, 29 in ulcerative colitis (UC) in remission group, 31 in IBS group and 30 in healthy control group. Assessment of cognition with the help of cognitive function tests mini-mental state examination (MMSE), Montreal Cognitive Assessment (MoCA) test and p300 was performed in all participants. A statistically significant number of the participants in IBD-UC in remission group had MMSE and MoCA score below the lower limit of normal, in comparison to the healthy control and IBS groups. The mean peak latency of the p300 wave was statistically significantly increased in people in the IBD-UC group, in comparison to the healthy control and IBS groups. Patients with IBD-UC in remission show impairments in cognitive functioning compared to the IBS and healthy control groups as assessed on cognitive function testing on MMSE, MoCA and mean peak latency of the p300 wave. This impairment in cognitive function isunlikely to be due to premorbid levels of intellectual functioning and is likely to have impact on health-related quality of life.

Chapter 9 - Neurovascular disease, diagnosis, and therapy: Subarachnoid hemorrhage and cerebral vasospasm

The worldwide incidence of spontaneous subarachnoid hemorrhage is about 6.1 per 100,000 cases per year (Etminan et al., 2019). Eighty-five percent of cases are due to intracranial aneurysms. The mean age of those affected is 55 years, and two-thirds of the patients are female. The prognosis is related mainly to the neurologic condition after the subarachnoid hemorrhage and the age of the patient. Overall, 15% of patients die before reaching the hospital, another 20% die within 30 days, and overall 75% are dead or remain disabled. Case fatality has declined by 17% over the last 3 decades. Despite the improvement in outcome probably due to improved diagnosis, early aneurysm repair, administration of nimodipine, and advanced intensive care support, the outcome is not very good. Even among survivors, 75% have permanent cognitive deficits, mood disorders, fatigue, inability to return to work, and executive dysfunction and are often unable to return to their premorbid level of functioning. The key diagnostic test is computed tomography, and the treatments that are most strongly supported by scientific evidence are to undertake aneurysm repair in a timely fashion by endovascular coiling rather than neurosurgical clipping when feasible and to administer enteral nimodipine. The most common complications are aneurysm rebleeding, hydrocephalus, delayed cerebral ischemia, and medical complications (fever, anemia, and hyperglycemia). Management also probably is optimized by neurologic intensive care units and multidisciplinary teams.