Residual Cognitive Function Research Articles

The relationship between Residual Kidney Function and Cognitive Function in Adults Receiving Peritoneal Dialysis: A Systematic Review and Meta-Analysis

Cognitive impairment is common in adults receiving peritoneal dialysis (PD) and has been linked to adverse outcomes. Residual kidney function (RKF) is a key determinant of clinical outcomes in dialysis patients but the evidence on whether it affects cognitive outcomes is unclear.

Self-esteem in stabilized individuals with chronic schizophrenia: association with residual symptoms and cognitive functioning

Low self-esteem is regarded as a barrier to recovery from schizophrenia and the identification of factors affecting this psychological characteristic may help to implement effective therapeutic interventions. To this end, the present study aimed to assess whether residual symptoms of the disorder and performance on a comprehensive neuropsychological test battery might differently impact self-esteem among 70 stabilized outpatients with chronic schizophrenia from public outpatient mental health services. Self-esteem inter-correlated with the severity of overall symptomatology, affective and negative symptoms, with premorbid intelligence, and with performance in the domains of verbal learning and memory, visual memory, working memory, and verbal fluency. Residual affective symptoms, premorbid intelligence, and female sex predicted poorer self-esteem in multiple linear regression analysis. The findings of this study implicate that next to psychological interventions therapeutic strategies that specifically target affective symptoms of schizophrenia may have a beneficial impact on patients’ self-esteem.

Use of functional magnetic resonance imaging to assess cognition and consciousness in severe Guillain-Barré syndrome

ObjectiveFunctional neuroimaging may provide a viable means of assessment and communication in patients with Guillain-Barré Syndrome (GBS) mimicking the complete locked-in state. Functional neuroimaging has been used to assess residual cognitive function and has allowed for binary communication with other behaviourally non-responsive patients, such as those diagnosed with unresponsive wakefulness syndrome. We evaluated the potential application of functional neuroimaging using a clinical-grade scanner to determine if individuals with severe GBS retained auditory function, command following, and communication. MethodsFourteen healthy participants and two GBS patients were asked to perform motor imagery and spatial navigation imagery tasks while being scanned using functional magnetic resonance imaging. The GBS patients were also asked to perform additional functional neuroimaging scans to attempt communication. ResultsThe motor imagery and spatial navigation task elicited significant activation in appropriate regions of interest for both GBS patients, indicating intact command following. Both patients were able to use the imagery technique to communicate in some instances. Patient 1 was able to use one of four communication tasks to answer a question correctly. Patient 2 was able to use three of seven communication tasks. However, two questions were incorrectly answered while a third was non-verifiable. ConclusionsGBS patients can respond using mental imagery and these responses can be detected using functional neuroimaging. Furthermore, these patients may also be able to use mental imagery to provide answers to ‘yes’ or ‘no’ questions in some instances. We argue that the most appropriate use of neuroimaging-based communication in these patients is to allow them to communicate wishes or preferences and assent to previously expressed decisions, rather than to facilitate decision-making.

Functional Neuroimaging as an Assessment Tool in Critically Ill Patients.

Little is known about residual cognitive function in the earliest stages of serious brain injury. Functional neuroimaging has yielded valuable diagnostic and prognostic information in chronic disorders of consciousness, such as the vegetative state (also termed unresponsive wakefulness syndrome). The objective of the current study was to determine if functional neuroimaging could be efficacious in the assessment of cognitive function in acute disorders of consciousness, such as coma, where decisions about the withdrawal of life-sustaining therapies are often made. A hierarchical functional magnetic resonance imaging (fMRI) approach assessed sound perception, speech perception, language comprehension, and covert command following in 17 critically ill patients admitted to the intensive care unit (ICU). Preserved auditory function was observed in 15 patients (88%), whereas 5 (29%) also had preserved higher-order language comprehension. Notably, one patient could willfully modulate his brain activity when instructed to do so, suggesting a level of covert conscious awareness that was entirely inconsistent with his clinical diagnosis at the time of the scan. Across patients, a positive relationship was also observed between fMRI responsivity and the level of functional recovery, such that patients with the greatest functional recovery had neural responses most similar to those observed in healthy control participants. These results suggest that fMRI may provide important diagnostic and prognostic information beyond standard clinical assessment in acutely unresponsive patients, which may aid discussions surrounding the continuation or removal of life-sustaining therapies during the early post-injury period. ANN NEUROL 2023;93:131-141.

Improving Diagnosis and Prognosis in Acute Severe Brain Injury: A Multimodal Imaging Protocol.

Multi-modal neuroimaging techniques have the potential to dramatically improve the diagnosis of the level consciousness and prognostication of neurological outcome for patients with severe brain injury in the intensive care unit (ICU). This protocol describes a study that will utilize functional Magnetic Resonance Imaging (fMRI), electroencephalography (EEG), and functional Near Infrared Spectroscopy (fNIRS) to measure and map the brain activity of acute critically ill patients. Our goal is to investigate whether these modalities can provide objective and quantifiable indicators of good neurological outcome and reliably detect conscious awareness. To this end, we will conduct a prospective longitudinal cohort study to validate the prognostic and diagnostic utility of neuroimaging techniques in the ICU. We will recruit 350 individuals from two ICUs over the course of 7 years. Participants will undergo fMRI, EEG, and fNIRS testing several times over the first 10 days of care to assess for residual cognitive function and evidence of covert awareness. Patients who regain behavioral awareness will be asked to complete web-based neurocognitive tests for 1 year, as well as return for follow up neuroimaging to determine which acute imaging features are most predictive of cognitive and functional recovery. Ultimately, multi-modal neuroimaging techniques may improve the clinical assessments of patients' level of consciousness, aid in the prediction of outcome, and facilitate efforts to find interventional methods that improve recovery and quality of life.

A Multidimensional Virtual Reality Neurorehabilitation Approach to Improve Functional Memory: Who Is the Ideal Candidate?

Aims: We aimed to identify the significant predictors of ecological memory amelioration after the Human Empowerment Aging and Disability (HEAD) rehabilitation program, a multidimensional treatment for chronic neurological diseases.Materials and Methods: Ninety-three patients with Parkinson disease (n = 29), multiple sclerosis (n = 26), and stroke (n = 38) underwent a multidimensional rehabilitation. We focused on changes after treatment on ecological memory (outcome measure) evaluated by Rivermead Behavioral Memory Test, Third Edition (RBMT-3). Minimal clinically important difference (MCID) after treatment were calculated for RBMT-3. The change score on RBMT-3 was categorized in positive effect, stabilization, or no effect of the treatment. Random forest classification identified who significantly benefited from treatment against who did not in terms of ecological memory functioning. Accordingly, logistic regression models were created to identify the best predictors of the treatment effect. A predicted probability value was derived, and the profile of the ideal candidate of HEAD protocol was shown by combining different ranks of significant predictors in a 3 × 3 matrix for each pair of predictors.Results: A significant number of cases reported positive effect of the treatment on ecological memory, with an amelioration over the MCID or a stabilization. The random forest analysis highlighted a discrete accuracy of prediction (>0.60) for all the variables considered at baseline for identifying participants who significantly benefited and who did not from the treatment. Significant logistic regression model (Wald method) showed a predictive role of Montreal Cognitive Assessment (MoCA; p = 0.007), 2-Minute Walk Test (2MWT; p = 0.038), and RBMT-3 (p < 0.001) at baseline on HEAD treatment effect. Finally, we observed a high probability of success in people with higher residual cognitive functioning (MoCA; odds ratio = 1.306) or functional mobility (2MWT; odds ratio = 1.013).Discussion: The HEAD program is a rehabilitation with effects on multiple domains, including ecological memory. Residual level of cognitive and/or motor functioning is a significant predictor of the treatment success. These findings confirm the intrinsic relationship subsisting between motor and cognitive functions and suggest the beneficial effects of physical activity on cognitive functions and vice versa.

Autonomic responses to emotional linguistic stimuli and amplitude of low-frequency fluctuations predict outcome after severe brain injury

An accurate prognosis on the outcome of brain-injured patients with disorders of consciousness (DOC) remains a significant challenge, especially in the acute stage. In this study, we applied a multiple-technique approach to provide accurate predictions on functional outcome after 6 months in 15 acute DOC patients. Electrophysiological correlates of implicit cognitive processing of verbal stimuli and data-driven voxel-wise resting-state fMRI signals, such as the fractional amplitude of low-frequency fluctuations (fALFF), were employed. Event-related electrodermal activity, an index of autonomic activation, was recorded in response to emotional words and pseudo-words at baseline (T0). On the same day, patients also underwent a resting-state fMRI scan. Six months later (T1), patients were classified as outcome-negative and outcome-positive using a standard functional outcome scale. We then revisited the baseline measures to test their predictive power for the functional outcome measured at T1. We found that only outcome-positive patients had an earlier, higher autonomic response for words compared to pseudo-words, a pattern similar to that of healthy awake controls. Furthermore, DOC patients showed reduced fALFF in the posterior cingulate cortex (PCC), a brain region that contributes to autonomic regulation and awareness. The event-related electrodermal marker of residual cognitive functioning was found to have a significant correlation with residual local neuronal activity in the PCC. We propose that a residual autonomic response to cognitively salient stimuli, together with a preserved resting-state activity in the PCC, can provide a useful prognostic index in acute DOC.

Applying the Conservation of Resources Theory to the Psychological Stress Experienced by a Random Sample of Americans With Multiple Sclerosis

Multiple sclerosis (MS) is a chronic, unpredictable neurological disorder whose wide ranging symptoms and capricious disease course are known to produce considerable psychological stress. This study applied the Conservation of Research theory in building a prediction model to explain variability in perceived stress and coping within a sample of Americans with MS. The study sample consisted of 1,114 people with MS, 219 men (20%) and 895 women (80%), who participated in a national survey of the employment and psychosocial concerns of Americans with MS. Primarily Caucasian (75%), participants ranged in age from 20 to 87 years (M= 50.57,SD= 10.31). A backward stepwise multiple regression analysis revealed that women; non-Caucasians; younger people; those who had more difficulties meeting their financial obligations and who were less satisfied with their housing situations; people who reported lower levels of community and social life engagement; and those whose MS resulted in higher numbers of reported symptoms, lower levels of residual cognitive functioning, and lower levels of mobility impairment reported higher levels of perceived stress than did other participants. The aggregated predictors explained 41% of the variability in participants' stress ratings. The findings demonstrate the complexity in predicting how the onset and progression of MS affects an individual's psychological functioning.

Association between Hippocampal Shape, Neuroinflammation, and Cognitive Decline in Alzheimer's Disease.

Alzheimer's disease (AD) is a neurodegenerative condition characterized by memory impairment and general decrease in cognitive functions and daily living competences, that leads to a complete loss of autonomy. The pathogenesis of AD is characterized by the deposition of amyloid-β plaques (Aβ plaques) and neurofibrillary tangles, initially involving cortical and hippocampal structures, and neuroinflammation. To date, no studies have investigated the topological association between neuroinflammation and hippocampal shape in AD. The aim of the present study is to assess the association between hippocampal shape, cognitive profile, and neuroinflammation in a group of AD patients in the mild stage of the disease. Thirty-one patients with typical onset AD (mild stage) underwent MRI examination (1.5T scanner); hippocampal structures were segmented using a vertex-wise analysis (FSL-FIRST). Immune parameters were evaluated on peripheral blood mononuclear cells by flow-cytometry. Correlation analyses were performed between hippocampal shape and both cognitive profile (ADAS-Cog and MMSE scores), and neuro-inflammatory variables (i.e., circulating monocytes, cytokines). Statistically significant correlations (p < 0.05FWE) between right hippocampal shape and cognitive measurements and between left hippocampal shape and inflammatory indices were detected. The hippocampal field mostly involved was the lateral portion of bilateral hippocampi, mainly overlapping with Cornu Ammonis, extending along the entire longitudinal axis. A topological relationship between hippocampal atrophy and both cognitive profile and neuroinflammation is found; the association with neuroinflammatory indices is in line with the pattern of AD-associated neuronal death, whereas the association with cognitive test might account for residual cognitive functions.

Relationships between residual blood pressure variability and cognitive function in the general population of the PAMELA study.

The present study was aimed at assessing the relationships between absolute and individual residual blood pressure (BP) variability and cognitive function in a general population. This cross-sectional study evaluated cognitive function using minimental state evaluation (MMSE) in 471 subjects enrolled in the PAMELA study. MMSE was calculated 10years after initial enrollment of the subjects in the PAMELA study. Measurements included office, home, and 24-hour ambulatory BP monitoring. BP variability was obtained by calculating: (a) 24-hour standard deviation (SD) for systolic and diastolic BP and (b) individual residual BP variability. Mean age (±SD) of the subjects enrolled was 63±5.7years at the initial evaluation, with a 10-year increase when MMSE was performed. There was no significant difference in BP or heart rate values measured at office, home, or during 24-h BP monitoring between subjects with MMSE<24 and those with ≥24. BP variability measured by SBP and DBP SD was also similar between these two groups. However, individual residual BP variability was significantly greater in subjects with lower MMSE and this difference became more pronounced when the study population was divided in three groups according to MMSE score (10-20, 21-23, 24-30). Individual residual SBP and DBP variability gradually decreased with the increase in MMSE score. Our data show that a sensitive parameter for the development of cognitive impairment is not BP or absolute BP variability but rather its short-term erratic component, which has been previously shown to be an important prognostic marker for organ damage, cardiovascular, and all-cause mortality.

Reduced delta-band modulation underlies the loss of P300 responses in disorders of consciousness

ObjectiveThe P300 component of a sensory event-related potential is one of the major electrophysiological markers used to explore remnants of cognitive function in patients with disorders of consciousness (DoC). However, measuring the P300 in patients is complicated by significant inter-trial variability commonly observed in levels of arousal and awareness. To overcome this limitation, we analyzed single-trial modulation of power in the delta and theta frequency bands, which underlie the P300. MethodsIn a preliminary cross-sectional study using a 24-channel EEG and a passive own-name oddball paradigm, we analyzed event-related synchronization (ERS) across trials in the delta and theta bands in a sample of 10 control and 12 DoC subjects. ResultsIn comparison to controls, DoC subjects presented a low percentage of trials where delta ERS was observed. In particular, coordinated modulation between delta and theta in response to the stimulus was absent, with a high percentage of trials where only theta ERS was observed. Further, we found a positive correlation between the percentage of epochs with delta ERS and the strength of the P300. ConclusionsReduced modulation of spectral activity in the delta band in response to stimuli indicates a dissociation in the activity of the neural networks that oscillate in delta and theta ranges and contribute to the generation of the P300. SignificanceThe reduction in spectral modulation observed in DoC provides a deeper understanding of neurophysiological dysfunction and the means to develop a more fine-grained marker of residual cognitive function in individual patients.

Brain, Behavior, and Cognitive Interplay in Disorders of Consciousness: A Multiple Case Study.

Patients with prolonged disorders of consciousness (DoC) after severe brain injury may present residual behavioral and cognitive functions. Yet the bedside assessment of these functions is compromised by patients' multiple impairments. Standardized behavioral scales such as the Coma Recovery Scale-Revised (CRS-R) have been developed to diagnose DoC, but there is also a need for neuropsychological measurement in these patients. The Cognitive Assessment by Visual Election (CAVE) was therefore recently created. In this study, we describe five patients in minimally conscious state (MCS) or emerging from the MCS (EMCS). Their cognitive profiles, derived from the CRS-R and CAVE, are presented alongside their neuroimaging results using structural magnetic resonance imaging (MRI) and fluorodeoxyglucose positron emission tomography (FDG-PET). Scores on the CAVE decreased along with the CRS-R total score, establishing a consistent behavioral/cognitive profile for each patient. Out of these five cases, the one with highest CRS-R and CAVE performance had the least extended cerebral hypometabolism. All patients showed structural and functional brain impairments that were consistent with their behavioral/cognitive profile as based on previous literature. For instance, the presence of visual and motor residual functions was respectively associated with a relative preservation of occipital and motor cortex/cerebellum metabolism. Moreover, residual language comprehension skills were found in the presence of preserved temporal and angular cortex metabolism. Some patients also presented structural impairment of hippocampus, suggesting the presence of memory impairments. Our results suggest that brain-behavior relationships might be observed even in severely brain-injured patients and they highlight the importance of developing new tools to assess residual cognition and language in MCS and EMCS patients. Indeed, a better characterization of their cognitive profile will be helpful in preparation of rehabilitation programs and daily routines.

Emotion-Related Consciousness Detection in Patients With Disorders of Consciousness Through an EEG-Based BCI System.

For patients with disorders of consciousness (DOC), such as vegetative state (VS) and minimally conscious state (MCS), detecting and assessing the residual cognitive functions of the brain remain challenging. Emotion-related cognitive functions are difficult to detect in patients with DOC using motor response-based clinical assessment scales such as the Coma Recovery Scale-Revised (CRS-R) because DOC patients have motor impairments and are unable to provide sufficient motor responses for emotion-related communication. In this study, we proposed an EEG-based brain-computer interface (BCI) system for emotion recognition in patients with DOC. Eight patients with DOC (5 VS and 3 MCS) and eight healthy controls participated in the BCI-based experiment. During the experiment, two movie clips flashed (appearing and disappearing) eight times with a random interstimulus interval between flashes to evoke P300 potentials. The subjects were instructed to focus on the crying or laughing movie clip and to count the flashes of the corresponding movie clip cued by instruction. The BCI system performed online P300 detection to determine which movie clip the patients responsed to and presented the result as feedback. Three of the eight patients and all eight healthy controls achieved online accuracies based on P300 detection that were significantly greater than chance level. P300 potentials were observed in the EEG signals from the three patients. These results indicated the three patients had abilities of emotion recognition and command following. Through spectral analysis, common spatial pattern (CSP) and differential entropy (DE) features in the delta, theta, alpha, beta, and gamma frequency bands were employed to classify the EEG signals during the crying and laughing movie clips. Two patients and all eight healthy controls achieved offline accuracies significantly greater than chance levels in the spectral analysis. Furthermore, stable topographic distribution patterns of CSP and DE features were observed in both the healthy subjects and these two patients. Our results suggest that cognitive experiments may be conducted using BCI systems in patients with DOC despite the inability of such patients to provide sufficient behavioral responses.

Factors associated with cognitive function that cause a decline in the level of activities of daily living in Alzheimer's disease.

The principal aim of the present study was to clarify what type of cognitive decline results in a decrease in the ability to carry out activities of daily living (ADL) in patients with Alzheimer's disease (AD). The participants comprised 1384 outpatients with mild AD. We used the Mini-Mental State Examination (MMSE) and Barthel Index (BI) as indicators of basic ADL, and the Lawton Index (LI) as an indicator of instrumental ADL (IADL). We then analyzed the relationships between MMSE and BI, as well as between MMSE and LI. We also carried out a logistic regression analysis with BI and LI subitems as dependent variables, and MMSE subitems as independent variables. For almost all BI and LI subitems, significantly high odds ratios (OR) were noted in MMSE "Copy the design shown" (e.g. dressing OR 3.66, toilet use OR 3.60 and transfers OR 2.80) and "Write a sentence" (e.g. ability to use telephone OR 5.24, laundry OR 2.60, grooming OR 2.50; P < 0.05). Visuospatial cognition had an important effect on the decrease in basic ADL and IADL. Furthermore, the subitems with minimal effect on the decrease of basic ADL and IADL differed. Therefore, it appears that specific activities have little effect on the maintenance of ADL and IADL, and that determining residual cognitive function and utilizing this as a means of compensating for decreased ADL is a useful strategy. Geriatr Gerontol Int 2018; 18: 50-56.

Period3 gene in disorder of consciousness: The role of neuroimaging in understanding the relationship between genotype and sleep. A brief communication

BackgroundSeveral methodologies including neuroimaging and sleep evaluation are being developed to complement the clinical bedside examinations in patients with disorder of consciousness (DOC). Recently, we demonstrated a possible association between Period3 (Per3) variable number tandem repeat (VNTR) polymorphism and functional impairment of DOC patients, speculating a possible role of this gene in sleep regulation. AimTo assess whether the degree of structural and metabolic damage of the main brain areas involved in the sleep generation and homeostasis may influence the different outcome of DOC patients carrying the Per35/5 genotype in comparison to Per34/4 ones. MethodsFor the present study, we reviewed 44 DOC patients from the Coma Research Centre of the Fondazione IRCCS Istituto Neurologico “C. Besta” of Milan. All patients underwent to polysomnographic sleep evaluation, cerebral structural magnetic resonance imaging (MRI) and 18F–fluoro-2-deoxyglucose positron emission tomography (FDG-PET) analysis. ResultsOur DOC patients presented a moderate anatomical (median score 2) and metabolic damage (median value 2.36 SUVmean) of the sleep areas at both MRI and FDG-PET evaluation. Total sleep time seemed to be higher in 5/5 genotype DOC patients (median value Per35/5, 221min, range 126–323min; median value Per34/4, 167min, range 36–477min; and median value Per34/5, 187min, range 29–422min). However, the MRI scores and FDG-PET values of whole brain, overall sleep areas, hypothalamus, midbrain and thalamus did not differ by genotype distribution. ConclusionAlthough limited by the small sample size, our data might support the idea that Per3 genetic predisposition in DOC patients could affect impairment and residual cognitive functions through sleep homeostasis independently from structural and/or metabolic integrity of sleep areas.

Folate and pyridoxine to ssri in major depression and residual cognitive Decline

IntroductionDepressive disorders are very common conditions, lifetime risk for experiencing major depression is approximately 15%.ObjectivePatients with major depression having an insufficient response to SSRI may benefit from addition of methylfolate and pyridoxine.AimThe aim of our study was to determine the effect of folate and pyridoxine augmentation to SSRI on emotional, physical and cognitive symptoms in major depression.MethodsEighteen patients with MDD were enrolled, were on citalopram 20 mg/day when folate/15 mg per day/and pyridoxine/40 mg per day/were added. They have been monitored for three months using standard scales for depression and assessment by interview.ResultsAfter three months of using folate and pyridoxine to SSRI there was a significant improvement in depression as measured by the scales. In 8 patients were recorded improvements of 30–50%. The most prominent changes were in cognitive sphere of depression such as attention, reasoning and problem solving, working memory and speed of processing.ConclusionLow levels of folate and pyridoxine have been associated with the presence of depression and residual poor cognitive function. Our study confirms that folate and pyridoxine as adjunctive therapy to SSRI-partially refractory major depression is useful in particular to issues of residual cognitive interference conditions such as impaired concentration and memory, slow mentation, attention/vigilance, problem solving, working memory and speed of processing.Disclosure of interestThe authors have not supplied their declaration of competing interest.

Evaluation of Cognitive Function When Hearing One's Own Name in Patients With Brain Injuries in Early Developmental Stages.

The level of residual cognitive function in patients with early brain injury is a key factor limiting rehabilitation and the quality of life. Although understanding residual function is necessary for appropriate rehabilitation, the extent of its effects on cognitive improvement remains unknown. This study evaluated cognitive function in patients with severe motor and intellectual disabilities after early brain injuries due to cerebral hemorrhage or periventricular leukomalacia. We focused on neural responses to hearing the subject's own name (SON). According to previous studies, differences in response to SON are associated with several types of cognitive dysfunction. We examined healthy subjects (aged 21.4 ± 1.10 years; control) and patients with a previous brain injury (aged 13-27 years at the time of our analysis) resulting in periventricular leukomalacia or a cerebral hemorrhage during the perinatal period or childhood. We recorded EEG responses to the SON and to other Japanese words, obtaining EEG-evoked potentials with wavelet transformations. Compared with healthy controls, beta power (not alpha power) revealed differences in response to SON by patients with brain injury, especially those with cerebral hemorrhage. We suggest that alpha and beta power differences reflect different cognitive functions and that the SON response reveals more than one process. Beta powers may reflect the intellectual disability of cognitive function in response to self-relevant stimuli, especially in patients with cerebral hemorrhage. Meanwhile, alpha powers did not differ from those of the healthy controls, suggesting that the patients perhaps paid attention to their own names.

P086 Will Neuroimaging Rule Out the Uncertainty in the Treatment of Patients with Disorders of Consciousness? A Qualitative Interview Study with Patients’ Next of Kin

Patients in a minimally conscious state (MCS) are expected to have better rehabilitation outcomes than patients with unresponsive wakefulness syndrome (UWS). We analyze, how the next of kin of patients with disorders of consciousness (DOC) interpret the results of diagnostic tests including HD-EEG to detect residual cognitive function and how these interpretations influence their surrogate treatment decisions. Qualitative interview study with next of kin after a patient with DOC has received a diagnostic HD-EEG examination at a rehabilitation center in Germany; maximum variation sampling; analyzing the verbatim transcripts with qualitative content analysis. So far, we conducted the first three interviews. Despite of different results of the diagnostic tests, all participants perceived the patients were interacting with them. The participants differed in the extent to which they valued the tests: Where the first participant had high hopes for the test to prove to others that here daughter was showing signs of consciousness, the third participant couldn’t recall which tests her husband underwent. For the second participant the test results were important but she struggled aligning it with her intuitive beliefs. The first two participants questioned the validity of neuroscientific examination methods. On the other hand, they hoped that professional caregivers and payers could be convinced by positive test results (MCS) to invest more in the rehabilitation of the patient. A negative test result (UWS) in the first case did not lead to a reconsideration of the therapeutic goal and treatment strategy. When the test result does not match the next of kin’s impression of the patient’s condition uncertainty is still used as an argument to overrule the divergent test results. The preliminary results show how next of kin use different strategies in dealing with diagnostic test results of DOC patients.

Employment Outcomes After Critical Illness: An Analysis of the Bringing to Light the Risk Factors and Incidence of Neuropsychological Dysfunction in ICU Survivors Cohort.

To characterize survivors' employment status after critical illness and to determine if duration of delirium during hospitalization and residual cognitive function are each independently associated with decreased employment. Prospective cohort investigation with baseline and in-hospital clinical data and follow-up at 3 and 12 months. Medical and surgical ICUs at two tertiary-care hospitals. Previously employed patients from the Bringing to Light the Risk Factors and Incidence of Neuropsychological Dysfunction in ICU Survivors study who survived a critical illness due to respiratory failure or shock were evaluated for global cognition and employment status at 3- and 12-month follow-up. We used multivariable logistic regression to evaluate independent associations between employment at both 3 and 12 months and global cognitive function at the same time point, and delirium during the hospital stay. At 3-month follow-up, 113 of the total survival cohort of 448 (25%) were identified as being employed at study enrollment. Of these, 94 survived to 12-month follow-up. At 3- and 12-month follow-up, 62% and 49% had a decrease in employment, 57% and 49% of whom, respectively, were newly unemployed. After adjustment for physical health status, depressive symptoms, marital status, level of education, and severity of illness, we did not find significant predictors of employment status at 3 months, but better cognition at 12 months was marginally associated with lower odds of employment reduction at 12 months (odds ratio, 0.49; p = 0.07). Reduction in employment after critical illness was present in the majority of our ICU survivors, approximately half of which was new unemployment. Cognitive function at 12 months was a predictor of subsequent employment status. Further research is needed into the potential relationship between the impact of critical illness on cognitive function and employment status.

Minimally Conscious State: Evolution of Concept, Diagnosis and Treatment.

The study of consciousness disorders is a scientific challenge, and clinical differentiation among the various sorts of alterations in consciousness is difficult. Persistent vegetative state was defined in 1972, but years later cases appeared in which diagnosed patients showed signs of cognitive activity, and therefore could not be considered vegetative. Minimally conscious state was defined in 2002. This article discusses minimally conscious state based on a literature review and the author's clinical experience. A brief historical outline is given, starting from 1886 when Horsley analyzed level of consciousness. The article reviews criteria for defining minimally conscious state, as well as the differential diagnosis from persistent vegetative state, brain death, coma, locked-in syndrome and akinetic mutism. Modern discoveries of residual cognitive functioning and new neural correlates have contributed to increased knowledge of this condition. Regardless, minimally conscious state continues to be a challenge for neuroscientists around the world, with issues still to be resolved. KEYWORDS Consciousness, consciousness disorders, minimally conscious state, persistent vegetative state, coma, akinetic mutism, brain death, neurosciences, locked-in syndrome, coma, Cuba.