The relationship between types of life events and the onset of functional neurological (conversion) disorder in adults: a systematic review and meta-analysis

Adverse life events precede the onset of functional neurological disorder (FND, also known as conversion disorder) more commonly than other neuropsychiatric conditions, but their aetiological role is unclear. We conducted a systematic review and quantitative analysis of the type, timing and number of life events preceding the onset of FND in adults, and a meta-analysis of the proportions of types of events in controlled studies. Fifty-one studies of different designs, covering 4247 patients, were eligible for inclusion. There was no clear majority of any type of preceding event. Family problems were the most common category of events, followed by relationship problems. Females were more likely to experience preceding family/relationship problems than males, who reported more work problems. Family problems were the commonest type of preceding event in studies in developing countries, whereas family and health problems were equally common in developed countries. Abuse was associated with early symptom onset, while patients with later onset were more likely to report family problems. The median number of events was one, and the events occurred closer to onset than in controls. Meta-analysis found that family, relationship and work events were all relatively more common in patients than pathological controls, as were events where symptoms might provide a solution to the stressor. In conclusion, although a range of events precede the onset of FND, they do not appear to do so uniformly. This may support a different aetiological role for stressors than in other disorders, although the support is indirect and the quality generally low.

Recurrent soft tissue infections associated with complex regional pain syndrome type ll: Reports of two unusual cases

Complex Regional Pain Syndrome (CRPS) (Synonyms: Reflex Sympathetic Dystrophy, Causalgia, Sudeck’s atrophy, Algodystrophy) is a chronic neurological condition, usually involving the limbs, that is characterized by severe pain along with sensory, autonomic, motor and trophic involvement. CRPS type ll is when there is an identifiable preceding event causing nerve damage. We present 2 unusual cases: 1. spontaneous bleeding from left leg associated with recurrent infections 2. a calcified mass in abdominal wall with recurrent infections. Recurrent soft tissue infections are rare in CRPS. Both presentations were unique.

Bilateral Basal Ganglia Lesions in Patients with Heroin Overdose: A Report of Two Cases

The prevalence of opioid use has increased worldwide. Two-thirds of deaths caused by drug overdose are opioid-related. Individuals with opioid use may present with a variety of complications. The available history in unconscious patients is often insufficient, which may cause diagnostic difficulty and delayed management. We present two cases of 54-year-old and 25-year-old male patients who were brought to our emergency department after being found unconscious at home, without any known preceding event. They were in a deep coma with a Glasgow coma score of 3/15. However, their brainstem reflexes were normal. Pinpoint pupils were observed bilaterally. Brain computed tomography (CT) demonstrated the presence of bilateral basal ganglia hypodensities in both patients, in addition to multiple hypodensities scattered in the cerebral hemispheres of one patient. Toxicology screening from both patients was positive for opioids. The patients were transferred to the intensive care unit for supportive management. One patient recovered completely, whereas the other remained in a vegetative state. The presence of bilateral basal ganglia lesions in brain CT in unconscious patients should alert the physician of opioid use disorder among these patients.

The Après-Coup, Après Coup

Here the author examines the question of après-coup (afterwardsness) in psychoanalysis, commenting in particular on Jean Laplanche’s book, Après-Coup. The author appreciates Laplanche’s determination to avoid either a positivist interpretation of après-coup (as a “delay-action bomb”, as simply a delayed psychic effect) or an hermeneutic interpretation that makes of it a post-factum re-signification of past events. Yet at the same time, the author shows that Laplanche’s solution—which assumes an initial trauma to the subject, who must “translate” an ambiguous and enigmatic message originating from an adult other—ends up being, in effect, a clever combination of the two approaches, positivist and hermeneutic, that Laplanche was trying to avoid. Laplanche advances a much too linear theory, placing “the other” (that is, the desire of the adult) at the beginning of the process, while Lacan’s approach to après-coup opens up far more complex and disturbing perspectives for psychoanalysis. The author, having shown the limitations of Laplanche’s result (“the primacy of the other”), proposes his own interpretation of après-coup, wherein it would connect, in a unique way, the cause and the sense of the psychic world: a subsequent event in some way makes the sense of a preceding event function as the cause of later psychic phenomena or symptoms.

Characteristics and demographics of reversible cerebral vasoconstriction syndrome: A large prospective series of Korean patients

Objectives To report demographics and characteristics of reversible cerebral vasoconstriction syndrome (RCVS) in the Korean cohort. Methods We prospectively recruited patients with definite (imaging-proven) RCVS and probable (imaging-negative) RCVS who visited Samsung Medical Center between June 2012 and September 2016. Clinical manifestations, neuroimaging, treatment, and clinical outcomes were evaluated in all patients. Characteristics of RCVS without typical causes (“idiopathic RCVS”) were compared with those of RCVS with identifiable causes (“secondary RCVS”). International Classification of Headache Disorders (ICHD)-3 beta criteria for 6.7.3 RCVS and 6.7.3.1 probable RCVS were tested. Results A total of 138 patients (104 definite and 34 probable RCVS) were included in this study. Patients with definite RCVS were predominantly female (85.6%) and middle-aged (mean, 50.7 [range, 23–82] years). Probable RCVS was associated with less female predominance (70.6%, p = 0.049), more typical manifestations ( p < 0.001), and none of neurological complications. One-hundred and one (97.1%) patients with definite RCVS had headache, but the typical “recurrent and/or triggered” thunderclap headache was reported in only 83 (82.2%). In most patients with definite RCVS (84.6%), RCVS was idiopathic, while only 16 (15.4%) had secondary causes. Compared to those with secondary RCVS, patients with idiopathic RCVS were older (52.8 ± 11.42 vs. 39.1 ± 9.55 years, p < 0.001). Patients with secondary RCVS had more complications than those with idiopathic RCVS (40.5% vs. 12.5%, p = 0.018). Among idiopathic RCVS patients, 33 (37.5%) reported a preceding event or a change in lifestyle, environment, health, or medication within one month before onset. Conclusion In our cohort, RCVS was benign and idiopathic in most patients, and occurred frequently in middle-aged women. Manifestations of RCVS were more diverse than previously recognized, and forms without any headache existed. Different genetic, social, and environmental factors should be taken into account to unveil the spectrum and pathophysiology of RCVS.

Management of developmental speech and language disorders. Part 2: acquired conditions

Many children who present with these acquired impairments of communication have a clear preceding event such as an acquired brain injury from a road traffic accident. Children often respond differently in this situation to adult presentations. They may have a period of mutism when the prognosis might look poor and yet they subsequently make rapid progress and recover speech. They have greater potential for neural plasticity and language recovery, although they often have persisting difficulties in oral and written language. Alternatively, there may be a presentation with a paroxysmal event such as a seizure or a period of depressed consciousness, and the unusual behaviour that may accompany dysphasia and dysarthria may be misinterpreted in the child, whereas for the adult with the more common ‘stroke-like’ presentation, it would be immediately considered. Rarely the aphasia/dysphasia may itself be the paroxysmal event where actually recognising that the child's disrupted communication is the basis of any observed behaviours can be the greater challenge.

Dicarbonyls linked to damage in the powerhouse: glycation of mitochondrial proteins and oxidative stress

Protection of mitochondrial proteins from glycation by endogenous dicarbonyl compounds, methylglyoxal and glyoxal, was found recently to prevent increased formation of reactive oxygen species and oxidative and nitrosative damage to the proteome during aging and produce life extension in the nematode Caenorhabditis elegans. This suggests that dicarbonyl glycation damage to the mitochondrial proteome may be a preceding event to mitochondrial dysfunction leading to oxidative stress. Future research will address the functional charges in mitochondrial proteins that are the targets for dicarbonyl glycation.

Postevent ventilation as a function of CO2 load during respiratory events in obstructive sleep apnea

Maintenance of eucapnia during sleep in obstructive sleep apnea (OSA) requires a balance between CO2 loading during apnea and CO2 elimination. This study examines individual respiratory events and relates magnitude of postevent ventilation to CO2 load during the preceding respiratory event in 14 patients with OSA (arterial Pco 2 42–56 Torr). Ventilation and expiratory CO2 and O2 fractions were measured on a breath-by-breath basis during daytime sleep. Calculations included CO2 load during each event (metabolic CO2 production − exhaled CO2) and postevent ventilation in the 10 s after an event. In 12 of 14 patients, a direct relationship existed between postevent ventilation and CO2 load during the preceding event ( P < 0.05); the slope of this relationship varied across subjects. Thus the postevent ventilation is tightly linked to CO2 loading during each respiratory event and may be an important mechanism that defends against development of acute hypercapnia in OSA. An inverse relationship was noted between this postevent ventilatory response slope and the chronic awake arterial Pco 2 ( r = 0.90, P < 0.001), suggesting that this mechanism is impaired in patients with chronic hypercapnia. The link between development of acute hypercapnia during respiratory events asleep and maintenance of chronic awake hypercapnia in OSA remains to be further investigated.