Iatrogenic depression: the case of Frederic Chopin

Psychological disorders caused by the doctor’s rash words are as common as the side effects of drug. Iatrogenic depression caused by ethical and psychological mistakes of doctors will never go away. Their frequency can be reduced only by improving the physicians’ skills in the fields of medical ethics and psychology. A clinical case analysis based on a famous person’s history of the disease is an effective pedagogical tool. The study aims to present the case of the famous Polish composer Frederic Chopin. The A comparative analysis of doctors’ objective actions and patients’ subjective evaluations of their actions were made based on a study of Chopin’s and Sand’s letters as well as the works of composer’s biographers. This approach provides a valuable opportunity to see doctors through the patient’s eyes. In the fall of 1838, during his rest in Majorca, the local doctors diagnosed pulmonary tuberculosis in Chopin. The Majorcan doctors made a serious ethical mistake. They ignored the patient’s anamnesis vitae indicating his phthisiophobia and informed Chopin about the diagnosis of pulmonary tuberculosis and a poor prognosis in a very cynical manner. Chopin wrote: ‘One (doctor) said I had died the second that I am dying, the 3rd that I shall die’. Chopin perceived the diagnosis of tuberculosis as a ‘death sentence’, as a result of which he developed iatrogenic depression. All previous and subsequent Chopin’s doctors used other tactics: they prescribed the correct treatment, but the diagnosis was not voiced. The analysis shows the effectiveness of this tactic: Chopin lived another 10 years after the Majorcan episode. Chopin’s case shows typical doctors’ ethical and psychological issues in informing the patient about the dangerous diagnosis and poor prognosis as well as tactics for building a good physician‑patient relationship.

Clinical neurological manifestations in patients suffering from peptic ulcer disease in the acute phase and in remission

Objective — to analyze clinical neurological manifestations in patients suffering from peptic ulcer disease in the acute phase and in remission, based on the findings of a comprehensive clinical neurological, neuropsychological and paraclinical study. Methods and subjects. 84 patients suffering from PUD were comprehensively examined while in the acute phase of the disease and then all 84 were reexamined while in remission. The age range of the patients was from 25 to 60 years. The average age of the patient was 39.90 ± 1.29 years. The examined individuals were destributed into two groups based on whether they presented symptoms of an acute phase or remission of the peptic ulcer disease. The comprehensive examination included: interview and complaint analysis, neurological examination focused on the state of the autonomic nervous system, study of the neuropsychological differences (the trait and state anxiety levels monitoring based on the Spielberg‑Khanin scale, depressive state evaluation using Beck Depression Inventory, self‑perceived health assessment, mood and activity monitoring using the SAN questionnaire, cognitive impairment evaluation using the MMSE scale, assessment of the refocusing speeds and performance distribution using Schulte tables), as well as lab tests and procedures. Results. Most often, subjects complained of headache (74 (88.0 %) in the acute stage and 37 (44.0 %) in remission). The second most common was a complaint of pain in the thoracic spine (69 (82.1 %) and 35 (41.6 %), respectively). Complaints of dizziness, pain in the heart, palpitations, «interruptions» in the heart, paresthesia were often recorded. In 11 (12.4 %) patients with duodenal ulcer in the acute stage experienced episodes of syncopal state, while in the remission stage they were absent. Complaints that indicated the presence of psychoemotional disorders were anxiety, decreased memory and attention, and sleep disturbances. In patients with duodenal ulcer disease we revealed lesions of the central and peripheral nervous system. Central nervous system disorders were manifested in the form of vestibulo‑cerebellar syndrome (in 30 (35.7 %) patients in the acute stage and in 14 (16.6 %) in the remission stage), extrapyramidal disorders (respectively in 10 (11.9 %) and 4 (4.76 %)) and signs of pyramidal dysfunction (37 (44.0 %) and 15 (17.8 %)). Clinical and neurological examination of the peripheral nervous system in 68 (80.9 %) patients with peptic ulcer in the acute stage and in 31 (36.9 %) in the remission stage revealed polyneuropathy syndrome of varying degrees. Signs of polyneuropathy were accompanied by complaints of disorders of the peripheral nervous system (45 (53.5 %) and 15 (17.8 %) cases, respectively). In 27.4 % of patients with peptic ulcer disease in the acute stage of the complaint were absent at all, and only a thorough neurological examination revealed signs of polyneuropathy. In 56 (66.6 %) patients with peptic ulcer disease in the acute stage and 28 (33.3 %) in the remission stage, the morbidity of paravertebral points in the lower thoracic spine was revealed. Conclusions. Having analyzed the data obtained through the interviews, as well as the neurological characteristics of patients with peptic ulcer disease of the duodenum in the acute phase and in remission it was concluded that most of the somatic complaints and neurological manifestations were common in both the acute phase and the remission of the disease. However, all of the identified neurological differences were significantly more common in the acute phase of the disease.

Post-stroke cognitive impairment: screening with MMSE and MoCA and predictors of their persistence after treatment at the Stroke Center

Objective — to analyze the results of screening for post‑stroke cognitive impairment (PCI) in patients with cerebral stroke (CS) admitted to the Stroke Center (SC) in different disease phases, and to determine independent predictors of the PCI persistence at discharge. Methods and subjects. 399 patients were enrolled, including 242 (60.7 %) men and 157 (39.3 %) women with the median age was 66.2 years (IQR 58.5 — 76.3). IS was diagnosed in 331 (82.9 %), and ICH in 68 (17.1 %) patients. Among patients with IS, 137 (41.4 %) had an atherothrombotic subtype, 152 (46.0 %) had a cardioembolic subtype, 21 (6.3 %) had a lacunar subtype, another 21 (6.3 %) had another or unknown cause of stroke. Patients were screened for PCI using the Mini‑Mental State Examination (MMSE) and Montreal Cognitive Assessment (MoCA) on admission and at discharge. Participants with MMSE score of 0 — 24 or a MoCA score of 0 — 25 were considered having PCI. Upon admission, all patients were assessed using the National Institutes of Health Stroke Scale (NIHSS), Bartel Index, and Modified Rankine Scale (mRS). The method of constructing and analyzing logistic regression models was used to determine independent predictors of the preservation of PCI at discharge. The analysis was carried out using the MedCalc v. 19.1. Results. The baseline NIHSS score ranged from 0 to 39 (median 11, IQR 6 — 18). The majority (64.2 %) of the subjects were hospitalized within the first 30 days from the CS onset. The MMSE score on admission ranged from 0 to 30 (median 20, IQR 2 — 27), and in 179 (44.9 %) of the patients the initial score was 0 to 17 (severe PCI), whereas in 61 (15 3 %) of the participants it was 18 to 24 (moderately severe PCI) and only 159 (39.8 %) persons scored 25 to 30 (no PCI). The baseline MoCA score ranged from 0 to 30 (median 15, IQR 1 — 24), and 356 (89.2 %) patients were shown to have PCI (score 0 to 25). According to screening with MMSE at discharge, 125 (31.4 %) patients had severe PCI, and 67 (16.8 %) had moderately severe PCI. The MoCA assessment before discharge indicated PCI in 324 (81.2 %) patients. According to both MMSE and MoCA, the rate of PCI on admission was significantly higher than at discharge (p < 0.001). Among the 240 patients who had PCI according to MMSE score, 239 (99.6 %) had PCI according to the MoCA score. However, among 159 patients who screened negative for PCI with MMSE at admission, 117 (73.6 %) screened positive with MoCA. Screening results using both MMSE and MoCA were not significantly associated with affected hemisphere. ICH was associated with lower (p < 0.0001) MMSE and MoCA scores compared with IS. Predictors of PCI according to MMSE score at discharge were a longer time interval from CS onset to SC admission, and a lower baseline MMSE score. However, with MoCA, the predictors were AT subtype IS, lesions in the distribution of the right or both middle cerebral arteries, older patient age, and a lower baseline MoCA score. Conclusions. In patients with MI, a high rate of PCI was documented on admission, but was significantly lower at discharge. In patients with established PCI, according to MMSE score, the use of MoCA for screening seems useless, however, screening with MoCA identified PCI in 3/4 in patients with a normal MMSE score. The independent predictors of scores on these two scales, indicating PCI, were significantly different, so they should not be considered interchangeable.

Experience of patients with herpetic ganglioneuritis observation in the neurological hospital

Objective — to evaluate the clinical, laboratory and functional parameters of patients with herpetic trigeminal ganglioneuritis in the neurological department. Methods and subjects. The case anamnesis of 43 patients (26 (60.5 %) female and 17 (39.5 %) male) with a diagnosis of herpetic trigeminal ganglioneuritis were retrospectively analyzed: clinical presentation, data on general blood and urine tests, biochemical blood tests, electrocardiography, ultrasound examination of the main arteries of the brain, organs of the abdominal cavity and small pelvis, rheoencephalography. Results. Out of 43 hospitalized patients, 31 (72.1 %) had lesion of the first branch (64.5 % of women and 35.5 % of men), 9 (20.9 %) had lesion of the second branch, and 3 (7.0 %) ) — III branch of the trigeminal nerve. Patients older than 46 years predominated (86.0 %). In general, right‑sided lesion was observed in 22 cases (51.2 %), left‑sided — in 21 (48.8 %) cases. In women, right‑sided lesions prevailed (16 patients — 61.5 %), while in men — left‑sided lesions (11 patients — 64.7 %). The main complaint, in addition to rashes, was local pain, which was mainly of a burning character (24 patients — 55.8 %) with simultaneous itching (15 patients — 34.9 %). Severe pain was observed in 23 (53.5 %), moderate in 14 (32.6 %) and mild in 6 cases (13.9 %). Hyperesthesia accompanied pain in 28 (65.1 %) cases, while only 6 (14.0 %) patients demonstrated hypoesthesia. In the case of involvement of the I branch, herpetic kerato‑uveitis was registered in 9 (29.0 %) cases. Edema of the periocular region was observed in 17 patients (54.8 %). In the case of elderly patients, intellectual and mind functions decrease (45 %), positive subcortical reflexes (46.5 %), and moderate coordination disorders (34.9 %) were observed. Among the general and functional analyses carried out, attention was drawn to an increase ESR (39.5 %), as well as metabolic changes in the myocardium on the ECG (65.1 %). In the case of older age group, comorbidities were dominated by bychronic cerebrovascular accident (45 %), arterial hypertension (40.0 %), type 2 diabetes mellitus (25.0 %), and osteochondrosis (20.0 %). Conclusions. In the case of herpetic lesions, clinical observations confirm the predominant lesion of the I branch of the trigeminal nerve, more marked predominance of elderly women with right‑sided symptoms in the pathological process was observed. Beside the background of typical rashes, severe baking local pain, accompanied by itching and hyperesthesia, dominates in the clinical picture. Despite sometimes delayed hospitalization due to attempts at outpatient or self‑treatment, a general blood analysis often reveals markers of inflammation. The complexity and variability of complaints, as well as examination results, can be mainly explained by the elderly age of patients.

Mechanisms of glycolysis and bioenergy state of cells at the stages of cardiosurgical interventions in patients with hypoxic — ischemic impairments of the brain

Objective — to study the features of bioenergetic provision of oxidative homeostasis (OH) in patients with hypoxic‑ischemic brain lesions (HIBL) before and after cardiac surgery (CS) using artificial circulation (AC). Methods and subjects. Clinical and biochemical studies were performed in 38 patients, including 14 with ischemic stroke, 15 with encephalopathy, and 9 with severe cognitive dysfunction. Results. Analysis of metabolic indicators of glycolysis activity and energy homeostasis of cells before and after CS revealed the patterns of changes in the disorganization of glycolysis mechanisms, intensification of anaerobic mechanisms while limiting the energy supply of cells. The obtained data confirm the formation of specific postoperative metabolic provision of bioenergy in patients with CS, which should be considered as one of the triggers of HIBL and individualization of antioxidant cerebroprotection in the preoperative period, taking into account the state of bioenergetic metabolism of cells and the dominant mechanisms of glycolysis. Conclusions. Preoperative antioxidant cerebroprotection as a means of prevention of hypoxic‑ischemic brain lesions during cardiac surgery using artificial circulation should be based on the determination of bioenergetic and metabolic reserves, the depletion of which by antioxidant drugs suppression should not be considered, as activation of anaerobic glycolysis at simultaneous metabolic suppression of mitochondrial bioenergetics is a factor of formation or aggravation of ischemic lesions of brain.

Corelation of gait parameters, cognitive impairment and brain atrophy in patients with Parkinson’s disease and the «normally aging population»

Objective — to identify the most significant markers of gait that indicate a decrease in cognitive function based on investigation of the corelation of cognitive impairment, gait parameters and atrophy of brain structures in groups of patients with Parkinson’s disease and the «normally aging population». Methods and subjects. 66 subjects were examined: 30 patients with Parkinson’s disease (mean age 54.9 ± 5.9, 50 % men) and 33 without neurological pathology (mean age 52.7 ± 7.6, 66 % men). All of them underwent neurological examination, assessment of temporal and spatial gait parameters using the GaitRite system, grading of brain atrophy using a comprehensive visual rating scale of MRI scans and assessment of cognitive status using the Montreal Cognitive Assessment Scale. Results. Cognitive performance was significantly lower in the subgroup of patients with Parkinson’s disease compared to the subgroup of «normally aging population». The gait profile of patients with Parkinson’s disease significantly differed from the gait profile of individuals from the «normal aging» subgroup by slower gait velocity, shorter step length and stride length for both limbs. The gait parameters, which showed a strong correlation with cognitive tests, differed in the subgroups, but gait velocity, stride length and step length for both extremities were common among them. These common gait parameters showed a strong direct correlation with brain atrophy in the subgroup of patients with Parkinson’s disease, but only velocity correlated with atrophy in the subgroup of «normal aging» among all of them. It was determined by the method of multiple regression analysis that it was precisely the atrophy of the brain that turned out to be the most influential factor in the decrease in cognitive function in the general group and subgroups. Conclusions. The gait profile in Parkinson’s disease subgroup is characterized by lower velocity, shorter step length, stride length for both limbs and significantly differs from the subgroup of «normal aging». These changes are a consequence of the influence of the disease on the motor sphere. Velocity showed a strong correlation in both subgroups not only with cognitive abilities, but also with cerebral atrophy. This confirms the hypothesis about the possibility of using gait velocity as a universal sensitive marker for current and longitudinal assessment of cognitive function, especially in clinical practice.

Neuroradiological signs of encephalopathy in children with autism spectrum disorders associated with genetic folate deficiency

The results of five meta‑analyzes indicate the association of autism spectrum disorders (ASD) with genetic deficiency of the folate cycle (GDFC) in children. In such cases, specific encephalopathy is formed with predominant immune‑dependent pathways of pathogenesis, the radiological signs of which are insufficiently studied. Objective —— to describe the typical neuroimaging signs of encephalopathy in children with GDFC suffering from ASD, and to find correlations between clinical signs, mechanisms of nervous system damage and neuroimaging data to optimize the algorithm of diagnosis, monitoring and treatment. Methods and subjects. The retrospective analysis of medical data of 225 children aged 2 to 9 years with GDFC, in which there were clinical manifestations of ASD (183 boys and 42 girls). The diagnosis of ASD was made by child psychiatrists according to the criteria of DSM‑IV‑TR (Diagnostic and Statistical Manual of mental disorders) and ICD‑10 (The International Statistical Classification of Diseases and Related Health Problems). Pathogenic polymorphic variants of folate cycle genes were determined by PCR with restriction. Neuroimaging was performed by MRI of the brain in conventional modes (T1‑ and T2‑weighted, FLAIR) on tomographs with a magnetic induction of 1.5 T. To study the associations between the indicators, the odds ratio (OR) and the 95 % confidence interval (95 % SI) were used. Results. There are 5 main groups of neuroimaging signs characteristic of leukoencephalopathy, temporal mesial sclerosis, PANS/PITANDS/PANDAS, congenital CMV neuroinfection and postnatal encephalitis, mild congenital CNS abnormalities. Neuroimaging signs are closely associated with the results of special laboratory tests that characterize the known immune‑dependent mechanisms of CNS damage, and with the emergence of relevant clinical syndromes, consistent with modern concepts of major infectious or autoimmune lesions of the nervous system in immunosuppressed patients. Laboratory‑radiological‑clinical complexes (virus‑induced temporal mesial sclerosis, autoimmune limbic encephalitis, autoimmune subcortical encephalitis, autoimmune or virus‑induced demyelinating lesions of the cerebral hemispheres and mild congenital malformations) have been identified. Conclusions. Encephalopathy in children with ASD associated with GDFC has a complex pathogenesis and is the result of combining a number of immune‑dependent forms of CNS damage in different ways in different patients, leading to a heterogeneous clinic‑radiological phenotype.

The Functional Independence Measure and the Functional Assessment Measure (FIM + FAM) as an effective tool for the evaluation of functional status in stroke rehabilitation

The Functional Independence Measure and Functional Assessment Measure (FIM + FAM) is an effective, efficient, and objective tool for tracking changes in the motor, cognitive, and psychosocial functions of patients over the entire treatment and rehabilitation period. It is estimated that in the Czech Republic (CR), stroke is the third most common cause of death and the most common cause of adult disability. To develop faster, better, and more cost‑effective stroke treatments and reduce or mitigate functional losses and restrictive situations, it is very important that patients be objectively evaluated, relative to their functional abilities, as soon as possible after a stroke. A critical part of stroke treatment is to calculate the length of in‑hospital treatment and estimate the length of the rehabilitation period after the stroke. Contemporary methods for evaluating and analyzing a patient’s condition are based on test results and evidence.The FIM offers a more sensitive rating scale compared to BI due to the presence of cognitive items and is used worldwide for assessment during the acute stage of the disease. Thus, it is an efficient instrument for setting therapy goals and evaluating the effects of rehabilitation. Not only can it assist the therapist in clinical decision making, but it also functions as a tool for evaluating rehabilitation outcomes. Based on this test, short‑term and long‑term rehabilitation plans can be determined. At the end of the rehabilitation process, assessing the patient’s functional condition helps to predict the specific long‑term rehabilitation services the patient will need as they return to society and regain their quality of life.

Guillain – Barré syndrome associated with SARS-CoV-2 infection

Neurological manifestations of COVID‑19 infection are caused by its effects on CNS (headache, dizziness, disturbance of consciousness, convulsions, etc.) and PNS (anosmia, ageusia, visual impairment, radiculo‑ and neuropathy). Guillain – Barré syndrome (GBS) is a rare autoimmune disease associated with damage to the peripheral nervous system. 40 — 70 % of cases are associated with a previous infection: cytomegalovirus, Epstein–Barr virus, Haemophilus influenzae type b, Mycoplasma pneumoniae, Campylobacter jejuni etc. The clinical characteristics of this condition are progressive muscle weakness, reduction or loss of tendon reflexes (hyporeflexia and areflexia), paresthesias, paresis of the cranial nerves. The diagnosis is based on clinical data, cerebrospinal fluid analysis (protein level, cytosis, antigangliosid antibodies), as well as electroneuromyography. Most patients with Guillain – Barré syndrome totally recover. However, the most dangerous and severe complication of acute inflammatory demyelinating polyneuropathy is paralysis of the respiratory muscles. About a quarter of patients require urgent treatment at intensive care unit with mechanical ventilation and/or tracheostomy. Mortality in Guillain – Barré syndrome can reach to 10 %. There have been several reports of COVID‑19‑related GBS in the world scientific medical literature during the last year, but more information about this association and its implications is still missing. The aim of this report was to analyze the available information about cases of Guillain – Barré syndrome associated with COVID‑19 infection, to compare different variants of this condition and to share our own experience in clinical management of such patient.