1
|
Anderson SG, McCaul M, Khoo S, Wiesner L, Sacktor N, Joska JA, Decloedt EH. The neurologic phenotype of South African patients with HIV-associated neurocognitive impairment. Neurol Clin Pract 2019; 10:15-22. [PMID: 32190416 DOI: 10.1212/cpj.0000000000000687] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2019] [Accepted: 04/30/2019] [Indexed: 11/15/2022]
Abstract
Background The neurologic manifestations of HIV include a spectrum of HIV-associated neurocognitive disorders, as well as a cluster of neurologic symptoms and signs. The neurologic manifestations have been modified but not eradicated by antiretroviral therapy (ART). We describe the neurologic phenotype in South African patients with predominant HIV-1 subtype C infection on ART and its association with neurocognitive impairment and efavirenz and 8-hydroxy-efavirenz concentrations. Methods We conducted a cross-sectional analysis of the neurologic examination findings of HIV+ patients with neurocognitive impairment and used multiple linear regression to explore associations with neurocognitive impairment, efavirenz, and 8-hydroxy-efavirenz pharmacokinetics (plasma and CSF). Results We included 80 participants established on ART (median 40 months) of which 72 (90%) were female. The median age was 35 (interquartile range [IQR], 32-42) and the median Global Deficit Score was 0.94 (IQR 0.63-1.36). We found associations between neurocognitive impairment and neurologic signs: gait (slow walking speed [p = 0.03; R2 = 0.06], gait ataxia [p < 0.01; R2 = 0.21], and abnormal gait appearance [p < 0.01; R2 = 0.18]); coordination (upper limb bradykinesia [p < 0.01; R2 = 0.10] and lower limb bradykinesia [p = 0.01; R2 = 0.10]); reflexes (jaw jerk [p = 0.04; R2 = 0.05] and palmomental response [p = 0.03; R2 = 0.06]); ocular signs (impaired smooth pursuit [p = 0.01; R2 = 0.09] and impaired saccades [p < 0.01; R2 = 0.15]); and motor signs (spasticity [p ≤ 0.01; R2 = 0.15] and muscle weakness [p = 0.01; R2 = 0.08]). No significant associations were found between plasma and CSF efavirenz or 8-hydroxy efavirenz concentrations and any neurologic sign. Conclusion We found that individual neurologic signs were associated with neurocognitive impairment in South African HIV+ patients with predominant HIV-1 subtype C infection on ART and could be used in clinical practice to assess severity. Registration number PACTR201310000635418.
Collapse
Affiliation(s)
- Sean G Anderson
- Division of Clinical Pharmacology (SGA, EHD), Faculty of Medicine and Health Sciences, University of Stellenbosch; Biostatistics Unit (MM), Division of Epidemiology and Biostatistics, Department of Global Health, Faculty of Medicine and Health Sciences, Stellenbosch University, South Africa; Institute of Translational Medicine (SK), University of Liverpool, and Royal Liverpool University Hospital, United Kingdom; Division of Clinical Pharmacology (LW), Department of Medicine, University of Cape Town, South Africa; Department of Neurology (NS), Johns Hopkins University School of Medicine, Baltimore, MD; and Division of Neuropsychiatry (JAJ), Department of Psychiatry and Mental Health, Faculty of Health Sciences, University of Cape Town, South Africa
| | - Michael McCaul
- Division of Clinical Pharmacology (SGA, EHD), Faculty of Medicine and Health Sciences, University of Stellenbosch; Biostatistics Unit (MM), Division of Epidemiology and Biostatistics, Department of Global Health, Faculty of Medicine and Health Sciences, Stellenbosch University, South Africa; Institute of Translational Medicine (SK), University of Liverpool, and Royal Liverpool University Hospital, United Kingdom; Division of Clinical Pharmacology (LW), Department of Medicine, University of Cape Town, South Africa; Department of Neurology (NS), Johns Hopkins University School of Medicine, Baltimore, MD; and Division of Neuropsychiatry (JAJ), Department of Psychiatry and Mental Health, Faculty of Health Sciences, University of Cape Town, South Africa
| | - Saye Khoo
- Division of Clinical Pharmacology (SGA, EHD), Faculty of Medicine and Health Sciences, University of Stellenbosch; Biostatistics Unit (MM), Division of Epidemiology and Biostatistics, Department of Global Health, Faculty of Medicine and Health Sciences, Stellenbosch University, South Africa; Institute of Translational Medicine (SK), University of Liverpool, and Royal Liverpool University Hospital, United Kingdom; Division of Clinical Pharmacology (LW), Department of Medicine, University of Cape Town, South Africa; Department of Neurology (NS), Johns Hopkins University School of Medicine, Baltimore, MD; and Division of Neuropsychiatry (JAJ), Department of Psychiatry and Mental Health, Faculty of Health Sciences, University of Cape Town, South Africa
| | - Lubbe Wiesner
- Division of Clinical Pharmacology (SGA, EHD), Faculty of Medicine and Health Sciences, University of Stellenbosch; Biostatistics Unit (MM), Division of Epidemiology and Biostatistics, Department of Global Health, Faculty of Medicine and Health Sciences, Stellenbosch University, South Africa; Institute of Translational Medicine (SK), University of Liverpool, and Royal Liverpool University Hospital, United Kingdom; Division of Clinical Pharmacology (LW), Department of Medicine, University of Cape Town, South Africa; Department of Neurology (NS), Johns Hopkins University School of Medicine, Baltimore, MD; and Division of Neuropsychiatry (JAJ), Department of Psychiatry and Mental Health, Faculty of Health Sciences, University of Cape Town, South Africa
| | - Ned Sacktor
- Division of Clinical Pharmacology (SGA, EHD), Faculty of Medicine and Health Sciences, University of Stellenbosch; Biostatistics Unit (MM), Division of Epidemiology and Biostatistics, Department of Global Health, Faculty of Medicine and Health Sciences, Stellenbosch University, South Africa; Institute of Translational Medicine (SK), University of Liverpool, and Royal Liverpool University Hospital, United Kingdom; Division of Clinical Pharmacology (LW), Department of Medicine, University of Cape Town, South Africa; Department of Neurology (NS), Johns Hopkins University School of Medicine, Baltimore, MD; and Division of Neuropsychiatry (JAJ), Department of Psychiatry and Mental Health, Faculty of Health Sciences, University of Cape Town, South Africa
| | - John A Joska
- Division of Clinical Pharmacology (SGA, EHD), Faculty of Medicine and Health Sciences, University of Stellenbosch; Biostatistics Unit (MM), Division of Epidemiology and Biostatistics, Department of Global Health, Faculty of Medicine and Health Sciences, Stellenbosch University, South Africa; Institute of Translational Medicine (SK), University of Liverpool, and Royal Liverpool University Hospital, United Kingdom; Division of Clinical Pharmacology (LW), Department of Medicine, University of Cape Town, South Africa; Department of Neurology (NS), Johns Hopkins University School of Medicine, Baltimore, MD; and Division of Neuropsychiatry (JAJ), Department of Psychiatry and Mental Health, Faculty of Health Sciences, University of Cape Town, South Africa
| | - Eric H Decloedt
- Division of Clinical Pharmacology (SGA, EHD), Faculty of Medicine and Health Sciences, University of Stellenbosch; Biostatistics Unit (MM), Division of Epidemiology and Biostatistics, Department of Global Health, Faculty of Medicine and Health Sciences, Stellenbosch University, South Africa; Institute of Translational Medicine (SK), University of Liverpool, and Royal Liverpool University Hospital, United Kingdom; Division of Clinical Pharmacology (LW), Department of Medicine, University of Cape Town, South Africa; Department of Neurology (NS), Johns Hopkins University School of Medicine, Baltimore, MD; and Division of Neuropsychiatry (JAJ), Department of Psychiatry and Mental Health, Faculty of Health Sciences, University of Cape Town, South Africa
| |
Collapse
|
4
|
Maldonado JR. Delirium in the acute care setting: characteristics, diagnosis and treatment. Crit Care Clin 2008; 24:657-722, vii. [PMID: 18929939 DOI: 10.1016/j.ccc.2008.05.008] [Citation(s) in RCA: 177] [Impact Index Per Article: 11.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Delirium is a neurobehavioral syndrome caused by the transient disruption of normal neuronal activity secondary to systemic disturbances. It is also the most common psychiatric syndrome found in the general hospital setting, its prevalence surpassing better known psychiatric disorders. This article reviews the published literature on delirium and addresses the epidemiology, known etiologic factors, presentation and characteristics of delirium, while emphasizing what is known about treatment strategies and prevention. Given increasing evidence that delirium is not always reversible and the many sequelae associated with its development, physicians must do everything possible to prevent its occurrence or shorten its duration, by recognizing its symptoms early, correcting underlying contributing causes, and using treatment strategies proven to help recover functional status.
Collapse
Affiliation(s)
- José R Maldonado
- Department of Psychiatry, Stanford University School of Medicine, Stanford, CA 94305, USA.
| |
Collapse
|
5
|
Abstract
OBJECTIVE To review the role of cortical release signs (CRS) in neuropsychiatry. METHOD A thorough literature review was conducted using Medline and Psychlit databases, and other relevant references available to the authors. RESULTS A number of neurological abnormalities are reported at elevated rates in neuropsychiatric conditions. CRS are a group of primitive reflexes that are present in the neonate but become inhibited as the infant central nervous system (CNS) develops, only to later re-emerge in the context of CNS disease. The clinical elicitation and interpretation of each CRS is described with reference to its neurobiology. The prevalence of CRS in schizophrenia, affective disorder, obsessive-compulsive disorder, Alzheimer's disease, vascular dementia, frontotemporal dementia and other neuropsychiatric illness allows for their use in the clinical management of these patients, including diagnostic assessment, treatment monitoring and prognosis. CONCLUSIONS A number of issues complicate their interpretation in neuropsychiatric illness, including the apparent high base rate of some CRS in non-clinical populations, their increasing prevalence with age, lack of specificity and uncertainty over what constitutes an 'abnormal' response. In some circumstances, CRS may assist in diagnostic differentiation and illness staging.
Collapse
Affiliation(s)
- Mark Walterfang
- Neuropsychiatry Centre, University of Melbourne, Melbourne, Australia.
| | | |
Collapse
|