Significance of cortical disinhibition signs

The grasp reflex in patients with idiopathic normal pressure hydrocephalus

OBJECTIVE

To investigate the prevalence and intensity of grasp reflexes and to examine changes in these reflexes after shunt surgery in patients with idiopathic normal pressure hydrocephalus (iNPH).

METHODS

We enrolled 147 patients with probable iNPH. A standard procedure was used to determine the presence of grasp reflexes, and the intensity of these reflexes was assessed using a four-category classification. Clinical rating scales and their correlation with grasp reflexes were also evaluated. Grasp reflexes were reassessed in 72 patients 1 year after surgery.

RESULTS

We found that approximately 50.3% of patients with iNPH exhibited a positive grasp reflex. Among these patients, 69% exhibited bilateral positivity, while the remaining patients showed unilateral positivity. Furthermore, the intensity of the grasp reflex was significantly correlated with the severity of gait and with cognitive, urinary, motor, and behavioural symptoms. Surgical interventions led to a reduction (41.7%) or maintenance (30.6%) of the reflex intensity in 72.3% of iNPH patients. The changes in reflex intensity showed significant positive correlations with changes in the number of steps of the Timed Up and Go test and Trail Making Test-A scores but not with changes in total scores on the iNPH Grading Scale.

CONCLUSION

This retrospective study identified grasp reflexes as a highly prevalent phenomenon in patients with iNPH. These reflexes can assist in evaluating the severity of various symptoms, including cognitive, gait, urinary, motor and emotional symptoms.

Pertussis and Rotavirus Vaccines - Controversies and Solutions

Pertussis and rotavirus vaccines have been the subject of several controversies over the years. In this paper the authors discuss facts and myths behind these controversies and also suggest solutions to overcome some limitations of these vaccines. The whole-cell pertussis vaccine (wPV) came into disrepute due to the associated adverse reactions, resulting in its replacement by acellular pertussis vaccine (aPV) in industrialized nations in 1990s. Although wPV is known to have more side effects; but they are usually minor. Whole-cell pertussis containing vaccine is being used safely in the National Immunization programme in India from many years. Another controversy erupted during 2009-2010, when there were reports of resurgence of pertussis cases among adolescents and adults, from developed nations. Present literature review raises doubts about long term protection offered by aPV, when compared with wPV. In spite of prevailing controversy, acellular pertussis containing vaccines should be acceptable, if timely delivery of primary and booster doses is ensured; including vaccination of adolescents and pregnant women. Initial rotavirus vaccine was withdrawn from the market because of increased risk of intussusception. Although three new generation rotavirus vaccines are currently available for use in India, but doubts about their efficacy, long term protection and safety still exists. Present literature review found them to be safe and moderately efficacious because of reasonable good cross protection. Even a moderately efficacious vaccine like rotavirus vaccine could significantly improve the outcome if disease burden is high. Therefore, it is being included in National Immunization Programme of India.

[Cortical Release Signs in Patients with Schizophrenia, Depressive Disorders, and Bipolar Affective Disorder]

BACKGROUND AND OBJECTIVES

Determining the presence of cortical release signs associated with white matter damage, is a clinically easy method to perform. The objective of this study is to determine the presence of cortical release signs in patients with mental illnesses and cerebrovascular disease, as well as its clinical usefulness, given that it indicates cortical damage.

MATERIAL AND METHODS

A review was made of cortical release signs in patients hospitalized in clinical psychiatry and general hospitals with bipolar affective disorder (40), depression (37), schizophrenia (33), cardiovascular disease (33) and dementia (37).

RESULTS

The signs of cortical release do not have the same importance as cortical damage. For example, the glabellar reflex was found in all the groups, that of paratonia, particularly in the group with schizophrenia, and others signs in the group of patients with dementia.

CONCLUSIONS

It is suggested that these signs imply subcortical white matter damage. The appearance of these signs shows the need for a follow up of patients diagnosed with bipolar affective disorder, depression and schizophrenia.

The grasp reflex: a symptom in need of treatment

The grasp reflex is one of the primitive reflexes frequently observed in neurodegenerative diseases. However, quality of life and treatment of the grasp reflex are neglected in the literature. Following two brief case vignettes of patients seen recently who experienced disability from a grasp reflex, we briefly review its phenomenology, anatomy-physiology and epidemiology in neurodegenerative movement disorders, and assess the limited current literature regarding the quality of life and treatment.

Potential Endophenotype for Schizophrenia: Neurological Soft Signs

Introduction: Neurological soft signs (NSS) are suggested as a candidate endophenotype for schizophrenia. This article aims to review relevant literature and discuss the role of NSS in understanding schizophrenia. Methods: This is an update on a review article published in 2003. Articles from 2003 onwards were specifically reviewed and discussed with relevance to the role of NSS as endophenotype for schizophrenia. Results: Consistent data suggest an excess of NSS in schizophrenic patients. NSS appear to be related to schizophrenic symptoms, in particular negative symptoms and disorganisation. Information on NSS and demographic correlates is scarce, and the confounding effects between age, education and intelligence on NSS constitute an important gap in current knowledge. Longitudinal data suggest NSS as both a trait and state variable in the course of disease. NSS are not specific with regard to diagnosis, although there are claims that individual sub-components may be more specific. The weight of evidence raises question on the specificity of NSS for schizophrenia. Conclusions: The usefulness and feasibility of NSS as a specific endophenotype target for schizophrenia is unclear. However, NSS remain an important feature and symptom correlate of schizophrenia. Future research should focus on delineating the effects of NSS from those of confounding demographic variables, and the stability of NSS over the course of illness to elucidate its role in schizophrenia. Key words: Diagnostic specificity, Neurological examination abnormalities, Psychotic symptoms, Review, Trait

Schizophrenia, "just the facts" 4. Clinical features and conceptualization

Although dementia praecox or schizophrenia has been considered a unique disease entity for the past century, its definitions and boundaries have continued to vary over this period. At any given time, the changing concept of schizophrenia has been influenced by available diagnostic tools and treatments, related conditions from which it most needs to be distinguished, extant knowledge and scientific paradigms. There is significant heterogeneity in the etiopathology, symptomatology, and course of schizophrenia. It is characterized by an admixture of positive, negative, cognitive, mood, and motor symptoms whose severity varies across patients and through the course of the illness. Positive symptoms usually first begin in adolescence or early adulthood, but are often preceded by varying degrees of negative and cognitive symptomatology. Schizophrenia tends to be a chronic and relapsing disorder with generally incomplete remissions, variable degrees of functional impairment and social disability, frequent comorbid substance abuse, and decreased longevity. Although schizophrenia may not represent a single disease with a unitary etiology or pathogenetic process, alternative approaches have thus far been unsuccessful in better defining this syndrome or its component entities. The symptomatologic, course, and etio-pathological heterogeneity can usefully be addressed by a dimensional approach to psychopathology, a clinical staging approach to illness course, and by elucidating endophenotypes and markers of illness progression, respectively. This will allow an approach to the deconstruction of schizophrenia into its multiple component parts and strategies to reconfigure these components in a more meaningful manner. Possible implications for DSM-V and ICD-11 definitions of schizophrenia are discussed.

Primitive reflexes and cognitive function

BACKGROUND: Data on the prevalence of primitive reflexes (PR) in adulthood, their pathological significance and relationship to age and cognition are controversial. OBJECTIVE: To study the relationship between PR and cognition in 30 patients with probable Alzheimer's disease (AD) and 154 control subjects. METHOD: Diagnosis of probable AD was based on DSM-IV, NINCDS-ADRDA, and CAMDEX criteria. Primitive reflexes were quantified from zero (absent) to 1 (mild) or 2 (markedly present). The Cognitive Abilities Screening Instrument - Short Form (CASI-S) was used to evaluate registration, temporal orientation, verbal fluency and recall. A drawing test was added. RESULTS: Most frequent PR among demented and controls were suck (77% and 62%, respectively) and snout (60% and 27%), followed by glabellar (30% and 19%), paratonia (37% and 5%), and palmomental (23% and 5%). None of controls had more than three PR. Frequency of PR tended to increase with age and cognitive deterioration. Grasp and Babinski responses were found only in dementia patients. Primitive reflexes were not correlated with each other, except snout with suck, and snout with glabellar reflex. CONCLUSION: The finding of grasp and Babinski sign, or the presence of more than three primitive signs, particularly the combination of paratonia, snout, suck, and palmomental reflexes strongly suggests brain dysfunction, especially when these signs are marked and accompanied by deficits in orientation, recall, verbal fluency, and constructional praxis.

Cortical release signs in psychiatry

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.

Molecular pathogenesis, epidemiology, and clinical manifestations of respiratory infections due to Bordetella pertussis and other Bordetella subspecies

Bordetella respiratory infections are common in people (B. pertussis) and in animals (B. bronchiseptica). During the last two decades, much has been learned about the virulence determinants, pathogenesis, and immunity of Bordetella. Clinically, the full spectrum of disease due to B. pertussis infection is now understood, and infections in adolescents and adults are recognized as the reservoir for cyclic outbreaks of disease. DTaP vaccines, which are less reactogenic than DTP vaccines, are now in general use in many developed countries, and it is expected that the expansion of their use to adolescents and adults will have a significant impact on reducing pertussis and perhaps decrease the circulation of B. pertussis. Future studies should seek to determine the cause of the unique cough which is associated with Bordetella respiratory infections. It is also hoped that data gathered from molecular Bordetella research will lead to a new generation of DTaP vaccines which provide greater efficacy than is provided by today's vaccines.

Crossed right hemisphere syndrome following left thalamic stroke

In most right-handed people, language and motor functions are more reliant on systems of the left hemisphere while several non-linguistic visuo-spatial and attentional processes depend more on the right hemisphere. The rare exceptions to these rules provide important clues as to what functions co-lateralise, and are thus crucial for models of cerebral specialization. Here we report on the case of a patient, who, after a lesion restricted to the left thalamic region, showed signs normally associated with right hemispheric injury including motor impersistence, visuo-spatial dysfunction and poor comprehension of facial expression. Language abilities were spared and no signs of apraxia were present, in spite of his right hand, foot and eye preference, a pattern normally associated with conventional cerebral dominance. In spite of his other right hemispheric signs, the patient showed no signs of hemi-spatial neglect. The patient's pattern of spared and impaired abilities is compared and contrasted with other rare cases of crossed right hemisphere syndrome.

Clinical implications of endotoxin concentrations in vaccines

BACKGROUND

A previous study suggested that high concentrations of endotoxin may be present in whole-cell diphtheria/tetanus/pertussis (DTP) vaccine, and the scientific literature contains many studies examining the reactivity of whole-cell DTP vaccine. The medical and scientific communities have previously reported that the presence of endotoxin in commercial vaccines may have negative effects on vaccine recipients.

OBJECTIVE

To determine the endotoxin concentrations in whole-cell DTP, acellular DTP(DTaP), and DT vaccines and determine the clinical experience with each vaccine.

METHODS

To study the endotoxin concentrations in vaccines, the Limulus amebocyte lysate (LAL) assay was used. The vaccines analyzed with the LAL assay were whole-cell DTP vaccine lots manufactured by Connaught, Lederle, the Michigan and Massachusetts Departments of Health, and Wyeth; DTaP vaccine lots manufactured by Merieux and Takeda; and DT vaccine lots manufactured by Wyeth and Lederle. The incidence of adverse reactions following whole-cell DTP, DTaP, and DT vaccines were determined based on analysis of the Vaccine Adverse Events Reporting System (VAERS) database.

RESULTS

The results of the LAL assay showed that whole-cell DTP vaccines contained considerably more endotoxin than either DTaP or DT vaccines. The VAERS showed that statistically significantly more adverse reactions were associated with whole-cell DTP vaccine than DTaP or DT vaccines.

CONCLUSIONS

This analysis confirmed higher concentrations of endotoxin in whole-cell DTP vaccines compared with DTaP or DT vaccines. As high concentrations of endotoxin may be correlated with a higher incidence of adverse events, the switch from whole-cell DTP to DTaP for routine vaccinations in the US seems well justified.

An analysis of the occurrence of convulsions and death after childhood vaccination

The association between the whole-cell diphtheria, tetanus, and pertussis (DTP) vaccine and the occurrence of convulsions and death has long been debated by the medical and scientific communities. A certified copy of the Vaccine Adverse Events Reporting System database was obtained from the Centers for Disease Control, and the data were analyzed using the Microsoft Access program. The results of this analysis reveal a statistically (p < .01) higher rate of occurrence of convulsions and death after whole-cell DTP vaccination than after acellular DTP and DT vaccination, showing, as do the previous findings of many other scientists, that acellular DTP vaccine is much less reactogenic than is whole-cell DTP vaccine. This study helps to validate the decision by American vaccine manufactures and the Food and Drug Administration to use only acellular DTP for the American childhood vaccination schedule. However, acellular DTP vaccine is still more reactogenic than is DT vaccine, probably because the pertussis component of most currently available acellular DPT vaccines contains toxoided pertussis toxin that has a significant rate of reversion to active toxin. This suggests the need to use the newer acellular pertussis vaccines, which are of higher purity and in which the reversion of the pertussis toxin is prevented.

Gait apraxia after bilateral supplementary motor area lesion

OBJECTIVES

The study aimed at addressing the issue of the precise nature of gait apraxia and the cerebral dysfunction responsible for it.

METHODS

The case of a patient, affected by a bilateral infarction limited to a portion of the anterior cerebral artery territory is reported. The patient's ability to walk was formally assessed by means of a new standardised test.

RESULTS

Due to an anomaly within the anterior cerebral artery system, the patient's lesion was centred on the supplementary motor regions of both hemispheres. He presented with clear signs of gait apraxia that could not be accounted for by paresis or other neurological deficits. No signs of any other form of apraxia were detected.

CONCLUSIONS

The clinical profile of the patient and the analysis of 49 cases from previous literature suggest that gait apraxia should be considered a clinical entity in its own right and lesions to the supplementary motor areas are responsible for it.

Effect of diabetes on some primitive reflexes

Primitive reflexes (PRs) are present in newborns; they disappear as the brain matures and increase in frequency in healthy elderly individuals. Primitive reflexes are more frequent in some neurological disorders than in age-matched controls. The aim of this study was to investigate the effect of diabetes on some PRs. We examined three PRs (glabellar tap, snout and palmomental reflexes) in 376 subjects: 111 normal age-matched controls, 60 patients with cerebrovascular disease (CVD) and 205 patients with type 2 diabetes mellitus. The latter patients were divided into three groups: (1) diabetics without neurological complications (D); (2) diabetics with cerebrovascular disease (D-CVD); and (3) diabetics with polyneuropathy (D-PN). The frequency of PRs was increased in CVD, unchanged in D-CVD (except palmomental) and greatly reduced in D and D-PN. It is possible that the vascular lesions in perforating arteries of the pons in diabetic subjects, previously studied in some pathological reports, can account for the reduced occurrence of primitive reflex responses.

Differences in Neuropsychological Functioning Associated With Age, Education, Neurological Status, and Magnetic Resonance Imaging Findings In Neurologically Healthy Elderly Individuals

In a cross-sectional study, a sample of 113 individuals, 55 to 85 years old, without any neurological diseases was investigated. The study provides information on differences associated with age, education, and gender, and in relation to neurological status, magnetic resonance imaging, and cognitive functioning. Differences between age groups were shown in memory, constructional, and language functions, and especially in tests related to speed and attention. Education was related to most of the cognitive functions, but especially to verbal intellectual functions, visual and logical memory, language functions, and calculation. Gender differences were found in finger tapping, constructional functions, and verbal intellectual functions. Primitive reflexes showed a tendency to correlate with comprehension and memory of sentences. Extrapyramidal signs were related to psychomotor speed, and attention, verbal fluency, and set shifting together with intellectual functions and learning. Central atrophy on magnetic resonance imaging was related to memory functions in those 65 and 70 years of age, whereas in the oldest age groups immediate recall was associated with the severity of lesions.

Positive and negative factors in movement control: a current review of Denny-Brown's hypothesis

In his extensive writings, Denny-Brown hypothesized that two competitive 'tropisms,' one positive (exploratory) and one negative (withdrawal) act to coordinate normal movements at all levels of the neuraxis. Lesions in particular areas of the central nervous system result in disequilibrium between these tropisms, leading to disorders of posture and movement, including involuntary movements. The tactile manifestations of unbalanced exploratory tropisms are grasping responses, whereas the complementary withdrawal tropisms are avoiding responses. In Denny-Brown's view, at the level of the cerebral cortex, grasping responses result from frontal lobe injury whereas avoiding responses result from parietal lobe lesions. In this report we review Denny-Brown's conceptions of positive and negative tropisms, their anatomical loci, and whether his hypothesis has merit in a contemporary approach to brain function. We find that Denny-Brown's view on the anatomical loci associated with these behaviors is incomplete, but that the idea of conflicting behavioral tendencies is valuable for understanding and managing some neurological and perhaps also psychiatric disorders. For example, his hypothesis offers an important perspective in understanding the paradoxical success of stereotaxic surgery to alleviate the symptoms of Parkinson's disease.

On crossed apraxia. Description of a right-handed apraxic patient with right supplementary motor area damage

GP, a right-handed woman, without evidence of familial left-handedness, showed clearcut bilateral ideo-motor apraxia and oro-facial apraxia after a vascular lesion of the right hemisphere, encroaching upon the fronto-mesial region. She scored normally in most other cognitive tests, including language, but showed signs of callosal disconnection, left anarchic hand and mild unilateral spatial neglect. This cognitive profile points to the possibility of praxis being localized to the right hemisphere in this right-handed patient. We argue in favour of individual variability of praxis dominance, and maintain that this dominance might be completely right-sided in some subjects. Moreover the anatomical locus of GP's lesion points to the possible role that the frontal lobes (and more specifically the Supplementary Motor Area) play in the genesis of apraxia.

The snout and palmomental reflexes in HIV disease in Tanzania

Following earlier observations on the snout (SR) and palmomental(PMR) reflexes in AIDS in Tanzania, a series of 1127 adults, 649 HIV-positive and 478 HIV-negative, from 4 groups at different risk of HIV infection were examined neurologically between 1987 and 1992. The prevalence of SR and PMR was calculated according to HIV status, HIV stage, demographic factors and neurologic findings. In the total series of HIV positives the prevalence ranged from SR 39.3% and PMR 22.6% in asymptomatic HIV disease to SR 87% and PMR 69% in terminal AIDS. In HIV negatives the prevalence of SR was 19.2% and PMR 15.3%, and increased with age. There was no relationship with age in the HIV positives and no gender differences. SR and PMR were also associated with neuropathy, myelopathy and AIDS dementia complex independent of HIV stage. This study shows a strong association between SR and PMR and HIV disease in Africa. The prevalence increased with HIV stage and related neurological disorders.

Primitive reflexes in Alzheimer's disease and vascular dementia

Data on the prevalence and clinical value of primitive reflexes (PRs) in dementia are controversial, mainly due to a lack of standardization of the methods by which these signs are elicited and scored. A standardized protocol was used to investigate eight PRs in 20 patients with Alzheimer's disease (AD), 20 patients with vascular dementia (VD), and 20 control subjects for each group. Both patient groups showed considerably more PRs than the control groups. The prevalence of PRs was related to the severity of dementia. No single reflex or combination of PR pathognomonic for dementia could be distinguished. The PR profile of AD and VD patients were similar.

The Cambridge Neurological Inventory: a clinical instrument for assessment of soft neurological signs in psychiatric patients

A schedule (the Cambridge Neurological Inventory) has been constructed for standardized neurological assessment of psychiatric patients. Normative data and data resulting from its application to a group of patients with schizophrenia are reported. The instrument is comprehensive, reliable, and easy to administer. In conjunction with other forms of clinical assessment, it may be useful for identifying soft neurological signs and other patterns of neurological impairment relevant to neurobiological localization and prognosis in schizophrenia and other psychiatric disorders.

Blinking and the release reflexes: are they clinically useful?

OBJECTIVE

To review the clinical utility of blinking and the release reflexes, palmomental, glabellar, grasp, and snout, as an important part of the bedside neurological examination.

DESIGN

Articles published from 1966 to 1993 that addressed blinking or the release reflexes were identified by searching the MEDLINE database. Thirty-seven references provided clinically useful and applicable information.

RESULTS

There is controversy regarding the optimal method of clinical elicitation of these reflexes. The release reflexes are frequently seen as an incidental abnormality in the elderly. A positive grasp reflex, especially if asymmetrical, is sensitive but not specific for abnormal brain function. Lack of habituation is more important than the mere presence or absence of a reflex. The brainstem circuits involved in the regulation of blinking and the release reflexes are discussed, as are their abnormalities in a variety of clinical settings.

CONCLUSION

Blinking and the release reflexes have clinical utility in the diagnosis and bedside clinical assessment of diseases as diverse as frontal lobe lesions, hydrocephalus, multiple sclerosis, Parkinson's disease, Alzheimer's disease and other dementias, falls in the elderly, ageing, HIV-encephalopathy, schizophrenia, tumors in the region of the sylvian aqueduct and recovery from head trauma.

Age-related changes in the neurologic examination of healthy sexagenarians, octogenarians, and centenarians

Although numerous studies have focused on age-related changes in the nervous system, few have systematically assessed global neurologic examination changes, and even fewer have included the most elderly population, ie, the centenarians. To perform such a study, we developed a quantitative assessment that includes the major components of a standard bedside neurologic evaluation, with special emphasis on cognitive function. First, we demonstrated that the quantitated examination could correctly classify healthy controls and patients with stroke or dementia based on discriminant analysis. This examination was then applied to healthy community-dwelling elderly ranging from 60 to 108 years of age. Significant age-related neurobehavioral changes were apparent across even these most "successfully" aged groups. Analysis of the full pattern of cognitive and neurologic findings provided the most accurate assessment. Pathologic reflexes, reportedly associated with normal aging, occurred infrequently in this healthy geriatric population, suggesting that age-related changes in the neurologic examination may be more accurately interpreted when assessed in conjunction with cognitive status. This quantitative examination may be useful in future population-based studies of neurologic function in the aged.

Frontal Release Signs and Their Relationship With the Initiation and Perseveration Component of the Mattis Dementia Rating Scale in Persons With Dementia

As part of a longitudinal study of dementia, 35 elderly patients with dementia were studied, correlating frontal release signs and performance on components of the Mattis Dementia Rating Scale. A frontal release score was developed using glabellar, palmar grasp, plantar grasp, and palmomental signs. There was a direct relationship between the frontal release score and the Initiation and Perseveration component of the Mattis Dementia Rating Scale. This relationship persisted between isolated glabellar sign findings and the Initiation and Perseveration component of the Mattis Dementia Rating Scale. These findings are highly preliminary. Refining frontal release sign testing and frontal lobe mental status testing may strengthen their relationship and lead to a better understanding of dementia and its progression.

Primitive reflexes in healthy, adult volunteers and neurological patients: methodological issues

A study was made to determine whether two experienced clinicians elicited and scored primitive reflexes (PR) differently and whether reliability could be improved by standardization. Three studies were carried out, using a protocol for the examination of 14 PR. In the first study with 31 healthy young subjects, two investigators found virtually no difference in the routine neurological examination. However, the interobserver agreement was very poor, indicating the need for a further improvement of the PR protocol. In the second study, 30 neurological patients were examined with an improved, more explicit and standardized protocol, in which the amplitude and the persistence of the reflex were scored separately. Interobserver agreement improved considerably, and was high for amplitude as well as persistence. In the third study, 36 neurological patients were examined twice by one investigator within 2 weeks. Good to excellent intraobserver agreement was found. No pathognomonic or strictly localizing reflex could be distinguished.

Release signs in Parkinson's disease with and without dementia

Release signs have been described in both age-associated diseases and in the healthy elderly. We investigated the palmomental, snout, grasp, corneomandibular and glabellar reflexes in demented and non-demented Parkinson-patients compared to Alzheimer's disease and age-matched controls. The palmomental reflex and a persisting glabellar reflex were linked to parkinsonism irrespective of dementia and were found also in Alzheimer's disease. A corneomandibular reflex was observed more frequently in demented than non-demented Parkinson-patients and in Alzheimer's disease. The snout-reflex was present in nearly all individuals irrespective of diagnosis. Thus, various release signs react quite differentially to degenerative brain disease and dementia.

Clinical significance of primitive reflexes in Alzheimer's disease

STUDY OBJECTIVE

To establish the relationship between cognition, behavior, function, and clinical characteristics on the one hand, and the presence of primitive reflexes (PR) (pout, snout, palmomental and grasp) in patients with Alzheimer's disease (AD).

DESIGN

Cross-sectional survey.

SETTING

Secondary care geriatric practice specializing in the assessment of cognitive impairment.

SUBJECTS

136 consecutive patients presenting with AD.

MEASUREMENTS

PR were assessed in standardized fashion by a single clinician. Cognitive function was measured using the Standardized Mini-Mental Status Examination, activities of daily living (ADL) and instrumental activities of daily living (IADL) were measured using the Lawton scale, and behavior was measured using the Behavioural Problem Checklist.

RESULTS

There was no difference in age or duration of dementia in those with and without PR, nor was there any difference in cognitive function. Despite this, patients with PR showed a greater degree of functional limitation and dysfunctional behavior. There was also a higher incidence of rigidity, gait abnormalities, and apraxia in patients with PR.

CONCLUSIONS

Patients with primitive reflexes had more severe impairment in ADL function and dysfunctional behavior for an equal level of cognitive function.

Extrapyramidal signs, primitive reflexes and frontal lobe function in senile dementia of the Alzheimer type

Of 146 elderly subjects suffering from Alzheimer-type dementia, 44% were found to have significant extrapyramidal signs. Although extrapyramidal signs were more common in those who had taken neuroleptic drugs in the preceding six months, 22 subjects (15%) who were drug free also had extrapyramidal signs. Scores for cognitive function and for 'frontal lobe' signs (verbal fluency, evidence of perseveration, and primitive reflexes) were found to correlate well with scores for extrapyramidal signs, suggesting that they reflect changes in a common substratum. It is tentatively suggested that this might be an abnormality in the dopamine system.

The relationship of negative schizophrenia to parkinsonism

The positive-negative distinction of schizophrenia has emerged as a valid means of clarifying its heterogeneity. Despite evidence that the two symptom classes may reflect different dimensions of the disease, there is presently no integrated model for understanding of the pathophysiology of these symptoms and their co-occurrence in schizophrenia. We propose that negative phenomena of schizophrenia may be a variant of Parkinsonism. This view is supported by the overlap with Parkinsonism in terms of clinical features, neurochemistry, pharmacology, as well as neuroradiological and neuropathological aspects. As such, negative symptoms may be a manifestation of disease of the basal ganglia and constitute the core pathology in schizophrenia. Positive symptoms, conversely, may reflect an "accessory" process related to a compensatory increase in striatal and limbic dopamine activity following an injury to the dopaminergic system. In the present communication we present a series of studies that support the association of negative schizophrenia and Parkinsonism. Based on this evidence, we suggest that schizophrenic patients with prominent negative symptoms might be managed like patients with Parkinson's disease, namely, with dopaminergic drugs and MAO-B inhibitors. Finally, the association of negative schizophrenia with Parkinsonism raises the possibility that adrenal medullary tissue transplantation, which may benefit a selected group of Parkinsonian patients, may be a future promising therapy for refractory negative schizophrenia.

Early neurological abnormalities following coronary artery bypass surgery. A prospective study

A prospective analysis of 78 patients undergoing coronary artery bypass surgery (CABS) was carried out to assess clinically the frequency and course of cerebral complications during the 1st postoperative week. Detailed evaluation of the patients showed that neurological abnormalities after CABS were common, occurring in 40 of the 78 patients (51%). However, there were no serious cerebral complications. Changes in reflexes and new focal signs were found in 26 and 25 cases respectively; in 7 patients (9%) they were confined to the first postoperative days. There was no statistically significant correlation between postoperative outcome and age, preoperative neurological state or bypass time. However, some strong associations could be calculated between a history of cerebrovascular signs or symptoms and the appearance of persisting focal signs or development reflexes during the 1st week after CABS.

Psychiatry and the frontal lobes

The frontal lobes of the brain have long been regarded as enigmatic in their function and perhaps should be considered even more so in states of dysfunction. Observed associations between structural lesions and psychiatric symptoms and the demonstration of disturbed function and morphology in the frontal lobes of individuals suffering from major psychiatric disorders have led to increased interest in this brain area. Psychiatrists have been particularly concerned with seeking the aetiogenesis of common diagnostic entities and this article attempts to synthesize the available facts. A brief overview of relevant biological data precedes a description of methods of neuropsychological testing and the clinical features arising from frontal lobe damage. A discussion of the role of the frontal lobes in some aspects of personality function follows. Neuropsychiatric features associated with known frontal lobe pathology are described, prefacing a discussion of those psychiatric conditions where an aetiological role for frontal lobe dysfunction has been proposed.

Acquired cognitive disorders of the elderly

Many gaps still exist in our understanding of the etiology and the management of dementing disorders. However, there are fairly well established guidelines for the clinical diagnosis of Alzheimer's disease, the major cause of acquired cognitive disorders in the elderly. The management of patients with dementing disorders should involve the entire family. The medical needs pale beside the functional and psychosocial issues. Therefore, a multidisciplinary approach in a team setting is ideal, where goals can be established and coordinated and communication with the family, patient, and consultants can be facilitated. Patients and family members need to know that life beyond the diagnosis can be meaningful. With the help of support groups, they learn to maximize the positive aspects and can cope with the struggle ahead. It should not be forgotten, however, that not all families had good relationships before the onset of the decline and often are in great need of counseling to manage the anger and guilt they will often experience. Future research is needed not only on the search for better medical treatments but also on the establishment of guidelines for the physician and family to deal with complex social issues such as when one is no longer safe to drive an automobile. Prospective studies on victims of head injury could establish the link of trauma to Alzheimer's disease, that has been proposed. The role of physicians in public policy for prevention of high risk behaviors (such as boxing) is controversial, but at the very least, physicians should play a major role in educating their patients of these dangers. Because of the rapid aging of our population, pressure for research and policy changes in national health and long term care financing has been growing, largely due to the impressive efforts of the Alzheimer's Association. In order to give the kind of attention that is required in the care of these patients, there must be a change in the present system of reimbursement. This will never happen, unless it can be demonstrated that lower costs of health care can be achieved by anticipating the needs of these patients and their families. It is quite possible that costs can be reduced by delaying the need for nursing home placement or decreasing utilization of emergency medical care and hospitalization. However, these assumptions must be investigated further.

Relationship between primitive reflexes, extra-pyramidal signs, reflective apraxia and severity of cognitive impairment in dementia of the Alzheimer type

Controversy exists in the literature about the significance of primitive reflexes (PR) and extrapyramidal signs (EP) as diffuse cortical dysfunction signs and their relationship to age and cognitive impairment. A sample of 91 patients with a dementia of the Alzheimer type were examined with a standardized technique to assess the relationship between the finding of PR, EP and severity of cognitive impairment measured by Mini-Mental Status Examination. The value of a short cognitive test, the reflective apraxia (i.e. imitation of meaningless gestures), were also assessed. A significantly lower MMS score was correlated with the number of present PR and with presence of snout, sucking and grasping reflexes. No correlation was found between presence or absence of PR and age, depression, or drug therapy. EP score was correlated with the number of present PR and MMS, but not with age. Reflective apraxia score was significantly correlated with the degree of cognitive impairment and was found with lower cognitive impairment than PR.

Risk of sudden infant death syndrome after immunization with the diphtheria-tetanus-pertussis vaccine

To evaluate recent immunization against diphtheria, tetanus, and pertussis (DTP) as a possible risk factor for sudden infant death syndrome (SIDS), we studied the rates of SIDS after the administration of DTP vaccine in a cohort of 129,834 children who were born in four urban Tennessee counties during the period from 1974 through 1984. All the children received at least one DTP immunization in the first year of life at county health-department clinics or from Medicaid providers. Computerized immunization records from these sources were linked with Tennessee birth and death certificates to establish the cohort, ascertain the timing of immunization, and identify cases of SIDS. These children represented 42 percent of the births in the four counties. Among these children, 204 deaths occurred at the ages of 29 to 365 days; 109 deaths were classified as due to SIDS. We estimated the risk of SIDS according to the length of time, up to 30 days, since DTP immunization and compared it with the risk 31 days or more after immunization to calculate the relative risk. With control for age, the relative risk from 0 to 3 days after DTP immunization was 0.18 (95 percent confidence interval, 0.04 to 0.8); from 4 to 7 days, 0.17 (95 percent confidence interval, 0.04 to 0.7); from 8 to 14 days, 0.75 (95 percent confidence interval, 0.4 to 1.5); and from 15 to 30 days, 1.0 (95 percent confidence interval, 0.6 to 1.6). A multivariate analysis in which we controlled for age, sex, race, year, birth weight, and Medicaid enrollment, produced similar results. We conclude that in this large population of children there was no increase in the risk of SIDS after immunization with the DTP vaccine.

Odd man out: a graphical approach to meta-analysis

The areas of overlap of confidence intervals from several studies can be used to create summary confidence regions. These summary regions lend themselves to graphical display, have readily derivable statistical properties, and can carry information about the influence both of available studies and of hypothetical future investigations. The case of a region covered by at least N-1 out of N confidence intervals is presented in some detail.

The association of gegenhalten in the upper limbs with dyspraxia

Ten patients with gegenhalten of the upper limb of mixed aetiology were studied, in nine of whom an association with dyspraxia was found. In four of the patients, the rigidity became more pronounced after the instruction to relax, and only one patient showed improvement after this instruction. In these patients, the resistance to movement, evident as gegenhalten, may be a direct consequence of the dyspraxia.

The role of clinical neuropsychology in the neurological diagnosis of Alzheimer's disease

This survey on the early diagnosis of Alzheimer's disease (AD) reinstates the role of clinical neuropsychology in describing the cognitive status of AD and its evolution. The role of clinical neuropsychology is restricted to the clinical diagnosis of organic mental deterioration and its contribution to the diagnosis of AD is separate from that of neurology and neuroradiology. The frequency of a single neuropsychological disturbance in early AD patients is illustrated by our own observations.

Primitive (developmental) reflexes and diffuse cerebral dysfunction in schizophrenia and bipolar affective disorder: overrepresentation in patients with tardive dyskinesia

Primitive (developmental) reflexes are present in fetal and infant life, but disappear in adulthood. Their elicitation in later life usually occurs in association with cortical or diffuse cerebral dysfunction and suggests a new approach to the issue of whether tardive dyskinesia is particularly likely to occur in patients with organic brain disorder(s). Sixty-six patients with schizophrenia (age range 50-86) and 18 with bipolar affective disorder (age range 40-77) were assessed for the presence of involuntary movements and for the release of the grasp, palmomental, snout, corneomandibular, and glabellar reflexes. In each diagnostic group, patients with involuntary movements showed a significant excess of primitive reflexes in comparison with otherwise indistinguishable patients without such movements. These results complement recent reports that similar patients with involuntary movements also show greater cognitive impairment and point anew to an association between the presence of tardive dyskinesia and of organic brain dysfunction. They raise again the issue of whether or not such dysfunction may be a consequence of neurodevelopmental abnormality rather than of neurodegenerative processes.

Cerebral complications of coronary by-pass surgery. A prospective study

A prospective study was undertaken of cerebral complications in 91 patients undergoing coronary by-pass surgery. Patients showing clinically relevant neurological complications had longer pump-times but did not differ in pre-operative variables. Worsening of neurological state correlated with duration of pump-time but not with pre-operative variables. Duration of pump-time appears to be the main predictor of neurological complications after coronary by-pass surgery.

Diphtheria-tetanus-pertussis immunization and sudden infant death syndrome

We compared the recency of diphtheria-tetanus-pertussis (DTP) immunization in healthy children with birthweights greater than 2500 gms who died of sudden infant death syndrome (SIDS) to that of age-matched reference children, using a modified case-control analysis. Focusing on very narrow time intervals following immunization, we found the SIDS mortality rate in the period zero to three days following DTP to be 7.3 times that in the period beginning 30 days after immunization (95 per cent confidence interval, 1.7 to 31). The mortality rate of non-immunized infants was 6.5 times that of immunized infants of the same age (95 per cent CI, 2.2 to 19). The latter result and to some extent the former appear to be ascribable to known risk factors for SIDS. Although the mortality ratios for SIDS following DTP, as estimated from this study, are high the period of apparently elevated risk was very short, so that only a small proportion of SIDS cases in infants with birthweights greater than 2500 gms could be associated with DTP.

Neurological abnormalities associated with severity of dementia in Alzheimer's disease

Abnormal findings on neurological examination were evaluated in 165 patients with a clinical diagnosis of Alzheimer's disease who attended a memory disorders clinic. Severity of dementia was measured by the Blessed Dementia Scale, and associations of abnormalities with dementia severity were evaluated using logistic regression. Presence of aphasia, apraxia, and primitive reflexes on neurological examination were strongly associated with severity, and weak associations were observed for abnormalities of muscle tone and gait. Among these associated neurological features, only aphasia and apraxia were present in mildly demented cases with sufficient frequency to suggest utility as diagnostic signs early in the course of the disease.

Relationship between primitive reflexes and severity in Parkinson's disease

The reliability of primitive reflexes as monitors of dementia, depression, and severity of Parkinson's disease were studied. The results indicated that the proportion of certain reflexes increased with severity of disease and cognitive impairment, but no relationship was seen between any of the reflexes and degree of depression.

Cerebral blood flow decrements in chronic head injury syndrome

Global and regional cerebral blood flow (CBF) has been reported to be decreased immediately after head injury. Since neuropsychological deficits in patients with chronic head injury syndrome persist long after the initial trauma, we studied CBF, which reflects cerebral metabolism and activity, and evaluated the results of neuropsychological tests in 12 alert, responsive patients aged 18-26, both 2-13 months after head injury and 1-12 months after they regained consciousness. Global CBF was significantly decreased in patients with head injury relative to age-matched normal controls. Four patients had well-localized injury; in three of these, CBF over the affected region was significantly decreased relative to the same region in the opposite hemisphere and relative to the same region in an age-matched normal control. In one patient with right frontal injury, cognitive improvement on repeat testing was associated with a relative increase in right frontal CBF. The remaining eight patients had diffuse bilateral injury. Asymmetry ratios (larger value of mean hemispheric CBF divided by the smaller) were significantly higher for the group with localized dysfunction (1.2 +/- 0.08 vs. 1.0 +/- 0.01, p less than 0.01), suggesting homolateral decrease in CBF in this group. Three patients with diffuse injury underwent repeat studies 5-14 weeks later; all improved on psychological tests, and two had a significant increase in global CBF. These results suggest that the chronic sequelae of head injury include decreased CBF, presumably reflecting decreased cerebral metabolism, which correlates with the neuropsychological impairment.