Does stroke laterality predict major depression and cognitive impairment after stroke? Two-year prospective evaluation in the EMMA study.

Depression and cognitive impairment are common conditions following stroke. We aimed to evaluate stroke laterality as predictor of post-stroke depression (PSD) and cognitive impairment (PCI) in a stroke cohort. Major depression (Patient Health Questionnaire-9, score ≥ 10) and cognitive impairment (Modified Telephone Interview for Cognitive Status, score < 14) were evaluated at 6 months and yearly up to 2 years. Survival analyses were performed by Kaplan-Meier curves and Cox logistic regression models, adjusted for potential confounders (cumulative hazard ratio, HR; 95% confidence interval, CI), for the likelihood of subsequent PSD or PCI progression at 6 months and 2 years, according to stroke laterality (right hemisphere-reference). Among 100 stroke patients, we found 19% had PSD and 38% had PCI 2 years after stroke. Most participants (53%) presented right-sided stroke. However, right-sided stroke was not associated with PSD or PCI. Overall, left-sided stroke was an independent and long-term predictor of PCI, but not of major depression. Left-sided stroke was associated with a high probability of PCI (42.6% and 53.2%, respectively at 6 months and 2 years, p-log-rank: 0.002). The HR of PCI due to left-sided stroke was 3.25 (95%CI, 1.30-8.12) at 6 months and remained almost the same at 2 years (HR,3.22;95%CI, 1.43-7.28). The risk of having worse cognition status increased by >3 times, 2 years after stroke. The results support the hypothesis that involvement of networks in the left, but not in the right hemisphere, contribute to long-term cognitive impairment. Lesion laterality did not influence the risk of PSD.

Post-stroke depression and cognitive impairment: Study design and preliminary findings in a Brazilian prospective stroke cohort (EMMA study).

BACKGROUND: Post-stroke depression (PSD) and cognitive impairment (PCI) are common conditions. This study aims to describe the protocol and preliminary findings of an investigation into factors associated with PSD and PCI 1-3 months after stroke (subacute phase) in survivors from the Study of Stroke Mortality and Morbidity (EMMA study). METHODS: Stroke patients underwent to clinical and neurological evaluations on admission to hospital. Cerebral magnetic resonance and biomarkers (serotonin, BDNF, IL-6 and IL-18) were carried out in the subacute phase. DSM-IV major depression for the diagnosis of PSD, cognitive functioning for the diagnosis of PCI and functional disability were also recorded at same time. RESULTS: Of the 103 eligible patients, 85.4% had ischemic stroke and 73.7% had first-ever stroke. In the subacute phase, 27.2% had PCI and 13.6% had current PSD (5.8% with 'first episode' and 7.8% with 'recurrent' depression). PCI was associated with low education (0-7 years of formal education: 75%) and ageing (median age: 70; interquartile range: 59-75 y-old). Left-sided stroke was more frequently associated with increased PCI than right-sided stroke (71.4% vs. 28.4%, p = 0.005). PSD was neither associated with stroke laterality nor tentorial area. Overall, biomarkers levels were not alterated in patients with PSD and PCI. LIMITATIONS: Findings are based on small sample and less disabled stroke participants, e.g. those without aphasia and deafness. CONCLUSIONS: Findings reinforce the need of early recognition and rehabilitation of PCI and PSD, mainly among those less educated and with left-sided stroke. PSD might occur through a pathophysiological pathway other than classical depression.

Validation of the Brazilian-Portuguese version of the Modified Telephone Interview for cognitive status among stroke patients.

AIMS: To examine the psychometric properties of the Brazilian version of the Modified Telephone Interview for Cognitive Status (TICS-M) for cognitive impairment in post-stroke patients from the Stroke Mortality and Morbidity Study. METHODS: The original version of the TICS-M was translated and adapted into Brazilian-Portuguese language in 30 non-clinical subjects. After that, two trained researchers applied the TICS-M in 73 stroke participants from the Stroke Mortality and Morbidity Study; however, 12 carried out only the first evaluation and 61 participants completed the follow up: (i) personal interview 6 months after stroke; (ii) telephone interview 1 week after the first evaluation; and (iii) telephone interview 2 weeks after the first evaluation. The reliability of the TICS-M was calculated by test-retest Pearson's correlation, intraclass correlation and Cronbach's alpha coefficient in 61 participants. Also, using data from the same participants, we carried out the analysis of the receiver operating characteristics curve using the Mini-Mental State Examination as a comparison. The structural validity of the TICS-M was assessed through principal components analysis in 103 individuals (30 non-clinical and 73 stroke patients). RESULTS: Test-retest reliability and intraclass correlation ranged from 0.87 to 0.97 across the evaluations. The Cronbach's alpha was 0.96. Principal components analysis extracted three meaningful domains: working memory, recall memory and orientation. The best cut-off point to screen cognitive impairment was 14 out of 15 (91.5% sensitivity, 71.4% specificity). The area under the curve was 0.89. CONCLUSIONS: The Brazilian version of the TICS-M has been found to be a reliable, stable and homogeneous instrument to screen cognitive impairment in stroke patients.

The sertraline vs. electrical current therapy for treating depression clinical study: results from a factorial, randomized, controlled trial.

IMPORTANCE: Transcranial direct current stimulation (tDCS) trials for major depressive disorder (MDD) have shown positive but mixed results. OBJECTIVE: To assess the combined safety and efficacy of tDCS vs a common pharmacological treatment (sertraline hydrochloride, 50 mg/d). DESIGN: Double-blind, controlled trial. Participants were randomized using a 2 × 2 factorial design to sertraline/placebo and active/sham tDCS. SETTING: Outpatient, single-center academic setting in São Paulo, Brazil. PARTICIPANTS: One hundred twenty antidepressant-free patients with moderate to severe, nonpsychotic, unipolar MDD. INTERVENTIONS: Six-week treatment of 2-mA anodal left/cathodal right prefrontal tDCS (twelve 30-minute sessions: 10 consecutive sessions once daily from Monday to Friday plus 2 extra sessions every other week) and sertraline hydrochloride (50 mg/d). MAIN OUTCOME MEASURES In this intention-to-treat analysis, the primary outcome measure was the change in Montgomery-Asberg depression rating scale score at 6 weeks (end point). We considered a difference of at least 3 points to be clinically relevant. The analysis plan was previously published. Safety was measured with an adverse effects questionnaire, the young mania rating scale, and cognitive assessment. Secondary measures were rates of clinical response and remission and scores on other scales. RESULTS: At the main end point, there was a significant difference in Montgomery-Asberg depression rating scale scores when comparing the combined treatment group (sertraline/active tDCS) vs sertraline only (mean difference, 8.5 points; 95% CI, 2.96 to 14.03; P = .002), tDCS only (mean difference, 5.9 points; 95% CI, 0.36 to 11.43; P = .03), and placebo/sham tDCS (mean difference, 11.5 points; 95% CI, 6.03 to 17.10; P < .001). Analysis of tDCS only vs sertraline only presented comparable efficacies (mean difference, 2.6 points; 95% CI, -2.90 to 8.13; P = .35). Use of tDCS only (but not sertraline only) was superior to placebo/sham tDCS. Common adverse effects did not differ between interventions, except for skin redness on the scalp in active tDCS (P = .03). There were 7 episodes of treatment-emergent mania or hypomania, 5 occurring in the combined treatment group. CONCLUSIONS AND RELEVANCE: In MDD, the combination of tDCS and sertraline increases the efficacy of each treatment. The efficacy and safety of tDCS and sertraline did not differ. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT01033084.

Sertraline vs. ELectrical Current Therapy for Treating Depression Clinical Trial--SELECT TDCS: design, rationale and objectives.

BACKGROUND: Despite significant advancements in psychopharmacology, treating major depressive disorder (MDD) is still a challenge considering the efficacy, tolerability, safety, and economical costs of most antidepressant drugs. One approach that has been increasingly investigated is modulation of cortical activity with tools of non-invasive brain stimulation - such as transcranial magnetic stimulation and transcranial direct current stimulation (tDCS). Due to its profile, tDCS seems to be a safe and affordable approach. METHODS AND DESIGN: The SELECT TDCS trial aims to compare sertraline vs. tDCS in a double-blinded, randomized, factorial trial enrolling 120 participants to be allocated to four groups to receive sertraline+tDCS, sertraline, tDCS or placebo. Eligibility criteria are moderate-to-severe unipolar depression (Hamilton Depression Rating Scale >17) not currently on sertraline treatment. Treatment will last 6weeks and the primary outcome is depression change in the Montgomery-Asberg Depression Rating Score (MADRS). Potential biological markers that mediate response, such as BDNF serum levels, Val66Met BDNF polymorphism, and heart rate variability will also be examined. A neuropsychological battery with a focus on executive functioning will be administered. DISCUSSION: With this design we will be able to investigate whether tDCS is more effective than placebo in a sample of patients free of antidepressants and in addition, we will be able to secondarily compare the effect sizes of sertraline vs. tDCS and also the comparison between tDCS and combination of tDCS and sertraline.

Mulheres guerreiras: identidade feminina e profissional entre vendedoras ambulantes da cidade de São Paulo / Female warriors: feminine identity and occupational identity among street vendors in the city of São Paulo

Este artigo se originou de uma pesquisa qualitativa realizada por meio de entrevistas semi-abertas com 20 mulheres vendedoras ambulantes da cidade de São Paulo. A pesquisa buscou investigar como se articulam as questões de trabalho e de gênero entre estas mulheres, a partir do referencial da identidade na Psicologia Social. Os resultados mostraram que o comércio ambulante aparece para elas como alternativa ao desemprego. Como em outras atividades do setor autônomo da economia, há entre elas constante sub-remuneração, implícita na elevada carga horária e no emprego de familiares no preparo das mercadorias a serem vendidas: geralmente comida em suas diversas formas. A produção de comida mostrou uma relação de continuidade com as representações de feminilidade mais comuns em nossa sociedade. Sua comercialização nas ruas, porém, implica em um rompimento com as prescrições de gênero na cultura brasileira, que associam a rua a um lugar masculino. As consequências da opressão de classe e de gênero em relação a estas mulheres mostraram a necessidade de incentivo ao cooperativismo entre elas, possibilitando um enfrentamento desta opressão.

This paper is the result of a qualitative survey conducted among twenty female street vendors in the city of São Paulo. The survey sought to investigate how issues of work and gender are articulated among these women, on the basis of perspectives of identity in Social Psychology. The results showed that street commerce appears to them as an alternative to unemployment. As with others who are self-employed, these women are subject to constant underpayment, which is implicit in the long hours worked and the engagement of relatives in preparing items for sale - usually food in various forms. Food preparation exhibits continuity with the most common representations of femininity in Brazilian society. But selling food in the street entails a break from gender roles in Brazilian culture, which looks upon the street as a place for men. The consequences of class and gender oppression for these women demonstrate the need to provide incentives for them to set up cooperatives among themselves, to allow them to confront such oppression.