NMDA receptor-related mechanisms of dopaminergic modulation of tDCS-induced neuroplasticity.

Dopamine is a key neuromodulator of neuroplasticity and an important neuronal substrate of learning, and memory formation, which critically involves glutamatergic N-methyl-D-aspartate (NMDA) receptors. Dopamine modulates NMDA receptor activity via dopamine D1 and D2 receptor subtypes. It is hypothesized that dopamine focuses on long-term potentiation (LTP)-like plasticity, i.e. reduces diffuse widespread but enhances locally restricted plasticity via a D2 receptor-dependent NMDA receptor activity reduction. Here, we explored NMDA receptor-dependent mechanisms underlying dopaminergic modulation of LTP-like plasticity induced by transcranial direct current stimulation (tDCS). Eleven healthy, right-handed volunteers received anodal tDCS (1 mA, 13 min) over the left motor cortex combined with dopaminergic agents (the D2 receptor agonist bromocriptine, levodopa for general dopamine enhancement, or placebo) and the partial NMDA receptor agonist D-cycloserine (dosages of 50, 100, and 200 mg, or placebo). Cortical excitability was monitored by transcranial magnetic stimulation-induced motor-evoked potentials. We found that LTP-like plasticity was abolished or converted into LTD-like plasticity via dopaminergic activation, but reestablished under medium-dose D-cycloserine. These results suggest that diffuse LTP-like plasticity is counteracted upon via D2 receptor-dependent reduction of NMDA receptor activity.

Dosage-Dependent Impact of Acute Serotonin Enhancement on Transcranial Direct Current Stimulation Effects.

BACKGROUND: The serotonergic system has an important impact on basic physiological and higher brain functions. Acute and chronic enhancement of serotonin levels via selective serotonin reuptake inhibitor administration impacts neuroplasticity in humans, as shown by its effects on cortical excitability alterations induced by non-invasive brain stimulation, including transcranial direct current stimulation (tDCS). Nevertheless, the interaction between serotonin activation and neuroplasticity is not fully understood, particularly considering dose-dependent effects. Our goal was to explore dosage-dependent effects of acute serotonin enhancement on stimulation-induced plasticity in healthy individuals. METHODS: Twelve healthy adults participated in 7 sessions conducted in a crossover, partially double-blinded, randomized, and sham-controlled study design. Anodal and cathodal tDCS was applied to the motor cortex under selective serotonin reuptake inhibitor (20 mg/40 mg citalopram) or placebo medication. Motor cortex excitability was monitored by single-pulse transcranial magnetic stimulation. RESULTS: Under placebo medication, anodal tDCS enhanced, and cathodal tDCS reduced, excitability for approximately 60-120 minutes after the intervention. Citalopram enhanced and prolonged the facilitation induced by anodal tDCS regardless of the dosage while turning cathodal tDCS-induced excitability diminution into facilitation. For the latter, prolonged effects were observed when 40 mg was administrated. CONCLUSIONS: Acute serotonin enhancement modulates tDCS after-effects and has largely similar modulatory effects on motor cortex neuroplasticity regardless of the specific dosage. A minor dosage-dependent effect was observed only for cathodal tDCS. The present findings support the concept of boosting the neuroplastic effects of anodal tDCS by serotonergic enhancement, a potential clinical approach for the treatment of neurological and psychiatric disorders.

Cerebellar Transcranial Direct Current Stimulation (ctDCS) Impairs Balance Control in Healthy Individuals.

The cerebellum plays an important role in the planning, initiation and stability of movements, as well as in postural control and balance. Modulation of neural regions underlying balance control may be a potential alternative to treat balance impairments in cerebellar patients. Transcranial direct current stimulation (tDCS) is a noninvasive and safe tool capable to modulate cerebellar activity. We aim to investigate the effects of cerebellar tDCS (ctDCS) on postural balance in healthy individuals. Fifteen healthy and right-handed subjects were submitted to three sessions of ctDCS (anodal, cathodal and sham), separated by at least 48 h. In each session, tests of static (right and left Athlete Single Leg tests) and dynamic balance (Limits of Stability test) were performed using the Biodex Balance System before and immediately after the ctDCS. The results revealed that cathodal ctDCS impaired static balance of healthy individuals, reflected in higher scores on overall stability index when compared to baseline for right (p = 0.034) and left (p = 0.01) Athlete Single Leg test. In addition, we found significant impairment for left Athlete Single Leg test in comparison to sham stimulation (p = 0.04). As far as we know, this is the first study that points changes on balance control after ctDCS in healthy individuals. This finding raises insights to further investigation about cerebellar modulation for neurological patients.

Efficacy of Noninvasive Brain Stimulation on Pain Control in Migraine Patients: A Systematic Review and Meta-Analysis.

OBJECTIVE: To evaluate the efficacy of noninvasive brain stimulation (NIBS) on pain control in migraine patients. BACKGROUND: Recent studies have used NIBS as an abortive and prophylactic treatment for migraine; however, its efficacy regarding meaningful clinical effects remains to be critically analyzed. DESIGN: Systematic review of controlled clinical trials. METHODS: Searches were conducted in six databases: MEDLINE (via PubMed), LILACS (via BIREME), CINAHL (via EBSCO), Scopus (via EBSCO), Web of Science, and CENTRAL. Two independent authors searched for randomized controlled clinical trials published through until January 2016 that involved the use of transcranial direct current stimulation (tDCS) and transcranial magnetic stimulation (TMS) in migraineurs. Studies which met the eligibility criteria were assessed and methodological quality was examined using the Cochrane tool for assessing risk of bias. Information about pain intensity (primary outcome), migraine attacks, painkiller intake, and adverse effects were extracted. RESULTS: Eight studies were included in the quantitative analysis with 153 migraine patients that received NIBS and 143 sham NIBS. In overall meta-analysis, we did not find significant results for pain intensity (SMD: -0.61; CI: -1.35 to 0.13; P = .11), for migraine attacks (SMD: -0.44; 95%; CI: -1.15 to 0.26; P = .22), and for painkiller intake (SMD: -0.57; 95% CI: -1.21 to 0.07; P = .08). However, subgroup analysis considering only tDCS effects have demonstrated a decrease for pain intensity (SMD: -0.91; 95% CI: -1.79 to -0.03; P = .04), migraine attacks (SMD: -0.75; 95% CI: -1.25 to -0.24; P = .004), and painkiller intake (SMD: -0.64; 95% CI: -1.21 to -0.07; P = .03). Subgroup analysis for TMS did not reveal significant effects for any outcome. CONCLUSION: Low or very low quality of evidence suggests that our primary outcome evaluation failed to find support for the superiority of NIBS over sham treatment. Although, subgroup analysis reveals that tDCS have moderate to high effects and could be a promising nonpharmacological alternative to pain control, mainly for painkiller intake reduction. However, there is a need for larger controlled trials with methodological rigor, which could increase the power of result inference.

Neurochemical mechanisms underlying serotonergic modulation of neuroplasticity in humans.

BACKGROUND: Studies in animals and humans have shown that cortical neuroplasticity can be modulated by increasing serotonin levels by administering selective serotonin reuptake inhibitors (SSRI). However, little is known about the mechanistic background, especially the contribution of intracortical inhibition and facilitation, which depend on gamma-aminobutyric acid (GABA) and glutamate. OBJECTIVE: We aimed to explore the relevance of drivers of plasticity (glutamate- and GABA-dependent processes) for the effects of serotonin enhancement on tDCS-induced plasticity in healthy humans. METHODS: A crossover, partially double-blinded, randomized, and sham-controlled study was conducted in 21 healthy right-handed individuals. In each of the 7 sessions, plasticity was induced via transcranial direct current stimulation (tDCS). Anodal, cathodal, and sham tDCS were applied to the left motor cortex under SSRI (20 mg/40 mg citalopram) or placebo. Short-interval cortical inhibition (SICI) and intracortical facilitation (ICF) were monitored by paired-pulse transcranial magnetic stimulation for 5-6 h after intervention. RESULTS: Under placebo, anodal tDCS-induced LTP-like plasticity decreased SICI and increased ICF. In contrast, cathodal tDCS-elicited LTD-like plasticity induced the opposite effect. Under 20 mg and 40 mg citalopram, anodal tDCS did not affect SICI largely, while ICF was enhanced and prolonged. For cathodal tDCS, citalopram converted the increase of SICI and decrease of ICF into antagonistic effects, and this effect was dosage-dependent since it lasted longer under 40 mg when compared to 20 mg. CONCLUSION: We speculate that the main effects of acute serotonergic enhancement on tDCS-induced plasticity, the increase and prolongation of LTP-like plasticity effects, involves mainly the glutamatergic system.

Optimizing the Effect of tDCS on Motor Sequence Learning in the Elderly.

One of the most visible effects of aging, even in healthy, normal aging, is a decline in motor performance. The range of strategies applicable to counteract this deterioration has increased. Transcranial direct current stimulation (tDCS), a non-invasive brain stimulation technique that can promote neuroplasticity, has recently gained attention. However, knowledge about optimized tDCS parameters in the elderly is limited. Therefore, in this study, we investigated the effect of different anodal tDCS intensities on motor sequence learning in the elderly. Over the course of four sessions, 25 healthy older adults (over 65 years old) completed the Serial Reaction Time Task (SRTT) while receiving 1, 2, or 3 mA of anodal or sham stimulation over the primary motor cortex (M1). Additionally, 24 h after stimulation, motor memory consolidation was assessed. The results confirmed that motor sequence learning in all tDCS conditions was maintained the following day. While increased anodal stimulation intensity over M1 showed longer lasting excitability enhancement in the elderly in a prior study, the combination of higher intensity stimulation with an implicit motor learning task showed no significant effect. Future research should focus on the reason behind this lack of effect and probe alternative stimulation protocols.

Could cathodal transcranial direct current stimulation modulate the power spectral density of alpha-band in migrainous occipital lobe?

OBJECTIVE: To identify the correlation between cathodal transcranial direct current stimulation (tDCS) and the power spectral density (PSD) of alpha-band on the occipital lobe of migraineurs. METHODS: Firstly, a cross-sectional study was performed to compare the PSD of alpha-band in the occipital cortex of 25 migraineurs versus 10 healthy volunteers in resting state and during repetitive light stimuli (RLS). Secondly, the patients participated in 12 sessions of cathodal (n = 11) or sham tDCS (n = 10) over the primary visual cortex (V1) to investigate the alpha-band PSD. RESULTS: The alpha-band PSD on the occipital cortex was higher in migraineurs than healthy subjects in resting state and lower during the first train of RLS. Cathodal tDCS over the V1 reduced the alpha-band occipital activity in resting state but did not interfere with the functional responses to RLS when light stimulation was turned on. CONCLUSIONS: Our findings suggest that the occipital cortex of migraineurs is hypoactive in the baseline condition, but becomes hyperactive when stimulated by light. Cathodal tDCS over the V1 decreases baseline alpha PSD in patients, possibly modulating the involved neuronal circuitries, but it cannot interfere once photic stimulation starts.

Ca2+ channel dynamics explain the nonlinear neuroplasticity induction by cathodal transcranial direct current stimulation over the primary motor cortex.

Transcranial direct current stimulation (tDCS) induces polarity-dependent neuroplasticity: with conventional protocols, anodal tDCS results in excitability enhancement while cathodal stimulation reduces excitability. However, partially non-linear responses are observed with increased stimulation intensity and/or duration. Cathodal tDCS with 2 mA for 20 min reverses the excitability-diminishing plasticity induced by stimulation with 1 mA into excitation, while cathodal tDCS with 3 mA again results in excitability diminution. Since tDCS generates NMDA receptor-dependent neuroplasticity, such non-linearity could be explained by different levels of calcium concentration changes, which have been demonstrated in animal models to control for the directionality of plasticity. In this study, we tested the calcium dependency of non-linear cortical plasticity induced by cathodal tDCS in human subjects in a placebo controlled, double-blind and randomized design. The calcium channel blocker flunarizine was applied in low (2.5 mg), medium (5 mg) or high (10 mg) dosages before 20 min cathodal motor cortex tDCS with 3 mA in 12 young healthy subjects. After-effects of stimulation were monitored with TMS-induced motor evoked potentials (MEPs) until 2 h after stimulation. The results show that motor cortical excitability-diminishing after-effects of stimulation were unchanged, diminished, or converted to excitability enhancement with low, medium and high dosages of flunarizine. These results suggest a calcium-dependency of the directionality of tDCS-induced neuroplasticity, which may have relevant implications for future basic and clinical research.

Trabalho Docente no Contexto da Expansão Universitária / Teaching Work in the Context of University Expansion / Trabajo Docente en el Contexto de la Expansión Universitaria

As reformas neoliberais promoveram transformações no ensino superior. Nesse contexto, diversas instituições aderiram ao Programa de Apoio a Planos de Reestruturação e Expansão das Universidades Federais (REUNI). Isto, contudo, se deu sem as contrapartidas necessárias. O propósito da investigação, assim, foi compreender os impedimentos ao poder de agir de docentes que atuavam em um campus estruturado a partir do REUNI. Adotou-se o referencial da Clínica da Atividade. Participaram do estudo três docentes, duas mulheres e um homem, que atuavam em cursos de graduação e pós-graduação. Em uma perspectiva histórico-desenvolvimentista, foram realizadas entrevistas a partir de imagens que representavam elementos do contexto laboral. Utilizou-se análise construtivo-interpretativa. Dentre os resultados, viu-se intensificação do trabalho promovida pela atuação em cursos de pós-graduação e por atividades invisibilizadas; desprofissionalização associada ao desempenho de atividades alheias ao fazer docente; estrutura física inadequada; carga de trabalho elevada; pressões para o cumprimento de prazos; uso do espaço doméstico para o trabalho; e invasão do tempo livre. Os achados podem nortear ações de promoção da saúde docente e dar balizas para a discussão sobre as melhorias dos contextos de trabalho.

Neoliberal reforms promoted transformations in higher education. In this context, several institutions joined the Support Program for Restructuring and Expansion Plans of Federal Universities (REUNI). This happened without the necessary counterparts. The purpose of the investigation was to understand the impediments to the power to act of professors who worked in a campus structured from the REUNI. The reference of the Clinic of Activity was adopted. Three professors participated in the study, two women and one man, who worked in undergraduate and graduate courses. From a historical-developmental perspective, interviews were carried out based on images that represented elements of the work context. Constructive-interpretative analysis was used. Among the results, it was seen the intensification of work promoted by the performance in postgraduate courses and by invisible activities; de professionalization associated with the performance of activities outside the teaching profession; inadequate physical structure; high workload; pressure to meet deadlines; use of domestic space for work and invasion of free time. The findings can guide actions to promote teachers' health and provide guidelines for the discussion on improvements in work contexts.

Las reformas neoliberales impulsaron transformaciones en la educación superior. En ese contexto, varias instituciones se adhirieron al Programa de Apoyo a los Planes de Reestructuración y Expansión de las Universidades Federales (REUNI). Esto sucedió sin las contrapartes necesarias. La investigación tuvo como objetivo comprender los impedimentos al poder de actuar de los profesores que actuaban en un campus estructurado a partir de lo REUNI. Se adoptó la referencia de la Clínica de la Actividad. Participaron del estudio tres profesores, dos mujeres y un hombre, que actuaban en cursos de pregrado y posgrado. Desde una perspectiva histórica e de desarrollo, se realizaron entrevistas a partir de imágenes que representaban elementos del contexto de trabajo. Se utilizó el análisis constructivo-interpretativo. Entre los resultados, se vio la intensificación del trabajo promovida por la actuación en cursos de posgrado y por actividades invisibles; desprofesionalización asociada al desempeño de actividades ajenas a la docencia; estructura física inadecuada; alta carga de trabajo; presión para cumplir los plazos; uso del espacio doméstico para el trabajo e invasión del tiempo libre. Los hallazgos pueden orientar acciones para promover la salud de los docentes y proporcionar pautas para la discusión sobre mejoras en los contextos de trabajo.

Efficacy of 2,6-dichlorophenol lure to control Dermacentor nitens.

This study was carried out with the objective of evaluating the efficacy of a 2,6-dichlorophenol (2,6-DCP) lure to control Dermacentor nitens (Acari: Ixodidae). Slow-release formulations of the pheromone formulated with and without cypermethrin were prepared. Olfactometer bioassays were used to define the best dose of the pheromone and to evaluate the effect of cypermethrin with 2,6-DCP attractiveness. Sexually active males were released 15 cm from 2 cmx1 cm pieces of polypropylene treated with different odors: 2,6-DCP in a liposphere system (1.5, 30 and 300 microg--without cypermethrin and 30 microg--with cypermethrin) and 2,6-DCP in hexane (30 microg). The tests were conducted 7 and 15 days after the preparation of the odor sources. The percentages of males that oriented, or showed directional movement toward the stimulus, and their tracks were recorded. Lures (10 cmx2 cm pieces of polypropylene) treated with the best dose of the liposphere formulation (30 microg) were prepared. The lures were evaluated in horses that had been artificially infested with D. nitens. The horses' ears were infested with 3000 D. nitens larvae per ear, once weekly for 4 weeks. The animals were divided into three groups: control, 2,6-DCP and 2,6-DCP+cypermethrin. On day 0, the lures of their respective treatments were attached to the horses' napes. From days 6 to 20 after attachment, female ticks of 4 mm or over in length were counted on the ears, every 2 or 3 days. Olfactometer analysis showed higher orientation to 30 microg dose and more prolonged release of the pheromone in the liposphere formulation than in hexane; cypermethrin did not interfere with the attractive effect of the pheromone. The lures were efficient in the first 10 days after attachment, when the mean number of females was higher in the control group (24.9) than in 2,6-DCP and cypermethrin (5.4), and 2,6-DCP (9.2) groups. After that period the number of females was similar in the control and treated groups. These results indicate that 2,6-DCP lures used in a liposphere formulation can control D. nitens for at least 10 days by preventing its copulation. However, further evaluation of longer-term pheromone release under natural conditions is needed in order to validate this kind of control. In addition, the use of extra lures on the horse's tail may help to control populations on the hindquarters.

Perineal Pain Management with Cryotherapy after Vaginal Delivery: A Randomized Clinical Trial.

Introduction Systematic reviews that evaluate the perineal cryotherapy to reduce pain in the vaginal postpartum are inconclusive. Purpose To evaluate clinical effectiveness of cryotherapy in the management of humanized postpartum perineal pain and vaginal edema. Methods A double-bind randomized controlled clinical trial (UTN number: U1111-1131-8433) was conducted in a hospital in Northeastern, Brazil. Women were included following humanized childbirth. All had vaginal deliveries of a single, full-term pregnancy with cephalic presentation. Exclusion criteria included previous perineal lesion, episiotomy during the current delivery, instrumental delivery, uterine curettage and postpartum hemorrhage. In the experimental group, an ice pack was applied six times on the perineum for 20 minutes, reducing the temperature between 10 and 15 ° C, then 60 minutes without exposure to cold. In the non-cryotherapy, a water bag unable to reduce the temperature to this extent was used, compliance with the same application protocol of the first group. Perineal temperature was monitored at zero, 10 and 20 minutes for application in both groups. Evaluations were made immediately before and after the applications and 24 hours after delivery spontaneous, to determine the association between variables. Results A total of 80 women were included in the study, 40 in each group. There was no significant difference in scores of perineal pain and edema between the groups with or without cryotherapy until 24 hours after childbirth. There was no difference between groups when accomplished repeated measures analysis over the 24 hours after delivery, considering the median perineal pain (p = 0.3) and edema (p = 0.9). Perineal cryotherapy did not influence the amount of analgesics used (p = 0.07) and no adverse effect was registered. Conclusion The use of cryotherapy following normal vaginal delivery within the concept of humanized minimally interventionist childbirth had no effect on perineal pain and edema, since it was already substantially lower, nor the need for pain medicaments.

Atuação do fisioterapeuta na atenção primária à saúde: revisão de escopo / Physiotherapeutic performance in primary health care: scoping review

Apesar das evidências científicas sobre a importância da inclusão do fisioterapeuta na atenção primária à saúde, constata-se que a práxis desse profissional nesse nível assistencial ainda é permeada de muitas indefinições. Este estudo teve como objetivo descrever a atuação dos fisioterapeutas que atuam na Atenção Primária à Saúde segundo evidências disponíveis na literatura científica mais atual. Trata-se de uma revisão de escopo. A coleta de dados ocorreu em janeiro e fevereiro de 2019 em três bases de dados. Foram identificados 965 estudos dos quais 27 foram selecionados segundo critérios: originalidade, disponibilidade, publicação a partir de 2009, idioma (inglês, português ou espanhol). Os resultados foram sistematizados em três categorias temáticas: atuação, principais demandas e dificuldades encontradas para atuação na atenção primária à saúde. Identificou-se diversidade de atividades realizadas pelo fisioterapeuta, com predomínio do atendimento específico individual. As principais demandas são de cuidado centrado nas doenças/agravos à saúde e as dificuldades mais citadas são a hegemonia da lógica curativo-reabilitadora e o desconhecimento dos trabalhadores e gestores quanto ao seu fazer nesse nível de atenção. (AU)

Despite the scientific evidence on the importance of including physical therapists in primary health care, it appears that the praxis of this professional at this level of care is still permeated with many vagueness. This study aimed to describe the performance of physical therapists who work in Primary Health Care according to evidence available in the most current scientific literature. This is a scoping review. Data collection took place in January and February 2019 in three databases. 965 studies were identified, of which 27 were selected according to criteria: originality, availability, publication from 2009, language (English, Portuguese or Spanish). The results were systematized into three thematic categories: performance, main demands and difficulties encountered in acting in primary health care. A diversity of activities carried out by the physical therapist was identified, with a predominance of specific individual care. The main demands are for care centered on diseases / health problems and the most common difficulties are the hegemony of the curativerehabilitation logic and the lack of knowledge of workers and managers regarding their work at this level of care. (AU)

Estratégias terapêuticas e atualizações no tratamento de vitiligo / Therapeutic strategies and updates for treatment of vitiligo

O vitiligo é uma desordem dermatológica complexa, cuja patogênese ainda não é totalmente esclarecida. Apesar de não apresentar complicações funcionais no organismo dos pacientes acometidos, o vitiligo pode resultar em um grande impacto psicossocial. Desse modo, é importante que os médicos saibam como conduzir o tratamento dessa patologia. O objetivo deste estudo foi documentar as terapias disponíveis para o tratamento do vitiligo, assim como apontar pesquisas que relataram a utilização dessas opções terapêuticas e os dados resultantes. As terapias abordadas foram corticoides tópicos e sistêmicos, fototerapia e fotoquimioterapias, antioxidantes, imunomoduladores, fenilalanina, despigmentação, procedimentos cirúrgicos e novas abordagens. A monoterapia parece ser menos eficaz no tratamento do vitiligo. A associação de medicação tópica e/ou sistêmica com o uso da fototerapia ultravioleta B de banda estreita parece ser o padrão-ouro para a repigmentação da pele dos pacientes. Medicamentos novos estão em estudo, porém sua eficácia e o estudo dos possíveis efeitos colaterais, principalmente a longo prazo, têm que ser melhores investigados. É necessário que o médico dermatologista, em conjunto com o paciente, escolha a melhor terapia dentre as disponíveis, de acordo com critérios clínicos e a possibilidade de acesso ao tratamento pelo portador. O acompanhamento e a abordagem por uma equipe multiprofissional também são importantes. (AU)

Vitiligo is a complex dermatological disorder, whose pathogenesis has not yet been fully elucidated. Although it does not present functional complications in the affected patients' body, vitiligo can result in a great psychosocial impact. Therefore, it is important that physicians know how to conduct its treatment. This study aimed at documenting the available therapies for the treatment of vitiligo, as well as pointing out studies reporting the use of these therapeutic options and their resulting data. The therapies addressed were topical and systemic corticosteroids, phototherapy, and photochemotherapies, antioxidants, immunomodulators, phenylalanine, depigmentation, surgical procedures, and new approaches. Monotherapy appears to be less effective in the treatment of vitiligo. The combination of topical and/or systemic medication with the use of narrowband ultraviolet B phototherapy seems to be the gold standard for the patients' skin repigmentation. New drugs are under study, but their effectiveness and study of possible side effects, especially in the long run, have to be better investigated. It is necessary that the dermatologist, together with the patient, choose the best therapy among those available, according to clinical criteria and the possibility of access to treatment by the patient. Monitoring and approach by a multiprofessional team is also important. (AU)

Transcranial direct current stimulation in the prophylactic treatment of migraine based on interictal visual cortex excitability abnormalities: A pilot randomized controlled trial.

PURPOSE: The aims of this paper are (i) to compare the excitability of visual cortex in migraine patients with healthy volunteers; and (ii) if an abnormal excitability has been found, to modulate cortical excitability in migraine patients with transcranial direct current stimulation (tDCS) and observe their clinical and neurophysiological effects. METHODS: The study was divided into two steps. A cross-sectional study (step 1) was conducted to compare the cortical excitability of 23 migraineurs (11 with and 12 without aura) on 11 healthy individuals. On step 2, a randomized, double blinded, controlled pilot trial was carried on with 19 migraineurs, randomly divided into: experimental and control group. During 12 sessions, experimental and group received active tDCS to visual cortex and control group received sham tDCS. The headache diary was applied for a total of 90days (before, during and after tDCS sessions). Phosphene threshold (PT) induced by transcranial magnetic stimulation was recorded to measure the excitability of the visual cortex before and after each session. RESULTS: Step 1 showed higher level of cortical excitability between migraineurs when compared to healthy volunteers; therefore, cathodal tDCS was applied over visual cortex in step 2. After tDCS application, a significant decrease was observed in a number of migraine attacks, painkiller intake and duration of each attack just in experimental group. The analysis of PT indicated no difference in cortical excitability after tDCS. CONCLUSIONS: Findings of the study suggested that inhibitory tDCS on visual cortex might be an alternative and non-pharmacological treatment for migraine prophylaxis. However the clinical improvements of patients after tDCS treatment are not correlated with changes in cortical excitability.

Avaliação do conhecimento de Agentes Comunitários de Saúde sobre o conteúdo da Caderneta da Saúde da Criança / Assessment of the knowledge of Community Health Agents on the content of the Child Health Records

Objetivo: caracterizar o conhecimento dos agentes comunitários de saúde (ACS) sobre o conteúdo da Caderneta da Saúde da Criança (CSC) e identificar a capacidade de detectar atraso no Desenvolvimento Neuropsicomotor (DNPM) das crianças por meio da caderneta. Método: estudo transversal, realizado entre agosto de 2018 e novembro de 2019, em Recife, Pernambuco (PE). A amostra foi composta por 109 ACS de diferentes municípios de PE, que responderam, voluntariamente, a um questionário semiestruturado sobre a CSC. A análise estatística foi realizada pelo programa Statistical Package for the Social Sciences (SPSS) versão 20.0, com medida da razão de chances e intervalos de confiança, assumindo um erro de 5% (Odds Ratio - OR e IC 95%). Resultados: 88,1% (n=96) dos ACS eram do sexo feminino; 85,2% (n=92) pertenciam à Estratégia de Saúde da Família e 58,9% (n=63) tinham cobertura de equipe do Núcleo Ampliado da Saúde da Família e Atenção Básica. Informações sobre vacinação foi o item mais assinalado na CSC (99,1%). Quanto à avaliação do DNPM, 60,4% dos ACS relataram saber usar o instrumento de vigilância contido na CSC. Uma análise bivariada encontrou que o ACS que já tinha participado de algum treinamento sobre DNPM referiu sentir-se 6,75 vezes mais capaz de detectar atraso no DNPM. Conclusão: a utilização da CSC pelos ACS tem sido caracterizada, principalmente, para acompanhamento e registro de atividades de vacinação e de crescimento pôndero-estatural. A realização de treinamentos com esses trabalhadores pode ampliar sua qualificação para o acompanhamento do DNPM, fortalecendo a vigilância do desenvolvimento infantil.

Objective: To characterize the knowledge of community health agents (CHA) on the content of the Child Health Records (CHR) and to identify the ability to detect delays in the Neuropsychomotor Development (NPMD) of children through the handbook. Method: cross-sectional study, conducted between August 2018 and November 2019, in Recife, Pernambuco (PE). The sample consisted of 109 Community Health Agents from different cities of Pernambuco (PE) who voluntarily answered a semi-structured questionnaire about the information contained in the CHR. Statistical analysis was performed using the Statistical Package for Social Sciences (SPSS), version 20.0, and by measuring the odds ratio and confidence intervals, assuming a 5% error (OddsRatio - OR and 95% CI). Results: A total of 88,1% (n = 96) of the CHA were female, 85.2% (n = 92) belonged to the Family Health Strategy and 58,9% (n = 63) had team coverage from the Expanded Center of the Family Health and Primary Care. Vaccination information was the most highlighted item in the CHR (99,1%). As for the NPMD assessment, 60,4% of the CHA reported knowing how to use the surveillance instrument contained in the CHR. A bivariate analysis found that the CHA who had already participated in some NPMD training reported feeling 6,75 times more capable of detecting delay in the NPMD. Conclusion: The use of the CHR by the CHA has been characterized mainly for monitoring and recording activities of vaccination and statural weight growth. Conducting training with these workers can increase their qualification for monitoring the NPMD follow-up by strengthening surveillance of child development.

Multiple symmetric lipomatosis.

BACKGROUND: Multiple symmetric lipomatosis (MSL) is a relatively uncommon entity of unknown etiology characterized by symmetrically subcutaneous accumulation of nonencapsulated adipose tissue. Approximately 200 to 300 cases have been published. OBJECTIVES: The aims of this article are to report the case of a 58-year-old Brazilian patient with MSL and provide a comprehensive overview of the current concepts concerning this disease. METHODS: Our search yielded 28 articles on MSL, including case reports and reviews of the literature. RESULTS: MSL predominantly affects Mediterranean males with a history of chronic alcohol abuse. It is usually asymptomatic and may be associated with diabetes mellitus, hyperlipidemia, hyperuricemia, macrocytic anemia, and oral cancer. Surgical resection is the best treatment option. CONCLUSION: The case reported is a classic presentation of MSL; however, it is particularly uncommon owing to the association with immune thrombocytopenic purpura. This association has been described only once in the medical literature.

Perineal Pain Management with Cryotherapy after Vaginal Delivery: A Randomized Clinical Trial / Manejo da dor perineal com crioterapia no pós-parto vaginal: ensaio clínico randomizado

Abstract Introduction Systematic reviews that evaluate the perineal cryotherapy to reduce pain in the vaginal postpartum are inconclusive. Purpose To evaluate clinical effectiveness of cryotherapy in the management of humanized postpartum perineal pain and vaginal edema. Methods A double-bind randomized controlled clinical trial (UTN number: U1111- 1131-8433) was conducted in a hospital in Northeastern, Brazil.Women were included following humanized childbirth. All had vaginal deliveries of a single, full-term pregnancy with cephalic presentation. Exclusion criteria included previous perineal lesion, episiotomy during the current delivery, instrumental delivery, uterine curettage and postpartum hemorrhage. In the experimental group, an ice pack was applied six times on the perineum for 20 minutes, reducing the temperature between 10 and 15° C, then 60 minutes without exposure to cold. In the non-cryotherapy, a water bag unable to reduce the temperature to this extent was used, compliance with the same application protocol of the first group. Perineal temperature wasmonitored at zero, 10 and 20 minutes for application in both groups. Evaluations were made immediately before and after the applications and 24 hours after delivery spontaneous, to determine the association between variables. Results A total of 80 women were included in the study, 40 in each group. There was no significant difference in scores of perineal pain and edema between the groups with or without cryotherapy until 24 hours after childbirth. There was no difference between groups when accomplished repeated measures analysis over the 24 hours after delivery, considering the median perineal pain (p = 0.3) and edema (p = 0.9). Perineal cryotherapy did not influence the amount of analgesics used (p = 0.07) and no adverse effect was registered. Conclusion The use of cryotherapy following normal vaginal delivery within the concept of humanized minimally interventionist childbirth had no effect on perineal pain and edema, since it was already substantially lower, nor the need for pain medicaments.

Resumo Introdução Revisões sistemáticas que avaliam a crioterapia perineal para redução da dor no pós-parto por via vaginal são inconclusivas. Objetivo Avaliar a efetividade clínica da crioterapia para controlar a dor e o edema perineais após parto vaginal humanizado. Métodos Ensaio clínico (n° UTN: U1111-1131-8433) randomizado controlado duplocego, realizado em uma maternidade no Nordeste do Brasil. Incluíram-se mulheres após parto vaginal humanizado, de gestação única, cefálica, a termo, e foram excluídas aquelas com lesão perineal prévia, episiotomia no parto atual, parto instrumental e hemorragia perineal ativa. O grupo experimental foi submetido a seis aplicações de bolsa de gelo triturado na região do períneo, por 20minutos, reduzindo a temperatura entre 10 e 15°C, com 60 minutos entre as aplicações. O grupo sem crioterapia recebeu uma bolsa de água, que não reduzia a temperatura a esse nível, respeitando o mesmo protocolo de aplicação do primeiro grupo. Amonitorização da temperatura perineal foi realizada nos minutos zero, 10 e 20 de aplicação, emambos os grupos. Para determinar a associação entre as variáveis, foramrealizadas avaliações imediatamente antes e após as aplicações e 24 horas após o parto. Resultados Foram incluídas 80 puérperas no estudo, sendo 40 em cada grupo. Não houve diferença significativa para os escores de dor e edema perineais entre os grupos comou sem crioterapia até 24 horas após o parto. Não houve diferença entre os grupos quando realizada análise de medidas repetidas em todas as avaliações, considerando a mediana dos escores de dor (p = 0,3) e edema (p = 0,9) perineais. A crioterapia perineal não influenciou na quantidade de analgésicos utilizados (p = 0,07) e nenhum efeito adverso foi registrado. Conclusões A utilização da crioterapia após parto vaginal humanizado, minimamente intervencionista, nãomodifica escores de dor e edema perineais, por já serem, substancialmente, baixos, tampouco altera a necessidade de medicamentos analgésicos.

Alterações dimensionais em modelos de gessos com fraturas e colagem com cianocrilato / Dimensional change in gypsum models with fractures and collage with cyanocrylate

Objetivo: avaliar a precisão dimensional de modelos de gesso tipos III e IV submetidos a diversos tipos de fraturas, seguidas de colagem com cianoacrilato. Materiais e mé-todo: a amostra foi constituída por 80 modelos de gesso obtidos a partir de moldes de silicone de adição Zetala-bor Platinum®, provenientes de um modelo mestre em aço inox, com dois pilares. Foram formados 2 grupos (n = 40): Grupo 1-Modelos de gesso tipo III e Grupo 2-Mo-delos de gesso tipo IV. Cada grupo foi subdividido em: Controle (n = 10) Modelos de gesso sem fratura; Experi-mental 1 (n = 10) Modelos de gesso colados com adesi-vo a base de cianoacrilato SuperBonder® após fratura no espaço protético, entre os dois pilares; Experimental 2 (n = 10) Modelos de gesso colados após fratura horizontal nos pilares, simulando fratura, ocorrida durante a remo-ção do modelo do molde; Experimental 3 (n = 10) Mo-delos de gesso colados após fratura simulando acidente de queda de uma bancada de laboratório. As unidades amostrais foram mensuradas com paquímetro digital. Os dados foram processados e submetidos à análise estatís-tica (teste de Shapiro-Wilk e teste t student). Resultados: os modelos de gesso fraturados e colados com cianoacri-lato exibiram alterações dimensionais lineares quando comparados aos respectivos controles. Os modelos de gesso tipo III do Grupo 1, se comportaram de forma di-ferente, quando comparados aos modelos de gesso tipo IV do mesmo grupo. Conclusão: a colagem de pilares em modelos de gesso de prótese fixa, sem padronização, põe em risco a precisão dimensional desses.