Appraising the effectiveness of electrical and magnetic brain stimulation techniques in acute major depressive episodes: an umbrella review of meta-analyses of randomized controlled trials

Electrical and magnetic brain stimulation techniques present distinct mechanisms and efficacy in the acute treatment of depression. This was an umbrella review of meta-analyses of randomized controlled trials of brain stimulation techniques for managing acute major depressive episodes. A systematic review was performed in the PubMed/MEDLINE databases from inception until March 2020. We included the English language meta-analysis with the most randomized controlled trials on the effects of any brain stimulation technique vs. control in adults with an acute depressive episode. Continuous and dichotomous outcomes were assessed. A Measurement Tool to Assess Systematic Reviews-2 was applied and the credibility of evidence was assessed using the Grading of Recommendations Assessment, Development and Evaluation framework. Seven meta-analyses were included (5,615 patients), providing evidence for different modalities of brain stimulation techniques. Three meta-analyses were evaluated as having high methodological quality, three as moderate, and one as low. The highest quality of evidence was found for high frequency-repetitive transcranial magnetic stimulation (rTMS), transcranial direct current stimulation, and bilateral rTMS. There is strong clinical research evidence to guide future clinical use of some techniques. Our results confirm the heterogeneity of the effects across these techniques, indicating that different mechanisms of action lead to different efficacy profiles.

Spinal Cord Stimulation as a Treatment Option for Refractory Chemotherapy-Induced Peripheral Neuropathy: Case Report

Colorectal cancer is one of the most common oncological diseases. Chemotherapy is usually recommended as an adjuvant treatment for stage-II, -III, and -IV tumors. Approximately 10% of the patients develop neuropathic pain after chemotherapy, and they may remain refractory despite the administration of drugs that are commonly used to treat neuropathic pain. Spinal cord stimulation is a good treatment option for neuropathic pain of the lower limbs, and it should be trialed in patients with chemotherapy-induced peripheral neuropathy. We report the case of a patient with oxaliplatin-induced neuropathy and neuropathic pain refractory to oral medication who was successfully treated by spinal cord stimulation.

Liposomal topical capsaicin in post-herpetic neuralgia: a safety pilot study / Capsaicina lipossomal tópica na neuralgia pós-herpética: um estudo piloto de segurança

Topical treatments have gained popularity for general use as an adjunct to systemic drugs in neuropathic pain, but their use produces variable clinical results and local adverse events. Objective To evaluate the safety and analgesic effect of a formulation of liposomal capsaicin (LC) (0.025%) in patients with post herpetic neuralgia (PHN). Method Patients who remained symptomatic after first-and second-line treatment were randomized to receive LC for six weeks in a placebo-controlled, crossover design study. Clinical assessment was performed at baseline, in the second, fourth and sixth week of treatment. Results Thirteen patients completed both treatment periods. Visual Analog Scale (VAS) was significantly decreased after the end of the study (p = 0.008), however the effect of treatment was not significant (p = 0.076). There was no difference on global impression of change and other pain characteristics. LC was safe and well tolerated. However, at the concentration used, its analgesic effects were marginal and not significant. .

Os tratamentos tópicos ganharam popularidade para uso geral como um adjuvante de medicamentos sistêmicos na dor neuropática, mas seu uso produz resultados clínicos variáveis e eventos adversos locais. Objetivo Avaliar o efeito de segurança e analgesia de uma formulação de capsaicina lipossomal (LC) (0,025%) em pacientes com neuralgia pós-herpética. Método Os pacientes que permaneceram sintomáticos após tratamento de primeira e de segunda linha foram randomizados para receber LC durante seis semanas em um estudo cruzado controlado por placebo. A avaliação clínica foi realizada no início do estudo, na segunda, quarta e sexta semana de tratamento. Resultados Treze pacientes completaram dois períodos de tratamento. Escala Visual Analógica diminuiu significativamente após o final do estudo (p = 0,008), no entanto, o efeito do tratamento não era significativo (p = 0,076). Não houve diferença na impressão global de mudança e de outras características da dor. LC foi segura e bem tolerada. No entanto, para a concentração utilizada, os seus efeitos analgésicos foram marginais e não significativos. .

Avaliação e tratamento de pacientes com dor facial atípica através da estimulação magnética transcraniana repetitiva / Assessment and treatment of patients with atypical facial pain patients that underwent repetitive transcranial magnetic stimulation

Dor facial atípica (DFA) é uma condição álgica crônica destacada pela etiopatogenia ainda desconhecida e pela característica rebelde aos tratamentos vigentes. O objetivo deste estudo é avaliar o limiar e padrões de excitabilidade cortical de doentes com DFA através de Estimulação Magnética Transcraniana (EMT) e compará-los a controles saudáveis, além de avaliar a eficácia terapêutica da EMT repetitiva (EMTr) ativa em doentes com DFA comparados à EMTr placebo. Durante o período de março de 2010 a dezembro de 2013 foram avaliados 29 doentes com DFA - os quais preencheram os critérios segundo a classificação proposta pela Associação Internacional de Cefaleia (2004) - e 28 controles saudáveis. A avaliação foi iniciada com a investigação da excitabilidade cortical bilateral. Em seguida, os doentes foram aleatorizados em dois grupos (ativo e placebo) para o tratamento com EMTr sobre o córtex motor primário na área de representação da face, esquematizado da seguinte forma: cinco sessões consecutivas para a fase de indução, e uma sessão semanal (pelo período de oito semanas) para a de manutenção; frequência excitatória de 10Hz; 80% do limiar motor de repouso; e 3000 pulsos no total por sessão. Os doentes foram avaliados quanto às características dolorosas no momento basal, no dia sete após a semana de indução, e nos dias 21, 30 e 60 para acompanhamento na fase de manutenção. Em todas as avaliações, utilizou-se os seguintes questionários validados para a língua portuguesa: Inventário Breve de Dor; DN4, Inventário de Sintomas de Dor Neuropática, Questionário de descritores breve de dor McGill e Questionário de qualidade de vida SF-36. Os doentes do grupo ativo e placebo apresentaram excitabilidade cortical inicial diferenciada em relação aos controles nos padrões de inibição e facilitação intracortical (p < 0,001). Ao final da última avaliação, os doentes do grupo ativo apresentavam padrões de excitabilidade cortical mais próximos dos controles do que os doentes...

Atypical facial pain (AFP) is a chronic condition with unknown physiopathology and refractory characteristics to the gold standard treatment. The aim this study was to compare the patterns of cortical excitability between AFP and health subjects (HS), and to assess the analgesic effect of repetitive transcranial magnetic stimulation (rTMS) in AFP patients. Twenty-eight HS and 29 patients with AFP were included according to the IHS criteria (2004). Participants underwent a cortical excitability battery bilaterally in the primary motor cortex (M1) representation of the masseter muscle. They were then randomized into active and sham rTMS groups. rTMS was performed over the contralateral motor cortex in the representation area of the face daily for a week and weekly for eight weeks in a total of 13 sessions (5 induction and 8 maintenance sessions). All participants received 10 Hz rTMS, at 80% of the rest motor threshold (total of 3000 pulses per session). Sham rTMS was performed with an identical sham coil that emitted a similar sound to the active one. Patients were clinically assessed at baseline, after the induction phase (one week) and after 21, 30 and 60 days after the beginning of the study. Evaluations included the following validated questionnaires to the Brazilian Portuguese language: brief pain inventory; DN-4; Neuropathic pain symptoms inventory, McGill pain questionnaire brief version and quality of life questionnaire SF-36. At the baseline assessment, patients with AFP showed defective intracortical excitability inhibition and facilitation (p < 0.001) compared to HS. After the final evaluation, the patients from the active group had cortical excitability patterns closer to HS than the patients from the sham group, although there was no significant difference. There was no difference between patients that underwent active and sham rTMS about their pain characteristics and quality of life; both had pain improvement...

Methadone in post-herpetic neuralgia: A pilot proof-of-concept study

OBJECTIVE: This research was designed as a pilot proof-of-concept study to evaluate the use of low-dose methadone in post-herpetic neuralgia patients who remained refractory after first and second line post-herpetic neuralgia treatments and had indications for adding an opioid agent to their current drug regimens. METHODS: This cross-over study was double blind and placebo controlled. Ten opioid naïve post-herpetic neuralgia patients received either methadone (5 mg bid) or placebo for three weeks, followed by a 15-day washout period and a second three-week treatment with either methadone or placebo, accordingly. Clinical evaluations were performed four times (before and after each three-week treatment period). The evaluations included the visual analogue scale, verbal category scale, daily activities scale, McGill pain questionnaire, adverse events profile, and evoked pain assessment. All patients provided written informed consent before being included in the study. ClinicalTrials.gov: NCT01752699 RESULTS: Methadone, when compared to placebo, did not significantly affect the intensity of spontaneous pain, as measured by the visual analogue scale. The intensity of spontaneous pain was significantly decreased after the methadone treatment compared to placebo on the category verbal scale (50% improved after the methadone treatment, none after the placebo, p = 0.031). Evoked pain was reduced under methadone compared to placebo (50% improved after the methadone treatment, none after the placebo, p = 0.031). Allodynia reduction correlated with sleep improvement (r = 0.67, p = 0.030) during the methadone treatment. The side effects profile was similar between both treatments. Conclusions: Methadone seems to be safe and efficacious in post-herpetic neuralgia. It should be tried as an adjunctive treatment for post-herpetic ...

Estimulação magnética transcraniana e aplicabilidade clínica: perspectivas na conduta terapêutica neuropsiquiátrica / Transcranial magnetic stimulation and clinical applicability: perspectives in neuropsychiatric therapeutics

Estimulação magnética transcraniana (EMT) é uma técnica conhecida desde o começo dos anos 90 e que atualmentetem ganhado destaque devido a sua segurança e possível aplicabilidade para tratar diversas patologias neuropsiquiátricas refratárias. A fim de clarificar os possíveis usos da EMT e suas variações no campo da clínica como forma de tratamento, procedemos à revisão da literatura selecionando os artigos nas áreas em que a técnica de EMT já tem sido largamente utilizada,a saber: AVC, Dor, Doença de Parkinson e Depressão. Essas doenças possuem elevada morbidade, possuindo grandesimplicações na qualidade de vida devido ao elevado grau de incapacidade associado e ao fato de ainda carecerem de métodos terapêuticos totalmente eficientes. Nesse contexto, a EMT emerge como ferramenta promissora, apresentando bons resultados, os quais fornecem margem para aplicações diretas na prática clínica. É necessário, todavia, o desenvolvimento de mais estudos randomizados, para se padronizar e aperfeiçoar as abordagensdessa técnica no tratamento de tais patologias...

Transcranial Magnetic Stimulation (TMS) is a technique that emerged in the 90s and has currently become recognized for its safety and potential applicability in the treatment of neuropsychiatry diseases. To clarify the possible uses of TMS and its variations in the clinical scope as a treatment, weproceeded a literature review selecting articles in the areas where the technique of TMS has already been widely used: Stroke, Pain, Parkinson’s Disease and Depression. These diseases have high morbidity, with large implications for the quality of life due to the high degree of disability and the fact that we still lack of fully efficient therapeutic methods. In this context, EMT emerges as a promising tool with amazing results, which provide scope for direct applications in clinical practice. However, the developmentof more randomized studies is necessary, in order to standardizeand improve the approaches of this technique in the treatment of such pathologies...

Envelhecimento bem-sucedido e vulnerabilidade em saúde: aproximações e perspectivas / Successful aging and health vulnerability: approaches and perspectives / Envejecimiento feliz y vulnerabilidad en salud: aproximaciones y perspectivas

Tomando como referência a natureza multidimensional e dinâmica do conceito de vulnerabilidade em saúde, o objetivo deste artigo foi promover uma discussão sobre o que vem a ser envelhecer de forma bem-sucedida mesmo na presença de vulnerabilidades. Foram selecionados estudos que discutiram dimensões da vulnerabilidade no contexto da velhice, problematizando os recursos pessoais, sociais, programáticos e comunitários que poderiam tornar as pessoas idosas menos vulneráveis em face das situações de dependência e capacidade funcional reduzida. Embora pouco aplicada no campo da Gerontologia, a articulação entre o conceito de vulnerabilidade em saúde e o envelhecimento saudável e bem-sucedido parece ser produtiva e precisa ser melhor explorada.

Considering the multidimensional and dynamic nature of the concept of health vulnerability, this article aimed to promote a discussion about the meaning of aging successfully even in the presence of vulnerabilities. We have selected studies which discussed dimensions of vulnerability in the context of old age, exploring personal, social, programmatic and community resources that could make older adults be less vulnerable in situations of dependence and reduced functional capacity. The articulation of the concept of health vulnerability and successful and healthy aging seems to be productive and should be further explored.

Tomando como referencia la naturaleza multi-dimensional y dinámica del concepto de vulnerabilidad en salud, el objetivo de este artículo es el promover una discusión sobre lo que viene a ser envejecer con éxito incluso en presencia de vulnerabilidades. Se han seleccionado estudios que discuten dimensiones de vulnerabilidad en el contexto de la vejez, encarando la problemática de los recursos personales, sociales, programáticos y comunitarios que podrían tornar a las personas ancianas menos vulnerables ante situaciones de dependencia y capacidad funcional reducida. Aunque poco aplicada en el campo de la Gerontología, la articulación del concepto de vulnerabilidad en salud y el envejecimiento saludable y feliz parece ser productiva y ha de ser mejor utilizada.

Liga acadêmica de gerontologia da EACH/USP: histórico e perspectivas para a atuação do bacharel em gerontologia / Academic league of gerontology of EACH/USP: history and perspectives for the graduate's professional action

O presente artigo tem como objetivo apresentar as atividades acadêmicas e de extensão desenvolvidas pela Liga Acadêmica de Gerontologia da Escola de Artes Ciências e Humanidades da USP (Liga), descrevendo a fundação da Liga, os projetos a serem desenvolvidos e o contexto de criação de áreas inovadoras de ensino, pesquisa e atuação profissional que tomam como referência o processo de envelhecimento, tal como os programas de graduação em Gerontologia. O principal desafio da Liga é aprimorar a relação de conteúdos teóricos com a prática do bacharel em Gerontologia.

This article presents the academic and extension activities developed by the Academic League of Gerontology of the School of Arts, Sciences and Humanities of USP (League). It describes the League’s foundation, the projects to be developed and the context of creation of innovative approaches in teaching, research and professional action that take the aging process as reference, such as the undergraduate programs in Gerontology. The main challenge of the League is to improve the relationship between theory and the practice of the graduate in Gerontology.

Envelhecimento bem-sucedido: trajetórias de um constructo e novas fronteiras / Envejecimiento exitoso: trayectorias de un constructo y nuevas fronteras / Successful aging: paths for a construct and new frontiers

Este artigo enfoca diferentes concepções de envelhecimento bem-sucedido, enfatizando o processo de envelhecimento como uma experiência heterogênea, que implica diferentes estratégias para a obtenção de bem-estar e qualidade de vida. Foram selecionados estudos que valorizam o processo de envelhecimento como parte do curso de vida humano, o papel da subjetividade e a auto-avaliação em saúde, como conceitos-chave para compreender o bem-estar e saúde na velhice. Os dados da literatura sugerem que a experiência do envelhecimento bem-sucedido valoriza a percepção dos próprios idosos, protagonistas de intervenções e dotados de julgamentos sobre bem-estar e qualidade de vida. Mesmo na presença de co-morbidades e diminuição da funcionalidade é possível identificar idosos que referem altos níveis de satisfação e boa qualidade de vida. Propomos questões que buscam aprimorar investigações e a elaboração deste constructo em gerontologia, tendo em vista a amplitude e complexidade do tema.

This article focuses on different conceptions of successful aging, emphasizing the process of aging as a heterogeneous experience that implies different strategies for achieving wellbeing and quality of life. Studies valuing the aging process as part of the course of human life and the role of subjectivity and health self-perception, as key concepts for understanding wellbeing and health in old age, were selected. Data in the literature suggest that the experience of successful aging values elderly people's own perceptions: they are the protagonists of interventions and possess judgment about wellbeing and quality of life. Even in the presence of comorbidities and diminished functional ability, it is possible to identify elderly people who report high levels of satisfaction and good quality of life. We propose questions that seek to improve investigations and elaborate this construct within gerontology, bearing in mind the size and complexity of this topic.

Este artículo aborda diferentes concepciones de envejecimiento bien llevado, enfatizando el proceso como una experiencia heterogénea que implica diferentes estrategias para la obtención del bienestar y calidad de vida; seleccionando estudios que evalúan el proceso de envejecimiento como parte del curso de vida humana, el papel de la subjetividad y la auto-evaluación en salud como conceptos clave para abarcar el bienestar y la salud en la vejez. Los datos obtenidos sugieren que este proceso resalta la percepción de los ancianos protagonistas de intervenciones. Proponemos cuestiones que tratan de perfeccionar investigaciones y la elaboración de este constructo en Gerontología.