[Hypothalamic-pituitary dysfunction in a patient with neurosarcoidosis].

This is a case report of a 64-year-old man with pulmonary sarcoidosis also affecting the joints. He was admitted to an emergency department following 21 days of fatigue, visual disturbances and headache. Initial blood tests revealed hypothalamic-pituitary dysfunction including acute adrenal insufficiency, and an MRI scan of the cerebrum showed a neurosarcoidosis tumour involving the hypothalamus-pituitary gland. Neurosarcoidosis is a condition with widespread clinical variation and early, and correct diagnosis is important.

Subjective outcome following neurostimulator implantation as drop foot therapy due to lesions in the central nervous system-midterm results.

BACKGROUND: Drop foot can be caused by many conditions. Stroke is one of the major causes of drop foot and 5% of stroke survivors suffer from hemiplegia, which in some cases, can manifest as drop foot. The abnormal gait resulting from the lack of innervation of the extensor muscles may result in a secondary malposition of the foot and lead to a steppage gait. Among the several therapy options for the treatment of drop foot, functional electrostimulation (FES) with a transcutaneous peroneal nerve stimulator (tPNS) or an implantable peroneal nerve stimulator (iPNS) represents the two recent approaches. OBJECTIVE: Although therapy with an iPNS has been proven to be effective, a subjective patient assessment has not yet been executed. The aim of this study was to assess the patient's satisfaction with the therapy by using two established surveys. METHODS: The Rivermead Mobility Index (RMI) and the Reintegration to Normal Life Index (RNLI) were used for this retrospective study. The RMI includes 15 questions which are to be answered as either "yes" or "no" and given a value of 1 or 0, respectively, with a maximum of 15 points possible. The RNLI includes 11 questions which are to be answered with the use of a visual analog scale (VAS, 0 to 10 cm). In this case, a maximum adjusted score of 100 points is possible. RESULTS: The total study cohort involved 56 patients treated with an iPNS. Thirty-five complete data sets for the RMI and 29 for the RNLI could be achieved. A significant difference in the total score of both surveys was observed between the deactivated and the activated iPNS (RMI: p = 0.02; RNL: p = 0.01). CONCLUSION: A significant improvement in patient satisfaction was detected with the use of an activated iPNS after a mean time span of 4 years. Due to the marked mobility, an increase in the social satisfaction and integration could be achieved. Both aspects represent essential components for the recovery and quality of life of the patients.

Vitamin D Supplementation in Central Nervous System Demyelinating Disease-Enough Is Enough.

The exact cause of multiple sclerosis (MS) remains elusive. Various factors, however, have been identified that increase an individual's risk of developing this central nervous system (CNS) demyelinating disease and are associated with an acceleration in disease severity. Besides genetic determinants, environmental factors are now established that influence MS, which is of enormous interest, as some of these contributing factors are relatively easy to change. In this regard, a low vitamin D status is associated with an elevated relapse frequency and worsened disease course in patients with MS. The most important question, however, is whether this association is causal or related. That supplementing vitamin D in MS is of direct therapeutic benefit, is still a matter of debate. In this manuscript, we first review the potentially immune modulating mechanisms of vitamin D, followed by a summary of current and ongoing clinical trials intended to assess whether vitamin D supplementation positively influences the outcome of MS. Furthermore, we provide emerging evidence that excessive vitamin D treatment via the T cell-stimulating effect of secondary hypercalcemia, could have negative effects in CNS demyelinating disease. This jointly merges into the balancing concept of a therapeutic window of vitamin D in MS.

VISTA expression by microglia decreases during inflammation and is differentially regulated in CNS diseases.

V-type immunoglobulin domain-containing suppressor of T-cell activation (VISTA) is a negative checkpoint regulator (NCR) involved in inhibition of T cell-mediated immunity. Expression changes of other NCRs (PD-1, PD-L1/L2, CTLA-4) during inflammation of the central nervous system (CNS) were previously demonstrated, but VISTA expression in the CNS has not yet been explored. Here, we report that in the human and mouse CNS, VISTA is most abundantly expressed by microglia, and to lower levels by endothelial cells. Upon TLR stimulation, VISTA expression was reduced in primary neonatal mouse and adult rhesus macaque microglia in vitro. In mice, microglial VISTA expression was reduced after lipopolysaccharide (LPS) injection, during experimental autoimmune encephalomyelitis (EAE), and in the accelerated aging Ercc1 Δ/- mouse model. After LPS injection, decreased VISTA expression in mouse microglia was accompanied by decreased acetylation of lysine residue 27 in histone 3 in both its promoter and enhancer region. ATAC-sequencing indicated a potential regulation of VISTA expression by Pu.1 and Mafb, two transcription factors crucial for microglia function. Finally, our data suggested that VISTA expression was decreased in microglia in multiple sclerosis lesion tissue, whereas it was increased in Alzheimer's disease patients. This study is the first to demonstrate that in the CNS, VISTA is expressed by microglia, and that VISTA is differentially expressed in CNS pathologies.

Diagnosis and Management of Neuropathic Itch.

Neuropathic pruritus is a challenging condition that can be caused by injury or dysfunction in any part of the nervous system. A vast array of clinical pictures exist, including both localized and generalized pruritus, and their principal entities are described in this article. Diagnosis is often difficult and depends on patient history, imaging, and neurophysiologic studies. Other causes of chronic itch should be excluded. The management of neuropathic itch is demanding and the majority of interventions are not curative. The best treatment options include anticonvulsants, topical anesthetics, and capsaicin.

Hypocretin Deficiency Associated with Narcolepsy Type 1 and Central Hypoventilation Syndrome in Neurosarcoidosis of the Hypothalamus.

We report a case of a 53-year-old man presenting with depressed alertness and severe excessive sleepiness in the setting of neurosarcoidosis. Neuroimaging demonstrated hypothalamic destruction due to sarcoidosis with a CSF hypocretin level of 0 pg/mL. The patient also experienced respiratory depression that presumably resulted from hypocretin-mediated hypothalamic dysfunction as a result of extensive diencephalic injury. This is a novel case, demonstrating both hypocretin deficiency syndrome, as well as respiratory dysfunction from destruction of hypocretin neurons and extensive destruction of key diencephalic structures secondary to the underlying neurosarcoidosis.

Management of sexual dysfunction due to central nervous system disorders: a systematic review.

OBJECTIVE: To systematically review the management of sexual dysfunction due to central nervous system (CNS) disorders. PATIENTS AND METHODS: The review was done according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. Studies were identified independently by two reviewers using electronic searches of MEDLINE and OVID (from January 2004 to August 2014) and hand searches of reference lists and review articles. RESULTS: In patients with CNS disorders, neuro-urological assessment is recommended for both genders before starting any treatment for sexual dysfunction. For men, blood sexual hormones evaluation is the main investigation performed before phosphodiesterase type 5 inhibitors (PDE5Is) treatment, whereas there is no consensus on routine laboratory tests for women. PDE5Is are the first-line medical treatment for men, with the most robust data derived from patients with spinal cord injury assessed by validated questionnaires, mainly the International Index of Erectile Function-15. There is no effective medical treatment for sexual dysfunction in women. Sacral neuromodulation for lower urinary tract dysfunction may improve sexual dysfunction in both genders. CONCLUSIONS: Although sexual dysfunction is a major burden for patients with CNS disorders, high-evidence level studies are rare and only available for PDE5Is treating erectile dysfunction. Well-designed prospective studies are urgently needed for both genders.

[Neurological diseases and nutrition -- what can we do?]. / Neurológiai kórképek és táplálás -- Mit tehetünk?

Neurological diseases and nutrition are in complex relationship. In the first part of this review the nutritional consequences of acute neurological diseases is presented, with special emphasis on traumatic injuries of the nervous system and stroke. Nutritional therapy of these patients is described in detail. In addition, chronic, degenerative neurological pathological conditions are also discussed, including nutritional consequences and possibilities of therapy. Some ethical and legal issues are also considered. The second part of this review article describes neurological consequences of nutritional problems, both deficits of macro- and micronutrients and toxic effects.

Management of faecal incontinence and constipation in adults with central neurological diseases.

BACKGROUND: People with central neurological disease or injury have a much higher risk of both faecal incontinence and constipation than the general population. There is often a fine line between the two symptoms, with any management intended to ameliorate one risking precipitating the other. Bowel problems are observed to be the cause of much anxiety and may reduce quality of life in these people. Current bowel management is largely empirical, with a limited research base. This is an update of a Cochrane review first published in 2001 and subsequently updated in 2003 and 2006. The review is relevant to individuals with any disease directly and chronically affecting the central nervous system (post-traumatic, degenerative, ischaemic or neoplastic), such as multiple sclerosis, spinal cord injury, cerebrovascular disease, Parkinson's disease and Alzheimer's disease. OBJECTIVES: To determine the effects of management strategies for faecal incontinence and constipation in people with a neurological disease or injury affecting the central nervous system. SEARCH METHODS: We searched the Cochrane Incontinence Group Trials Register (searched 8 June 2012), which includes searches of the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE and MEDLINE In-Process as well as handsearching of journals and conference proceedings; and all reference lists of relevant articles. SELECTION CRITERIA: Randomised and quasi-randomised trials evaluating any type of conservative or surgical intervention for the management of faecal incontinence and constipation in people with central neurological disease or injury were selected. Specific therapies for the treatment of neurological diseases that indirectly affect bowel dysfunction were also considered. DATA COLLECTION AND ANALYSIS: At least two review authors independently assessed the risk of bias of eligible trials and independently extracted data from the included trials using a range of pre-specified outcome measures. MAIN RESULTS: Twenty trials involving 902 people were included. Oral medications There was evidence from individual small trials that people with Parkinson's disease had a statistically significant improvement in the number of bowel motions or successful bowel care routines per week when fibre (psyllium) (mean difference (MD) -2.2 bowel motions, 95% confidence interval (CI) -3.3 to -1.4) or oral laxative (isosmotic macrogol electrolyte solution) (MD 2.9 bowel motions per week, 95% CI 1.48 to 4.32) are used compared with placebo. One trial in people with spinal cord injury showed statistically significant improvement in total bowel care time comparing intramuscular neostigmine-glycopyrrolate (anticholinesterase plus an anticholinergic drug) with placebo (MD 23.3 minutes, 95% CI 4.68 to 41.92).Five studies reported the use of cisapride and tegaserod in people with spinal cord injuries or Parkinson's disease. These drugs have since been withdrawn from the market due to adverse effects; as they are no longer available they have been removed from this review. Rectal stimulants One small trial in people with spinal cord injuries compared two bisacodyl suppositories, one polyethylene glycol-based (PGB) and one hydrogenated vegetable oil-based (HVB). The trial found that the PGB bisacodyl suppository significantly reduced the mean defaecation period (PGB 20 minutes versus HVB 36 minutes, P < 0.03) and mean total time for bowel care (PGB 43 minutes versus HVB 74.5 minutes, P < 0.01) compared with the HVB bisacodyl suppository.Physical interventions There was evidence from one small trial with 31 participants that abdominal massage statistically improved the number of bowel motions in people who had a stroke compared with no massage (MD 1.7 bowel motions per week, 95% CI 2.22 to 1.18). A small feasibility trial including 30 individuals with multiple sclerosis also found evidence to support the use of abdominal massage. Constipation scores were statistically better with the abdominal massage during treatment although this was not supported by a change in outcome measures (for example the neurogenic bowel dysfunction score).One small trial in people with spinal cord injury showed statistically significant improvement in total bowel care time using electrical stimulation of abdominal muscles compared with no electrical stimulation (MD 29.3 minutes, 95% CI 7.35 to 51.25).There was evidence from one trial with a low risk of bias that for people with spinal cord injury transanal irrigation, compared against conservative bowel care, statistically improved constipation scores, neurogenic bowel dysfunction score, faecal incontinence score and total time for bowel care (MD 27.4 minutes, 95% CI 7.96 to 46.84). Patients were also more satisfied with this method.Other interventions In one trial in stroke patients, there appeared to be a short term benefit (less than six months) to patients in terms of the number of bowel motions per week with a one-off educational intervention from nurses (a structured nurse assessment leading to targeted education versus routine care), but this did not persist at 12 months. A trial in individuals with spinal cord injury found that a stepwise protocol did not reduce the need for oral laxatives and manual evacuation of stool.Finally, one further trial reported in abstract form showed that oral carbonated water (rather than tap water) improved constipation scores in people who had had a stroke. AUTHORS' CONCLUSIONS: There is still remarkably little research on this common and, to patients, very significant issue of bowel management. The available evidence is almost uniformly of low methodological quality. The clinical significance of some of the research findings presented here is difficult to interpret, not least because each intervention has only been addressed in individual trials, against control rather than compared against each other, and the interventions are very different from each other.There was very limited evidence from individual trials in favour of a bulk-forming laxative (psyllium), an isosmotic macrogol laxative, abdominal massage, electrical stimulation and an anticholinesterase-anticholinergic drug combination (neostigmine-glycopyrrolate) compared to no treatment or controls. There was also evidence in favour of transanal irrigation (compared to conservative management), oral carbonated (rather than tap) water and abdominal massage with lifestyle advice (compared to lifestyle advice alone). However, these findings need to be confirmed by larger well-designed controlled trials which should include evaluation of the acceptability of the intervention to patients and the effect on their quality of life.

Management of faecal incontinence and constipation in adults with central neurological diseases.

BACKGROUND: People with central neurological disease or injury have a much higher risk of both faecal incontinence and constipation than the general population. There is often a fine line between the two symptoms, with any management intended to ameliorate one risking precipitating the other. Bowel problems are observed to be the cause of much anxiety and may reduce quality of life in these people. Current bowel management is largely empirical, with a limited research base. This is an update of a Cochrane review first published in 2001 and subsequently updated in 2003 and 2006. The review is relevant to individuals with any disease directly and chronically affecting the central nervous system (post-traumatic, degenerative, ischaemic or neoplastic), such as multiple sclerosis, spinal cord injury, cerebrovascular disease, Parkinson's disease and Alzheimer's disease. OBJECTIVES: To determine the effects of management strategies for faecal incontinence and constipation in people with a neurological disease or injury affecting the central nervous system. SEARCH METHODS: We searched the Cochrane Incontinence Group Trials Register (searched 8 June 2012), which includes searches of the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE and MEDLINE In-Process as well as handsearching of journals and conference proceedings; and all reference lists of relevant articles. SELECTION CRITERIA: Randomised and quasi-randomised trials evaluating any type of conservative or surgical intervention for the management of faecal incontinence and constipation in people with central neurological disease or injury were selected. Specific therapies for the treatment of neurological diseases that indirectly affect bowel dysfunction were also considered. DATA COLLECTION AND ANALYSIS: Two review authors independently assessed the risk of bias of eligible trials and independently extracted data from the included trials using a range of pre-specified outcome measures. MAIN RESULTS: Twenty trials involving 902 people were included.Oral medicationsThere was evidence from individual small trials that people with Parkinson's disease had a statistically significant improvement in the number of bowel motions or successful bowel care routines per week when fibre (psyllium) (mean difference (MD) -2.2 bowel motions, 95% confidence interval (CI) -3.3 to -1.4) or oral laxative (isosmotic macrogol electrolyte solution) (MD 2.9 bowel motions per week, 95% CI 1.48 to 4.32) are used compared with placebo. One trial in people with spinal cord injury showed statistically significant improvement in total bowel care time comparing intramuscular neostigmine-glycopyrrolate (anticholinesterase plus an anticholinergic drug) with placebo (MD 23.3 minutes, 95% CI 4.68 to 41.92).Five studies reported the use of cisapride and tegaserod in people with spinal cord injuries or Parkinson's disease. These drugs have since been withdrawn from the market due to adverse effects; as they are no longer available they have been removed from this review.Rectal stimulantsOne small trial in people with spinal cord injuries compared two bisacodyl suppositories, one polyethylene glycol-based (PGB) and one hydrogenated vegetable oil-based (HVB). The trial found that the PGB bisacodyl suppository significantly reduced the mean defaecation period (PGB 20 minutes versus HVB 36 minutes, P < 0.03) and mean total time for bowel care (PGB 43 minutes versus HVB 74.5 minutes, P < 0.01) compared with the HVB bisacodyl suppository.Physical interventionsThere was evidence from one small trial with 31 participants that abdominal massage statistically improved the number of bowel motions in people who had a stroke compared with no massage (MD 1.7 bowel motions per week, 95% CI 2.22 to 1.18). A small feasibility trial including 30 individuals with multiple sclerosis also found evidence to support the use of abdominal massage. Constipation scores were statistically better with the abdominal massage during treatment although this was not supported by a change in outcome measures (for example the neurogenic bowel dysfunction score).One small trial in people with spinal cord injury showed statistically significant improvement in total bowel care time using electrical stimulation of abdominal muscles compared with no electrical stimulation (MD 29.3 minutes, 95% CI 7.35 to 51.25).There was evidence from one trial with a low risk of bias that for people with spinal cord injury transanal irrigation, compared against conservative bowel care, statistically improved constipation scores, neurogenic bowel dysfunction score, faecal incontinence score and total time for bowel care (MD 27.4 minutes, 95% CI 7.96 to 46.84). Patients were also more satisfied with this method.Other interventionsIn one trial in stroke patients, there appeared to be a short term benefit (less than six months) to patients in terms of the number of bowel motions per week with a one-off educational intervention from nurses (a structured nurse assessment leading to targeted education versus routine care), but this did not persist at 12 months. A trial in individuals with spinal cord injury found that a stepwise protocol did not reduce the need for oral laxatives and manual evacuation of stool.Finally, one further trial reported in abstract form showed that oral carbonated water (rather than tap water) improved constipation scores in people who had had a stroke. AUTHORS' CONCLUSIONS: There is still remarkably little research on this common and, to patients, very significant issue of bowel management. The available evidence is almost uniformly of low methodological quality. The clinical significance of some of the research findings presented here is difficult to interpret, not least because each intervention has only been addressed in individual trials, against control rather than compared against each other, and the interventions are very different from each other.There was very limited evidence from individual trials in favour of a bulk-forming laxative (psyllium), an isosmotic macrogol laxative, abdominal massage, electrical stimulation and an anticholinesterase-anticholinergic drug combination (neostigmine-glycopyrrolate) compared to no treatment or controls. There was also evidence in favour of transanal irrigation (compared to conservative management), oral carbonated (rather than tap) water and abdominal massage with lifestyle advice (compared to lifestyle advice alone). However, these findings need to be confirmed by larger well-designed controlled trials which should include evaluation of the acceptability of the intervention to patients and the effect on their quality of life.

A narrative review on haptic devices: relating the physiology and psychophysical properties of the hand to devices for rehabilitation in central nervous system disorders.

PURPOSE: This article provides rehabilitation professionals and engineers with a theoretical and pragmatic rationale for the inclusion of haptic feedback in the rehabilitation of central nervous system disorders affecting the hand. METHOD: A narrative review of haptic devices used in sensorimotor hand rehabilitation was undertaken. Presented papers were selected to outline and clarify the underlying somatosensory mechanisms underpinning these technologies and provide exemplars of the evidence to date. RESULTS: Haptic devices provide kinaesthetic and/or tactile stimulation. Kinaesthetic haptics are beginning to be incorporated in central nervous system rehabilitation; however, there has been limited development of tactile haptics. Clinical research in haptic rehabilitation of the hand is embryonic but initial findings indicate potential clinical benefit. CONCLUSIONS: Haptic rehabilitation offers the potential to advance sensorimotor hand rehabilitation but both scientific and pragmatic developments are needed to ensure that its potential is realized.

[Neuro-urological dysfunction of the lower urinary tract in CNS diseases: pathophysiology, epidemiology, and treatment options]. / Neurourologische Funktionsstörungen des unteren Harntraktes bei Erkrankungen des ZNS : Pathophysiologie, Epidemiologie und Therapieoptionen.

The lower urinary tract (LUT) is regulated by a complex neural network that is subject to supraspinal control. Neurological disorders, especially of the central nervous system (CNS), can rapidly lead to disruption of this control. Multiple sclerosis, Parkinson's disease, multiple system atrophy, and stroke are neurological disorders which quite frequently cause dysfunction of the LUT. With respect to the pathophysiology of bladder dysfunction in CNS diseases there are various hypotheses regarding the individual disorders: disturbances of neural communication between the frontal cortex and pontine micturition center, between the pontine micturition center and the lumbosacral parts of the spinal cord, and between the basal ganglia, thalamus, and anterior cingulate gyrus appear to play a pivotal role in the development of bladder dysfunction. The symptoms and urodynamic presentation of LUT dysfunction can vary considerably depending on the disease and disease progression and can change in the course of the disease. The incidence and prevalence of LUT dysfunctions rise with increasing progression of the underlying neurological disease.Various conservative, minimally invasive, and open surgical procedures are available to prevent harmful sequelae and to improve the quality of life of these patients. As yet, however, few data exist on most of the treatment options in cases of the above-mentioned CNS diseases. Intermittent self-catheterization and antimuscarinic medications are among the most important conservative treatment options. Injection of botulinum neurotoxin type A into the detrusor muscle and increasingly sacral or pudendal neuromodulation are among the most important minimally invasive treatment options. Surgical methods include reconstructive continent or incontinent urinary diversion.When planning therapy the patient's current needs and neurological limitations as well as possible disease progression must be taken into consideration. It is often advisable to consult with and enlist the cooperation of the attending neurologist when planning treatment.

Langerhans cell histiocytosis with central nervous system involvement--complete response to 2-chlorodeoxyadenosine after failure of tyrosine kinase inhibitor therapies with sorafenib and imatinib.

Langerhans cell histiocytosis (LCH) is rare in adults, and only a subset of these patients suffers from central nervous system (CNS) involvement. Hence, evidence-based treatment recommendations are lacking. A case of a 20-year-old student with multisystem LCH and extensive CNS involvement is described, who showed a durable response to 2-chlorodeoxyadenosine after prior therapies with the tyrosine kinase inhibitors sorafenib and imatinib. In accordance to the experiences provided by other case series, which are reviewed herein, 2-chlorodeoxyadenosine can be considered an effective and safe option for adult LCH with CNS involvement.

[Computer-aided techniques for the treatment and rehabilitation of patients suffering vertigo and balance disorders].

A new computerized method is proposed for the correction and elimination of undesirable illusory sensations (dizziness), vestibulo-oculomotor (nystagmus), and vestibulo-postural (imbalance) reactions. The method allows to teach the subject about how to avoid generalization of afferent signals over the effector mechanisms in the central nervous system by developing a fixational reflex employing delayed biological feedback for the assessment of efforts being exerted (self-control of training results). Three variants of application of this technique were evaluated depending on the type of stimulation software intended to induce illusory and oculomotor reactions of a defined sensory modality (visual, vestibular or combined). The study involved 30 subjects divided into three groups. They had been taught using the visual (group 1), vestibular (group 2) or combined (group 3) methods. Each group was comprised of an approximately equal number of subjects with vestibulopathies of either peripheral or central origin. The study demonstrated that the proposed approach allows to invoke, with the use of a computer stimulation software, abnormal illusory and vestibulo-oculomotor responses and inhibit them by developing the adequate fixational reflex. Comparative analysis of the results obtained by teaching the patients with the help of the three different methods revealed the dependence of their effectiveness on the level of disturbances in the vestibular system. The visual method of correction proved to be especially efficacious for the patients with peripheral vestibulopathy, and the vestibular methods for the patients with central vestibulopathy. Patients with combined peripheral and central vestibulopathy required the choice of training modalities (either visual or vestibular) on an individual basis.

The role of hyperhomocysteinemia and B-vitamin deficiency in neurological and psychiatric diseases.

Hyperhomocysteinemia (HHcy) is related to central nervous system diseases. Epidemiological studies show a positive, dose-dependent relationship between plasma total homocysteine (tHcy) concentration and neurodegenerative disease risk. tHcy is a marker of B-vitamin (folate, B(12), B(6)) status. Hypomethylation, caused by low B-vitamin status and HHcy, is linked to key pathomechanisms of dementia; B-vitamin supplementation could potentially reduce neurological damage. In retrospective studies, the association between tHcy and cognition is impressive; there is also evidence that tHcy-lowering treatment could be effective in primary and secondary stroke prevention. Increased tHcy and low serum folate occur in patients with Parkinson's disease, especially those receiving L-dopa. There is also an association between HHcy and multiple sclerosis, and between B-vitamin status and depression. Studies also confirm a causal role for tHcy in epilepsy, and certain anti-epileptics enhance HHcy. B-vitamin status should be optimized by ensuring sufficient intake in patients with neuropsychiatric diseases. HHcy occurs commonly in the elderly and can contribute to age-related neurodegeneration. Treatment with folic acid, B(12) and B(6) lowers tHcy. For secondary and primary prevention from several neuropsychiatric disorders, it seems prudent to actively identify deficient subjects and ensure sufficient vitamin intake.

Psychoneuroimmunology and related mechanisms in understanding health disparities in vulnerable populations.

The nervous system as well as the endocrine system maintain extensive communication with the immune system through the influence of hormones and neurotransmitters and also by way of the hardwiring of sympathetic and parasympathetic nerves to the lymphoid organs. There is now convincing evidence that the communication between these three body systems is bidirectional. This chapter will provide a succinct review of how neuroendocrine and immune functions are affected in factors that impact vulnerability, such as aging, acute infection, and central nervous system injury. Given that the relevant literature on these topics is vast, the presentation in this chapter will serve to highlight primary references that reflect state of the science in these systems of focus.

Extradural cortical stimulation for central pain.

Central pain results from a central nervous system injury and represents a challenge for the pain therapist. Human studies have shown that motor cortex stimulation (MCS), i.e. the placement of a stimulating plate on the dura overlying the motor cortex can relieve brain central pain. Studies suggest that MCS directly affects activity in the first and second order somatosensory areas, thalamic nuclei and also inhibits spinal primary afferents and spinothalamic tract neurons. The following factors have been found to predict analgesia by MCS: intact or almost intact corticospinal motor function, mild or negligible sensory loss, absence of thermal sensory threshold alteration within the painful area, positive response to the barbiturate and/or ketamine test, positive response to the propofol test, positive response to transcranial magnetic stimulation (TMS). The targeting of the cortical area is made by anatomical localization by computed tomography (CT), magnetic resonance imaging (MRI), neuronavigation, intraoperative neurophysiological recordings, functional MRI (fMRI), and intraoperative clinical assessment. We perform the procedure under local anaesthesia. We describe in detail our surgical technique and stimulation protocol. Furthermore, we review the most important studies with respect to their results, the observed side effects and complications. The future prospects and likely developments of MCS for central pain are also discussed.

Aporte clínico en la patología cráneo cervico mandibular / Clinical contribution in cranio-cervical-mandibular pathology

Introducción: El objetivo de este trabajo es valorar las alteraciones biomecánicas que conllevan a desequilibrios musculares, causadas principalmente por hipoactividad o hiperactividad muscular y movilidad articular limitada. Material y método: Se realiza una propuesta de evaluación que involucra tres aspectos relacionados, que son: Una modificación de la pauta original hecha para pacientes con trastornos temporomandibulares, desarrollada por el Dr. Prof. Mariano Rocabado. Aspectos de la evaluación orofacial, que es un segmento perteneciente al curso básico de Evaluación y tratamiento de la hemiplejia del adulto, Bobath, y la Evaluación muscular de Daniels-Worthingham's para músculos mandibulares y cervico-torácicos. Se evaluaron 13 pacientes adultos, secuelados de Parálisis Cerebral Espástica (PCE), Accidente Cerebrovascular (ACV), Traumatismo Encefalocraneano (TEC), Esclerosis Lateral Amiotrófica (ELA) y Enfermedad de Parkinson (EP), pertenecientes a Centros de neurorehabilitación especializados (Fundación Alterego/Centro Los Coihues). Conclusiones: El grupo de pacientes con mayor compromiso neurológico (ELA, ACV hemorrágico y PCE) son los más comprometidos, en cuanto a debilidad de grupos musculares estabilizadores cervicales (principalmenete Esternocleidomasteoideo), grado funcional moderado de pterigoideos interno y externo, aumento de tono en masetero y temporal (no mensurable aún, pero inferido por la menor apertura bucal), y alteraciones posturales cervicotoracicas, de preferencia.