Evaluation of the Cutaneous Silent Period in a Healthy Brazilian Population.

PURPOSE: To establish cutaneous silent period (CSP) normative values and investigate the variables that may influence them. METHODS: We tested 41 healthy subjects. All subjects underwent nerve conduction studies, and we evaluated the CSP in both arms. RESULTS: Four subjects did not have CSP and were excluded. The analyses were performed in the healthy group composed of 23 women and 14 men, with a mean age of 35 (range, 19-64) years. The CSP median duration was 23.2 milliseconds (ms), with 2 to 98th percentile at 11.3 and 48.7 ms. The median onset latency was 87.9 (range, 72.9-109) ms, and the median end latency was 112 (range, 93.8-138) ms. The CSP onset latency positively correlated with height, whereas CSP end latency and duration were weakly but significantly associated with age. Some measurements of ulnar nerve conduction study also correlated with CSP measures. The interrater coefficients for the primary measures of onset and end latency demonstrates the reproducibility of the method. CONCLUSIONS: The CSP with the fifth digit stimulation and recording from the abductor digiti minimi muscle is a valid diagnostic tool that can be used in clinical practice.

Motor cortical excitability behavior in chronic spinal cord injury neuropathic pain individuals submitted to transcranial direct current stimulation-case reports.

INTRODUCTION: Increased excitability of the motor cortex through transcranial direct current stimulation (tDCS) has been described as a non-pharmacological strategy for the treatment of Spinal Cord Injury neuropathic pain (SCINP). It is also believed that the ability to enhance motor cortex excitability (MCE) could be impaired within chronic SCINP individuals. The following case reports describe the MCE behavior in individuals with chronic SCINP submitted to electrical non-invasive neuromodulation. CASE PRESENTATIONS: This article reports 11 cases with chronic SCINP in which each individual was submitted to a 5-day pre-post MCE analysis in order to evaluate its behavior after the anodal tDCS sessions. All cases maintained ongoing pharmacological treatment. Four individuals have shown negative variation of the MCE, two of which reported pain intensity reduction. Three other individuals had MCE-positive variation along 5 days, from which only one reported a VAS 0.5 pain reduction after the 5th day of observation. The other four individuals did not present significant variation of the MCE. DISCUSSION: The positive variation of MCE was significantly altered by adjunctive tDCS only in three individuals, though no clinically relevant reduction in pain intensity was reported among these participants. Key factors such as pain and injury duration, age, chronic medication use and underlying maladaptive neuroplasticity may influence responsiveness to brain stimulation within this population. These case reports try to add evidence for cautious recommendation of tDCS in chronic SCINP individuals and to the necessity of identifying groups of individuals that are most susceptible to neuromodulation.

Effects of Caffeine on Behavioural and Cognitive Deficits in Rats.

There are many studies that have sought to find drug therapies to prevent harm arising from sepsis. Such studies have represented a progress in the support to septic patients and also in the development of new pharmacological alternatives. Our interest was to investigate the caffeine effect on sepsis behavioural and memory impairments. Male rats were anaesthetized and the surgery was made to allow exposure of the caecum, which was then squeezed to extrude a small amount of faeces from the perforation site, which was later placed back into the peritoneal cavity. This procedure, which served to generate experimental sepsis, is herein referred to as ceccum ligation and perforation (CLP). The caffeine (10 mg/kg) was administered by gavage route, once daily, during 7 or 14 consecutive days to investigate the effects of acute or subchronic caffeine treatment on long-term behavioural and cognitive deficits induced by CLP. On the last day, 1 hr after caffeine administration, the animals were submitted to open-field, elevated plus maze (EPM), forced swimming and step-down inhibitory avoidance tests. The results showed that caffeine increased the percentage of open arm entries and open arm time in the EPM test, and reduced the immobility time when compared to the sham-operated group. The caffeine also increased the latency in the inhibitory avoidance test platform. Our results demonstrated that the caffeine improved behavioural changes and improved the neurocognitive deficits of sepsis-surviving animals. It is possible that blockage of the adenosine receptors may be responsible for the results here observed.

Effects of Prefrontal Transcranial Direct Current Stimulation and Motivation to Quit in Tobacco Smokers: A Randomized, Sham Controlled, Double-Blind Trial.

Transcranial direct current stimulation (tDCS) applied over the dorsolateral prefrontal cortex (DLPFC) has been shown to reduce cravings in tobacco addiction; however, results have been somewhat mixed. In this study, we hypothesized that motivation to quit smoking is a critical factor of tDCS effects in smokers. Therefore, we conducted a double-blind, randomized clinical trial to evaluate the effects of both tDCS and motivation to quit on cigarette consumption and the relationship between these two factors. DLPFC tDCS was applied once a day for 5 days. Our primary outcome was the amount of cigarettes smoked per day. We collected this information at baseline (d1), at the end of the treatment period (d5), 2 days later (d7) and at the 4-week follow-up (d35). Visual Analog Scale (VAS) for motivation to quit was collected at the same time-points. 36 subjects (45 ± 11 years old; 24.2 ± 11.5 cigarettes daily smoked, 21 women) were randomized to receive either active or sham tDCS. In our multivariate analysis, as to take into account the mediation and moderation effects of motivation to quit, we found a significant main effect of tDCS, showing that tDCS was associated with a significant reduction of cigarettes smoked per day. We also showed a significant interaction effect of motivation to quit and treatment, supporting our hypothesis that tDCS effects were moderated by motivation to quit, indicating that higher levels of motivation were associated with a larger tDCS response. We found that the participants' motivation to quit alone, both at baseline and at follow-up, does not explain the decrease in the average cigarette consumption. Repetitive prefrontal tDCS coupled with high motivation significantly reduced cigarette consumption up to 4-weeks post-intervention. CLINICAL TRIAL REGISTRATION: http://ClinicalTrials.gov, NCT02146014.

ASSERT trial - How to assess the safety and efficacy of a high frequency rTMS in postpartum depression ? A multicenter, double blinded, randomized, placebo-controlled clinical trial.

BACKGROUND: Postpartum Depression affects a considerable number of women worldwide. This condition inflicts severe consequences to mother and child health. Thus far, available treatments have low response and high relapse rates. We designed this trial to evaluate a safe and more efficacious innovative therapy. AIMS: To report a feasible and ethical study design to assess the safety and efficacy of a high frequency repetitive Transcranial Magnetic Stimulation 10 Hz (rTMS) compared to sham rTMS in women with moderate to severe Post-Partum Depression using standard treatment (sertraline).To conduct an ancillary, exploratory, randomized, active controlled, double blind study with a hypothesis to assess the safety and efficacy of 10 Hz rTMS compared to sertraline. METHODS: A multicenter, parallel arm, randomized, placebo-controlled, double-blind design to assess safety and efficacy of 10 Hz rTMS compared to sham.An ancillary study will be conducted with parallel arm, randomized, active controlled and double dummy design to assess safety and efficacy of 10 Hz rTMS compared to sertraline.

Transcranial magnetic stimulation and transcranial direct current stimulation appear to be safe neuromodulatory techniques useful in the treatment of anxiety disorders and other neuropsychiatric disorders.

Transcranial magnetic stimulation (TMS) has recently been investigated as a possible adjuvant treatment for many neuropsychiatric disorders, and has already been approved for the treatment of drug-resistant depression in the United States and in Brazil, among other countries. Although its use in other neuropsychiatric disorders is still largely experimental, many physicians have been using it as an off-label add-on therapy for various disorders. More recently, another technique, transcranial direct current stimulation (tDCS), has also become available as a much cheaper and portable alternative to TMS, although its mechanisms of action are different from those of TMS. The use of off-label therapeutic TMS or tDCS tends to occur in the setting of diseases that are notoriously resistant to other treatment modalities. Here we discuss the case of anxiety disorders, namely panic and post-traumatic stress disorders, highlighting the uncertainties and potential problems and benefits of the clinical use of these neuromodulatory techniques at the current stage of knowledge.

Transcranial magnetic stimulation and transcranial direct current stimulation appear to be safe neuromodulatory techniques useful in the treatment of anxiety disorders and other neuropsychiatric disorders / Uso clínico da estimulação magnética transcraniana e da estimulação transcraniana por corrente direta em transtornos de ansiedade e de transtornos neuropsiquiátricos

ABSTRACT Transcranial magnetic stimulation (TMS) has recently been investigated as a possible adjuvant treatment for many neuropsychiatric disorders, and has already been approved for the treatment of drug-resistant depression in the United States and in Brazil, among other countries. Although its use in other neuropsychiatric disorders is still largely experimental, many physicians have been using it as an off-label add-on therapy for various disorders. More recently, another technique, transcranial direct current stimulation (tDCS), has also become available as a much cheaper and portable alternative to TMS, although its mechanisms of action are different from those of TMS. The use of off-label therapeutic TMS or tDCS tends to occur in the setting of diseases that are notoriously resistant to other treatment modalities. Here we discuss the case of anxiety disorders, namely panic and post-traumatic stress disorders, highlighting the uncertainties and potential problems and benefits of the clinical use of these neuromodulatory techniques at the current stage of knowledge.

RESUMO A estimulação magnética transcraniana (TMS) foi recentemente proposta como um possível tratamento adjuvante para muitos distúrbios neuropsiquiátricos, e já foi aprovada para o tratamento de depressão fármaco-resistente nos Estados Unidos e no Brasil, entre outros países. Apesar do fato de que seu uso em outros transtornos neuropsiquiátricos ainda é em grande parte experimental, muitos médicos têm utilizado essas técnicas como uma terapia off-label em várias doenças. Mais recentemente, uma outra técnica, a estimulação transcraniana por corrente contínua (ETCC), tornou-se também disponível como uma alternativa muito mais barata e portátil do que a TMS, embora os seus mecanismos de ação sejam diferentes daqueles da TMS. O uso off-label de TMS ou ETCC tende a ocorrer no caso de doenças que são notoriamente resistentes a outras modalidades terapêuticas. Aqui nós discutimos o caso dos transtornos de ansiedade, ou seja, transtorno do pânico e estresse pós-traumático, destacando as incertezas, benefícios e problemas potenciais inerentes ao uso clínico dessas técnicas neuromoduladoras no atual estágio do conhecimento.

[Risk factors associated with suicides in Palmas in the state of Tocantins, Brazil, between 2006 and 2009 investigated by psycho-social autopsy]. / Fatores de risco relacionados com suicídios em Palmas (TO), Brasil, 2006-2009, investigados por meio de autópsia psicossocial.

The scope of this article is to analyze and describe the risk factors and determinants linked to 24 suicides in the city of Palmas in the state of Tocantins between 2006 and 2009. The psychological and psycho-social autopsy method was used in order to investigate the consummated suicides by interviewing family members. It contextualized the subjects' life characteristics to understand the family dynamics and the affective, social, economic and cultural background, based on the reconstruction of the history and personality of the individuals. The associated socio-economic factors were: being male, aged between 20 and 40, single, with mixed ethnicity and basic education. The major risk factors identified were: mental disorder, alcohol and other drug abuse, disturbed family relationship and a history of previous suicide attempts. An attempt was made to contextualize and reflect on some cases reported by family members, as well as on the response of the health care teams to the demands of the families. The need to implement prevention programs and to train the primary health care professionals was considered a priority.

Fatores de risco relacionados com suicidios em Palmas (TO), Brasil, 2006-2009, investigados por meio de autopsia psicossocial / Risk factors associated with suicides in Palmas in the state of Tocantins, Brazil, between 2006 and 2009 investigated by psycho-social autopsy

Este artigo objetiva analisar e descrever os fatores de risco e seus determinantes, associados a 24 casos de suicídios ocorridos na cidade de Palmas (TO), no período de 2006 a 2009. Utilizou-se o método de autópsia psicológica e psicossocial, a qual, por meio de entrevistas com familiares, busca investigar os suicídios consumados, contextualizando características da vida do sujeito, e compreender os processos familiares e as circunstâncias afetivas, sociais, econômicas e culturais, fundamentando-se na reconstrução da história e da personalidade da pessoa. Os fatores socioeconômicos associados foram: ser do sexo masculino, solteiro, de cor parda, estar na faixa etária de 20 a 40 anos e com ensino fundamental. Os principais fatores de risco identificados foram: transtornos mentais, abuso de álcool e outras drogas, relacionamento familiar conturbado e histórico de tentativas anteriores. Buscamos contextualizar e refletir sobre alguns casos relatados pelos familiares e sobre a resposta das equipes de saúde às demandas das famílias. A necessidade de implantar programas de prevenção e de capacitar os profissionais da atenção básica foi verificada. .

The scope of this article is to analyze and describe the risk factors and determinants linked to 24 suicides in the city of Palmas in the state of Tocantins between 2006 and 2009. The psychological and psycho-social autopsy method was used in order to investigate the consummated suicides by interviewing family members. It contextualized the subjects' life characteristics to understand the family dynamics and the affective, social, economic and cultural background, based on the reconstruction of the history and personality of the individuals. The associated socio-economic factors were: being male, aged between 20 and 40, single, with mixed ethnicity and basic education. The major risk factors identified were: mental disorder, alcohol and other drug abuse, disturbed family relationship and a history of previous suicide attempts. An attempt was made to contextualize and reflect on some cases reported by family members, as well as on the response of the health care teams to the demands of the families. The need to implement prevention programs and to train the primary health care professionals was considered a priority. .

Normative study of tympanic infrared thermometry: a non-invasive index of asymmetric cerebral activity.

Human and primate studies have demonstrated that performance of tasks that induce asymmetrical physiological activation of the cerebral hemispheres leads to a reduction of tympanic temperature (TT) ipsilateral to the most active hemisphere. It is possible that diseases that interfere in an asymmetrical fashion with the degree of cerebral activity cause similar TT changes. There are not, however, normative studies of the acceptable interaural difference in TT in normal subjects at rest. This study was done to establish normative values for interaural TT values measured by means of infrared tympanic thermometry in resting normal subjects not engaged in any specific task. TT values were measured in 47 normal volunteers (20 men and 27 women, aged 39.38+/-12.57 years old) at rest; mean interaural differences of TT were calculated. Mean right ear TT was 36.85+/-0.50 degrees C and mean left ear TT was 36.74+/-0.57 degrees C; these values are in agreement with those already reported in the literature. Mean interaural TT difference was 0.25 degrees C (SD 0.21 degrees C). These findings indicate that maximal normal values for interaural TT differences, with confidence levels of 99% and 95%, are, respectively, 0.88 and 0.67 degrees C. The value of interaural differences of TT as a marker of asymmetrical hemispheric activity in neurological patients will have to be established by additional studies.

Normative study of tympanic infrared thermometry: a non-invasive index of asymmetric cerebral activity

Human and primate studies have demonstrated that performance of tasks that induce asymmetrical physiological activation of the cerebral hemispheres leads to a reduction of tympanic temperature (TT) ipsilateral to the most active hemisphere. It is possible that diseases that interfere in an asymmetrical fashion with the degree of cerebral activity cause similar TT changes. There are not, however, normative studies of the acceptable interaural difference in TT in normal subjects at rest. This study was done to establish normative values for interaural TT values measured by means of infrared tympanic thermometry in resting normal subjects not engaged in any specific task. TT values were measured in 47 normal volunteers (20 men and 27 women, aged 39.38±12.57 years old) at rest; mean interaural differences of TT were calculated. Mean right ear TT was 36.85±0.50ºC and mean left ear TT was 36.74±0.57ºC; these values are in agreement with those already reported in the literature. Mean interaural TT difference was 0.25ºC (SD 0.21ºC). These findings indicate that maximal normal values for interaural TT differences, with confidence levels of 99 percent and 95 percent, are, respectively, 0.88 and 0.67ºC. The value of interaural differences of TT as a marker of asymmetrical hemispheric activity in neurological patients will have to be established by additional studies.

Estudos em humanos e outros primatas demonstraram que a realização de tarefas que causam ativação assimétrica fisiológica dos hemisférios cerebrais resulta em redução da temperatura timpânica (TT) ipsilateral ao hemisfério cerebral mais ativo. É possível que patologias que interfiram de modo assimétrico com o grau de atividade cerebral causem alterações similares da TT. Não existem, entretanto, estudos normativos da diferença normal aceitável de TT entre os tímpanos de um mesmo indivíduo em repouso. Este estudo teve como objetivo estabelecer uma normatização dos valores bilaterais da TT, e principalmente das diferenças interauriculares desse parâmetro, obtidas por termometria timpânica por infravermelho, em indivíduos normais, na ausência de execução de tarefas específicas. Foram obtidas medidas da TT em 47 voluntários normais (20 homens e 27 mulheres, com média de idade de 39,38±12,57 anos) em repouso e calculadas as diferenças interauriculares, sua média e desvio-padrão. A TT média foi de 36,85±0,50ºC à direita e de 36,74± 0,57ºC à esquerda, o que está de acordo com dados da literatura. A média das diferenças de TT encontrada foi de 0,25ºC e o desvio padrão (DP) 0,21ºC. Com base nesses achados, os valores máximos considerados normais para a diferença interauricular da TT, com níveis de confiança de 99 por cento e de 95 por cento, são de 0,88ºC e 0,67ºC, respectivamente. A utilidade da medida da diferença interauricular da TT como marcador de assimetria da atividade cerebral em pacientes com patologias neurológicas deverá ser avaliada em estudos adicionais.

[Transcranial Magnetic Stimulation in depression: results of bi-weekly treatment]. / Estimulação Magnética Transcraniana na depressão: resultados obtidos com duas aplicações semanais.

OBJECTIVE: Transcranial Magnetic Stimulation (TMS) has been shown to be a useful therapy for depression. This paper evaluates the results of bi-weekly low-frequency TMS of 4 weeks duration, in 10 patients with depression who do not respond or are intolerant to antidepressive medication. METHODS: This is a case series study. DMS-IV criteria were used to diagnose depression. In order to disclose possible improvements in depressive symptoms, the 17 items Hamilton scale was used at three different moments: at the beginning, middle and end of the treatment period. Results were analysed using Friedman's chi2 test. RESULTS: Hamilton's scale score improvement was > 50% in five patients and > 75% in 3 of these. CONCLUSIONS: TMS may be efficacious, safe and easily performed as an adjunct to medical treatment of depression. We cannot differentiate a potentiation of the effect of antidepressive medication from an intrinsic effect of TMS alone, since we did not treat any subjects without the concurrent use of medication.

Aspectos da história e evolução da estimulação magnética transcraniana / aspects of transcranial magnetic stimulation history and evolution

Este artigo descreve o surgimento da estimulação magnética transcraniana (EMT) desde os primórdios do uso do campo magnético em seres vivos, como instrumento de pesquisa e método terapêutico, até o estágio atual, com as principais indicações na psiquiatria e considerações sobre o seu uso

Estimulação Magnética Transcraniana na depressão: resultados obtidos com duas aplicações semanais / Transcranial Magnetic Stimulation in depression: results of bi-weekly treatment

OBJETIVO: A Estimulação Magnética Transcraniana (EMT) tem se mostrado útil como forma terapêutica para a depressão. Este artigo avalia os resultados da aplicação da EMT de baixa freqüência, duas vezes por semana, durante quatro semanas, em 10 pacientes com depressão, não responsivos ou intolerantes à utilização de antidepressivos. MÉTODOS: Trata-se de um estudo descritivo, ou não controlado, do tipo série de casos. Para diagnosticar a depressão, foram utilizados os critérios do DSM-IV. Com o intuito de avaliar uma possível melhora, utilizamos a escala de Hamilton-17 itens em três momentos: no início, meio e final do tratamento. Para análise estatística dos resultados, utilizamos o teste x², de Friedman. RESULTADOS: Foi observada melhora > 50 por cento na escala em cinco pacientes e > 75 por cento em três destes ao longo de todo o tratamento. CONCLUSÕES: O emprego da EMT de baixa freqüência, aplicada duas vezes por semana, pode ser seguro, prático e eficaz no tratamento da depressão, como um coadjuvante ao antidepressivo. Porém, não podemos afirmar se o efeito clínico apresentado se deve a uma potencialização dos antidepressivos ou a um efeito direto da EMT, já que esta não foi testada isoladamente.

Experimental therapy of epilepsy with transcranial magnetic stimulation: lack of additional benefit with prolonged treatment.

OBJECTIVE: To investigate the effect of three months of low-frequency repetitive transcranial magnetic stimulation (rTMS) treatment in intractable epilepsy. METHODS: Five patients (four males, one female; ages 6 to 50 years), were enrolled in the study; their epilepsy could not be controlled by medical treatment and surgery was not indicated. rTMS was performed twice a week for three months; patients kept records of seizure frequency for an equal period of time before, during, and after rTMS sessions. rTMS was delivered to the vertex with a round coil, at an intensity 5% below motor threshold. During rTMS sessions, 100 stimuli (five series of 20 stimuli, with one-minute intervals between series) were delivered at a frequency of 0.3 Hz. RESULTS: Mean daily number of seizures (MDNS) decreased in three patients and increased in two during rTMS--one of these was treated for only one month; the best result was achieved in a patient with focal cortical dysplasia (reduction of 43.09% in MDNS). In the whole patient group, there was a significant (p<0.01) decrease in MDNS of 22.8%. CONCLUSION: Although prolonged rTMS treatment is safe and moderately decreases MDNS in a group of patients with intractable epilepsy, individual patient responses were mostly subtle and clinical relevance of this method is probably low. Our data suggest, however, that patients with focal cortical lesions may indeed benefit from this novel treatment. Further studies should concentrate on that patient subgroup.

Experimental therapy of epilepsy with transcranial magnetic stimulation: lack of additional benefit with prolonged treatment

OBJETIVO: investigar o efeito de três meses de estimulação magnética transcraniana repetitiva (EMTr) de baixa freqüência, na epilepsia de difícil controle. MÉTODO: Cinco pacientes (quatro homens, uma mulher, idades entre 6 e 50 anos), participaram do estudo; suas crises epilépticas não puderam ser controlados por tratamento medicamentoso e não tinham indicação cirúrgica; a EMTr foi realizada duas vezes por semana durante três meses, sendo que os pacientes anotaram o número diário de crises neste período, assim como nos três meses anteriores e posteriores ao tratamento. A aplicação da EMTr foi feita no vértex com bobina circular, com intensidade 5 por cento abaixo do limiar motor. Durante as sessões de EMTr, 100 estímulos (5 séries de 20 estímulos, com um minuto de intervalo entre as séries) foram realizadas na freqüência de 0,3 Hz. RESULTADOS: A média diária de crises (MDC) decresceu em três pacientes e aumentou em dois durante o uso da EMTr; um destes casos foi tratado somente por um mês; o melhor resultado foi encontrado em um paciente com displasia cortical focal (redução de 43,09 por cento na MDC). Em todo o grupo de pacientes, houve decréscimo significativo na MDC de 22,8 por cento (p<0,01). CONCLUSAO: Embora o tratamento prolongado com a EMTr seja seguro e tenha sido registrado decréscimo moderado da MDC em um grupo de pacientes com epilepsia de difícil controle, respostas individuais de pacientes foram imprevisíveis e a relevância clínica deste método é provavelmente baixa. Nossos dados sugerem, contudo, que pacientes com lesões corticais focais podem ser beneficiar deste novo tipo de tratamento. Estudos futuros devem se concentrar neste grupo de pacientes.

Estimulação magnética transcraniana de baixa freqüência no tratamento da depressão / Low frequency transcranial magnetic stimulation for treatment of depression

Este artigo descreve aspectos neurofisiológicos e clínicos do uso da estimulação magnética transcraniana repetitiva (EMTr), especialmente a de baixa freqüência. Técnicas de neuroimagem e hipóteses sobre o funcionamento da EMTr em longo prazo são abordados. Alguns resultados de estudos que envolvem EMTr de baixa freqüência no tratamento da depressão são citados, especialmente um estudo realizado na Universidade de Brasília usando a aplicação da EMTr de baixa freqüência (0,5Hz), duas vezes por semana, durante quatro semanas, em dez pacientes. Neste estudo utilizando a escala de Hamilton de 17 itens, os pacientes foram analisados em três momentos: T-0, T-1 e T-2, respectivamente, início, meio e final das aplicações. Como resultado se observou um decréscimo significativo (p < 0,01) nas suas pontuações, quando comparados os três momentos, utilizando-se o teste x² de Friedman. As possíveis vantagens desta técnica são discutidas.