Appearance of fetal pain could be associated with maturation of the mesodiencephalic structures.

Fetal pain remains a controversial subject both in terms of recognizing its existence and the time-frame within which it appears. This article investigates the hypothesis that pain perception during development is not related to any determined structures of the central nervous system (CNS), on the contrary, the process of perception could be made with any structure satisfying conditions that the perception of pain is the organization, identification, and interpretation of sensory information in order to represent and understand the environment. According to this definition, chronic decerebrate and decorticate experimental animals, anencephalic, and hydranencephalic patients demonstrate that the basic, most general, appropriate interaction with the environment can be achieved with a functional mesodiencephalon (brain stem, and diencephalon) as the hierarchically highest structure of the CNS during development. In intact fetuses, this structure shows signs of sufficient maturation starting from the 15th week of gestation. Bearing in mind the dominant role of the reticular formation of the brain stem, which is marked by a wide divergence of afferent information, a sense of pain transmitted through it is diffuse and can dominate the overall perception of the fetus. The threshold for tactile stimuli is lower at earlier stages of gestation. The pain inhibition mechanisms are not sufficiently developed during intrauterine development, which is another factor that leads to increased intensity of pain in the fetus. As a conclusion it could be proposed that the fetus is exposed to rudimentary painful stimuli starting from the 15th gestation week and that it is extremely sensitive to painful stimuli.

Guillain-Barré syndrome in the elderly.

The aim of the study was to analyze specific features of Guillain-Barré syndrome (GBS) in old people. The study included 403 GBS patients (62% young [<60 years], 35% young-old [60-80 years], and 3% old-old [>80 years]). Diagnosis of GBS was made according to the National Institute of Neurological Disorders and Stroke (NINDS criteria). Severe disability (GBS disability score of >3) at nadir was more common in old compared with young patients (p = 0.0001) as was mortality (9% vs. 2%, respectively). Acute motor and sensory axonal neuropathy and hyponatremia were more common in old compared with young patients (12% vs. 6% and 27% vs. 18%, respectively, p = 0.04). A positive history for malignancy was more than three times more common in old than young patients (11% vs. 3%, respectively, p = 0.01). Disability on nadir was similar in young-old and old-old subjects with disability on discharge being more severe in old-old (p = 0.04) suggesting slower recovery in this subgroup. Bulbar symptoms were more common in old-old compared with young-old (50% vs. 19%, respectively, p = 0.01). Comorbidities were present in virtually all old-old patients compared with 66% of young-old patients (p = 0.04). In conclusion, Elderly patients, and especially old-old patients, with GBS have more severe disease with slower recovery than do younger patients.

Intravenous thrombolysis in acute ischemic stroke due to occlusion of internal carotid artery - a Serbian Experience with Thrombolysis in Ischemic Stroke (SETIS).

OBJECTIVE: The benefit of intravenous thrombolysis in patients with internal carotid artery (ICA) occlusion is still unclear. The aim of this study was to assess the influence on outcome of intravenous thrombolysis in patients with ICA occlusion comparing to those without it. METHODS: Data were from the national register of all acute ischemic stroke patients treated with intravenous thrombolysis in Serbia. Patients with nonlacunar anterior circulation infarction were included and were divided into two groups, those with and those without ICA occlusion. We compared the differences in demographic characteristics, risk factors, baseline NIHSS score, early neurological improvement, 3-month functional outcome, complications and death between these two groups. RESULTS: Among 521 included patients there were 13.4% with ICA occlusion. Group with ICA occlusion had more males (82.9% vs. 60.5%; p=0.0008), and more severe stroke (baseline NIHSS score 15.3 vs. 13.6; p=0.004). Excellent functional outcome (mRS 0-1) at 3 months was recorded in 32.9% patients with ICA occlusion and in 50.6% patients without (p=0.009), while favorable functional outcome (mRS 0-2) was recorded in 50.0% of patients with ICA occlusion vs. 60.1% without (p=0.14). Death occurred in 12.9% patients with ICA occlusion and in 17.3% patients without it (p=0.40). There was no significant difference in rate of symptomatic ICH between the two groups (1.4% vs. 4.2%; p=0.5). Multivariate logistic regression analysis showed that ICA occlusion was associated with the absence of early neurological improvement (p=0.03; OR 1.78, 95% CI 1.05-3.04). However, the presence of ICA occlusion was not significantly associated with an unfavorable outcome at 3-month (p=0.44; OR 1.24, 95% CI 0.72-2.16) or with death (p=0.18; OR 0.57, 95% CI 0.25-1.29). CONCLUSION: The patients with ICA occlusion treated with intravenous thrombolysis have a worse outcome than patients without it.

Clinical and epidemiological features of Guillain-Barré syndrome in the Western Balkans.

The aim of this study was to define features of Guillain-Barré syndrome in a large cohort of patients from three Western Balkans countries. Data from adult Guillain-Barré syndrome (GBS) cases from 2009 to 2013 were retrospectively obtained from all tertiary health care centers. During the 5-year period, 327 new cases of GBS were identified with a male to female ratio of 1.7 : 1. The most common GBS variants were demyelinating (65%) and axonal (12%). At nadir 45% of patients were chair-bound, confined to bed, or required assisted ventilation, while 5% died. The crude incidence of GBS in Serbia and Montenegro was 0.93 per 100,000 population, and age-adjusted incidence according to the world standard population was 0.86 per 100,000. Incidence was particularly high in 50- to 80-year-old men. Statistically significant seasonal variations of GBS were not observed. This study of patients with GBS in the Western Balkans allows us to prepare the health system better and to improve the management of patients. This study also opens opportunities for international collaboration and for taking part in the multinational studies on GBS.

[Autoimmune polyglandular syndrome, type 2 associated with myasthenia gravis].

INTRODUCTION: Autoimmune polyglandular syndrome type 2 is defined as adrenal insufficiency associated with autoimmune primary hypothyroidism and/or with autoimmune type 1 diabetes mellitus, but very rare vith myasthenia gravis. CASE REPORT: We presented a case of an autoimmune polyglandular syndrome, type 2 associated with myasthenia gravis. A 49-year-old female with symptoms of muscle weakness and low serum levels of cortisol and aldosterone was already diagnosed with primary adrenal insufficiency. Primary hypothyroidism was identified with low values of free thyroxine 4 (FT4) and raised values of thyroidstumulating hormone (TSH). The immune system as a cause of hypothyroidism was confirmed by the presence of thyroid antibodies to peroxidase and TSH receptors. Myasthenia gravis was diagnosed on the basis of a typical clinical feature, positive diagnostic tests and an increased titre of antibodies against the acetylcholine receptors. It was not possible to confirm the immune nature of adrenal insufficiency by the presence of antibodies to 21-hydroxylase. The normal morphological finding of the adrenal glands was an indirect confirmation of the condition as well as the absence of other diseases that might have led to adrenal insufficiency and low levels of both serum cortisol and aldosterone. Hormone replacement therapy, anticholinergic therapy and corticosteroid therapy for myasthenia gravis improved the patient's general state of health and muscle weakness. CONCLUSION: This case report indicates a need to examine each patient with an autoimmune disease carefully as this condition may be associated with another autoimmune diseases.

[Contemporary treatment neuropathic pain].

INTRODUCTION: Neuropathic pain, or pain associated with disease or injury to the peripheral or central nervous system, is a common symptom of a heterogeneous group of conditions, including diabetic neuropathy; trigeminal neuralgia, postherpetic neuralgia and spinal cord injury. Chronic neuropathic pain should not be thought of as a symptom. It should truly be thought of as a disease with a very complicated pathophysiology. PATHOPHYSIOLOGY: The mechanisms involved in neuropathic pain are complex and involve both peripheral and central pathophysiologic phenomenon. The underlying dysfunction may involve deafferentation within the peripheral nervous system (e.g. neuropathy), deafferentation within the central nervous system (e.g. post-thalamic stroke) or an imbalance between the two (e.g. phantom limb pain). CLINICAL CHARACTERISTICS: Neuropathic pain is non-nociceptive, in contrast to acute nociceptive pain, and it can be described as "burning", "electric", "tingling", and "shooting" in nature. TREATMENT: Rational polypharmacy is often necessary and actually it is almost always the rule. It would be an exception if a patient was completely satisfied with his treatment. Treatment goals should include understanding that our patients may need to be titrated and managed with more than one agent and one type of treatment. There should be the balance of safety, efficacy, and tolerability. CONCLUSION: There are many new agents and new applications of the existing agents being currently studied which will most certainly lead to even more improved ways of managing this very complicated set of disorders.

The sensitivity of electromyoneurography in the diagnosis of diabetic polyneuropathy.

Diabetic polyneuropathy is a complex set of clinical syndromes, which deplete various regions of the nervous system. The process leading to diabetic neuropathy is multi-factorial. Its symptoms are paresthesia, dysesthesia and pain. The signs of damage to the peripheral neurons are hypoesthesia, hypoalgesia, hyperesthesia and hyperalgesia, decreased tendon reflexes, and, possibly, weakness and muscle atrophy. There is no universal classification. Electromyoneurography is indispensable in the diagnosis of diabetic polyneuropathy. However, there is no agreement on the most sensitive parameter for an early diagnosis. One hundred patients with diabetes mellitus were examined in order to investigate the sensitivity of different electromyographic parameters. Electromyographic techniques proved to be entirely sensitive for the early diagnosis of diabetic polyneuropathy. Some of the parameters are more suitable for an early detection of peripheral nerve damage, and others, which are not so sensitive but easy to use and stable, are suitable to follow up the course of diabetic polyneuropathy.

[Importance of electromiographic examination in diagnostification and monitoring of chronic inflammatory demyelinating polyneuropathy].

INTRODUCTION: Polyneuropathies or peripheral neuropathies present a dysfunction or disease of larger number of peripheral nerves or their dysfunction. Considering their morbidity - mortality characteristics they present an important aspect in daily clinical practice. One particular polyneuropathy that deserves special review is chronic inflammatory demyelinating polyneuropathy, which, due to its clinical-laboratory presentation, does not include the group of "simple" neuropathies, thus requiring further examinations. Neurophysiological testing should be performed using the protocol for neuropathy examinations. Neurophysiological examination, during the electroneurographic examination, shows neurographic parameters referring to polyneuropatic demyelinating type of lesion, while the electromyographic finding records the presence of neuropathic lesions (denervation activity, great action potentials with a reduced sample). CASE REPORT: A 54-year-old patient was diagnosed to have a "complicated" demyelinating polyneuropathy according to the clinical-laboratory findings and electromyographic examination. Exclusion criteria, targeted diagnostic examinations, considering the mentioned peripheral neuropathies, pointed to acute inflammatory demyelinating polyneuropathy. However, the chronic inflammatory demyelinating polyneuropathy was finally differentiated during the clinical and electromyographic monitoring.

[Menstrual migraine].

INTRODUCTION: The prevalence of migraine in childhood and adolescence has not changed to a great extent, but it increases in adolescence, especially in female adolescents. MENSTRUAL MIGRAINE--DEFINITION: There are two types of menstrual migraine: true menstrual migraine and menstrually related migraine. True menstrual migraine occurs predominantly around menstruation, whereas menstrually related migraine occurs during menstruation, but also at other times during the month. CAUSES: Exaggerated or abnormal neurotransmitter responses to normal cyclic changes in the ovarian hormones are probably the basic cause of menstrual migraines. The fall in estrogen levels during menstrual cycle is trigger for the menstrual migraine. SYMPTOMS: Menstrual migraine has the same symptoms as other types of migraine, but the pain is stronger, it lasts longer, and it is more frequent than other types of migraines. DIAGNOSIS: In order to make a diagnosis, women are asked to keep a headache diary for three months. If the migraine headache is severe and occurs regularly between two days before and three days after the start of menstrual bleeding, it is true menstrual migraine. THERAPY: Menstrual migraines are more difficult to treat than other types of migraines. Treatment principles for menstrual migraine are the same as for migraines in general, with certain particularities. CONCLUSION: Hormonally associated migraine is a specific clinical entity. It is important to diagnose the type of migraine, considering the fact that a decline in estrogen level at the end of menstrual cycle triggers migraine, so it can be treated by low levels of estrogen.

The impact of headache severity on quality of life of patients with migraine.

Migraine is a chronic disease characterized by episodic headache attacks, most often on one side of the head with pulsating, moderate to severe pain. We conducted an assessment of headache severity by using the MIGSEV questionnaire, and the quality of life assessment by using the QVM questionnaire, on a sample of 30 patients suffering from migraine. Afterwards, the research results were compared. The research results indicate that the majority of patients suffer from severe and moderate headaches. The quality of life is poorer in patients suffering from severe headaches.

[Multiple brain abscesses: a case report]. / Prikaz slucaja multiplih apscesa mozga.

CASE REPORT: 10 days before admission a 45-year old female experienced general weakness, and T 38 degrees C. During that period she had no cardio-respiratory nor neurological complaints, and the temperature varied between 37.5 degrees C and 38 degrees C. Her medical history was unremarkable, without immunodeficiency. The day before admission she presented with left arm paresis and during the next day it progressed to paralysis. She had no headache. On admission the following diagnostic procedures were performed: the cranial CT scan showed two lesions (possibly meta lesions). Chest X-ray was normal. WBC=15x10(9)/L, ESR=90/120. On the second day following admission brain MRI showed multiple abscesses in both hemispheres, mostly in the gray/white junction. High doses of IV metronidasol, cephtriaxon and cipfloxacin were administered without obtaining specimens for micro-biological diagnosis. In next two days she developed coma, respiratory insufficiency and septic temperature. Brain surgery was not performed due to severe involvement of the brain with multiple abscesses. Repeated chest X-ray revealed bilateral pneumonia. A lethal outcome occurred on the third day, regardless of all efforts. Autopsy showed multiple brain abscesses as well as on the lungs and liver. A beta-hemolytic streptococcal infection was established. CONCLUSIONS: Prevention includes treatment of the infection source. The classic triad of headache, fever and focal deficit occur in less than 50% of patients. Even in such cases brain abscess must be reconsidered CT appearance of brain abscess is similar to that of neoplastic and other infectious and non infectious diseases--especially in the stage of early cerebritis. If the CT findings are not clear, MRI should be performed.