Blunted Pain Modulation Response to Induced Stress in Women with Fibromyalgia with and without Posttraumatic Stress Disorder Comorbidity: New Evidence of Hypo-Reactivity to Stress in Fibromyalgia?

There is evidence regarding the presence of alterations in both the stress response and the endogenous pain modulation systems of people with fibromyalgia (FM). However, research on pain modulation under induced stress on FM patients is scarce and contradictory. The present study analyzes stress-induced changes in pain and intolerance thresholds among FM patients, examining the possible existence of differences linked to PTSD comorbidity and gaining insights into the role of cardiovascular reactivity. Eighteen women diagnosed with FM and comorbid PTSD (FM + PTSD), 18 women diagnosed with FM and no PTSD (FM-PTSD), and 38 healthy women (HC) were exposed to the Social Stress Test task. Pressure pain thresholds and intolerance thresholds were measured before and during stress induction, and after a recovery period, while systolic blood pressure and heart rate were simultaneously recorded. Overall, while pain thresholds decreased during stress and recovery for HC, no significant changes were observed for women with FM. The intolerance threshold decreased for HC during stress, but was maintained at basal level during recovery. FM-PTSD women exhibited a delayed response, with a drop at recovery. For FM + PTSD, tolerance levels remained unchanged. In addition, cardiovascular reactivity did not seem to explain these results. This performance of the pain modulation system seems to follow the same pattern of hypoactive responsiveness under stressors that has previously been observed in FM patients on the autonomic and neuroendocrine axes. Such a hypoactive pattern may involve a non-adaptive response that may contribute to the development and maintenance of chronic pain.

[Rivastigmine solution prescribing habits in patients with Alzheimer-type dementia in Spain (RIVASOL study)]. / Hábitos de prescripción de rivastigmina en solución en pacientes con demencia de tipo Alzheimer en España (estudio RIVASOL).

INTRODUCTION: One of the most notable advances in the treatment of Alzheimer's disease today is the appearance of the drugs rivastigmine, donepezil, galanthamine and memantine. AIMS. We attempt to throw light on the dosage regimens, degree of effectiveness and safety profile of rivastigmine solution by means of a retrospective, descriptive, cross-sectional study known as the RIVASOL study. PATIENTS AND METHODS: The study involved 1516 patients (1386 of whom were evaluable) who had been diagnosed with Alzheimer-type dementia (ATD) according to the criteria in the Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-IV); these patients, who were selected by 157 participating physicians (neurologists, psychiatrists and geriatricians), gave their informed written consent and had been receiving treatment with rivastigmine solution over the past six months. The main variable was the rivastigmine solution treatment regimen and the secondary variables included socio-demographic data, health care data and the researcher's overall clinical impression from the time treatment was begun, among others. RESULTS: Most of the patients who were evaluated were attended by neurologists (57.4%). The mean time elapsed since Alzheimer's disease was diagnosed was 2.14 +/- 1.68 years. After approximately one year's treatment with rivastigmine solution, the mean score on the Folstein minimental test (MMSE) fell by 0.48 points. CONCLUSIONS: Rivastigmine solution represents a convenient means of administration for patients with moderate and moderately advanced phases of ATD; their cognitive performance is significantly improved with a reduction in the side effects due to a slower and more progressive adjustment of the initial dosage.

[The psychometric properties of the Spanish version of the stroke-adapted 30-item Sickness Impact Profile (SIP30-AI)]. / Propiedades métricas de la versión española del perfil de las consecuencias de la enfermedad de 30 ítems adaptado al ictus (SIP30-AI).

AIM: To assess the psychometric attributes of the stroke-adapted 30-item version of the Sickness Impact Profile, Spanish version (SA-SIP30), in stroke survivors. PATIENTS AND METHODS: 79 patients were evaluated (mean age: 68.1 years) by means of the modified Rankin Scale (m-RS), Scandinavian Stroke Scale (SSS), Barthel Index (BI), and the modified 23-item Beck-Hamilton's Depression Rating Scale (HDRS). Health-related quality of life was evaluated using the MOS-Short Form 36 (SF-36) and the SA-SIP30. RESULTS: SA-SIP30 mean score was 36.8. SA-SIP30 floor and ceiling effects were 3.8% and 0%. Regarding SA-SIP30 categories, floor effect ranged from 15.2% (social interaction) to 49.4% (alertness behavior), whereas ceiling effect ranged from 2.5% (social interaction) to 26.6% (household management). A floor effect was observed in seven SA-SIP30 categories. The internal consistency of SA-SIP30 (Cronbach's alpha = 0.87), physical (Cronbach's alpha = 0.89) and psychosocial (Cronbach's alpha = 0.75) dimensions were satisfactory. Standard error of measurement (SEM) values for each SA-SIP30 category ranged from 15.9 (household management) to 26.3 (ambulation). SEM values for overall SA-SIP30, physical and psychosocial dimensions were 8, 10 and 17.3, respectively. Corrected item-category correlations ranged from 0.17 (item 28) to 0.83 (item 23). A significant correlation (Spearman's correlation coefficient; p < 0.0001) between SA-SIP30 scores and BI (-0.71), m-RS (0.68), SSS (-0.67), HDRS (0.52), SF-36 physical (-0.67) and mental components (-0.51) was found. SA-SIP30 mean score significantly increased as m-RS increased (discriminative validity; Kruskal-Wallis, p < 0.0001). CONCLUSION: The Spanish-version of the SA-SIP30 has satisfactory internal consistency, convergent validity and discriminative validity in stroke patients.

[Transient paradoxical embolism. Importance of early ultrasonography diagnosis]. / Embolia paradójica en tránsito. Importancia del diagnóstico ecocardiográfico precoz.

The paradoxical embolism or the crossing of an embolism through a permeable foramen ovale is considered to be a rare mechanism of cerebral embolism although its real frequency is unknown. Reports demonstrating the embolism during its crossing through cardiac cavities are scarce. Two cases of moving paradoxical embolism are presented. In the first, an infarction of the superior branch of the left middle cerebral artery was produced during the course of deep vein thrombosis and pulmonary thromboembolism with transesophageal echocardiography demonstrating the crossing of the embolism through the foramen ovale. Surgery performed 12 days later did not discover the auricular thrombus. In the second case, a mass was discovered in the right auricle with a permeable foramen ovale during the course of a left middle cerebral artery infarction and a large auricular thrombus was demonstrated in surgery. The diagnostic usefulness of early transsesophageal echocardiography in the diagnosis of moving paradoxal embolism is discussed.

[The stroke unit a the Clinical Hospital in Madrid]. / Experiencia de una Unidad de Ictus en el Hospital Clínico de Madrid.

The outcome in 195 patients admitted in a non-intensive stroke unit was compared to that in 198 patients admitted in general wards during a 12 months period. At admission, both groups were similar in prognostic indicators (age, sex, previous history, level of consciousness and motor impairment). Short-term mortality rates was reduced among patients admitted in stroke unit (p < 0.001). This difference was independent of patient's age, previous history and neurological impairment on admission. The length of stay in the hospital was also reduced (p < 0.001). Among survivors, functional outcome at discharge was better in those admitted in the stroke unit, with a greater proportion of patients independent for activities of daily living. We conclude that stroke unit in an efficient strategy that improves the clinical outcome of patients with acute stroke.

[Comparative clinico-radiological study of lacunar infarcts of the cerebral hemispheres and brain stem in 110 cases]. / Estudio clinicorradiológico comparativo entre infartos lacunares hemisféricos y de tronco cerebral en 110 casos.

INTRODUCTION: Lacunar infarcts (LI) are small deep infarcts due to occlusion of perforating branches. OBJECTIVE: Our objective was to outline the clinical and epidemiological characteristics which differentiate hemispherical lacunar infarcts (HLI) from those of the brain stem (SLI). PATIENTS AND METHODS: We present 110 cases of LI (80 HLI, 30 SLI) analysing risk factors, clinical syndromes, findings on neurological examination (dysarthria, gravity, distribution and proportional paresia), form of clinical presentation, evolution whilst in hospital, site and results of carotid duplex. Diagnosis was made in 72 patients using magnetic resonance (MR) and in 38 patients using computerized axial tomography (CT). RESULTS: The commonest characteristics of SLI, as compared with HLI, with statistical significance (p < 0.05) was the appearance of supranuclear facial paresia (OR = 2.68), severe motor involvement (OR = 4.23), form of presentation with previous TIA (OR = 6.33), fluctuating evolution of the symptoms (OR = 5.78) and progression of the paresia (OR = 6.41). Also, in the pontine LI there was significant correlation between site and gravity: the lower the site of the lesion, the more serious was the paresia. Patients with multiple LI presented with no previous risk factors significantly more frequently than those with a single LI. CONCLUSION: The different clinical profiles may help to establish the subgroups of IL, according to where they occur.

[Hashimoto's encephalopathy associated with scleromyxedema: coincidental or the overlapping of two syndromes with a possible autoimmune origin?]. / Asociación de encefalopatía de Hashimoto y escleromixedema: coincidencia o solapamiento de dos síndromes de posible origen autoinmune?

INTRODUCTION: The encephalopathies that may accompany Hashimoto's thyroiditis and scleromyxedema, both of which are diseases that probably have an autoimmune origin, are clinically similar. The presence of both Hashimoto's thyroiditis and scleromyxedema in a patient with encephalopathy led us to compare the clinical symptoms and the different possible mechanisms accounting for the pathology. CASE REPORT: We describe the case of a 54-year-old male who was admitted to hospital because of several occurrences of transient neurological focus that finally developed into a clinical picture of aphasia, acalculia and right homonymous hemianopsia. The patient had previously been diagnosed as suffering from scleromyxedema, which responded poorly to treatment, as well as IgG kappa paraproteinemia and, six months before admission to hospital, Hashimoto's thyroiditis. No abnormalities were found in the complementary tests, except for slightly high protein levels in the cerebrospinal fluid, a diffuse slowing of brain waves in the electroencephalogram and alterations due to thyroiditis and paraproteinemia. Neurological symptoms improved after a few days of corticoid therapy. CONCLUSIONS: The presentation of encephalopathy as a stroke and its excellent response to treatment with corticoids pointed to a case of Hashimoto's encephalopathy, although we cannot completely rule out the possibility of it being a dermato-neuro syndrome, which is associated to scleromyxedema. In this paper we review the different pathological mechanisms proposed for the two clinical entities, as well as the clinical features that are similar in both syndromes and which could be an indication of some common mechanism shared by them.

[Direct cost of cerebrovascular disease during the first year of follow-up]. / Coste directo de la enfermedad cerebrovascular en el primer año de seguimiento.

INTRODUCTION AND OBJECTIVE: There are not sufficient studies analyzing the health costs of ictus in Spain. We carried out a prospective study to evaluate the health costs incurred by a person with a stroke during the first postictal year. PATIENTS AND METHODS: We included 118 patients from the Stroke Unit of the Hospital Universitario San Carlos in Madrid, admitted between 1 July and 31 December 1996. We studied 90 survivors, of an average age of 68 years, one year after having an stroke and specifically calculated the cost of an average period in hospital, neuroimaging tests, rehabilitation treatment, medical follow-up in the Outpatient Clinic, transport costs and the cost of medicines. RESULTS: The average cost patient/year was: hospital admission (418,203 ptas.), health transport (108,209 ptas.), cost of medicines (74,647 ptas.), follow-up visits (64,496 ptas.), neuroimaging (61,203 ptas.), rehabilitation (58,643 ptas.). The total cost was 79,930,719 ptas. and the average cost patient/year 888,119 ptas. during the first year following the ictus. The use of health resources depended on the variables: handicap (increased in patients with a score < 60 on the Barthel scale), average neurological deficit on the Scandinavian neurological scale and sex (cost greater in women). The clinical follow-up of total infarcts of the territory of the anterior circulation cost twice as much as follow-up in cases of lacunar infarcts. CONCLUSIONS: Cerebrovascular disease is expensive in terms of health-care. Fifty four percent of the health-care expenses are incurred during the acute phase of the ictus and the other 46% during the first year of follow-up.

[Perception of long term overload in care-givers of patients who have survived a stroke]. / Percepción de la sobrecarga a largo plazo en cuidadores de supervivientes de un ictus.

INTRODUCTION: Increased survival of patients with stroke, and reduction in the time spent in hospital, has led to more domiciliary care and extra problems of adjustment for the patient chronically disabled by the stroke and for his carer. MATERIAL AND METHODS: Ninety patient-carer units from the Stroke Unit of the Hospital Universitario San Carlos in Madrid were evaluated one year after the stroke. Eighty carers were assessed on the Zarit Overload Scale, SF-36 Health Questionnaire and the Quality of Life Questionnaire for carers. RESULTS: The carer overload after one year, as measured on the Zarit Scale correlated with the neurological deficit on the Scandinavian Scale (p = 0.003), disability according to the Barthel index (p < 0.0001), female sex (p = 0.0009) and state of mind (p = 0.0001) of the patients. The health SF-36 profile categories most affected were mental health, vitality, pain and general health with average values of 61-62; women scored worse than men in the pain category (p = 0.01) and in physical functions (p = 0.005). Forty two percent recognized that their role was emotionally exhausting and 56% had low morale on the quality of life questionnaire for carers. CONCLUSIONS: Overload of the carers of stroke patients has a considerable effect on their emotional state and social relations, so evaluation is necessary to avoid pathological effects on careers of chronic overload.

[Post stroke depression: predictive factors at one year follow up]. / Depresión postictus: factores predictivos al año de seguimiento.

INTRODUCTION: The presence of depression constitutes one of the treatable complications in stroke survivors. Its long term prevalence and the triggering factors are unknown in our community. Moreover, its presence can interfere in the process of rehabilitating the patient and in family dynamics. PATIENTS AND METHODS: A sample of 118 patients from the Stroke Unit at the Hospital Universitario San Carlos in Madrid were studied. After one year follow up, 90 survivors (41 females and 49 males; average age: 68 years) were evaluated, with their informed consent, with the Hamilton depression and Beck s melancholia scale, the Barthel index, the Rankin scale, Psychosocial Dimension of Sickness Impact Profile and the Scandinavian neurological scale. A factorial ANOVA model was used to conduct the statistical analysis. RESULTS: On discharge, a third of the patients presented symptoms of depression, while a year after the stroke the figure had risen to 67%. The average score on the Hamilton scale at one year follow up was 13.1 and was rated as mild depression. The variables related with depression one year after the stroke were of a socio demographic nature (female, women working in the home, long lasting occupational disability; p< 0.0001), whereas biological variables (cortical/subcortical distribution, laterality, aetiology and subtype of the stroke) were not statistically significant. Subjects suffering from serious disabilities that affected the performance of their daily activities (Barthel< 60) scored significantly worse (p= 0.005). Motor deficit, according to the Scandinavian scale, was of no use as a predictor of depression one year after the stroke (p= 0.0617). CONCLUSIONS: Post stroke depression is highly prevalent in our community and, late on in the follow up, is associated with socio demographic variables and with the degree of disability.

[Stroke and intracranial stenosis: clinical profile in a series of 134 patients in Spain]. / Ictus y estenosis intracraneal: perfil clínico de una serie española de 134 pacientes.

INTRODUCTION: Intracranial stenoses (IS) are known to be a manifestation of atherosclerosis and a cause of cerebral ischemia, although very few clinical reports have appeared describing such patients in our milieu. OBJECTIVE: The aim of this study was to describe the vascular risk factors, clinical presentation, radiological characteristics, aetiological role played in strokes and the vessels affected in a series of Spanish patients suffering from stroke and IS. PATIENTS AND METHODS: We conducted a retrospective descriptive study of patients admitted to the Cerebrovascular Pathology Unit with strokes and IS between 1990 and 2001. Data collected included: age, sex, arterial hypertension (AHT), diabetes (Db), hypercholesterolemia (HC), smoking (Sm), ischemic or emboligenic heart disease, intermittent claudication, carotid atheromatosis, clinical presentation of stroke and earlier lesions in computerised axial tomography (CAT) scans of the brain. RESULTS: 132 patients; 187 stenotic vessels: 65.7% males, mean age 68.3 years. AHT 65%, Db 39%, HC 40%, Sm 43%, ischemic heart disease 22%, emboligenic heart disease 17%, intermittent claudication 13%. CLINICAL PRESENTATION: TIA 16%, LACI 33%; PACI 25%, TACI 4%, POCI 19%. Significant carotid atheromatosis 26.5%. Symptomatic IS 50%: mean age 63.3 years, 64% females. Arteries affected: vertebral (VA) 28%; middle cerebral (MCA) 27%; carotid siphon 21%; basilar (BA) 10% (65% symptomatic); anterior cerebral (ACA) 5% and posterior cerebral (CPA) 4%. Normal cranial CAT scan 24%, lacunar infarcts 42%, territorial 32%; leukoaraiosis 17%. CONCLUSIONS: Patients with stroke and IS display different clinical profiles according to their sex (males: a higher number of vascular risk factors and clinical involvement of other territories; females are more symptomatic, AHT and HC); they usually present clinically as lacunar syndromes, with a scarce amount of significant atheromatous carotid involvement, except IS of the VA, and IS of the BA are the most symptomatic.

[Cerebral activation during movement of both hands. A study with transcranial Doppler]. / Activación cerebral durante el movimiento de ambas manos. Estudio con Doppler transcraneal.

INTRODUCTION AND OBJECTIVE: In healthy persons, the force carried out by a group of muscles doing bilateral exercise with maximum effort is less than that done during unilateral exercise. The nervous control of movement is probably different in these two cases. Our objective was to study and compare cerebral activation on movement of one and of both hands by means of transcranial Doppler (TCD). MATERIAL AND METHODS: We studied 30 healthy volunteers (19 men and 11 women; average age 65.4 +/- 9.5 years). Using transtemporal TCD we assessed the relative changes in average velocity of flow in both middle cerebral arteries during the exercise of sequential opposition of the fingers of one hand and of both hands. RESULTS: The activity due to the exercise of the hand contralateral to the hemisphere being studied was greater than that due to exercise of both hands together, both on the right side (p < 0.001) and on the left (p < 0.001). CONCLUSIONS: The functional activity of each cerebral hemisphere is not necessarily greater when both hands are exercised than when the contralateral hand is used, and may even be less. The possible increase in activity due to the additional contribution to ipsilateral movement in the first case may be compensated by simultaneous transhemispherical inhibition.

Bihemispheric contribution to motor recovery after stroke: A longitudinal study with transcranial doppler ultrasonography.

BACKGROUND: Both cerebral hemispheres seem to contribute to motor recovery after stroke. We studied the effect of motor activity on cerebral blood flow in both hemispheres at different stages of stroke evolution. METHODS: Thirty patients with hemiplegic stroke and 30 controls were included. Patients were examined within the first week (T1), 1 month (T2) and 6 months after stroke (T3). All subjects performed a 2-min sequential thumb-to-finger opposition task while blood flow velocities in both middle cerebral arteries were measured with transcranial Doppler ultrasonography (TCD). RESULTS: Contralateral movement caused a higher increase in blood flow velocity than ipsilateral movement in controls (p < 0.0001). On the healthy side, patients showed a striking increase with ipsilateral movement (affected hand), which was similar to the increase with contralateral movement (normal hand) at all stages. On the damaged side, the increase with contralateral movement (affected hand) was low and was similar to the increase with ipsilateral movement (normal hand) at T1 and T2; however, at T3 the increase with contralateral movement was higher and the pattern of response was similar to that found in controls. CONCLUSIONS: TCD can trace the evolution of brain motor output following stroke. Compensatory activation of the healthy side of the brain may be already present soon after stroke, whereas function of the damaged side may improve during several months.

[Cerebral cavernoma. A retrospective analysis of 24 cases]. / Cavernomas cerebrales. Análisis retrospectivo de una serie de 24 casos.

We retrospectively analyzed 24 patients with cerebral cavernomas diagnosed according to histological and/or radiological criteria; epidemiological data, complementary techniques, therapy and evolution are reviewed and the cases are compared to those of previously reported series. Diagnosis was based on histological data in 18 patients and on magnetic resonance imaging (MRI) in the remaining 6. Five patients had compatible clinical histories symptoms compatible with the diagnosis. Mean age of the patients was 37.7 years, the most frequent location was the parietal lobe (27%), and seizures were the most common clinical symptoms of presentation (62%). Surgery was performed on 75%, sequelae were reported in 37.5% and exitus in 11%; 54% were asymptomatic. Six patients did not undergo surgery: 4 had multiple cavernomata, 1 received drug treatment that controlled the seizures and in 1 the cavernoma was located in the protuberance. We recommend the use of cerebral MRI for initial diagnosis, along with follow-up and investigation into similar profiles among family members. The treatment of choice is surgery in patients with acute, progressive or recurring deficits, and when lesions are superficial. At present there is no consensus about the treatment to follow when cavernomas are located in the brain stem.