Influence of phytoestrogens on endometrial thickness: a systematic review and meta-analysis.

The objective of this systematic review was to evaluate the influence of the use of phytoestrogens on variations in endometrial thickness in postmenopausal women. Randomized controlled trials were searched in the following electronic databases until March 2020: MEDLINE, Embase, Cochrane Library, Web of Science and LILACS. We used the terms 'phytoestrogens' and 'endometrium' or 'endometrial hyperplasia' to search for relevant trials. The data were analyzed using RevMan 5.3 software. A total of 10 studies involving 1476 patients were included. The difference in endometrial thickness was evaluated in 10 studies, with a total of 805 participants in the phytoestrogen group and 761 in the control group. Such a difference was not significant between groups after 3 months (standardized mean difference [SMD] 0.00, 95% confidence interval [CI] - 0.37 to 0.37; I2 = 63%), 6 months (SMD -0.30, 95% CI -0.79 to 0.19; I2 = 70%), 12 months (SMD -0.02, 95% CI 0.22 to -0.18; I2 = 0%) and 24 months (SMD -0.09, 95% CI -0.25, 0.08; I2 = 0%) of use. Our meta-analysis shows no changes in endometrial thickness in women using phytoestrogens. Evidence is still uncertain owing to the presence of heterogeneity among the studies currently available, whose reported outcomes cover a period between 3 and 6 months.

Psychiatric symptoms are frequent in idiopathic intracranial hypertension patients.

Idiopathic intracranial hypertension (IIH) is a rare disease with an incidence rate of 0.5-2.0/100,000/year. Characteristic symptoms are headache and several degrees of visual impairment. Psychiatric symptoms in association with IIH are usually poorly described and underestimated. In this study, we evaluated IIH subjects to determine the association with psychiatric symptoms. We evaluated thirty consecutive patients with IIH submitted to neurosurgery from January 2017 to January 2020 in two Brazilian tertiary hospitals. They underwent clinical evaluation, obtaining medical history, comorbidities, body mass index (BMI-kg/m2), and applying Neuropsychiatric Inventory Questionnaire (NPI-Q). There were 28 females and 2 males. Ages ranged from 18 to 66 years old, with mean age of 37.97 ± 12.78. Twenty-five (83%) presented comorbidities, being obese and having arterial hypertension the most frequent. Body mass index ranged from 25 to 35 kg/m2 and mean value was 31 ± 3.42. After application of Neuropsychiatric Interview, 26 of 30 presented psychiatric symptoms (86%). Depression-anxiety syndromes were reported in 25 patients (83%). Nighttime disturbances were reported by 14 subjects (46%). Appetite and eating disorders were described by 23 (76%). Psychiatric symptoms in association with IIH are usually poorly described and underestimated. In our sample, twenty-six out of 30 (86%) reported psychiatric symptoms. We highlight the high prevalence of psychiatric symptoms among IIH patients and the need of managing these patients with a multidisciplinary team, including psychiatrists.

Cerebral blood flow autoregulation in ischemic heart failure.

Patients with ischemic heart failure (iHF) have a high risk of neurological complications such as cognitive impairment and stroke. We hypothesized that iHF patients have a higher incidence of impaired dynamic cerebral autoregulation (dCA). Adult patients with iHF and healthy volunteers were included. Cerebral blood flow velocity (CBFV, transcranial Doppler, middle cerebral artery), end-tidal CO2 (capnography), and arterial blood pressure (Finometer) were continuously recorded supine for 5 min at rest. Autoregulation index (ARI) was estimated from the CBFV step response derived by transfer function analysis using standard template curves. Fifty-two iHF patients and 54 age-, gender-, and BP-matched healthy volunteers were studied. Echocardiogram ejection fraction was 40 (20-45) % in iHF group. iHF patients compared with control subjects had reduced end-tidal CO2 (34.1 ± 3.7 vs. 38.3 ± 4.0 mmHg, P < 0.001) and lower ARI values (5.1 ± 1.6 vs. 5.9 ± 1.0, P = 0.012). ARI <4, suggestive of impaired CA, was more common in iHF patients (28.8 vs. 7.4%, P = 0.004). These results confirm that iHF patients are more likely to have impaired dCA compared with age-matched controls. The relationship between impaired dCA and neurological complications in iHF patients deserves further investigation.

Restless legs syndrome in Wilson's disease: frequency, characteristics, and mimics.

OBJECTIVE: To determine characteristics, clinical significance, frequency, and mimics of restless legs syndrome (RLS) in a cohort of Wilson's disease (WD, n = 42/f = 18), compared to healthy, matched controls. MATERIALS AND METHODS: Structured clinical interviews (patients and caregiving family members), repeated neurological examinations (afternoon and presleep), comprehensive laboratory tests, WD-, RLS-, and sleep-specific rating scales, and video-polysomnography. RESULTS: Thirteen patients with WD (13/42 = 31.0%) clearly fulfilled the five diagnostic criteria of RLS; in eight patients (19.1%), the burden of RLS was clinically significant. The RLS was of moderate severity, equally distributed among sexes, manifested mainly in the evening and before falling asleep, and had developed mostly after clinical manifestation of WD (time elapsed 10.2 ± 14.5 years), still at a young mean age (27.5 ± 11.5 years). The known RLS-associated features were absent (normal iron and kidney parameters) or rare (positive family history, polyneuropathy). Compared to WD patients without RLS, patients with RLS were significantly elder and had suffered longer from WD. WD-specific RLS mimics as well as RLS confounding motor comorbidities (dystonia, tremor, chorea) were frequent and a diagnostic challenge; in difficult cases, the differentiation was reached by clinical observation of the motor behavior in the evening or at nighttime. CONCLUSION: RLS was frequent in this cohort of WD and might be causally related to WD. RLS should be included in the diagnostic work-up of WD. In complex motor disorders, differential diagnosis of RLS might require evening/nighttime examination and video-polysomnography. In WD patients with a clinically significant RLS, treatment with dopaminergic substances may be considered.

Cerebral Hemodynamic Effects of Cheyne-Stokes Respiration in a Patient with Stroke.

INTRODUCTION: Cheyne-Stokes respiration (CSR) and central sleep apnea (CSA) are common in patients with heart failure and/or stroke. We aim to describe the cerebrovascular effects of CSR during the acute phase of stroke in a heart failure patient. CASE REPORT: A 74-year-old male with previous dilated cardiomyopathy had sudden onset of right hemiparesis and aphasia. A transcranial Doppler was performed with continuous measurement of blood pressure (BP) (Finometer) and end-tidal CO2 (nasal capnography). Offline analysis of hemodynamic data disclosed relatively large periodic oscillations of both cerebral blood flow velocity and BP related to the CSR breathing pattern. Derivate variables from the cerebrovascular resistance were calculated (critical closing pressure and resistance-area product), demonstrating that there may be a myogenic impairment of cerebral blood flow (CBF) control in the affected hemisphere of this subgroup of patient. CONCLUSION: There is an impairment of CBF regulation in the affected hemisphere of the patient with ischemic stroke and CSR, highlighting the role of cerebral hemodynamic monitoring in this scenario.

Sensorial differences according to sex and ages.

OBJECTIVE: To investigate age and sex differences in orofacial sensory detection. METHODS: One hundred and twenty-six (126) healthy subjects were divided into five groups according to their ages. They were assessed with a quantitative sensory testing protocol for gustative, olfactory, thermal (cold/warm), mechanical (tactile/vibration/electric), and pain (deep/superficial) detection thresholds. The corneal reflex was also evaluated. Data were analyzed with the one-way ANOVA, chi-squared, Fisher's exact, Mann-Whitney, and Kruskal-Wallis tests. RESULTS: The groups of subjects over 61 years old had higher olfactory (P < 0.001), gustative (sweet P = 0.004, salty P = 0.007, sour P = 0.006), thermal (warm P < 0.001, cold P < 0.001), and tactile (P < 0.001) detection thresholds than the others. The vibration detection threshold was high only for subjects over 75 years old (P < 0.001). The electric and deep pain detection thresholds were different for the 61-75 years old group (P ≤ 0.001). Women in all age groups had lower gustative (sweet P = 0.020, salty P = 0.002, sour P < 0.001, and bitter P = 0.002), olfactory (P = 0.010), warm (P < 0.001) and deep (P < 0.001), and superficial pain (P = 0.008) detection thresholds than men, and men from all age groups had lower vibratory detection thresholds (P = 0.006) than women. CONCLUSION: High sensory detection thresholds were observed in subjects over the 6th decade of life, and women had a more accurate sensory perception than men.

Functional improvements associated with cranioplasty after stroke and traumatic brain injury: a cohort study.

OBJECTIVE: Decompressive craniectomy is part of the acute management of several neurosurgical illnesses, and is commonly followed by cranioplasty. Data are still scarce on the functional and cognitive outcomes following cranioplasty. We aim to evaluate these outcomes in patients who underwent cranioplasty following traumatic brain injury (TBI) or stroke. METHODS: In this prospective cohort, we assessed 1-month and 6-month neuropsychological and functional outcomes in TBI and stroke patients who underwent cranioplasty at a Brazilian tertiary center. The primary outcome was the change in the Digits Test at 1 and 6 months after cranioplasty. Repeated measures general linear models were employed to assess the patients' evolution and interactions with baseline characteristics. Effect size was estimated by the partial η2. RESULTS: A total of 20 TBI and 14 stroke patients were included (mean age 42 ± 14 years; 52.9% male; average schooling 9.5 ± 3.8 years; 91.2% right-handed). We found significant improvements in the Digits Tests up to 6 months after cranioplasty (p = 0.004, partial η2 = 0.183), as well as in attention, episodic memory, verbal fluency, working memory, inhibitory control, visuoconstructive and visuospatial abilities (partial η2 0.106-0.305). We found no interaction between the cranioplasty effect and age, sex or schooling. Patients submitted to cranioplasty earlier (<1 year) after injury had better outcomes. CONCLUSION: Cognitive and functional outcomes improved after cranioplasty following decompressive craniectomy for stroke or TBI. This effect was consistent regardless of age, sex, or education level and persisted after 6 months. Some degree of spontaneous improvement might have contributed to the results.

Infection rate and risk factors associated with infections related to external ventricular drain.

OBJECTIVE: To describe incidence rates and risk factors associated with external ventricular drain (EVD)-related infections at a tertiary Brazilian teaching hospital. METHODS: The patient cohort consisted of all patients at a major teaching hospital in Brazil with an EVD during the period 1 April 2007 to 30 June 2008 (15 months). Patients were followed up for 30 days after catheter removal. According to the Center for Diseases Control and Prevention criteria for meningitis/ventriculitis, all of the central nervous system (CNS) infections that occurred during this period could be considered to be meningitis or ventriculitis related to EVD placement. Infection rates were calculated using different denominators, such as (1) per patient (incidence), (2) per procedure, and (3) per 1,000 catheter-days (drain-associated infection rate). Patient demographic data, medical history of underlying diseases, antibiotic prophylaxis usage, American Society of Anesthesiologists Score classification, duration of surgery and hospitalization, length of time the EVD was in place, and overall mortality were evaluated during the study period. A logistic regression model was developed to identify factors associated with infection. RESULTS: A total of 119 patients, 130 EVD procedures, and 839 catheter-days were evaluated. The incidence of infection was 18.3%, the infection rate was 16.9% per procedure, and the drain-associated infection rate was 22.4 per 1,000 catheter-days; 77% of the infections were caused by Gram-negative micro-organisms. Only 75% of patients received antibiotic prophylaxis. The infection rate increased with length of the hospital stay. The length of time the catheter was in place was the only independent risk factor associated with infection (p = 0.0369). CONCLUSION: The incidence of EVD-related infections is high in our hospital, Gram-negative micro-organisms were the most frequent causal agents identified and length of time that the catheter was in place contributed to the infection rate.

Somesthetic, gustatory, olfactory function and salivary flow in patients with neuropathic trigeminal pain.

OBJECTIVES: To determine somesthetic, olfactory, gustative and salivary abnormalities in patients with burning mouth syndrome (BMS), idiopathic trigeminal neuralgia (ITN) and trigeminal postherpetic neuralgia (PHN). SUBJECTS AND METHODS: Twenty patients from each group (BMS, ITN, PHN) and 60 healthy controls were evaluated with a systematized quantitative approach of thermal (cold and warm), mechanical, pain, gustation, olfaction and salivary flow; data were analyzed with ANOVA, Tukey, Kruskal-Wallis and Dunn tests with a level of significance of 5%. RESULTS: There were no salivary differences among the groups with matched ages; the cold perception was abnormal only at the mandibular branch of PHN (P = 0.001) and warm was abnormal in all trigeminal branches of PHN and BMS; mechanical sensitivity was altered at the mandibular branch of PHN and in all trigeminal branches of BMS. The salty, sweet and olfactory thresholds were higher in all studied groups; the sour threshold was lower and there were no differences of bitter. CONCLUSION: All groups showed abnormal thresholds of gustation and olfaction; somesthetic findings were discrete in ITN and more common in PHN and BMS; central mechanisms of balance of sensorial inputs might be underlying these observations.

Minimally invasive computer-assisted stereotactic fenestration of an aqueductal cyst: case report.

INTRODUCTION: Current advances in frame modeling and computer software allow stereotactic procedures to be performed with great accuracy and minimal risk of neural tissue or vascular injury. CASE REPORT: In this report we associate a previously described minimally invasive stereotactic technique with state-of-the-art 3D computer guidance technology to successfully treat a 55-year-old patient with an arachnoidal cyst obstructing the aqueduct of Sylvius. We provide detailed technical information and discuss how this technique deals with previous limitations for stereotactic manipulation of the aqueductal region. We further discuss current advances in neuroendoscopy for treating obstructive hydrocephalus and make comparisons with our proposed technique. CONCLUSION: We advocate that this technique is not only capable of treating this pathology but it also has the advantages to enable reestablishment of physiological CSF flow thus preventing future brainstem compression by cyst enlargement.

Management of brachial plexus region tumours and tumour-like conditions: relevant diagnostic and surgical features in a consecutive series of eighteen patients.

BACKGROUND: Tumours of the brachial plexus region are rare and most publications are case reports or studies with a small series of patients. The aim of this study is to present our experience in managing these lesions. METHODS: We review 18 patients with tumours in the brachial plexus region submitted to surgical treatment in a 6 year period, including their clinical presentation, neuro-imaging data, surgical findings and outcome. FINDINGS: The tumours comprised a heterogeneous group of lesions, including schwannomas, neurofibromas, malignant peripheral nerve sheath tumour (MPNST), sarcomas, metastases, desmoids and an aneurysmal bone cyst. The most common presentation was an expanding lump (83.33%). Eleven tumours were benign and 7 were malignant. Neurofibromatosis was present in only 2 patients (11.11%). Gross total resection was achieved in 14 patients and sub-total resection in the others. Only 3 patients presented with new post-operative motor deficits. The incidence of complications was low (16.5 %). CONCLUSIONS: The majority of tumours were benign and most of them could be excised with a low incidence of additional deficits. Some of the malignant tumours could be controlled by surgery plus adjuvant therapy, but this category is still associated with high morbidity and mortality rates.

Neurovascular compression in painful tic convulsif.

This article describes the case of a 67-year-old woman who presented with a typical left hemifacial spasm of 8-month duration. After 2 months, she experienced lacinating and sharp shock-like pain in the left side of her face affecting the V1 and V2 territories and a discrete attenuation of nauseous reflex on the left side. CT angiography and MRI revealed significant compression of left cranial nerves V, VII, VIII, IX and X by a giant and tortuous vertebro-basilar arterial complex. This case illustrates the nonlinearity of the relationship between the presence of the stressor factor and the actual manifestation of the disease.

Evaluation of pain before and after vaginal delivery.

PURPOSE: The objective of this pilot study was to determine pain characteristics of pregnant women immediately before and after childbirth by vaginal delivery and to compare them with the pain intensity reported by physicians. METHODS: We evaluated 20 Brazilian women between September and December 2007 with the WHOQOL-Bref instrument, VAS, McGill Pain Questionnaire, and Anxiety Adapted Scale. We interviewed the obstetrician with the VAS about the patient's pain. Data were analyzed with the chi-square test. RESULTS: Mean age was 22.35 years (SD = 6.24, range 15-39 years). It was necessary to use oxytocin in 15 (75%) patients, which had no correlation with anxiety degree. Higher intensity of pain (p < 0.05) and higher anxiety index (p < 0.05) were more common in women in the first pregnancy. CONCLUSIONS: Higher pain intensity was associated with higher anxiety levels (p < 0.05). Around half of the obstetricians' VAS scores were lower than the VAS scores of women, and probably pain at labor was underestimated and not controlled. Higher indices of anxiety and pain were associated, and were more frequent in women in the first pregnancy.

Beyond neuropathy in hereditary sensory and autonomic neuropathy type V: cognitive evaluation.

BACKGROUND AND PURPOSE: Hereditary sensory and autonomic neuropathy (HSAN) type V is a very rare disorder. It is characterized by the absence of thermal and mechanical pain perception caused by decreased number of small diameter neurons in peripheral nerves. Recent genetic studies have pointed out the aetiological role of nerve growth factor beta, which is also involved in the development of the autonomic nervous system and cholinergic pathways in the brain. HSAN type V is usually reported not to cause mental retardation or cognitive decline. However, a structured assessment of the cognitive profile of these patients has never been made. METHODS AND RESULTS: We performed a throughout evaluation of four HSAN type V patients and compared their performance with 37 normal individuals. Our patients showed no cognitive deficits, not even mild ones. DISCUSSION AND CONCLUSIONS: Although newer mutations on this and related disorders are continuously described, their clinical characterization has been restricted to the peripheral aspects of these conditions. A broader characterization of this rare disorder may contribute to better understand the mechanisms of the nociceptive and cognitive aspects of pain.

Glossopharyngeal neuralgia: neurosurgical treatment and differential diagnosis.

The objective of this study was to review the literature on glossopharyngeal neuralgia (GN) and to discuss its differential diagnosis and treatment options. Despite the significant improvement of trigeminal neuralgia with pharmacological treatment, GN has a higher incidence of treatment failure and neurosurgery is necessary for the majority of patients. Functional neurosurgery has a great rate of success for GN, especially techniques such as percutaneous thermal rhizotomy, trigeminal tractotomy and/or nucleotomy. The main problem with GN remains the diagnosis as it is a rare disease with similarities to trigeminal neuralgia, including the same pharmacological treatment. Facial pain specialists should be trained to achieve a better accuracy of diagnosis.

Beyond weakness: Characterization of pain, sensory profile and conditioned pain modulation in patients with motor neuron disease: A controlled study.

BACKGROUND: Motor neuron diseases (MND) represent a group of disorders that evolve with inexorable muscle weakness and medical management is based on symptom control. However, deeper characterization of non-motor symptoms in these patients have been rarely reported. METHODS: This cross-sectional study aimed to describe non-motor symptoms in MND and their impact on quality of life and functional status, with a focus on pain and sensory changes. Eighty patients (31 females, 55.7 ± 12.9 years old) with MND underwent a neurological examination, pain, mood, catastrophizing and psychophysics assessments [quantitative sensory testing (QST) and conditioned pain modulation (CPM)], and were compared to sex- and age-matched healthy controls (HC). RESULTS: Chronic pain was present in 46% of patients (VAS =5.18 ± 2.0). Pain of musculoskeletal origin occurred in 40.5% and was mainly located in the head/neck (51%) and lower back (35%). Neuropathic pain was not present in this sample. Compared to HC, MND patients had a lower cold detection threshold (p < 0.002), and significantly lower CPM scores (4.9 ± 0.2% vs. 22.1 ± 0.2%, p = 0.012). QST/CPM results did not differ between MND patients with and without pain. Pain intensity was statistically correlated with anxiety, depression and catastrophism, and spasticity scores were inversely correlated with CPM (ρ = -0.30, p = 0.026). CONCLUSIONS: Pain is frequently reported by patients with MNDs. Somatosensory and CPM changes exist in MNDs and may be related to the neurodegenerative nature of the disease. Further studies should investigate the most appropriate treatment strategies for these patients. SIGNIFICANCE: We report a comprehensive evaluation of pain and sensory abnormalities in motor neuron disease (MND) patients. We assessed the different pain syndromes present in MND with validated tools, and described the QST and conditioned pain modulation profiles in a controlled design.

Treadmill training in Parkinson's patients after deep brain stimulation: Effects on gait kinematic.

OBJECTIVE: The purpose of this study was to evaluate the effect of treadmill training with body weight support on gait kinematics parameters in patients with PD using DBS. DESIGN: Twelve patients completed the protocols (age: 60.9±10.6 years; disease duration: 20±7 years; and time since DBS surgery: 20±4 months). The same set of patients underwent two trainings protocols and four gait analyses (before and after each training). They received eight weeks of treadmill training without body weight support (16 sessions) in conjunction with physiotherapy program followed by six weeks of wash out period, followed by eight weeks of body-weight-supported treadmill training in conjunction with a same physiotherapy program. The Gait Kinematic Analysis involved eight infrared cameras that detected 19 reflective spherical markers attached in limb lower of patients. Statistical analysis used the Wilcoxon test (p≤0.05). RESULTS: Both the training no showed significant differences in linear variables. As the angular variables, only training with support showed significant increase of ranges of motion: pelvis tilt, obliquity and rotation amplitude; hip adduction-abduction and rotation amplitude; percentage of peak flexion in swing phase; foot progression amplitude. CONCLUSION: The body weight supported treadmill training may promote increase of mobility of lower limbs during gait and it could be a targeted intervention for PD patients treated with DBS.

Olfactory threshold increase in trigeminal neuralgia after balloon compression.

Idiopathic trigeminal neuralgia (ITN) is a well-known disease often treated with neurosurgical procedures, which may produce sensorial abnormalities, such as numbness, dysesthesia and taste complaints. We studied 12 patients that underwent this technique, in order to verify pain, gustative and olfactory thresholds abnormalities, with a follow-up of 120 days. We compared the patients with a matched control group of 12 patients. Our results found a significant difference in the olfactory threshold at the immediate post-operative period (p=0.048). We concluded that injured trigeminal fibers are probably associated with the increase in the olfactory threshold after the surgery, supporting the sensorial interaction theory.

The carotid artery as an alternative site for dynamic autoregulation measurement: an inter-observer reproducibility study.

The internal carotid artery (ICA) has been proposed as an alternative site to the middle cerebral artery (MCA) to measure dynamic cerebral autoregulation (dCA) using transcranial Doppler ultrasound (TCD). Our aim was to test the inter-operator reproducibility of dCA assessment in the ICA and the effect of interaction amongst different variables (artery source × operator × intra-subject variability). Two operators measured blood flow velocity using TCD at the ICA and MCA simultaneously on each side in 12 healthy volunteers. The autoregulation index (ARI) was estimated by transfer function analysis. A two-way repeated measurements ANOVA with post-hoc Tukey tested the difference between ARI by different operators and interaction effects were analysed based on the generalized linear model. In this healthy population, no significant differences between operator and no interaction effects were identified amongst the different variables. This study reinforced the validity of using the ICA as an alternative site for the assessment of dCA. Further work is needed to confirm and extend our findings, particularly to disease populations.

Sensory abnormalities and pain in Parkinson disease and its modulation by treatment of motor symptoms.

Pain and sensory abnormalities are present in a large proportion of Parkinson disease (PD) patients and have a significant negative impact in quality of life. It remains undetermined whether pain occurs secondary to motor impairment and to which extent it can be relieved by improvement of motor symptoms. The aim of this review was to examine the current knowledge on the mechanisms behind sensory changes and pain in PD and to assess the modulatory effects of motor treatment on these sensory abnormalities. A comprehensive literature search was performed. We selected studies investigating sensory changes and pain in PD and the effects of levodopa administration and deep brain stimulation (DBS) on these symptoms. PD patients have altered sensory and pain thresholds in the off-medication state. Both levodopa and DBS improve motor symptoms (i.e.: bradykinesia, tremor) and change sensory abnormalities towards normal levels. However, there is no direct correlation between sensory/pain changes and motor improvement, suggesting that motor and non-motor symptoms do not necessarily share the same mechanisms. Whether dopamine and DBS have a real antinociceptive effect or simply a modulatory effect in pain perception remain uncertain. These data may provide useful insights into a mechanism-based approach to pain in PD, pointing out the role of the dopaminergic system in pain perception and the importance of the characterization of different pain syndromes related to PD before specific treatment can be instituted.