Escalas para avaliação de dor em crianças e associação entre dor e ansiedade pré e pós-operatórias

Justificativa para a pesquisa: Para diagnosticar e manejar adequadamente a dor é preciso conhecer o pertil de acurácia dos testes. Como a dor é uma experiência subjetiva, somente pode ser aferida de maneira adequada através do auto-relato. Dor é um sintoma que acarreta grande sofrimento ao ser humano, para amenizá-lo, estratégias terapêuticas são articuladas, mas essas devem ser precisamente avaliadas para quantificar o benefício conferido ao paciente. Ainda, para compreender o processo fisiopatogênico da dor, deve-se avaliar fatores que precipitam ou minoram o episódio doloroso - situacionais, emocionais, cognitivos. Portanto, somente será possível quantificar com certeza a aferição do fenômeno dor, através da aplicação de escalas com perfil diagnóstico de sensibilidade, especificidade e valores preditivos conhecidos. Objetivo: Avaliar a responsividade das escalas de auto-relato de dor (análogo-visual, faces, verbal) e a associação entre seus escores e a ansiedade pré e pós-operatória em crianças de 7 a 13 anos, submetidas a cirurgias eletivas. Métodos : Efetuou-se um quase experimento, no qual estudaram-se 90 crianças de 7 a 13 anos submetidas a cirurgia eletiva no Hospital de Clínicas de Porto Alegre. Os dados foram coletados nos períodos préoperatório e pós-operatório, através da aplicação de escalas de autorelato de dor (verbal, faces, análogo-visual), inventários de ansiedade traço-estado e questionário estruturado. Para avaliar a associação entre dor e ansiedade selecionou-se a escala análogo-visual por apresentar melhor perfil de acurácia no diagnóstico de dor do que as escalas de faces e verbal. O grau de ansiedade foi classificado segundo pontos de corte em ansiedade alto (acima da média) e baixo. Resultados: Através da análise fatorial de correspondência observa-se que as escalas de auto-relato apresentam concordância nos escores de dor. Os maiores escores estão associados a ausência de bloqueio, história de cirurgia prévia, cirurgias de médio e grande portes e alta ansiedade-estado pós-operatória. Os menores escores de dor estão associados a presença de bloqueio analgésico, ausência de cirurgia prévia, baixa ansiedade-estado pós-operatória e cirurgias de pequeno porte. Ainda, através da responsividade das escalas, determinada a partir da variação dos escores do período pré-operatório para o período pós-operatório, estabeleceu-se o perfil de sensibilidade, especificidade e valores preditivos. A escala análogo-visual apresentou-se como o melhor teste em termos de sensibilidade e de especificidade, quando comparada com as escalas de faces e verbal. Ainda, estabeleceram-se fatores de risco ou de proteção para dor pós-operatória através da associação bruta e ajustada entre dor e ansiedade pré e pós-operatória. A presença de alta ansiedade-estado pós-operatória aumenta em aproximadamente dez vezes o risco para o relato de dor. Conclusões: Conclui-se que as escalas de auto-relato de dor (faces, verbal, análogo-visual) apresentam responsividade ao grau de intensidade dolorosa. Também que há associação entre dor e ansiedade-estado pós-operatória ajustada para o efeito das seguintes variáveis: sexo, idade, escolaridade, cirurgia prévia, porte cirúrgico, realização de bloqueios analgésicos, uso de Midazolam pré-operatório e dose de analgésico opióide usada no período transoperatório.Background: The diagnose and management of pain can be one the most demanding task, even when undertaken by an experienced physician. Since pain can only be measured through patient"s self-report, it is essential to know the profile of accuracy of the tests applicable, to properly asses its subjective nature. Pain is symptom that inflicts upon patients a myriad of suffering, to lesses it, therapeutic strategic assessed to measure the benefit given to the patient.. Yet, to understand the physiopatogenic process of pain, factors that increase or decrease the painful episode must be assessed - as situational, emotional and cognitive factors. Therefore, it only will be possible to measure safety the pain phenomenom through the application of the scale with known sensibility, specificity and predictives values. Objective: To assess the responsiveness of se If-reported , pain scales (analogvisual, faces, verbal) and the association beMieen the scores and the perioperative levei of anxiety in children aged 7-13 years old, submitted to elective surgery. Methods: A design that is almost an experiment was carried out in 90 children aged 7 - 13 years old submitted to elective surgery at the Hospital de Clinicas de Porto Alegre. The data were collected in the preoperative and postoperative periods using the following instruments: a self-report pain scale (verbal, faces, analg-visual), State-Trait Anxiety Inventory for Children and State-Trait Anxiety Inventory for adults. It was selected the analog-visual scales to assess the association between pain and anxiety, in the way, that this scale shows better accuracy profile in the pain diagnostic that the other scales (faces an verbal). The anxiety levei was classified according to cut point in high anxiety (about average) and low anxiety. Results: The factorial correspondence analysis showed that self-reported scales present an agreement in the pain scores. According to the analysis of correspondence the higher scores were associated with the lack blockage, history of previous surgery, medium and high sized surgical procedures and high leveis postoperative state-anxiety. The lowest pain score were associated with the presence of analgesic blockage, absence of previous surgeries, low state-anxiety in the postoperative period and minor operalions. Through lhe responsiveness of the scales, based on lhe variation of the scores from lhe preoperative to post-operative period; a profile of sensibility, specificity and predictive values could be established. The analog-visual scale was considered the best test in terms of sensibility and specificity. Risk or protection factors for pain in the postoperative period were established through a postoperative state-anxiety analysis that was carried out by the association of crude and adjusted data related to pain. Conclusion: One can conclude that the self-reported scales (faces, verbal, analogvisual) present responsiveness to the degree of pain intensity. Also, there is an association between pain and adjusted postoperative state-anxiety with the following variants: Sex, age, schooling, previous surgery, type of surgical procedure, analgesic blockage, the use of Midazolan and opiod use in the perioperative period

Novel Insights of Effects of Pregabalin on Neural Mechanisms of Intracortical Disinhibition in Physiopathology of Fibromyalgia: An Explanatory, Randomized, Double-Blind Crossover Study

Background: The fibromyalgia (FM) physiopathology involves an intracortical excitability/inhibition imbalance as measured by transcranial magnetic stimulation measures (TMS). TMS measures provide an index that can help to understand how the basal neuronal plasticity state (i.e., levels of the serum neurotrophins brain-derived neurotrophic factor (BDNF) and S100-B protein) could predict the effect of therapeutic approaches on the cortical circuitries. We used an experimental paradigm to evaluate if pregabalin could be more effective than a placebo, to improve the disinhibition in the cortical circuitries in FM patients, than in healthy subjects (HS). We compared the acute intragroup effect of pregabalin with the placebo in FM patients and healthy subjects (HS) on the current silent period (CSP) and short intracortical inhibition (SICI), which were the primary outcomes. Pain scores and the pain pressure threshold (PPT) were secondary outcomes.Methods: This study included 27 women (17 FM and 10 HS), with ages ranging from 19 to 65 years. In a blinded, placebo-controlled clinical trial, participants were randomized to receive, in a cross-over manner, oral pregabalin of 150 mg or a placebo. The cortical excitability pain measures were assessed before and 90 min after receiving the medication.Results: A generalized estimating equation (GEE) model revealed that in FM, pregabalin increased the CSP by 14.34% [confidence interval (CI) 95%; 4.02 to 21.63] and the placebo reduced the CSP by 1.58% (CI 95%; −57 to 25.9) (P = 0.00). Pregabalin reduced the SICI by 8.82% (CI 95%, −26 to 46.00) and the placebo increased it by 19.56% (CI 95%; 8.10 to 59.45; P = 0.02). Pregabalin also improved the pain measures. In the treatment group, the BDNF-adjusted index was positively correlated and the serum S100-B negatively correlated with the CSP, respectively. However, in the HS, pregabalin and the placebo did not induce a statistically significant effect in either intracortical excitability or pain measures.Conclusion: These results suggest that pregabalin’s effect on cortical neural networks occurs, particularly under basal neuronal hyperexcitability, because its impact on the cortical excitability and the pain measures was observed only in the FM group. This indicates that pregabalin increased the CSP to induce inhibition in specific neural networks, while it increased the SICI to improve the excitability in other neurobiological systems. Trial registration in clinicaltrials.gov Identifier: NCT02639533

Academic performance of doctoral graduates from the Graduate Program in Medicine : Medical Sciences at UFRGS School of Medicine

Introdução: embora, no Brasil, muito tenha sido feito para estimular a criação e manutenção de programas de pós-graduação ainda há carência de meios para avaliar e para mensurar a evolução profissional dos egressos. O objetivo é compreender a trajetória dos Doutores formados pelo Programa de Pós-Graduação em Medicina Ciências Médicas (PPGCM), Faculdade de Medicina, Universidade Federal do Rio Grande do Sul (UFRGS) e propor um índice de desempenho acadêmico e de inserção profissional. Métodos: foi realizado um estudo transversal. Foram coletados dados dos Currículos Lattes dos egressos de doutorado do Programa de Pós-Graduação em Medicina: Ciências Médicas (PPGCM), no período de 1987 a 2014. Foram extraídos apenas os dados pertinentes a sua origem, curso de graduação e de mestrado, produção intelectual, inserção acadêmica e a posição profissional. Resultados: foram analisados 324 doutores egressos, 221 eram graduados em Medicina. Foram utilizadas as variáveis: graduação em medicina, vínculo laboral em universidade pública, exerce atividade como orientador em nível de doutorado, exerce atividade como orientador em nível de mestrado, bolsista de produtividade em pesquisa do CNPq e possui registro do índice H no currículo Lattes. O coeficiente de determinação (R2) demonstrou que as variáveis incluídas no modelo explicam 99% do modelo hierárquico. Conclusão: os resultados demonstram que os egressos têm contribuído para a construção de conhecimento qualificado disseminado em jornais de circulação internacional, formação de recursos humanos, interagir e criar parcerias em seu ambiente de trabalho, gerenciar e repassar o conhecimento, bem como para fomentar o conhecimento na área das ciências médicas com relevância regional, nacional e internacional.Introduction: Although, in Brazil, much has been done to encourage the creation and maintenance of graduate programs, there remains a lack of means to assess and measure the professional outcomes of graduates. The objective is to understand the trajectory of doctoral graduates from the Graduate Program in Medicine: Medical Sciences (PPGCM), School of Medicine, Universidade Federal do Rio Grande do Sul (UFRGS), and propose an index for academic performance and professional placement. Methods: A cross-sectional study was conducted. Data available at CV Lattes database of the National Council for Scientific and Technological Development (CNPq) were collected on doctoral graduates from the PPGCM, from 1987 to 2014. Only data pertaining to their origin, undergraduate and master’s degrees, intellectual output, academic performance, and professional placement were retrieved. Results: Data on 324 doctoral graduates were analyzed, 221 had graduated in medicine. Undergraduate degree, employment at a public university, working as a doctoral-level advisor, working as a master’s-level advisor, CNPq research productivity grantee, and having a recorded h-index in the Lattes curriculum were collected. The coefficient of determination (R2) demonstrated that the variables included in the model explain 99% of the hierarchical model. Conclusion: The results show that the graduates have contributed to developing qualified knowledge disseminated in international newspapers, training human resources, interacting and creating partnerships in the workplace, managing and passing on knowledge, as well as fostering knowledge in the area of medical sciences with regional, national, and international relevance

Transcranial direct current stimulation in patients with anxiety : current perspectives

Anxiety is one of the most prevalent and debilitating psychiatric conditions worldwide. Pharmaco- and psycho-therapies have been employed in the treatment of human anxiety to date. Yet, either alone or in combination, unsatisfactory patient outcomes are prevalent, resulting in a considerable number of people whose symptoms fail to respond to conventional therapies with symptoms remaining after intervention. The demand for new therapies has given birth to several noninvasive brain stimulation techniques. Transcranial direct current stimulation (tDCS) has arisen as a promising tool and has been proven to be safe and well tolerated for the treatment of many diseases, including chronic pain, depression, and anxiety. Here, reports of the use of tDCS in anxiety disorders in human patients were reviewed and summarized. A literature search was conducted in mid-2019, to identify clinical studies that evaluated the use of tDCS for the treatment of anxiety behavior. The PubMed, Web of Science, and Scielo and PsycInfo databases were explored using the following descriptors: “anxiety”, “anxious behavior”, “tDCS”, and “transcranial direct current stimulation”. Among the selected articles, considerable variability in the type of tDCS treatment applied in interventions was observed. Evidence shows that tDCS may be more effective when used in combination with drugs and cognitive behavioral therapies; however future large-scale clinical trials are recommended to better clarify the real effects of this intervention alone, or in combination with others

Differential Neuroplastic Changes in Fibromyalgia and Depression Indexed by Up-Regulation of Motor Cortex Inhibition and Disinhibition of the Descending Pain System: An Exploratory Study

Background: Major depressive disorder (MDD) and fibromyalgia (FM) present overlapped symptoms. Although the connection between these two disorders has not been elucidated yet, the disruption of neuroplastic processes that mediate the equilibrium in the inhibitory systems stands out as a possible mechanism. Thus, the purpose of this cross-sectional exploratory study was: (i) to compare the motor cortex inhibition indexed by transcranial magnetic stimulation (TMS) measures [short intracortical inhibition (SICI) and intracortical facilitation (ICF)], as well as the function of descending pain modulatory systems (DPMS) among FM, MDD, and healthy subjects (HS); (ii) to compare SICI, ICF, and the role of DPMS evaluated by the change on Numerical Pain Scale (NPS) during the conditioned pain modulation test (CPM-test) between FM and MDD considering the BDNF-adjusted index; (iii) to assess the relationship between the role of DPMS and the BDNF-adjusted index, despite clinical diagnosis.Patients and Methods: A cohort of 63 women, aged 18 to 75 years [FM (n = 18), MDD (n = 19), and HC (n = 29)].Results: The MANCOVA analysis revealed that the mean of SICI was 53.40% larger in FM compared to MDD [1.03 (0.50) vs. 0.55 (0.43)] and 66.99% larger compared to HC [1.03 (0.50) vs. 0.34 (0.19)], respectively. The inhibitory potency of the DPMS assessed by the change on the NPS during CPM-test was 112.29 % lower in the FM compared to MDD [0.22 (1.37) vs. −0.87 (1.49)]. The mean of BDNF from FM compared to MDD was 35.70% higher [49.82 (16.31) vs. 14.12 (8.86)]. In FM, the Spearman’s coefficient between the change in the NPS during CPM-test with the SICI was Rho = −0.49, [confidence interval (CI) 95%; −0.78 to −0.03]. The BDNF-adjusted index was positively correlated with the disinhibition of the DPMS.Conclusion: These findings support the hypothesis that in FM a deteriorated function of cortical inhibition, indexed by a higher SICI parameter, a lower function of the DPMS, together with a higher level of BDNF indicate that FM has different pathological substrates from depression. They suggest that an up-regulation phenomenon of intracortical inhibitory networks associated with a disruption of the DPMS function occurs in FM

The mapping of cortical activation by near infra-red spectroscopy might be a biomarker related to the severity of fibromyalgia

The delta value of oxyhemoglobin (Δ-HbO) determined by functional near-infrared spectroscopy at prefrontal cortex (PFC) and motor cortex (MC) based on primary (25 °C) and secondary (5 °C) thermal stimuli presented a larger peak latency at left MC in fibromyalgia than in controls. The difference between HbO concentration 15 s after the thermal stimuli ending and HbO concentration before the thermal stimuli onset (Δ-HbO*) at left PFC increased 47.82% in fibromyalgia and 76.66% in controls. This value had satisfactory discriminatory properties to differentiate cortical activation in fibromyalgia versus controls. A receiver operator characteristics (ROC) analysis showed the Δ-HbO* cutoffs of − 0.175 at left PFC and − 0.205 at right PFC offer sensitivity and specificity of at least 80% in screening fibromyalgia from controls. In fibromyalgia, a ROC analysis showed that these cutoffs could discriminate those with higher disability due to pain and more severe central sensitization symptoms (CSS). The ROC with the best discriminatory profile was the CSS score with the Δ-HbO* at left PFC (area under the curve = 0.82, 95% confidence interval = 0.61–100). These results indicate that cortical activation based on Δ-HbO* at left PFC might be a sensitive marker to identify fibromyalgia subjects with more severe clinical symptoms