White Matter Integrity as a Biomarker for Stroke Recovery: Implications for TMS Treatment

White matter consists of myelinated axons which integrate information across remote brain regions. Following stroke white matter integrity is often compromised leading to functional impairment and disability. Despite its prevalence among stroke patients the role of white matter in development of post-stroke rehabilitation has been largely ignored. Rehabilitation interventions like repetitive transcranial magnetic stimulation (rTMS) are promising but reports on its efficacy have been conflicting. By understanding the role of white matter integrity in post-stroke motor recovery, brain reorganization and TMS efficacy we may be able to improve the development of future interventions. In this dissertation we set out answer these questions by investigating the relationship between white matter integrity and 1) bimanual motor performance following stroke, 2) cortical laterality following stroke and 3) TMS signal propagation (in a group of cocaine users without stroke). We identified white matter integrity of the corpus callosum as a key structure influencing bimanual performance using kinematic measures of hand symmetry (Chapter 2). Second, we found that reduced white matter integrity of corpus callosum was correlated with loss of functional laterality of the primary motor cortex during movement of the affected hand (Chapter 3). Lastly, we found that reduced white matter tract integrity from the site of stimulation to a downstream subcortical target, was correlated to the ability to modulate that target (Chapter 4). Taken together these studies support white matter integrity as a valuable biomarker for future rTMS trials in stroke. To emphasize the implications of these findings, we provide an example of how to incorporate white matter integrity at multiple levels of rTMS study design

The Importance of Hydration in Wound Healing: Reinvigorating the clinical perspective

Balancing skin hydration levels is important as any disruption in skin integrity will result in disturbance of the dermal water balance. The discovery that a moist wound healing environment actively supports the healing response when compared to a dry environment highlights the importance of water and good hydration levels for optimal wound healing. The benefits of “wet” or “hyper-hydrated” wound healing appears to offer benefits that are similar to those offered by moist wound healing over wounds healing in a dry environment. This suggests that the presence of free water itself during wound healing may not be detrimental to healing but that any adverse effects of wound fluid on tissues is more likely related to the biological components contained within chronic wound exudate (e.g. elevated protease levels). Appropriate dressings applied to wounds must be able to absorb not only the exudate but also retain this excess fluid together with its protease solutes while concurrently preventing desiccation. This is particularly important in the case of chronic wounds where peri-wound skin barrier properties are compromised and there is increased permeation across the injured skin barrier. This review discusses the importance of appropriate levels of hydration in skin with a particular focus on the need for optimal hydration levels for effective healing

Impetigo herpetiformis during the puerperium triggered by secondary hypoparathyroidism: a case report

A 38-year-old multiparous woman with post thyroidectomy hypoparathyroidism developed pruritic erythematous patches with multiple pustules on its margins on her thighs and groin accompanied by fever few days after delivery by caesarean section. Impetigo herpetiformis was diagnosed based on the typical clinicopathological findings. The patient was treated with intravenous fluids, calcium, Calcitrol and corticosteroids. The correction of hypocalcaemia was accompanied with rapid improvement of her skin disease and general condition. Our case is the fourth case of impetigo herpetiformis initially presented during puerperium and the first case of puerperal impetigo herpetiformis that is precipitated by secondary hypoparathyroidism. The awareness of the possible occurrence of impetigo herpetiformis during the puerperium allows early diagnosis, treatment and prevention of maternal complications

Intra-abdominal pectus bar migration – a rare clinical entity: case report

We present the case of a 20-year-old male who underwent successful surgical correction of pectus excavatum with the Highly Modified Ravitch Repair (HMRR). At 29 months the attempted operative removal of the Ravitch bar was unsuccessful despite the impression of adequate bar location on chest x-ray. Subsequent imaging with computed tomography was unclear in determining whether the bar was supra or infra-diaphragmatic due to the tissue distortion subsequent to initial surgery. Video assisted thoracoscopic surgery (VATS) successfully retrieved the bar and revealed that it was not in the thorax, but had migrated to the intra-abdominal bare area of the liver, with no evidence of associated diaphragmatic defect or hernia. Intra-abdominal pectus bar migration is a rare clinical entity, and safe removal can be facilitated by the use of the VATS technique

Atopic dermatitis : a cutaneous or systemic disease? The search for answers in the history of Dermatology

A dermatite atópica é doença inflamatória cutânea associada à atopia, predisposição a produzir resposta IgE a alérgenos ambientais, constituindo uma das manifestações das doenças atópicas, junto com a asma e a rinite alérgica. A dermatite atópica é caracterizada por episódios recorrentes de eczema associado a prurido, acometendo superfície cutânea geneticamente alterada, induzindo, por fenômenos imunológicos, a presença de inflamação. Trata-se de doença multifatorial, com enfoque nas alterações sistêmicas e alérgicas ou nas manifestações cutâneas, de acordo com diferentes visões da doença. A conceituação da dermatite atópica é importante, porque a conduta terapêutica pode variar segundo essas duas formas diferentes de analisá-la. Autores modernos discutem extensivamente esses aspectos sem, contudo, alcançar uma conclusão sobre a dermatite atópica como doença sistêmica ou cutânea. A procura dos conceitos sobre a doença, desde os primeiros relatos, associada à evolução do pensamento na dermatologia, poderia esclarecer a origem dessas dúvidas. Uma análise histórica demonstra que a dermatite atópica tem seus conceitos atuais oriundos dos estudos de diversos pensadores, que, em diferentes momentos históricos, descreveram a doença, e que muito do que acreditamos atualmente tem, nesses escritos, seus fundamentos.Atopic dermatitis is an inflammatory disease associated to atopy, which is a predisposition to produce an IgE response to environmental allergens and considered one of the manifestations of the atopic diseases, including asthma and allergic rhinitis. Atopic dermatitis is characterized by recurrent eczema flares, associated to pruritus, affecting a genetically disrupted skin surface, inducing, by immunological phenomena, the onset of inflammation. It is a multifactorial disease, with an emphasis on systemic and allergic alterations or skin manifestations, according to different concepts. The definition of atopic dermatitis is important, since its management may vary according to these two different points of view. Modern authors have extensively discussed these concepts, though with no conclusion as to its nature - systemic or cutaneous disease. The search for concepts about the disease, since its first descriptions, associated to the evolution of the dermatology rationale through history, may help understand the origin of these doubts. A historical analysis demonstrates that the currently accepted concepts of atopic dermatitis have their background from different researchers, who, at different historical moments, described the disease, and a great part of our beliefs about atopic dermatitis are related to these ancient writings