Segurança da estimulação transcraniana por corrente contínua em uma paciente com implante de eletrodos de estimulação cerebral profunda

Descrição: A estimulação transcraniana por corrente contínua (ETCC) tem sido investigada nos distúrbios de movimento, tornando-a uma alternativa terapêutica no contexto clínico. Contudo, não há consenso quanto aos protocolos mais apropriados na maioria dos casos e a presença de eletrodos de estimulação cerebral profunda (ECP) é geralmente considerada uma contraindicação. Recentemente, estudamos os efeitos da ETCC cerebelar em uma paciente do sexo feminino com implante de eletrodos de estimulação cerebral profunda (ECP) para distonia generalizada. Ela também apresentava dor crônica e depressão. A ETCC foi realizada dois anos após o implante de eletrodos de ECP. Com a ECP houve melhora da distonia e a toxina botulínica reduziu a dor. Contudo, os sintomas depressivos pioraram após a cirurgia de ECP. Métodos: Foi proposta ETCC cerebelar anódica de 2mA, sobre os dois hemisférios em cada sessão de 30min: 15 min de ETCC cerebelar esquerda seguida de 15min de ETCC cerebelar direita. Resultados: Embora o nosso objetivo tenha sido melhorar os movimentos distônicos, após 10 sessões de ETCC houve melhora também do humor da paciente. Não houve nenhuma complicação, apesar da presença de eletrodos de ECP. Conclusão: Nossos resultados apontam para a segurança da tDCS e sua aplicação potencial e efetiva como ferramenta neuromodulatória adicional no tratamento de possíveis sintomas persistentes após a ECP em pacientes com distúrbios de movimento.Background: Transcranial direct current stimulation (tDCS) has been investigated in movement disorders, making it a therapeutic alternative in clinical settings. However, there is still no consensus on the most appropriate treatment protocols in most cases, and the presence of deep brain stimulation (DBS) electrodes has been regarded as a contraindication to the procedure. We recently studied the effects of cerebellar tDCS on a female patient already undergoing subthalamic nucleus deep brain stimulation (STN-DBS) for generalized dystonia. She also presented with chronic pain and depression. With STN-DBS, there was improvement of dystonia, and botulinum toxin significantly reduced pain. However, depressive symptoms were worse after STN-DBS surgery. Methods: Neuromodulation with 2 mA anodal cerebellar tDCS was initiated, targeting both hemispheres in each daily 30 minute session: 15 minutes of left cerebellar stimulation followed by 15 minutes of right cerebellar stimulation. The DBS electrodes were in place and functional, but the current was turned off during tDCS. Results: Although our goal was to improve dystonic movements, after 10 tDCS sessions there was also improvement in mood with normalization of Beck Depression Inventory scores. There were no complications in spite of the implanted STN-DBS leads. Conclusion: Our results indicate that tDCS is safe in patients with DBS electrodes and may be an effective add-on neuromodulatory tool in the treatment of potential DBS partial efficacy in patients with movement disorders

The effect of entrepreneurial orientation on business performance: Evidence from small medium size enterprise

Entrepreneurship has long been considered a significant factor for socioeconomic growth and development because it provides millions of job opportunities, offers a variety of consumer goods and services, and generally increases national prosperity and competitiveness (Lee, 2000). Many scholars have focused on the individual level behavior analysis for the entrepreneurs and others as Wiklund (2005) focused on the firm level in behavior in explaining entrepreneurial performance on the basis that the behavior gives a meaning to entrepreneurial process. Other scholars remain in the area of studying entrepreneurship without entrepreneurs and it remains worthwhile for a certain period at the individual level (e.g. using a trait-based approach). Although, we believe that the dispositional characteristics are to be related to the firm level behavior as well as affect the firm performance outcomes for a complete understanding of the entrepreneurial process. To date, few studies have examined how dispositional traits, firm-level behaviors, and firm-level outcomes are related (Poon et al., 2006)

Alívio da distonia cervical primária com o uso da estimulação magnética transcraniana de baixa freqüência sobre o córtex pré-motor : relato de caso

ABSTRACTObjective: To evaluate the effect of low-frequency repetitive transcranial magnetic stimulation (rTMS) on the symptoms of a patient with primary segmental dystonia (PSD). Method: 1200 TMS pulses at a frequency of 1Hz, over the premotor cortex, with an intensity of 90% of the motor threshold (MT), using an eight-shaped coil; a total of 5 sessions were carried out. Results: A reduction of 50 percent in the neck subset of the Burke, Fahn and Marsden torsion dystonia scale (BFM) was observed in our patient. Conclusion: The reduction in the BFM scale supports the concept that rTMS of the premotor cortex may reduce specific motor symptoms in PSD. ________________________________________________________________________________ RESUMOObjetivo: Investigar o efeito da estimulação magnética transcraniana repetitiva (EMTr) de baixa freqüência nos sintomas de um paciente com distonia segmentar primária (DSP). Método: 1200 pulsos a uma freqüência de 1Hz, sobre o córtex pré-motor, a uma intensidade de 90% do limiar motor (LM), usando uma bobina em forma de 8. Foram realizadas 5 sessões. Resultados: Uma redução de 50% no sub-item "pescoço" na escala de distonia de torção de Burke, Fahn e Marsden (BFM) foi observada no paciente em questão. Conclusão: A redução na escala BFM corrobora a idéia de que a EMTr sobre o córtex pré-motor pode reduzir sintomas motores específicos na DSP

Systematic Evaluation for the Impact of the Geological Conditions on the Adsorption Affinities of Calcite as an Adsorbent of Zn2+ Ions from Aqueous Solutions: Experimental and Theoretical Studies

Three samples of calcite (calcite crystal (CA), calcite of limestone (L.CA), and metamorphosed calcite (marble) (M.CA)) were assessed as adsorbents of Zn (II) to consider the impact of the different geological conditions. The three samples exhibit remarkable changes in their Zn (II) retention capacities (Qsat = 384.6 mg/g (CA), 274.5 mg/g (L.CA), and 512.6 mg/g (M.CA)). The retention systems of the three calcite samples were described on the basis of the suggested statistical physics-based equilibrium studies as well as the traditional kinetic and isotherm models. However, the M.CA samples exhibited the best retention capacity, the steric properties reflecting a higher active site density of CA (Nm (Zn) = 113.46 mg/g) than both M.CA (Nm (Zn) = 82.8 mg/g) and L.CA (Nm (Zn) = 52.4 mg/g) at 323 K. This was assigned to the controlling effect of the sequestered numbers of Zn (II) per site on the surfaces of the calcite phase (n(Zn) = 3.39 (CA), 5.24 (L.CA), and 6.19 (M.CA)) in addition to the higher surface area and ion exchange of the metamorphosed and deformed M.CA. The previous n(Zn) values suggested the retention of Zn (II) by a multi-ionic mechanism in a vertical orientation. The Gaussian energies (8 to 16 KJ/mol) and retention energies (˂40 KJ/mol) of Zn (II) by CA and L.CA suggested complex physical and weak chemical mechanisms involving ion exchange, hydrogen bonding, dipole bonding forces, electrostatic attractions, and van der Waals forces. The thermodynamic properties were illustrated on the basis of the internal energy, free enthalpy, and entropy functions, which validate the endothermic and spontaneous nature of the Zn (II) retention system by the three calcite samples

Isokinetic muscle strength of knee extensors in individuals with Parkinson's disease

INTRODUÇÃO: Apesar do tremor, bradicinesia e rigidez serem os sintomas motores clássicos da doença de Parkinson (DP), a fraqueza muscular também tem sido apontada como um dos mais importantes sintomas motores associados a essa doença, porém, essa condição ainda é pouco estudada e os resultados são inconsistentes. OBJETIVOS: O presente estudo teve o propósito de comparar a força muscular do quadríceps entre indivíduos portadores de DP e indivíduos neurologicamente saudáveis pareados por idade e gênero. Foi comparada também a força muscular do membro mais acometido e menos acometido pela doença. MATERIAIS E MÉTODOS: Participaram deste estudo 26 voluntários, 13 do grupo Parkinson (GP: 64,08 ± 6,87 anos; 73,82 ± 13,03 Kg; 1,66 ± 0,07m;) e 13 do grupo controle (GC: 62,73 ± 6,42 anos; 79,46 ± 11,40 kg; 1,71 ± 0,07 m). Foi mensurado o pico de torque (PT) dos extensores do joelho por meio da dinamometria isocinética, na velocidade de 90º.s-1. Foi utilizado o teste t para comparar as médias intra e entre os grupos (p < 0,05). RESULTADOS: O PT absoluto foi significativamente menor no GP (119,29 ± 40,06 N.m) quando comparado ao GC (145,15 ± 20,05 N.m). Entre os indivíduos com DP, foram encontrados valores significativamente inferiores de força muscular do membro mais acometido quando comparado com o menos acometido (119,29± 40,06 N.m vs. 128,86 ± 35,56 N.m; p < 0,05). CONCLUSÃO: Com base nos resultados, conclui-se que portadores da DP apresentam reduzido PT isocinético dos extensores do joelho, sendo esses achados exacerbados no membro mais acometido pela doença.INTRODUCTION: Despite the tremor, bradykinesia and rigidity are the classic motor symptoms of Parkinson's disease (PD), muscle weakness has also been pointed out as an important motor symptom associated to this disease, however this condition is still poorly studied and results are inconsistent. OBJECTIVES: This study aimed to compare quadriceps muscle strength between individuals with PD and neurologically healthy individuals matched for age and gender. We also compared muscle strength in the limb more and less affected by the disease. MATERIALS AND METHODS: This study had the participation of 26 volunteers: 13 from the Parkinson Group (64.08 ± 6.87 years, 73.82 ± 13.03 kg, 1.66 ± 0.07 m;) and 13 from the control group (62.73 ± 6.42 years, 79.46 ± 11.40 kg, 1.71 ± 0.07 m). Peak Torque (PT) was measured in knee extensors using an isokinetic dynamometer at a velocity of 90º.s -1. Student's t-test was used to compare average values intraand inter-groups (p < 0.05). RESULTS: Absolute PT was significantly lower in the Parkinson group (119.29 ± 40.06) when compared to the control group (145.15 ± 20.05 Nm). Among individuals with PD, we found significantly lower values of muscle strength in the more affected limb when compared to the less affected limb (119.29 ± 40.06 N.m vs 128.86 ± 35.56 N.m, P < 0.05). CONCLUSION: Based on the results, we concluded that patients with PD showed a decreased isokinetic PT in knee extensors, and these findings are exacerbated in the limb more affected by the disease

O ultrassom transcraniano é útil para o diagnóstico da doença de Parkinson na prática clínica?

A ultrassonografia transcraniana (UTC) é um exame complementar para diagnóstico de doença de Parkinson (DP). Objetivo Avaliar as características da UTC em pacientes com DP e seus diagnósticos diferenciais e estabelecer a precisão desse exame para o diagnóstico clínico de DP após seguimento. Métodos Avaliou-se retrospectivamente 85 pacientes com suspeita clínica inicial de DP, parkinsonismo atípico (PA) ou tremor essencial (TE), todos submetidos a UTC. Um consenso de dois especialistas determinou o diagnóstico clínico final após revisar os registros médicos das consultas de seguimento. A precisão do UTC foi calculada usando métodos estatísticos Bayesianos. Resultados O achado de hiperecogenicidade da substância negra (> 20 mm2) mostrou alta sensibilidade (93,4%) e especificidade (86,6%). A razão de verossimilhança positiva mostra 6.93 vezes mais chances de diagnosticar DP do que uma condição alternativa, se o achado estiver presente. Conclusões Este estudo demonstra a utilidade prática do UTC na diferenciação de DP de condições clínicas similares quando o diagnóstico clínico é inicialmente pouco claro.Transcranial sonography (TCS) is an emerging ancillary examination for diagnosing Parkinson’s disease (PD). Objective To evaluate TCS features in patients with PD and its mimics, and establish their accuracy in predicting the final clinical diagnosis after follow-up. Methods We retrospectively studied 85 patients with an initial clinical suspicion of PD, atypical parkinsonism or essential tremor, all of whom underwent TCS. Two specialists reviewed the follow-up clinical visit records and determined the final clinical diagnosis. The accuracy analysis of the TCS was determined using Bayesian statistical methods. Results The finding of substantia nigra hyperechogenicity (> 20 mm2) showed high sensitivity (93.4%) and specificity (86.6%). The positive likelihood ratio showed 6.93-fold greater odds for diagnosing PD than an alternative condition when this finding was present. Conclusions This study revealed the practical usefulness of TCS in differentiating PD from its prevalent mimics when the clinical diagnosis was initially unclear

Decisões a respeito da terapia com estimulação cerebral profunda na doença de Parkinson

A doença de Parkinson pode ser tratada cirurgicamente em pacientes que desenvolveram complicações motoras, como flutuações e discinesias, ou tremores refratários ao uso de medicação. Nesta revisão, um grupo de especialistas formulou sugestões para um protocolo de avaliação pré-operatória, depois de revisar a literatura publicada até outubro de 2017. Neste protocolo, são sugeridos critérios de elegibilidade e inadmissibilidade para tratamento cirúrgico, bem como procedimentos que devem ser realizados antes das decisões terapêuticas multidisciplinares. A revisão enfatiza a necessidade de estabelecer “equipes de DBS”, com profissionais dedicados especialmente a esta área. Ao final, a seleção do alvo cirúrgico (núcleo subtalâmico ou globo pálido interno) é discutida brevemente, ponderando prós e contras de cada escolha.Parkinson’s disease can be treated surgically in patients who present with motor complications such as fluctuations and dyskinesias, or medically-refractory disabling tremor. In this review, a group of specialists formulated suggestions for a preoperative evaluation protocol after reviewing the literature published up to October 2017. In this protocol, eligibility and ineligibility criteria for surgical treatment were suggested, as well as procedures that should be carried out before the multidisciplinary therapeutic decisions. The review emphasizes the need to establish “DBS teams”, with professionals dedicated specifically to this area. Finally, surgical target selection (subthalamic nucleus or globus pallidus internus) is discussed briefly, weighing the pros and cons of each target

Impact of opioid-free analgesia on pain severity and patient satisfaction after discharge from surgery: multispecialty, prospective cohort study in 25 countries

Background: Balancing opioid stewardship and the need for adequate analgesia following discharge after surgery is challenging. This study aimed to compare the outcomes for patients discharged with opioid versus opioid-free analgesia after common surgical procedures.Methods: This international, multicentre, prospective cohort study collected data from patients undergoing common acute and elective general surgical, urological, gynaecological, and orthopaedic procedures. The primary outcomes were patient-reported time in severe pain measured on a numerical analogue scale from 0 to 100% and patient-reported satisfaction with pain relief during the first week following discharge. Data were collected by in-hospital chart review and patient telephone interview 1 week after discharge.Results: The study recruited 4273 patients from 144 centres in 25 countries; 1311 patients (30.7%) were prescribed opioid analgesia at discharge. Patients reported being in severe pain for 10 (i.q.r. 1-30)% of the first week after discharge and rated satisfaction with analgesia as 90 (i.q.r. 80-100) of 100. After adjustment for confounders, opioid analgesia on discharge was independently associated with increased pain severity (risk ratio 1.52, 95% c.i. 1.31 to 1.76; P &lt; 0.001) and re-presentation to healthcare providers owing to side-effects of medication (OR 2.38, 95% c.i. 1.36 to 4.17; P = 0.004), but not with satisfaction with analgesia (beta coefficient 0.92, 95% c.i. -1.52 to 3.36; P = 0.468) compared with opioid-free analgesia. Although opioid prescribing varied greatly between high-income and low- and middle-income countries, patient-reported outcomes did not.Conclusion: Opioid analgesia prescription on surgical discharge is associated with a higher risk of re-presentation owing to side-effects of medication and increased patient-reported pain, but not with changes in patient-reported satisfaction. Opioid-free discharge analgesia should be adopted routinely