Novel neurotherapeutics in psychiatry: use and rationale of transcranial direct current stimulation in major depressive disorder

Background : Transcranial direct current stimulation (tDCS) is a novel non-pharmacological intervention being investigated for the treatment of major depressive disorder (MDD). Objective : To perform an updated review of tDCS for MDD. Method : Systematic review in Medline/PubMed and other databases of all clinical studies evaluating the clinical efficacy of tDCS in MDD, from the first date available to December/2013. Results : Out of 55 articles, 24 were included, being 6 open-label studies; 8 randomized, double-blind, sham-controlled trials; 2 follow-up studies; 2 meta-analyses and 6 case reports. We observed an improvement of 20-40% in depressive symptoms, being slightly better in open studies. Five randomized clinical trials displayed positive results. The meta-analyses presented mixed results; although none included the study of Brunoni et al. (2013) that represents almost 50% of the evaluated sample. Open-label studies and case reports also investigated tDCS in bipolar depression, post-stroke depression and employed different parameters of stimulation. Discussion : TDCS is a novel, promising treatment for MDD. Definite evidence from large, ongoing clinical trials will be available in the next years

Novas neuroterapêuticas em psiquiatria: racional e uso da estimulação transcraniana por corrente contínua no transtorno depressivo maior

Background : Transcranial direct current stimulation (tDCS) is a novel non-pharmacological intervention being investigated for the treatment of major depressive disorder (MDD). Objective : To perform an updated review of tDCS for MDD. Method : Systematic review in Medline/PubMed and other databases of all clinical studies evaluating the clinical efficacy of tDCS in MDD, from the first date available to December/2013. Results : Out of 55 articles, 24 were included, being 6 open-label studies; 8 randomized, double-blind, sham-controlled trials; 2 follow-up studies; 2 meta-analyses and 6 case reports. We observed an improvement of 20-40% in depressive symptoms, being slightly better in open studies. Five randomized clinical trials displayed positive results. The meta-analyses presented mixed results; although none included the study of Brunoni et al. (2013) that represents almost 50% of the evaluated sample. Open-label studies and case reports also investigated tDCS in bipolar depression, post-stroke depression and employed different parameters of stimulation. Discussion : TDCS is a novel, promising treatment for MDD. Definite evidence from large, ongoing clinical trials will be available in the next years.Contexto : A estimulação transcraniana por corrente contínua (ETCC) é uma nova intervenção não farmacológica investigada como tratamento no transtorno depressivo maior (TDM). Objetivo : Apresentar uma revisão atualizada da ETCC no TDM. Método : Revisão sistemática no banco de dados Medline/PubMed e outros de todos os estudos clínicos publicados avaliando a eficácia da ETCC no TDM, da primeira data disponível a dezembro/2013. Resultados : De 55 artigos, 24 foram incluídos, sendo 6 estudos abertos; 8 ensaios clínicos randomizados, duplo-cego, placebo controlados; 2 estudos de seguimento; 2 metanálises e 6 relatos de caso. Observa-se uma melhora de 20-40% nos sintomas depressivos, sendo ligeiramente maior nos estudos abertos. Entre os ensaios controlados, 5 demonstraram eficácia da técnica. As metanálises divergiram quanto aos resultados, mostrando presença e ausência de eficácia e ausência da ETCC. Porém, nenhuma incluiu o estudo de Brunoni et al. (2013), que representa quase 50% da população estudada. Estudos abertos e relatos de caso também investigaram o uso da ETCC na depressão bipolar, na depressão pós-AVC e usaram variações nos parâmetros de estimulação. Conclusões : A ETCC é uma técnica promissora no tratamento da TDM. Evidências definitivas devem estar disponíveis nos próximos anos, com a divulgação de resultados de grandes ensaios clínicos em andamento

Tolerabilidade e segurança do lítio em transtornos do humor: uma revisão crítica

Background : Lithium is a first-line treatment for bipolar disorder in all phases, also indicated as add-on drug for unipolar depression and suicide prevention. This study encompasses a broad critical review on the safety and tolerability of lithium for mood disorders. Methods : A computerized search for English written human studies was made in MEDLINE, using the keywords “lithium” and “mood disorders”, starting from July 1993 through July 2013 (n = 416). This initial search aimed to select clinical trials, prospective data, and controlled design studies of lithium treatment for mood disorders reporting adverse effects (n = 36). The final selection yielded 91 studies. Results : The most common general side effects in patients on lithium treatment were thirst, frequent urination, dry mouth, weight gain, fatigue and cognitive complaints. Lithium users showed a high prevalence of hypothyroidism, hyperparathyroidism, and decrease in urinary concentration ability. Reduction of glomerular filtration rate in patients using lithium was also observed, but in a lesser extent. The evidence of teratogenicity associated with lithium use is not well established. Anti-inflammatory non-steroidal drugs, thiazide diuretics, angiotensin-converting enzyme inhibitors, and alprazolam may increase serum lithium and the consequent risk for intoxication. Discussion : Short-term lithium treatment is associated with mild side effects. Medium and long-term lithium treatment, however, might have effects on target organs which may be prevented by periodical monitoring. Overall, lithium is still a safe option for the treatment of mood disorders.Contexto : O lítio é um tratamento de primeira linha para o transtorno bipolar, em todas as fases, e também é indicado como terapia adjunta para a depressão unipolar e prevenção do suicídio. Este estudo abrange uma ampla revisão crítica sobre a segurança e a tolerabilidade do lítio para transtornos do humor. Métodos : Uma busca informatizada para estudos com humanos escritos em inglês foi feita no MEDLINE, usando as palavras-chave “lítio” e “transtornos de humor”, a partir de julho de 1993 a julho de 2013 (n = 416). Esta pesquisa inicial teve como objetivo selecionar ensaios clínicos, estudos prospectivos e estudos controlados com tratamento com lítio para transtornos de humor, relatando efeitos adversos (n = 36). A seleção final identificou 91 estudos. Resultados : Os efeitos colaterais mais comuns nos pacientes em tratamento com lítio foram sede, micção frequente, boca seca, ganho de peso, fadiga e queixas cognitivas. Usuários de lítio mostraram uma alta prevalência de hipotireoidismo, hiperparatireoidismo e diminuição da capacidade de concentração urinária. Também foi observada redução da taxa de filtração glomerular em pacientes utilizando lítio, mas em menor grau. A evidência de teratogenicidade associada com o uso de lítio não está bem estabelecida. Os medicamentos anti-inflamatórios não esteroides, diuréticos, inibidores da enzima de conversão da angiotensina e alprazolam podem aumentar o lítio sérico e o consequente risco de intoxicação. Conclusões : O tratamento de curto prazo com lítio está associado com efeitos colaterais leves. No entanto, tratamentos de médio a longo prazo com lítio podem ter efeitos sobre órgãos-alvo que podem ser prevenidos por acompanhamento periódico. Em geral, o lítio é ainda uma alternativa segura para o tratamento dos transtornos de humor

Lithium safety and tolerability in mood disorders: a critical review

Background : Lithium is a first-line treatment for bipolar disorder in all phases, also indicated as add-on drug for unipolar depression and suicide prevention. This study encompasses a broad critical review on the safety and tolerability of lithium for mood disorders. Methods : A computerized search for English written human studies was made in MEDLINE, using the keywords “lithium” and “mood disorders”, starting from July 1993 through July 2013 (n = 416). This initial search aimed to select clinical trials, prospective data, and controlled design studies of lithium treatment for mood disorders reporting adverse effects (n = 36). The final selection yielded 91 studies. Results : The most common general side effects in patients on lithium treatment were thirst, frequent urination, dry mouth, weight gain, fatigue and cognitive complaints. Lithium users showed a high prevalence of hypothyroidism, hyperparathyroidism, and decrease in urinary concentration ability. Reduction of glomerular filtration rate in patients using lithium was also observed, but in a lesser extent. The evidence of teratogenicity associated with lithium use is not well established. Anti-inflammatory non-steroidal drugs, thiazide diuretics, angiotensin-converting enzyme inhibitors, and alprazolam may increase serum lithium and the consequent risk for intoxication. Discussion : Short-term lithium treatment is associated with mild side effects. Medium and long-term lithium treatment, however, might have effects on target organs which may be prevented by periodical monitoring. Overall, lithium is still a safe option for the treatment of mood disorders

Repetitive Transcranial Magnetic Stimulation for Major Depressive Disorder in Older Adults: Systematic Review and Meta-analysis

Background Major depressive disorder (MDD) in older adults is a serious public health concern. Repetitive transcranial magnetic stimulation (rTMS) is a nonpharmacological intervention approved for MDD treatment in adults, but its value in older adults remains unknown. This study aims to systematically review and meta-analyze evidence of rTMS efficacy in MDD treatment among older adults. Methods We systematically reviewed the literature for randomized controlled trials (RCTs) and open-label studies assessing rTMS for the treatment of MDD in patients older than 50 years, published until June 2020. Random-effects meta-analyses using standardized mean differences (SMDs) were conducted to assess change in depression severity score (primary outcome), while odds ratios (ORs) were used to assess secondary categorical outcomes (response and remission). Additionally, univariate meta-regression analyses were performed to identify potential predictors of change in depression severity scores. Results Fourteen RCTs were included in meta-analyses and 26 studies (10 RCTs and 16 open-label studies) in meta-regression. Active rTMS was significantly superior to sham treatment for reduction of severity (SMD = 0.36; 95% CI = 0.13–0.60), as well as response (OR = 3.26; 95% CI = 2.11–5.04) and remission (OR = 4.63; 95% CI = 2.24–9.55). Studies were of moderate to high quality, with funnel plots and Egger’s regression test not suggestive of publication bias. In meta-regressions, higher mean age and number of sessions were significantly associated with greater improvement. Conclusions Our results support that rTMS is an effective, safe, and well-tolerated treatment for MDD in older adults and that it should be considered in the treatment of this vulnerable population.info:eu-repo/semantics/publishedVersio

Spondilodiscit caused by Candida parapsilosis: case report and literature review

INTRODUÇÃO: São raras as espondilodiscites fúngicas decorrentes de espécies do gênero Candida, sendo que até 2004 foram descritos menos de 75 casos. RELATO DECASO: Homem, 42 anos, com história de etilismo por 35 anos, foi admitido com quadro de dor em abdome inferior com irradiação para membros inferiores e fraqueza dos mesmos nos últimos 3 meses. Os achados do exame físico foram: atrofia muscular em região glútea, dor à mobilização da articulação coxo-femoral, lombalgia em níveis L4 e L5 e força muscular grau II de parte distal de membros inferiores. O paciente foi internado e introduziu-se empiracamente clindamicina e ciprofloxacina por suspeita de espondilodiscite, confirmada por meio do exame de Ressonância Magnética (RM). Após duas semanas o paciente começou a apresentar quadro de dor à inspiração. A radiografia e a tomografia de tórax mostraram quadro difuso multinodular em pulmão sugestivo de infecção fúngica ou tuberculose de apresentação atípica. A biópsia demonstrou granuloma com necrose central e a cultura Candida albicans. Após 1 mês deantibioticoterapia houve melhora da dor em abdome inferior e membros inferiores porém sem melhora radiológica. Foi então realizada punção aspirativa da massa lombar com cultura positiva para Candida parapsilosis, introduzindo-se Anfoterecina B. Cinco meses após uso contínuo desta droga houve melhora radiológica pulmonar e da coluna lombar, com remissão dos sintomas. DISCUSSÃO: O uso abusivo de álcool constitui um fator de risco para o desenvolvimento de espondilodiscite por espécies do gênero Candida, visto que teoricamente predispõe a ocorrência de infecções sistêmicas por organismos normalmente de baixa virulência. CONCLUSÃO: A espondilodiscite causada por Candida é um evento raro, mas deve ser suspeitada em pacientes com algum tipo de imunosupressão, como o etilismo grave.Introduction: Fungic Spondilodiscit decorrent of Candida generus species are rare, being less than 75 cases described until 2004. Case Report: Man, 42 years old, with 35 years history of alcohol abuse, was admitted with a lower abdomen pain with irradiation to inferior members and weakness of them in the past 3 months. The physical exam were: gluteus muscular atrophy, mobilization pain of the coxo-femoral articulation, L4 and L5 back pain and muscle strength grade II in the inferior member distal part. The patient was admitted and initiated clindamicin and ciprofloxacin with the suspect of spondilodiscit, confirmed by Magnetic Ressonance (RM). Two weeks latter the patient started a breathing pain. Chest radiography and computadorizated tomography shown a difuse multinodule pulmonary presentation suggestive of fungic infection or atypic tubercular presentation. Biopsy shown a granuloma with central necrosis and the culture Candida albicans. One month of antibioticotherapy there was an improvement of inferior abdomen pain and inferior members therefore without radiologic improvement. Aspirative biopsy of the lumbar mass was made with positive culture for parapsilosis candida, introducing Anfotericin B. Five months after the continuous use of these drug there were pulmonary and lumbar spine radiologic improvement with symptoms remission. Discussion: The abusive use of alcohol constitute a risk factor to the development of spondilodiscit of the Candida generus, considered that theorically improve predisposition for systemic infections by regular low virulency organisms. Conclusion: Spondilodisct caused by Cândida is a rare event, therefore must be suspected in patients with some kind of imunossupression, like severe etilism