Função cognitiva e sistema modulatório descendente da dor : o efeito da estimulação transcrânia de corrente continua (ETCC) na fibromialgia

Fibromyalgia (FM) is a chronic primary pain condition characterized by generalized musculoskeletal pain, fatigue, and non-repairing sleep. Additionally, there is a significant cognitive impairment related to working memory (WM), associated with higher levels of pain, stiffness, and severe depression and anxiety symptoms. These complaints comprise the "FibroFog'' syndrome, which includes forgetfulness, mental activity blurring, sensory overload, and diminished ability to think, process information, or follow conversations. The same cortical and subcortical brain networks that manage the cognitive functions mentioned above, also control the emotional - motivational process that convey directly with the descending pain modulatory system (DPMS), essential for the effective modulation of sensory input to the central nervous system and behavioral responses to pain. Growing evidence supports the concept that chronic pain is associated with dysregulation in DPMS. However, persist a gap in the research about the relationship between the severity of symptoms affecting Prefrontal Cortex (PFC) neural networks and the effectiveness of the descending pain inhibitory system (DPIS). Based on this, it is conceivable to hypothesize that the PFC, the internal DPMS, and the system controlling the neuroplasticity state are involved in the dysfunction of pain processing pathways and cognitive impairment. Moreover, to treat such hassle, besides pharmacological interventions, Transcranial Direct Current Stimulation (tDCS), a safe and cost-effective neuromodulation technique that modulates the membrane potential of neurons, has demonstrated clinical benefits for complex chronic pain conditions, including FM. This thesis has two main aims. The first study evaluated if working memory, verbal and semantic fluency, and sustained, and divided attention could be suitable to discriminate cognitive impairment in FM compared to Healthy Controls (HC). Additionally, it investigated, using a standardized paradigm, the link between cognitive ability and the function of the DPMS in responders and non-responders of the conditioned pain modulation test (CPM-test). We included 69 FM subjects and 21 HC women aged from 30 to 65 years old. For the Cross sectional study we used scores from the Digits subtest from Wechsler Adult Intelligence Scale (WAIS-III) (short-term and working memory), Controlled Oral Word Association Test (COWAT) (orthographic and semantic fluency), and Trail Making Test (TMT-B-A) (sustained and divided attention) as dependent variables. A generalized linear model (GLM) adjusted by educational level revealed significantly lower scores in FM than HC on the Span digits forward, COWAT-orthographic, and TMT-B-A. For FM patients, multilevel MANCOVA revealed that the cognitive performance of non-responders compared to responders to CPM-test showed lower adjusted scores in Span digits forward (Partial-η2=0.358, P=0.001), Span digits backward (Partial-η2=0.358, P=0.001), COWAT-orthographic (Partial-η2=0.551, P=0.001), COWAT-semantic (Partial-η2=0.355, P=0.001), and TMT-B-A (Partial-η2=0.360, P=0.001). Serum brain-derived neurotrophic factor (BDNF) is a moderating factor in the relationship between the cognitive tests and DPMS. Besides, antidepressant use and pain pressure threshold were positively correlated with these cognitive tests. In contrast, the cognitive tests were conversely associated with the quality of life. The second study evaluates the efficacy of twenty sessions of anodal-(a)-tDCS on the left-DLPFC and cathodal on the right-DLPFC over four weeks would be better than a sham-(s)-tDCS to increase the cognitive performance evaluated by the sustained and divided attention (primary outcome), WM, verbal fluency (secondary outcomes). Besides, we explored if the severity of dysfunction of the Descendant Pain Modulation System (DPMS) predicts the tDCS effect and if its effect is linked to changes in neuroplasticity as measured by the brain-derived neurotrophic factor (BDNF). In this randomized, double-blind, parallel, sham-controlled trial, we included 36 FM subject, assigned 2:1 to receive active (a)-tDCS (n=24) and sham (s)-tDCS (n=12). The intervention of home-based tDCS lasted 20-minute per daily session for four weeks (total 20 sessions), 2 mA anodal-left (F3) and cathodal-right (F4) prefrontal stimulation with 35 cm2 carbon electrodes. A GLM revealed a main effect for treatment Wald χ2=6.176; Df=1; P=0.03 in the TMT-B-A. The a-tDCS improved cognitive performance. The effect size estimated Cohen’s d at treatment end in the TMT-B-A scores was large [-1.48, confidence interval (CI) 95%= -2.07 to -0.90]. Likewise, the a-tDCS effects compared to s-tDCS improved the performance in the WM, verbal and phonemic fluency, and improved scores on the quality-of-life scale. The impact of a-tDCS on the cognitive tests was positively correlated with the reduction in serum BDNF from baseline to treatment end. Besides, the reduction in the serum BDNF was positively correlated with the improvement in the quality of life due to FM symptoms. In summ, these findings showed that HC performed substantially better on cognitive exams than FM did. They demonstrated a link between clinical complaints about attention and memory and decreased DPMS effectiveness. Additionally, they demonstrated that the BDNF is a moderating element in a potential relationship between the severity of cognitive impairment and DPMS dysfunction. And we also have found that daily treatment with a home-based tDCS device over l-DLPFC compared to sham stimulation improved the cognitive impairment in FM, being the a-tDCS at home stimulation well-tolerated, underlining its potential as an alternative treatment for cognitive dysfunction. Besides, the a-tDCS effect is related to the severity of DPMS dysfunction and changes in neuroplasticity state.A fibromialgia (FM) é uma condição crônica de dor primária caracterizada por dor musculoesquelética generalizada, fadiga e sono não reparador. Além disso, há um comprometimento cognitivo significativo relacionado à memória de trabalho (WM), associado a níveis mais altos de dor, rigidez e sintomas graves de depressão e ansiedade. Essas queixas compreendem a síndrome "FibroFog", que inclui esquecimento, desfocagem da atividade mental, sobrecarga sensorial e diminuição da capacidade de pensar, processar informações ou acompanhar conversas. As mesmas redes cerebrais corticais e subcorticais que administram as funções cognitivas mencionadas acima, também controlam o processo emocional - motivacional que transmite diretamente com o sistema modulatório descendente da dor (DPMS), essencial para a modulação efetiva da entrada sensorial no sistema nervoso central e comportamental das respostas à dor. Evidências crescentes apoiam o conceito de que a dor crônica está associada à desregulação no DPMS. No entanto, persiste uma lacuna nas pesquisas sobre a relação entre a gravidade dos sintomas que afetam as redes neurais do córtex pré-frontal (PFC) e a eficácia do sistema descendente inibitório da dor (DPIS). Com base nisso, é concebível a hipótese de que o PFC, o DPMS interno e o sistema que controla o estado de neuroplasticidade estejam envolvidos na disfunção das vias de processamento da dor e no comprometimento cognitivo. Ademais, para tratar esse incômodo, além de intervenções farmacológicas, a Estimulação Transcraniana por Corrente Contínua (tDCS), uma técnica de neuromodulação segura e econômica que modula o potencial de membrana dos neurônios, demonstrou benefícios clínicos para condições complexas de dor crônica, incluindo FM. Esta tese tem dois objetivos principais. O primeiro estudo avaliou se a memória de trabalho, a fluência verbal e semântica e a atenção sustentada e dividida poderiam ser adequadas para discriminar o comprometimento cognitivo em FM em comparação com Controles Saudáveis (HC). Além disso, investigou, usando um paradigma padronizado, a ligação entre a capacidade cognitiva e a função do DPMS em respondedores e não respondedores do teste de modulação da dor condicionada (CPM-test). Para pacientes com FM, a MANCOVA multinível revelou que o desempenho cognitivo de não respondedores em comparação com respondedores ao teste CPM apresentou pontuações ajustadas mais baixas em dígitos Span para frente (Parcial-η2 = 0,358, P = 0,001), dígitos Span para trás (Parcial-η2 = 0,358, P=0,001), COWAT-ortográfico (Parcial-η2=0,551, P=0,001), COWAT-semântico (Parcial-η2=0,355, P=0,001) e TMT-B-A (Parcial-η2=0,360, P= 0,001). O fator neurotrófico sérico derivado do cérebro (BDNF) é um fator moderador na relação entre os testes cognitivos e o DPMS. Além disso, o uso de antidepressivos e o limiar de pressão de dor foram positivamente correlacionados com esses testes cognitivos. Em contraste, os testes cognitivos foram inversamente associados à qualidade de vida. O segundo estudo avalia a eficácia de vinte sessões de tDCS anodal-(a)-tDCS no DLPFC esquerdo e catódico no DLPFC direito ao longo de quatro semanas seria melhor do que um sham-(s)-tDCS para aumentar o desempenho cognitivo avaliado pela atenção sustentada e dividida (desfecho primário), WM, fluência verbal (desfechos secundários). Além disso, exploramos se a gravidade da disfunção do DPMS prediz o efeito do tDCS e se seu efeito está ligado a alterações na neuroplasticidade medida pelo BDNF. Neste estudo randomizado, duplo-cego, paralelo e controlado simuladamente, incluímos 36 indivíduos FM, designados 2:1 para receber (a)-tDCS ativo (n=24) e simulado (s)-tDCS (n=12). A intervenção de ETCC domiciliar durou 20 minutos por sessão diária por quatro semanas (total de 20 sessões), estimulação pré-frontal 2 mA anodal-esquerda (F3) e catódica-direita (F4) com eletrodos de carbono de 35 cm2. Um GLM revelou um efeito principal para o tratamento Wald χ2=6,176; Df=1; P=0,03 no TMT-B-A. O a-tDCS melhorou o desempenho cognitivo. O tamanho do efeito estimado de Cohen no final do tratamento nas pontuações TMT-B-A foi grande [-1,48, intervalo de confiança (IC) 95% = -2,07 a -0,90]. Da mesma forma, os efeitos a-tDCS comparados ao s-tDCS, melhoraram o desempenho na WM, fluência verbal e fonêmica e melhoraram os escores na escala de qualidade de vida. O impacto da a-tDCS nos testes cognitivos foi positivamente correlacionado com a redução do BDNF sérico desde o início até o final do tratamento. Além disso, a redução do BDNF sérico correlacionou-se positivamente com a melhora da qualidade de vida devido aos sintomas da FM. Assim, esses achados mostraram que os sujeitos saudaveis tiveram um desempenho substancialmente melhor em exames cognitivos do que o FM. Eles demonstraram uma ligação entre queixas clínicas sobre atenção e memória e diminuição da eficácia do DPMS. Além disso, demonstraram que o BDNF é um elemento moderador em uma potencial relação entre a gravidade do comprometimento cognitivo e a disfunção do DPMS. E também descobrimos que o tratamento diário com um dispositivo tDCS domiciliar sobre o l-DLPFC comparado à estimulação simulada melhorou o comprometimento cognitivo na FM, sendo a estimulação domiciliar do a-tDCS bem tolerada, destacando seu potencial como tratamento alternativo para disfunção cognitiva. Além disso, o efeito do a-tDCS está relacionado com a gravidade da disfunção do DPMS e alterações no estado de neuroplasticidade

Influencia del clima organizacional en la productividad laboral de los trabajadores de la gerencia de desarrollo urbano de la municipalidad distrital de San Juan de Lurigancho, Lima – 2017

Esta investigación refleja resultados y permiten tomar decisiones que contribuyan a la mejora de la productividad laboral, tuvo como objetivo determinar la influencia del Clima Organizacional en la productividad laboral de los trabajadores de la Gerencia de Desarrollo Urbano de la municipalidad distrital de San Juan de Lurigancho 2017. La metodología empleada para la elaboración de este estudio estuvo bajo el enfoque cuantitativo, utilizando el método hipotético deductivo, fue una investigación de tipo aplicada, constructiva o utilitaria, el diseño de la investigación fue no experimental transeccional de alcance correlacional-causal. La población censal estuvo conformada por 52 trabajadores de la Gerencia de desarrollo urbano. Se empleó como técnica la encuesta y como instrumento dos cuestionarios debidamente validados y confiables con escalamiento likert y para la comprobación de hipótesis se utilizó el análisis de regresión logística ordinal con un nivel de significación del 0.05. Entre los resultados se obtuvo en la prueba de contraste de la razón de verosimilitud, que el modelo logístico es significativo (p<0,05); se ajusta bien a los datos (Desviación con p<0,05); y explica el 40.3% de la variable dependiente productividad laboral. Por lo tanto, se decide rechazar la hipótesis nula y aceptar la alterna es decir: Existe influencia del Clima Organizacional en la Productividad Laboral de los trabajadores de la Gerencia de Desarrollo Urbano de la Municipalidad distrital de San Juan de Lurigancho – 2017

Riesgo ocupacional y comunicación interna en la satisfacción laboral del fiscalizador de un Organismo Técnico Especializado del Sector Transporte, 2022

La presente investigación tuvo como objetivo principal determinar la incidencia del riesgo ocupacional y la comunicación interna en la satisfacción laboral del fiscalizador de un organismo técnico especializado del sector transporte, 2022. El estudio utilizo el enfoque cuantitativo, el método utilizado fue el hipotético deductivo, el tipo de investigación fue la aplicada con un diseño no Experimental, transeccional de alcance corrrelaciónal-Causal; la población estuvo conformada por 441 fiscalizadores de transporte, obteniendo una muestra de 168 fiscalizadores mediante muestreo probabilístico, de tipo aleatorio simple. La técnica de recolección de datos fue la encuesta cuyo instrumentó fue el cuestionario para las 3 variables. Se concluye que los riesgos ocupacionales y la comunicación interna son factores que inciden en la satisfacción laboral del fiscalizador de acuerdo a la significatividad estadística del Chi-cuadrado=45,443 y de Sig=0,000 con un 32,8% de incidencia de ambos factores predictivos sobre la variable dependiente según el Pseudo R cuadrado de Nagelkerke

Modelo de vivienda autosostenible para la ciudad de Puno

El presente trabajo abordó la problemática de determinar en qué medida los materiales constructivos con cualidades térmicas y energías alternativas influyen sobre los niveles de habitabilidad y confort de las viviendas de la ciudad de Puno; así en función de ello se tiene como objetivo identificar las características de un modelo de vivienda autosostenible que haga uso de materiales constructivos con cualidades térmicas y sistemas alternativos de energía que logren influir en los niveles de habitabilidad y confort de las viviendas de la ciudad de Puno. Para ello se realizó estudio cuantitativo y el uso de métodos descriptivos explicativos para analizar las viviendas de la ciudad de Puno en sus características de hogar, vivienda y población, haciendo uso de datos provenientes de la ciudad (base de datos del INEI, último censo de población y vivienda). Así, en un primer momento la investigación tendrá un alcance descriptivo, recopilando toda la información documental relacionada a las variables de estudio. Y, después, pasar al procesamiento y análisis de la información recopilada para identificar las características del modelo de vivienda autosostenible en concordancia con el medio climático y natural de la ciudad de Puno. Como resultado se identificó las características constructivas y funcionales de un modelo de vivienda autosostenible, que, en función del uso de elementos constructivos con cualidades térmicas y sistemas de energía alternativa contribuyan en la mejora de la eficiencia térmica y energética de las viviendas de la ciudad de Puno. Así se concluye que la identificación de las características constructivas y de eficiencia energética del modelo de vivienda autosostenible propuesto representan un modelo de adaptación al medio climático, interacción con el entorno ecológico y natural de la ciudad y la búsqueda de la mejora de calidad de vida del poblador en función de sus necesidades y la influencia en los niveles de habitabilidad y confort de la vivienda

The McGill Quality of Life Questionnaire-Revised (MQOL-R) : psychometric properties and validation of a Brazilian version on palliative care patients : a cross-sectional study

Background: To assess the psychometric properties, including internal consistency, construct validity, criterion validity, criterion-group validity, and responsiveness, the Reviewed McGill Quality of Life Questionnaire (MQOL-R), into Brazilian Portuguese-(BrP). Also, to analyze the relationship of the BrP-MQOL-R with the scores on the Karnofsky Performance Scale (KPS) and on the Numerical Pain Scale (NPS 0–10). Methods: The BrP-MQOL-R was administered to a sample of 146 adults (men=78). A team of experts translated the MQOL-R according to international guidelines. Convergent validity and Confrmatory factor analysis (CFA) was performed. Results: The BrP-MQOL-R Cronbach’s alpha was 0.85. CFA supported the original four-factor structure, with the following revised model ft-indices: PCLOSE=0.131, Tucker-Lewis Index (TLI) rho 2=0.918, incremental ft index (IFI) delta 2=0.936. The convergence validity is supported by a signifcant correlation between BrP-MQOL-R total scores and their subscales with KPS and with the single item related to the quality of life. And by a converse correlation with the pain scores in the NPS (0–10). Receiver operator characteristics (ROC) analysis showed subjects with KPS equal to or lower than 30% could be discriminated from those with scores on KPS higher than 30% by an area under the curve (AUC)=0.71, sensitivity=97%, and specifcity=92%). Conclusion: The BrP-MQOL-R proves to be a reliable instrument for assessing the quality of life (QOL) in palliative care (PC), with primary evidence of validity. BrP-MQOL-R presented adequate discriminate properties to identify distinct conditions that impact the QOL in PC

Spectral power density analysis of the resting-state as a marker of the central effects of opioid use in fibromyalgia

Spectral power density (SPD) indexed by electroencephalogram (EEG) recordings has recently gained attention in elucidating neural mechanisms of chronic pain syndromes and medication use. We compared SPD variations between 15 fibromyalgia (FM) women in use of opioid in the last three months (73.33% used tramadol) with 32 non-users. EEG data were obtained with Eyes Open (EO) and Eyes Closed (EC) resting state. SPD peak amplitudes between EO-EC were smaller in opioid users in central theta, central beta, and parietal beta, and at parietal delta. However, these variations were positive for opioid users. Multivariate analyses of variance (ANOVAs) revealed that EO-EC variations in parietal delta were negatively correlated with the disability due to pain, and central and parietal beta activity variations were positively correlated with worse sleep quality. These clinical variables explained from 12.5 to 17.2% of SPD variance. In addition, central beta showed 67% sensitivity / 72% specificity and parietal beta showed 73% sensitivity/62% specificity in discriminating opioid users from non-users. These findings suggest oscillations in EEG might be a sensitive surrogate marker to screen FM opioid users and a promising tool to understand the effects of opioid use and how these effects relate to functional and sleep-related symptoms

Quality of life in patients with epilepsy attending in neurology department of San José Hospital in Bogotá.

Introducción: en el mundo aproximadamente 50 millones de personas presentan epilepsia, La enfermedad genera una gran secuela en el paciente, y en las familias con esta enfermedad. Objetivo: describir condiciones que afecten la calidad de vida, mediante el formulario QOLIE-10, en los pacientes con epilepsia valorados en el Hospital de San José en Bogotá. Materiales y métodos: estudio observacional descriptivo de corte transversal a partir de la encuesta de calidad de vida en epilepsia (QOLIE-10). La información se resumió con frecuencias y medidas de tendencia central y de dispersión. Resultados: se realizaron 157 encuestas. Según la clasificación del QOLIE 10, 43,3% de los pacientes presentaron mala calidad de vida, por lo cual, sumada la calificación regular (19,8%), se interpreta que la mayoría de pacientes no tienen buena calidad de vida. La calidad de vida, al igual que en el resto de la población mundial, se ve afectada por la frecuencia ictal. Conclusión: en la población de pacientes con epilepsia su calidad de vida no es buena a pesar de que 71% son tratados con monoterapia y tienen control de la enfermedad.Introduction: in the world about 50 million people have epilepsy, the disease causes a great sequel to the patient, and families with this disease Objective: to describe conditions that affect the quality of life by QOLIE-10 form in patients with epilepsy, valued at San José Hospital of Bogotá. Materials and methods: cross-sectional descriptive observation from the survey of quality of life in epilepsy (QOLIE-10). The information was summarized using frequencies, measures of central tendency and dispersion. Results: 157 surveys were obtained. According to the classification of QOLIE 10, 43.3% of patients had poor quality of life, which along with the regular grade (19.8%) is interpreted that most patients do not have a good quality of life. Quality of life as in the rest of the world population is affected by the ictal frequency. Conclusion: in patients with epilepsy Population their quality of life is not good although 71% are on monotherapy and have control of the disease

Association between descending pain modulatory system and cognitive impairment in fibromyalgia : a cross-sectional exploratory study

Background: The successful regulation of sensory input to the central nervous system depends on the descending pain modulatory system (DPMS). For the effective regulation of sensory input to the central nervous system and behavioral responses to pain, the DPMS is required. Its connection to fibromyalgia (FM)-related cognitive dysfunction has not yet been investigated. Therefore, this study tested whether measures of verbal fluency, sustained attention, and short-term and working memory could distinguish FM patients from healthy controls (HC). Additionally, it investigated, using a standardized paradigm, the link between cognitive ability and the function of the DPMS in responders and non-responders to the conditioned pain modulation test (CPM-test). Materials and methods: We enrolled 21 HC women and 69 FM patients, all of whom ranged in age from 30 to 65. We employed scores from the Trail Making Test (TMTB-A) (sustained and divided attention), the Controlled Oral Word Association Test (COWAT) (orthographic and semantic fluency), and the Digits subtest of the Wechsler Adult Intelligence Scale (WAIS-III) as dependent variables. Results: A generalized linear model (GLM) adjusted by educational level revealed significantly lower scores in FM than HC on the Span digits forward, COWAT-orthographic, and TMTB-A. For FM patients, multilevel MANCOVA revealed that the cognitive performance of non-responders compared to responders to CPM-test showed lower adjusted scores in Span digits forward (Partial-η2 = 0.358, P = 0.001), Span digits backward (Partial-η2 = 0.358, P = 0.001), COWAT-orthographic (Partial-η2 = 0.551, P = 0.001), COWAR-semantic (Partial-η2 = 0.355, P = 0.001), and TMTB-A (Partial-η2 = 0.360, P = 0.001). The association between the cognitive tests and the DPMS is moderated by the serum level of brain-derived neurotrophic factor (BDNF). Additionally, these cognitive assessments had a positive correlation with antidepressant use and pain threshold. The cognitive assessments, on the other hand, were conversely associated with a life of quality. Conclusion: Based on these findings, it can be shown that HC performed substantially better on cognitive exams than FM did. They demonstrated a link between clinical complaints about attention and memory and decreased DPMS effectiveness. Additionally, they demonstrated that the BDNF is a moderating element in a potential relationship between the severity of cognitive impairment and DPMS dysfunction

Evoked potentials as biomarkers of hereditary spastic paraplegias : a case-control study

Introduction: The Hereditary Spastic Paraplegias (HSP) are a group of genetic diseases that lead to slow deterioration of locomotion. Clinical scales seem to have low sensitivity in detecting disease progression, making the search for additional biomarkers a paramount task. This study aims to evaluate the role of evoked potentials (EPs) as disease biomarkers of HSPs. Methods: A single center cross-sectional case-control study was performed, in which 18 individuals with genetic diagnosis of HSP and 21 healthy controls were evaluated. Motor evoked potentials (MEP) obtained with transcranial magnetic stimulation and somatosensory evoked potentials (SSEP) were performed in lower (LL) and upper limbs (UL). Results: Central motor conduction time in lower limbs (CMCT-LL) was prolonged in HSP subjects, with marked reductions in MEP-LL amplitudes when compared to the control group (p<0.001 for both comparisons). CMCT-UL was 3.59ms (95% CI: 0.73 to 6.46; p = 0.015) prolonged and MEP-UL amplitudes were reduced (p = 0.008) in the HSP group. SSEP-LL latencies were prolonged in HSP subjects when compared to controls (p<0.001), with no statistically significant differences for upper limbs (p = 0.147). SSEP-UL and SSEP-LL latencies presented moderate to strong correlations with age at onset (Rho = 0.613, p = 0.012) and disease duration (Rho = 0.835, p<0.001), respectively. Similar results were obtained for the SPG4 subgroups of patients. Conclusion: Motor and somatosensory evoked potentials can adequately differentiate HSP individuals from controls. MEP were severely affected in HSP subjects and SSEP-LL latencies were prolonged, with longer latencies being related to more severe disease. Future longitudinal studies should address if SSEP is a sensitive disease progression biomarker for HSP