Centralna bol: Mehanizmi, semiologija i terapija

Pain problems associated with lesion, disorder or dysfunction of the central nervous system are a common and prominent problem. The objective of this review is to summarize recent advances in our understanding of the etiology, clinical presentation, and treatment of central pain (CP), with emphasis being placed on studies published within the recent years. The incidence, qualities of the pain experience, associated sensory abnormalities, and other characteristics are discussed. Particular attention is paid to CP associated with stroke as the most prominent and best studied of the many CP problems. In general, there is poor understanding of the pathophysiology of CP, problems are often severe and intractable, and treatment is typically difficult. The goal of treatment should be pain reduction rather than complete pain relief. Recent studies have indicated possible roles for tricyclic antidepressants, antiseizure medications, and motor cortex stimulation in the treatment of CP. Surgical procedures have been used for specific causes of CP, but no one surgical technique helps relieve pain over the long term in all CP patients. Perhaps because of the lack of clinical trials, treatment is still largely based on traditional prescribing methods and anecdotal evidence. Our poor understanding of the etiology of central pain and the relative lack of effective treatments emphasize the need for further research into this disorder.Bol koja je posljedica oštećenja ili poremećaja funkcije centralnog živčanog sustava čest je problem u svakodnevnoj praksi. Cilj ovog istraživanja bio je prikupiti rezultate dosadašnjih studija vezane uz ovu tematiku te prikazati etiologiju, patogenezu, kliničku prezentaciju i mogućnosti liječenja centralne boli. Osobita pažnja posvećena je moždanom udaru kao uzroku centralne boli. Općenito, etiologija i patofiziologija centralne boli slabo je istražena, a liječenje je dugotrajno i najčeće slabih rezultata. U najvećem broju slučajeva, centralnu bol nije moguće u potpunosti izliječiti, može se samo djelomično ublažiti. Od metoda liječenja najčešće se koriste antidepresivi, antiepileptici te stimulacija motoričkog korteksa. Kirurške metode liječenja se rijetko koriste jer nisu dugotrajne, njima se centralna bol može samo nakratko ukloniti. Za sada ne postoje jasne kliničke smjernice za liječenje centralne boli, postoje samo sporadične studije o liječenju iste što je vjerojatno posljedica nedovoljnog poznavanja etiologije i patogeneze centralne boli te je u tu svrhu potrebno planirati daljnja istraživanja

Psychometric Validation of the Croatian Version of the Quality of Life in Epilepsy Inventory (QOLIE-31)

The primary goals of this study were to adapt the Quality of Life in Epilepsy Inventory – 31 items (QOLIE-31) questionnaire to the Croatian language and to assess the translated questionnaire’s psychometric properties. Translation/ retranslation of the English version of the QOLIE-31 was done, and all steps for cross-cultural adaptation process were performed properly by an expert committee. Later, QOLIE-31 questionnaires and previously validated Short Form-36 (SF-36) outcome instruments were given to 200 patients with epilepsy. 172 patients (86%) responded to the first set of questionnaires, and 114 of the first time respondents (66%) returned their second survey. The two measures of reliability as internal consistency and reproducibility were determined by Cronbach a statistics and intraclass correlation coefficient, respectively. Concurrent validity was measured by comparing with a SF-36 questionnaire, and measurement was made using the Pearson correlation coefficient (r). The study demonstrated satisfactory internal consistency with high Cronbach a values for all of the corresponding domains (seizure worry 0.84, medication effects 0.80, emotional well-being 0.73, energy/fatigue 0.76, cognitive functioning 0.71, social functioning 0.77, overall quality of life 0.65). The intraclass correlation coefficient for six domains of QOLIE-31 questionnaire demonstrated excellent test/retest reproducibility (ICC 0.75), and good test/retest reproducibility (ICC 0.71) in one domain (cognitive functioning). Considering concurrent validity, three domains had excellent correlation (r=0.75–1), while 11 had good correlation (r=0.50 to 0.75), and 3 had moderate correlation (r=0.25–0.50). This study demonstrated that, if measures are to be used across cultures, the items must not only be translated well linguistically but also must be culturally adapted to maintain the content validity of the instrument at a conceptual level across different cultures. Croatian version of QOLIE-31 will be a valuable contribution to outcome measurement in epilepsy patients, particularly in the context of treatment trials, but als in a wider research context

Psychometric Validation of the Croatian Version of the Quality of Life in Epilepsy Inventory (QOLIE-31)

The primary goals of this study were to adapt the Quality of Life in Epilepsy Inventory – 31 items (QOLIE-31) questionnaire to the Croatian language and to assess the translated questionnaire’s psychometric properties. Translation/ retranslation of the English version of the QOLIE-31 was done, and all steps for cross-cultural adaptation process were performed properly by an expert committee. Later, QOLIE-31 questionnaires and previously validated Short Form-36 (SF-36) outcome instruments were given to 200 patients with epilepsy. 172 patients (86%) responded to the first set of questionnaires, and 114 of the first time respondents (66%) returned their second survey. The two measures of reliability as internal consistency and reproducibility were determined by Cronbach a statistics and intraclass correlation coefficient, respectively. Concurrent validity was measured by comparing with a SF-36 questionnaire, and measurement was made using the Pearson correlation coefficient (r). The study demonstrated satisfactory internal consistency with high Cronbach a values for all of the corresponding domains (seizure worry 0.84, medication effects 0.80, emotional well-being 0.73, energy/fatigue 0.76, cognitive functioning 0.71, social functioning 0.77, overall quality of life 0.65). The intraclass correlation coefficient for six domains of QOLIE-31 questionnaire demonstrated excellent test/retest reproducibility (ICC 0.75), and good test/retest reproducibility (ICC 0.71) in one domain (cognitive functioning). Considering concurrent validity, three domains had excellent correlation (r=0.75–1), while 11 had good correlation (r=0.50 to 0.75), and 3 had moderate correlation (r=0.25–0.50). This study demonstrated that, if measures are to be used across cultures, the items must not only be translated well linguistically but also must be culturally adapted to maintain the content validity of the instrument at a conceptual level across different cultures. Croatian version of QOLIE-31 will be a valuable contribution to outcome measurement in epilepsy patients, particularly in the context of treatment trials, but als in a wider research context

Vrijeme do prijema u bolnicu kod bolesnika s akutnim moždanim udarom - opservacijska studija u Splitsko-Dalmatinskoj županiji, Hrvatska

The objective of this prospective observational study was to determine and document the time elapsed from symptom onset to hospital admission in patients with acute stroke. The study was conducted at Emergency Department, University Department of Neurology, Split University Hospital in Split, Croatia, from October 1, 2004 to December 21, 2004, and included 115 patients with acute stroke. Data on the time of onset of stroke symptoms, brain computed tomography finding and current clinical status were noted. Fifteen patients were excluded from the study because the exact time of symptom onset could not be determined. A standardized interview with patients and/or their relatives was taken to collect the information needed. Ischemic stroke was diagnosed in 82 of 100 patients. Only 13 patients arrived in hospital within 3 hours of stroke symptom onset, and 29 were admitted to hospital more than 24 hours of stroke symptom onset. Sex had no significant effect on arrival time. It was concluded that the majority of patients with acute stroke did not present to emergency department within 3 hours of symptom onset, the current time window for thrombolytic therapy. It seems crucial to identify the factors associated with late presentation to the hospital. Public recognition of stroke symptoms and understanding of the importance of early hospital admission are mandatory for improving the results recorded in this study with time elapsed from symptom onset to hospital admission and eligibility for thrombolytic therapy taken as the main outcome measures. Additional public education is needed to increase awareness of the stroke warning signs.Cilj ove prospektivne opservacijske studije bio je utvrditi i dokumentirati vrijeme proteklo od nastupa simptoma do prijema u bolnicu kod bolesnika s akutnim moždanim udarom. Studija je provedena na Hitnom odjelu Klinike za neurolog¬iju, Kliničke bolnice Split u Splitu od 1. listopada 2004. do 21. prosinca 2004. godine i uključila je 115 bolesnika s akutnim moždanim udarom. Bilježili su se podatci o vremenu nastupa simptoma moždanog udara, nalazu kompjutorizirane tomografije mozga i aktualnom kliničkom statusu. Iz studije je isključeno 15 bolesnika u kojih se točno vrijeme nastupa simptoma nije moglo utvrditi. Proveden je standardizirani razgovor s bolesnicima i/ili njihovom rodbinom kako bi se dobile potrebne informacije. Ishemijski moždani udar je utvrđen u 82 od 100 bolesnika. Samo je 13 bolesnika stiglo u bolnicu unutar 3 sata od nastupa simptoma akutnog moždanog udara, a 29 ih je u bolnicu primljeno vi.e od 24 sata od nastupa simptoma. Spol nije imao značajnog utjecaja na vrijeme dolaska u bolnicu. Rezultati su pokazali kako većina bolesnika s akutnim moždanim udarom nije pristigla na hitni odjel unutar 3 sata od nastupa simptoma, što danas predstavlja vremen¬ski okvir za trombolitičnu terapiju. Od ključne je važnosti utvrditi čimbenike koji su povezani sa zakašnjelim dolaskom u bolnicu. Opće prepoznavanje simptoma moždanog udara i shvaćanje važnosti ranog prijema u bolnicu neophodno je za poboljšanje rezultata dobivenih u ovoj studiji, u kojoj su glavne mjere ishoda bili vrijeme proteklo od nastupa simptoma do prijema u bolnicu i podobnost za trombolitičnu terapiju. Potrebna je daljnja izobrazba javnosti kako bi se povećala svijest o upozoravajućim znacima moždanoga udara

Na dokazima zasnovane smjernice za liječenje primarnih glavobolja

A proportion of headache patients should be evaluated by a neurologist. These guidelines are developed to help physicians in making appropriate choice in the work-up and treatment of headache patients. Most migraine sufferers have not been diagnosed by a physician and are not receiving medical guidance to effectively address their migraine attacks. In the past 15 years new therapies (acute and preventive) have been introduced. In migraine patients nonresponders to analgesics, especially in patients with moderate to severe migraine, triptans should be introduced. In migraine with frequent attacks or long lasting attacks, preventive treatment according to comorbid diseases should be recommended. In tension type headache, an underlying pathology should be excluded; management includes pharmacological and non-pharmacological treatment. Although rare, patients with cluster headache experience major pain and disability; in acute management oxygen inhalation or triptans are recommended, in certain cases prophylaxis is indicated. These guidelines contain classification, diagnostic criteria, and principles of management of all primary headaches. These recommendations for headache treatment are based on a comprehensive review and meta-analysis of scientific literature with regard to treatment possibilities in Croatia.U dijela bolesnika koji pate od glavobolja potreban je neurološki pregled. Smjernice za dijagnostiku i liječenje glavobolja imaju za cilj pomoći liječnicima u svakodnevnom radu s bolesnicima s glavoboljom. U većine bolesnika migrenu nije dijagnosticirao liječnik, te im nije pružena odgovarajuća pomoć za liječenje napadaja. U proteklih petnaestak godina uvedene su nove terapijske metode (za akutno i preventivno liječenje). Bolesnicima koji ne reagiraju na obične analgetike, osobito onima s umjerenim i jakim migrenama, treba ponuditi triptane. Preventivnu terapiju, ovisno o drugim pridruženim bolestima, treba preporučiti osobama s učestalim ili dugotrajnim napadajima migrene. Kod osoba s tenzijskim glavoboljama potrebno je isključiti organsku podlogu glavobolja, a liječenje uključuje farmakološke i nefarmakološke mjere. Premda rijetki, bolesnici s cluster glavoboljama imaju jake bolove; u akutnom napadaju preporuča se inhalacija kisika ili triptani, a u pojedinim slučajevima indicirana je i preventivna terapija. Smjernice uključuju klasifikaciju, dijagnostičke kriterije i načela liječenja primarnih glavobolja. Sve preporuke u Smjernicama se temelje na meta-analizama i preporukama iz svjetske literature s osvrtom na terapijske mogućnosti u Hrvatskoj

Autonomic dysfunction in clinically isolated syndrome suggestive of multiple sclerosis

OBJECTIVES: The aim of this study was to determine the extent of autonomic dysfunction in patients with clinically isolated syndrome (CIS) by using a standardized battery of autonomic tests in the form of the Composite Autonomic Scoring Scale (CASS). ----- METHODS: This was a prospective, cross sectional study which included 24 consecutive patients who were diagnosed with CIS and 17 healthy controls. In all participants, heart rate and blood pressure responses to the Valsalva maneuver, heart rate response to deep breathing and blood pressure response to passive tilt were performed. In 16 patients, Quantitative Sudomotor Axon Reflex Test (QSART) and catecholamine measurement was performed. ----- RESULTS: The proportion of CIS patients with pathological adrenergic index was statistically significantly higher compared to healthy controls (12 vs 2, p=0.018), while there was no difference in cardiovagal index between groups. Five patients had a sudomotor index of 1 (in 4 there was hypohydrosis <50% and in 1 persistent foot hyperhidrosis). When combining adrenergic, cardiovagal and sudomotor index into CASS, 8 patients (50%) had evidence of autonomic dysfunction, 7 mild and one moderate. ----- CONCLUSION: Sympathetic nervous system is frequently affected in CIS patients. ----- SIGNIFICANCE: CASS is able to detect autonomic nervous system dysfunction in CIS patients

An update on the management of young-onset Parkinson's disease

In the text that follows, we review the main clinical features, genetic characteristics, and treatment options for Parkinson's disease (PD), considering the age at onset. The clinical variability between patients with PD points at the existence of subtypes of the disease. Identification of subtypes is important, since a focus on homogenous group may lead to tailored treatment strategies. One of the factors that determine variability of clinical features of PD is age of onset. Young-onset Parkinson's disease (YOPD) is defined as parkinsonism starting between the ages of 21 and 40. YOPD has a slower disease progression and a greater incidence and earlier appearance of levodopa-induced motor complications; namely, motor fluctuations and dyskinesias. Moreover, YOPD patients face a lifetime of a progressive disease with gradual worsening of quality of life and their expectations are different from those of their older counterparts. Knowing this, treatment plans and management of symptoms must be paid careful attention to in order to maintain an acceptable quality of life in YOPD patients