Cláudia Sousa

Suicide Attempts after Subthalamic Nucleus Stimulation for Parkinson’s Disease

A higher risk of suicidal attempt after subthalamic nucleus deep brain stimulation (STN-DBS) for Parkinson’s disease (PD) has been consistently reported. We retrospectively analyzed 3 PD patients with suicide attempts after STN-DBS. All patients had normal pre- and immediate postoperative psychopathological and cognitive evaluations, with STN-DBS yielding a good motor benefit. Levodopa medication was markedly reduced. Albeit there was a significant reduction in dopaminergic medication, there was also a considerable time lag to suicide attempt. Impulsive behavior could have played a higher role, going unnoticed in punctual psychopathological examinations. STN-DBS patients need a closer postoperative psychiatric and behavioral follow-up.

Successful pallidal deep brain stimulation in 15-year-old with Tourette syndrome: 2-year follow-up

Dear Sirs,Tourette syndrome (TS) is a potentially disabling chronictic disorder often associated with neuropsychiatric comor-bidities and typical onset during childhood [1]. Medicationfrequently causes bothersome adverse effects and deepbrain stimulation (DBS) has been tried in severe refractorycases [2].A 14-year-old boy with several motor and phonic tics(including coprolalia) since the age of 8 years was referredto surgery due to symptom refractoriness. Pregnancy andbirth were uneventful, and developmental milestones werenormally achieved. Family history was unremarkable,except for one maternal uncle with simple motor tics.Investigations, including uric acid, copper, ceruloplasmin,and brain MRI were normal. Medication was haloperidol8 mg/day and pimozide 8 mg/day. Previously, risperidoneand quetiapine had been tried, as well as habit reversaltherapy and psychoeducational interventions. At this pointseveral motor tics were seen almost continuously, one ofthem causing significant physical injury (see Supplemen-tary online video, captured and published with consentfrom the patient and his mother). Comorbidities includedtroublesome obsessions (e.g. intense fear that he might losecontrol and stab his mother; obsessive concern with con-tagious diseases), compulsions (e.g. compulsive checkingof locks; compulsive re-writing), anxiety and depression. Inthe classroom he found it very difficult to concentrate, andwould get very anxious; constant conflicts with his class-mates occurred, and he was a victim of bullying. Eventu-ally, the patient became unable to attend school or socializenormally, due to embarrassment. Therapeutic optimizationwas tried with clonidine 0.3 mg/day, aripiprazole 20 mg/day, tetrabenazine 50 mg/day, clonazepam 6 mg/day, ser-traline 100 mg/day, and fluvoxamine 200 mg/day, withoutsignificant benefit; higher doses were not tolerated.After careful review of evidence of efficacy and safetywith the multidisciplinary team, bilateral anteromedialinternal pallidal (AM-GPi) DBS was performed at the ageof 15 years. The procedure was approved by the institu-tional ethics committee. Significant benefits were notedimmediately after surgery, with functional and quality oflife (QOL) improvements and no adverse events occurred.There was also significant psychopathological improve-ment, including mood. The patient reported subjectivelylower anxiety levels, and feeling more confident. Table 1details serial assessments, as well as drug therapy andstimulation parameters at each time point (see also Sup-plementary material online). Symptomatic deteriorationwas noted around 1 year after surgery, namely with regardto tics, depression, and QOL. Despite thorough investiga-tion and questioning no life-events or contextual factorscould be related to the worsening. Drug therapy and

Qigong as a Traditional Vegetative Biofeedback Therapy: Long-Term Conditioning of Physiological Mind-Body Effects

A contemporary understanding of Chinese Medicine (CM) regards CM diagnosis as a functional vegetative state that may be treated by vegetative reflex therapies such as acupuncture. Within this context, traditional mind-body exercises such as Qigong can be understood as an attempt to enhance physiological proprioception, by combining a special state of “awareness” with posture, movement, and breath control. We have formerly trained young auditing flutists in “White Ball” Qigong to minimize anxiety-induced cold hands and lower anxiety-induced heart rate. Functional changes occurred 2–5 min after training and were observed over the whole training program, allowing the children to control their symptoms. In our current work, we report that warm fingers and calm hearts could be induced by the children even without Qigong exercises. Thus, these positive changes once induced and “conditioned” vegetatively were stable after weeks of training. This may show the mechanism by which Qigong acts as a therapeutic measure in disease: positive vegetative pathways may be activated instead of dysfunctional functional patterns. The positive vegetative patterns then may be available in critical stressful situations. Qigong exercise programs may therefore be understood as an ancient vegetative biofeedback exercise inducing positive vegetative functions which are added to the individual reactive repertoire.

Effects of self-administered exercises based on Tuina techniques on musculoskeletal disorders of professional orchestra musicians： a randomized controlled trial

BACKGROUND Musicians are frequently affected by playing-related musculoskeletal disorders (PRMD). Common solutions used by Western medicine to treat musculoskeletal pain include rehabilitation programs and drugs, but their results are sometimes disappointing. OBJECTIVE To study the effects of self-administered exercises based on Tuina techniques on the pain intensity caused by PRMD of professional orchestra musicians, using numeric visual scale (NVS). DESIGN, SETTING, PARTICIPANTS AND INTERVENTIONS We performed a prospective, controlled, single-blinded, randomized study with musicians suffering from PRMD. Participating musicians were randomly distributed into the experimental (n=39) and the control (n=30) groups. After an individual diagnostic assessment, specific Tuina self-administered exercises were developed and taught to the participants. Musicians were instructed to repeat the exercises every day for 3 weeks. MAIN OUTCOME MEASURES Pain intensity was measured by NVS before the intervention and after 1, 3, 5, 10, 15 and 20 d of treatment. The procedure was the same for the control group, however the Tuina exercises were executed in points away from the commonly-used acupuncture points. RESULTS In the treatment group, but not the control group, pain intensity was significantly reduced on days 1, 3, 5, 10, 15 and 20. CONCLUSION The results obtained are consistent with the hypothesis that self-administered exercises based on Tuina techniques could help professional musicians controlling the pain caused by PRMD. Although our results are very promising, further studies are needed employing a larger sample size and double blinding designs.

Long-Term Mortality Analysis in Parkinson’s Disease Treated with Deep Brain Stimulation

Background. Few data have been published regarding long-term mortality in patients with Parkinsons disease treated with DBS. Methods. This study analyzed long-term mortality rates, causes, and correlates in PD patients treated with DBS. Results. 184 consecutive patients were included; mean follow-up was 50 months. Fifteen deaths occurred (total 8.15%, annual mortality rate 1.94%). Mean age at disease onset and at surgery was 48 ± 2.4 and 63 ± 1.6 years, respectively. Mean disease duration until death was 21 ± 7.8 years. Most deaths related to stroke, myocardial infarction, other vascular/heart disorders, or severe infection; one suicide was recorded. Deceased PD patients were mostly male and had lower motor benefit after DBS, but univariate analysis failed to show significant differences regarding gender and motor benefit. Survival was 99% and 94% at 3 and 5 years. Conclusions. Long-term survival is to be expected in PD patients treated with DBS, possibly higher than previously expected. Death usually supervenes due to vascular events or infection.

Immediate effects of Tuina techniques on working-related musculoskeletal disorder of professional orchestra musicians

BACKGROUND Musicians are a prone group to suffer from working-related musculoskeletal disorder (WRMD). Conventional solutions to control musculoskeletal pain include pharmacological treatment and rehabilitation programs but their efficiency is sometimes disappointing. OBJECTIVE The aim of this research is to study the immediate effects of Tuina techniques on WRMD of professional orchestra musicians from the north of Portugal. DESIGN, SETTING, PARTICIPANTS AND INTERVENTIONS We performed a prospective, controlled, single-blinded, randomized study. Professional orchestra musicians with a diagnosis of WRMD were randomly distributed into the experimental group (n=39) and the control group (n=30). During an individual interview, Chinese diagnosis took place and treatment points were chosen. Real acupoints were treated by Tuina techniques into the experimental group and non-specific skin points were treated into the control group. Pain was measured by verbal numerical scale before and immediately after intervention. RESULTS After one treatment session, pain was reduced in 91.8% of the cases for the experimental group and 7.9% for the control group. CONCLUSION Although results showed that Tuina techniques are effectively reducing WRMD in professional orchestra musicians of the north of Portugal, further investigations with stronger measurements, double-blinding designs and bigger simple sizes are needed.

Relevance of Omega-3 and Omega-6 / Omega-3 Ratio in Preventing Cognitive Impairment

INTRODUCTION The epidemiological and social relevance of dementia and mild cognitive impairment increases with life expectancy and prevalence of metabolic disorders. The recognition of an important role for dietary nutrients on cognitive functioning opens new preventive strategies. This work analyses the association between erythrocyte omega-3 index and omega-6 / omega-3 ratio and cognitive performance/ mild cognitive impairment. MATERIAL AND METHODS We selected a random sample of individuals registered at a health centre aged ≥ 55 years. Participants were asked about their alimentary habits, erythrocyte indexes were determined and neuropsychological evaluation included the Montreal Cognitive Assessment and a comprehensive test battery. RESULTS Mean age of 90 participants was 64 years (sd = 5.6), 71.1% had four years of education and 40% of them had more than one vascular risk factor. Limits for omega-3 index and omega-6 / omega-3 ratio were 2.90 - 9.79 (mean = 6.20; sd = 1.50) and 1.14 - 2.95 (mean = 2.12; sd = 0.39), respectively. Montreal Cognitive Assessment scores ranged from 10 to 29 (mean = 22; sd = 4.5), increasing on average 1 - 2 points for above average omega-3 values and an omega-6 / omega-3 ratio ≤ 2 (Group 1) and decreasing 5 - 6 points for omega-3 below mean values and the same omega-6 / omega-3 ratio (Group 2). Prevalence of mild cognitive impairment was 25.6% (95% CI: 16.4 - 34.7), ranging from 12.5% to 83.3% in the two groups above. DISCUSSION This preliminary study is one of the first analyzing the repercussion of omega-3 index and omega-6 / omega-3 ratio on cognitive functioning, considering additionally the participant clinical and dietary profiles. CONCLUSION The association found suggests that omega-3 and omega-6 / omega-3 ratio could be important biomarkers in the prevention of cognitive impairment.