Impacto da aplicação de diretrizes na solicitação de tomografia computadorizada de crânio em traumatismo cranioencefálico leve: revisão sistemática / Impact of application of guidelines on the utilization of head computed tomography in minor head injury: systematic review

A tomografia computadorizada (TC) é exame de escolha para rastreamento de lesões no traumatismo cranioencefálico (TCE). Apesar disso, seu uso rotineiro no TCE leve é controverso O objetivo desta revisão foi avaliar o impacto da aplicação de diretrizes de manejo e conduta de TCE leve quanto à solicitação de TC de crânio. É busca realizada nas bases de dados LILACS, Medline, PubMed, SciELO, utilizando descritores do MeSH e DeCS. A busca inicial identificou 30.191 artigos. Após remoção de publicações duplicadas, seleção pelo título, seleção pelo resumo, restaram 25 publicações, que foram lidas na íntegra e cinco incluídas na presente revisão sistemática. Em conclusão, os artigos analisados apresentaram, em média, redução de 25,8% na solicitação de TC de crânio quando aplicadas as diretrizes, e orientam que protocolos para TCE leve são ferramentas eficientes para auxiliar a prática médica, impactando positivamente quando aplicados na população, devendo sempre ser levado em conta a avaliação clínica.

Computed tomography (CT) is the exam of choice for tracking injuries in traumatic brain injury (TBI). Despite this, its routine use in mild TBI is controversial. The objective of this review was to evaluate the impact of applying guidelines for the management and conduct of mild TBI on the request for CT of the head. A search was carried out in the LILACS, Medline, PubMed, SciELO databases, using MeSH and DeCS descriptors. The initial search identified 30,191 articles. After removal of duplicate publications, selection by title, selection by abstract, 25 publications remained, which were read in full and five were included in this systematic review. In conclusion, the articles analyzed showed, on average, a 25.8% reduction in the request for cranial CT when the guidelines were applied, and guide that protocols for mild TBI are efficient tools to assist medical practice, positively impacting when applied to the population. , and clinical evaluation should always be taken into account.

Rendimiento en pruebas cognitivas breves, de adultos mayores con demencia en estadios avanzados, residentes de una comunidad urbana de Lima, Perú / Performance of cognitive brief test in elderly patients with dementia in advanced stage living in an urban community of Lima, Peru

RESUMEN Objetivos. Evaluar el rendimiento de la prueba de dibujo de reloj en versión de Manos (PDR-M) y Mini Mental State Examination (MMSE) en su versión peruana, para detectar demencia de cualquier tipo en adultos mayores residentes de una comunidad urbana de Lima, Perú. Materiales y métodos. Análisis secundario de base de datos, de tipo observacional, analítico y transversal; con diseño de prueba diagnóstica, teniendo como prueba estándar a las evaluaciones clínica y neuropsicológica en conjunto. Se evaluó el rendimiento de las pruebas individualmente, así como de forma combinada. Resultados. El rendimiento de MMSE para la evaluación de pacientes con demencia de cualquier tipo presentó sensibilidad de 64,1%, especificidad de 84,1%, VPP de 24,4%, VPN de 96,7%, LR (+) de 4,03 y LR (-) de 0,43. La PDR-M presentó sensibilidad de 89,3%, especificidad de 98,1%, VPP de 79,3%, VPN de 99,1%, LR (+) de 47,79 y LR (-) de 0,11. Cuando se aplicaron ambas pruebas, y al menos una de ellas fue positiva, presentaron sensibilidad de 98,1%, especificidad de 84,1%, VPP de 33,1%, VPN de 99,8%, LR (+) de 6,17 y LR (-) de 0,02. Al realizar el análisis, por separado, de demencia tipo alzhéimer y no alzhéimer, los valores de los parámetros no se diferencian sustancialmente de los obtenidos para demencias de cualquier tipo. Conclusiones. La combinación de MMSE y PDR-M demuestran un buen rendimiento para detectar demencia en estadios moderado y severo en población residente de una comunidad urbana de Lima.

ABSTRACT Objectives. Evaluate the performance of clock drawing test- Manos versión (PDR-M) and Mini Mental State Examination -Peruvian version (MMSE) to detect dementia in a sample based on urban community of Lima, Peru. Materials and methods. This study is a secondary analysis database, observational, analytical and cross-sectional, the gold standard was the clinical and the neuropsychological evaluations together. Performance testing individually and in combination were evaluated.. Data were obtained from prevalence study conducted in 2008 in Cercado de Lima. Results. MMSE performance for evaluation of patients with dementia of any kind showed sensitivity of 64,1%, specificity of 84,1%, PPV of 24.4%, NPV of 96.7%, PLR of 4,03 and NLR of 0,43. PDR-M showed sensitivity of 89,3%, specificity of 98,1%, PPV of 79.3%, NPV of 99.1%, PLR of 47,79 and NLR of 0,11. When both tests were applied, and at least one of them was positive, they showed sensitivity 98.1%, specificity 84.1%, PPV of 33.1%, NPV of 99.8%, PLR of 6,17 and NLR of 0,02. When performing separate analysis of Alzheimer-type dementia and non- Alzheimer dementia, the values of the parameters do not differ substantially from those obtained for dementia of any kind. Conclussions. The combination of MMSE and PDR-M show good discriminative ability to detect moderate and severe dementia in population living in urban community in Lima.

Diagnóstico y evaluación de la esclerosis múltiple: lo que el radiólogo debe conocer e informar. Conceptos actuales / Diagnosis and Evaluation of Multiple Sclerosis: What the Radiologist Should Know and Report. Current Concepts

La esclerosis múltiple (EM) es una enfermedad inflamatoria y neurodegenerativa, de curso crónico, caracterizada por áreas focales de desmielinización/daño axonal, llamadas "placas". Los criterios actualmente utilizados en su diagnóstico incluyen la demostración clínica o paraclínica de diseminación de estas lesiones en el espacio y en el tiempo, y la exclusión de diagnósticos alternativos. La resonancia magnética (RM) es la herramienta paraclínica más importante para establecer el diagnóstico de EM y permite demostrar la diseminación en el espacio, con base en la presencia de, al menos, un criterio en dos de las cinco localizaciones características: una lesión en cortical-yuxtacortical, tres en la sustancia blanca periventricular, una en el tejido nervioso infratentorial, una en la médula espinal y una en el nervio óptico. La diseminación en tiempo se puede establecer a partir de la detección simultánea de lesiones con y sin realce con el medio de contraste en un mismo examen de RM, o mediante la demostración de nuevas lesiones en estudios de RM de seguimiento. El curso de la enfermedad y el tratamiento farmacológico producen cambios característicos en las imágenes de RM que incluyen el desarrollo de atrofia, la leucoencefalopatía multifocal progresiva y el síndrome inflamatorio de reconstitución inmunológica.

Multiple sclerosis (MS) is a chronic inflammatory and neurodegenerative disease characterized by focal areas of demyelination/axonal damage known as "plaques". The diagnostic criteria currently used include clinical or para-clinical demonstration of the dissemination of these lesions in space and time, and the exclusion of alternative diagnoses. Magnetic resonance imaging (MRI) is the most important para-clinical tool for the diagnosis of MS and allows to demonstrate the dissemination in space based on the presence of at least one criteria in two of the five characteristic locations: one lesion in cortical-yuxtacortical, three in the periventricular white matter, one in the infratentorial nervous tissue, one in the spinal cord and one in the optic nerve. Dissemination in time can be established from the simultaneous detection of lesions with and without contrast enhancement in a single MRI study, or through the demostration of new lesions in follow-up MRI studies. The course of the disease and its pharmacological treatment lead to characteristic changes in imaging including the development of atrophy, multifocal progressive leukoencephalopathy and immune reconstitution inflammatory syndrome.

Delirium em pacientes na unidade de terapia intensiva submetidos à ventilação não invasiva: um inquérito multinacional / Delirium in intensive care unit patients under noninvasive ventilation: a multinational survey

RESUMO Objetivos: Conduzir um inquérito multinacional com profissionais de unidades de terapia intensiva para determinar as práticas relacionadas à avaliação e ao manejo do delirium, bem como as percepções e as atitudes relacionadas à avaliação e ao impacto do delirium em pacientes submetidos à ventilação não invasiva. Métodos: Foi elaborado um questionário eletrônico para avaliar o perfil dos respondedores e das unidades de terapia intensiva a eles relacionadas; a realização de avaliação sistemática e a forma de manejo do delirium; e as percepções e condutas dos profissionais com relação à presença de delirium em pacientes submetidos à ventilação não invasiva. O questionário foi distribuído por meio da mala direta de correio eletrônico da rede de cooperação em pesquisa clínica da Associação de Medicina Intensiva Brasileira (AMIB-Net) e para pesquisadores em diferentes centros da América Latina e Europa. Resultados: Foram analisados 436 questionários que, em sua maioria, eram provenientes do Brasil (61,9%), seguidos por Turquia (8,7%) e Itália (4,8%). Aproximadamente 61% dos respondedores relataram não proceder à avaliação de delirium na unidade de terapia intensiva, enquanto 31% a realizavam em pacientes submetidos à ventilação não invasiva. Confusion Assessment Method for the Intensive Care Unit foi a ferramenta diagnóstica validada mais frequentemente citada (66,9%). Com relação à indicação de ventilação não invasiva para pacientes em delirium, 16,3% dos respondedores nunca permitiam o uso de ventilação não invasiva neste contexto clínico. Conclusão: Este inquérito fornece dados que enfatizam a escassez de esforços direcionados à avaliação e ao manejo do delirium no ambiente da terapia intensiva, em especial nos pacientes submetidos à ventilação não invasiva.

ABSTRACT Objective: To conduct a multinational survey of intensive care unit professionals to determine the practices on delirium assessment and management, in addition to their perceptions and attitudes toward the evaluation and impact of delirium in patients requiring noninvasive ventilation. Methods: An electronic questionnaire was created to evaluate the profiles of the respondents and their related intensive care units, the systematic delirium assessment and management and the respondents' perceptions and attitudes regarding delirium in patients requiring noninvasive ventilation. The questionnaire was distributed to the cooperative network for research of the Associação de Medicina Intensiva Brasileira (AMIB-Net) mailing list and to researchers in different centers in Latin America and Europe. Results: Four hundred thirty-six questionnaires were available for analysis; the majority of the questionnaires were from Brazil (61.9%), followed by Turkey (8.7%) and Italy (4.8%). Approximately 61% of the respondents reported no delirium assessment in the intensive care unit, and 31% evaluated delirium in patients under noninvasive ventilation. The Confusion Assessment Method for the intensive care unit was the most reported validated diagnostic tool (66.9%). Concerning the indication of noninvasive ventilation in patients already presenting with delirium, 16.3% of respondents never allow the use of noninvasive ventilation in this clinical context. Conclusion: This survey provides data that strongly reemphasizes poor efforts toward delirium assessment and management in the intensive care unit setting, especially regarding patients requiring noninvasive ventilation.

Neuroradiology and voice findings in stroke / Achados de neurorradiologia e voz no acidente vascular encefálico

Neurological dysphonias are vocal disorders followed by injuries or changes in the nervous system. Stroke is the second leading cause of death worldwide and the brain damage caused by it can affect communication in several aspects. The changes in the vocal features caused by these lesions are poorly described regarding the location and extent of cerebral involvement. The aim of this study was to describe vocal parameters of ten elderly patients affected by stroke according to the topography of the lesion at neuroimaging. We recorded from them: perceptual and auditory evaluation of voice and laryngeal diadochokinesis. Neuroimaging studies were classified according to location, extent, laterality territory of brain injury. The results show a population of extensive middle cerebral artery strokes and strokes with varied location in the brain. The subjects' voices showed predominantly the presence of roughness, breathiness, richeness and instability, and change in laryngeal motor control, demonstrated by reduced speed and instability in laryngeal diadochokinesis. These features presented in patients with extensive middle cerebral artery stroke and in patients with short strokes with varied location in the brain. The results suggest that the vocal features in the assessed cases do not depend only on the topography of the brain damage. Thus, it is important to consider the patient as unique in clinical evaluation.

As disfonias neurológicas são distúrbios vocais que acompanham lesões ou alterações no sistema nervoso. O acidente vascular encefálico (AVE) é a segunda causa de morte no mundo e os danos cerebrais causados podem afetar a comunicação do indivíduo em diversos aspectos. As alterações de voz características dessas lesões são pouco descritas quanto à localização e extensão do acometimento cerebral. O objetivo deste estudo foi descrever as características fonatórias de dez idosos acometidos por AVE, de acordo com a topografia da lesão observada ao exame de neuroimagem. Todos os participantes tiveram amostras de voz gravadas e foi realizada avaliação perceptivo-auditiva da voz e da diadococinesia laríngea. Os exames de neuroimagem foram classificados quanto à localização, extensão, lateralidade e território de vascularização da lesão cerebral. Os resultados mostram uma população de AVEs extensos de artéria cerebral média e AVEs de localização variada no cérebro. As vozes dos sujeitos mostraram predominantemente presença de rugosidade, soprosidade, instabilidade e pastosidade, além de alteração no controle motor laríngeo, demonstrado pela velocidade reduzida e instabilidade na repetição de vogais. Essas características ocorreram tanto no grupo de pacientes com AVE extenso de lesão da artéria cerebral média como em pacientes com AVEs menores de localização variada no cérebro. Os achados sugerem que as manifestações vocais dos casos estudados não dependem apenas da topografia da lesão. Daí a importância de considerar as individualidades de cada paciente no momento da avaliação clínica.

Contribuições da neuroimagem para o diagnóstico de dislexia do desenvolvimento / Contributions of neuroimaging for the diagnosis of developmental dyslexia

A eficácia da neuroimagem como comprovação do diagnóstico de dislexia é indiscutível. Mesmo não havendo tratamento medicamentoso ou de qualquer outra espécie, as providências que possam ser tomadas na vida escolar e no dia-a-dia do paciente são imprescindíveis, podendo mudar sua vida positivamente. O presente estudo tem como objetivo realizar uma análise de artigos que relacionam neuroimagem e dislexia, apresentando, ainda, como objetivos específicos, determinar a quantidade de artigos publicados nos últimos cinco anos em revistas indexadas, relacionados com o tema citado anteriormente; estabelecer o que esses achados contribuíram para o estudo desse distúrbio e quais bases foram os suportes para os artigos mencionados. Foi realizada revisão bibliográfica nas bases PubMed e SciELO, entre janeiro de 2008 e agosto de 2013. Os artigos analisados demonstram exames de imagem possibilitaram o início de pesquisas e o conhecimento mais a fundo das diferenças anatômicas e funcionais do sistema nervoso central dos portadores de dislexia do desenvolvimento quando comparados a indivíduos que não apresentam tal condição.

The effectiveness of neuroimaging as evidence of dyslexia diagnosis is indisputable. Even without medication or any other kind of treatment, steps that can be taken in school and in day- to-day patient are essential and can change your life positively. The present study aims to performe an analysis of articles relating neuroimaging and dyslexia, also presenting specific objectives , determining the quantity of articles published in the last five years in indexed journals, related to the subject cited above and to describe what these findings contributed to the study of this disorder and what basis were the supports for the items mentioned. Literature review from articles published between January 2008 and August 2013 was performed in PubMed and SciELO databases. The articles analyzed demonstrate imaging enabled the beginning of research and deeper knowledge of the anatomical and functional differences in the central nervous system of patients with developmental dyslexia when compared to individuals with no such condition.

Validación de la prueba de dibujo del reloj - versión de Manos - como prueba de cribado para detectar demencia en una población adulta mayor de Lima, Perú / Validation of the clock drawing test - Manos´ version - as a screening test for detection of dementia in older persons of Lima, Peru

Introducción. La prueba de dibujo del reloj versión de Manos (PDR-M) es un instrumento de evaluación cognitiva breve para la detección de demencia. Objetivos. Evaluar la validez y confiabilidad de la PDR-M para discriminar entre pacientes con demencia y sujetos controles sanos. Materiales y métodos. Se evaluaron sujetos mayores de 65 años de edad, excluyendo los que presentaban enfermedades concomitantes graves y con dificultades auditivas o visuales. Se recogieron datos demográficos y se les realizó PDR-M y Mini Mental State Examination (MMSE). A los individuos del grupo de demencia se les realizó además evaluaciones clínicas, de laboratorio, neuropsicológicas y tomografía cerebral. Se calculó la sensibilidad y especificidad de la PDR-M así como el área bajo la curva ROC. Resultados. Se evaluó 210 individuos, 103 con diagnóstico confirmado de demencia y 107 controles sanos, con edad y sexo similares en ambos grupos; y mayor nivel educativo en el grupo control. Estableciendo un punto de corte de 7 se obtuvo una sensibilidad de 99,0 por ciento y una especificidad de 83,5 por ciento. Cuando se compararon las áreas bajo la curva ROC de la PDR-M y del MMSE no se encontraron diferencias significativas. Conclusiones. La PDR-M es un instrumento breve y confiable para la detección de demencia en la población urbana de Lima en el Perú.

Introduction. The clock drawing test (PDR-M) - Manos´ version - is a brief cognitive assessment tool for dementia detection. Objectives. To assess the validity and reliability of the PDR-M to discriminate between patients with dementia and healthy control subjects. Materials and methods. We evaluated subjects over 65 years of age, excluding those with severe concomitant diseases and those with hearing or visual impairment. We obtained demographic data and performed the PDR-M and Mini Mental State Examination (MMSE). Subjects of the dementia group were also submitted to clinical, laboratory and neuropsychological evaluations as well as computed tomography scanning. Sensitivity and specificity of the PDR-M were calculated as well as the area under the ROC curve. Results. We evaluated 210 individuals, 103 with confirmed diagnosis of dementia and 107 healthy controls with similar age and sex in both groups, but a higher educational level in the control group. Setting a cutoff point of 7, a sensitivity of 99.0 percent and a specificity of 83.5 percent were found. When comparing the areas under the ROC curves of the PDR-M and MMSE we found no statistically significant difference. Conclusions. The PDR-M is a brief and reliable instrument for the detection of dementia in the urban population of Lima, Peru.

Triple stimulation technique: normative value of Chinese adults / 中华神经科杂志

Objective To validate the technique and to establish the reference values of triple stimulation technique(TST)in healthy Chinese adults.Methods One hundred healthy subjects were recruited to undergo TST from April 2010 to February 2011 in both abductor digiti minimi.The TST combines transcranial magnetic stimulation(TMS)of the motor cortex with peripheral collision studies.Three stimuli were given,leading to two collisions.A first magnetic stimulus was applied to the scalp overlying the motor cortex.After a delay,an electric stimulus was applied over the ulnar nerve at the wrist.The delay was chosen so that the action potentials descending from the cortex collided with the antidromic action potentials evoked at the wrist,with the collision site at the wrist and above.After another delay,another electrical stimulus was applied to Erb' s point.This delay was chosen so that ascending antidromic action potentials evoked by wrist stimulation collided at or distal to Erb' s point.At the same time,TST test curves were recorded.The TST test curve was compared with a TST control curve in which the first stimulus was applied to Erb' s point and the other two stimulus sites were the same as the test curve.Control stimuli were thus applied successively to Erb' s point,the wrist,Erb' s point.TST quantifies the number of conducting central motor neurons(expressed by the TST amplitude ratio).The values were compared among genders,age groups,arm length and sides respectively.Results The TST amplitude ratio(TSTteat/TSTcontrol)was 85.0％ ± 6.7％.There were no difference among genders,age groups,arm length and sides respectively.The TST amplitude ratio were 85.0％ ± 2.6％ and 85.0％ ± 8.7％,respectively in subjects with arm length 61-70 cm and 71-80 cm.Conclusion TST could be examined precisely and the normative value could be got.

Halothane effect on formalin-induced paw edema and flinching in rat

The formalin test is a model of injury-produced inflammatory pain. Anesthetics, in clinically relevant concentrations, affect neutrophils and immune suppression. This study was to determine whether halothane reliably inhibits inflammatory reaction and formalin induced pain behavior or does not. Rats were exposed to 100% oxygen (control) or halothane, respectively for 30 min and then 24 hr later five percent formalin test was assessed. The base values of the paw's diameter were obtained earlier, and then formalin induced edema was assessed by measuring diameters of the injected paws at 5 min, 1 hr, 4 hr and 24 hr after the injection. Nociceptive behavior was quantified by counting the number of times with the paw flinched at 5 min intervals for 60 min. The diameters of edema in the halothane group lessened more than those in the oxygen group at 1 and 24 hr in each following of the injection (p<0.05). The rats pre-administered with oxygen or halothane were similar appearances in nociceptive behaviors. It suggests that halothane anesthesia might inhibit slightly the inflammatory reaction with the formalin-induced edema but might not inhibit the formalin-induced pain behavior in the event of pre-administration halothane 24 hr earlier before the formalin test of rat.