Intravascular ketamine infusion for the treatment of chronic pain and depression. Case report / Infusão intravascular de cetamina para o tratamento de dor crônica e depressão. Relato de caso

ABSTRACT BACKGROUND AND OBJECTIVES: Chronic pain and depression are two comorbidities that correlate at the molecular level in the central nervous system and cause sufering to the patient, being dificult to be managed. In recent years, several studies have shown significant analgesic and antidepressant efects from intravascular infusion of ketamine, being a promising alternative option for refractory patients. Tus, the aim of the study was to report the case of a patient with refractory chronic pain and depression submitted to serial ketamine single dose infusions. CASE REPORT: Female patient, 33 years old, diagnosed with interstitial cystitis 13 years ago with refractory chronic pain and depression, submitted to serial infusions of intravascular ketamine. Tree serial infusions were performed, providing a significant improvement in pain and mood. However, the patient could not tolerate the adverse efects, particularly, the transient sensation of impending death and panic attack, and abandoned the treatment. CONCLUSION: Ketamine is a safe and promising treatment option for chronic pain and depression and can promote significant, albeit transient, pain and mood relief using subanesthetic dosage. However, its adverse efects can be an important limitation for therapeutic success. Standardized clinical studies are needed to better understand the relationship between chronic pain and depression and to establish the best therapeutic approach.

RESUMO JUSTIFICATIVA E OBJETIVOS: A dor crônica e a depressão são duas comorbidades que se correlacionam em nível molecular no sistema nervoso central e promovem sofrimento ao paciente, sendo de difícil manejo. Nos últimos anos, diversos estudos demonstraram efeitos analgésicos e antidepressivos significativos a partir da infusão intravascular de cetamina, sendo uma opção alternativa para pacientes refratários ao tratamento convencional. Assim, o objetivo do estudo foi relatar o caso de uma paciente com dor crônica e depressão refratária submetida a infusões seriadas de doses únicas de cetamina. RELATO DO CASO: Paciente do sexo feminino, 33 anos, diagnosticada com cistite intersticial há 13 anos com refratariedade no manejo da dor e da depressão, submetida a infusões seriadas de cetamina intravascular. Foram realizadas 3 infusões seriadas que proporcionaram uma melhora significativa na dor e no humor. Entretanto, a paciente não tolerou os efeitos adversos, particularmente, de sensação de morte iminente e ataque de pânico, e abandonou o tratamento. CONCLUSÃO: A cetamina é uma opção de tratamento promissora para dor crônica e depressão e pode promover alívio significativo, embora transitório, da dor e humor utilizando dose subanestésica. No entanto, seus efeitos adversos podem ser uma limitação para o sucesso terapêutico. Estudos clínicos padronizados são necessários para compreender melhor a relação entre dor crônica e depressão e para estabelecer a melhor abordagem terapêutica.

Neurosurgery in the Treatment of Alcohol Use Disorder: A Systematic Literature Review

Alcohol abuse has impacts on public health worldwide. Conservative treatment to achieve abstinence consists of detoxification combined with psychotherapy and the use of drugs, but it is estimated that only half of the individuals achieve long-term abstinence with the available treatments. In this sense, neurosurgery appears as a therapeutic proposal. The present study aimed to gather information about the circuitry related to alcohol use disorder (AUD), to describe possible surgical targets, and to establish whether a surgical approach could be a safe and effective treatment option. A systematic review of the literature was conducted and reported according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) statement. The 14 selected articles analyze ablative operations, deep brain stimulation (DBS), and a new procedure in which the patient is first submitted to repetitive transcranial magnetic stimulation to evaluate their response, and later an implant is surgically positioned on the evaluated target to obtain more lasting results. The most relevant outcomes were found when the anterior cingulate cortex (ACC) and the nucleus accumbens (NAcc) were used as targets, demonstrating a large reduction in alcohol intake and even its cessation. However, important side effects were observed, such as psychotic symptoms, right frontal venous infarction, seizures after implantation in the ACC and a hypomanic period after DBS in the NAcc, which could be reversed. Due to the lack of studies involving the surgical treatment of AUD, more clinical trials are needed to compare targets, to assess surgical techniques, and to estimate the safety of these techniques.

Thermocoagulation as a Surgical Approach for the Treatment of Obsessive-Compulsive Disorder in Refractory Patients: Systematic Review

Obsessive-compulsive disorder (OCD), a disabling chronic neuropsychiatric disease, entails high economic costs to society and has high morbidity and mortality rates. The first-line treatments for OCD are selective serotonin reuptake inhibitors and cognitivebehavioral therapy. However, this disorder has the highest refractory index to noninvasive treatment. Alternatively, ablative thermocoagulation neurosurgical techniques have shown efficacy and few adverse effects. The present systematic review aimed to identify validated protocols to observe the effectiveness of ablative procedures in the treatment of severe and refractory OCD, as well as their possible adverse effects and benefits. This review supports the effectiveness of ablative methods by presenting them as a safe non-experimental therapeutic option for cases of highlyrefractory OCD. Additional relevant findings were the improvement in cognitive function, functional capacity, affective orientation, and quality of life, which contribute to the destigmatization of this surgical technique. Further controlled studies may lead to the individualization of recommendations of targets for ablative thermocoagulation.

Landmarks for the Location of the Subthalamic Nucleus Using Magnetic Resonance Imaging

Deep brain stimulation has become an option for advanced Parkinson's disease treatment since the 1990s, but the first reports are from Benabid's team, a French neurosurgeon, in the 1980s. The subthalamic nucleus (STN), more specifically its dorsolateral portion, is the most commonly stimulated brain area. One of the major aspects for a good surgical result is the accurate location of this target. Therefore, the present article aimed to identify landmarks that facilitate and refine the location of the STN using nuclear magnetic resonance imaging (NMRI) of the skull. In order to achieve this goal, a search for articles was performed using the PubMed and Science Direct online databases, and articles regarding the use of NMRI to target STN were included. The precise location of the dorsolateral portion of the STN is fundamental to achieve the best possible effect on motor symptoms and to minimize side effects. One of the most used location methods is the NMRI, associated or not with tomography or ventriculography. The location strategies can be classified as direct and indirect. Landmarks are among the indirect strategies, and the most important ones (red nucleus, Sukeroku sign, dent internal capsule sign, supramammillary commissure, mammillothalamic tract, and interpeduncular cistern) are described in the present article. The various landmarks can be combined to locate with more accuracy the dorsolateral portion of the STN and the ideal position of the electrodes to achieve the best possible clinical result.

Chronic Postoperative Pain: Comprehending It to Intervene

It is estimated that between 266.2 and 359.5 million operations were performed in 2012 worldwide, and this number is on the rise. Chronic postoperative pain (CPOP) is the most important and still neglected postoperative complication, with a multifactorial causality, leading to a major impact on morbidity rates, high costs for the public health system, and direct and negative effects on the quality of life of the patients. The present systematic literature review aimed to elucidate the processes of postoperative pain chronification, biopsychosocial factors, risk factors, management of pain, and types of surgical procedures mainly associated with it. The review was based on the methodological recommendations of Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). The following databases were consulted: the Medical Literature, Analysis, and Retrieval System Online (MEDLINE), the Latin American and Caribbean Health Sciences Literature (LILACS), the Scientific Electronic Library Online (SciELO), and the Cochrane Central Register of Controlled Trials (CENTRAL). After reading the selected articles, the following surgical specialties were chosen to be addressed: general, orthopedics, breast cancer, gynecology, obstetrics, and thoracic. In conclusion, a deficient management of acute postoperative pain is the main risk factor for the development of CPOP. To prevent CPOP, training programs for healthcare professionals should be implemented to improve their skills and knowledge of the management of pain before, during, and after surgeries. It is also necessary to conduct more in-depth studies on the evaluation and management of this condition.

Neurosurgical Treatment for Drug Addiction: Systematic Review

Substance-related disorders are psychiatric conditions that have a worldwide impact. Their multifactorial cycle has been treated pharmacologically and with therapeutic support. However, high refractoriness rates and difficulty to control relapses are among the pitfalls associated with these disorders. Thus, recent studies have shown that deep brain stimulation (DBS) is a promising treatment, with a direct intervention in the neurocircuitry of addiction. The results of the present systematic review of the use of DBS for the treatment of drug addiction show that this surgical procedure can reduce the desire for the drug, and, in some cases, establish abstinence, improve psychiatric symptoms related to mood and quality of life, and reintroduce the patient into the social and family environments. Nevertheless, this approach is still limited to the academic realm, based mainly on case reports, with ethics and therapeutic protocols still to be defined. Further in-depth scientific investigations are required to recommend its clinical application.

Neurosurgery for Refractory Schizophrenia: A Systematic Literature Review

Schizophrenia is a chronic and disabling psychiatric disease that can be refractory to conventional treatment. The present study aims to gather information about the circuitry related to schizophrenia to describe possible surgical targets, and to establish whether psychosurgery can be a safe and effective treatment option for refractory schizophrenia. A systematic review of the literature was conducted and reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. An electronic search was performed in the Pubmed and BVSalud databases using medical subject headings (MeSH) combined with Boolean operators. Out of the 724 studies retrieved, 13 were included in the review. Regarding leucotomy without a stereotactic approach, we found side effects such as irritability, nervous excitement, cases of disinhibition, and compromised normal social control. In other stereotactic procedures, there was some improvement, mainly regarding aggressiveness and positive symptoms; an anterior capsulotomy had an efficacy rate of 74% according to the Clinical Global Impression (CGI) rating scales. The only deep brain stimulation (DBS) case report found in our study described a significant improvement in the positive and negative symptoms. The use of a stereotactic approach enables psychosurgery to be a safe and effective treatment option in cases of refractory schizophrenia, improving the quality of life and the symptoms. Cognitive and negative symptoms remain a challenge in the treatment of schizophrenia, revealing that more targets in the circuitrymust be surgically explored. Furthermore,more clinical trials are needed to compare these many surgical techniques and targets, using a standard evaluation parameter. The results show that DBS has a promising future in the treatment of refractory schizophrenia.

The use of opioids in the treatment of oncologic pain in the elderly / O uso de opioides no tratamento da dor oncológica em idosos

ABSTRACT BACKGROUND AND OBJECTIVES: The use of opioids in cancer is already widespread and proven by several well-controlled clinical trials. However, the elderly with cancer pain are=un-dertreated due to the lack of knowledge in the management of these patients, the underestimation of pain, as well as the fear of complications arising in this age group. Therefore, the scientific community contributes to giving inputs to create possible clinical and health guidelines. The present study aimed to perform a systematic literature review of opioid treatments proposed for cancer-related pain in elderly patients. CONTENTS: The search on the literature included papers addressing cancer pain treatment with opioids among the elderly, published from 2008 to 2018, and available in Portuguese or English. Searches were conducted on Medical Literature, Analysis, and Retrieval System Online (MEDLINE) and Latin American and Caribbean Health Sciences Literature (LILACS) electronic databases using the keywords "cancer pain", "opioids", and "elderly" in both languages, combined with the Boolean operator "AND". To analyze the quality of the method, the adapted Critical Appraisal Skills Programme was used. Of a total of 411 studies found, 32 were included. About 75% of the selected articles were published in the last five years. CONCLUSION: The results showed that opioids remain the pillar to treat cancer-related pain in the elderly. They can be used for better management of pain, but with caution due to the possible adverse effects. In addition, pain management in the elderly requires a multifactorial analysis, including comorbidities, polypharmacy, and patient functionality. Therefore, an individualized approach in the elderly patient is required in order to enhance results, reduce side effects, and improve quality of life.

RESUMO JUSTIFICATIVA E OBJETIVOS: O uso de opioides em dor oncológica já é amplamente difundido e comprovado por diversos ensaios clínicos bem controlados. Entretanto, os idosos com dor oncológica são subtratados pela falta de conhecimento no manejo, a não valorização álgica nesses pacientes, bem como o receio das complicações advindas nesse grupo etário. Portanto, contribui a comunidade científica, dando substrato para a elaboração de possíveis diretrizes clínicas e de saúde. Este estudo teve como objetivo realizar uma revisão sistemática da literatura sobre o tratamento farmacológico com opioides proposto para dor oncológica em pacientes idosos. CONTEÚDO: A busca na literatura incluiu artigos sobre o uso de opioides para o tratamento da dor oncológica em idosos, publicados entre 2008 e 2018, disponíveis em português ou inglês. Foram conduzidas buscas nas bases eletrônicas de dados Medical Literature, Analysis, and Retrieval System Online (MEDLINE) and Latin American and Caribbean Health Sciences Literature (LILACS) utilizando os descritores "dor oncológica","opioides" e "idoso" em ambas as línguas, combinados com o operador booleano "AND". Para a análise da qualidade metodológica, foi utilizado o Critical Appraisal Skills Programme adaptado. Do total de 411 estudos resultantes, foram incluídos 32. Cerca de 75% dos artigos selecionados foram publicados nos últimos cinco anos. CONCLUSÃO: Os resultados demonstraram que os opioides continuam sendo o pilar no tratamento da dor oncológica em idosos. Podem ser usados para o melhor gerenciamento da dor, mas com cautela por causa dos possíveis efeitos adversos. Além disso, o manejo da dor em idosos requer uma análise multifatorial incluindo as comorbidades, a polifarmácia e a funcionalidade do paciente. Portanto, é necessário tratar de modo individualizado o paciente idoso com o intuito de maximizar os resultados, diminuir os efeitos adversos e melhorar a qualidade de vida.

Deep Brain Stimulation as a Treatment Approach for Anorexia Nervosa: a Systematic Literature Review

Anorexia nervosa is a psychiatric disorder characterized by distortions of body size, weight, and shape perception, as well as by food restriction and/or binge and purging behaviors. It mostly affects young women and causes severe negative impacts on their physical, psychological, and social health. Recent studies have analyzed deep brain stimulation (DBS), a neurosurgical procedure that involves electrode implantation in strategical brain areas, to obtain remission of the symptoms of anorexia nervosa. The results showed that the stimulation of areas associated to the neurocircuitry of anorexia nervosa, such as nucleus accumbens, anterior cingulate cortex, ventral striatum, and bed nucleus of the stria terminalis, provokes beneficial responses in terms of bodymass index, quality of life, social functioning, and psychiatric comorbidities. Nevertheless, broader investigations are needed to endorse the clinical usage of DBS in the management of anorexia nervosa.

Deep Brain Stimulation for the Treatment of Resistant Depression: Systematic Review of the Literature

Depression is the leading cause of disability worldwide, and it is related to high suicide rates. Furthermore, a great number of patients do not respond to any of the available treatments. Deep brain stimulation (DBS), a versatile technology with expanding indications, is considered a potential treatment for resistant depression. However, in over 10 years of clinical research, its efficacy has not been completely proven. Although new trials using DBS for treatment-resistant depression keep emerging, two of the three Level I evidence-based studies recently conducted have not provided conclusive data. Methodological limitations andmajor biases have compromised the obtention of clearer results. In this systematic review of the literature, we intend to critically assess the clinical trials performed in this field.

Deep Brain Stimulation for the Treatment of Juvenile Parkinsonism: Case Report

Juvenile parkinsonism (JP) is characterized by the clinical manifestation of Parkinson syndrome before the age of 21 years old. This entity is often associated with genetic mutations. After all the possibilities of clinical treatment have been exhausted, surgical treatment is recommended, performed via deep brain stimulation (DBS) in the subthalamic nucleus (STN) or in the internal segment of the globus pallidus (GPi). The present study aimed to report the case of a patient with JP who underwent DBS in the STN with good clinical response. Neuromodulation via DBS is an option for the treatment of JP. However, since this entity is very rare, and even more peculiar when treated surgically, more studies are necessary to evaluate DBS used to control refractory manifestations and levodopa-induced dyskinesia, as well as surgical complications that may occur, aiming to gather more knowledge of the surgical management of JP. Despite the dysarthria after the DBS, the patient presented a satisfactory response regarding the symptoms, corroborated by the Parkinson's Disease Questionnaire (PDQ-39) score, which was 61.19% before the procedure, and decreased to 21.05% 14 months after the DBS.

Pharmacological treatment of chronic non-malignant pain among elderly persons: an integrative review / Tratamento farmacológico da dor crônica não oncológica em idosos: Revisão integrativa

Abstract Objective: The objective of the present study was to perform an integrative review of proposed pharmacological treatments for chronic non-malignant pain in elderly patients. Method: An integrative review was carried out. The search of literature included papers about the treatment of chronic pain among the elderly, published from 2007 to 2017 and available in Portuguese or English. Searches were conducted on the LILACS and MEDLINE electronic databases using the key words "chronic pain", "treatment" and "elderly" combined with the Boolean operator "AND". To analyse methodological quality, the adapted Critical Appraisal Skill Program (CASP) was used. Results: Of a total of 303 studies found, 32 were included. The articles selected included 20 reviews, five observational studies, five clinical trials, one case series and one retrospective study. A total of 75% of the articles were published in the last five years, of which one was in Portuguese and 31 in English. Conclusion :The results demonstrate a variety of treatments for chronic pain among the elderly population, highlighting the role of opioids which, according to more recent evidence, can be carefully used in treatment. Several drugs, however, have not been specifically tested for the elderly population. A number of factors are relevant in pain management of elderly patients, including comorbidities, polypharmacy and patient functionality. An individualized approach should be applied to elderly patients to improve outcomes and reduce side effects.

Resumo Objetivo: Realizar uma revisão integrativa da literatura sobre o tratamento farmacológico da dor crônica não oncológica em idosos. Método: Trata-se de uma revisão integrativa da literatura. A busca na literatura incluiu artigos sobre o tratamento farmacológico da dor crônica em idosos, publicados entre 2007 e 2017, disponíveis na íntegra nas línguas portuguesa ou inglesa. Realizou-se a busca dos artigos nas bases de dados LILACS e MEDLINE utilizando os descritores "dor crônica", "tratamento" e "idoso", combinados com o operador booleano AND. Para análise da qualidade metodológica, o instrumento utilizado foi o Critical Appraisal Skill Programme (CASP). Resultados: Do total de 303 estudos que resultaram da busca, foram incluídos 32 artigos na amostragem final. Foram selecionados: 20 artigos de revisão, cinco estudos observacionais, cinco ensaios clínicos, um série de casos e um estudo retrospectivo; 75% dos artigos foram publicados nos últimos cinco anos, sendo um em português e o restante em inglês. Conclusão: Os resultados demonstram variadas opções de tratamento da dor crônica na população idosa, destacando o papel dos opioides, que podem vir a ser usados, com cautela, no tratamento. Chama-se atenção também ao fato de que diversas drogas não foram testadas especificamente na população idosa. Além disso, o manejo da dor no idoso requer atenção a diversos fatores, entre eles as comorbidades, polifarmácia e funcionalidade do paciente. Assim, deve ser feita uma abordagem individualizada do paciente idoso, a fim de melhorar os resultados e diminuir efeitos colaterais.

Radiofrequency Denervation for Facet Syndrome: A Meta-Analysis of Treatment Outcomes / Denervação de síndrome facetária por radiofrequência: metanálise de resultados de tratamentos

Objective The aim of this study was to carry out a systematic literature review on the facet syndrome and a meta-analysis of the outcomes of radiofrequency denervation in patients presenting with the syndrome. Methods A systematic literature review was performed based on 52 articles published from 1999 to 2013, available at Bireme, Scielo, PubMed, and MEDLINE databases. The meta-analysis comprises eight case-control studies, found during the literature review, totaling 440 patients. The heterogeneity of the collected data was assessed using the chi-square test (χ2). To estimate the effect of the proposed correlation, we combined the values of each study with the Mantel-Haensze test, which has fixed effects, using the BioEstat 5.0 software. Results The selected studies were statistically relevant when grouped, determining an effect in favor of the use of facet denervation as a technique capable of relieving chronic low back pain in pre-determined periods of follow-up (OR » 1.251; 95% CI: 1.028­1.524). Conclusion The results of the systematic literature review and meta-analysis herein presented may be used for the creation of diagnosis and management protocols for facet syndrome, and can also attract the interest of other researchers to conduct further studies on the theme.

Objetivo Este estudo teve como objetivo elaborar uma revisão sistematizada sobre síndrome facetária e umametanálise sobre os desfechos do tratamento neurocirúrgico com denervação por radiofrequência em pacientes acometidos por esta síndrome. Métodos A revisão sistematizada foi elaborada com base em 52 artigos publicados de 2000 a 2013, disponíveis nas bases de dados eletrônicos Bireme, Scielo, PubMed e MEDLINE. A metanálise foi composta por oito casos-controle, selecionados durante a revisão, totalizando 440 pacientes. Os dados coletados foram avaliados quanto à sua heterogeneidade pelo teste qui-quadrado (χ2). Para estimar o efeito da correlação proposta, os valores de cada estudo foram combinados com o teste de Mantel- Haensze, que tem efeitos fixos, utilizando o software BioEstat 5.0. Resultados Os estudos selecionados são estatisticamente relevantes quando agrupados, determinando um efeito a favor do uso da denervação facetária como técnica capaz de diminuir a lombalgia crônica em seguimentos pré-determinados, mostrando OR de 1,251 e IC95% entre 1,028 e 1,524. Conclusão Os resultados da revisão sistemática de literatura e da metanálise aqui apresentados podem servir de base para a criação de protocolos de diagnóstico e conduta da síndrome facetária, assim como despertar o interesse de outros pesquisadores para a condução de novos estudos sobre o tema.

Importância da neuroestimulação medular no tratamento da síndrome do insucesso da cirurgia espinal / Importance of spinal cord stimulation for the treatment of failed back surgery syndrome

Eletrodos vêm sendo utilizados desde 1967 para estimulação da coluna espinal (em inglês, spinal cord stimulation ? SCS) no tratamento de dor crônica refratária em uma série de distúrbios dolorosos, entre eles a síndrome do insucesso da cirurgia espinal (em inglês, failed-back surgery syndrome ? FBSS), caracterizada por dor persistente após cirurgias de coluna, principalmente laminectomia. Neste artigo, apresenta-se uma revisão sistemática da literatura sobre o estudo da neuromodulação no tratamento da FBSS, utilizando-se as plataformas dos portais virtuais PubMed e MedLine, com o objetivo de levantar evidências que corroborem a eficácia e a segurança desse procedimento para dor crônica lombar decorrente de FBSS. A seleção dos estudos, publicados no período entre janeiro de 2003 e janeiro de 2013, envolveu critérios de análise de eficácia (melhora da dor, com redução de 50% ou mais, utilizando a Escala Visual Analógica ? VAS ? ou outras similares) e de segurança (quando complicações foram citadas). Foram inicialmente identificados 186 artigos, entre os quais nove foram selecionados por preencherem os critérios de inclusão/exclusão, totalizando 313 pacientes. Em todos os trabalhos selecionados, observou-se melhora considerável da dor após os procedimentos neuromodulatórios. Conclui-se que, quando bem indicada, a SCS é mais eficaz do que a reoperação ou qualquer outro tipo de terapia conservadora no tratamento de dor crônica lombossacral.

Electrodes have been used since 1967 for spinal cord stimulation (SCS) for the treatment of chronic pain in a series of painful conditions, such as failed-back surgery syndrome (FBSS), characterized by persistent pain after surgical procedures in the spinal column, mainly laminectomy. In this article, a systematic review of the literature is presented about the study of neuromodulation for the treatment of FBSS using data available at PubMed and MedLine, aiming to assess evidences that corroborate the efficacy and safety of this procedure for the treatment of low back chronic pain due to FBSS. The selection of the articles, published from January 2003 to January 2013, involved criteria of efficacy analysis (pain relief, with reduction by 50% or more, using the visual analogue scale ? VAS or other similar ones) and safety (when complications were mentioned). Initially, 186 articles were identified, among which, nine were selected because they fulfilled the inclusion/exclusion criteria, in a total of 313 patients. In all the articles selected, considerable pain relief was observed after neuromodulation procedures. We conclude that, when correctly indicated, SCS is more efficient than a new surgery or any other type of conservative therapy for the treatment of low back chronic pain.

Neurocisticercose: evolução incomum para forma gigante intraventricular / Neurocysticercosis: unusual evolution to giant intraventricular form

Neurocisticercose é a parasitose mais frequente do sistema nervoso central. Os cisticercos se localizam principalmente no córtex do parênquima cerebral, menos frequentemente no espaço subaracnoideo, ou no sistema ventricular. Geralmente possuem 4 a 20 mm de diâmetro e, ocasionalmente, quando maiores que 50 mm determinam sua forma gigante de apresentação. Reportamos um caso incomum de neurocisticercose por cisto gigante intraventricular. Comentamos sobre os aspectos diagnósticos e terapêuticos...

Reflexões sobre o envelhecimento e os processos criativos na maturidade a partir dos autorretratos de Rembrandt / Reflections about the Aging and the criatives processes from the self-portraits of Rembrandt

Feito levantamento e reflexão sobre os autorretratos de Rembrandt, artista holandês do século XVII, mostrando-o na juventude, na maturidade e na velhice. O artista fez mais de 100 autorretratos durante a trajetória de vida, que documentaram impiedosa e cruelmente o perecimento de seu corpo. A altivez e o vigor, retratados nos autorretratos da juventude, foram substituídos por qualidades adquiridas na dura caminhada pela vida. Diante da decadência da carne, desnudaram-se a paciência, a reflexão e a sabedoria. Rembrandt, na última etapa da vida, velho e pobre, continuou a trabalhar executando pinturas de grande qualidade. Com paixão e amor pelo seu trabalho, experiente e maduro, esmerou-se na técnica pictórica e produziu seus melhores quadros. A pintura foi o refúgio do artista, dando-lhe forças e ânimo, até sua morte aos 63 anos de idade. Em nossa sociedade atual, da mesma forma que ocorria na época de Rembrandt, o velho ainda é desprezado, descartado e excluído, em fase da vida na qual poderia continuar a ser útil, em decorrência dos conhecimentos e experiências adquiridos ao longo dos anos, o que o predispõe ao aparecimento de doenças, como depressão e demências. Portanto, da mesma forma que Rembrandt, os indivíduos idosos podem-se manter produtivos contribuindo ativamente para sua qualidade de vida, assim como da sociedade atual.

It was made a survey and reflection about the self-portraits of Rembrandt, dutch artist of the seventeenth century, showing him on youth, maturity and old age. The artist made more than 100 self-portraits during his life course, merciless and cruelly documenting his body extinction. The loftiness and vigor portrayed in the youth self-portraits, were replaced by qualities acquired in the hard journey through life. Given the decay of the flesh, they were stripped by patience, reflection and wisdom. Rembrandt, in the last stage of life, old and poor, continued to work creating great quality paintings. With passion and love for his work, experienced and matured, he excelled in the painting technique and produced his best paintings. The painting was the artist refuge, giving him strength and courage until his death at age 63. In our current society, same way in the time of Rembrandt, the old man is still despised, discarded and excluded, in a life phase in which he could continue to be useful due to the knowledge and experience acquired over the years, that predisposes him to diseases such as depression and dementia. Therefore, just as Rembrandt, older people can remain productive, contributing actively to the society quality of life.

Morte encefálica: diagnóstico possível sem utilização de exames complementares / Brain death: possible diagnosis without complementary exams

Objetivo: A necessidade da utilização de testes confirmatórios para o diagnóstico de morte encefálica vem sendo questionada nos últimos tempos. Acredita-se que o exame clínico completo, realizado de acordo com o protocolo do Conselho Federal de Medicina, seja suficiente para constatar a ausência irreversível de função no tronco encefálico. Assim, este estudo teve como objetivo averiguar a real necessidade da utilização de exames complementares no diagnóstico de morte encefálica. Método: Foi realizado estudo prospectivo analisando os prontuários de pacientes que receberam diagnóstico de morte encefálica desde a abertura do protocolo até a realização dos exames clínicos completos e exame complementar (Doppler transcraniano). Resultados: Não foi registrado nenhum caso de recuperação da função cortical e/ou do tronco cerebral após o diagnóstico de morte encefálica utilizando os critérios clínicos. A dificuldade para a realização do Doppler transcraniano e as falhas inerentes ao exame contribuíram para tornar mais lento o diagnóstico. Conclusão: É possível diagnosticar morte encefálica apenas utilizando exame clínico completo, sem a necessidade de exames complementares.

Objective: The need to use confirmatory tests for brain death diagnosis has been questioned lately. It is believed that a full clinical examination, performed according to the protocol of brain death diagnosis of the Brazilian National Council of Medicine, is sufficient to certify the irreversible loss of brain-stem function. Therefore, this study aimed to verify the real need to use complementary exams for brain death diagnosis. Method: We carried out a prospective study analyzing the files of patients with brain death diagnoses since the beginning of the protocol and that underwent a full clinical examination and transcranial Doppler as a complementary exam. Results: No cases of cortical and/or brain-stem function recovery after brain death diagnosis using clinical criteria were registered. Difficulty to perform transcranial Doppler and failures inherent to the exam contributed to late diagnosis. Conclusion: It is possible to diagnose brain death only using a full clinical examination, with no need to perform complementary exams.