Evaluation of cerebral hemodynamic status in patients with unilateral symptomatic carotid artery stenosis during motor tasks, through use of transcranial Doppler sonography / Avaliação do estado hemodinâmico cerebral em pacientes com estenose sintomática unilateral da artéria carótida durante tarefas motoras, por meio de ultrassonografia Doppler transcraniana

ABSTRACT Background: Carotid artery stenosis increases cerebral ischemic event risk through changing different cerebral hemodynamic parameters. Objective: To investigate how cerebral hemodynamics in the M1 segment of middle cerebral artery change in patients with carotid artery stenosis, after motor tasks using transcranial Doppler sonography (TCD). Methods: Thirty-two healthy subjects and 30 patients with unilateral symptomatic carotid artery stenosis were recruited. The patient population was divided into three groups according to the degree of stenosis (group 1: ≥50 to 69%, group 2: 70 to 89% and group 3: ≥90 to 99%). TCD was used to measure the pulsatility index (PI) and cerebral vasomotor reactivity (CVR). Results: In the patient group, significant differences for symptomatic side PI values (p=0.01) and mean CVR increases (p=0.05) were observed, compared with the healthy controls. However, the difference was not statistically significant for asymptomatic side PI values and mean CVR increases. The results from the intergroup comparison showed significantly higher percentages of symptomatic and asymptomatic side CVR increases in group 1, compared with groups 2 and 3 (p=0.001 and p=0.002, respectively). Conclusions: Our study showed that cerebral autoregulation and hemodynamic mechanisms are impaired in patients with carotid artery stenosis. Furthermore, the impairment of PI and CVR tends to get worse with increasing degrees of stenosis. In addition, this study demonstrated that assessment of these two hemodynamic parameters in clinical practice might be helpful for monitoring the progress of carotid artery stenosis.

RESUMO Antecedentes: A estenose da artéria carótida aumenta o risco de evento isquêmico cerebral por meio da alteração de diferentes parâmetros hemodinâmicos cerebrais. Objetivo: Investigar como a hemodinâmica cerebral no segmento M1 da artéria cerebral média se altera em pacientes com estenose da artéria carótida, após tarefas motoras com ultrassonografia Doppler transcraniana (DTC). Métodos: Foram recrutados trinta e dois indivíduos saudáveis e 30 pacientes com estenose da artéria carótida sintomática unilateral. A população de pacientes foi dividida em três grupos de acordo com o grau de estenose (grupo 1: ≥50 a 69%, grupo 2: 70 a 89% e grupo 3: ≥90 a 99%). A DTC foi usada para medir o índice de pulsatilidade (IP) e a reatividade vasomotora cerebral (RVC). Resultados: No grupo de pacientes, foram observadas diferenças significativas para os valores de IP do lado sintomático (p=0,01) e aumentos médios da RVC (p=0,05), em comparação com os controles saudáveis. No entanto, a diferença não foi estatisticamente significativa para os valores de IP laterais assintomáticos e aumentos médios de RVC. Os resultados da comparação intergrupos mostraram percentagens significativamente maiores de aumentos da RVC do lado sintomático e assintomático no grupo 1, em comparação com os grupos 2 e 3 (p=0,001 e p=0,002, respectivamente). Conclusões: Nosso estudo mostrou que a autorregulação cerebral e os mecanismos hemodinâmicos estão prejudicados em pacientes com estenose da artéria carótida. Além disso, o comprometimento do IP e da RVC tende a piorar com o aumento dos graus de estenose. Além disso, este estudo demonstrou que a avaliação desses dois parâmetros hemodinâmicos na prática clínica pode ser útil para monitorar a evolução da estenose da artéria carótida.

Associations Between Cerebral Vasoreactivity and Cognitive Function in the Middle-Aged Non-Demented Population.

BACKGROUND: Increasing evidence shows early vascular dysregulation in the pathophysiology of Alzheimer's disease (AD) in elderly population. OBJECTIVE: We wondered about the relationship between vascular health and cognitive performance in middle-aged adults. The present study aims to evaluate whether and which brain vascular hemodynamic parameters are associated with cognitive functions in a middle-aged, non-demented population. METHODS: We recruited 490 middle-aged community-based participants (30-60 years). Transcranial color-coded sonography was used to measure cerebral vascular hemodynamics, including mean flow velocity, pulsatility index, and breath-holding index (BHI) in the middle cerebral arteries (MCAs). Cognitive functions were assessed using the Montreal Cognitive Assessment (MoCA). A multivariate linear regression model was used to determine the association between the MoCA scores and each intracranial hemodynamic parameter. RESULTS: In 369 participants (median age 52 years [IQR 47-56], 48.8% men) with robust acoustic windows, the factors related to poorer MoCA scores were older age, less education extent, and the habitats of cigarette smoking or alcohol consumption. Multivariate analyses did not show a significant association between any intracranial hemodynamic parameters in both MCAs and MoCA scores in the total study population. Left MCA BHI was found to be significantly and independently correlated with the MoCA scores only in people aged 55-60 years (n = 111, B = 0.70, 95% confidence interval, 0.13-1.26, p = 0.017), however, not in people younger than 55 years. CONCLUSION: Our results emphasize the role of neurovascular abnormalities in the early pathophysiology of cognitive impairment and suggest cerebral vasoreactivity as the earliest detectable cognition-associated hemodynamic parameter.

Cardiovascular Imaging of Biology and Emotion: Considerations Toward a New Paradigm.

Central activation in response to emotion and cognitive stress induces perturbations in the heart and the peripheral vasculature that differ in physiology and clinical manifestations when compared with exercise-induced changes. While our conventional framework of epicardial coronary artery disease is foundational in cardiology, an expanded paradigm is required to address the cardiovascular response to mental stress (MS) and its associated risks, thus addressing the intersection of the patient's ecological and psychosocial experience with cardiovascular biology. To advance the field of MS in cardiovascular health, certain core challenges must be addressed. These include differences in the trigger activation between exercise and emotion, identification and interpretation of imaging cues as measures of pathophysiologic changes, characterization of the vascular response, and identification of central and peripheral treatment targets. Sex and psychosocial determinants of health are important in understanding the emerging overlap of MS-induced myocardial ischemia with microvascular dysfunction and symptoms in the absence of obstructive disease. In overcoming these critical knowledge gaps, integration of the field of MS will require implementation studies to guide use of MS testing, to support diagnosis of MS induced cardiac and vascular pathophysiology, to assess prognosis, and understand the role of endotying to direct therapy.

Updated treatment guideline for hormone therapy in postmenopausal women

Since menopause hormone therapy was first introduced, it has been widely used worldwide as the most effective treatment for vasomotor symptoms in menopausal women and for genitourinary syndrome of menopause. Menopause hormone therapy has been shown to prevent bone loss and fracture, but it may additionally offer various benefits for numerous other symptoms. The benefit-to-risk ratio of menopause hormone therapy is most favorable for women aged younger than 60 years or who are within 10 years of menopause onset and have no contraindications. Longer durations of therapy should be limited to patients with documented indications, such as persistent vasomotor symptoms or bone loss. For genitourinary syndrome of menopause, low-dose vaginal estrogen therapy or other therapies are recommended. Tibolone is a synthetic steroid that provides a therapeutic effect in the treatment of menopausal symptoms.

STRENGTH TRAINING AND ANABOLIC STEROID DO NOT AFFECT MUSCLE CAPILLARIZATION OF MIDDLE-AGED RATS / TREINAMENTO DE FORÇA E ESTEROIDE ANABOLIZANTE NÃO AFETAM A CAPILARIZAÇÃO MUSCULAR DE RATOS DE MEIA-IDADE / ENTRENAMIENTO DE FUERZA Y ESTEROIDE ANABOLIZANTE NO AFECTAN LA CAPILARIDAD MUSCULAR DE RATAS DE MEDIANA EDAD

ABSTRACT Introduction: It is generally accepted that the capillary network decreases with advancing age. The combined effect of resistance training (RT) and testosterone still needs to be elucidated. Objective: This study aimed to measure capillary profile of different skeletal muscles of middle-aged rats undergoing RT and administration of exogenous testosterone. Methods: Wistar rats were divided into five experimental groups: control with 13-month-old rats (SC), control with 16-month-old rats (SE), aged rats + anabolic agent (SA), aged rats + RT (T), and aged rats + RT + anabolic agent (TA). Results: For soleus, the SE group presented a decrease in the percentage of capillaries in comparison to SC group. SA, T, and TA groups had increased capillary volume in comparison to SC. As for the extensor digitorum longus (EDL), SA, T, and TA groups demonstrated lower capillary volume and numeric density in comparison to SC and SE. The EDL of the T and TA groups presented 70% less capillaries than soleus. The numerical and volumetric density and capillary ratio by muscle fiber were not statistically altered by any intervention. The cross-sectional area (CSA) of the soleus of the SA, T and TA groups was statistically different from SC group. The soleus CSA was greater in the TA and T groups than in the SC, SE and SA groups, and the EDL CSA was greater in the TA compared to all other groups. The TA group had greater values than the SE, SA, and T groups. Conclusion: The type of intervention used did not affect any variables measured in the capillary profile. However, the use of anabolic steroid and/or RT showed a tendency to decrease the density of capillaries in the EDL.

RESUMO Introdução: Em geral, se aceita que a rede capilar diminui com o avanço da idade. O efeito combinado de treinamento resistido (TR) e testosterona ainda precisa ser elucidado. Objetivo: Este estudo visou medir o perfil capilar de diferentes músculos esqueléticos em ratos de meia-idade submetidos a TR e administração de testosterona exógena. Métodos: Ratos Wistar foram divididos em cinco grupos experimentais: controle com ratos de 13 meses de idade (SC), controle com ratos de 16 meses de idade (SE), ratos idosos + anabolizante (SA), ratos idosos + TR (T) e ratos idosos + TR + anabolizante (TA) . Resultados: Para o músculo sóleo, o grupo SE apresentou decréscimo do percentual de capilares em comparação com o grupo SC. Os grupos SA, T e TA tiveram aumento do volume de capilares em comparação com o SC. Por outro lado, para o músculo extensor longo dos dedos (ELD), os grupos SA, T e TA demonstraram menor volume e densidade numérica de capilares, em comparação com SC e SE. O músculo ELD dos grupos T e TA apresentou 70% menos capilares do que o sóleo. A densidade numérica e volumétrica e a razão de capilares por fibra muscular não foram estatisticamente alteradas por nenhuma das intervenções. A área de corte transversal (ACT) do músculo sóleo dos grupos SA, T e TA foi estatisticamente diferente do grupo SC. A ACT do sóleo foi maior nos grupos TA e T do que nos grupos SC, SE e SA e a ACT do ELD foi maior no grupo TA comparada com todos os outros grupos. O grupo TA teve valores maiores do que os grupos SE, SA e T. Conclusão: O tipo de intervenção usada não afetou qualquer variável mensurada do perfil capilar. Entretanto, o uso de esteroide anabolizante e/ou TR mostrou tendência de diminuir a densidade de capilares no músculo ELD.

RESUMEN Introducción: Se acepta en general que la red capilar disminuye con la edad. El efecto combinado de entrenamiento de resistencia (ER) y la testosterona todavía necesita ser aclarado. Objetivo: Este estudio tuvo como objetivo medir el perfil capilar de diferentes músculos esqueléticos de ratas de mediana edad sometidas a ER y la administración de testosterona exógena. Métodos: Se dividieron ratas Wistar en cinco grupos: control con ratas de 13 meses de edad (SC), control con ratas de 16 meses de edad (SE), ratas de edad avanzada + anabolizantes (SA), ratas de edad avanzada + ER (T) y ratas de edad avanzada + ER + anabolizante (TA). Resultados: Para el músculo sóleo, el grupo SE mostró una disminución en el porcentaje de capilares en comparación con el grupo SC. Los grupos SA, T y TA presentaron aumento del volumen de capilares en comparación con el SC. Por otro lado, para el músculo extensor largo de los dedos (ELD), los grupos SA, T y TA mostraron menor volumen y menor número de capilares en comparación con los grupo SC y SE. El músculo ELD de los grupos T y TA presentó 70% menos capilares que el sóleo. La densidad numérica y volumétrica y la proporción de capilares por fibra muscular no se alteraron significativamente por ninguna de las intervenciones. El área de sección transversal (AST) del músculo sóleo de los grupos SA, T y TA fue estadísticamente diferente que el grupo SC. El AST del sóleo fue mayor en los grupos TA y T que en los grupos SC, SE y SA, y el AST del ELD fue mayor en el grupo TA en comparación con todos los demás grupos. El grupo TA tuvo valores más altos que los grupos SE, SA y T. Conclusión: El tipo de intervención utilizada no afecta a ninguna variable medida del perfil capilar. Sin embargo, el uso de esteroides anabolizantes y/o ER tendió a reducir la densidad capilar en el músculo ELD.

Skin sympathetic function in complex regional pain syndrome type 1.

PURPOSE: Cutaneous sympathetic pathophysiology in complex regional pain syndrome type 1 (CRPS-1) is not yet completely understood. To evaluate cutaneous sympathetic dysfunction in CRPS-1, we evaluated sympathetic sweat response (SSwR) and skin vasomotor reflex (SkVR) in CRPS-1 patients. METHODS: We studied 10 CRPS-1 patients (age 41 ± 13 years; 5 females and 5 males; disease duration 20 ± 22 months) and 10 healthy subjects (age 44 ± 13 years; 3 females and 7 males). SkVRs and SSwRs to several sympathetic activating procedures were recorded on the palms of the CRPS-1 patients (affected side) and controls (right side). RESULTS: There were no significant differences in the baselines of sweat output and skin blood flow between the CRPS-1 and control groups. SSwR and SkVR amplitudes were significantly lower in the CRPS-1 group than in the control group. There was no significant correlation between disease duration and SSwR or SkVR amplitudes among the patients. CONCLUSIONS: The reduced SSwRs and SkVRs in the affected limb of our CRPS-1 patients may reflect underlying damage to the sympathetic postganglionic fibres.

Stellate Ganglion Block for the Treatment of Hot Flashes in Patients with Breast Cancer: A Literature Review.

BACKGROUND: Currently, hormone replacement therapy (HRT) is the only US Food and Drug Administration-approved treatment for hot flashes, resulting in clinical improvement in 80%-90% of symptomatic women. However, HRT is not recommended for patients with breast cancer. Current data regarding the use of stellate ganglion block (SGB) for the treatment of vasomotor symptoms in symptomatic women with a diagnosis of breast cancer are promising. METHODS: A PubMed search for recent articles on the effects of SGB for the treatment of hot flashes in patients with breast cancer identified 11 articles published between 2005-2014. RESULTS: Five articles described the physiology of hot flashes and the hypothesis of why SGB would be a treatment option, and 6 were clinical articles. CONCLUSION: The available results of SGB efficacy are promising but demonstrate significant variability. A large prospective randomized controlled trial is required to determine the exact success of SGB on hot flashes and quality of life in breast cancer survivors.

Complex regional pain syndrome (CRPS) type I: historical perspective and critical issues.

The history of algodystrophy is controversial and its denomination has changed significantly over time. Silas Weir Mitchell described several cases of causalgia due to gunshot wounds that occurred during the American Civil War, increasing knowledge about this clinical condition. A later key milestone in the history of CRPS is tied to the name of Paul Sudeck that, using X-ray examinations, described findings of bone atrophy following a traumatic event or infection of the upper limb. The most widely accepted pathogenic hypothesis, proposed by Rene Leriche, supported a key role of the sympathetic nervous system in the onset of the typical clinical picture of the disease, which was thus defined as "reflex sympathetic dystrophy". In the 50s John J. Bonica proposed a staging of CRPS. In a consensus conference held in Budapest in 2003, it was proposed a new classification system that included the presence of at least two clinical signs included in the four categories and at least three symptoms in its four categories. There have been other classification systems proposed for the diagnosis of CRPS, such as Veldman diagnostic criteria based on the presence of at least 4 signs and symptoms of the disease associated with a worsening of the same following the use of the limb and their location in the same area distal to the one that suffered the injury. On the other hand, the Atkins diagnostic criteria are much more objective than those proposed by IASP and are specifically applicable to an orthopaedic context. However, current classification systems and related criteria proposed to make a diagnosis of CRPS, do not include instrumental evaluations and imaging, but rely solely on clinical findings. This approach does not allow an optimal disease staging especially in orthopaedics.

Butylphthalide improves cerebrovascular reactivity in patients with severe intracranial internal carotid artery stenosis / 国际脑血管病杂志

Objective To investigate the effect of butylphthalide on cerebrovascular reactivity (CVR) in patients with severe intracranial internal carotid stenosis.Methods The patients with severe intracranial internal carotid stenosis diagnosed by cerebral angiography in Nanjing Stroke Registry Program from January 2010 to November 2010 were randomly divided into either the butylphthalide group or the control group.All patients received the oral drugs for ischemic cerebrovascular disease that met the guideline criteria,and butylphthalide 20 mg,3 times a day orally was added in the butylphthalide group.The CVR was evaluated by transcranial Doppler and CO2 inhalation challenge test,and reexamined 3 months after treatment.Results A total of 81 patients met the inclusion criteria,11 (13.6％) were lost to follow-up,and finally 70 (n =35 in each group) were included in the analysis.The mean age of the patients was 55.2 ± 9.0 years,47 of them were male and 23 were female.The degree of vascular stenosis was 72％ to 99％ (mean 79.4％ ± 9.5％).The CVR was improved significantly after 3 months of treatment in the butylphthalide group than that in the control group (P =0.007),but it was not improvedsignificantly in the control group (P =0.330).All the patients did not have ischemic stroke events during the medication.No serious adverse reactions occurred in the butylphthalide group.Conclusions Butylphthalide may improve the CVR in patients with severe intracranial internal carotid stenosis.