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To compare the serum levels of renin-angiotensin system (RAS) components between patients with migraine and healthy controls, and to evaluate whether these levels are associated with migraine severity. We hypothesized that migraine would be associated with the activation of the inflammatory arm of the RAS, possibly leading to increased levels of angiotensin (Ang) II.Recent studies have proposed the use of drugs that interfere with RAS, a hormonal system primarily implicated in blood pressure regulation, as a prophylactic strategy for migraine. However, no previous studies have directly assessed RAS components in migraine.This was a cross-sectional study involving 30 patients with episodic migraine who were in the interictal period and 20 healthy controls. This study was conducted at Hospital das Clínicas (Universidade Federal de Minas Gerais, Belo Horizonte, Brazil) outpatient clinic. Headache severity was evaluated using the Headache Impact Test, version 6 (HIT-6) and the Migraine Disability Test (MIDAS) questionnaires. Given that migraine is comorbid with mood disorders, depressive and anxious symptoms were evaluated using the Beck Anxiety and Depression Inventories (BDI and BAI), respectively. Clinical and demographic data were also collected. Serum levels of angiotensin-converting enzyme (ACE), ACE2, Ang II, and Ang (1-7) were measured by enzyme-linked immunosorbent assay.Patients with migraine and controls were comparable in age, body mass index, blood pressure, and depressive and anxious symptoms. Patients with migraine showed lower levels of ACE [85.2 (66.8, 101.2) vs 65.5 (54.2, 77.5); P = .005] and lower ACE/ACE2 ratio [4.3 (3.4, 5.2) vs 3.5 (2.9, 4.1); P = .032] than controls. Conversely, patients with migraine had higher levels of Ang II [309.7 ± 147.4 vs 605.4 ± 200.4; difference: -287.1 (95% CI: -391.4--182.8), P .001] and Ang (1-7) [214.4 ± 155.8 vs 397.9 ± 217.9; difference: -184.6 (95% CI: -296.7--72.6), P = .001] than controls. There were no correlations between RAS serum markers and migraine severity scores (HIT and MIDAS) or depressive and anxious symptoms (BDI and BAI) (P .05).Altogether, our results suggest the participation of RAS in migraine pathophysiology, but not in its severity.

Myasthenia gravis (MG) is a neuromuscular autoimmune disease characterized by skeletal muscle weakness which can impact motor function and, furthermore, produce negative impact on the health-related quality of life (HRQOL).To evaluate the predictors for HRQOL in patients with MG.Eighty patients were evaluated with the MG Foundation of America classification and the MG Composite scale. HRQOL was estimated by the MGQOL15, while anxious and depressive symptoms were evaluated with the Hospital Anxiety and Depression Scale (HAD).The mean age of patients was 41.9 years with mean illness duration of 13.5 years. Almost half of the patients (43.75%) had significant anxiety and more than a quarter (27.50%) had depressive symptoms. Factors that influenced the HRQOL in MG were skeletal muscle weakness and anxiety and depressive symptoms (p .001 in logistic regression model).Anxiety and depressive symptoms, besides motor symptoms, influence HRQOL in MG. Mental health must be a clinical focus in addition to the treatment of somatic symptoms during the course of MG.

This current study aimed to evaluate the frequency of low bone mass, osteopenia, and osteoporosis in patients with myasthenia gravis (MG) and to investigate the possible association between bone mineral density (BMD) and plasma levels of bone metabolism markers. Eighty patients with MG and 62 controls BMD were measured in the right femoral neck and lumbar spine by dual-energy X-ray absorptiometry. Plasma concentrations of osteocalcin, osteopontin, osteoprotegerin, tumor necrosis factor (TNF-α), interleukin (IL)-1β, IL-6, dickkopf (DKK-1), sclerostin, insulin, leptin, adrenocorticotropic hormone, parathyroid hormone, and fibroblast growth factor (FGF-23) were analyzed by Luminex®. The mean age of patients was 41.9 years, with 13.5 years of length of illness, and a mean cumulative dose of glucocorticoids 38,123 mg. Patients had significant reduction in BMD of the lumbar, the femoral neck, and in the whole body when compared with controls. Fourteen percent MG patients had osteoporosis at the lumbar spine and 2.5% at the femoral neck. In comparison with controls, patients with MG presented lower levels of osteocalcin, adrenocorticotropic hormone, parathyroid hormone, sclerostin, TNF-α, and DKK-1 and higher levels of FGF-23, leptin, and IL-6. There was a significant negative correlation between cumulative glucocorticoid dose and serum calcium, lumbar spine T-score, femoral neck BMD, T-score, and Z-score. After multivariate analysis, higher TNF-α levels increased the likelihood of presenting low bone mass by 2.62. MG patients under corticotherapy presented low BMD and altered levels of bone markers.

Previous studies have shown an analgesic effect of ginger in the acute treatment of migraine, and there is anecdotal evidence of its efficacy in migraine prophylaxis.This study aimed to evaluate the potential of ginger to prevent migraine attacks.This double-blind, placebo-controlled randomized clinical trial took place at the Headache Clinic, Universidade Federal de Minas Gerais (Belo Horizonte, Minas Gerais, Brazil), involving 107 patients. Only subjects diagnosed with episodic migraine, aged between 18 and 60 years old, and who were not taking any prophylactic medication, were enrolled in the study. After one month of observation, subjects selected for the study were randomized 1:1 into placebo and treatment groups. Patients received capsules three times per day of 200 mg of dry extract of ginger (5% active ingredient) or placebo (cellulose) for three months. Visits were performed monthly and the patients were asked to fill in a migraine diary. The adherence to treatment was evaluated by counting capsules.The percentage of patients who responded to treatment (i.e. a reduction of 50% in the number of migraine attacks at the end of treatment) did not differ between the groups. There was a decrease in the number of days with severe pain, analgesic use for acute migraine and duration of migraine attacks in both groups, without significant difference between ginger and placebo groups.Ginger provides no greater benefit in the prophylactic treatment of migraine when compared to placebo. This trial is registered at ClinicalTrials.gov (NCT02570633).

This blind randomized clinical trial evaluated the effect of CIMT on the functionality and quality of life (QOL) of chronic hemiparetics. Thirty volunteers were divided into two groups: Control (CG) and CIMT (CIMTG); evaluated before and after 12 and 24 intervention sessions. The scales used were: adapted Fugl-Meyer Motor Assessment (FMA), Modified Ashworth, Stroke Specific Quality Of Life (SS-QOL) and the Functional Reach Test (FRT). The scores for all FMA variables in the CIMTG increased until the 24th session, differing from the pre-treatment. In the CG, the scores increased for pain, coordination/ speed and sensitivity. In the FRT there was an increase in the scores in both groups; after the 12th and 24th sessions, the result of the CIMTG was superior to the CG. For the SS-QOL in the CIMTG, the general score and most of the variables increased, as well as in the CG. Muscle tone in CIMTG was lower compared to CG after 24 sessions. Both protocols used in the study were effective, the CIMT protocol showed benefits in recovering the functionality of the paretic upper limb, in the functional range and in reducing muscle tone, with a consequent improvement in quality of life.

The study of traits that enable species to thrive in urban habitats is critical to a better understanding the evolution of urban ecosystems. Here, we examined variation in boldness, neophobia, and exploratory behavior in a generalist raptor, the Chimango Caracara, Milvago chimango, occurring in areas with different urbanization level. We also focused on the relationship between object exploration and neophobia in rural and urban population of this species. The results showed that birds from more urbanized habitats showed more tolerance to humans than rural raptors, without any effect of age and sex in this trait. Rural birds were also more neophobic and were slower to explore than urban raptors, though they dedicated a similar amount of time to exploring novel objects, indicating a non-correspondence between the speed to approach and contact these objects and the amount of exploration performed. Finally, we found a correlation between exploration speed and neophobia in rural birds, whereas for urban raptors this correlation was not observed. Our results show that urbanization not only influences the expression of risk-taking behaviors and novelty responses in the chimango, but can also modify the relationship between exploration and neophobia.

To investigate the clinical manifestation, disease course, and prognosis of migraine patients with or without personality disorders. This cross-sectional study evaluated 61 patients with migraine diagnosed according to the criteria of the International Headache Society (IHS). Personality disorders were assessed with the Structured Clinical Interview for DSM-IV (SCID-II). Migraine severity was assessed with the Headache Impact Test-6 (HIT-6). We also used a structured clinical interview to diagnose comorbid mood disorders. Of the 61 patients, 20 (32.8%) had personality disorders. Personality disorders included obsessive–compulsive 14/61 (23.0%), avoidant 6/61 (9.8%), borderline 6/61 (9.8%), paranoid 6/61 (9.8%), schizoid 2/61 (3.3%), histrionic 1/61 (1.6%) and dependent 1/61 (1.6%) types. Compared to migraine patients without personality disorders, comorbidity with any personality disorders was associated with an increased frequency of chronic migraine (p

Objective To evaluate potential associations between clinical features and inflammatory markers in patients with amyotrophic lateral sclerosis (ALS). Methods A consecutive series of 68 patients (39 males and 29 females) with sporadic ALS were subjected to a comprehensive clinical assessment and blood draw. A subset of these patients underwent a new assessment within 6–12 months after the baseline visit. In addition, a group of 62 subjects composed by age and sex-matched healthy subjects (38 males and 24 females) was enrolled in this study. Peripheral blood was drawn and plasma levels of chemokines and cytokines were measured by cytometric bead array and enzyme-linked immunosorbent assay. Results Our sample was composed by patients with ALS with an average age of 58 (±12.3) years old and 3 (±2.7) years of disease length at the baseline visit. Patients with ALS presented increased plasma levels of interleukin (IL)-6 and IL-8 in comparison with controls. After multivariate analysis, higher levels of IL-6 and lower levels of IL-2 were significantly associated with increased likelihood of ALS diagnosis. When evaluating the subset of patients assessed longitudinally, we did not find any significant difference in the levels of inflammatory markers between the two time points. Older age at ALS onset was the only factor associated with a faster rate of disease progression. Conclusions IL-6 levels could discriminate between ALS and controls and may be regarded as a potential biomarker of ALS diagnosis. An increase in IL-2 levels was associated with a protective effect on the odds of ALS diagnosis. Older age at ALS onset predicted a fast rate of disease progression.

The aim of this study was to compare computed tomography (CT) scans of chest and lung function among patients with Human T-Lymphotropic Virus Type 1 (HTLV) with and without HTLV-1 associated myelopathy/tropical spastic paraparesis (HAM/TSP). In this cross-sectional study performed between January 2013 and June 2016, we included 48 patients with HAM/TSP (19 women and 11 men) and without HAM/TSP (12 women and 6 men). We compared CT findings and lung functions of these groups. Patients who had HAM/TSP had abnormal CT findings (P = 0.000), including more frequent bronchiectasis (P = 0.049), parenchymal bands (P = 0.007), interlobular septal thickening (P = 0.035), and pleural thickening (P = 0.009). In addition, neither patients with HAM/TSP (9/30; 30%) nor the controls (0/18; 0%) had obstructive or restrictive lung disease (P = 0.009). HTLV diagnosis should be considered in all patients with abnormal CT findings in whom no other cause is apparent. It is important to remember that lung disease increases the rates of morbidity and mortality in developing countries.

Objective To investigate the frequency of anxiety and depression and their association with clinical features of amyotrophic lateral sclerosis. Methods This is a cross-sectional and descriptive study including a consecutive series of patients with sporadic amyotrophic lateral sclerosis according to Awaji’s criteria. Patients underwent clinical and psychiatric assessment (anxiety and depression symptoms). Results We included 76 patients. The men/women ratio was 1.6:1. Participants’ mean age at disease onset was 55 years (SD±12.1). Sixty-six patients (86.8%) were able to complete psychiatric evaluation. Clinically significant anxiety was found in 23 patients (34.8%) while clinically significant depression was found in 24 patients (36.4%). When we compared patients with and without depression a significant difference was seen only in the frequency of anxiety symptoms (p

OBJECTIVES: The aims of the current study were 1) to evaluate the reliability and validity of the Brazilian version of the 15-item Myasthenia Gravis Quality of Life Scale and 2) to investigate the quality of life of Brazilian patients with myasthenia gravis and its determinants. METHODS: This cross-sectional study included 69 patients with myasthenia gravis who underwent neurological evaluation and completed questionnaires regarding quality of life (the 36-item Short Form of the Medical Outcomes Study and the 15-item Myasthenia Gravis Quality of Life Scale), anxiety and depressive symptoms. RESULTS: The Brazilian version of the 15-item Myasthenia Gravis Quality of Life Scale showed high internal consistency and good concurrent validity with the 36-item Short Form of the Medical Outcomes Study and its subscales. Determinants of quality of life in Brazilian patients with myasthenia gravis included the current status of myasthenia gravis as assessed by the Myasthenia Gravis Composite, the current prednisone dose and the levels of anxiety and depression. CONCLUSION: The Brazilian version of the 15-item Myasthenia Gravis Quality of Life Scale is a valid instrument. Symptom severity, prednisone dosage and anxiety and depression levels impact the quality of life of patients with myasthenia gravis.

Our objective was to systematically analyse the first series of cases of amyotrophic lateral sclerosis (ALS) in Minas Gerais and to review the Brazilian literature about clinical studies in ALS. This was a cross-sectional and descriptive study of a consecutive series of patients with probable or defined sporadic ALS according to the Awaji criteria, followed at two referral centres of Belo Horizonte (South-east Brazil). Patients underwent full clinical assessment. Comparisons of patient subgroups according to disease duration and initial presentation were performed. A systematic review was performed about Brazilian clinical studies in ALS. Results showed that of the 61 enrolled patients the male/female ratio was 1.6:1. The mean age at onset of symptoms was 54.9 years (SD ± 11.4). Mean age at diagnosis was 56.3 years (SD ± 11.1). Regarding the initial form of presentation, 43 cases (70.5%) were spinal, 12 cases (19.7%) were generalized and six cases (9.8%) were bulbar. Eight studies were found in the systematic review. In conclusion, the profile of our sample was similar to other national and international series, except for fewer cases of bulbar ALS in our series. There are few clinical studies of ALS in Brazil. The national data of prevalence and incidence are still uncertain.

Although the association between episodic migraine and psychiatric comorbidities is well documented, few studies have focused on the comorbidity with chronic migraine (CM) and discrepancies exist between population-based and clinic-based data. The objective of this study is to compare demographic and psychiatric comorbidity correlates between CM samples drawn from the community and tertiary care. All inhabitants from a city borough were interviewed for the presence of headaches occurring 15 or more days per month. CM was diagnosed after subjects had been interviewed and examined by a headache doctor. Participants were also assessed with a structured interview by a psychiatrist, who assigned diagnoses based on the DSM-IV. The same investigators assessed all patients consecutively seen in a university-based outpatient headache center over a 4-month period. The samples consist of 41 individuals from the community and 43 from the headache center. Sociodemographic profiles were similar between groups with the exception of the mean number of years of formal education. Among individuals from the community, psychiatric diagnoses were present in 65.9 % of cases, relative to 83.7 % in those from the headache center (p = 0.06). Phobias (41.9 vs. 29.3 %) and depression (32.6 vs. 29.3 %) were more frequent in patients from the headache center, but this difference did not reach statistical significance. Thus the frequency of psychiatric disorders in patients with CM was elevated in both settings, being higher in the specialty care clinic.

In order to properly assess patients with primary headache, one needs to follow the cases up longitudinally. In Brazil, there were no studies using this methodology published after the publication of the latest issue of the International Classification of Headaches in 2004 - ICHD-2. This is especially important when we consider that it was only after such publication that we had the criteria used to classify some types of headaches which evolve with daily, or almost daily, spells, and which are very common in tertiary health care centers. OBJECTIVE: To assess the frequency of headache types in a tertiary health care center, in a longitudinal fashion. METHOD: We assessed 95 consecutive patients. These patients were diagnosed and classified according to the ICDH-2. The subjects were followed up for 18 months, they were treated and reassessed. RESULTS: Most of the individuals had more than one type of headache. Among those with episodic migraine in 2007, 6 developed chronic migraine in 2008, producing an incidence rate of 7.2%. Among those with chronic migraine in 2007, 9 remitted, producing a remission rate of 75%. In 2007, 24 individuals abused analgesic agents and 17 no longer showed abuse criteria in 2008 - when 7 new cases were found. CONCLUSION: The diagnosis of migraine remained stable. On the other hand, treatment brought about a reduction in the frequency of headaches caused by excessive use of analgesic, although the frequency of daily chronic headache was almost unaltered. Em casos de cefaléia primária é fundamental o acompanhamento longitudinal do paciente. No Brasil não há estudos que utilizaram essa metodologia após a publicação da Classificação Internacional de Cefaléias em 2004 (ICDH-2). Isso é especialmente importante quando consideramos que, apenas após tal publicação, obtivemos critérios para classificar cefaléias diárias, ou quase diárias, tão comuns em centros terciários. OBJETIVO: Avaliar longitudinalmente a frequência dos tipos de cefaléia em um centro de cefaléias. MÉTODO: Foram avaliados 95 pacientes consecutivos. Estes pacientes foram diagnosticados e classificados conforme a ICDH-2. Os indivíduos foram acompanhados por 18 meses, tratados e reavaliados. RESULTADOS: A maioria dos indivíduos recebeu mais de um diagnóstico. Entre aqueles com migrânea episódica em 2007, 6 desenvolveram migrânea crônica em 2008, com 7,2% de incidência; entre aqueles com migrânea crônica em 2007, 9 remitiram, sendo a taxa de remissão de 75%. Em 2007, o abuso de analgésicos foi encontrado em 24 indivíduos. Desses, 17 não apresentavam mais critérios de abuso em 2008, enquanto 7 novos casos foram encontrados. CONCLUSÃO: Houve estabilidade diagnóstica da migrânea. Por outro lado, a intervenção terapêutica permitiu a redução da frequência dos casos de cefaléia por uso excessivo de analgésicos, embora a frequência de cefaléia crônica diária mostrou-se praticamente inalterada.

There is a growing body of evidence implicating inflammatory cytokines and brain-derived neurotropic factor (BDNF) in the generation of migraine pain. No previous study evaluated BNDF levels during migraine attacks and there are conflicting results regarding tumor necrosis factor-alpha (TNF-alpha) serum levels. This study compared serum levels of TNF-alpha, soluble TNF receptors 1 and 2 (sTNF-R1 and sTNF-R2), and BDNF during migraine attacks and in headache-free periods. Nine patients with episodic migraine were clinically evaluated during a migraine attack and in a headache-free period. Blood sample of each patient in both occasions was collected and all serum was submitted to TNF-alpha, sTNF-R1, sTNF-R2, and BDNF determination by ELISA. There was no significant difference in the serum levels of TNF-alpha, sTNF-R1 and sTNF-R2 in migraine attack period and headache-free period. BDNF serum levels were significantly higher during migraine attack than in pain-free period. This is the first report showing that BDNF serum levels increase during migraine attack. This reinforces the view that BDNF may be implicated in the physiopathology of migraine.

Psychiatric disorders, notably mood and anxiety disorders, are frequently associated with migraine and chronic daily headaches. The obsessive-compulsive disorder (OCD) is included in the spectrum of anxiety disorders and may be a comorbid condition in headache patients. However, little information has been reported in the literature about this association. This is an important issue as OCD may contribute to the development or maintenance of treatment-resistant chronic headaches. In this paper, we describe a young female patient with refractory chronic migraine and OCD. Considerations on diagnosis, management and treatment of these comorbid conditions are presented.

The fish assemblage in a mangrove tidal creek was studied in monthly collections between August 1998 and July 1999 in the quadrature low tide and high tide, using a fyke net of 30 m x 1.5 m and meshes of 8 and 10 mm. Simultaneously with the biological collections, temperature, salinity, pH, water transparency, and current speed data were obtained. The collections resulted in the capture of 36,873 fish representing 22 families and 52 species. Immature individuals abounded (63.8%), and among the adult specimens there was a larger number of females. The species Anchoa parva, Harengula clupeola, Genidens genidens, and Bairdiella ronchus, contributed to 84.9% of the total capture of fish, however the contribution in mass was of 55.2%, indicating a predominance of small individuals. A smaller number of fish and species seem to occupy the area in the period between August and December, in comparison to the period between February and July, when the larger aggregations appear, mainly of the species Anchoa parva, Harengula clupeola, Opisthonema oglinum, Genidens genidens, Diapterus rhombeus, and Bairdiella ronchus. The environmental factors, pH, water transparency, and rainfall seem to have an influence in the structure of the observed biological patterns. A assembléia de peixes em um rio de maré de mangue foi estudada em coletas mensais entre agosto de 1998 e julho de 1999 na baixa-mar e preamar de quadratura, utilizando-se uma rede fixa tipo "fyke" com 30 m x 1,5 m e malhas de 8 e 10 mm. Simultaneamente às coletas biológicas, foram registrados dados de temperatura, salinidade, pH, transparência da água e velocidade da corrente. As coletas resultaram na captura de 36.873 peixes, representando 22 famílias e 52 espécies. Predominaram indivíduos imaturos (63,8%) e as fêmeas, entre os adultos. As espécies Anchoa parva, Harengula clupeola, Genidens genidens e Bairdiella ronchus constituíram 84,9% da captura total de peixes, no entanto, a participação em peso foi de 55,2%, indicando o predomínio de indivíduos de pequeno porte. Um menor número de peixes e espécies parece ocupar a área no período entre agosto e dezembro, comparado ao período entre fevereiro e julho, quando aparecem os maiores agregados, principalmente das espécies Anchoa parva, Harengula clupeola, Opisthonema oglinum, Genidens genidens, Diapterus rhombeus e Bairdiella ronchus. O pH, a transparência da água e a pluviosidade parecem influenciar a estruturação dos padrões biológicos observados.

Summary Objective: to determine the clinical profile of patients with myasthenia gravis (MG); followed at the Neuromuscular Diseases Clinic of the University Hospital, Federal University of Minas Gerais, Brazil, and to compare it with other Brazilian case series. Methods: sociodemographic and clinical data were collected from patients, and a systematic literature review performed, focusing on national studies on the clinical profile of MG patients. Results: sixty nine patients were enrolled in the study. Fifty five (91%) subjects were female and the mean age (SD) was 37.6 (±11.4) years. The mean disease duration was 14.1 years. Regarding treatment, prednisone was the most used strategy (64%), followed by the use of azathioprine (43%). There was no difference between thymectomized (42) and non-thymectomized (27) patients regarding disease severity and medication use. Conclusion: clinical and socio-demographic features of this MG sample from a University-based clinic resemble those reported in other Brazilian series and in the international literature. Objetivo: determinar o perfil clínico dos pacientes com miastenia gravis (MG) atendidos na Clínica de Doenças Neuromusculares do Serviço de Neurologia do Hospital das Clínicas da Universidade Federal de Minas Gerais, e comparar com outras séries de casos brasileiras. Métodos: foram coletados dados clínicos e sociodemográficos dos pacientes, e realizada revisão sistemática de literatura, focando em estudos nacionais sobre o perfil clínico de pacientes com MG. Resultados: sessenta e nove pacientes participaram do estudo, sendo 55 (91%) do sexo feminino, e a média de idade (desvio-padrão) de 37,6 (±11,4) anos. O tempo médio de doença foi de 14,1 anos. Em relação ao tratamento, o uso isolado de prednisona foi a estratégia mais adotada (64%), seguida do uso de azatioprina (43,3%). Não houve diferença entre os pacientes timectomizados (47) e não timectomizados (22) no que diz respeito à gravidade da doença e ao tratamento. Conclusão: as características clínicas e sociodemográficas da presente amostra de pacientes com MG de um serviço universitário assemelham-se às características de outras séries brasileiras e da literatura internacional.

Clinical differentiation between the primary headaches and temporomandibular disorders (TMD) can be challenging. Objectives : To investigate the relationship between TMD and primary headaches by conducting face to face assessments in patients from an orofacial pain clinic and a headache tertiary center. Method : Sample consists of 289 individuals consecutively identified at a headache center and 78 individuals seen in an orofacial pain clinic because of symptoms suggestive of TMD. Results : Migraine was diagnosed in 79.8% of headache sufferers, in headache tertiary center, and 25.6% of those in orofacial pain clinic (p

A50-year-oldpreviouslyhealthywomanpresentedwitha4-day history of low back pain, nausea, vomiting, diarrhea, jaundice, and fever.Shedevelopedhypoxemic respiratory insufficiencyandachest radiographshoweddiffusealveolarand interstitial infiltrates.Shewas promptly intubatedandbecamehemodynamicallyunstableanddevelopeddialytic-renal insufficiency.At this time, laboratoryworkup revealed a hemoglobin level of 6.1 mg/dL (to convert to grams per liter, multiply by 10), leukocyte count of 0.2603/μL (to convert to ×109/L,multiplyby0.001),C-reactiveprotein level of 59 000mg/L (toconvert tonanomolesper liter,multiplyby9.524),platelet count of 28×103/μL (to convert to×109/L,multiply by 1), serumurea level of 80mg/dL (to convert to millimoles per liter, multiply by 0.357), serumcreatinine level of 2.24mg/dL (to convert tomicromolesper liter,multiplyby88.4), serumpotassiumlevelof0.72mEq/L (toconvert to millimoles per liter, multiply by 1), and abnormal coagulation profile (international normalized ratio of 1.8; D-dimer level of 125 200 mg/mL [to convert to nanomoles per liter, multiply by 5.476).Apresumptivediagnosis of hemolytic-uremic syndrome led to a day of plasmapheresis, but then no schizocytes were found in the peripheral blood and results of the Coombs testwere negative. Empirical antibiotic andantiviral treatmentwere startedwith ceftriaxonesodium,clarithromycin,andoseltamivirphosphate.Herblood and urine culture findings were negative. After 4 days of intensive care unit treatment, the patient progressively recovered and became hemodynamically stable. She no longer needed daily hemodialysis and she was being ventilated in spontaneous mode without sedativedrugs.However, noawakeningoccurred.Neurological examination revealed a comatose patient with decorticated posturing after noxious stimuli, with normal brainstem functions and pupillary responses, without focal signs. Cranial computed tomographyshowed widespread cortical and deep brain hemorrhages (Figure, A and B). Brain magnetic resonance imaging and

Objective To translate and to perform the cross-cultural adaptation of the “Questionnaire of Life Quality Specific for Myasthenia Gravis - 15 items” (MG-QOL15). Method The original English version of the questionnaire was translated into Portuguese. This version was revised and translated back into English. Later, both English versions were compared and the divergences were corrected in the Portuguese text. At a second stage, ten patients with MG followed at the Neuromuscular Diseases Clinic from the University Hospital, Universidade Federal de Minas Gerais answered the questionnaire. The authors analyzed the difficulties and misunderstandings in the application of the questionnaire. Results The questions 8, 13 and 15 were considered difficult to understand and were modified in the final Portuguese version. Most patients (70%) had a total score above 25, and the statements 3, 8 and 9 showed the highest scores. Conclusion The Brazilian version of the questionnaire MG-QOL15 seems to be a promising tool for the assessment of Brazilian patients with MG. Objetivo Realizar a tradução e a adaptação transcultural do “Questionário de Qualidade de Vida Específico para Miastenia Gravis – 15 itens” (MG-QOL15). Método Inicialmente, foi realizada a tradução do instrumento original em inglês para o português. Esta versão foi revisada e retrotraduzida para o inglês. A versão retrotraduzida foi comparada à versão original em inglês, sendo corrigidas as divergências no texto em português. Em um segundo momento, dez pacientes com MG acompanhados na Clínica de Doenças Neuromusculares do Hospital das Clínicas da Universidade Federal de Minas Gerais responderam ao questionário. Na aplicação do questionário, os itens mal compreendidos foram analisados pelos autores. Resultados Os itens 8, 13 e 15 foram considerados de difícil compreensão e modificados na versão final em português. A maioria dos pacientes (70%) apresentou uma pontuação total superior a 25, sendo que os itens 3, 8 e 9 apresentaram os escores mais elevados. Conclusão A versão brasileira do MG-QOL15 é um instrumento promissor para a avaliação de pacientes brasileiros com MG.

Background Chronic daily headaches (CDHs) are often associated with temporomandibular disorders (TMDs). However, large studies assessing the relationship were conducted in general, and not clinical, populations. Thus, clinical exams were not completed. Clinic-based studies with expert diagnosis are, in turn, often small and may not be representative. Objective To contrast the demographic and clinical symptoms of CDH and TMD in participants within the general population relative to patients seen in a headache clinic. Methods All inhabitants 10 years and older of a small city in Brazil were interviewed. Those with more than 15 days of headache per month were examined by a team consisting of a neurologist, a dentist, and a physical therapist. Headaches were classified as per the Second Edition of the International Classification of Headache Disorders and TMD as per the Research Diagnostic Criteria. The procedure was repeated (by the same team) with CDH sufferers consecutively seen in a headache center. Results Of 1605 inhabitants interviewed, 57 (3.6%) had CDH, and 43 completed all physical assessments. For specialty care group, of 289 patients, 92 had CDH, and 85 completed all assessments. No significant differences were seen for gender and age, but education level was significantly higher among those recruited at specialty care. Muscular TMD happened in 30.2% of CDH patients from the community vs 55.3% in the headache center (difference of −25.1%, 95% confidence interval of difference = −40.8% to −9.4%). No TMD happened in 41.9% of those recruited from the population relative to 20% of those in the headache center (21.9%, 95% confidence interval = 6.7-37.1%). Conclusion Individuals with CDH recruited from the general population are significantly less likely to have CDH relative to those selected from the headache center. Issues of generalizability are of concern when conducting clinic-based studies on the topic.

General paresis of the insane is a late and severe form of neurosyphilis characterized by nonspecific neuropsychiatric symptoms. There are a limited number of case reports of mood disorders presenting in neurosyphilis, with depressive illness being the most common.We performed a literature review of case reports of secondary bipolar disorder induced by syphilitic infection.Herein reported is a case of a 53-year-old woman who initially presented with symptoms of mania and depression, mimicking bipolar disorder, but was subsequently diagnosed with general paresis of the insane.The present case report emphasizes that if a substantial delay occurs in syphilis diagnosis and management, the patient may have a very poor prognosis.

To assess the frequency of different diagnoses of headaches in the Headache Outpatient Clinic of the Hospital das Clínicas of the Universidade Federal de Minas Gerais (AmbCef-UFMG).Cross sectional study with 289 patients consecutively attended to at AmbCef-UFMG. Headaches were diagnosed based on the criteria established by the International Classification of Headache Disorders (ICDH-2004).The average age of patients was 42.6 years, mostly women (86.9%) with less than nine years of education. Primary headaches were the most common type, with migraine found in 79.8% of cases, and tension-type headache (TTH) in 20.4%. Among the secondary types, the most common was headache caused by overuse of analgesics (16.6%), followed by less common types, such as idiopathic intracranial hypertension. Chronic daily headache (CDH) was found in 31.8% of cases.This study confirms literature data showing migraine as the most common headache in tertiary care centers. The expressive number of cases of CDH and headaches caused by overuse of analgesics indicates that, starting at the primary care level, patients should be advised to avoid the abuse of symptomatic drugs.

OBJECTIVE: To investigate the prevalence of psychiatric disorders in patients with myasthenia gravis (MG). METHOD: Forty-one patients with MG answered to a structured psychiatric interview (MINI-Plus). RESULTS: Eleven (26.1%) patients were diagnosed with a depressive disorder and 19 (46.3%) were diagnosed with an anxiety disorder. Patients with dysthymia were older (p=0.029) and had longer disease duration (p=0.006). Patients with social phobia also had longer disease duration (p=0.039). CONCLUSION: Psychiatric disorders in MG are common, especially depressive and anxiety disorders. OBJETIVO: Investigar a prevalência de transtornos psiquiátricos em pacientes com miastenia gravis (MG). MÉTODO: Quarenta e um pacientes com MG responderam a uma entrevista psiquiátrica estruturada (MINI-Plus). RESULTADOS: Onze (26,1%) pacientes foram diagnosticados com transtorno depressivo e 19 (46,3%) foram diagnosticados com um transtorno de ansiedade. Pacientes com distimia eram mais velhos (p=0,029) e tinham maior tempo de doença (p=0,006). Os pacientes com fobia social também tiveram maior tempo de doença (p=0,039). CONCLUSÃO: Transtornos psiquiátricos na MG são bastante comuns, principalmente transtornos depressivos e de ansiedade.

Studies using resources of a public family health program to estimate the prevalence of chronic daily headaches (CDH) are lacking.To estimate the 1-year prevalence of CDH, as well as the presence of associated psychiatric and temporomandibular disorders (TMD) comorbidities, on the entire population of a city representative of the rural area of Brazil.This was a cross-sectional, population-based, 2-phase study. In the first phase, health agents interviewed all individuals older than 10 years, in a rural area of Brazil. In the second stage, all individuals who reported headaches on 4 or more days per week were then evaluated by a multidisciplinary team. CDH were classified according to the second edition of the International Classification of Headache Disorders (ICHD-2). Medication overuse headache was diagnosed, as per the ICHD-2, after detoxification trials. Psychiatric comorbidities and TMD were diagnosed based on the DSM-IV and on the Research Diagnostic Criteria for Temporomandibular Disorders criteria, respectively.A total of 1631 subjects participated in the direct interviews. Of them, 57 (3.6%) had CDH. Chronic migraine was the most common of the CDH (21, 36.8%). Chronic tension-type headache (10, 17.5%), medication overuse headache (13, 22.8%) and probable medication overuse headache (10, 17.5%) were also common. Psychiatric disorders were observed in 38 (67.3%) of the CDH subjects. TMD were seen in 33 (58.1)% of them.The prevalence of CDH in the rural area of Brazil is similar to what has been reported in previous studies. A significant proportion of them have psychiatric comorbidities and/or TMD. In this sample, comorbidities were as frequent as reported in convenience samples from tertiary headache centers.

Objective.— To estimate the 1-year prevalence of headache, using face-to-face interviews of the entire population of a city in Brazil. Methods.— This was a cross-sectional, population-based study. We conducted face-to-face interviews of all individuals older than 10 years, in a town (Capela Nova) in Brazil. Prevalence of the headache was estimated using prevalence ratios, adjusted by gender, age, marital status, and level education. Results.— The estimated 1-year prevalence of any headache was 65.4%. Headache was 1.5 times more prevalent in women and individuals aged 20 and 29, but less prevalent in the elderly and divorced. There was not association with the level of education. Conclusions.— From a public healthcare perspective, headache should be seen as hypertension and diabetes, and actively screened and treated.

Ophthalmoplegic migraine (OM) is a rare disorder characterized by recurrent episodes of migraine-like headaches associated with extrinsic ocular musculature palsy. In this article, we report a patient with OM that presented recurrent palsy of the abducens nerve and other atypical features. Case reports of OM with abducens nerve palsy were also reviewed.

This study has evaluated depression in patients with episodic migraine (n=98), chronic migraine without medication overuse (n=23), and chronic migraine with medication overuse (n=57). The Beck Depression Inventory (BDI) was used to evaluate depressive symptoms in these three groups. The mean BDI score obtained in all patients was higher than that observed in asymptomatic subjects (episodic migraine=16.09±11.79, chronic migraine with medication overuse=18.91±12.53, chronic migraine without medication overuse=19.83±14.79). This finding corroborates previous studies suggesting a co-morbid association between migraine and depression. Depression did not seem to be crucial in the transformation of migraine as the median BDI scores did not differ significantly between patients with episodic and chronic migraine. The median BDI scores of the patients with chronic migraine with medication overuse and that patients with chronic migraine without medication overuse were similar as well. Therefore, medication overuse behavior may not be related with depression.

Purpose We sought to evaluate the response of 6 patients with masseter muscle hypertrophy to botulinum toxin type A therapy. Patients and methods Six patients with unilateral or bilateral masseter muscle hypertrophy received intramuscular injection of the botulinum toxin type A. The functional and cosmetic results were evaluated as well as recurrence. Results In all patients, satisfactory regression of the masseter muscle hypertrophy occurred and mild muscular pain was relieved. Recurrence was observed in 2 cases. Conclusions The use of botulinum toxin type A in masseter muscle hypertrophy therapy was shown to be a successful and safe treatment method. This procedure to control parafunctional activities involving the masticatory muscles of patients appears to be useful.

Although some studies have investigated the role of nutritional intervention on migraine, they had focused on triggers or on weight change and, to the best of our knowledge, none studied diet quality. Objective To investigate whether nutritional intervention focused on improving diet quality and healthy weight can promote improvement in clinical parameters of women with migraine. Methods Non-controlled and non-randomized intervention study conducted for 90 days. Women received an individualized diet meal plan and nutritional orientation according to their nutritional diagnosis. Anthropometric, clinical and nutritional data were measured once a month. Diet energy content and macronutrients were evaluated using 24-hour dietary recall. Diet quality was assessed through the Brazilian Healthy Eating Index–Revised (BHEI-R). The Migraine Disability Assessment and Headache Impact Test version 6 were used to assess the severity of migraine, and the Beck Depression Inventory evaluated depressive symptoms. Results Fifty-two women aged 44.0 ± 13.0 years were enrolled. Anthropometric characteristics, energy, macronutrients and fiber intake did not change after intervention. However, the BHEI-R scores improved after 60 and 90 days of intervention. Concurrent to this, the Beck Depression Inventory scores and Headache Impact Test scores decreased after 60 and 90 days, respectively. The change in the BHEI-R score was negatively correlated with the migraine severity as assessed by the Headache Impact Test at the end of the intervention. Conclusions We concluded that the management of diet quality may be a good strategy for improving migraine severity, regardless of the nutritional status and weight change. RESUMO Estudos investigaram o papel da intervenção nutricional, focada no consumo de alimentos “gatilhos” ou na alteração de peso, na melhora da migrânea. Porém, mudanças na qualidade da dieta ainda não foram abordadas. Objetivo Investigar se intervenção nutricional focada na qualidade da dieta e peso saudável pode melhorar parâmetros clínicos em mulheres com migrânea. Métodos Estudo de intervenção, não controlado e não randomizado. As mulheres receberam plano alimentar individualizado e orientações nutricionais, conforme o diagnóstico nutricional. Dados antropométricos, clínicos e alimentares foram medidos uma vez por mês durante três meses. Recordatório alimentar de 24 horas forneceu informações sobre o consumo alimentar. Qualidade da dieta foi avaliada pelo Índice Brasileiro de Alimentação Saudável (IQD-R). Os questionários Migraine Disability Test (MIDAS) e Headache Impact Test, versão 6 (HIT-6) avaliaram a incapacidade gerada pela enxaqueca e o Inventário de Depressão de Beck (BDI) investigou sintomas depressivos. Resultados Cinquenta e duas mulheres com 44,0 ± 13,0 anos participaram da amostra. Características antropométricas e consumo de energia, macronutrientes e fibras não se alteraram depois da intervenção. No entanto, os escores do IQD-R melhoraram após 60 e 90 dias de intervenção. Os escores do BDI e do HIT-6 diminuíram após 60 e 90 dias, respectivamente. A mudança no escore do IQD-R correlacionou de maneira negativa com a gravidade da enxaqueca avaliada pelo HIT-6 ao final da intervenção. Conclusões O manejo da qualidade da dieta pode ser estratégia para melhorar a gravidade da migrânea, independente do estado nutricional e da mudança de peso dos pacientes.