Clinical Neuroscience

[The effect of palliative neural therapy on the improvement of chronic pain]

MOLNÁR István1, HEGYI Gabriella2, KOVÁCS Zoltán3, KAPÓCS Gábor4, SZŐKE Henrik2

JANUARY 30, 2019

Clinical Neuroscience - 2019;72(01-02)

DOI: https://doi.org/10.18071/isz.72.0023

[Objective - To assess the extent to which pain therapy can improve chronic pain in a heterogeneous group of patients, its impact on their quality of life and the correlation of the changes with their age and the underlying disease. The investigation has its actuality by its impact on public health. Methods - a prospective, non-randomized, interventional, clinical cohort study was conducted under real-life conditions in a general pain clinic, which lasted for 6 months. Changes in pain intensity (VAS) and related quality of life changes (SF-36 HRQoL) were measured using validated internationally accepted questionnaires. The questionnaires were filled out by all patients on their own, so they provided information of self-esteem on their own. All patient post-treatment results were compared to pre-treatment results. The general quality of life changes found in our patients were compared to the representative norms of healthy population in Hungary. Subjects - patients participated voluntarily at their own decision in the survey. The underlying disease of chronic pain, age and gender of the patients did not limit the inclusion into the study. Results - Data of 231 patients were evaluated. After pain therapy, the decrease in intensity of pain was confirmed by VAS at p=0.002. This was linked to a quality of life change that has been shown to be p=0.003 for men, with p=0.002 in women with SF-36 HRQoL. Based on the correlation coefficients, the changes in quality of life improved regardless of the age of the patients and the nature of the underlying conditions causing the pain. Conclusions - Although analgesia is basicly a symptomatic therapy, our findings suggest that the reduction of pain improves the quality of life of patients independently from their, and the curability of the underlying and accompanying diseases. ]

AFFILIATIONS

  1. Pándy Kálmán Kórház, Gyula és PTE, ETK, Doktori Iskola, Pécs
  2. PTE, ETK, Komplementer Medicina Tanszék, Pécs
  3. PTE, ETK, Doktori Iskola, Pécs
  4. Szent János Kórház, Budapest

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Clinical Neuroscience

[Selection of the optimal device-aided therapy in Parkinson’s disease]

KOVÁCS Norbert, ASCHERMANN Zsuzsanna, JUHÁSZ Annamária, HARMAT Márk, PINTÉR Dávid, JANSZKY József

[For the treatment of advanced Parkinson’s disease the deep brain stimulation (DBS) and the levodopa/carbidopa intestinal gel (LCIG) therapies are available in Hungary. Although they may have similar impact on the health-related quality of life and disabilities associated with the disease, they have different indications, and inclusion- and exclusion criteria. Consequently, the patient population treated with DBS and LCIG may be different. In the present review, the authors try to help the process of selection of the optimal device-aided therapy for the patients with advanced Parkinson’s disease. ]

Clinical Neuroscience

[Tension type headache and its treatment possibilities]

ERTSEY Csaba, MAGYAR Máté, GYÜRE Tamás, BALOGH Eszter, BOZSIK György

[Tension type headache, the most common type of primary headaches, affects approximately 80% of the population. Mainly because of its high prevalence, the socio-economic consequences of tension type headache are significant. The pain in tension type headache is usually bilateral, mild to moderate, is of a pressing or tightening quality, and is not accompanied by other symptoms. Patients with frequent or daily occurrence of tension type headache may experience significant distress because of the condition. The two main therapeutic avenues of tension type headache are acute and prophylactic treatment. Simple or combined analgesics are the mainstay of acute treatment. Prophylactic treatment is needed in case of attacks that are frequent and/or difficult to treat. The first drugs of choice as preventatives of tension type headache are tricyclic antidepressants, with a special focus on amitriptyline, the efficacy of which having been documented in multiple double-blind, placebo-controlled studies. Among other antidepressants, the efficacy of mirtazapine and venlafaxine has been documented. There is weaker evidence about the efficacy of gabapentine, topiramate, and tizanidin. Non-pharmacological prophylactic methods of tension type headache with a documented efficacy include certain types of psychotherapy and acupuncture. ]

Clinical Neuroscience

Evaluation of neutrophil-to-lymphocyte ratio and platelet-to-lymphocyte ratio in essential tremor

TAK Zeynal Abidin Ali, SENGUL Yildizhan

Introduction - Although essential tremor (ET) is the most common cause of tremor, the pathology and underlying mechanisms have not fully understood yet. In addition to kinetic tremor, patients may present several types of tremor, gait ataxia, hearing deficits and eye movement abnormalities. Non-motor symptoms and signs have also added to definition of ET. There is significant evidence indicating the neurodegenerative nature of the disease. New studies indicate that inflammation may have a place in the etiology. The neutrophil-to lymphocyte ratio (NLR) and the platelet-to lymphocyte ratio (PLR) have recently begun to be used as a marker of systemic inflammation. Our study aims at finding a clue for systemic inflammation in ET. Methods - 67 patients with ET and 40 healthy controls were recruited for the study. The total white blood cells (WBC), absolute neutrophil count, lymphocyte count and platelet count were retrieved. The NLR was calculated by dividing the neutrophil count by the lymphocyte count and the PLR was calculated by dividing the platelet count by the lymphocyte count. Results - Patient and control groups were similar in terms of age and gender. The mean age of patient group was 25.29 ± 8.24 years and that of control group was 26.77 ± 6.73 years. The NLRs were 1.85 ± 0.58 in the patient group and 1.96 ± 0.53 in the control group. For the patient group and the control group the PLRs were 103.52 ±32.80 and 91.26 ± 31.57 respectively. There were no statistically significant differences between the participants for both NLR and PLR. Conclusion - The pathophysiological mechanism for essential tremor (ET) remains unclear. However, there is an increasing amount of research being conducted on the subject. Discussions about ET’s definition as a neurodegenerative disease are ongoing. Although previous studies showed that neuroinflammation could be a part of etiology of disease, this study has failed to demonstrate systemic inflammation in ET.

Clinical Neuroscience

Additional value of tau protein measurement in the diagnosis of Creutzfeldt-Jakob disease

CSEH Katalin Edina, VERES Gábor, DANICS Krisztina, SZALÁRDY Levente, NÁNÁSI Nikolett, KLIVÉNYI Péter, VÉCSEI László, ZÁDORI Dénes

Since the definite diagnosis of Creutzfeldt-Jakob disease (CJD) can currently only be provided by autopsy, there is a special need for fine diagnostic tools in live patients to achieve accurate diagnosis as early as possible. The aim of this study was to perform a preliminary retrospective analysis on the utility of the measurement of total Tau (tTau) and some other biomarkers from the cerebrospinal fluid (CSF) of patients with rapidly progressive dementia in the diagnostic work up of CJD. Beside the assessment of relevant clinical data and the findings of electroencephalography and brain magnetic resonance imaging, the presence of 14-3-3 protein and the levels of tTau were determined by Western blot technique and enzyme-linked immunosorbent assay from the CSF of 19 patients diagnosed with rapidly progressive dementia between the period of 2004-2017 at the Department of Neurology, University of Szeged. This preliminary study provided 100% sensitivity for 14-3-3, and interestingly, only 40% specificity to support the clinical diagnosis of CJD. Regarding tTau, the sensitivity values were calculated to be 100% or 83%, whereas the specificity values were 71% or 86%, depending on the applied cut-off levels. The poor specificity of 14-3-3 is not in line with literature data and may be the result of the small number of patients in the cohort with non-prion disease, predominantly consisting of disorders with considerable tissue damage, whereas tTau presented good sensitivity and specificity values. The combined application of these and novel chemical biomarkers may increase both sensitivity and specificity to a desired level.

Clinical Neuroscience

Evaluation of body image perception in multiple sclerosis patients without neurological deficit

SENGUL S Hakan, SENGUL Yildizhan, TAK Zeynel Abidin Ali, KOCAK Müge, TUNC Abdulkadir

Objective - There is a lack of research on the association between body image perception (BIP) and multiple sclerosis (MS). The aim of this study was to evaluate BIP in MS patients and its correlation with depression, anxiety, duration of the disease, and sociodemographic characteristics of the patients. Methods - Fifty patients with MS who applied to our outpatient clinic were examined. Forty-five healthy control were recruited for the study. All patients were diagnosed with MS according to 2010 revisions of McDonald criteria. Expanded Disability Status Scale (EDSS) was performed by the same neurologist for all patients. The participants were asked to complete a sociodemographic form, Body Cathexis Scale (BCS), Beck Depression Inventory (BDI), and Beck Anxiety Inventory (BAI). Results - The mean BCS score was 86.54 ± 32.24 in MS patients and 155.00 ± 20.90 in the healthy subjects (p<0.001). While MS patients had significantly higher anxiety levels, depression scores were similar in both groups. The mean BAI score was 18.50 ± 14.03 for MS patients and 10.06 ± 7.96 in the control group (p=0.001). The BDI score of the patients was 13.77 ± 11.61 and 11.91 ± 8.65 for the controls (p=0.34). Early age of the disease onset, increased number of attacks, increased depressive symptoms, and higher anxiety levels were significantly correlated with higher BCS scores. Age and being single/ divorced/ widowed were also correlated with BCS scores. Conclusions - It is important to preserve the mental well-being of patients. Even in apparently healthy patients, the body perception may be severely impaired.

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[Examining the psychometric properties of a new quality of life questionnaire in migraineurs]

MANHALTER Nóra, PALÁSTI Ágnes, BOZSIK György, ÁFRA Judit, ERTSEY Csaba

[Background - The deleterious effect of primary headaches on the sufferers’ quality of life (QOL) has been abundantly documented using both generic and headache-specific instruments. The currently used questionnaires focus on a limited number of factors and therefore may not be sensitive enough to detect the effect of headache type and headache characteristics on QOL, despite the obvious clinical differences. We have devised a comprehensive questionnaire that may be more sensitive to the burden of headache. Objective - To assess the psychometric properties of the new questionnaire on a group of migraineurs. Patients and method - We studied 117 migraineurs who completed the validated Hungarian version of the SF-36 generic QOL measure and our new, 25-item questionnaire. Reliability was assessed by internal consistency, measured by Cronbach’s a of all items. Content validity was exam- ined by calculating the correlation of the items with subscales of the SF-36 measure. The correlation of the patients’ migraine characteristics with the questionnaire’s items was used to assess criterion validity. Results - The questionnaire was quick and easy to administer. The questionnaire demonstrated good reliability, with Cronbach’s alpha being 0.893. Content validity was adequate; most “physical” items of the new questionnaire showed significant correlations with the bodily pain and role physical SF-36 subscales and most “psychical” and “social” items were correlated with mental health and social functioning SF-36 subscales. Criterion validity was adequate, with headache severity being correlated with most of the items. Discussion - In this study the new headache-specific quality of life instrument showed adequate psychometric properties.]

Clinical Neuroscience

[Earlier and more efficiently: the role of deep brain stimulation for parkinson’s disease preserving the working capabilities]

DELI Gabriella, BALÁS István, KOMOLY Sámuel, DÓCZI Tamás, JANSZKY József, ASCHERMANN Zsuzsanna, NAGY Ferenc, BOSNYÁK Edit, KOVÁCS Norbert

[Background – The recently published “EarlyStim” study demonstrated that deep brain stimulation (DBS) for the treatment of Parkinson’s disease (PD) with early fluctuations is superior to the optimal pharmacological treatment in improving the quality of life and motor symptoms, and preserving sociocultural position. Our retrospective investigation aimed to evaluate if DBS therapy was able to preserve the working capabilities of our patients. Methods – We reviewed the data of 39 young (<60 years-old) PD patients who underwent subthalamic DBS implantation at University of Pécs and had at least two years follow-up. Patients were categorized into two groups based on their working capabilities: Patients with active job (“Job+” group, n=15) and retired patients (without active job, “Job-” group, n=24). Severity of motor symptoms (UPDRS part 3), quality of life (EQ-5D) and presence of active job were evaluated one and two years after the operation. Results – As far as the severity of motor symptoms were concerned, similar (approximately 50%) improvement was achieved in both groups. However, the postoperative quality of life was significantly better in the Job+ group. Majority (12/15, 80%) of Job+ group members were able to preserve their job two years after the operation. However, only a minimal portion (1/24, 4.2%) of the Job- group members was able to return to the world of active employees (p<0.01, McNemar test). Conclusion – Although our retrospective study has several limitations, our results fit well with the conclusions of “EarlyStim” study. Both of them suggest that with optimal timing of DBS implantation we may preserve the working capabilities of our patients.]

Lege Artis Medicinae

[End of the line? Addenda to the health and social care career of psychiatric patients living in Hungary’s asylums]

KAPÓCS Gábor, BACSÁK Dániel

[The authors are focusing on a special type of long term psychiatric care taking place in Hungary outside of the conventional mental health care system, by introducing some institutional aspects of the not well known world of so called social homes for psychiatric patients (asylums). After reviewing several caracteristics of institutional development of psychiatric care in Hun­gary based on selected Hungarian and in­ternational historical sources, the main struc­tural data of present Hungarian institutional capacities of psychiatric health and social care services are shown. Finally, the authors based on own personal experiences describe several functional ascpects of the largest existing asylum in EU, a so­cial home for long term care of psychiatric pa­tients. By the beginning of the 20th century, Hungarian psychiatric institutions were operating on an infrastructure of three large mental hospitals standing alone and several psychiatric wards incorporated into hospitals. Nevertheless, at the very first session of the Psychiatrists’ Conference held in 1900 many professionals gave warning: mental institutions were overcrowded and the quality of care provided in psychiatric hospital wards, many of which located in the countryside of Hungary, in most cases was far from what would have been professionally acceptable. The solution was seen in the building of new independent mental hospitals and the introduction of a family nursing institution already established in Western Europe; only the latter measure was implemented in the first half of the 20th century but with great success. However, as a result of the socio-political-economic-ideological turn following the Second World War, the institution of family nursing was dismantled while different types of psychiatric care facilities were developed, such as institutionalised hospital and outpatient care. In the meantime, a new type of institution emerged in the 1950s: the social home for psychiatric pa­tients, which provided care for approximately the same number of chronic psychiatric patients nationwide as the number of functioning hospital beds for acute psychiatric patients. This have not changed significantly since, while so­cial homes for psychiatric patients are perhaps less visible to the professional and lay public nowadays, altough their operational conditions are deteriorating of late years. Data show, that for historical reasons the current sys­tem of inpatient psychiatric care is proportionately arranged between health care and social care institutions; each covering one third. Further research is needed to fully explore and understand the current challenges that the system of psychiatric care social- and health care institu­tions are facing. An in-depth analysis would significantly contribute to the comprehensive improvement of the quality of services and the quality of lives of patients, their relatives and the health- and social care professionals who support them. ]

Clinical Neuroscience

[The quality of life of the cluster headache patients during the active phase of the headache]

DIÓSSY Mária, BALOGH Eszter, MAGYAR Máté, GYÜRE Tamás, CSÉPÁNY Éva, BOZSIK György, ERTSEY Csaba

[Introduction - Cluster headache (CH), which affects 0.1% of the population, is one of the most painful human conditions: despite adequate treatment, the frequent and severe headaches cause a significant burden to the patients. According to a small number of previous studies, CH has a serious negative effect on the sufferers’ quality of life (QOL). In the current study, we set out to examine the quality of life of the CH patients attending our outpatient service between 2013 and 2016, using generic and headache-specific QOL instruments. Methods - A total of 42 CH patients (16 females and 26 males; mean age: 39.1±13.5 years) completed the SF-36 generic QOL questionnaire and the headache- specific CHQQ questionnaire (Comprehensive Headache- related Quality of life Questionnaire), during the active phase of their headache. Their data were compared to those of patients suffering from chronic tension type headache (CTH) and to data obtained from controls not suffering from significant forms of headache, using Kruskal-Wallis tests. Results - During the active phase of the CH, the patients’ generic QOL was significantly worse than that of normal controls in four of the 8 domains of the SF-36 instrument. Apart from a significantly worse result in the ‘Bodily pain’ SF-36 domain, there were no significant differences between the CH patients’ and the CTH patients’ results. All the dimensions and the total score of the headache-specific CHQQ instrument showed significantly worse QOL in the CH group than in the CTH group or in the control group. Conclusion - Cluster headache has a significant negative effect on the quality of life. The decrease of QOL experienced by the patients was better reflected by the headache-specific CHQQ instrument than by the generic SF-36 instrument. ]

Clinical Neuroscience

[Treatment of dystonia by deep brain stimulation: a summary of 40 cases]

DELI Gabriella, BALÁS István, KOMOLY Sámuel, DÓCZI Tamás, JANSZKY József, ILLÉS Zsolt, ASCHERMANN Zsuzsanna, TASNÁDI Emese, NAGY Ferenc, PFUND Zoltán, BÓNÉ Beáta, BOSNYÁK Edit, KULIFFAY Zsolt, SZIJJÁRTÓ Gábo

[Background - Bilateral pallidal deep brain stimulation (DBS) is an established treatment option for primary generalized and segmental dystonia. In the present study we evaluated the results of our dystonia patients treated by DBS. Methods - The surgical results of forty consecutive dystonia patients underwent DBS implantation were analyzed (age: 43.7±17.7 years; sex: 22 men; etiology: 24 primary and 16 secondary dystonia; topography: 24 generalized, 12 segmental and four hemidystonia; disease duration: 16.1±9.3 years). Severity of dystonia measured by Burke-Fahn-Marsden Dystonia Rating Scale (BFMDRS) and health-related quality of life measured by EQ-5D scale were obtained preoperatively and compared to the scores obtained at postoperative six months and subsequent yearly follow-ups. The average follow-up lasted 2.5 years (median, 0.5-8 years). In all cases the BFMDRS scores were re-evaluated by a rater blinded to the treatment. Treatment responsiveness was defined as an at least 25% improvement on the BFMDRS scores. Non-parametric Mann-Whitney, McNemar and Kruskal-Wallis tests were applied to test statistical significance. Results - Severity of dystonia improved from 31 to 10 points (median, 68% improvement, p<0.01) in the primary dystonia group, whereas in secondary dystonia these changes were statistically insignificant (improvement from 40 to 31.5 points, 21.2%, p>0.05). However, the health-related quality of life significantly improved in both groups (primary dystonia: 0.378 vs. 0.788 and secondary dystonia: 0.110 vs. 0.388, p<0.01). Significantly more patients in the primary dystonia group responded to DBS treatment than those in the secondary dystonia group (83.3% vs. 37.5%, p<0.01). Conclusion - Our results are in accordance with previously published international findings demonstrating that DBS is a highly effective and long-lasting treatment option for primary dystonia. DBS is considerably less efficient in secondary dystonia; however, it still has a high impact on the quality of life presumably due to its pain-relieving effect.]