Transcranial direct current stimulation for the treatment of post-stroke depression in aphasic patients: a case series

ABSTRACT

Aphasia is a common consequence of stroke; it is estimated that about two-thirds of aphasic patients will develop depression in the first year after the stroke. Treatment of post-stroke depression (PSD) is challenging due to the adverse effects of pharmacotherapy and difficulties in evaluating clinical outcomes, including aphasia. Transcranial direct current stimulation (tDCS) is a novel treatment that may improve clinical outcomes in the traditionally pharmacotherapy-refractory PSD. Our aim was to evaluate the safety and efficacy of tDCS for patients with PSD and with aphasia. The Stroke Aphasic Depression Questionnaire (SADQ) and the Aphasic Depression Rating Scale (ADRS) were used to evaluate the severity of PSD. The diagnoses of PSD and aphasia were confirmed by a psychiatrist and a speech-language pathologist, respectively. In this open case series, patients (n = 4) received 10 sessions (once a day) of bilateral tDCS to the dorsolateral prefrontal cortex (DLPFC) and two additional sessions after two and four weeks, for a total of 12 sessions. All patients exhibited improvement in depression after tDCS, as indicated by a decrease in SADQ (47.5%) and in ADRS (65.7%). This improvement was maintained four weeks after the treatment. In this preliminary, open-label study conducted in four PSD patients with aphasia, bilateral tDCS over the DLPFC was shown to induce a substantial mood improvement; tDCS was safe and well tolerated by every patient. Stroke patients with aphasia can be safely treated for PSD with tDCS. Sham-controlled studies are necessary to evaluate this technique further.     

The prevalence of priapism in children and adolescents with sickle cell disease in Brazil

To evaluate priapism rates in individuals <18 years of age with sickle cell disease (SCD) at a referral center. An evaluation was made of 599 consecutive male patients with SCD, separated according to type of hemoglobinopathy (HbSS, HbSC and HbS-β-thalassemia). Age at first episode and number of episodes were recorded. Cases of sickle cell trait were excluded. Mean age was similar in all groups. Overall, priapism occurred in 3.6 % of patients (5.6 % of those with HbSS and 1.1 % of those with HbSC; P = 0.01). In HbSS patients, the prevalence rate of priapism was from 3.5 (CI 95 % 0.94-13.4) when compared with patients with HbSC. No patient with β-thalassemia had priapism. Mean follow-up was 39.7 months (range 1-202 months). Since 91 % of patients with priapism had HbSS, this group was evaluated separately, revealing a rate of priapism of 1.6 % in patients <10 years and 8.3 % in those ≥ 10 years of age (P = 0.002). Regarding priapism in HbSS patients ≥ 10 years (8.3 %) when compared with patients <10 years (1.6 %), the prevalence rate was from 3.3 (CI 95 % 1.1-9.5). Duration of follow-up was not correlated with priapism (P = 0.774). Forty-seven patients were lost to follow-up. Telephone contact was successful with 14/22 patients with priapism, 50 % of whom had required hospital treatment. Most episodes (86 %) occurred at night, always during sleep. Medical interventions were required in 13 cases as follows: intravenous hydration (n = 4), corpora cavernosa puncture and drainage (n = 7) and corpus cavernosum-corpus spongiosum shunts (n = 2). The prevalence of priapism in children <18 years of age with SCD was 3.6 %, lower than previously reported. Prevalence was higher in HbSS patients, increasing in patients >10 years of age. Most episodes occurred at night and half of the patients required some form of urological procedure.     

Evaluation of bacterial contamination after “pure” (totally) transvaginal NOTES® diagnostic peritoneoscopy with biopsies in swine: a comparative study with laparoscopy

Introduction

Bacterial contamination from viscerotomy is a barrier to natural orifice translumenal endoscopic surgery (NOTES). The aim of this survival study is to evaluate pure (totally) transvaginal NOTES bacterial contamination compared with laparoscopy in pigs.

Methods

Twelve adult female pigs underwent peritoneoscopy with liver and peritoneal biopsies, using either laparoscopy (Glap, six animals) or pure transvaginal (GNOTES) access, and were maintained alive for 7 days. In all animals, blood cultures were taken at baseline, and after 24 h and 7 days postoperatively. Swab cultures from vagina (GNOTES) and skin (Glap) were obtained pre- and post-antisepsis. Peritoneal fluid culture was obtained at necropsy. For statistical analysis, Glap and GNOTES were compared for presence of positive bacterial cultures (qualitative bacterial analysis) using Fisher’s test, with level of significance set at p < 0.05.

Results

All animals had good postoperative outcome. One animal had transient perioperative bleeding from a transvaginal access. Two animals in Glap and one in GNOTES had positive blood cultures after the procedure. All animals from GNOTES and Glap presented with mixed flora pre-antisepsis. After antisepsis, one animal (GNOTES) presented with a positive vaginal swab culture (a single bacterial strain was identified). There was no positive skin swab culture in Glap. There were no signs of intra-abdominal infection at necropsy. In two animals, one from Glap and another from GNOTES, intra-abdominal culture was positive for Corynebacterium spp. and Escherichia coli, respectively. There was no correlation between the bacterial flora found at the access site and in the peritoneal cultures.

Conclusions

Pure transvaginal peritoneoscopy with liver and peritoneal biopsy in swine is feasible and associated with bacterial contamination comparable to laparoscopy. Peritoneal bacterial contamination was clinically insignificant after 1 week postoperatively. Preoperative antisepsis provided significant reduction of bacterial load prior to transvaginal and laparoscopic procedures.     

Wound healing potential of topical bacteriophage therapy on diabetic cutaneous wounds

Chronic wounds that fail to heal are a common complication of diabetes mellitus and the most common precipitating reason for nontraumatic lower limb amputation. Unfortunately, the bacterial species that cause these infections are becoming more resistant to antibiotics, making them increasingly difficult to treat. We assessed the feasibility of combating chronic bacterial infections with a topically delivered bacteriophage cocktail in two animal models of diabetes mellitus. Microbiological, planimetric, and histological parameters were compared in debrided infected wounds with or without topical bacteriophage treatment. We determined that bacteriophage treatment effectively decreased bacterial colony counts and improved wound healing, as indicated by smaller epithelial and dermal gaps, in Staphylococcus aureus and Pseudomonas aeruginosa infections but was not as effective against Acinetobacter baumannii. Although the improvements were more significant in the rodent model than in the porcine model, our results suggest that topically administered bacteriophage treatment may be effective in resolving chronic infections, especially when applied in conjunction with wound debridement. These findings have important implications for the feasibility of using topical antimicrobial therapies to safely treat chronic infections in diabetes mellitus patients.