Background: Dementia is a progressive neurodegenerative disorder characterized by cognitive decline and its incidence in Brazil is 5 times higher in illiterates. Early life education is a well-established modifiable risk factor for dementia prevention. However, whether learning to read and write in adulthood contributes to brain health is still unknown. Objective: To elucidate the effects of a late-life literacy intervention on cognitive reserve and brain connectivity in illiterate adults. We conducted a longitudinal clinical trial within an adult-literacy program targeting low-educated adults which is called PROAME (“Programa de Alfabetização e Memória”) Methods: First, 130 illiterate adults were screened at the basic education program for adults called EJA (“Educação de Jovens e Adultos”). After applying the exclusion criteria, 108 were recruited. Participants were divided into two groups: the control group (50 participants) attended the regular classes (literature, math, geography, history and sciences) and the intervention group (58 participants) attended part of the regular classes plus a specific training focused on learning how to read and write. Both groups attended their activities 4 days a week for 6 months. At the 6 month follow up visit, 77 participants successfully completed all required clinical assessments and interviews. Interviews were conducted to gather basic socio-demographic information, past and current medical history, use of tobacco, alcohol and illicit substances, physical activity levels and the presence of anxiety and depression. Participants also underwent a comprehensive cognitive assessment, which included executive functions assessment (digit span backwards, rapid number naming and phonemic verbal fluency), a functional brain MRI was performed to assess brain connectivity, especially the frontoparietal network, and a blood sample collection to measure plasma neurofilament levels. Results: We observed a significant increase in the episodic memory and executive functions in all participants, without a significant difference between the groups (control x intervention). When we adjusted the model for age, sex, reason for illiteracy and executive functions at baseline, we saw a significant improvement of executive functions in the intervention group. Factors that influenced in this result were attendance to classes combined with intensive literacy training, previous illiteracy related to rural areas residency, low executive performance at the baseline and lower levels of serum neurofilaments at baseline. In terms of brain connectivity, we saw that the intervention group had an increase in the frontal parietal and in the left hippocampal-temporal connectivity. Conclusion: Late life literacy training seems to improve executive functions, with and underlying rearrangement of the hippocampal and frontal connectivity.
Background:Stroke is the second leading cause of mortality in the general population. Spatial neglect syndrome is one of the most common complications following stroke and is associated with poor prognosis, including prolonged hospitalization. Objective:To examine the main clinical signs and symptoms associated with spatial neglect in stroke patients in the literature. Methods:The present systematic review and meta-analysis was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses protocol. The Grading of Recommendations Assessment, Development and Evaluation approach was applied to assess the certainty of evidence, and the data were processed with RevMan Web (The Cochrane Collaboration). Results:A total of 362 articles were assessed, out of which 23 were included. A strong correlation was observed between clinical events and the presence of spatial neglect syndrome compared to control groups (oculomotor exploratory behavior [p < 0.00001; 95% CI 4.03-22.41], difficulty detecting stimuli on the left side (p < 0.0001; 95% CI 3.20-24.89), and prolonged reaction time to left-sided stimuli (p = 0.004; 95% CI 1.11-273.20). The present study confirms that spatial neglect syndrome presents as a clinically diverse condition. The quantitative analysis demonstrated that abnormal oculomotor behavior is the most robust and consistent clinical predictor for diagnosis. Other frequent symptoms included delayed reaction times and impaired detection of stimuli in the left visual field. Additionally, the presence of hemianopia and the crossed legs sign were also associated with spatial neglect syndrome among others. Conclusion:The symptomatology described may serve as an indication of spatial neglect syndrome. Therefore, the present meta-analysis highlights the clinical importance of early identification and targeted evaluation in stroke cases.
Background:The Revised Amyotrophic Lateral Sclerosis Functional Rating Scale (ALSFRS-R) is a standard tool for evaluating functional decline in patients with ALS. Despite its clinical value, administration by healthcare professionals can be time-consuming and resource intensive. Objective:To assess the reliability and feasibility of a self-administration version of the ALSFRS-R as an alternative for use in clinical and research settings. Methods:The present was an observational, analytical, prospective, single-center study involving ALS patients followed at the Neurology Outpatient Clinic of the Hospital Universitário Onofre Lopes (HUOL). Three independent assessments of the ALSFRS-R were conducted: one self-administered version and two interviewer-administered versions performed by different researchers during face-to-face consultations. Interrater reliability was assessed using intraclass correlation coefficients (ICCs), and agreement among the three versions was analyzed using Bland-Altman plots. Results:A total of 43 participants were included in the study, with a mean age of 57 ± 11.67 years. The ICCs indicated high reliability for both the total ALSFRS-R score and its functional domains. Linear regression analyses demonstrated strong agreement between the two researchers (R2 = 0.98, p < 0.001), as well as between each researcher and the self-administered version (R2 = 0.90 and 0.88, respectively). Bland-Altman analyses showed minimal bias and acceptable limits of agreement across all comparisons. Conclusion:The self-administered version of the ALSFRS-R demonstrated high reliability and strong agreement with the researcher-administered versions, supporting its potential use for remote monitoring of ALS patients. Nonetheless, it should not replace professional assessments in clinical trial settings. Further research is warranted to validate its applicability in broader clinical contexts and diverse patient populations.
Background:Migraine and voice are related because of the shared pathophysiological mechanisms involving the vagus nerve, which also innervates the larynx. Objective:To conduct acoustic voice analysis and evaluate voice-related quality of life in women with migraine, in comparison with a control group. Methods:In the current cross-sectional study, we performed voice recordings and used the Voice-Related Quality of Life and migraine characteristics questionnaires. The variables included loudness, fundamental frequency, jitter, shimmer, glottal-to-noise excitation ratio, and phonatory deviation diagram. Results:The sample comprised 193 women (55 in the control group and 138 in the migraine group). No statistically significant differences were observed between the groups regarding the acoustic variables studied. The migraine group reported poorer scores in the physical domain of the Voice-Related Quality of Life questionnaire (p = 0.003) compared to the control group. The Random Forest statistical model predicted group allocation with 76% of precision. Conclusion:In the studied sample, no differences were observed between women with migraine and the control group regarding the parameters of acoustic voice analysis. Women with migraine presented poorer voice-related quality of life compared to the control group.
Background:Behavior change remains challenging despite a vast body of evidence linking health behaviors with several health outcomes. Over the past few decades, various health behavioral change theories and techniques have emerged, leading to significant advances in the field. However, although some existing theories provide competent models for structuring approaches, they do not provide a unified neurobiological foundation. Objective:To outline the connections between neuroscientific foundations in Part 1 and behavioral change theories in Part 2 and propose an overarching neuroscientific perspective. Methods:A narrative review of the relevant history and background of the most widely adopted behavior change theories and integrates them into the proposed framework of the Behavior Change Resource Model described in Part 1. Results:A structured overview of selected theories was performed. The main theories and techniques described were Social Cognitive Theory, Self-Determination Theory, Motivational Interviewing, Behavioral Activation, Transtheoretical Model, Cognitive Behavioral Therapy, Mindfulness Meditation, Positive Psychology, and Health and Lifestyle Coaching. Finally, their relation to motivation science and the Behavior Change Resource Model was detailed. Conclusion:By bridging the Behavior Change Resource Model (Part 1), and an array of related theories and techniques (Part 2) it was possible to provide a conceptual perspective to further support and propel the scientific understanding of human behavior, especially towards keeping and expanding health through lifespan and across society.
Background:Childhood sleep problems are an increasing public health concern. Although screen-based technology use is a potential cause, the specific effects of distinct screen-based behaviors on children's sleep remain unclear. Objective:To examine associations between technology use characteristics and sleep quality among primary school-aged children. Methods:The present descriptive and correlational study was conducted based on parent reports from 600 primary school students. Sleep quality was assessed using the Children's Sleep Habits Questionnaire (CSHQ). The following were investigated: sociodemographic variables, television, tablet, and smartphone usage times; the presence of technological devices in the children's rooms; and technology use before bedtime. Group comparisons were made using non-parametric tests, and a multiple linear regression analysis was used to examine the independent predictors of the CSHQ total score. Results:The mean CSAQ score for children was 52.79 ± 6.73, and 98.7% of participants were above the clinical sleep problem threshold. The utilization of technological devices was found to be associated with a substantial effect on sleep quality. The utilization of technology prior to bedtime, in addition to smartphone usage that exceeds 2 hours per day, has been demonstrated to be significantly associated with elevated CSHQ scores. In the multiple regression analysis, it was identified that smartphone use (> 2 hours/day) was the strongest independent predictor of sleep quality (β = 0.34; p < 0.001). Conclusion:The findings of the present study indicate that smartphone use, particularly before bedtime and for extended periods, has a substantial and adverse effect on the quality of sleep in elementary school children.
Background:Arquivos de Neuro-Psiquiatria (ANP) celebrated 80 years in 2023. We have previously evaluated the publication trends throughout the journal's first 40 years. Objective:To analyze the publication trends, authorship, and editorial patterns of the volumes 41 to 60 of ANP. Methods:We analyzed the volumes 41 to 60 of ANP (1983-2002). Data were tabulated independently by five blinded researchers and crossverified by two independent researchers. Results:From 1983 to 2002, 20 volumes, 91 issues and 2,424 articles were published. We analyzed 2,066 articles after excluding nonresearch papers (1,159 original articles and 770 case reports). Compared with the first 20 years, there was a significant increase in the total number of authors/article (3.96 vs. 2.73, p < 0.00001), a significant increase of female authors, from 11 to 28.6% (p < 0.05), and a decrease in the number of pages/article (p < 0.05). Lineu Cesar Werneck, Hélio Afonso Ghizoni Teive, and Milberto Scaff were the most prolific authors. Most of the articles focused on Neurology/Child Neurology subjects, with a progressive decreased percentage of Psychiatry papers and increase in Basic Research contributions. There was a linear increase in the total number of articles from 1983 to 2002 as detected by regression analysis (R2 = 0.9134; p < 0.0001) and an exponential increase from 1943 to 2002 (R2 = 0.9046; p < 0.0001). Most of the articles were written in Brazilian Portuguese, by authors from Southeastern Brazil (60.2%). Conclusion:The years 1983 to 2002 marked the transition to the current ANP format: minimal Psychiatry contributions; greater contribution from Southern Brazilian states; and, starting in 1999, greater acknowledgment of sponsorship from research agencies and postgraduate training.
Abstract:Autoimmune-associated epilepsy (AAE) is an increasingly-recognized condition in which seizures result from immune-mediated mechanisms, such as Rasmussen's encephalitis and antibody-associated epilepsies. Its timely identification may enable more efficacious therapy and improve outcomes. The current paper aims to provide a clinically-oriented review of AAE, focusing on clinical identification, use of diagnostic scoring systems, and immunological testing strategies. Antibody-associated epilepsy encompasses a broad spectrum of presentations, from postencephalitic epilepsy to isolated drug-resistant temporal-lobe epilepsy. Neuronal-surface autoantibodies (such as anti-N-methyl-D-aspartate receptor (anti-NMDAR), anti- leucine-rich glioma-inactivated protein 1 (anti-LGI1), anti-CASPR2) and intracellular antibodies (such as anti-GAD65) are variably associated with pathogenesis and chronicity. Clinical scoring systems (such as Antibody Prevalence in Epilepsy and Encephalopathy - APE2, Antibody Contributing to Focal Epilepsy Signs and Symptoms - ACES, ntibody Prevalence in Epilepsy before Surgery - APES, Antibody in Drug-Resistant Temporal Lobe Epilepsy - ARTE and 'Obvious' Indications for Neural Antibody Testing in Epilepsy or Seizures - ONES) are helpful in selecting patients for autoantibody testing. A comprehensive workup includes magnetic resonance imaging (MRI) scans, prolonged electroencephalographic (EEG) monitoring, cerebrospinal fluid (CSF) analysis, and combined serum/CSF antibody panels. Testing methodology and antibody type must be carefully interpreted in the light of clinical context. In low-resource settings, cost-effective testing strategies and clinical-screening tools are crucial to optimize the diagnostic yield. Early clinical suspicion, guided use of diagnostic scores, and appropriate immunological investigation are central to manage AAE. Recognizing AAE as a distinct diagnostic category is essential to improve care and guide immunotherapeutic decisions.
Background:Behavioral change remains challenging despite a vast body of evidence linking health behaviors with several health outcomes. Over the past few decades, various health-behavior change theories and techniques have emerged, leading to significant advances in the field. However, although some existing theories provide competent models to structure behavioral-change approaches, they do not provide a unified neurobiological foundation. Objective:To outline the connections between neuroscientific foundations and behavioral-change theories and to provide an overarching neuroscientific perspective. Methods:We conducted a structured narrative review based on data retrieved from major biomedical databases and authoritative neuroscience textbooks to integrate neuroscience data with behavioral-change theories. Results:We describe the neuroscience of behavior from neuroanatomical to neurophysiological mechanisms, emphasizing four brain systems: the hypothalamus, the amygdala, the mesocorticolimbic system, and the prefrontal cortex. Finally, we integrate these mechanisms with a neuroscience-based motivational theory called the Behavior Change Resource Model. Conclusion:The present work integrates established neurobiological knowledge and behavioral-change theories, providing a framework to link theory and health-behavior interventions.
Background:Hereditary spastic paraplegia (HSP) is a neurodegenerative disorder characterized by spasticity, lower limb weakness, impaired balance, and increased risk of falls. Objective:To evaluate the effect of vestibular rehabilitation associated with virtual reality (VRi) on functional balance in patients with HSP. Methods:A randomized pilot clinical trial was conducted with 16 patients who were diagnosed with HSP and divided into two groups: GI (balance games) and GII (balance + strength games). Interventions were performed via the Wii console and the Wii Balance Board platform (Nintendo Co, Ltd.). The Berg balance scale (BBS) and physiological profile assessment (PPA) were administered at T0 (prerehabilitation), T1 (after 10 sessions), and T2 (after 20 sessions). The Friedman test and Wilcoxon test were used to analyze temporal changes, the Mann-Whitney test was used to compare the groups. Results:All patients reported imbalance and muscle fatigue, whereas heaviness in the lower limbs and weakness were more common in GII. The visual contrast domain showed a significant change from T0 to T2, with scores increasing by a median of 2.0 (18.5-20.5) units. Conclusion:The use of VRi showed potential as a therapeutic adjunct in HSP rehabilitation, with improvements in balance and fall risk. However, larger studies are needed to corroborate these results. Clinical trial registration:ReBEC (RBR-3JMX67, 01/29/2020). https://ensaiosclinicos.gov.br/rg/RBR-3jmx67.
Background:Cluster headache (CH) has well-defined diagnostic criteria, but its diagnostic delay (DD) remains substantial, averaging 3.6 to 9 years, leading to inappropriate treatments and significant psychosocial and socioeconomic burdens. Objective:To identify demographic and clinical factors associated with DD in CH to promote earlier diagnosis. Methods:A multicenter cross-sectional study recruited 64 patients with episodic or chronic CH from 6 Portuguese neurology centers. Participants completed an online questionnaire covering demographics, clinical features, prior consultations, diagnoses, and treatments. Diagnostic delay was defined as the time from symptom onset to formal diagnosis. Correlation tests and multiple linear regression were performed to identify predictors of DD. Results:The mean DD was of 6.4 ± 8.3 (range: 0-39) years, with 46.9% experiencing delays > 4 years. No sex differences were observed. Younger age at onset (ρ = -0.45; p < 0.001); attack onset between midnight and 3 am (p = 0.029), and eyelid edema (p = 0.001) were associated with shorter DD. The number of pain episodes before neurology consultation strongly correlated with DD (ρ = 0.92; p < 0.001), underscoring the impact of referral delays. Most patients (59.4%) received alternative diagnoses, mainly migraine and sinusitis. Prior triptan (p = 0.037) and topiramate use (p = 0.012) were linked to longer DD. Multivariate models highlighted age at onset and clinical features as primary predictors, explaining nearly 60% of variance. Conclusion:Diagnostic delay in CH remains considerable in Portugal. Increasing awareness among primary care physicians and non-neurologist specialists is crucial to reduce DD and inappropriate treatments. Further research should clarify the role of educational level and support targeted interventions for timely recognition.
Background:Stroke is the main public health problem in Brazil. Objective:To evaluate the incidence of moderate-to-severe disability in patients admitted to the Stroke Unit in Roraima (2024), and estimate the impact of Stroke Unit implementation on neurological outcomes compared with historical data. Methods:This hospital-based observational cohort study assessed factors associated with moderate-to-severe disability in patients admitted to the Stroke Unit. Clinical and sociodemographic data were collected using a semistructured questionnaire. Participants were evaluated daily until discharge or death using the National Institutes of Health stroke scale (NIHSS). Results:A total of 400 patients was included. Mean age was 64.2 ± 15.8 years, and 52% of patients were male. Most cases were of ischemic stroke (82.2%), followed by wake-up stroke (13%), transient ischemic attack (TIA: 10%), and hemorrhagic stroke (1%). Systemic arterial hypertension (SAH: 57.1%), and diabetes (33.1%) were the most frequent comorbidities. Nearly 80% of patients were discharged, and the mortality rate was 3.7%. According to the modified Rankin Scale (mRS), moderate-to-severe disability at day 90 was associated with age > 70 years (RR = 1.45; 95% CI = 1.02-4.53), previous stroke (RR = 1.35; 95% CI = 1.12-3.42), and structural heart disease (RR = 1.80; 95% CI = 1.23-3.28). Thrombolytic therapy was performed in 12.5% of cases and reduced moderate-to-severe sequelae by 50%. Conclusion:Stroke Unit implementation represented a significant advance in stroke care in Roraima, reducing sequelae severity and mortality, including among older patients. However, access to thrombolytic therapy remains limited due to delayed hospital admission.
Background:Restless legs syndrome (RLS) is traditionally considered a sensorimotor disorder, but increasing evidence suggests that it may also involve brain systems related to emotional and cognitive functions. In this exploratory study, we investigated whether individuals with RLS show differences in social cognition, particularly in the ability to interpret others' emotional expressions and mental states. Objective:To investigate social cognition in individuals with RLS, particularly affective theory of mind. Methods:We compared 22 individuals with RLS and 22 healthy controls matched for age, sex, and education. Participants completed standardized tasks assessing different aspects of social cognition, including affective theory of mind, which refers to the ability to infer others' emotions. Results:We found that individuals with RLS scored lower on the task assessing affective theory of mind. No significant differences were observed in other social-cognitive measures, although the relatively modest sample size may have limited the detection of subtle differences. The group difference in affective theory of mind remained significant after accounting for depressive symptoms. Conclusion:These preliminary findings suggest that RLS may be associated with alterations in affective theory of mind independent of depressive symptoms. This pattern may reflect involvement of limbic-striatal networks. Larger studies incorporating sleep-related measures are needed to better understand social cognition in RLS.
Abstract:Cryptococcus meningoencephalitis (CM) is the most frequently encountered manifestation of cryptococcosis. We report the case of a previously healthy, human immunodeficiency virus (HIV)-negative 65-year-old man who presented with 3 days of severe holocranial headache followed by sudden psychomotor agitation, confusion, and disorganized speech, without improvement after midazolam, requiring endotracheal intubation. Initial neuroimaging suggested inactive neurocysticercosis. Early cerebrospinal fluid (CSF) analysis showed lymphocytic pleocytosis with negative India ink but positive cryptococcal antigen (latex agglutination), and subsequent testing confirmed Cryptococcus neoformans. The patient received fluconazole and amphotericin B and underwent therapeutic lumbar punctures for intracranial pressure control, with opening pressures decreasing from 25 to 13 cmH2O and transient clinical improvement. Despite this response, he experienced sudden deterioration and died. Autopsy revealed diffuse cerebral edema and granulomatous adrenal involvement. This case illustrates the potential fulminant course of cryptococcal meningoencephalitis in immunocompetent individuals and reinforces the importance of early recognition and aggressive intracranial pressure management.
Abstract:Spontaneous downbeat nystagmus (DBN) is the most common form of acquired nystagmus, characterized by a slow upward ocular drift and a corrective downward quick phase. The pathophysiology involves a final common pathway leading to decreased inhibition of the superior vestibular nucleus, often secondary to lesions in the flocculonodular lobes (flocculus/paraflocculus, FL/PFL), the paramedian tract (PMT), or the dorsal vermis. The clinical presentation generally includes chronic dizziness, gait unsteadiness, and oscillopsia. The causes are diverse, encompassing Chiari malformation, vascular and demyelinating lesions, hereditary and acquired cerebellar ataxias, and toxic-metabolic causes. Approximately 40% of DBN cases remain idiopathic. The treatment involves disease-specific management, prism glasses, and vestibular rehabilitation. Pharmacotherapy, such as clonazepam, gabapentin, or baclofen (with 4-aminopyridine being the most beneficial but often unavailable), is considered a second-line intervention.
Background:Third cranial nerve (III CN) palsy is an extremely disabling condition with several etiologies and clinical onsets. Identifying the underlying causes and individual risk factors is critical to determine prognosis and guide treatment. Objective:To analyze factors associated with III CN palsy, estimate recovery rates across different etiologies, and identify independent predictors of recovery, considering patient characteristics and comorbidities. Methods:A retrospective study was performed, including demographics and neurological data of a consecutive series of patients affected by III CN palsy from 2010 onwards. All patients underwent neurological examination, routine neuroimaging, and follow-up. Kaplan-Meier curve and the log-rank method were used to estimate recovery rates by etiology. Univariate and multivariate logistic regressions assessed patient-specific factors as independent predictors of recovery. Statistical significance was fixed as p-value < 0.05. Results:Overall, 50 patients were included. The prevailing causative factors were microangiopathy in 36% and miscellaneous in 36% of cases. Hypertension (50%), diabetes mellitus (34%), and cardiovascular diseases (14%) were the predominant comorbidities. Total recovery of the oculomotor function was found in 46% of patients. Kaplan-Meier analysis reported microangiopathy and syndromes as etiological factors significantly related to early recovery time. Age and pupillary involvement emerged as significant independent prognostic factors. Conclusion:The etiology significantly influences the recovery estimates of the oculomotor function. At the same time, patients' age, pupillary involvement, and especially hypertension as a comorbidity were the main predictive factors of good outcomes. More extensive studies are required to confirm these findings and include then in clinical practice.
Abstract:In 1869, Charcot and Alix Joffroy published the first detailed clinical and neuropathological description of amyotrophic lateral sclerosis (ALS), establishing the correlation involving muscle weakness, atrophy, spasticity, and degeneration of the lateral corticospinal tracts. Charcot unified the involvement of upper and lower motor neurons into a single clinical entity. His pioneering description was limited to the motor system, reflecting the scientific constraints of his time. Charcot interpreted ALS primarily as a disorder of the motor system, a conclusion consistent with the clinical and pathological methods available in the late nineteenth century. Neurological investigation at that time relied mainly on detailed clinical observation, anatomical correlation at autopsy, and relatively-simple physiological techniques. These approaches were well suited to identify motor dysfunction but were far less capable of revealing subtle cognitive or behavioral alterations. Currently, ALS is recognized as a multisystem neurodegenerative disorder. Thus, Charcot's historical contribution was crucial for the initial understanding of ALS, while modern perspectives acknowledge its broader clinical complexity beyond the motor system.
