Dor neuropática (DN) é definida como “dor iniciada ou causada por lesão primária ou disfunção em sistema nervoso”, porém sua prevalência depende do tipo de trauma e da disfunção relacionada. Apesar desta condição dolorosa ser considerada altamente prevalente e debilitante, os tratamentos disponíveis são relacionados a efeitos adversos dificultando a adesão. Devido a isso, buscam-se alternativas não farmacológicas para o tratamento deste tipo de dor, entre elas, as técnicas de neuromodulação periférica, como acupuntura (AC) e eletroacupuntura (EA). Estas técnicas podem ser combinadas com intervenções farmacológicas e não farmacológicas e têm apresentado resultados promissores no tratamento da dor neuropática. No entanto, seus mecanismos de ação não estão totalmente elucidados, desta forma a utilização de modelos animais é de grande valia para o estudo destes mecanismos no tratamento da dor neuropática e da patofisiologia deste tipo de dor crônica. É importante salientar que a aplicação de AC e EA em animais acordados é complexa, visto que gera desconforto e pode alterar a analgesia induzida pelo tratamento. Em muitos estudos a anestesia com isoflurano é utilizada durante a aplicação dos tratamentos, porém sua utilização pode gerar um viés no estudo, considerando a possível interferência do fármaco nos resultados comportamentais e neuroquímicos. Outro importante foco de estudo consiste em comparar as duas técnicas, AC e EA, buscando determinar qual destas é a mais eficaz no tratamento da dor neuropática. Considerando o exposto acima, os objetivos desta tese foram: 1) avaliar os parâmetros comportamentais e neuroquímicos dos efeitos da utilização de anestesia na aplicação de AC e EA em ratos submetidos ao modelo de DN; 2) comparar os efeitos da AC e EA em modelo animal de DN por meio de parâmentros comportamentais, neuroquímicos e histológicos. Considerando os resultados obtidos nesta tese, concluímos que o isoflurano aumenta a analgesia promovida por AC e EA, provavelmente diminuindo o efeito do estresse gerado pela aplicação dos tratamentos em animais acordados, resultado que é corroborado pela diminuição do nível de S100β periférico (marcador de morte neuronal central); Por outro lado, o isoflurano diminuiu os níveis de fator de crescimento neuronal (NGF) no nervo periférico lesado, indicando diminuição do processo de regeneração neural, enquanto a EA aumentou. Ao mesmo tempo, o isoflurano alterou os efeitos dos tratamentos nos comportamentos exploratórios e nos níveis de N-metil D-aspartato em tronco encefáfio e medula espinhal. A AC apresentou-se mais eficaz no tratamento da DN em comparação à EA, porém nenhum dos tratamentos foi capaz de alterar os danos causados pela indução da DN no músculo gastrocnemio esquerdo dos animais demonstrado na histologia. Todavia, este resultado não alterou a analgesia gerada pelos tratamentos. / Neuropathic pain (NP) is defined as "pain initiated or caused by primary injury or dysfunction in the nervous system," but its prevalence depends on the type of trauma and related dysfunction. Although this painful condition is considered to be highly prevalent and debilitating, the available treatments are related to adverse effects, making adherence difficult. Because of this, non-pharmacological alternatives for the treatment of this type of pain are sought, among them, the techniques of peripheral neuromodulation, such as acupuncture (AC) and electroacupuncture (EA). These techniques can be combined with pharmacological and non-pharmacological interventions and have shown promising results in the treatment of neuropathic pain. However, its mechanisms of action are not fully elucidated, so the use of animal models is of great value for the study of these mechanisms in the treatment of neuropathic pain and the pathophysiology of this type of chronic pain. It is important to emphasize that the application of AC and EA in awake animals is complex, since it generates discomfort and can alter the analgesia induced by the treatment. In many studies, anesthesia with isoflurane is used during the application of the treatments, but its use may generate a bias in the study, considering the possible interference of the drug in the behavioral and neurochemical results. Another important focus of the study is to compare the two techniques, AC and EA, seeking to determine which is the most effective in the treatment of neuropathic pain. Considering the above, the objectives of this thesis were: 1) to evaluate the behavioral and neurochemical parameters of the effects of the use of anesthesia in the application of AC and EA in rats submitted to the DN model; 2) to compare the effects of AC and EA on animal model of DN by means of behavioral, neurochemical and morphological parameters. Considering the results obtained in this thesis, we conclude that isoflurane increases the analgesia promoted by AC and EA, probably decreasing the effect of the stress generated by the application of the treatments in agreed animals, a result that is corroborated by the decrease in the level of peripheral S100β (biomarker of central neuronal injury); On the other hand, isoflurane decreased the levels of neural grown factor (NGF) in the injured peripheral nerve, indicating a decrease in the neural regeneration process, while the EA increased. At the same time, isoflurane altered the effects of treatments on exploratory behaviors and N-metil-D-aspartato (NMDA) levels in the brainstem and spinal cord. AC was more effective in the treatment of DN compared to EA, but none of the treatments was able to alter the damage caused by DN induction in the left gastrocnemius muscle of the animals showed in histology. However, this result did not alter the analgesia generated by the treatments.

Este trabalho apresenta a continuidade da avaliação farmacológica do derivado Nfenilpiperazínico LASSBio-579 em busca de um novo candidato a antipsicótico de segunda geração. Em estudos anteriores, demonstramos que LASSBio-579 base livre é um potencial candidato a antipsicótico atípico capaz de modular três diferentes sistemas neurotransmissores envolvidos na patofisiologia da esquizofrenia: a neurotransmissão dopaminérgica, serotonérgica e glutamatérgica; entretanto, LASSBio-579 na forma de cloridrato apresenta baixa biodisponibilidade. Neste trabalho avaliamos inicialmente a ação de LASSBio-579.HCl. -ciclodextrina, proposto como alternativa para melhorar a biodisponibilidade. Porém, quando avaliado no modelo de escalada induzida por apomorfina, preditivo de atividade antipsicótica, essa preparação não foi efetiva. Assim, seguimos a avaliação farmacodinâmica com LASSBio-579 base livre, utilizando modelos preditivos de atividade antipsicótica, em camundongos. Neste trabalho foram realizados ainda ensaios in vitro, onde se avaliou a ação de LASSBio-579 sobre a viabilidade celular, captação de glutamato e secreção de proteína S100B, utilizando-se para isso fatias hipocampais de ratos tratadas de forma aguda com LASSBio-579 nas concentrações de 0,1; 1,0; 10 e 20μM. / This study presents the continuity of the pharmacological evaluation of the Nphenilpiperazine derivative LASSBio-579, searching a new second generation antipsychotic compound. In previous studies we have demonstrated that LASSBio- 579 in form of base is a potential atypical antipsychotic able to modulate three different neurotransmitter systems involved in the pathophysiology of schizophrenia: dopaminergic, glutamatergic and serotonergic. However, LASSBio-579 hydrochloride has low bioavailability. In this study we evaluated LASSBio-579.HCl. -cyclodextrin, prepared with the aim of increasing oral bioavailability, in the apomorphine induced climbing in mice, which is a model predictive of antipsychotic activity; and it was not effective. Thus, we continue the study with LASSBio-579 in form of base by testing it in others mice models predictive of antipsychotic activity. In this study, also were made in vitro studies performed in hippocampal acute slices which demonstrated that LASSBio-579 induced a glutamate uptake inhibition and also inhibited the S100B protein secretion.

A participação de marcadores bioquímicos na avaliação de quadros de asfixia neonatal é cada vez mais relevante. A proteína S100B tem um papel destacado nestas pesquisas. O objetivo deste estudo foi procurar destacar a importância da proteína S100B na avaliação de recém-nascidos a termo com quadros de encefalopatia hipóxico-isquêmica, assim como correlacionar com outras substâncias que também participam do processo isquêmico. Foram analisados 21 casos de recém-nascidos a termo que desenvolveram quadro de encefalopatia hipóxico-isquêmica, no período de setembro de 2003 a outubro de 2004. Realizadas coletas no 1º e 4º dia de vida e dosadas, por método imunocitoquímico, a proteína S100B e o lactato. Foi possível detectar uma correlação positiva entre as 2 substâncias, assim como, quando comparadas entre si, observou-se também significância estatística. / Biochemical markers have played an increasingly relevant role in the assessment of neonatal asphyxia. The S100B protein is particularly important in research conducted in this field. The purpose of this study was to underline the importance of S100B protein in the assessment of term newborn infants with hypoxic ischemic encephalopathy, as well as to relate it to other substances also involved in the ischemic process. An assessment was made from September 2003 to October 2004 of twenty-one term newborn infants who developed hypoxic ischemic encephalopathy. Samples were collected on the 1st and 4th day of life and S100B protein and lactate levels were calculated using the immune cytochemical method. A positive relationship was found between the 2 substances. Additionally, a comparison between the two substances showed a statistically significant correlation.

As respostas inflamatórias no cérebro são mediadas principalmente pela microglia, mas evidências crescentes sugerem uma importância crucial dos astrócitos. A S100B, uma proteína ligante de cálcio e secretada por astrócitos, tem propriedades neurotróficas e de citocina inflamatória. No entanto, não se sabe se sinais primários que ocorrem durante a indução de uma resposta inflamatória como, por exemplo, lipopolissacarídeo (LPS) modulam diretamente a S100B. A neuroinflamação está implicada na patogênese ou na progressão de uma variedade de distúrbios neurodegenerativos e muitos estudos procuram uma conexão entre S100B e doenças degenerativas, incluindo a doença de Alzheimer e esquizofrenia. O uso terapêutico de fármacos anti-inflamatórios não-esteroidais (AINEs) para estas doenças tem aumentado. No entanto, existem poucos estudos sobre o efeito desses fármacos em relação à proteína S100B. Neste trabalho, nós avaliamos se os níveis de S100B no líquido cefalorraquidiano (LCR) e soro de ratos Wistar são afetados por injeção de LPS administrado por via intraperitoneal (IP) ou intracerebroventricular (ICV), bem como se as culturas primárias de astrócitos respondem diretamente ao LPS. Além disso, nós avaliamos o conteúdo e a secreção de S100B medido por ELISA (bem como o conteúdo de GFAP e secreção de TNF-α) em culturas primárias de astrócitos expostos a dexametasona e quatro classes químicas diferentes de AINEs (ácido acetilsalicílico, ibuprofeno, diclofenaco e nimesulida) durante 24 h. Os nossos dados sugerem que a secreção de S100B no tecido cerebral é estimulada rapidamente e persistentemente (durante pelo menos 24 h) por administração ICV de LPS. Este aumento da S100B no LCR foi transitório quando o LPS foi administrado IP. Em contraste com estes resultados de S100B, observou-se um aumento nos níveis de TNF-α no soro, mas não no LCR, após a administração IP de LPS. Em astrócitos isolados e em fatias de hipocampo frescas, observou-se uma estimulação direta da secreção de S100B por LPS numa concentração de 10 ug/ml. Um envolvimento de TLR4 foi confirmado pelo uso de antagonistas específicos deste receptor. No entanto, baixas concentrações de LPS em culturas de astrócitos foram capazes de induzir uma diminuição na secreção de S100B após 24 h, sem alteração significativa no conteúdo intracelular de S100B. Além disso, após 24 horas de exposição ao LPS, observou-se um decréscimo na glutationa e um aumento na proteína ácida fibrilar glial. Também foi observado que os AINEs apresentam diferentes efeitos sobre parâmetros gliais. O ácido acetilsalicílico e o diclofenaco foram capazes de aumentar a GFAP, enquanto que a nimesulida, um inibidor seletivo de COX-2, e a dexametasona diminuiram a secreção de S100B. No entanto, todos os AINEs reduziram os níveis de PGE2. Juntos, esses dados contribuem para a compreensão dos efeitos de LPS em astrócitos, especialmente sobre a secreção de S100B, e nos ajuda a interpretar mudanças nesta proteína no LCR e soro em doenças neuroinflamatórias. Além disso, tecidos periféricos que expressam S100B talvez devam ser regulados diferentemente, uma vez que a administração IP de LPS não foi capaz de aumentar os níveis séricos de S100B. Em relação aos AINEs, a PGE2 parece estar envolvida no mecanismo de secreção de S100B, mas vias adicionais, não claras neste momento, necessitam de uma maior caracterização. O papel inflamatório de S100B em doenças degenerativas, onde também são observados níveis elevados da COX-2 e PGE2, poderia ser atenuado por inibidores de COX-2. / Inflammatory responses in brain are primarily mediated by microglia, but growing evidence suggests a crucial importance of astrocytes. S100B, a calciumbinding protein secreted by astrocytes, may act as a neurotrophic or an inflammatory cytokine. However, it is not known whether primary signals occurring during induction of an inflammatory response (e.g. lipopolysaccharide, LPS) directly modulate S100B. Neuroinflammation has been implicated in the pathogenesis or progression of a variety of neurodegenerative disorders and several studies have looked for a connection of S100B, and degenerative diseases including Alzheimer’s disease and schizophrenia. The therapeutic use of non-steroid anti-inflammatory drugs (NSAID) to these diseases has growth up. However, there are few reports about the effect of these drugs on S100B. In this work, we evaluated whether S100B levels in cerebrospinal fluid (CSF) and serum of Wistar rats are affected by LPS administered by intraperitoneal (IP) or intracerebroventricular (ICV) injection, as well as whether primary astrocyte cultures respond directly to lipopolysaccharide. Moreover we evaluated S100B content and secretion measured by ELISA (as well as GFAP content and TNF-α secretion) in primary astrocyte cultures exposed to dexamethasone and 4 different chemical classes of NSAID (acetyl salicylic acid, ibuprofen, diclofenac and nimesulide) for 24 h. Our data suggest that S100B secretion in brain tissue is stimulated rapidly and persistently (for at least 24 h) by ICV LPS administration. This increase in CSF S100B was transient when LPS was IP administered. In contrast to these S100B results, we observed an increase in in TNFα levels in serum, but not in CSF, after IP administration of LPS. In isolated astrocytes and in acute hippocampal slices, we observed a direct stimulation of S100B secretion by LPS at a concentration of 10 μg/mL. An involvement of TLR4 was confirmed by use of specific inhibitors. However, lower levels of LPS in astrocyte cultures were able to induce a decrease in S100B secretion after 24 h, without significant change in intracellular content of S100B. In addition, after 24 h exposure to LPS, we observed a decrease in astrocytic glutathione and an increase in astrocytic glial fibrillary acidic protein. We also observe that NSAIDs have distinct effects on glial parameters. ASA and diclofenac are able to increase GFAP, while nimesulide, a selective COX-2 inhibitor, and dexamethasone were able to decrease S100B secretion. However, all anti-inflammatories were able to reduce levels of PGE2. Together, these data contribute to the understanding of the effects of LPS on astrocytes, particularly on S100B secretion, and help us to interpret cerebrospinal fluid and serum changes for this protein in neuroinflammatory diseases. Moreover, non-brain S100B-expressing tissues may be differentially regulated, since LPS administration did not lead to increased serum levels of S100. With respect to NSAIDs, PGE2 is possibly involved in the mechanism of S100B secretion but additional pathways, unclear at this moment, demand further characterization. The inflammatory role of S100B in degenerative diseases, where also is observed elevated levels of COX-2 and PGE2, could be attenuated by COX-2 inhibitors in which elevated levels of COX-2.

Abstract Head injury is the leading cause of death and disability in trauma patients, and alcohol misuse is often associated with such injuries. Despite modern diagnostic facilities, the extent of traumatic brain injury (TBI) is difficult to assess and supplementary diagnostic tools are warranted. The contribution of alcohol misuse to traumas also needs to be elucidated, as the role of different patterns of alcohol drinking in particular has received less attention. We investigated the clinical utility of a novel serum marker of brain damage, protein S100B, as a tool for assessing TBI in patients with trauma. We also investigated the patterns of alcohol drinking among trauma patients and the trauma mechanisms in relation to blood alcohol concentration (BAC), with special emphasis on head traumas. Finally, we studied the early identification of hazardous drinkers among trauma patients. Serum protein S100B was found to be a feasible supplementary method for assessing TBI, as the latter was shown to elevate its levels significantly, the highest values being found in patients with severe injuries. S100B was also found to be elevated in patients with mild head injury, where it was associated with an increased risk of developing post-concussion symptoms (PCSs). Extracranial injuries also increased S100B values in patients with multitrauma. Accordingly, S100B was not specific to TBI. The more severe the extracranial injury, the higher the S100B value that was found. Binge drinking was found to be the predominant pattern in trauma patients. Alcohol intoxication on admission and hazardous drinking patterns were more often present in patients with head injury than in those with other types of trauma. The risk of sustaining a head trauma significantly increased with increasing BAC. The results also demonstrated that BAC on admission is the best marker of alcohol misuse in trauma patients. The BAC test depicts hazardous alcohol drinking better than conventional biochemical markers of alcohol misuse such as gamma-glutamyl transpeptidase (GGT), aspartate aminotransferase (AST), carbohydrate-deficient transferrin (CDT), or mean corpuscular volume (MCV) of erythrocytes. The findings support the use of S100B as a supplementary method for assessing TBI and the use of BAC as a marker of alcohol misuse in trauma patients.

Preeclampsia and eclampsia are among the most common causes of maternal and fetal mortality and morbidity worldwide. There are no reliable means to predict eclampsia or cerebral edema in women with preeclampsia and knowledge of the brain involvement in preeclampsia is still limited. S100B and neuron specific enolase (NSE) are two cerebral biomarkers of glial- and neuronal origin respectively. They are used as predictors for neurological outcome after traumatic brain injuries and cardiac arrest but have not yet been investigated in preeclampsia. This thesis is based on one longitudinal cohort study of pregnant women (n=469, Paper I and III), one cross sectional study of women with preeclampsia and women with normal pregnancies (n=53 and 58 respectively, Paper II and IV) and one experimental animal study of eclampsia (Paper V). In Paper I and III, plasma concentrations of S100B and NSE were investigated throughout pregnancy in women developing preeclampsia (n=16) and in women with normal pregnancies (n=36) in a nested case control study. Plasma concentrations were increased in women developing preeclampsia in gestational week 33 and 37 for S100B and in gestational week 37 for NSE compared to women with normal pregnancies. In Paper II and IV, increased plasma concentrations of S100B and NSE were confirmed among women with preeclampsia compared to women with normal pregnancies. Furthermore, increased plasma concentrations of S100B correlated to visual disturbances among women with preeclampsia (Paper II) and plasma concentrations of S100B and NSE remained increased among women with preeclampsia one year after delivery (Paper IV). In Paper V, an experimental rat model of preeclampsia and eclampsia demonstrated increased serum concentrations of S100B after seizures in normal pregnancy (n=5) and a tendency towards increased plasma concentrations of S100B in preeclampsia (n=5) compared to normal pregnancy (n=5) without seizures. Furthermore, after seizures, animals with magnesium sulphate treatment demonstrated increased serum concentrations of S100B and NSE compared to no treatment. In conclusion; plasma concentrations of S100B and NSE are increased in preeclampsia during late pregnancy and postpartum and S100B correlates to visual disturbances in women with preeclampsia. The findings are partly confirmed in an animal model of eclampsia.

Severe traumatic brain injury (sTBI) is a cause of death and disability worldwide and requires treatment at specialized neuro-intensive care units (NICU) with a multimodal monitoring approach. The CT scan imaging supports the monitoring and diagnostics. The level of S100B and neuron specific enolase (NSE) reflects the severity of the injury. The therapy resistant intracranial hypertension requires decompressive craniectomy (DC). After DC, the cranium must be reconstructed to recreate the normal intracranial physiology as well as to address cosmetic issues. The evolution of the pathological intracranial changes was analyzed in accordance with the three CT classifications: Marshall, Rotterdam and Morris-Marshall. The Rotterdam scale was best in describing the dynamics of the pathological evolution. Both the Rotterdam score and Morris- Marshall classification showed strong correlation with the clinical outcome, a finding that suggests that they could be used for prognostication. We demonstrated a clear correlation between the CT classifications and concentrations of S100B and NSE. The results revealed a concomitant correlation between NSE and S100B and clinical outcome. We found that the interaction between the ICP, Rotterdam CT classification, and concentrations of biochemical biomarkers are all associated with DC. We found a high percentage of complications following cranioplasty. Our results call into question whether custom-made allograft should be considered the best material for cranioplasty. It is concluded that both the Rotterdam and Morris-Marshall classification contribute to clinical evaluation of intracranial dynamics after sTBI, and might be used in combination with biochemical biomarkers for better assessment. The decision to perform DC should include a re-assesment of ICP evolution, CT scan images and concentration of the biochemical biomarkers. Furthermore, when determining whether DC treatment should be used, surgeon should also consider the risks of the following cranioplasty.

No description available.

Introdução: A fibromialgia (FM) é uma síndrome de dor crônica musculoesquelética difusa, cuja etiologia não está totalmente conhecida. A síndrome cursa com dor, alterações do humor e sintomas de ruptura do ritmo circadiano. Sabe-se que seu processo fisiopatogênico envolve um desbalanço entre os sistemas de modulação excitatório e inibitório da dor. A capacidade do sistema modulatório inibitório está enfraquecida, com hiperativação de neurônios e da neuroglia, constituindo um quadro de sensibilização central. Portanto, estudos adicionais são necessários para compreender a relação entre possíveis marcadores séricos da hiperativação neuronal, tais como o Brain Derived Neurotrophic Factor (BDNF) e a proteína S100 beta (S100B). Além disso, estudos que busquem opções terapêuticas com efeito em vias neurobiológicas alternativas, tais como a melatonina, uma indolamina com efeitos ressincronizador, analgésico, anti-inflamatório e em sistemas moduladores da dor, como o gabaérgico, opioidérgico e glutamatérgico. Objetivos: 1) Primário: Avaliar se os níveis séricos de BDNF e S100B teriam associação com a FM e se ambos os mediadores sorológicos poderiam ser associados com o limiar de dor à pressão. 2) Secundário: Testar o tratamento com melatonina isolada ou em combinação com amitriptilina é melhor que amitriptilina isolada para modificar o sistema modulatório da dor. Assim, para provar tais hipóteses, neste estudo foram quantificados a modulação condicionada da dor e níveis de BDNF sérico em pacientes que receberam tratamento com melatonina isolada ou associada com amitriptilina. Foi também testado se melatonina melhoraria os sintomas clínicos como dor, limiar de dor à pressão e qualidade do sono relacionado à FM. Métodos: Foram selecionadas pacientes com diagnóstico de FM de acordo com o American College of Rheumatology (ACR) 2010. No primeiro estudo, de desenho transversal, foram incluídas 56 mulheres com FM, com idades entre 18 e 65 anos. Foram avaliados o limiar de dor à pressão e dosagem sérica de BDNF e S100B. No segundo estudo, foram incluídas 63 pacientes com os mesmos critérios de inclusão descritos no estudo transversal. As pacientes foram randomizadas e receberam, ao deitar, amitriptilina (25mg) (n=21), melatonina (10mg) (n=21) ou melatonina (10 mg) + amitriptilina (25mg) (n=21), durante seis semanas. O sistema modulatório descendente da dor foi acessado pela modulação condicionada da dor, através da mensuração da escala numérica de dor (NPS(0-10)) durante aferição do limiar de dor ao calor. Resultados: O resultado do estudo transversal mostrou que BDNF e S100B séricos foram correlacionados. BDNF e S100B foram inversamente correlacionados com limiar de dor à pressão. BDNF sérico foi associado com limiar de dor à pressão, idade e transtorno obsessivo compulsivo, enquanto que S100B sérica foi apenas associada com limiar de dor à pressão. O ensaio clínico randomizado demonstrou que a melatonina aumentou a potência do sistema modulatório da dor inibitório e que a modulação condicionada da dor foi negativamente correlacionada com BDNF sérico. Conclusões: Os estudos desta tese demonstram que S100B e BDNF, ambos mediadores chave no processo de sensibilização central, foram inversamente correlacionados com o limiar de dor à pressão. BDNF sérico foi, ainda, inversamente correlacionado com a redução da dor. Portanto, a avaliação sérica de BDNF e S100B merece estudos adicionais para determinar seu potencial papel sinalizador no espectro da sensibilização central nessa doença. / Introduction: Fibromyalgia (FM) is a syndrome of chronic diffuse musculoskeletal pain whose etiology is not fully known. This syndrome causes pain, mood swings and symptoms of rupture of the circadian rhythm. Its pathophysiological process involves an imbalance between excitatory and inhibitory pain modulatory systems. The ability of inhibitory systems is weakened, providing a framework of central sensitization, with dysfunction in the descending pain modulatory system, hyper-activation of neurons and neuroglia. Therefore, additional studies are needed to understand the possible relationship between serum markers of neuronal hyperactivity, such as Brain Derived Neurotrophic Factor (BDNF) and S100B. Particularly, studies seeking therapeutic options with effect in neurobiological alternative pathways such as melatonin, a indolamine with resynchronization, analgesic, and anti-inflammatory effects and actions on the modulatory pain systems such as GABAergic, opiodergic and glutamatergic. Objectives: 1) Primary: Evaluate whether the serum levels of BDNF and S100B have association with FM and if both serological mediators could be associated with pressure pain threshold. 2) Secondary: To test the hypothesis that treatment with melatonin alone or in combination with amitriptyline is better than amitriptyline alone to modify the endogenous pain modulatory system. Thus, to prove these hypothesis, it was quantified the conditioned pain modulation and serum BDNF levels in FM patients receiving treatment with melatonin alone or in combination with amitriptyline. Also, it was tested whether melatonin would improve clinical symptoms such as pain, pressure pain threshold and quality of sleep related to FM. Methods: Patients with FM according to the American College of Rheumatology (ACR) 2010 were selected. In the first study, a cross-sectional design, 56 women aging 18-65 years old, with FM were included. It was evaluated the pressure pain threshold, and serum levels of BDNF and S100B. In the second study, 63 patients were included with the same inclusion criteria described in the cross-sectional study. Patients were randomized and received at bedtime amitriptyline (25 mg) (n = 21), melatonin (10 mg) (n = 21) or melatonin (10 mg) + amitriptyline (25 mg) (n = 21) for six weeks. The descending pain modulatory system was accessed by the conditioned pain modulation, measuring the numerical pain scale [NPS (0-10)] during the heat pain threshold. Results: On the cross-sectional study serum BDNF and S100B were correlated. Serum BDNF and S100B were correlated with the pressure pain threshold. Serum BDNF was associated with pressure pain threshold, age and obsessive compulsive disorder, while serum S100B was associated with pressure pain threshold, only. The randomized clinical trial showed that melatonin increased the efficacy of inhibitory pain modulatory system and the conditioned pain modulation was negatively correlated with serum BDNF. Conclusions: The studies of this thesis show that both key mediators of the central sensitization process, BDNF and S100B, were inversely correlated with the pressure pain threshold. They also showed that melatonin increased the inhibitory pain modutalory system. Furthermore, it emphasizes that serum BDNF was inversely correlated with pain reduction. Therefore, assessment of serum BDNF and S100B deserve further studies to determine their potential as a proxy for the central sensitization spectrum in FM.

Severe Traumatic Brain Injury (sTBI) is a major cause of mortality and morbidity. At the Department of Neurosurgery Umeå University Hospital subjects with sTBI are treated with an intracranial pressure (ICP) guided therapy based on physiological principles, aiming to optimise the microcirculation of the brain so avoiding secondary brain injuries. The investigations in this thesis are unique in the sense that all patients with sTBI were treated according to the guidelines of an ICP targeted therapy based on the “Lund concept”. As the treatment is based on normalisation of the ICP, the accuracy and reliability of the measuring device is of outmost importance. Therefore the accuracy, drift, and complications related to the measuring device was prospectively studied (n=128). The drift was 0,9 ± 0,2 mmHg during a mean of 7,2 ± 0,4 days and the accuracy high. No clinical significant complications were noted. In 1997 uni- or bilateral decompressive hemi-craniectomy (DC) was introduced into the treatment guidelines. The effect of DC on the ICP and outcome was retrospectively analysed for subjects with sTBI treated 1998-2001. In the subjects who underwent DC the ICP was 36,4 mmHg immediately before and 12,6 mmHg immediately after the DC. The ICP then levelled out at just above 20 mmHg. The ICP was significant lower during the 72 hours following DC. The outcome did not differ between subjects who had undergone DC or not. Subclinical electroencephalographic seizures and status epilepticus have been reported to be common in subjects treated for traumatic brain injury (TBI). This can negatively influence the outcome giving rise to secondary brain injuries. The occurrence of seizures in subjects treated for TBI using continuous EEG monitoring was therefore prospectively studied. During 7334 hours of EEG recording in 47 patients no electroencephalographic seizures were observed. Theoretically, and based on animal studies, prostacyclin (PGI2) can improve the microcirculation of the brain, decreasing the risk for secondary ischaemic brain injury. PGI2 was introduced to the treatment in a prospective randomised double blinded study (epoprostenol 0,5 ng/kg/min). The effect of PGI1 pkt was analysed using the lactate/pyruvate ratio (L/P) measured by cerebral microdialysis in order to study the energy metabolism in the brain. The outcome was measured as Glasgow Outcome Scale (GOS) at 3 months follow-up. Forty-eight subjects were included. The L/P was pathological high during the first day, thereafter decreasing. There was no significant difference in L/P or outcome between the treated and non-treated group. At 3 months the mortality was 12,5% (95,8% was discharged alive from the ICU), and favourable outcome (GOS 4-5) was 52%. In the same study the brain injury biomarkers S-100B and NSE were followed twice a day for five days to evaluate brain injury and investigate the possible use of these biomarkers for outcome prediction. Initially the biomarkers were elevated to pathological levels which decreased over time. The biomarkers were significant elevated in subjects with Glasgow Coma Scale 3 (GCS) and GOS 1 compared with subjects with GCS 4-8 and GOS 2–5, respectively. A correlation to outcome was found but this correlation could not be used to predict clinical outcome. It is concluded that the ICP measurements are valid and the treatment protocol is a safe and solid protocol, yielding among the best reported results in the world, in regard to favourable outcome as well as in regard to mortality. Epoprostenol in the given dose was not shown to have any effects on the microdialysis parameters nor the clinical outcome. In sTBI L/P and brain injury biomarkers can not be used to predict the final outcome.