Public health surveillance and incidence of adulthood Guillain-Barré syndrome in Spain, 1998-1999: the view from a sentinel network of neurologists

Temporal variation in Guillain-Barré syndrome (GBS) warrants monitoring in certain situations. This study sought to describe a public-health-based GBS surveillance service in Spain and conduct pilot surveillance in the period 1998-1999. Neurologists from 11 hospitals countrywide, serving a population of 3.9 million, reported all patients, ages 20 years or over, admitted to hospital with suspected GBS. Cases that did not belong to the designated hospital catchment area or failed to fulfill diagnostic criteria after follow- up were excluded. Reported monthly incidence was compared against predicted incidence obtained from retrospective data (1985-1997) using a reported method based on 97.5% percentile values. Alarm thresholds for 2000 onwards were obtained by applying the same method to the updated 1985-1999 series. During the 2-year period, 98 GBS cases were reported, yielding an overall age-adjusted incidence of 1.26 per 100 000 population, with a breakdown by sex of 1.83 for males and 0.76 for females. Monthly incidence remained below or was similar to the corresponding threshold limit value. Seasonality with highest incidence in winter was more pronounced in the elderly. Preceding events, mainly respiratory infections, were identified in 71% of patients. Pilot two-year GBS surveillance in Spain resulted neither in alarm nor in preventive measures. Adult GBS incidence in Spain might be monitored by a surveillance system set up at short notice when a possible threat is perceived. A monthly incidence of over 3 per 100 000 person-years in the population aged 20 years or older would exceed threshold values.

Corticosteroids, ibuprofen, and acetaminophen for IFN -1a flu symptoms in MS: A randomized trial

OBJECTIVE

To compare the efficacy of acetaminophen, ibuprofen, and prednisone in the treatment of interferon beta-1a (IFNbeta-1a) flu-like syndrome (FLS).

METHODS

Patients with relapsing-remitting multiple sclerosis initiating treatment with IM IFNbeta-1a were randomized in a multicenter, randomized, double-blind, controlled trial to receive acetaminophen 500 mg before and 6 and 12 hours after each injection, ibuprofen 400 mg before and 6 and 12 hours after each injection, or prednisone 60 mg daily for 1 week, plus tapering. Patients were instructed to keep a daily diary of fever severity, myalgia, chills, headache, and asthenia for 27 days. The sum of the scores of individual symptoms was used to obtain a daily FLS index. The primary outcome was the FLS index area under the curve (AUC) corrected by the number of measurement days.

RESULTS

Eighty-four patients were randomized at 11 hospitals: acetaminophen (n = 28), ibuprofen (n = 28), and corticosteroids (n = 28). No differences were detected between treatments in the mean AUC of the FLS index. With limitation of the analysis to the days of IM IFNbeta-1a injection, differences favoring ibuprofen were observed in the mean FLS index (p = 0.0007).

CONCLUSIONS

No prophylactic treatment for flu-like syndrome seems to be superior to another in terms of overall well-being during the first month of IM IFNbeta-1a therapy. However, ibuprofen confers better control of symptoms immediately following IM IFNbeta-1a injection.

Guillain-Barré syndrome in Spain, 1985-1997: epidemiological and public health views

Retrospective demographic information and hospital record data were collected for 337 patients resident in Spain who had validated Guillain-Barré syndrome (GBS) diagnoses and clinical onset during the period 1985-1997 and had been admitted to 11 centres, covering a population of 3.9 million. The European age-adjusted GBS incidence per 100,000 for 1985-1997 among the population aged 20 and over was 0.85, with a breakdown of 1.14 in men and 0.58 in women. Incidence increased with age and time, with occasional rises that mimicked outbreaks and occurred at irregular 2- to 4-year intervals, mainly in winter. Spatial variation was modest. Respiratory and gastrointestinal infections respectively constituted 49.3 and 19.3% of recorded preceding events. The 97.5% intercentile limit, obtained from the 1985-1997 monthly incidences using predictions from a Poisson model, was proposed as the threshold value for pilot epidemiological surveillance of GBS in 1998-1999.

Evaluation of handicap and socio-economic status in patients with multiple sclerosis--data from a population-based survey in the sanitary area of Calatayud, northern Spain

There are a few reports about handicap and socio-economic status in patients with multiple sclerosis (MS) based on epidemiological studies. The objective of our work is to evaluate handicap in patients with multiple sclerosis in the sanitary area of Calatayud, northern Spain, as well as the socio-economic situation--in comparison with patients from other parts off the world. In this study we included 34 patients with clinically definite MS found in a long-term and prospective population-based survey. For assessing the handicap degree and socio-economic status we used the Environmental Status Scale (ESS) recommended by the International Federation of MS. We compared the results with those found in 1116 patients from 7 different international series. The global mean score in ESS was 9.9 (sd 9.3, range 0-31). The mean score for the item "actual work status" was 3.3 (sd 2.3, range 0-5), for the item "financial/economic status" was 1 (sd 1.7, range 0-5), for the item "personal residence/home" was 0.8 (sd 1, range 0-4), for the item "personal assistance" was 1.2 (sd 1.7, range 0-5), for the item "transportation" was 1.5 (sd 1.7, range 0-5), for the item "community health services" was 0.7 (sd 1.3, range 0-5) and for "social activity" was 1.3 (sd 1.5, range 0-4). In the comparative assessment we found that our patients were better in all items, but in the item "actual work status" where our patients yielded higher scores than those obtained in other series. Socio-economic status measured with ESS correlates well with the degree of impairment measured with EDSS and it is more favourable than previously recognized, except for "actual work status" item. The high rate of labour incapacity in our series could be due to the considerable restrictions handicapped people have to cope with in order to find employment in rural areas.

[Hypoxic encephalopathy and cortical laminar necrosis]

INTRODUCTION

Cortical laminar necrosis is characterized by destruction of the cerebral cortex, mainly of the third layer, in situations of reduced energy supply to the brain. The cerebral lesions caused are known through studies made at autopsies, but there are few descriptions in the literature of the neuroimaging changes. We report the case of a patient who suffered hypoxic encephalopathy secondary to prolonged status epilepticus, and in whom cerebral MR showed changes compatible with cortical laminar necrosis.

CLINICAL CASE

A 16 year old girl who had been epileptic since infancy presented with a state of generalized tonic-clonic convulsions followed by coma. Three weeks later she was mute, had a blink reflect to threats and followed visual stimuli with eye movements but no voluntary motor or verbal response. She also showed generalized hypertonia and fine tremor of her arms, which she moved spontaneously with no asymmetry. After two months her clinical condition became stable. Cerebral MR at this time showed diffuse hypersignal of the cortex and basal ganglia in T2 and FLAIR sequences and hyposignal of the subcortical white matter associated with a marked hypersignal delimiting the grooves of convexity in T1 sequences.

CONCLUSIONS

Situations of prolonged hypoxia, such as in status epilepticus, lead to necrosis of layers of the cerebral cortex. Clinically this is seen as the appearance of hypoxic encephalopathy and radiologically as characteristic alterations of neuroimaging known as cortical laminar necrosis.

[Demyelinating pseudotumoral lesion prior to a primary cerebral lymphoma]

INTRODUCTION

Some case of demyelinating pseudotumoral lesions preceding the appearance of primary cerebral lymphoma have been reported. The relation between the two conditions is not known. We report the case of a woman in whom a demyelinating pseudotumoral lesion had been diagnosed on biopsy and who developed a primary cerebral lymphoma 13 months later.

CLINICAL CASE

In October 1997 a 38 year old woman presented with a secondarily generalized focal motor seizure. Neuroimaging showed a left frontal tumour with marked oedema and uptake of contrast medium. Based on the clinicoradiological suspicion of a primary cerebral tumour or metastasis, treatment was started with dexamethasone. Approximately two weeks later a stereotaxic biopsy was done, in which there was demyelination with conservation of the axons and perivascular inflammatory infiltration with polyclonal T and B lymphocytes. The diagnosis was 'a pseudotumoral form of a demyelinating disease'. Thirteen months later the patient had episodes of falling to the floor, followed by subsequent slight confusion and difficulty in speaking. On neuroimaging studies (cerebral CAT and MR) there was a tumour of the left basal ganglia, considerable oedema and homogeneous marking following the injection of contrast. Anatomopathological study of the lesion showed a B cell lymphoma.

CONCLUSION

In cases of pseudotumoral demyelinating lesions the possibility of a primary cerebral lymphoma of the central nervous system must be remembered.

Prevalence of multiple sclerosis in the sanitary district of Calatayud, Northern Spain: is Spain a zone of high risk for this disease?

We undertook an epidemiologic study to ascertain the prevalence of multiple sclerosis (MS) in the Sanitary District of Calatayud, in the north-east of Spain.

METHODS

The study was performed from October 1990 to July 1996. The total number of residents in the area was 58,591. An extensive search was carried out to identify all cases of known or suspected MS through general practitioners and specialists, sanitary authorities in the area, the reference hospital, the Spanish Multiple Sclerosis Society, the newspaper and radio.

RESULTS

April 1, 1995 was chosen as prevalence day. The crude prevalence rate for the area was 58 per 100,000 (95% CI: 39-78). The approximate annual incidence rate was 2.6/100,000 (1980-1989).

CONCLUSIONS

This study and others conducted recently in Spain show that MS is more prevalent than was previously thought and afflicts at least 53-65 per 100,000 population.

Neurological impairment in alpha-mannosidosis: a longitudinal clinical and MRI study of a brother and sister

Neurological development over a period of 25 years and MRI findings are reported in two members of the same family affected by mannosidosis type II. Progressive axial and appendicular cerebellar syndrome, moderate hearing loss and deterioration of gait were present in both patients. Neuropsychological deficiency was severe, but progression over the years was not observed except in the woman's speech capacity. Neither of the patients showed clinical improvement. A progressive corticosubcortical atrophy stands out in the brain neuroimaging studies, especially at the vermian cerebellar level. The osseous cranial deformities are very characteristic and include brachycephaly, thickening of the calvaria at the expense of the diploe, and poor pneumatization of the sphenoid. Neither of our cases showed an empty sella turcica.

[Severe polyneuropathy after using nitrous oxide as an anesthetic. A preventable disease?]

INTRODUCTION

Nitrous oxide is a commonly used anaesthetic agent. One complication of this is due to its capacity to inactivate cobalamin. Therefore, in patients with poor reserves of vitamin B12, neurological and hematological alterations may be induced after a short period of exposure to nitrous oxide.

CLINICAL CASE

A 69 year old man was anesthetized for three hours with 50% nitrous oxide during a surgical operation. Two weeks later he complained of severe mixed, mainly sensory polyneuropathy and was unable to walk. On diagnostic studies, vitamin B12 levels were found to be 18 pg/ml. The Shilling test confirmed that there was lack of intrinsic factor. In the preoperative studies a striking increase in motor conduction velocity was observed. Neurophysiological studies showed that there was mixed polyneuropathy, predominantly axonal. After starting treatment with hydroxycobalamin there was marked improvement and the patient became able to walk unaided.

CONCLUSION

Since nitrous oxide may cause serious neurological alterations in patients with subclinical deficits of cobalamin, which may not always be accompanied by hematological changes, we consider the need for determination of plasma levels of vitamin B12 and if possible, of methylmalonic acid and homocysteine in elderly patients who are to have general anesthetics involving nitrous oxide.

Prevalence of Parkinson's disease in lower Aragon, Spain

OBJECTIVE

We attempted to measure the prevalence of Parkinson's disease (PD) and to improve PD diagnosis in Lower Aragon (LA), a rural area located in northeast Spain with an elderly population numbering 60,724.

METHODS

Hospital records and a questionnaire targeted at general practitioners and retirement home personnel were used for case finding. Neurologic diagnoses were ascertained by a neurologist using a clinicoepidemiologic protocol and established diagnostic criteria after examining 84% of patients diagnosed with PD. Using stratified analysis, a comparison was run against reported PD prevalence from worldwide door-to-door surveys.

RESULTS

On the prevalence date, 134 individuals were found to be affected with PD. The prevalence per 100,000 population was 220.6 (crude) and 121.9 when age-adjusted using the European Standard Population. Prevalence increased with age, declining at 90 years and over. Questionnaires returned by general practitioners disclosed 20% of the prevalent PD cases. The prevalence of PD in pooled European populations was 2.56 times (95% confidence interval [CI]: 2.02-3.24) greater than that found in our study.

CONCLUSION

PD prevalence in Lower Aragon ranks at levels similar to those reported for white populations (European and non-European). One out of two individuals with PD was estimated to be undiagnosed before and three out of eight after the study.

Study of HLA as a predisposing factor and its possible influence on the outcome of multiple sclerosis in the sanitary district of Calatayud, northern Spain

The relationship between multiple sclerosis (MS) and the HLA antigens DR2 and DQ1 is well recognised, but, in Spain, it has not been clearly defined. The aim of our study was to investigate the relationship between MS and HLA antigens in the sanitary district of Calatayud, northern Spain, and to correlate these antigens with the progression of the disease. Thirty-four patients were selected from a long-term (October 1990 to July 1996) prospective survey in the region where there was a prevalence rate of 58 per 100,000 population. The HLA antigens were determined in 31 patients. A control group of 895 people of Caucasian race was recruited from the same population. We performed serologic tests on all participants. Nucleotide typing was carried out in DR2-positive patients. The most frequent antigens in excess in MS were: A19 (odds ratio, OR: 2.29, p = 0.04), B5 (OR: 2.85, p = 0.02), B41 (OR: 7.65, p = 0.04), CW7 (OR: 3.4, p = 0.004), DR6 (OR: 6.18, p = 0.0001) and DR10 (OR: 3.4, p = 0. 004). The DR2 antigen was also more frequent in MS patients (39%) than in controls (19%; OR: 2.69, p = 0.01). All positive DR2 patients showed the DR15(2) split but not the DR16(2) split. The frequency of antigens CW4 and DR1 was lower in MS patients than in controls. The CW4 antigen was detected in 12% of the patients and in 33% of the controls (OR: 0.28, p = 0.04). The DR1 antigen was found in 20% of the controls and in none of the MS patients (OR: undefined, p = 0.01). The DQ1 antigen was observed in 68% of the patients and in 50% of the controls (OR: 2.1, p = 0.07). We did not find any relationship between HLA antigens and progression of the disease. Although we found that DR2 antigen is linked to MS, we also found other antigens related to the disease. This suggests a genetic heterogeneity in our geographic area. We also concluded that the DR1 antigen may play a protective role, as it was detected in 20% of the controls and in none of the MS cases.

[Depression and Parkinson disease]

OBJECTIVE

Depression occurs more often in Parkinson's disease (PD) than in other chronic illnesses with important disability. The relationship between the depression level and some clinical features of PD remains controversial. Frequency of depression in these patients has been estimated and relationship between this symptom with some clinical features of PD.

METHODS

A diagnosis of PD was taken according to the United Kingdom Parkinson's Disease Society Brain Bank criteria. Depression status was rated with Geriatric Depression Scale (GDS).

RESULTS

Sixty-two patients (56%), 24 male and 38 female, were depressed at the time of study. The frequency of depression was higher in female (61% vs 39%, p < 0.05) and younger patients with a significant difference (p < 0.001). 53.4% of the patients became depressed previous of beginning PD symptoms, being 71% female (p < 0.05). Patients with depression had had PD longer than patients without depression (7.7 vs 5.3 years old, respectively; p < 0.05). Patients with depression were found to be more affected on motor rating scales (p < 0.01).

CONCLUSIONS

Depression was found in 56% of PD patients, with female predominance (61%). Frequency of depression was higher in younger patients. Depression was associated with duration of PD and an inverse relationship between depression and cognitive status was found.

[Cognition deterioration in Parkinson's disease: associated risk factors]

INTRODUCTION

Frequency estimation of dementia in Parkinson's disease (PD) has often been the source of controversy owing to variations in the case selection methods and diagnosis criteria used. We examined the frequency of dementia and differences found in some clinical features between PD patients with or without cognitive impairment, to determine the risk factors for incident dementia in PD patients.

METHODS

A diagnosis of PD was taken according to the United Kingdom Parkinson's Disease Society Brain Bank criteria. Subjects were considered as affected from cognitive impairment if Minimental State Examination score was below to 21.

RESULTS

Cognitive impairment was present in 36% of PD patients. The mean age was higher in PD patients with cognitive impairment (76 vs 69 years old, respectively; p < 0.001). The age onset of PD was higher in patients with cognitive impairment (68 vs 63 years old, respectively; p < 0.01). The rate of PD patients with low educational level were higher in patients with cognitive impairment (59 vs 30%, respectively; p < 0.01). Patients with cognitive impairment had higher rating scale score (p < 0.001).

CONCLUSIONS

Cognitive impairment was present in 36% of examined PD patients, based in our operative diagnostic criteria. The cognitive status decrease continuously with age. It's also evidence an inverse relation between educational level and rating scale score with cognitive impairment.

[Electro-clinical and neuroimaging studies in epilepsy in elderly patients]

INTRODUCTION

Due to the aging population in developed countries, epidemiological studies show an increasing tendency to the prevalence of epilepsy in the elderly.

PATIENTS AND METHODS

During 54 months, we have studied the electroclinical and neuroimaging features in outpatients older than 60, with active epilepsy. Every patient was interviewed by one of the authors. Then, we have reviewed the medical records about the clinical features, EEG and neuroimaging (NI) studies and seizures frequency (SF) outcome. Differences in crude proportions were assessed by chi 2 test for independence by 2 x 2 tables.

RESULTS

The study was been performed in 78 patients with 70.3 +/- 7.3 years of mean age at review. Partial seizures were significantly related with an higher SF at onset and, in the series of complex partial seizures was more frequent a temporal EEG topography. There was predominance of men, NI abnormal, symptomatic etiology and SF at onset > or = 1 by day in that patients who started their epilepsy after 60 years. A 51.3% was seizures-free in the last year and in 80% the SF was improved a 50% or more from the beginning.

CONCLUSION

A significantly greater percentage of patients remained with seizures in four cases: in those with a SF at onset greater than 1 every day, in those suffering complex partial seizures, in women and in patients with temporal EEG topography.

Brucellar spinal epidural abscess

Spinal epidural abscesses account for approximately one of every 10, 000 admissions to tertiary hospitals. The midthoracic vertebrae are the most frequently affected, whilst the cervical spine is involved in fewer patients. Staphylococcus aureus is identified as the cause in most cases of epidural abscess; other bacteria responsible include Gram-negative bacteria, Streptococcus species and Brucella species. We report the case of a patient with cervical spondylodiscitis at level C4-C5 and an epidural abscess which was compressing the spinal cord and the retropharyngeal space. The previous symptoms of brucellosis were atypical. We discuss the clinical manifestations, diagnosis, treatment and prognosis of the case.

[Polyneuropathy caused by vitamin B12 deficiency secondary to chronic atrophic gastritis and giardiasis]

INTRODUCTION

In chronic atrophic gastritis atrophy of the stomach glands leads to intrinsic factor deficit, with consequent failure to absorb vitamin B12 and gastric achylia, which predisposes to Giardia infection which in itself leads to depletion of vitamin B12. We describe the case of a patient with peripheral and central nervous system pathology due to lack of vitamin B12 secondary to the combined effect of these two disorders.

CLINICAL CASE

A 54 year old woman consulted us for paraesthesia and weakness of the legs which had been progressive for the previous two years. She presented with tactile hypoaesthesia, hypoparaesthesia, distal hyperreflexia and dysymmetry of the legs, ataxic-spastic gait and a positive Romberg sign. The investigations carried out showed the serum vitamin B12 level to be 3 pg/ml (N: 180-900), hemoglobin 13 g/dl and MCV 111 fl with MCHC 348/dl; neurophysiological studies: compatible with demyelinating motor polyneuropathy. Schilling test: deficit of absorption of vitamin B12 which was corrected on administration of intrinsic factor; gastroscopy; atrophic gastritis which confirmed the morbid anatomy findings. There was also flora containing Helicobacter and massive Giardia infection. Replacement and antibiotic therapy was followed by complete remission of the clinical picture.

CONCLUSION

We emphasize the excellent clinical response to treatment in spite of the time elapsed since onset of symptoms.

[Ocular myasthenia: clinical course and strategies for treatment]

INTRODUCTION

Ocular myasthenia gravis is a localized form of myasthenia in which only the extra-ocular muscles are clinically affected, namely the levator palpebrae superioris and orbicularis oculi. Two years after onset of the ocular condition, it became generalized in 44-53% of the patients.

OBJECTIVE

1. To describe the clinical features, diagnostic characteristics and clinical course of seven patients who fulfilled the criteria for diagnosis of ocular myasthenia and in whom the condition did not become generalized: 2. Review recent papers on this. Material and methods. We studied seven patients (two men and two women) diagnosed as having ocular myasthenia gravis, and followed them up for at least three years.

RESULTS

The average age was 56.5. The clinical findings were of ptosis of the eyelids and diplopia. All seven patients were treated with pyridostigmine. In six cases prednisone was also given and in one patient thymectomy was done. There was a satisfactory result in all cases.

CONCLUSIONS

The basic treatment of ocular myasthenia is with anticholinesterases and corticosteroids. Occasionally other immunosuppressives may be required. Prednisone seems to reduce the number of patients who go on to develop the generalized form.

[Determining factors in decisions regarding cardio-pulmonary resuscitation in patients with cerebral hemorrhage]

INTRODUCTION AND OBJECTIVE

Some medical factors related with cardiopulmonary resuscitation (CPR) outcome are known. Moreover, there are other factors, not strictly medical ones, as age, gender, race and socioeconomic status, that influence on decisions of CPR. The aim of this study was to analyse the influence of all this factors on in-hospital CPR of the patients with intracerebral hemorrhage.

MATERIAL AND METHODS

This retrospective study comprised all the consecutive patients hospitalized with spontaneous intracerebral hemorrhage who died within 30 days of hospital admission in a public hospital during the period 1987-1994. We used stepwise logistic regression to identify variables that had a significant independent relation with decision of CPR.

RESULTS

We identified 73 patients, 50 men and 23 women. Their mean age was 61 years. RCP was performed in 25 patients (34%). A logistic regression revealed that age (OR 0.8), Glasgow score on admission (OR 0.67) and time of death (OR 1.2) were significantly associated with CPR decision.

CONCLUSIONS

CPR was less probable in aged even though they had better level of consciousness on admission. Moreover, CPR was less probable early in the morning.