Clinical utility of a personalized and long-term monitoring device for Parkinson's disease in a real clinical practice setting: An expert opinion survey on STAT-ON™

BACKGROUND

STAT-ON™ is an objective tool that registers ON-OFF fluctuations making possible to know the state of the patient at every moment of the day in normal life. Our aim was to analyze the opinion of different Parkinson's disease experts about the STAT-ON™ tool after using the device in a real clinical practice setting (RCPS).

METHODS

STAT-ON™ was provided by the Company Sense4Care to Spanish neurologists for using it in a RCPS. Each neurologist had the device for at least three months and could use it in PD patients at his/her own discretion. In February 2020, a survey with 30 questions was sent to all participants.

RESULTS

Two thirds of neurologists (53.8% females; mean age 44.9±9 years old) worked in a Movement Disorders Unit, the average experience in PD was 16±6.9 years, and 40.7% of them had previously used other devices. A total of 119 evaluations were performed in 114 patients (range 2-9 by neurologist; mean 4.5±2.3). STAT-ON™ was considered "quite" to "very useful" by 74% of the neurologists with an overall opinion of 6.9±1.7 (0, worst; 10, best). STAT-ON™ was considered better than diaries by 70.3% of neurologists and a useful tool for the identification of patients with advanced PD by 81.5%. Proper identification of freezing of gait episodes and falls were frequent limitations reported.

CONCLUSION

STAT-ON™ could be a useful device for using in PD patients in clinical practice.

Clinical utility of a personalized and long-term monitoring device for Parkinson's disease in a real clinical practice setting: An expert opinion survey on STAT-ON™

BACKGROUND

STAT-ON™ is an objective tool that registers ON-OFF fluctuations making possible to know the state of the patient at every moment of the day in normal life. Our aim was to analyze the opinion of different Parkinson's disease experts about the STAT-ON™ tool after using the device in a real clinical practice setting (RCPS).

METHODS

STAT-ON™ was provided by the Company Sense4Care to Spanish neurologists for using it in a RCPS. Each neurologist had the device for at least three months and could use it in PD patients at his/her own discretion. In February 2020, a survey with 30 questions was sent to all participants.

RESULTS

Two thirds of neurologists (53.8% females; mean age 44.9±9 years old) worked in a Movement Disorders Unit, the average experience in PD was 16±6.9 years, and 40.7% of them had previously used other devices. A total of 119 evaluations were performed in 114 patients (range 2-9 by neurologist; mean 4.5±2.3). STAT-ON™ was considered "quite" to "very useful" by 74% of the neurologists with an overall opinion of 6.9±1.7 (0, worst; 10, best). STAT-ON™ was considered better than diaries by 70.3% of neurologists and a useful tool for the identification of patients with advanced PD by 81.5%. Proper identification of freezing of gait episodes and falls were frequent limitations reported.

CONCLUSION

STAT-ON™ could be a useful device for using in PD patients in clinical practice.

[Clinical experience in the treatment of motor fluctuations in Parkinson's disease. Delphi consensus of a group of experts in movement disorders]

INTRODUCTION

Motor fluctuations are one of the most common complications of Parkinson's disease and their treatment is still a complex matter. Therefore, from the Neurology Movement Disorders Group we present our clinical experience in the treatment of these complications, with the intention of it being useful in decision-making in daily clinical practice.

DEVELOPMENT

Nineteen questions were developed based on a literature review and an open survey answered by members of this group. These issues were discussed in two phases, using the Delphi methodology. Considering the results of the survey, levodopa dose adjustment and dopamine agonists are the option with the best efficacy/tolerability ratio in the treatment of motor fluctuations. Rotigotine is useful in the motor fluctuations associated with gastroparesis, and intermittent subcutaneous apomorphine has positive effects in patients with unpredictable off periods. The most relevant adverse effect associated with dopamine agonists is impulse control disorder. Catechol-O-methyltransferase inhibitors are useful in the initial stages of motor fluctuations, especially in wearing off. Monoamine oxidase inhibitors are generally drugs that are well-tolerated and useful in motor fluctuations. If these measures are not effective, second-line treatments should be indicated on a case-by-case basis.

CONCLUSION

The clinical profile of patients with Parkinson's disease is paramount in deciding the most appropriate therapy for the treatment of motor fluctuations.

Eurados review of retrospective dosimetry techniques for internal exposures to ionising radiation and their applications

This work presents an overview of the applications of retrospective dosimetry techniques in case of incorporation of radionuclides. The fact that internal exposures are characterized by a spatially inhomogeneous irradiation of the body, which is potentially prolonged over large periods and variable over time, is particularly problematic for biological and electron paramagnetic resonance (EPR) dosimetry methods when compared with external exposures. The paper gives initially specific information about internal dosimetry methods, the most common cytogenetic techniques used in biological dosimetry and EPR dosimetry applied to tooth enamel. Based on real-case scenarios, dose estimates obtained from bioassay data as well as with biological and/or EPR dosimetry are compared and critically discussed. In most of the scenarios presented, concomitant external exposures were responsible for the greater portion of the received dose. As no assay is available which can discriminate between radiation of different types and different LETs on the basis of the type of damage induced, it is not possible to infer from these studies specific conclusions valid for incorporated radionuclides alone. The biological dosimetry assays and EPR techniques proved to be most applicable in cases when the radionuclides are almost homogeneously distributed in the body. No compelling evidence was obtained in other cases of extremely inhomogeneous distribution. Retrospective dosimetry needs to be optimized and further developed in order to be able to deal with real exposure cases, where a mixture of both external and internal exposures will be encountered most of the times.

Real-life data in 115 chronic migraine patients treated with Onabotulinumtoxin A during more than one year

Background

OnabotulinumtoxinA (OnabotA) is effective in Chronic Migraine (CM) during first year of treatment and longer. In real clinical setting, CM patients with acute Medication Overuse (MO) or concurrently receiving oral preventatives are treated with OnabotA. We aim to assess evolution of CM patients beyond first year on OnabotA.

Methods

Data were retrospectively collected in three headache units. We analyzed cases who had received at least five sessions of OnabotA according to PREEMPT protocol. We continued OnabotA therapy when a reduction of number of headache days of at least 30% was achieved.

Results

We included 115 patients (98 females, 17 males) who completed 7.6 ± 2.3 (5–13) OnabotA procedures. Previously they had not responded to topiramate and, at least, one other preventative. Age at inclusion was 45.3 ± 12 (14–74) years, and latency between CM onset and OnabotA therapy was 43.1 ± 38.2 (6–166) months. At first OnabotA session 92 patients (80%) fulfilled MO criteria and 107 (93%) received a concurrent oral preventative. In 42 cases (36.5%) OnabotA dose was increased over 155 units. After first year in 57 out of 92 patients (61.9%) MO was discontinued. Among those receiving preventatives, in 52 out of 107 they were retired (48.6%). In 22 cases (19.1%) OnabotA administration was delayed to the fourth or fifth month and in 12 (10.4%) it was temporally stopped. Finally, in 18 patients (15.7%) OnabotA was discontinued due to lack of efficacy beyond first year of treatment.

Conclusion

Our results suggest that discontinuation of acute medication overuse and oral preventive therapies are achievable objectives in long-term using of OnabotA in CM patients.

SECOND LATIN AMERICAN INTERCOMPARISON ON INTERNAL DOSE ASSESSMENT

Internal dosimetry intercomparisons are essential for the verification of applied models and the consistency of results'. To that aim, the First Regional Intercomparison was organised in 2005, and that results led to the Second Regional Intercomparison Exercise in 2013, which was organised in the frame of the RLA 9/066 and coordinated by Autoridad Regulatoria Nuclear of Argentina. Four simulated cases covering intakes of (131)I, (137)Cs and Tritium were proposed. Ninteen centres from thirteen different countries participated in this exercise. This paper analyses the participants' results in this second exercise in order to test their skills and acquired knowledge, particularly in the application of the IDEAS Guidelines. It is important to highlight the increased number of countries that participated in this exercise compared with the first one and, furthermore, the improvement in the overall performance. The impact of the International Atomic Energy Agency (IAEA) Projects since 2003 has led to a significant enhancement of internal dosimetry capabilities that strengthen the radiation protection of workers.

Preoperative estimated glomerular filtration rate and the risk of major adverse cardiovascular and cerebrovascular events in non-cardiac surgery

BACKGROUND

Chronic kidney disease is an independent predictor of perioperative cardiovascular morbidity and mortality. We analysed the preoperative estimated glomerular filtration rate (eGFR) as a risk factor for perioperative major adverse cardiovascular and cerebrovascular events (MACCE) in non-cardiac surgery.

METHODS

In a post hoc analysis of the ANESCARDIOCAT database, patients were classified into six stages of eGFR calculated with the abbreviated Modification of Diet in Renal Disease Study and the Chronic Kidney Disease Epidemiology Collaboration equations: >90 (1), 60-89.9 (2), 45-59.9 (3a), 30-44.9 (3b), 15-29.9 (4), and <15 (5) ml min(-1) 1.73 m(-2). We analysed differences in MACCE, length of hospital stay, and all-cause mortality between eGFR stages.

RESULTS

The eGFR was available in 2323 patients. Perioperative MACCE occurred in 4.5% of patients and cardiac-related mortality was 0.5%. Five hundred and forty-three (23.4%) patients had an eGFR of <60 ml min(-1) 1.73 m(-2) and 127 (5.4%) had an eGFR below 45 ml min(-1) 1.73 m(-2). Logistic regression analysis showed that MACCE increased with eGFR impairment (P<0.001), with a marked increase from stage 3b onwards (odds ratio 1.8 vs 3.9 in 3a and 3b, respectively, P=0.047). All-cause mortality was not related to eGFR (P=0.071), but increased substantially between stages 3b and 4. The length of stay correlated with eGFR (P<0.001).

CONCLUSIONS

Perioperative MACCE increase with declining eGFR, primarily when <45 ml min(-1) 1.73 m(-2). We recommend the use of preoperative eGFR for cardiovascular risk assessment.

Growth performance of immunologically castrated (with Improvest) barrows (with or without ractopamine) compared to gilt, physically castrated barrow, and intact male pigs

The study used a randomized complete block design (blocking factor was date of start on test) with 5 treatments: 1) physically castrated barrows (PC), 2) intact males (IM), 3) gilts (G), 4) immunologically castrated barrows (IC), and 5) immunologically castrated barrows fed ractopamine at 5 mg/kg (IC+RAC). The study used 192 pigs and was performed from the 16 wk of age (67.2 ± 2.52 kg BW) to a pen mean BW of 132.5 ± 3.60 kg. For IC+RAC, ractopamine was fed for the final 23 d of the study. Pigs were housed in groups of 4 (10 groups for PC, IM, G, and IC and 8 groups for IC+RAC) in a finishing building at a floor space of 1.18 m(2)/pig. Diets were formulated to meet requirements of IM except that the diet for the IC+RAC fed during the ractopamine feeding period was formulated to meet requirements of pigs on that treatment. Pigs had ad libitum access to feed and water throughout the study period and were individually weighed at the start, wk 2 and 4, and subsequently every week until the end of study. For the overall study period, IC had greater (P ≤ 0.05) ADG than the other genders (1,150, 1,024, 1,064, and 954 g/d for IC, PC, IM, and G, respectively; SEM = 25.8) and required fewer days to reach slaughter weight than the other genders (58.1, 61.6, 61.6, and 66.5 d for IC, PC, IM, and G, respectively; SEM = 1.26). Overall ADFI was less (P ≤ 0.05) for IM and G than IC and PC, which were similar (P > 0.05) in this respect (3.11, 3.06, 2.68, and 2.75 kg/d for IC, PC, IM, and G, respectively; SEM = 0.061). Overall G:F was greater (P ≤ 0.05) for IM than the other genders; IC had greater overall G:F than PC and G, which were similar in this respect (0.371, 0.335, 0.397, and 0.347 kg/kg for IC, PC, IM, and G, respectively; SEM = 0.0068). Immunologically castrated barrows had greater (P ≤ 0.05) ADG (30.7%) and ADFI (22.5%) than PC from the second week following the second Improvest dose to the end of the study. During the ractopamine feeding period, IC+RAC had greater (P ≤ 0.05) ADG (11.6%) and G:F (17.3%) than IC. The results of this study confirmed previously observed gender differences and effects of ractopamine on growth performance and that IC grew faster and had greater feed efficiency than PC during the study period.

Utility of Histoscanning™ prior to prostate biopsy for the diagnosis of prostate adenocarcinoma

OBJECTIVES

HistoScanning™ (HS) is a method of ecographic diagnosis of prostate cancer. We analyze the effectiveness of the HS realization prior to the biopsies for the prostate adenocarcinoma diagnosis.

MATERIAL AND METHODS

From August to October 2012 we have carried out a study with HS prior to the biopsies in 32 patients. In all cases sextants transrectal biopsies have been realized (two cores in each sextant) in the periphery zone. In those sextants in which there were suspicious areas with HS, the biopsies were addressed to those areas. Transperineal biopsies were added to those zones placed in the half-front or apical prostatic zone. The medium age was 63.7 years (range 40-82) with a medium PSA of 8.0 ng/ml (range 3.5-36.2) and a medium prostatic volume of 46.6cc (range 18.2-103.2). In eight cases it was the first biopsy, in 14 cases they were repetition biopsies and 10 patients had a previous diagnosis of prostate adenocarcinoma (8 in a program of active surveillance and 2 T1a in RTU of previous prostate).

RESULTS

In the 32 patients a medium of 7,5 zones were biopsied (range 6-9) with a total of 239 zones studied. There were identified a medium of 3.2 zones with suspicious areas (ZS) with HS (range 2-5) with a total of 103 ZS. In 72 zones of 25 patients it was found adenocarcinoma or PIN (2 PIN, 11 score Gleason 6, 7 score Gleason 7, 3 score Gleason 8 and 2 score Gleason 9). There were 35 positive false zones in 20 patients (11 normal parenquima and 9 chronic inflammation). Negative falses were produced in 5 zones in 5 patients (2PIN, 2 score Gleason 6 and 1 score Gleason 7) although in all 5 cases adenocarcinoma was encountered (o discovered) in other zones. The HS presented a sensibility of a 93.5% with a specificity of 79.5%. The positive predictive value was of the 67.35% with a negative predictive value of 96.5%.

CONCLUSIONS

In spite of being a selected serie, with a high rate of patients with adenocarcinoma, the exploration with HS has presented a great sensibility and a high negative predictive value. These data, although they must be confirmed in less selected series, state that the prior exploration with HS can help as in the diagnostic in the biopsies as in the follow-up of programs of active surveillance.

Analysis of coenzyme Q(10) in lymphocytes by HPLC-MS/MS

Coenzyme Q(10) (CoQ(10)) deficiency syndromes are potentially treatable disorders. Skeletal muscle is the most widely accepted tissue for their study, but sampling is an invasive procedure. Cultured skin fibroblasts seem to improve the biochemical diagnosis, but their growth requires a certain period of time. Our aim was to set up a minimally invasive, fast and reliable analytical procedure to measure CoQ(10) in lymphocytes, to prevent any delay in diagnosing primary CoQ(10) deficiency. HPLC-MS/MS analysis of CoQ(10) showed high sensitivity and specificity. The reference range was established in apparently healthy volunteers (n=33); the mean of CoQ(10) in lymphocytes was 107nmol/g protein (95% confidence interval: 105-120) and 2.0nmol/UCS (95% confidence interval: 2.06-2.46). Therefore, the range was narrower when normalized to units of citrate synthase (UCS) than when normalized to grams of protein. The method was linear from 0.01 to 1μM with a good precision and sensitivity (limit of quantification 0.01μM). Intra-assay and inter-assay coefficients of variation were lower than 13%. Recovery was higher than 95%. In our hands, lymphocytes seem to be a reliable matrix as they reflect intracellular content of CoQ(10). In addition, they can be obtained by a minimally invasive procedure (venipuncture).

Prospective transGEICAM study of the impact of the 21-gene Recurrence Score assay and traditional clinicopathological factors on adjuvant clinical decision making in women with estrogen receptor-positive (ER+) node-negative breast cancer

BACKGROUND

This study examined the impact of the Recurrence Score (RS) in Spanish breast cancer patients and explored the associations between clinicopathological markers and likelihood of change in treatment recommendations.

PATIENTS AND METHODS

Enrollment was offered consecutively to eligible women with estrogen receptor-positive; human epidermal growth factor receptor 2-negative, node-negative breast cancer. Oncologists recorded treatment recommendation and confidence in it before and after knowing the patient's RS.

RESULTS

Treatment recommendation changed in 32% of 107 patients enrolled: in 21% from chemohormonal (CHT) to hormonal therapy (HT) and in 11% from HT to CHT. RS was associated with the likelihood of change from HT to CHT (P < 0.001) and from CHT to HT (P < 0.001). Confidence of oncologists in treatment recommendations increased for 60% of cases. Higher tumor grade (P = 0.007) and a high proliferative index (Ki-67) (P = 0.023) were significantly associated with a greater chance of changing from HT to CHT, while positive progesterone receptor status (P = 0.002) with a greater probability of changing from CHT to HT.

CONCLUSIONS

Results from the first prospective European study are consistent with published experience and use of the RS as proposed in European clinical practice guidelines and provide evidence on how Oncotype DX and clinicopathological factors are complementary and patient selection may be improved.

Efficacy and safety of pallidal stimulation in primary dystonia: results of the Spanish multicentric study

BACKGROUND

Dystonia is a complex clinical syndrome originated by a wide range of aetiologies. The diagnosis of dystonia is made after the evaluation of aetiological, phenomenological and genetic factors. Medications, except in patients with dopa-responsive dystonia, are of limited efficacy. Botulinum toxin injections are not applicable to patients with generalised dystonia, since many muscular groups contribute to disability. Clinical studies in children and adults with primary generalised dystonia (PGD) have reported beneficial effects of bilateral GPi deep brain stimulation (DBS) in both motor symptoms and disability produced by dystonia as well as a favourable impact of DBS in the health-related quality of life (HRQoL). Some clinical aspects of GPi stimulation in primary dystonia still remain controversial such as the influence of disease duration or age at onset in determining the postoperative clinical outcome.

RESULTS

The authors report the results of a multicentric study designed to assess the tolerability and clinical effects of bilateral pallidal DBS on motor impairment, functional disability, quality of life, pain and mood in patients with medically refractory primary generalised or segmental dystonia.

Lutetium-177-EDTMP for bone pain palliation. Preparation, biodistribution and pre-clinical studies

Beta emitting radionuclides have demonstrated excellent properties for radionuclide endotherapy using appropriate carrier molecules. In an effort to search for alternative radionuclides, the preparation of 177Lu-EDTMP was undertaken, as a palliative agent for bone metastasis. Natural Lu2O3 was irradiated at the RA-3 Nuclear Reactor of the Ezeiza Atomic Center (Argentina). The optimum molar ratio of Lu:EDTMP, the radiochemical purity, the in vivo and in vitro stability and the biological behaviour in Wistar rats and New Zealand rabbits were studied. The results indicate that an excellent alternative therapeutic radiopharmaceutical, with comparable characteristics as its 153Sm-EDTMP counterpart, was successfully achieved.

[The value of genetic and neuroimaging studies in the differential diagnosis of Parkinson's disease]

INTRODUCTION

Parkinson's disease (PD) is usually diagnosed on the basis of clinical criteria. Today there are genetic and neuroimaging tests that can make a valuable contribution to the study of this disease.

AIMS

To review the recent advances in genetic studies and in neuroimaging techniques applied to PD, as well as looking at their shortcomings, and to analyse the reasons for conducting such tests and to discuss their importance in everyday clinical practice, including a series of reflections on ethical issues.

DEVELOPMENT

The list of genetic disorders associated with PD is continually being extended and reviewed, and pathological alterations have been defined in at least 10 genes. The most frequent mutations in our setting are to be found in the parkin gene (PARK2) and in the LRKK2 gene (PARK8). These mutations have a penetrance that is not very high and their clinical expression is variable. Images obtained by nuclear resonance, single-photon emission tomography, positron emission tomography or by cranial sonography provide data that can help in the diagnosis of PD and to differentiate it from other diseases. None of the techniques is wholly specific, however, and there are clinico-radiological disagreements.

CONCLUSIONS

The detection of mutations does not allow a clear prognostic differentiation or a distinct therapeutic attitude to be established. The value of neuroimaging techniques in very early phases and in dubious cases is still not altogether clear. Whether establishing a diagnosis in very early phases currently offers the patient any benefits is subject to debate. It would be advisable to attempt to distinguish between tests that are carried out for clinical reasons and those which are conducted for research purposes so as to be able to proceed in the most suitable manner.

[Usefulness of activated recombinant factor VII for controlling massive bleeding: 4 years' experience in a university hospital]

OBJECTIVE

Massive bleeding that cannot be controlled by the usual means, such as transfusion, is a serious medical problem with high associated mortality. Our aim was to assess the efficacy and safety of treatment with activated recombinant factor VII (rFVIIa) to control massive bleeding after the failure of other methods.

PATIENTS AND METHODS

This was a retrospective study of all cases of rFVIIa-treated massive bleeding in patients without a history of coagulation disorder from January 2003 through June 2007.

RESULTS

The prevalence of rFVIIa treatment for this indication was 1 in 5200 hospitalized patients. Thirty patients were treated. Bleeding was reduced or stopped in 80% and consumption of blood products was reduced after administration of rFVIIa. Mortality was 43% and death was due to continued bleeding in 5 cases. No deaths were due to thromboembolism.

CONCLUSIONS

rFVIIa is efficacious for controlling bleeding and reducing transfusion requirements in cases of massive hemorrhage, but mortality unrelated to bleeding is high in patients experiencing this complication. Further study is needed to better assess the utility, dosing, and ideal timing in the use of this drug.

Harmonization of internal dosimetry procedures in Latin America--ARCAL/IAEA project

Under the auspices of the Regional Coordination Agreement for Latin America, representatives of the eight member states have participated in a project to improve radiological protection for workers exposed to unsealed sources of radiation. The design of the project was based on information obtained from a questionnaire circulated among the participants, from which the initial status of internal dosimetry services in each country was characterised. The objective of the project is to harmonize internal dosimetry procedures, with reference to International Atomic Energy Agency recommendations. After the implementation of new procedures and personnel training, four intercomparison exercises were carried out: measurement of iodine in thyroid phantoms, measurement of gamma emitters in urine samples, measurement of beta emitters in urine samples and internal dose assessments. This project has resulted in important improvements in internal dosimetry services in the region.

[A pilot study on a specific measure for sleep disorders in Parkinson's disease: SCOPA-Sleep]

INTRODUCTION

There is a high prevalence of sleep disorders in Parkinson's disease (PD). AIMS. To assess some basic metric attributes of the SCOPA-Sleep scale, a measure for PD patients; secondary objective: to check the impact caused by the sleep disorder on the health-related quality of life (HRQoL) of patients and their caregivers.

SUBJECTS AND METHODS

68 PD patients and their main caregivers; measures: Hoehn and Yahr staging, SCOPA-Motor, Clinical Impression of Severity Index (CISI-PD), PDSS, Hospital Anxiety and Depression Scale, SCOPA-Psychosocial, and EuroQoL. Carers filled in a PDSS questionnaire about patient sleep and HRQoL measures (SF-36, EuroQoL). SCOPA-Sleep acceptability, scaling assumptions, internal consistency, construct validity and precision were determined.

RESULTS

SCOPA-Sleep acceptability and scaling assumptions resulted satisfactory, although the nocturnal sleep subescale (SC-Ns) showed a mild ceiling effect (22.1%) and a defective convergent validity was found for daytime sleepiness (SC-Ds) item 6. Internal consistency also was satisfactory for both scales (alpha = 0.84 and 0.75, respectively). The correlation between SC-Ns and PDSS was high (rs = -0.70), as it was between SC-Ns and PDSS questionnaire by caregiver (rs = -0.53). The corresponding coefficients with the SC-Ds gained lower values (rs = -0.41 y -0.50). Standard error of measurement was 1.45 for the SC-Ns and 1.76 for the SC-Ds. Both, patient and caregiver HRQoL showed a loose association with the sleep measures.

CONCLUSION

SCOPA-Sleep is a feasible, consistent, and useful scale for assessment of sleep disorder in PD patients. A weak association between sleep disorder and HRQoL was found.

NARP-MILS syndrome caused by 8993 T>G mitochondrial DNA mutation: a clinical, genetic and neuropathological study

The 8993 T>G mutation in mitochondrial DNA has been associated with variable syndromes of differing severity ranging from maternally inherited Leigh's syndrome (MILS) to neuropathy, ataxia, retinitis pigmentosa (NARP), depending on the mutation loads in affected patients. We report a kindred with several members in the same generation suffering NARP or Leigh's syndrome due to a 8993 T>G mutation. Post-mortem studies of the brain in one affected member clinically presenting with a neurological disorder intermediate between adult Leigh's syndrome and NARP showed symmetrical lesions of the basal ganglia and brainstem closely resembling those usually described in typical Leigh's syndrome. Analysis of mtDNA in different tissues showed a high proportion of mutant genome in brainstem, cerebral cortex, putamen, cerebellum and thalamus. These observations illustrate the continuum of clinical and neuropathological manifestations associated with the 8993 T>G mutation of the mtDNA.

Spinocerebellar ataxia type 2 (SCA2) with white matter involvement

Two sisters presented with olivopontocerebellar atrophy, neuronal loss in the substantia nigra, intranuclear ubiquitin-, ataxin-2-positive inclusions in neurons, and severe demyelination and axon loss of the cerebral white matter with no accompanying inflammatory pathology. The genetic study demonstrated a 22/36 CAG triplet expansion in the SCA2 gene in one of the sisters; SCA1, SCA3, SCA6, SCA7, SCA8, SCA12, SCA17 and DRPL were ruled out in this patient. The present report shows that severe cerebral white matter pathology may occur in the context of SCA2.

[Freezing of gait or freezing of quadruped gait]

Parkinson's disease (PD) is frequently associated with freezing of gait. Patients with advanced PD learn to use tricks to relieve freezing of gait. Recently one of our patients informed us that he could overcome freezing of gait by crawling. Since crawling is a sort of quadruped gait that humans develop transiently, we wondered whether quadruped gait is preserved in PD. We recruited 16 patients with PD who had frequent and disabling freezing of gait. Under experimental conditions, after 12 hours without medication, seven patients developed biped freezing of gait. Of these seven patients, only two patients (the patients with the most severe freezing) also developed quadruped freezing of gait. This experiment suggests that bipedal gait is affected early in PD, while quadruped gait is preserved until late in this disease.

Depression in Parkinson's disease: clinical correlates and outcome

Depression has been shown to be more common in Parkinson's disease (PD) than in other chronic and disabling disorders. Neurochemical and functional disturbances are important etiopathogenic factors. The prevalence and clinical features associated with depression in PD remain controversial. The purpose of this study is to estimate the prevalence of depressive symptoms in our patients, as related to other clinical data, and to assess clinical outcomes of these symptoms. A series of PD patients were evaluated over a 9-year period, using the Unified Parkinson's Disease Rating Scale (UPDRS), Hoehn and Yahr stage (HY), Schwab and England Scale (SE), Mini-Mental State Examination (MMSE), and Yesavage Geriatric Depression Scale (GDS). Presence of depressive symptoms was considered if GDS score was higher than 10: mild-moderate (MD) for GDS scores between 11 and 20 and moderate-severe (SD) for GDS scores greater than 20. Three hundred and fifty-three patients were included in this study and additional follow up information was obtained for 184 patients. MD and SD were found in 40.2 and 16.7% of PD patients, respectively. Female gender, high HY, high UPDRS total and subtotal, and low MMSE and SE scores were significantly associated with depressive symptoms. According to changes in GDS score, 34% of patients remained stable, 35% showed an improvement, and 30.9% worsened in the follow up study. Gender, age, age of onset, HY, UPDRS, and PD duration are not related to depression outcome.

The importance of educational and psychological factors in Parkinson's disease quality of life

OBJECTIVE

To define the factors correlated with quality of life (QoL) in patients with idiopathic Parkinson's disease (PD).

BACKGROUND

PD has a substantial impact on QoL. Although several clinical factors have been associated with QoL in PD, the influence of patient's education still remains controversial.

METHODOLOGY

A consecutive series of patients with PD were examined using the unified Parkinson's Disease Rating Scale (UPDRS part I, II, III), Schwab and England (SE), and Hoehn and Yahr stage (H&Y). QoL was rated with the PDQ-39, cognition with the Mini-Mental State examination (MMSE), and the presence of depressive symptoms with the geriatric depression scale (GDS). Patient's characteristics, estimated cumulative levodopa dose (CLD), UPDRS, H&Y, MMSE and GDS were correlated with the PDQ-39 using univariate and multiple regression analysis.

RESULTS

A total of one hundred 58 patients (68 men, 90 women) with a mean age of 65.6 +/- 9.3 years, PD duration of 8.1 +/- 10.6 years, and education of 6.6 +/- 3.9 years were included. The mean PDQ-39 was 48.8 +/- 27.8, mean MMSE was 25.7 +/- 4, and mean GDS was 11.7 +/- 6.8. Using stepwise multiple regression analysis, the most important predictive factors were depression, UPDRS part I, UPDRS part II, and educational background, which accounted for a 61% of the variability of the PDQ-39 scores.

CONCLUSIONS

In our PD sample, educational, behavioural, and psychological factors influenced life satisfaction more than physical ones.

[Glia conditioned medium offers protection against the toxicity induced by 6-OH-dopamine in vivo]

INTRODUCTION

Glia conditioned medium (GCM) is neurotrophic for dopaminergic (DA) neurons and protects against MPP+ toxicity in vitro. We present the data from the first study in vivo of the effects of GCM.

MATERIAL AND METHODS

The restorative effects were examined in rats with lesions produced by 6-hydroxy-dopamine (6-OH-DA) in the medial longitudinal fasciculus. At four weeks, animals with an apomorphine induced rotation rate above three per minute were randomised for infusion with GCM, defined medium (DM) or saline through a striatal cannula for two weeks. To investigate the protective effects of GCM, the animals received a striatal injection of GCM or vehicle at the same time as the lesion was induced by 6-OH-DA and were sacrificed three weeks later.

RESULTS

In the experiments on the restorative effect, the GCM infusion produced a significant increase in dopamine (DA) levels on the side with the lesion, in the limbic system (455.8 108.4 ng/g of tissue) and in the striatum (242.1 69.2 ng/g of tissue), as compared with the controls (110.8 36,4 and 108.4 22 ng/g). In the experiments on the protective effect, GCM induced higher levels of DA, 3,4-dihydroxyphenylacetic acid and 3 methoxytyramine (3-MT). In both models, the apomorphine induced rotation in animals with lesions caused by 6-OH-DA and treated with GCM was lower than that of the animals infused with DM or saline.

CONCLUSIONS

These experiments show that GCM has protective and restorative effects in an experimental model of Parkinson's disease.

[Disorders in gaze saccades in Huntington disease. Clinical correlations]

Oculomotor abnormalities have long been recognized in Huntington's disease (HD). The precise correlation between them and other clinical findings has not yet been determined. Using videonystagmography, we studied reflexive, visually guided horizontal saccades in 32 patients with genetically confirmed HD: nine female and 23 male patients, including six with young onset HD (YOHD), 19 with adult onset HD (AOD), and seven with late onset HD (LOHD). Huntington's patients exhibited increased saccade latency (P < 0.05), decreased saccade velocity (P < 0.0005), and impaired saccade accuracy (P < 0.01). A significant difference between the different groups of patients could be determined, and YOHD was characterized by normal latency and decreased saccade velocity while LOHD showed increased saccade latency but normal velocity. Furthermore, we found a significant difference between the genetic data (length of CAG-repeats) and saccadic abnormalities, with higher repeat numbers corresponding to shorter latency and decreased velocity, as in YOHD. The study of saccade parameters might be useful as an objective method for testing the effectiveness of future therapies.

Tolcapone increases plasma catecholamine levels in patients with Parkinson's disease

Tolcapone is a catechol-ortho-methyl-tranferase (COMT) inhibitor that increases the L-DOPA half-life and the duration of effect in Parkinson's disease. We investigated the effect of tolcapone on the plasma catecholamine levels. We measured plasma catecholamines 2h after the first daily dose of L-DOPA or L-DOPA+tolcapone while resting and 2 and 10min after standing. We also measured the pharmacokinetics of L-DOPA and 3-OM-DOPA and the clinical response to the medication for 6h after the early morning dose. The levels of dopamine, norepinephrine, adrenaline and total catecholamines significantly increased and 3-OM-DOPA decreased with tolcapone. We did not observe significant changes in the plasma L-DOPA levels at the doses of tolcapone used in this study. Tolcapone side effects included worsening of dyskinesia and psychosis, diarrhea and elevation of liver enzymes. Twenty-four-hour ambulatory recording of arterial blood pressure and heart rate did not reveal cardiovascular side effects in patients treated with tolcapone for less than 1year. Since adrenergic stimulation may increase the hepatotoxic potential of commonly used drugs, usually thought of as safe for the liver, we postulate that some of the already reported life threatening complications of tolcapone could be related to excessive adrenergic stimulation by high catecholamine levels caused by inhibition of COMT activity.

Unilateral 6-hydroxydopamine lesions of nigrostriatal dopaminergic neurons increased CB1 receptor mRNA levels in the caudate-putamen

It has been recently suggested that the effects of cannabinoids on motor behavior might be different in rats with lesions of nigrostriatal dopaminergic neurons than in controls. In the present study, we examined the possible alteration in the status of cannabinoid CB1 receptors in the basal ganglia of rats with unilateral lesions of those neurons caused by 6-hydroxydopamine. We used two different experimental groups depending on the duration of the period of recovery after the lesion, and comparisons were done between the lesioned and nonlesioned sides at the level of the basal ganglia. Both groups of lesioned rats exhibited a similar marked reduction in tyrosine hydroxylase (TH)-mRNA levels, measured by in situ hybridization, in the substantia nigra of the lesioned side. In the same way, lesioned rats exhibited the characteristic rotational behavior after a single injection of apomorphine and the intensity of this rotation was stable at the two times analyzed after the lesion. Also as expected, lesioned rats exhibited an increase in proenkephalin mRNA levels in the caudate-putamen, whereas mRNA levels of substance P decreased, although differences between the two times of recovery analyzed were observed in this case. We did not find any significant changes in CB1 receptor binding, measured by [3H]WIN-55,212,2 autoradiography, or in the activation of signal transduction mechanisms, measured by WIN-55,212,2-stimulated [35S]GTPgammaS binding autoradiography, between the lesioned and nonlesioned sides at the level of the lateral caudate-putamen, globus pallidus and substantia nigra in both groups of lesioned rats. However, we found a significant increase in levels of CB1 receptor-mRNA transcripts, measured by in situ hybridization, in the lesioned side in both the lateral and medial caudate-putamen. This occurred 7-10 weeks after the lesion, but the increase was markedly waned after 17-18 weeks. In summary, the unilateral 6-hydroxydopamine lesion of nigrostriatal dopaminergic neurons originated a marked increase in CB1 receptor-mRNA levels in cell bodies of striatal efferent neurons, although accompanied by no changes in CB1 receptor binding and activation of signal transduction mechanisms. This supports a critical role for dopamine in the control of CB1 receptor gene expression. However, the magnitude of the effect significantly waned as a function of the duration of the period after lesion.

[Nd-YAG capsulotomy and intravitreal antibiotics as treatment of chronic endophthalmitis]

PURPOSE

To study the effectiveness of Yag capsulotomy, therapeutic vitreal aspiration and intravitreal injection of antibiotics combination on the treatment of chronic postoperative endophthalmitis.

METHODS

Six patients with symptoms of refractory postoperative endophthalmitis after extracapsular cataract extraction, with an intraocular lens were treated following a protocol that included: YAG capsulotomy, vitreal aspiration and intravitreal injection of antibiotics.

RESULTS

In four cases -66%- the micro-organism was isolated -three cases of coagulase- negative staphylococci and one case Corynebacterium spp. In all the cases the inflammatory process decreased, and a noticeable improvement of visual acuity was achieved. No recurrent cases were observed (two patients died before the end of the study).

CONCLUSIONS

As way of conclusion we can state that the initial capsulotomy allows the destruction of the infection reservoir in order to eradicate the agent. This endophthalmitis therapeutic alternative is effective, easy and reliable for the ophthalmologist.

Bradykinesia in Huntington's disease

Huntington's disease (HD) is characterized by the presence of hyperkinesias, but bradykinesia is also present in most patients. We studied the motor performance of 18 patients with genetically proven HD (age, 38.5 +/- 10 y; clinical stage, 1.7 +/- 1.7; (CAG) triplet length, 49.2 +/- 6.8 triplets; all but three patients were free from neuroleptics) and compared with a control group (n = 18) and with a typical Parkinson's disease (PD) group (n = 20). Motor study included the four timed tests commonly used for PD: Pronation-supination (PS), finger dexterity (FD), movement between two points (MTP) and walking test (WT). Tests were done at 9 AM. The PD group was studied in "off" condition, with no medication given for 12 hours. The HD group was slower than the controls on all tasks (all tests significant, p < 0.01, Mann-Whitney U test) and even slower than PD group (for FD, p < 0.05). A significant correlation was found between each test and clinical stage (for PS, r = 0.84; for FD, r = 0.75; for MTP, r = 087, and for WT, r = 0.77, Pearson). Severe bradykinesia was present in HD, and motor impairment is related to clinical stage.

Clinical genetics of familial progressive supranuclear palsy

Recent studies have shown that progressive supranuclear palsy (PSP) could be inherited, but the pattern of inheritance and the spectrum of the clinical findings in relatives are unknown. We here report 12 pedigrees, confirmed by pathology in four probands, with familial PSP. Pathological diagnosis was confirmed according to recently reported internationally agreed criteria. The spectrum of the clinical phenotypes in these families was variable including 34 typical cases of PSP (12 probands plus 22 secondary cases), three patients with postural tremor, three with dementia, one with parkinsonism, two with tremor, dystonia, gaze palsy and tics, and one with gait disturbance. The presence of affected members in at least two generations in eight of the families and the absence of consanguinity suggests autosomal dominant transmission with incomplete penetrance. We conclude that hereditary PSP is more frequent than previously thought and that the scarcity of familial cases may be related to a lack of recognition of the variable phenotypic expression of the disease.

[Neuroimaging of hypoglycemia]

INTRODUCTION

Sustained hypoglycemia causes serious cerebral damage. The cortex, hippocampus and basal ganglia are particularly vulnerable to this. Exceptionally, there have been communications regarding neuroimaging visualization of cerebral lesions attributable to hypoglycemia only. We present the case of a woman who suffered hypoglycemic coma with permanent neurological damage. Lesions were seen on magnetic resonance (MR) and cranial computerized tomography (CT).

CLINICAL CASE

A 22 year old woman with no vascular risk factors was admitted to hospital in hypoglycemic coma, after attempting suicide with oral antidiabetic drugs. The duration of the coma was unknown. On admission the glycaemia was 28 mg/dl. Cranial CT scan was normal during the first 24 hours. Cerebral MR scan one week late showed hyperintense lesions in T2, basal ganglia and left hippocampus. The cranial CT scan one year later showed diffuse atrophy, with bilateral lesions of low attenuation in the basal ganglia and dilatation of the ventricular system.

CONCLUSIONS

It is unusual to see lesions secondary to hypoglycemia on neuroimaging investigations. The etiopathogenic mechanism is still unknown and it has generally been described in diabetic patients. In our case these lesions can only be attributed to hypoglycemia. MR is more sensitive than cranial CT scan for the detection of these lesions during the acute phase.

Iron stores in professional athletes throughout the sports season

Sports anemia provoked by iron deficiency develops slowly and although the existence or reality of this condition is under discussion, the ferritin levels tend to reduce with sports practice. This paper analyzes the variations of iron metabolism, including the organism stores of this metal throughout a sports season in a group of professional sportsmen (soccer players) belonging to a team of the Spanish First Division. For the determination of the iron stores, a computer program has been developed that takes into account the ferritin concentrations, hemoglobin, and saturation of transferrin. The results show that at the end of the season, when the ferric supplementation, which had been performed at the other moments of analysis, was no longer administered the iron stores reduced significantly, as well as the serum ferritin concentration, without such decreases being considered as a prelatent (grade I) anemia.

[An epidemiological and social study of 127 patients with AIDS IN Aragon]

OBJECTIVE

To evaluate the profile epidemiology and social of the patient with AIDS in our environment and the direct relation with primary care.

DESIGN

A descriptive, analytic and retrospective study.

SETTING

The study was carried out in the Miguel Servet Hospital in Zaragoza.

PARTICIPANTS

Patients with AIDS between January 1991 and june 1993 and who fulfilled the requisite diagnostic criteria.

MEASUREMENTS AND MAIN RESULTS

Out of the 127 patients studied, 74.8% were male and the age was 20 to 30 years old. The transmission mechanism was blood way in drug addicts in 63.8% and heterosexual way in 14.8%. It was socioeconomic problems in 40.94%, and 69.23% of them were drug addicts. The familiar support were proved in 29.13% and had relation with primary care only 15.74%.

CONCLUSIONS

An increase of the incidence of AIDS is observed, prevailing men between 31-40 years old. The heterosexual way transmission is increasing, but the blood way in drug addicts is more frequently. The majority presents socioeconomic problems and they haven't familiar support.