Multi-disciplinary diabetic limb salvage programme in octogenarians with diabetic foot ulcers is not futile: An observational study with historical controls

This study evaluated the effectiveness of a multi-disciplinary diabetic limb salvage programme in improving clinical outcomes and optimising healthcare utilisation in 406 patients aged ≥80 years with diabetic foot ulcers (DFUs), compared to 2392 younger patients enrolled from June 2020 to June 2021 and against 1716 historical controls using one-to-one propensity score matching. Results showed that elderly programme patients had lower odds of amputation-free survival (odds ratio: 0.64, 95% CI: 0.47, 0.88) and shorter cumulative length of stay (LOS) compared to younger programme patients (incidence rate ratio: 0.45, 95% CI: 0.29, 0.69). Compared to the matched controls, participating in the programme was associated with 5% higher probability of minor lower extremity amputation, reduced inpatient admissions and emergency visits, shorter LOS but increased specialist and primary care visits (all p-values <0.05). The findings suggest that the programme yielded favourable impacts on the clinical outcomes of patients aged≥80 years with DFUs. Further research is needed to develop specific interventions tailoring to the needs of the elderly population and to determine their effectiveness on patient outcomes while accounting for potential confounding factors.

Ethnic disparity in prevalence of diabetic kidney disease in an Asian primary healthcare cluster

AIMS

Diabetic kidney disease (DKD) incidence is rising in Singapore. While measures to prevent onset and early detection of diabetes as well as optimal diabetes and blood pressure control are important, early detection and treatment of DKD at primary care are crucial to ameliorate its course. This study aimed to evaluate the prevalence of DKD in a primary care cluster in Singapore and identify its risk factors in a multi-ethnic Asian population.

METHODS

A total of 57,594 patients with type 2 diabetes mellitus (T2DM) followed-up at the National Healthcare Group Polyclinics with estimated glomerular filtration rate and at least two urine albumin/creatinine ratio (UACR) were stratified into DKD stages: normoalbuminuria (UACR <30 mg/g), microalbuminuria (MI, UACR 30-299 mg/g), macroalbuminuria (MA, ≥300 mg/g) and renal impairment (RI, estimated glomerular filtration rate eGFR <60 mL/min per 1.73 m(2)). Factors associated with DKD stages were evaluated.

RESULTS

Overall DKD prevalence (T2DM with MI, MA or RI) was high at 52.5%; 32.1% had MI, 5.3% had MA and 15.1% had RI. DKD prevalence within ethnic subpopulations was different: 52.2% of Chinese, 60.4% of Malays and 45.3% of Indians had DKD, respectively. Malays had a 1.42-fold higher DKD prevalence, while Indians had a 0.86-fold lower. Other independent risk factors were age, female gender, duration of diabetes and hypertension, HbA1c and body mass index.

CONCLUSION

The high prevalence of DKD and its interethnic differences suggest need for additional measures to optimize the care of T2DM at primary care to mitigate its progression.

Demographic and lifestyle characteristics associated with non-willingness to participate in health promotion programmes among adults of a lower socioeconomic status in Singapore

INTRODUCTION/OBJECTIVE

Lower socioeconomic groups have been found to have poorer health outcomes and engage in fewer health promoting behaviours. Understanding the reasons behind adverse lifestyle habits and non-willingness to participate in health promotion programmes among lower socioeconomic groups will enable administrators to modify the programmes and increase participation in this population. This study aimed to determine reasons for non-exercise, smoking and non-willingness to participate, and characteristics associated with non-willingness to participate in health promotion programmes among residents in Singapore.

METHOD

A cross-sectional survey was conducted on a purposive sample of residents living in four housing developments of one- and two-room households in Singapore from June to October 2009. The patterns of exercise and smoking, receptiveness towards health promotion programmes and the reasons for non-willingness to participate were elicited. Chi-square tests and logistic regression analysis were performed to identify differences between groups.

RESULTS

Seven hundred and seventy-eight responses were analysed. Only 36.1% of respondents were willing to participate in at least one health promotion programme (health screening, talk or workshop). Older respondents aged 45-64 years and more than 65 years were less likely to participate than their younger counterparts (18-44 years). Malays were more likely than Chinese to participate, and respondents who do not exercise were less likely to participate than respondents who exercise (regularly/occasionally). Reasons for non-willingness to participate were 'not interested' and 'no time'.

CONCLUSION

Health promotion messages should adapt to the needs and situation of the disadvantaged, to increase participation.

Online eLearning for undergraduates in health professions: A systematic review of the impact on knowledge, skills, attitudes and satisfaction

Background

Health systems worldwide are facing shortages in health professional workforce. Several studies have demonstrated the direct correlation between the availability of health workers, coverage of health services, and population health outcomes. To address this shortage, online eLearning is increasingly being adopted in health professionals’ education. To inform policy–making, in online eLearning, we need to determine its effectiveness.

Methods

We performed a systematic review of the effectiveness of online eLearning through a comprehensive search of the major databases for randomised controlled trials that compared online eLearning to traditional learning or alternative learning methods. The search period was from January 2000 to August 2013. We included articles which primarily focused on students' knowledge, skills, satisfaction and attitudes toward eLearning and cost-effectiveness and adverse effects as secondary outcomes. Two reviewers independently extracted data from the included studies. Due to significant heterogeneity among the included studies, we presented our results as a narrative synthesis.

Findings

Fifty–nine studies, including 6750 students enrolled in medicine, dentistry, nursing, physical therapy and pharmacy studies, met the inclusion criteria. Twelve of the 50 studies testing knowledge gains found significantly higher gains in the online eLearning intervention groups compared to traditional learning, whereas 27 did not detect significant differences or found mixed results. Eleven studies did not test for differences. Six studies detected significantly higher skill gains in the online eLearning intervention groups, whilst 3 other studies testing skill gains did not detect differences between groups and 1 study showed mixed results. Twelve studies tested students' attitudes, of which 8 studies showed no differences in attitudes or preferences for online eLearning. Students' satisfaction was measured in 29 studies, 4 studies showed higher satisfaction for online eLearning and 20 studies showed no difference in satisfaction between online eLearning and traditional learning. Risk of bias was high for several of the included studies.

Conclusion

The current evidence base suggests that online eLearning is equivalent, possibly superior to traditional learning. These findings present a potential incentive for policy makers to cautiously encourage its adoption, while respecting the heterogeneity among the studies.

Offline eLearning for undergraduates in health professions: A systematic review of the impact on knowledge, skills, attitudes and satisfaction

BACKGROUND

The world is short of 7.2 million health-care workers and this figure is growing. The shortage of teachers is even greater, which limits traditional education modes. eLearning may help overcome this training need. Offline eLearning is useful in remote and resource-limited settings with poor internet access. To inform investments in offline eLearning, we need to establish its effectiveness in terms of gaining knowledge and skills, students' satisfaction and attitudes towards eLearning.

METHODS

We conducted a systematic review of offline eLearning for students enrolled in undergraduate, health-related university degrees. We included randomised controlled trials that compared offline eLearning to traditional learning or an alternative eLearning method. We searched the major bibliographic databases in August 2013 to identify articles that focused primarily on students' knowledge, skills, satisfaction and attitudes toward eLearning, and health economic information and adverse effects as secondary outcomes. We also searched reference lists of relevant studies. Two reviewers independently extracted data from the included studies. We synthesized the findings using a thematic summary approach.

FINDINGS

Forty-nine studies, including 4955 students enrolled in undergraduate medical, dentistry, nursing, psychology, or physical therapy studies, met the inclusion criteria. Eleven of the 33 studies testing knowledge gains found significantly higher gains in the eLearning intervention groups compared to traditional learning, whereas 21 did not detect significant differences or found mixed results. One study did not test for differences. Eight studies detected significantly higher skill gains in the eLearning intervention groups, whilst the other 5 testing skill gains did not detect differences between groups. No study found offline eLearning as inferior. Generally no differences in attitudes or preference of eLearning over traditional learning were observed. No clear trends were found in the comparison of different modes of eLearning. Most of the studies were small and subject to several biases.

CONCLUSIONS

Our results suggest that offline eLearning is equivalent and possibly superior to traditional learning regarding knowledge, skills, attitudes and satisfaction. Although a robust conclusion cannot be drawn due to variable quality of the evidence, these results justify further investment into offline eLearning to address the global health care workforce shortage.

Decreased serum selenium concentrations in patients with Parkinson's disease

Selenium is an essential component of the antioxidant enzyme glutathione peroxidase. The activity of this enzyme is reduced in the substantia nigra of patients with Parkinson's disease (PD), but the results of studies on erythrocytes are controversial. We compared the serum levels of selenium and the 24 h urinary selenium excretion (measured by hydride generation atomic absorption spectrophotometry) in 29 PD patients and 30 matched controls. Serum selenium levels were significantly lower in PD patients than in controls (34.6 ± 2.35 and 45.2 ± 3.83 μg/l, p < 0.05) while urinary excretion was similar for both groups (47.1 ± 6.25 and 45.5 ± 5.38 μg/24 h). These values were not influenced by antiparkinsonian drugs, and they did not correlate with age, age at onset and duration of the PD, scores of the Unified PD Rating Scale or the Hoehn and Yahr staging in the PD group. These results might suggest a possible role of low serum selenium levels in the risk for, or a consequence of the oxidative stress in PD.

Peripheral iron metabolism in patients with focal cerebral ischemia

To ascertain the possible role of iron as a risk factor for cerebral ischemia, we studied the serum levels of iron, transferrin and ferritin in 42 patients between the third and seventh days after a cerebral ischemic event (transient ischemic attack, reversible ischemic neurological deficit or cerebral infarction) and in 62 matched controls. The serum levels of iron did not differ significantly between cerebral ischemic patient and control groups. Serum transferrin levels were lower and ferritin higher in stroke patients than in controls. These values were not influenced by age, blood pressure, or smoking and alcohol drinking habits. These results suggest that iron stores could be related to the risk for cerebral ischemia.

[Sense of smell, physiological ageing and neurodegenerative diseases: II. Ageing and neurodegenerative diseases]

INTRODUCTION

The sense of smell, which was once studied because of its biological and evolutionary significance, is today one of the centres of interest in research on normal and pathological ageing. The latest scientific developments point to an inversely proportional relationship between age and olfactory sensitivity. In certain neurodegenerative diseases this sensory decline is one of the first symptoms of the disorder and is correlated with the progression of the disease.

DEVELOPMENT

In this work we are going to review the scientific knowledge on loss of sense of smell in ageing and in neurodegenerative diseases, with special attention given to Alzheimer's and Parkinson's diseases.

CONCLUSIONS

A survey of studies that have examined the olfactory deficits in ageing and in some neurodegenerative diseases offers conclusive results about the presence of these impairments in the early stages of these disorders and even among healthy elderly persons. Although a number of causes contribute to these sensory losses in physiological ageing, a common neurological foundation has been proposed for Alzheimer's and Parkinson's diseases. Nevertheless, despite certain initial similarities, the olfactory deficits shown in these disorders seem to be qualitatively different.

[Sense of smell, physiological ageing and neurodegenerative diseases: I. Anatomy and clinical examination]

INTRODUCTION

Different studies on normal and pathological ageing have shown structural and functional impairment by means of psychophysical measures, electrophysiological studies and brain imaging studies. Lower sensory perception from peripheral olfactory structures, together with alterations in the medulla oblongata and cortex, are the most frequent causes of olfactory impairment in ageing.

AIM

To outline the most important tests that can be applied in clinical evaluation.

DEVELOPMENT

The article begins by reviewing concepts involved in olfactory anatomy and physiology and then goes on to describe the different methods of examination and their applicability to medical diagnosis.

CONCLUSIONS

Incorporating olfactory tests into clinical practice makes it possible to study the presence of sensory and cognitive impairment in greater depth, especially in ageing and in neurodegenerative diseases; this will allow a possible diagnosis to be expanded and completed.

Effects of survey mode on results of a patient satisfaction survey at the observation unit of an acute care hospital in Singapore

INTRODUCTION

Over the years, surveys have become powerful tools for assessing a wide range of outcomes among patients. Healthcare managers and professionals now consider patient satisfaction as an outcome by itself. This study aims to determine if results of a patient satisfaction survey are affected by the manner by which the survey instrument is administered.

MATERIALS AND METHODS

A patient satisfaction survey was conducted from May 2006 to October 2007 in a tertiary level acute care facility. All patients admitted to the observation unit during the study period were invited to participate. Using a contextualized version of the Consumer Assessment of Healthcare Providers and Systems (CAHPS) Hospital Survey, data was collected through either a phone interview, face to face interview or self-administered questionnaire. Each of these survey modes was administered during 3 different phases within the study period.

RESULTS

Eight hundred thirty-two (832) patients were included in the survey. Based on results of univariate analysis, out of the 18 questions, responses to 11 (61.1%) were related to survey mode. Face-to-face interview resulted in the greatest proportion of socially desirable responses (72.7%), while phone interview yielded the highest proportion of socially undesirable responses (63.3%). After controlling for possible confounders, logistic regression results showed that responses to 55.6% of the questions were affected by survey mode. Variations in response between phone interview and self-administered questionnaire accounted for 87.5% of the observed differences.

CONCLUSIONS

Researchers must be aware that the choice of survey method has serious implications on results of patient satisfaction surveys.

[The NEDICES cohort of the elderly. Methodology and main neurological findings]

AIM

To summarise the methodological aspects and main findings of the NEDICES (Neurological Disorders in Central Spain) cohort study of the elderly population, with over 5000 participants.

DEVELOPMENT

The article outlines the findings concerning the following chronic neurological diseases (CND): dementia, Parkinson's disease and Parkinsonisms, stroke and essential, or senile, tremor. The NEDICES study examined the health, mortality and a series of sociological aspects of the cohort that are not discussed here. The paper does describe, however, the objectives, methods, population and development, with the baseline (1994) and incidence (1997) cut-off points, and the main findings regarding the CND under study are discussed.

CONCLUSIONS

The prevalence and incidence of the CND are comparable to those of other Spanish and European population-based studies, but with certain peculiarities, such as the fact that incidence of senile tremor is the highest of those reported in the literature and that this CND is associated with dementia. Over half the cases of Parkinson's disease were reported de novo with the study and Alzheimer's disease was associated with vascular risk factors.

Hormonal treatments for increasing the oocyte and embryo production in an OPU–IVP system

The objective was to enhance the inherent developmental ability of bovine oocytes retrieved by ultrasound-guided transvaginal aspiration. Various hormonal regimes were utilized to produce partially matured oocytes in vivo, in order to improve embryo development following IVF. In the first experiment, a two-by-two factorial design was used with FSH (multiple versus single dose) and im administration of LH (yes versus no) 6h prior to OPU. In all protocols (which lasted for nine consecutive weeks), ovarian stimulation was performed in the presence of a CIDR. One FSH administration was adequate for ovarian stimulation (9.33+/-0.7 and 10.14+/-0.7 follicles per cow per OPU session); however, multiple injections increased (P<0.05) follicular response (12.97+/-0.7 and 13.97+/-0.7). In the second experiment, a two-by-two factorial design was used to compare the effects, during ovarian stimulation, of the presence or absence of CIDR, and iv treatment with LH 6h prior to OPU (yes versus no), on oocyte competence (judged by blastocyst development rates following IVF). Presence of CIDR during superstimulation had no effect on the follicular response. Administration of LH 6h prior to OPU increased (P<0.05) the oocytes of higher morphological grades, and in the absence of a CIDR, improved (P<0.05) blastocyst development rate. Treatment with LH, 6h prior to OPU without the use of CIDR during ovarian stimulation, resulted in 2.89+/-0.4 blastocysts per cow per OPU session as compared to 1.56+/-0.4, 1.56+/-0.4 and 1.33+/-0.4 for all other groups. In conclusion, compared to single administration, multiple FSH administration increased (P<0.05) available follicles for aspiration. Moreover, when ovarian stimulation in the absence of CIDR was followed by administration of LH 6h prior to OPU, it increased (P<0.05) the number of blastocysts per OPU session.

Causes of ischemic stroke in young adults, and evolution of the etiological diagnosis over the long term

BACKGROUND

Causes of ischemic stroke in young adults (15-45 years) are diverse, but undetermined etiology is common in a majority of studies.

AIMS

The present series study aims to evaluate causes and changes in the etiological diagnosis of ischemic stroke in young adult patients admitted to a tertiary medical center over a period of 27 years.

METHODS

We retrospectively reviewed the records of patients with a first-ever stroke in the age range of 15-45 years who were admitted to the '12 de Octubre' University Hospital between 1974 and 2002.

RESULTS

272 young adults with ischemic stroke were identified. The etiological diagnoses were: undetermined in 36% of patients, large-artery atherosclerosis in 21%, cardioembolism in 17%, non-atherosclerotic vasculopathy in 17%, and other specific etiologies in 9%. While in the first study period (1974-1988) 45% of patients were diagnosed with uncertain etiology, in the last period (1989-2002) only 26% were diagnosed with cryptogenic stroke (45% with two or more potential etiologies identified; 45% with no identified cause despite complete evaluation, and 10% with incomplete evaluation).

CONCLUSIONS

The etiological diagnosis of stroke in young adults has changed over time as a result of improvements in diagnostic workup. While cryptogenic stroke was the most frequent diagnosis in the past, today specific causes (non-atherosclerotic vasculopathy, large-artery atherosclerosis, cardioembolism and hematological disorder) are identified in the majority of patients.

Increased frequency of rapid acetylator genotypes in patients with brain astrocytoma and meningioma

OBJECTIVES

The arylamine N-acetyltransferase (NAT2) is a polymorphic enzyme involved in deactivation and activation of carcinogens through N- and O-acetylation. We investigated the association between the genetic NAT2 polymorphism and brain tumors by analysis of genomic DNA from 71 brain tumor patients and 258 healthy controls.

MATERIALS AND METHODS

Seven single nucleotide polymorphisms of the NAT2 gene were studied by using allele-specific polymerase chain reaction amplification.

RESULTS

Ten different NAT2 allelic variants were identified in both patient and control groups. A higher number of individuals carrying functional NAT2 genes, and therefore with a rapid acetylation phenotype, was found in brain tumor patients vs healthy volunteers (OR 1.79, 95% CI 1.05-3.05; P < 0.05). This is observed either for patients suffering from meningioma or astrocytoma, and this is due to an increase of the wild-type NAT2*4 allelic variant frequency (OR 1.48, 95% CI 0.99-2.19), and a reduction of the commonest defective allelic variant NAT2*5B in the brain tumor patients, compared with healthy subjects (OR 0.54, 95% CI 0.37-0.80).

CONCLUSIONS

This observation indicates that NAT2 could be considered as a low-penetrance gene for brain tumors, and that individuals carrying rapid acetylation alleles are at increased risk of developing brain tumors.

Comparison of different transvaginal ovum pick-up protocols to optimise oocyte retrieval and embryo production over a 10-week period in cows

The objective was to develop a simple and effective ovum pick-up (OPU) protocol for cows, optimised for oocyte harvest and subsequent in vitro embryo production (IVP). Five protocols differing in collection frequency, dominant follicle removal (DFR) and FSH stimulation were tested on groups of three cows each, over an interval of 10 consecutive weeks. Performance was evaluated on per OPU session, per week and pooled (3 cowsx10weeks) basis. Among the non-stimulated groups, on a per cow per session basis, once- or twice-weekly OPU had no effect on the mean (+/- S.E.M.) number of follicles aspirated, oocytes retrieved and blastocysts produced (0.6+/-0.8 and 0.7 +/- 0.7, respectively). However, DFR 72 h prior to OPU almost doubled blastocyst production (1.2 +/- 1.3). In stimulated groups, FSH treatment (80 mg IM and 120 mg SC) was given once weekly prior to OPU. Treatment with FSH, followed by twice-weekly OPU, failed to show any synergistic effect of FSH and increased aspiration frequency. When FSH was given 36 h after DFR, followed by OPU 48 h later, more (P < 0.05) follicles (16.0 +/- 5.0), oocytes (10.6 +/- 4.5) and embryos (2.1 +/- 1.2) were obtained during each session, but not on a weekly basis. Pooled results over 10 weeks showed an overall improved performance for the treatment groups with twice-weekly OPU sessions, due to double the number of OPU sessions performed. However, the protocol that consisted of DFR, FSH treatment and a subsequent single OPU per week, was the most productive and cost-effective, with potential commercial appeal.

The Almadén district (Spain): anatomy of one of the world's largest Hg-contaminated sites

We present data from an early reconnaissance survey (stream sediments, soil, and water Hg chemistry; plants and water crustaceans Hg intake) of the Almadén district (central Spain), that was carried out to establish the potential environmental hazards derived from the anomalous mercury concentrations measured in this realm. The Almadén mercury district (approximately 300 km2) can be regarded as the largest geochemical anomaly of mercury on Earth. The district includes a series of mercury mineral deposits, having in common a simple mineralogy (dominant cinnabar: HgS, and minor pyrite: FeS2). The ore deposits have been mined for more than 2000 years, and the main mine of the district (Almadén), has been active from Roman times to present day with almost no interruptions. The mercury distribution in soils of the district reveals the existence of high, and extremely high mercury values (up to 8889 microg g(-1)), whereas concentrations in stream sediments and waters reach exceptional values of up to 16,000 microg g(-1) and 11,200 ng l(-1) respectively. On the other hand, very high concentrations of methylmercury (MeHg) have been detected in calcines (up to 3100 ng g(-1)), sediments (0.32-82 ng g(-1)), and waters (0.040-30 ng l(-1)). Mercury gets incorporated to edible river crustaceans and plants. The red swamp crayfish Procambarus clarkii, has Hg concentrations of up to 9060 ng g(-1) (muscle) and 26,150 ng g(-1) (hepatopancreas). Regarding plants, the local wild asparagus (Asparagus acutifolius) yields values of up to 298 microg g(-1) Hg. Mercury also escapes to the atmosphere, and mineral deposits, together with metallurgical activities, generate strong anomalies of atmospheric Hg. The most important concentrations relate to the emissions from the Almadén metallurgical roaster, in the order of 14,000 ng Hg m(-3). Additionally, large open pit operations also contribute to the district atmospheric pool of mercury, with high concentrations above 1000 ng Hg m(-3). Thus, no system (rocks, soils, sediments, waters, atmosphere, biota) in the Almadén district is free from strong Hg contamination.

Diagnosis and management of dementia with Lewy bodies: third report of the DLB Consortium

The dementia with Lewy bodies (DLB) Consortium has revised criteria for the clinical and pathologic diagnosis of DLB incorporating new information about the core clinical features and suggesting improved methods to assess them. REM sleep behavior disorder, severe neuroleptic sensitivity, and reduced striatal dopamine transporter activity on functional neuroimaging are given greater diagnostic weighting as features suggestive of a DLB diagnosis. The 1-year rule distinguishing between DLB and Parkinson disease with dementia may be difficult to apply in clinical settings and in such cases the term most appropriate to each individual patient should be used. Generic terms such as Lewy body (LB) disease are often helpful. The authors propose a new scheme for the pathologic assessment of LBs and Lewy neurites (LN) using alpha-synuclein immunohistochemistry and semiquantitative grading of lesion density, with the pattern of regional involvement being more important than total LB count. The new criteria take into account both Lewy-related and Alzheimer disease (AD)-type pathology to allocate a probability that these are associated with the clinical DLB syndrome. Finally, the authors suggest patient management guidelines including the need for accurate diagnosis, a target symptom approach, and use of appropriate outcome measures. There is limited evidence about specific interventions but available data suggest only a partial response of motor symptoms to levodopa: severe sensitivity to typical and atypical antipsychotics in approximately 50%, and improvements in attention, visual hallucinations, and sleep disorders with cholinesterase inhibitors.

Long-term prognosis of ischemic stroke in young adults. Study of 272 cases

BACKGROUND

There have been few studies of the long-term prognosis of young adults with ischemic stroke. The present study aimed to evaluate the long-term clinical outcome in a large series of young adults with ischemic stroke admitted to a tertiary medical center over the last 27 years, and to identify possible predictors for mortality, stroke recurrence and poor functional recovery.

METHODS

We retrospectively reviewed 272 young adults (15-45 years) with a first-ever ischemic stroke admitted to the Neurology Department of University Hospital "12 de Octubre" between 1974 and 2001. Follow-up assessments were performed by review of medical records and telephone interviews.

RESULTS

Nine patients (3%) died as the result of their initial stroke and follow-up information about the status of 23 (8%) patients was not available. The remaining 240 patients (89%) were followed. Two hundred and ten of them (88%) were alive with a mean follow-up of 12.3 years and 30 (12%) died during follow-up. The average annual mortality rate was 1.4%, being notably higher during the first (4.9%) than in the subsequent years (0.9%) after the initial stroke. Ninety per cent of the followed patients were independent and 53% returned to work, although adjustments were necessary for 23% of them. The annual stroke recurrence rate during the first year was 3.6% dropping to 1.7% in subsequent years. Age over 35 years, male gender, the presence of cardiovascular risk factors and large-artery atherosclerosis in the carotid territory were predictors of negative long-term outcome after the initial stroke.

CONCLUSIONS

The long-term prognosis for the ischemic stroke in the young is better than in the elderly, but the risk of mortality in young adults with ischemic stroke is much higher than in the general population of the same age. A bad prognosis is associated with an atherosclerotic risk profile, with a higher mortality and recurrent stroke rates and poorer functional recovery. The main functional limitation in the young survivors of their initial ischemic stroke occurs in work activity, since most patients are independent but almost half of them do not return to work.

Neurotransmitter amino acid in cerebrospinal fluid of patients with dementia with Lewy bodies

The purpose of the present study was to compare neurotransmitter amino acid concentrations in the cerebrospinal fluid (CSF) and CSF/plasma ratios in 21 patients with dementia with Lewy bodies (DLB) and 26 matched controls. To this purpose, we used an ion-exchange chromatographic method. DLB patients exhibit higher CSF concentrations of asparagine (+25%) and glycine (+21%) compared to a control group, whereas no differences in CSF/plasma ratios were found between both groups. On the other hand, no alterations in concentrations of glutamate, aspartate and GABA were detected in CSF of patients compared to a control group. There was no correlation among amino acid levels and CSF/plasma ratios with age, age of onset, body mass index, duration of the disease or scores of the Mini Mental State Examination, UPDRS and Hoehn and Yahr stage. These results suggest a possible role of glycine and asparagine in the pathogenic mechanism of dementia with Lewy bodies.

Myoglobinuria and COX deficiency in a patient taking cerivastatin and gemfibrozil

The authors describe a patient who presented with myoglobinuria after starting cerivastatin-gemfibrozil therapy. Muscle histochemistry revealed ragged-red fibers and cytochrome c oxidase negative (COX) fibers, and biochemistry showed a defect of COX activity. Immunoblot analysis showed a 60% reduction of COX I and COX II polypeptides. Cerivastatin myotoxicity might be related to a depletion of essential metabolites needed to anchor COX subunit I to mitochondrial membrane.

Commercialization of animal biotechnology

Commercialization of animal biotechnology is a wide-ranging topic for discussion. In this paper, we will attempt to review embryo transfer (ET) and related technologies that relate to food-producing mammals. A brief review of the history of advances in biotechnology will provide a glimpse to present and future applications. Commercialization of animal biotechnology is presently taking two pathways. The first application involves the use of animals for biomedical purposes. Very few companies have developed all of the core competencies and intellectual properties to complete the bridge from lab bench to product. The second pathway of application is for the production of animals used for food. Artificial insemination (AI), embryo transfer, in vitro fertilization (IVF), cloning, transgenics, and genomics all are components of the toolbox for present and future applications. Individually, these are powerful tools capable of providing significant improvements in productivity. Combinations of these technologies coupled with information systems and data analysis, will provide even more significant change in the next decade. Any strategies for the commercial application of animal biotechnology must include a careful review of regulatory and social concerns. Careful review of industry infrastructure is also important. Our colleagues in plant biotechnology have helped highlight some of these pitfalls and provide us with a retrospective review. In summary, today we have core competencies that provide a wealth of opportunities for the members of this society, commercial companies, producers, and the general population. Successful commercialization will benefit all of the above stakeholders.

Cerebrospinal fluid levels of insulin in patients with Alzheimer's disease

OBJECTIVES

Some previous reports suggested a potential role of insulin in memory and in the pathophysiology of Alzheimer's disease (AD). We assessed the cerebrospinal fluid (CSF) levels of insulin in patients with AD and in age and sex-matched controls trying to elucidate whether this value could be related with the risk or severity of AD.

PATIENTS AND METHODS

We measured the CSF insulin levels in 27 patients with AD and 16 matched controls using a RadioImmunoanalysis method.

RESULTS

CSF insulin levels did not differ significantly between AD-patient and control groups. These values were not correlated with age, age at onset, duration of the disease, and scores of the MiniMental State Examination in the AD group.

CONCLUSION

These results suggest that CSF insulin concentrations are not related with the risk or severity of AD.

Proton magnetic resonance spectroscopy in dementia with Lewy bodies

Proton magnetic resonance spectroscopy ((1)H-MRS) provides a non-invasive, in vivo insight into the brain metabolism, and has been successfully used in several neurological conditions. Our objective was to characterise the cerebral metabolic changes in dementia with Lewy bodies (DLB) patients using (1)H-MRS. Single Voxel (1)H-MRS was performed in 12 DLB patients with mild to moderate symptoms and 11 age-matched healthy controls. Volumes of interest (VOI) were selected, including white matter (WM) in the centrum semiovale and grey matter (GM) in the parasagittal parietal cortex. Main metabolic peaks corresponding to N-acetylaspartate (NAA), glutamate/glutamine (Glx), choline-containing compounds (Cho), myo-inositol (Ins), and creatine plus phosphocreatine (Cr) were identified. These areas were measured and referred to that of the water. Metabolic ratios among the different peak areas were also calculated. In comparison with the control group, DLB patients showed significantly lower mean NAA/Cr, Glx1/Cr and Cho/Cr ratios in the WM, while their Ins/Cr and Ins/NAA ratios did not differ from those of the control group. In the GM, no significant differences were found between both groups. Correlations between age at onset, disease duration, Mini-Mental State Examination, the motor section of the Unified Parkinson's Disease Rating Scale, Hoehn and Yahr staging and metabolic ratios, both for WM and GM, were not significant in DLB patients. Our spectroscopy data show WM involvement, along with GM preservation, in DLB patients with early or intermediate stages. Hence, (1)H-MRS may provide adjunctive information in the ante-mortem diagnosis of DLB.

Cerebrospinal fluid and plasma concentrations of nitric oxide metabolites are increased in dementia with Lewy bodies

We compared cerebrospinal fluid (CSF) and plasma concentrations of nitric oxide metabolites (NO(-)(x)) in 22 patients with dementia with Lewy bodies (DLB) and 13 matched controls. We found a pronounced increase in NO(-)(x) CSF and plasma levels in DLB patients. No changes were found in L-arginine and L-citrulline levels in CSF or plasma. There was no correlation between CSF and plasma levels and age, age of onset, duration of the disease or scores of the MiniMental State Examination. These findings reveal that excessive nitric oxide production may be related to the pathogenesis of DLB.

Serum levels of coenzyme Q in patients with Lewy body disease

The purpose of the present study was to compare serum levels of coenzyme Q(10) (CoQ(10)) and the coenzyme Q(10) cholesterol (CoQ(10)/cholesterol) ratio in 18 patients with Lewy body disease (LBD) with 20 matched controls. The mean serum coenzyme Q10 levels in patients with LBD were significantly reduced with respect to control group, however, no differences were found in CoQ(10)/cholesterol ratio between LBD patients and control group. There was no correlation among CoQ(10) and CoQ(10)/cholesterol ratio with age, age of onset, body mass index, duration of the disease or scores of the Mini Mental State Examination, UPDRS and Hoehn and Yahr stage. These results suggest the involvement of this enzimatic system in the pathogenic mechanism of LBD.

Cerebrospinal fluid levels of thiamine in patients with Alzheimer's disease

Thiamine is an essential cofactor for several important enzymes involved in brain oxidative metabolism, such as the alpha-ketoglutarate dehydrogenase complex (KGDHC), pyruvate-dehydrogenase complex (PDHC), and transketolase. Some investigators reported decreased thiamine-diphosphate levels and decreased activities of KGDHC, pyruvate-dehydrogenase complex and transketolase in the brain tissue of Alzheimer's disease (AD) patients. We measured cerebrospinal (CSF) levels of thiamine-diphosphate, thiamine-monophosphate, free thiamine, and total thiamine, using ion-pair reversed phase high performance liquid chromatography, in 33 patients with sporadic AD and 32 matched controls. The mean CSF levels of thiamine-derivatives did not differ significantly from those of controls, while the mean plasma levels of thiamine-diphosphate, free and total thiamine were significantly lower in the AD-patient group. CSF and plasma thiamine levels were not correlated with age, age at onset, duration of the disease, and scores of the MiniMental State Examination, with the exception of plasma thiamine-diphosphate with MiniMental State Examination (r = 0.41, p < 0.05) in the AD-patients group. CSF and plasma values did not predict dementia progression, assessed with the MiniMental State Examination scores. These results suggest that CSF thiamine levels are not related with the risk for and the progression of AD.

Mitochondrial dysfunction associated with a mutation in the Notch3 gene in a CADASIL family

BACKGROUND

Cerebral autosomal arteriopathy with subcortical infarcts and leukoencephalopathy (CADASIL) is characterized by recurrent subcortical ischemic strokes and dementia caused by mutations in the Notch3 gene. In Drosophila melanogaster, Notch signaling has a pleiotropic effect, affecting most tissues of the organism during development.

OBJECTIVE

To characterize a potential mitochondrial dysfunction associated with mutations in the Notch3 gene.

METHODS

Biochemical, histochemical, molecular, and genetic analyses were performed on muscle biopsy specimens and fibroblasts obtained from patients of a Spanish family with CADASIL. Additional biochemical and molecular analyses of the N(55e11) mutant of D. melanogaster were performed.

RESULTS

In muscle biopsy specimens, a significant decrease was found in the activity of complex I (NADH [reduced form of nicotinamide adenine dinucleotide] dehydrogenase), and in one patient, histochemical analysis showed the presence of ragged-red fibers with abnormal cytochrome c oxidase staining. Reduced fibroblast activity of complex V (ATP synthase) was found. Supporting data on patients with CADASIL, it was found that the mutation N(55e11) in Drosophila decreases the activity of mitochondrial respiratory complexes I and V.

CONCLUSIONS

Mitochondrial respiratory chain activity responds, directly or indirectly, to the Notch signaling pathway. Mitochondrial dysfunction in patients with CADASIL may be an epiphenomenon, but results of this study suggest that the pathophysiology of the disease could include a defect in oxidative phosphorylation.

Normal cerebrospinal fluid levels of insulin in patients with Parkinson's disease

We compared CSF levels insulin, measured by a Radioimmunoanalysis method, in 24 patients with Parkinson's disease (PD) and 21 matched controls. The CSF insulin levels did not differ significantly between PD patients and controls. CSF insulin levels were not correlated with age, age at onset, duration of the disease, scores of the Unified Parkinson Disease Rating Scale of the Hoehn and Yahr staging in the PD group. Antiparkinsonian therapy did not influence significantly and CSF levels of insulin. These results suggest that CSF insulin concentrations are not a biological marker of PD and its severity.

Serum levels of coenzyme Q10 in patients with amyotrophic lateral sclerosis

To elucidate whether serum coenzyme Q10 levels are related with the risk for amyotrophic lateral sclerosis (ALS), we compared serum levels of coenzyme Q10 and the coenzyme Q10/cholesterol ratio, in 30 patients with ALS and 42 matched controls using a high performance liquid chromatography technique. The mean serum coenzyme Q10 levels and the coenzyme Q10/cholesterol ratio did not differ significantly between the 2 study groups. These values were not influenced by the clinical form (spinal vs. bulbar) of ALS, and they did not correlate with age, age at onset, and duration of the disease. These results suggest that serum coenzyme Q10 concentrations are unrelated with the risk for ALS.

Serum levels of coenzyme Q10 in patients with Parkinson's disease

We compared serum levels of coenzyme Q10 and the coenzyme Q10/cholesterol ratio in 33 patients with Parkinson's disease (PD) and 31 matched controls. The mean serum coenzyme Q10 levels did not differ significantly between the 2 study groups. Coenzyme Q10 levels were not correlated with age, age at onset, duration of the disease, scores of the Unified Parkinson Disease Rating Scale (UPDRS) or the Hoehn and Yahr staging in the PD group. The coenzyme Q10/cholesterol ratio had a significant correlation (although low) with duration of the disease (r = -0.46), total UPDRS score (r = -0.39), motor examination of the UPDRS (r = 0.45). These values were not influenced significantly by therapy with levodopa or dopamine agonists. The normality of serum coenzyme Q10 and coenzyme Q10/cholesterol ratio suggest that these values are not related with the risk for PD.

Serum levels of coenzyme Q10 in patients with Alzheimer's disease

We compared serum levels of coenzyme Q10 and the coenzyme Q10/cholesterol ratio in 44 patients with Alzheimer's disease (AD), 17 patients with vascular dementia (VD), and 21 matched controls. The mean serum coenzyme Q10 and cholesterol levels and the coenzyme Q10/cholesterol ratio of patients with AD or VD did not differ significantly from those of controls. Coenzyme Q10 levels and coenzyme Q10/cholesterol ratio of AD or VD patients were not correlated with age, age at onset, duration of the disease or scores of the MiniMental State Examination. These results suggest that these values are not related with the risk for AD or VD.

Pathologic gambling in Parkinson's disease: a behavioral manifestation of pharmacologic treatment?

We describe 12 patients with Parkinson's disease and pathologic gambling. This association has apparently never been reported. The patients were selected from a Parkinson's disease unit of 250 patients. They met Diagnostic and Statistical Manual of Mental Disorders, 4th edition, criteria for pathologic gambling. All patients underwent a neurologic, psychiatric, and psychologic examination, specifically noting the presence or absence of psychopathology in the spectrum of impulse control disorder and the nature of the gambling. Ten patients started gambling after the onset of Parkinson's disease and treatment with levodopa. The pathologic behavior was exclusively present or was markedly increased in "on" periods in 11 patients. All patients had motor fluctuations at the time of the study. Slot machines were the preferred source of gambling for 10 patients, similar to the Spanish gambling population. That the gambling behavior appears more often in the "on" periods of motor fluctuations and that it begins after the onset of Parkinson's disease in most patients and worsens with levodopa therapy suggest that it could be related to the dopaminergic tone in patients with Parkinson's disease and motor fluctuations (that is, it could represent a behavioral manifestation of pharmacologic treatment).

Serum levels of coenzyme Q10 in patients with multiple sclerosis

To elucidate whether serum coenzyme Q10 levels are related with the risk for multiple sclerosis (MS) or are a marker for the activity of the disease, we compared serum levels of coenzyme Q10 and the coenzyme Q10/cholesterol ratio, in 31 patients with MS (during exacerbations) and 19 matched controls using a high performance liquid chromatography technique. The mean serum coenzyme Q10 levels and the coenzyme Q10/cholesterol ratio did not differ significantly between the 2 study groups. The values did not correlate with age, age at onset, and duration of the disease. These results suggest that serum coenzyme Q10 concentrations are unrelated with the risk for MS and are not a useful marker of activity of the disease.

Respiratory chain enzyme activities in spermatozoa from untreated Parkinson's disease patients

We studied respiratory chain enzyme activities in spermatozoa homogenates from 12 untreated Parkinson's disease (PD) male patients and from 23 age matched healthy male controls. When compared with controls, PD patients showed significantly lower specific activities for complexes I+ III, II+III, and IV. However, citrate synthase corrected activities were similar in patients and controls. Values for enzyme activities in the PD group did not correlate with age at onset, duration, scores of the Unified Parkinson's Disease Rating Scales and Hoehn and Yahr staging. These results suggest that this tissue cannot be used to develop a diagnostic test for PD.

[Estimation of the neurologic demand in a health care area of Madrid, Spain (area 11, University Hospital, 12 of October)]

OBJECTIVES

To analyse the demand for neurologic care and the neurological resources in a health district.

PATIENTS AND METHODS

Demographic, medical care aspects, neurologic care demands and neurological resources of the health district 11 of Madrid (University Hospital "12 de Octubre"), referred to 1996, were reviewed.

RESULTS

The rate of aging (17%) and the consulting rates in the National Health System (86%) versus private care were high in this health district. The neurologic care demands were 17.5-18.1 and 36 consultations respectively per 1,000 inhabitants/year. There were 2 patient-care neurologists and 3.7 neurologic beds per 100,000 inhabitants.

CONCLUSIONS

The neurologic care was considered high and with a tendency to increase. The available neurological resources were judged to be insufficient.

[Do antioxidants in the diet affect the risk of developing Parkinson disease?]

OBJECTIVE

A number of studies suggest the existence of 'oxidative stress' in the substantia nigra from parkinsonian patients. If 'oxidative stress' should be relevant in the pathogenesis of Parkinson's disease (PD), the consumption of antioxidant or prooxidant substances in the diet could theoretically influence the risk for this disease.

DEVELOPMENT

A critical up to date review of the literature regarding premorbid consumption of antioxidants or prooxidants by PD patients and controls has been done. Most studies have been retrospective, they have been performed following different designs, and disclosed contradictory results.

CONCLUSION

From the current literature, it is unlikely that dietetic consumption of prooxidants and antioxidant, specially vitamin E (the most frequently studied antioxidant) have any influence on the risk for PD.

[Neurological complications of peri-spinal block in regional anesthesia]

INTRODUCTION

A perispinal block (intradural and/or epidural) is a technique which is considered to be safe under certain conditions. Nevertheless, neurological complications are possible and may be associated with transient or permanent sequelae, as is shown by symptoms ranging from minor alterations (most commonly) to major neurological defects (rarely).

DEVELOPMENT

In this article we describe a review of the bibliography on physiopathological mechanisms (ischaemia, compression, trauma per se, neurotoxicity of the anesthetic drugs and infection), and also the risk factors associated with the development of these complications.

CONCLUSION

Knowledge permits the use of a series of preventive measures to be followed before, during and after carrying out the technique.

Cerebrospinal fluid levels of thiamine in patients with Parkinson's disease

Thiamine is an essential cofactor for several important enzymes involved in brain oxidative metabolism, such as the alpha-ketoglutarate dehydrogenase complex (KGDHC), pyruvate-dehydrogenase complex, and transketolase. The activity of KGDHC is decreased in the substantia nigra or patients with Parkinson's disease (PD). We measured cerebrospinal (CSF) levels of thiamine-diphosphate, thiamine-monophosphate, free thiamine, and total thiamine, using ion-pair reversed phase high performance liquid chromatography, in 24 PD patients and 40 matched controls. The mean CSF levels of thiamine-derivatives did not differ significantly from those of controls, with the exception of lower CSF free thiamine levels in the PD-patient group. PD patients under levodopa therapy had significantly higher CSF thiaminediphosphate and total thiamine than those not treated with this drug. CSF thiamine levels were not correlated with age, age at onset, duration of the disease, scores of the Unified Parkinson Disease Rating Scale of the Hoehn and Yahr staging in the PD group. These results suggest that low CSF free thiamine levels could be related with the risk for PD.

Cerebrospinal fluid levels of selenium in patients with Alzheimer's disease

We compared CSF and serum selenium levels, measured by atomic absorption spectrophotometry, in 27 patients with Alzheimer's disease (AD) (13 females, 14 males, mean +/- SD age 73.6 +/- 7.4 years) without major clinical signs of undernutrition, and 34 matched controls (18 females, 16 males, mean +/- SD age 70.7 +/- 7.8 years). CSF and serum selenium levels did not differ significantly between AD-patient (11.4 +/- 7.8 ng/ml and 28.5 +/- 13.0 ng/ml, respectively) and control groups (13.3 +/- 7.0 ng/ml and 22.5 +/- 17.5 ng/ml). These values were not correlated with age, age at onset, duration of the disease, and scores of the MiniMental State Examination in the AD group. Weight and body mass index were significantly lower in AD patients than in controls. These results suggest that CSF selenium concentrations are apparently unrelated with the reported oxidative stress processes in patients with AD.

Serum levels of beta-carotene, alpha-carotene and vitamin A in patients with Alzheimer's disease

To elucidate the possible role of carotenoids and vitamin A as risk factors for Alzheimer's disease (AD), we compared serum levels of beta-carotene and alpha-carotene, and vitamin A, measured by isocratic high performance liquid chromatography, of 38 AD patients and 42 controls. The serum levels of alpha-carotene did not differ significantly between AD patients and control groups. However, the serum levels of beta-carotene and vitamin A were significantly lower in the AD-patient group. These values did not correlate to age, age at onset or score on the MiniMental State Examination. Weight and body mass index were significantly lower in AD patients than in controls. These results suggest that low serum beta-carotene concentrations in AD patients could be related to a deficiency in dietary intake of this provitamin, although its possible relationship with risk for AD could not be excluded.

[Motor and mental complications in the long-term treatment of complicated Parkinson's disease with levodopa]

INTRODUCTION

The progression of Parkinson's disease and levodopa therapy leads to development of motor and psychic complications that cause serious limitations to the management of the advanced disease.

DEVELOPMENT

This article reviews the current literature regarding the pathophysiology and the therapeutic approaches to the management of motor and psychic fluctuations in Parkinson's disease.

CONCLUSIONS

1. The most important risk factors for the development of motor fluctuations are the young age at onset and severity of Parkinson's disease, and duration and maximum dose of levodopa. 2. Pathophysiological data include the denervation of substantia nigra compacta and postsynaptic pharmacodynamic mechanisms, with a lesser contribution of pharmacokinetic factors. 3. The main therapeutic approaches include changes in the form of administration of levodopa, inhibitors of levodopa catabolism, and dopamine agonists. 4. A number of psychiatric symptoms, including depression, panic attacks, mania and cognitive impairment, can have a fluctuating course, coinciding with the motor fluctuations.

Serum levels of beta-carotene, alpha-carotene, and vitamin A in patients with amyotrophic lateral sclerosis

To elucidate whether serum alpha and beta-carotene and retinol levels are related with the risk for amyotrophic lateral sclerosis (ALS), we compared serum levels of alpha-carotene, beta-carotene, and retinol (vitamin A), measured by HPLC, in 40 patients with amyotrophic lateral sclerosis (ALS) and 87 matched controls using an isocratic high performance liquid chromatography technique. The mean serum alpha and beta-carotene, and retinol levels did not differ significantly between the 2 study groups. These values were not influenced by the clinical form (spinal vs bulbar) of ALS, and they did not correlate with age, age at onset, and duration of the disease. These results suggest that serum alpha and beta-carotene and retinol concentrations are unrelated with the risk for ALS.

[Pharmacological mechanisms of the treatment of dyskinesias in Parkinson disease]

OBJECTIVE

The progression of Parkinson's disease (PD) and levodopa therapy leads to development of motor and psychic complications that cause serious limitations to the management of the advanced disease.

DEVELOPMENT

This article reviews the current literature regarding epidemiological, clinical, pathophysiological and therapeutics of levodopa-induced dyskinesias (LID).

CONCLUSIONS

1) The most important risk factors for LID are the cumulated doses of levodopa, young age at onset and severity of PD. 2) Pathophysiological data include the nigrostriatal system denervation, the prolonged exposure to levodopa and the integrity of striatal eferences; in addition there are some alterations of dopamine receptors and other neurotransmitter systems. 3) Some pharmacological measures, different for each type of LID, and surgery (pallidotomy, pallidal stimulation, subthalamic stimulation) can be useful for the therapy of LID.

Ternary complex structure of human HGPRTase, PRPP, Mg2+, and the inhibitor HPP reveals the involvement of the flexible loop in substrate binding

Site-directed mutagenesis was used to replace Lys68 of the human hypoxanthine phosphoribosyltransferase (HGPRTase) with alanine to exploit this less reactive form of the enzyme to gain additional insights into the structure activity relationship of HGPRTase. Although this substitution resulted in only a minimal (one- to threefold) increase in the Km values for binding pyrophosphate or phosphoribosylpyrophosphate, the catalytic efficiencies (k(cat)/Km) of the forward and reverse reactions were more severely reduced (6- to 30-fold), and the mutant enzyme showed positive cooperativity in binding of alpha-D-5-phosphoribosyl-1-pyrophosphate (PRPP) and nucleotide. The K68A form of the human HGPRTase was cocrystallized with 7-hydroxy [4,3-d] pyrazolo pyrimidine (HPP) and Mg PRPP, and the refined structure reported. The PRPP molecule built into the [(Fo - Fc)phi(calc)] electron density shows atomic interactions between the Mg PRPP and enzyme residues in the pyrophosphate binding domain as well as in a long flexible loop (residues Leu101 to Gly111) that closes over the active site. Loop closure reveals the functional roles for the conserved SY dipeptide of the loop as well as the molecular basis for one form of gouty arthritis (S103R). In addition, the closed loop conformation provides structural information relevant to the mechanism of catalysis in human HGPRTase.

Cerebrospinal fluid selenium and chromium levels in patients with Parkinson's disease

We compared CSF and serum levels of selenium and chromium, measured by atomic absorption spectrophotometry, in 28 patients with Parkinson's disease (PD) and 43 matched controls. The CSF and serum levels of these trace metals did not differ significantly between PD patients and controls. CSF selenium and chromium levels were not correlated with age, age at onset, duration of the disease, scores of the Unified Parkinson Disease Rating Scale of the Hoehn and Yahr staging in the PD group. Although antiparkinsonian therapy did not influence significantly the CSF levels of selenium, PD patients not treated with levodopa had significantly higher CSF selenium levels than controls (p < 0.01). It is possible that increased CSF selenium levels could indicate an attempt of protection against oxidative stress. The normality of CSF and serum chromium levels suggest that these values are not related with the risk for PD.