[Advanced Parkinson's disease: clinical characteristics and treatment (part 1)]

INTRODUCTION

A large percentage of patients with Parkinson's disease (PD) develop motor fluctuations, dyskinesias, and severe non-motor symptoms within 3 to 5 years of starting dopaminergic therapy, and these motor complications are refractory to treatment. Several authors refer to this stage of the disease as advanced Parkinson's disease.

OBJECTIVE

To define the clinical manifestations of advanced PD and the risk factors for reaching this stage of the disease.

DEVELOPMENT

This consensus document has been prepared by using an exhaustive literature search and by discussion of the contents by an expert group on movement disorders of the Sociedad Española de Neurología (Spanish Neurology Society), coordinated by two of the authors (JK and MRL).

CONCLUSIONS

Severe motor fluctuations and dyskinesias, axial motor symptoms resistant to levodopa, and cognitive decline are the main signs in the clinical phenotype of advanced PD.

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.

[Quality of life in Alzheimer's disease]

INTRODUCTION

Quality of life is a concept that is receiving increasing amounts of attention; its assessment complements the traditional clinical evaluation, which is of special interest in areas related with healthcare organisation. Here, we present a study on quality of life in Alzheimer's disease and its relationship with cognitive and functional measures.

PATIENTS AND METHODS

Quality of life was evaluated by means of the EQ-5D scale in a sample of cases of Alzheimer's disease (diagnosed according to criteria established by the National Institute of Neurologic, Communicative Disorders and Stroke-Alzheimer's Disease and Related Disorders Association) that donated blood samples for the National DNA Bank. The status of the global deterioration scale was determined and a verbal fluency test and the Folstein minimental test were also carried out. A classic analysis, variable contrast by means of chi-square for proportions and Student's t test for measurements were conducted, as well as estimation of r for the regression models in the quantitative variables. The social rate was determined using the software application SPSS v. 11.

RESULTS

Altogether 141 cases were analysed, with a male to female ratio of 2:1, and a mean age of 76.2 years. Aspects such as personal hygiene, activity and, to a lesser extent, motility are affected in Alzheimer's disease, but pain and anxiety aspects do not seem to be affected. There is a relationship between quality of life, functional scales and cognitive scales. Functional aspects correlate with quality of life better than cognitive ones.

CONCLUSIONS

Quality of life is evaluated in Alzheimer's disease using general scales, such as EQ-5D. Cognitive aspects do not appear to provide relevant information about quality of life that is not already provided by the functional aspects.

[Neuroprotection in Parkinson's disease: analysis though group of experts' methodology]

INTRODUCTION

Currently used antiparkinsonian drugs neither stop nor slow-down the progressive nature of the disease. The final phase of PD is characterized by the presence of symptoms and signs resistant to dopaminergic agents, such as depression, dementia, freezing and falls. Therefore, it is urgent to develop therapies able to positively modify this outcome. Despite neuroprotection is a research priority in PD, no effective strategies have been found so far.

METHOD

A key informants study was conducted. A group of experts in PD fulfilled a questionnaire of 10 questions to explore the most important topics related to neuroprotection. Afterwards a consensus about the current situation of neuroprotection in PD was established and future directions of development were suggested.

RESULTS

Most of the answers emphasized the need of new concepts, the limitations of animal models and the difficulties in the difficulties in demonstrating a neuroprotective effects in humans owing to a lack of biomarkers. Some of the experts believe that we are already exerting a disease modifying effect.

CONCLUSIONS

The concept of neuroprotection should be widened. Animal models should be improved. A reliable biomarker to start neuroprotective therapies long before the appearance of motor symptoms and to evaluate the neuroprotective effect of any therapy should be urgently developed.

[Diagnosis of vascular parkinsonism: correlation of the symptoms with neuroimaging and utility of SPECT with 123I-ioflupane]

INTRODUCTION

The concept of vascular parkinsonism (VP) has evolved since it was introduced by Critchley. The relationships between the clinical manifestations and neuroimagining of patients with VP to determine the utility of SPECT in its diagnosis have been established.

MATERIAL AND METHODS

Retrospective study of patients with suspicion of VP according to Ziljmans 2004 criteria.

RESULTS

A total of 22 patients were included. The most frequent risk factor was AHT. The most frequent manifestations were: bradykinesis, followed by gait disorder. Response to L-dopa was related with symptoms in lower limbs (p=0.014). The most frequent alterations on the magnetic resonance imaging were: atrophy with ventricular dilation followed by white matter lesions. The Hachinski scale was related with acute onset (p=0.022) and territorial infarction (p=0.039), and the Winikates with subcortical- paraventricular white matter lesions (p=0.036), and both with gender (male) (p=0.031), and stroke background (p=0.022). Alteration in gait was associated with paraventricular white matter lesions (p = 0.043), and other manifestations with lesions in the medulla (p=0,020). Tremor was associated with bilateral involvement of putamens in SPECT (p=0.039), strategic lesion with putamen involvement (p = 0.028) and lesions of periventricular white matter lesions with SPECT type 1 and 2 (p=0.045). There were no significant relationships of the SPECT with response to L-dopa or with the scales. Discussion. The different relationships between symptoms, scales and neuroimagin show the complexity of the subject and the need to use all of them in the diagnosis of VP.

Unique origin and low penetrance of the 946delGAG mutation in Valencian DYT1 families

Mutations in the DYT1 gene cause idiopathic torsion dystonia (ITD) transmitted in families as an autosomal dominant trait with incomplete penetrance. The most common mutation, 946delGAG, has been observed in populations with different ethnic and geographic origins. We have investigated 40 individuals from 22 unrelated families with ITD originating from the Land of Valencia, Spain, for the presence of this mutation and we found 5 patients and 6 unaffected subjects from 4 families who were carriers of the mutation. This finding indicates that 18% of families may be diagnosed as DYT1 and that penetrance is reduced. We detected two different geographic and linguistic origins of the Valencian families. However, by haplotype analysis using D9S1260, D9S1261, D9S63 and D9S1262 as flanking markers, we demonstrated that all affected and unaffected carriers shared a common chromosome confirming identical origin of the mutation in the four families. We postulate a unique origin for the 946delGAG mutation in the Land of Valencia and, based on linguistic criterion, we propose that the mutation might have occurred at the beginning of the second millennium. Genetic analysis of another family from Castilla-La Mancha showed a different haplotype segregating with the disease, suggesting that at least two distinct mutational events for the 946delGAG mutation have occurred in Spain.

Action hand dystonia after cortical parietal infarction

A 46-year-old patient with a pure left cortical infarct affecting mainly the gyrus postcentralis developed action dystonia in the right hand. Mechanisms involved in the genesis of focal secondary dystonia are discussed with emphasis on abnormal cortical sensory processing.

[Results of a program of presymptomatic diagnosis of Huntington's disease: evaluation of a 6 year period]

OBJECTIVE

To know the uptake of predictive testing of Huntington's disease, the characteristics of the applicants, as well as the consequences for them.

METHODS

Prospective observational study between January of 1994 and December of 1999 of the predictive testing applicants who entered in the protocol consisted of: informative interview, psychiatric interview, blood extraction for molecular study, as well as outcome and follow-up interviews.

RESULTS

There were 87 applicants with a 50% risk. The mean age of the applicants was 28 years (SD = 7). Thirty one per cent already had children in the moment of predictive testing. The application rate according to the estimate population with 50% risk for the Comunidad Valenciana is 13,4%. The rate varies depending on the access to the information of the population in risk, being of 24,7% when they have direct access and of 8,3% when they do not have it (p < 0,01). Forty per cent did not come to the post-outcome visit, the positive or negative result for the mutation not influencing over it. Only 6,8% had some adverse event in the six years of follow-up all being slight.

CONCLUSIONS

The application rate is determined by the access to the information of the population in risk. The fulfilment of the protocol designed for presymptomatic diagnosis of Huntington's disease keeps the adverse events presentation to a minimum.

[Descriptive study of a serie of patients affected by progressive supranuclear palsy]

INTRODUCTION

Progressive supranuclear palsy is a neurodegenerative disorder affecting diverse neurologic systems. The actual treatment response is poor in most patients.

OBJECTIVE

review of a long series of patients affected by PSP in several aspects.

PATIENTS AND METHODS

A series of patients was reviewed by means of the register questionnaire of PSP in Spain (from PSP Disabling Rating Scale and Staging System). This is carried out on the patients when the diagnostic is done. It was achieved a descriptive of the patients, in several aspects, and an evaluation of the treatment in relation to the dose and the duration.

RESULTS

In general, the age of diagnostic is 66 years, there is not neurological illness in the family, falls and disorders of gait are the most representative parameters. The neuroimage shows fronto temporal atrophy. The treatment response is poor, despite the dose and the duration.

CONCLUSIONS

Our series confirms the typical dates of the illness an the poor response to treatment with L Dopa.

Polyradiculoneuritis after botulinum toxin therapy for cervical dystonia

A 40-year-old man with cervical dystonia developed an acute inflammatory demyelinating polyradiculoneuritis after botulinum toxin type A treatment. Some cases of idiopathic brachial plexopathy and polyradiculoneuritis have been reported to date. Although a causal relationship is not firmly established, the clinical temporal profile suggests a pathogenic relationship. In patients with cervical dystonia, further use of type A botulinum toxin should be considered contraindicated, and the use of another type of botulinum toxin should be taken into consideration.

[Entacapone: is it useful as complimentary treatment with levodopa?]

Entacapone (Comtan) is a potent, selective inhibitor of peripheral catechol-O-methyltransferase (COMT) with therapeutic potential as an adjuvant to levodopa therapy in patients with Parkinson's disease. Entacapone decreases peripheral conversion of levodopa to 3-O-methyldopa increasing central extracellular levodopa and consequently striatal dopamine concentrations. At doses of 200 mg 2 to 10 times daily coadministered with levodopa/carbidopa or levodopa/benserazide entacapone may increase the duration of clinical response both after the first single dose and after repeated dosing in patients with end-of-dose fluctuations. At this dosage, it has a time to peak-plasma concentration of 1.2 hours and an elimination half life of 3.4 hours. In two multicentric, long-term (approximately 6 month), randomized and placebo-controlled studies, the duration of 'on' time was increased and the duration of 'off time' was decreased in patients who received adjunctive entacapone therapy. Moreover, patients randomized to entacapone reduced their levodopa requirements. In these and other phase III studies, entacapone was generally well tolerated, with few reported adverse events, mainly dyskinesias and gastrointestinal disorders. The dyskinesias were generally well controlled by decreasing the mean daily levodopa dose. Entacapone appears as a clinically significant and beneficial adjunct to levodopa therapy in Parkinson's disease patients with end-of-dose fluctuations.

[Outpatient care of patients with Parkinson disease]

INTRODUCTION

Some neurology clinics have been set up in specialist centres during the last ten years and their activities described. The group of patients with Parkinson's disease attended in the clinics of specialist centres have the distinguishing feature of where they are treated, which makes them different to other groups with the same disorder.

OBJECTIVE

In this article we describe the general data of neurological attention for patients with Parkinson's disease, seen in two clinics belonging to specialist centres.

PATIENTS AND METHODS

This article is based on records of patients made by neurologists of two structured centres in Hospital La Fe.

RESULTS

In a period of 18 months 228 patients with Parkinson's disease were recorded out of a total case register of 5,101. Patients with Parkinson's disease made up between 4% and 5% of the patients attending the clinic. Between 30% and 50% of the patients seen in these clinics were evaluated only once during the period recorded.

CONCLUSIONS

There seems to be a large number of cases recorded and these represent 70% of the estimated number of cases in the area. It seems that some patients do not keep in contact with the neurologist. Differences in function noted in clinics of specialist centres, between each other and compared with hospitals, are due to specific organizations and structures.

[Familial multiple sclerosis: a study of six families]

INTRODUCTION

Multiple sclerosis (MS) is a demyelinating disorder of the CNS, of autoimmune pathology and unknown aetiology. Several theories regarding its aetiology have been suggested, although none seems to be completely convincing. Genetically predisposed persons are affected, therefore groups of MS are seen in certain families.

OBJECTIVES

To describe the family links, type of illness and evolution of 12 patients from six families with two or more members diagnosed as having MS, and to evaluate any differences from the other cases recorded in our data base.

PATIENTS AND METHODS

We studied 12 patients diagnosed on the criteria of Poser, and with at least one first or second degree relation with MS. We compared clinical data, form of presentation and course with 127 patients recorded in the data base.

RESULTS

We describe six families: two homozygotic twins, two families in which transmission was from father to child and three families with first degree cousins affected. We found no clinical variation in the presentation, number of attacks or evolution, as compared with the other patients. Nor was there homogeneity between the familial forms of MS.

CONCLUSIONS

Familial forms make up approximately 10% of the series. We do not have any data available for early diagnosis nor for prognostic significance of familial MS.

[Estimate of the prevalence of Huntington disease in the Valencia region using the capture-recapture method]

INTRODUCTION AND OBJECTIVE

The objective of this study was to estimate the prevalence of Huntington's disease in order to devise a programme for diagnosis and prevention. Because of the characteristics of this disease, which is hereditary and of low incidence, few epidemiological studies have been carried out in Spain. Many studies (Medline 1990-1996) give cross-checking of registers as the key to determining the relative extent of the illness. The findings of this comparison of registers are not limited to the numerical quantification of a health problem, but are combined with active case search strategies, since there is now an approximation of probability to a previously unknown area of the disease.

MATERIAL AND METHODS

Prevalence in the Valencia Region (Spain), which has a population census of 3,873,812 inhabitants, was estimated by means of the probability method known as capture-recapture. The estimated maximum probability and its confidence interval were calculated. The sources of information used were clinical histories from the regional hospitals and official figures of registered deaths during the period 1987-1992.

RESULTS

It was found that there were 41 cases seen in the regional hospitals and 17 deaths recorded in the official statistics, while 4 cases coincided in both sets of statistics. Recovery of 45 cases histories enabled an analysis to be made of the relationship between the disease, sex, age of onset of symptoms, and family history.

CONCLUSION

The estimated prevalence was 5.38 x 10(5). The most notable finding was that of a systematically earlier onset of symptoms in women, which was greater when the family history was on the paternal side.

Early combination of bromocriptine and levodopa in Parkinson's disease: a prospective randomized study of two parallel groups over a total follow-up period of 44 months including an initial 8-month double-blind stage

To determine if the combination of levodopa (LD) plus bromocriptine (Br) in the early stages of Parkinson's disease (PD) permits reduction of LD dosage and consequently results in fewer motor fluctuations and dyskinesias, a double-blind, multicenter prospective study in 50 PD patients who had responded favorably to LD while under treatment with that drug for < or = 6 months was undertaken. Patients were randomized into two parallel groups (LD alone and LD plus Br). During the first placebo-controlled stage of the study lasting 8 months, association of a fixed dose of Br (15 mg/day) in the LD regimen did not allow a significant reduction in the daily LD dose. Still, in patients on combined LD plus Br, there was a tendency toward smaller daily requirements of LD as compared with those on LD alone, and the difference in LD dose between the two groups was significantly different (515.4 +/- 240 vs. 725.6 +/- 230 mg/day; p < 0.01) after 44 months of continuous treatment in the 40 patients still enrolled in the open-label stage. At that point in time, the mean dose of Br had been increased by 9.2 mg in the combined treatment group, and the mean dose of LD was 40.7% lower than in the group receiving LD alone. On subsequent evaluations, the number of patients with dyskinesias or describing wearing-off fluctuations severe enough to require changes in treatment was lower than in the group under combined therapy, the differences being significant after 20 and 44 months, respectively (36.8 vs. 9.5 and 47.3 vs. 14.2%). Our results support early combined LD-Br therapy in PD, but no conclusions can be drawn as to whether this dopamine agonist exerts a preventive effect on the late side effects of LD or has another mechanism of action.

Lithium-induced Creutzfeldt-Jakob syndrome

a 67-year-old man with bipolar disorder developed a Creutzfeldt-Jakob like syndrome during lithium carbonate treatment. Lithium serum level was within the therapeutic range. Complete clinical-electroencephalographic recovery was achieved after lithium therapy was discontinued. Several cases of lithium-induced Creutzfeldt-Jakob syndrome have been reported to date; all of them were elderly patients and a half had "therapeutic" lithium serum levels. Patients in this age group receiving antimanic maintenance treatment should keep lithium serum levels as low as possible. Lithium neurotoxicity should be considered in Creutzfeldt-Jakob disease differential diagnosis, serial electroencephalograms being the most valuable.

[New forms of Parkinsonism in hospice care]

Parkinson's disease is a well known phenomenon with characteristic evolution and clinical picture although having considerable variation in its presenting symptoms. From an extra-hospital consulting room we carried out a study of the characteristics of the clinical presentation of parkinsonisms in a series of one hundred cases so diagnosed from onset. The average age of the patients was around 66 years with a slight female predominance. Most patients had been referred to us by their own GPs. Some 70% of patients came suffering from shaking, 23% for slowness or clumsiness and 10% for unsteadiness. 71% of cases had unilateral onset and 29% had bilateral onset. Most of the patients we saw arrived at level 2 on the Hoehn and Yahr scale. The duration of the symptoms was approximately one year. In some 27% of cases drug consumption might have brought on parkinsonism. Almost two-thirds of these cases brought about by medicaments were being treated with cinaricine or flunaricine and nearly one third were undergoing neuroleptic treatment. Practically one out of every four cases, and one out of three women, could be considered as having iatrogenic parkinsonism. The onset of shaking with bilateral affectation is particularly suggestive of drug induced parkinsonism.

[Sleep disorders and Parkinson disease: study of a series]

Disturbances of sleep are frequent and varied in patients with Parkinson's disease. In an attempt to find out about these disturbances, we carried out interviews using the Vanna and Mazzuia questionnaire, modified for forty-five sufferers of Parkinson's disease, and forty healthy adults. We researched sleep habits and disturbances, as well as the consumption of hypnotics. We found that both groups had similar habits, although those with PD altered according to the stage of development of the disease, thus difficulty in staying sleep and parasomnia were more frequent in PD sufferers and worsened in the most advanced cases. On the other hand the quality of night sleep and the consumption of hypnotics interfered in the daytime efficiency of those suffering from Parkinson's Disease.

[Sexual dysfunction in Parkinson's disease]

Sexual activity, function and libido in 50 patients with idiopathic Parkinson's disease and no signs of mental deterioration were evaluated by an estructured questionnaire. The sample included 36 men and 14 women with a mean age of 57.9 +/- 10.1 years and a mean time elapsed since onset of 7.01 +/- 3.9 years. We found decreased sexual activity in 68% and a lack of libido admitted by 26%. Although the decrease in sexual activity was found more often in women, this dysfunction was not statistically significant. Decreased sexual desire, however, was statistically significant. Erectile dysfunction was found in 38.8% and was more frequent in patients over 61 years of age.

Chlormethiazole in the management of the opsoclonus-myoclonus syndrome

Two instances of successful treatment of the rare ocular dyskinesia, opsoclonus, with chlormethiazole are reported. A 65-year-old woman had the opsoclonus-myoclonus syndrome associated with carcinoma of the breast; her myoclonia and opsoclonus did not respond to intravenous diazepam or phenytoin. Treatment with intravenous chlormethiazole resulted in rapid control of her myoclonic attacks, followed by slower but complete resolution of the opsoclonus. Following control of the acute symptoms the patient was transferred to an oral chlormethiazole maintenance dose which was further reduced and subsequently discontinued after 5 months, when the patient's overall clinical status had improved. A 53-year-old man with opsoclonia, myoclonia, ataxia and encephalopathy, not associated with neoplasia, was given immunosuppressor drugs to establish basal control, and oral chlormethiazole for symptomatic treatment. Almost immediately after the initial dose of chlormethiazole the patient became more orientated; he was sedated and the agitation and myoclonic fits were brought under control quite quickly. The opsoclonus responded progressively and was completely resolved after a few days. The initial oral dose of chlormethiazole was gradually reduced and was discontinued after 5-6 months. Chlormethiazole was well tolerated; it may have an important role in the management of the rare opsoclonus-myoclonus syndrome.

[Mortality from Parkinson's disease in Spain (1980-1985). Distribution by age, sex and geographic areas]

An approximation of Parkinson's disease in Spain was carried out based on the data of mortality by this disease over the period 1980-1985. The annual number of deaths by Parkinson's disease as well as its distribution by sex, age groups and Spanish provinces was obtained from information published annually by the National Institute of Statistics in the Natural Movement of the Spanish Population. The global mortality rate during the period studied was of 2.14 per 100,000 inhabitants. The specific mortality rate by Parkinson's disease in males was slightly higher than that of females. A specific mortality rate was also observed by age groups being higher in the older age groups. From the point of geographical distribution, higher rates were observed in the northern provinces with respect to the south and in rural areas compared to provinces capitals. Following the analysis of the results obtained and upon comparing the findings published in other countries it was concluded that place of residence may be related to the development of Parkinson's disease. From these data new epidemiological studies are required oriented to the identification of the environmental factors which may play a role in the etiology of this entity.

Blood serum selenium in the province of Mérida, Venezuela, related to sex, cancer incidence and soil selenium content

Blood serum selenium levels were measured in healthy subjects of six districts located throughout the province of Mérida, Venezuela. There were either high (87-115 micrograms/L) or low (58-72 micrograms/L) serum selenium-containing districts. Serum selenium in males from three districts were statistically significantly lower (p less than 0.001) than in females. There was a general tendency for serum selenium to increase with age. On the average, a reduction in cancer was observed in the districts with high serum selenium content. Further, serum selenium was lower in male patients from the Mérida district with cancer disease. Association between selenium in soil and in the blood serum of healthy subjects has been observed.

[Findings of computed tomography in the acute form of Marchiafava-Bignami disease]

We report a case of Marchiafava-Bignami's disease with acute evolution. Pathological examination was carried out and a cavitary lesion with discontinuous longitudinal extension was found throughout the corpus callosum. CT had shown a narrow hypodense area symmetrically localized just anterior to the frontal horns of the lateral ventricles, corresponding to the genus of the corpus callosum. The literature is reviewed, the anatomical-radiological correlations are discussed, and the possibility of the diagnosis of this condition during life is commented.

[The electroretinogram and visual evoked potentials in patients with Parkinson's disease]

Whether Parkinson's disease patients have been shown to have abnormal visual evoked cortical potentials (VEPs) to flash and pattern stimulation or not, is a matter widely discussed. Actually it is said that this variability may be due to the stimulus method used and how the patients were selected. The retina is rich in dopamine and together with previous animal and human studies, this suggests that the abnormal VEPs in Parkinson's disease patients may be due to a biochemical and electrophysiological disorder in the retina. This hypothesis has been examined by studying the flash VEPs, pattern VEPs and with light electroretinogram in 29 Parkinson's disease patients and matched control subjects. We have found: a) Slower FVEPs and PEVPs latencies in Parkinson disease patients. Flash VEPS were more frequently abnormal than pattern VEPs. We have only found a significant relationship between slow flash VEPs and the patient age. b) Electroretinograms waves (a) and (b) amplitudes were smaller in Parkinson disease patients than in control subjects. b/a coefficient abnormal values must be due basically to wave (a) alterations. These values are statistically significant with respect to the number of years of L-Dopa in the evaluative stage and the evolutive stage of the illness. For all these reasons, we can deduce that an anomaly exists in the dopaminergic pathway in the retina, localized in the plexiform layer and neurophysiologically detectable by a study of the wave variations of the ERG and of the b/a coefficient.

[Wilson's disease: difficulties in diagnosis and therapeutic management in our country]

The clinical analytical and therapeutic results of a retrospective study of 11 cases of Wilson's disease carried out in "La Fe" Hospital in Valencia are presented. The disease had a neurological onset in 5 cases, an hepatic onset in 4 cases (3 acute hepatitis and 1 chronic hypertransaminemia), 2 cases started as an acute hemolytic anemia; one of the outbreaks occurred during a period of treatment interruption. Diagnosis showed some difficulty in one case since the disease was associated with positive hepatitis B markers, positive anti HIV antibodies and initially normal ceruloplasminemia values. The diagnostic difficulties derived from the interpretation of ceruloplasminemia, and blood and urine copper levels are pointed out as well as the difficulties encountered in our environment to determine intrahepatic copper levels and to perform a kinetic study with radioactive copper both of which are of vital importance to confirm doubtful cases. Two patients became pregnant in the course of the disease having normal pregnancies and deliveries, without any apparent abnormalities in the newborns. Treatment with D-Penicillamine was started in 9 cases, observing a low to moderate intolerance in 7 cases; there was one case of severe intolerance for which treatment had to be interrupted. The new therapeutical approaches based on the use of trientine (not available in our country) are discussed, together with the expectations of liver transplant in this disease.

[Abnormal movements of vascular origin]

Three patients with hemichorea and ten with dystonia of vascular origin are reported. Five were secondary to ischemic infarcts, two to lacunar infarcts, three to intraparenchymal hematoma, and in the remaining three the type of lesion could not be determined. The patients with chorea, as opposed to those with dystonia, presented abruptly immediately after the stroke, and had a regressive evolution and good therapeutic response. The type of dyskinesia was not useful to identify the precise localization of the lesion or to determine its nature. In addition, in 5 patients multiple lesions were found and 5 had release of archaic reflexes or cortical atrophy in CT; this shows the importance of the overall functional impairment and focal lesions in the genesis of dyskinesia. There were sensory deficits in 7 patients. In 2 patients lesions were not found in the CT in spite of the presence of previous hemiparesis; this suggests that this technique has limitations to discover focal cerebral lesions in patients with focal or hemicorporal dyskinesia.

[Opsoclonic cerebellar disease. A paraneoplastic syndrome sensitive to chlormethiazole]

Opsoclonus is a very rare ocular dyskinesia associated to a viral infection or neoplasms, being neuroblastoma in children or carcinoma in adults. A case of opsoclonus as a paraneoplastic symptom preceding the diagnosis of breast carcinoma is presented. The abnormal movements had a complete response to the administration of chlormethiazole.

Determination of lead in hair of exposed gas station workers and in unexposed adults by microwave-aided dissolution of samples and flow injection/atomic absorption spectrometry

Lead content in head hair of 53 gas station workers together with an equal number of normal controls was determined. Samples of hair were washed with ethanol and water and microwave-aided wet digested prior to the determination of lead by flow injection/atomic absorption spectrometry. The lead content in hair of the gas station workers (48.7 +/- 17.5 micrograms/g) was significantly higher than that of the normal controls (17.2 +/- 8.1 micrograms/g). The effects of washing and sample digestion procedures, head sampling site, hair color, age, smoking habits and duration of exposure to the metal are discussed.

[Effect of hypervitaminosis D on the activity of various enzymes in the rat liver]

The effect of eight doses of 10,000, 20,000 and 30,000 UI of vitamin D2 administered every other day to three groups of rats, on the activities of some enzymes in the animals' liver was evaluated. In general terms, findings revealed a decrease in the activities of glucose-6-phosphatase, phosphorylase and arginase. Likewise, an increase of the activities of maltase and of glutamic oxaloacetic and glutamic pyruvic transaminases was observed. Furthermore, the activities of cholinesterase and alpha-amylase also varied depending on the vitamin D2 doses administered.

Influence of selenium on aflatoxin B1 or crotalaria toxicity in turkey poults

This research compared the toxic effects of aflatoxin B1 and monocrotaline, the active principle of Crotalaria spectabilis, and the additive effect between aflatoxin B1 and monocrotaline in turkey poults. It was of interest whether selenium fed at dosage levels of 0.1, 5, or 10 micrograms/g of feed would protect against the toxic effect of aflatoxin and/or monocrotaline, and whether the toxicants would result in detectable residues in poult tissues. A total of 180 healthy 1-day-old male turkey poults was assigned at random to 12 treatment groups (15 birds/group). Body and liver weight losses, and low serum concentrations in total protein (TP), albumin (A), alpha-globulin (alpha G), and beta-globulin (beta G), as well as high values in gamma-globulin (gamma G), were produced in the groups fed crotalaria. Pathologic changes were induced by monocrotaline with no protection afforded by the added selenium. Low values in TP, A, alpha G, and beta G and in body and liver weights were observed in groups given the combination of aflatoxin plus crotalaria. Gross lesions were associated with an additive toxic effect and a lack of protective effect of selenium against this combination. However, higher values in TP, A, alpha G, and beta G, and liver weights in groups fed aflatoxin B1 plus selenium indicated that selenium had a protective effect against aflatoxin toxicity. Residues of aflatoxin B1 and aflatoxin M1 were found in the kidneys of poults fed aflatoxin B1; also, dehydroretronecine (the metabolite of monocrotaline) was detected in livers of poults fed Crotalaria spectabilis seeds.