Memantine versus donepezil in mild to moderate Alzheimer's disease: a randomized trial with magnetic resonance spectroscopy.

BACKGROUND AND PURPOSE: To compare memantine with the most prescribed cholinesterase inhibitor (donepezil) from a clinical viewpoint when administered in early phases of Alzheimer disease (AD), and to find out whether memantine may produce changes in brain metabolite concentrations in comparison with donepezil. METHODS: In this comparative rater-blinded parallel group randomized trial we recruited a consecutive sample of patients with probable mild to moderate AD. At baseline we carried out neuropsychological assessment with mini-mental, Clinical Dementia Rating Scale (CDR), Blessed Dementia Rating Scale, Alzheimer's Disease Assessment Scale, cognitive part (ADAS-cog), neuropsychiatric inventory (NPI), and disability assessment for dementia (DAD), as well as (1)H magnetic resonance spectroscopy (MRS) in several areas of the brain. Patients were randomized to receive either donepezil or memantine for 6 months. After this elapse of time we repeated the same procedures and observed the changes in clinical scales (ADAS-cog, NPI, DAD), as well as the changes in metabolite levels in every area of exploration (temporal, pre-frontal, posterior cingulated (PCG), and occipital), especially those of N-acetyl-aspartate (NAA) which is regarded as a surrogate marker of neuronal density. RESULTS: A total of sixty-three patients completed the trial. We did not see significant differences in clinical scales and metabolite levels between those on donepezil (n = 32) and those on memantine (n = 31). In general, more patients worsened than improved on either of the drugs. The changes in the NAA/creatine ratio in the PCG correlated significantly with the changes in the ADAS-cog (P = 0.004). CONCLUSIONS: Donepezil and memantine have similar modest clinical and spectroscopic effect on mild to moderate AD. MRS could be useful to monitor progression of the disease.

Prevalence of Parkinson's disease in lower Aragon, Spain.

OBJECTIVE: We attempted to measure the prevalence of Parkinson's disease (PD) and to improve PD diagnosis in Lower Aragon (LA), a rural area located in northeast Spain with an elderly population numbering 60,724. METHODS: Hospital records and a questionnaire targeted at general practitioners and retirement home personnel were used for case finding. Neurologic diagnoses were ascertained by a neurologist using a clinicoepidemiologic protocol and established diagnostic criteria after examining 84% of patients diagnosed with PD. Using stratified analysis, a comparison was run against reported PD prevalence from worldwide door-to-door surveys. RESULTS: On the prevalence date, 134 individuals were found to be affected with PD. The prevalence per 100,000 population was 220.6 (crude) and 121.9 when age-adjusted using the European Standard Population. Prevalence increased with age, declining at 90 years and over. Questionnaires returned by general practitioners disclosed 20% of the prevalent PD cases. The prevalence of PD in pooled European populations was 2.56 times (95% confidence interval [CI]: 2.02-3.24) greater than that found in our study. CONCLUSION: PD prevalence in Lower Aragon ranks at levels similar to those reported for white populations (European and non-European). One out of two individuals with PD was estimated to be undiagnosed before and three out of eight after the study.

[Depression and Parkinson disease]. / Depresión y enfermedad de Parkinson.

OBJECTIVE: Depression occurs more often in Parkinson's disease (PD) than in other chronic illnesses with important disability. The relationship between the depression level and some clinical features of PD remains controversial. Frequency of depression in these patients has been estimated and relationship between this symptom with some clinical features of PD. METHODS: A diagnosis of PD was taken according to the United Kingdom Parkinson's Disease Society Brain Bank criteria. Depression status was rated with Geriatric Depression Scale (GDS). RESULTS: Sixty-two patients (56%), 24 male and 38 female, were depressed at the time of study. The frequency of depression was higher in female (61% vs 39%, p < 0.05) and younger patients with a significant difference (p < 0.001). 53.4% of the patients became depressed previous of beginning PD symptoms, being 71% female (p < 0.05). Patients with depression had had PD longer than patients without depression (7.7 vs 5.3 years old, respectively; p < 0.05). Patients with depression were found to be more affected on motor rating scales (p < 0.01). CONCLUSIONS: Depression was found in 56% of PD patients, with female predominance (61%). Frequency of depression was higher in younger patients. Depression was associated with duration of PD and an inverse relationship between depression and cognitive status was found.

[Cognition deterioration in Parkinson's disease: associated risk factors]. / Deterioro cognoscitivo en la enfermedad de Parkinson: factores de riesgo asociados.

INTRODUCTION: Frequency estimation of dementia in Parkinson's disease (PD) has often been the source of controversy owing to variations in the case selection methods and diagnosis criteria used. We examined the frequency of dementia and differences found in some clinical features between PD patients with or without cognitive impairment, to determine the risk factors for incident dementia in PD patients. METHODS: A diagnosis of PD was taken according to the United Kingdom Parkinson's Disease Society Brain Bank criteria. Subjects were considered as affected from cognitive impairment if Minimental State Examination score was below to 21. RESULTS: Cognitive impairment was present in 36% of PD patients. The mean age was higher in PD patients with cognitive impairment (76 vs 69 years old, respectively; p < 0.001). The age onset of PD was higher in patients with cognitive impairment (68 vs 63 years old, respectively; p < 0.01). The rate of PD patients with low educational level were higher in patients with cognitive impairment (59 vs 30%, respectively; p < 0.01). Patients with cognitive impairment had higher rating scale score (p < 0.001). CONCLUSIONS: Cognitive impairment was present in 36% of examined PD patients, based in our operative diagnostic criteria. The cognitive status decrease continuously with age. It's also evidence an inverse relation between educational level and rating scale score with cognitive impairment.

Prevalence of multiple sclerosis in the province of Teruel, Spain.

There have been few reports about the frequency of multiple sclerosis (MS) in Spain. We undertook a prevalence study in the province of Teruel, which is served by two hospitals as referral centres for a population of 143,680. We found a total of 46 patients who fulfilled Poser's criteria for clinically definite or probable MS with a prevalence rate of 32/100,000 [95% confidence interval (CI): 22.8-41.3]. The prevalence rates for males and females were 23.5 (95% CI: 12.3-34.7) and 40.6 (95% CI: 25.8-55.4) respectively. We found an incidence rate of 2.2/year per 100,000 in the last 5 years. The sex ratio (females/males) was 1.7. The mean age on prevalence day was 40.6 years (range: 15-76). The clinical course was relapsing-remitting in 82% of patients, progressive in 9% and secondary progressive in the other 9%. The mean EDSS score was 3.73 (range: 1-8.5). Our results confirm the hypothesis that Spain is an area at high risk for MS.

[Phenotype variability in adrenoleukodystrophy. Presentation of three new cases and a review of literature]. / Variabilidad fenotípica de la adrenoleucodistrofia. Presentación de tres casos y revisión de literatura.

INTRODUCTION: Adrenoleukodystrophy is a hereditary recessive sex-linked disorder with very variable phenotype expression, including classical infantil ALD, adrenomyeloneuropathy (AMN) in adults and sex-linked Addison's disease. Clinical observations. Three affected patients are presented. The first showed signs of myeloneuropathy from the age of 38 and diagnosis was made by showing raised serum and fibroblasts levels of very long chain fatty acids (C26:0). In the second case symptoms started at the age of 13 and cerebral and peripheral nervous system changes developed progressively. This patient's brother was the third case, showing symptoms when he was 21 and developing cerebral, medullary and peripheral nervous system involvement. In the latter two cases, diagnosis was made by showing intracytoplasmatic trilaminary inclusions in the nervous system. CONCLUSIONS: It is important to recognize the different varieties of this disease in view of the possibilities of genetic counselling and of the therapeutic implications which are currently being evaluated.

[The validity of the system of obligatory disease declaration for the epidemiologic surveillance of meningococcal meningitis]. / Validez del sistema de enfermedades de declaración obligatoria para la vigilancia epidemiológica de la meningitis meningocócica.

In Spain meningococcic meningitis is a disease of obligatory declaration which is declared under the name of "Meningococcic infection". In this section other process are also included with the declaration being made under suspicion, with no knowledge of the degree of fulfillment and the significance of the official data. To know this the clinical history of meningitis patients of all the hospitals in Aragon from January 1985 to December 1988 were reviewed comparing the results with those from the system of obligatory disease declaration. The degree of fulfillment for meningococcic meningitis was 90% with the annual rates of incidence of meningococcic meningitis being 1.11 to 2.13 fold higher, according to hospitalary data, higher than the rates of the obligatory disease declaration system.

[Syringomyelia due to arachnoiditis. Clinical-radiological description of 5 patients]. / Siringomielia por aracnoiditis. Descripción clinicorradiológica de 5 pacientes.

Five patients (mean age 44 years--range 21-67 years) with arachnoiditis of different origin who posteriorly developed syringomyelia are presented. The etiopathogenic mechanism of the arachnoiditis was post injury in one case, 2 patients had history of meningitis (tuberculous and pneumococcic) and in the other two no related factor was found. The period of latency among the causes which originated arachnoiditis and the diagnosis of syringomyelia oscillated between 10 months and 16 years. The localization of the cavity was dorsal in 3 cases, cervical in another and in the last it was extended along the whole spine. No patient demonstrated the Arnold-Chiari malformation nor basilar impression. Analyzing the clinical history, radiologic studies and surgical findings the most probable etiopathogenic mechanism involved in each case is discussed.

[The evaluation of cognitive deterioration in transient ischemic attacks]. / Valoración del deterioro cognitivo en el accidente isquémico transitorio (AIT).

We compared the degree of dementia in a group of 41 patients who, four years previously, had presented a first TIA with that of 31 healthy controls of similar age. For pathogenic diagnosis the Hachinski and Gustafson-Nilsson scales were applied, while mental state was evaluated by the Folstein, Blessed, GDS and CDR tests. We performed in all cases cerebral CT and several MR. The findings associated with dementia were the presence of multi-infarctions, leucoaraiosis or lacunes in the cerebral CT and the presentation of new ischemic episodes, sphincterian or gait disturbances and focal deficits. There were no differences with the control group in the cases only presenting one TIA. Polyglobulia was the only factor significantly associated with vascular dementia in these patients.

[Anterior spinal artery syndrome caused by cervical disc protrusion. Diagnosis by magnetic resonance]. / Síndrome de la arteria espinal anterior debido a protrusión discal cervical. Diagnóstico por resonancia magnética.

The syndrome of the anterior spinal artery is a rare disease with a diagnosis based an its characteristic clinical features. Until the widespread use of the Magnetic Resonance (MR) the lesional confirmation required an anatomopathological study. We report a 49-years-old male with lacinating interscapular pain and sudden asymmetrical tetraparesia, in whom MR scan disclosed a plurisegmental anterior spinal lesion and a posterolateral disk protrusion at C6-C7 level. We discuss the etiological and pathogenetical relation between degenerative vertebral disk disease and spinal infarctions.

[Primary intraventricular hemorrhage in the adult]. / Hemorragia intraventricular primaria en el adulto.

Forty two instances of primary intraventricular hemorrhage (PIVH) out of overall 592 cases of intracerebral hemorrhages diagnosed by CT in 1980-1989, to evaluate the general prognosis attributable to PIVH and its factors. The mortality rate was 23.8%, and persistent residual disability was small or absent in 59.5% of patients. The prognosis was influenced by the clinical status at admission and the magnitude of ventricular bleeding. We conclude that PIVH is comparatively benign.