High altitude headache. A prospective study of its clinical characteristics.

Altitude headache (AH) is the most common symptom of high altitude exposure. This prospective cross-sectional and analytical study, conducted in the Ecuadorian Andes, aimed to explore AH symptomatology, taking into account subjects' views. Thirty mountain climbers took part in the Questionnaire Elaboration. The symptoms were grouped into three categories: (A) pain dimension (PD)--intensity, location, quality, outset form, evolution, exacerbating and relieving elements; (B) concurrent symptom dimension (CSD); and (C) feeling/mood dimension (FMD). Ninety-eight mountain climbers comprised the sample for Field Research. Three evaluations were carried out: 4700-5000 m, n=1, and 5700-5800 m, n=2. Pearson's correlation coefficient was used to assess internal consistency. Scores between 0.7 and 1 were considered as significant to assess the strength of association between the PD and its different items and CSD and FMD. The following clinical features were found: holocranial 65.6%; pulsatile-burst type quality 75.3%; oscillating evolution 36.7%; increasing with exercise 49.5%; relieved by rest 41.8%; concurrent symptoms referred to, anorexia 26.8%, irritability 26.5%, and finally pessimism and anxiety feelings 33.2 and 29.5%, respectively. We believe that elements provided by us must lead to a new official AH diagnosis criterion.

[Sialorrhea in patients with Parkinson. A six year prospective study]. / Sialorrea en enfermos con Parkinson. Estudio prospectivo de seis años de duración.

INTRODUCTION: The sialorrhea has been recognised as one of the manifestations of Parkinson's disease, with a frequency of up to 80%. The evolution of patients with sialorrhea is unknown. PATIENTS AND METHODS: We study 26 male and 17 female patients with Parkinson's disease and sialorrhea. RESULTS: Evaluation at three years showed that sialorrhea had persisting in 18 of them, at six years showed that persisted in 8 patients. We found significant impairment in the sialorrhea group. CONCLUSION: If we accept the principle, that sialorrhea are levodopa-resistant disorders as non nigrostriatal symptoms, secondary to a diffuser and more extended cerebral stem degeneration, we could assume that in these patients with sialorrhea cortical-sub cortical circuits are more widely involved leading to motor and cognitive impairment and depression.

[Clonidine versus propranolol in the treatment of essential tremor. A double-blind trial with a one-year follow-up]. / Clonidina frente a propanolol en el tratamiento del temblor esencial. Estudio doble ciego con un año de seguimiento.

INTRODUCTION: To compare the efficacy of clonidine vs propranolol in the control of essential tremor, a double-blind randomized controlled trial with a one year follow-up was designed to obtain 80 % power and 95 % confidence level. PATIENTS AND METHODS: The participants (186 patients with the essential tremor diagnosis) were recruited from the community, 122 (65.6 %) of these patients completed the trial. They were assessed using a Clinical-Evaluation Scale for Tremor and were examined 5 times, once at baseline and 4 times during the treatment phase. We used ANOVA with Bonferroni corrections, a p> value of 0.01 was considered significant. Dropouts due to side effects were compared using the Fisher's exact X (2) test for two tails, a p>value of 0.05 was considered statistically significant. RESULTS: Propranolol as well as clonidine (p> = 0.005) proved to be statistically efficacious (p> = 0.0005). Propranolol was not more efficacious than clonidine (p> = 0.4). Dropouts were significantly higher in the clonidine group, 22 patients (p> = 0.006) and the most common undesirable side effect in this group was mouth dryness (in 8 patients). CONCLUSIONS: Clonidine was useful; when both drugs were compared propranolol was not shown to be superior to clonidine. Based on the results of this study, clonidine appears to be a good option for the treatment of mild to moderate essential tremor.

[Treatment of sialorrhea in Parkinson's disease patients with clonidine. Double-blind, comparative study with placebo]. / Tratamiento de la sialorrea de enfermos parkinsonianos con clonidina. Estudio comparativo doble ciego, frente a placebo.

BACKGROUND: sialorrhea is one of the common nonmotor, non-neuropsychiatric symptoms in Parkinson's disease and its pre-sence can cause limitation in the patient's social life. The traditional treatment with anticholinergic medication is capable of triggering important neuropsychiatric complications. OBJECTIVES: this is a prospective, double-blind, placebo compared study, which follow-up Parkinson's disease patients for 3 months. METHODS: we measured the efficacy of clonidine in the management of sialorrhea. The study was performed in 32 patients (20 males and 12 females), with a mean age of 70.75 years and mean duration of the disease of 8.84 years. Randomly, 17 patients received clonidine 0.15 mg/day and the remaining 15 patients received placebo. Both groups were made up of subjects with similar characteristics, age, years of illness, sex, stage of disease (H and Y), disability (S and C) and motor score (UPDRS). Likewise, salivation affected both groups in the same intensity. We used the variable analysis and there was a p < 0.05 significance. RESULTS: the group which received clonidine showed a significant improvement of the salivation symptoms both at one month as well as at 3 months of treatment (p < 0.00001, respectively). There was no evidence of worsening of the stage of the disease, incapacity or motor score. The side effects were found only in the group that received clonidine (4 patients) without showing statistically significant. CONCLUSION: the use of clonidine can be useful in the management and treatment of sialorrhea in patients with Parkinsons disease.

[A comparison between low doses of amitriptyline and low doses of fluoxetin used in the control of depression in patients suffering from Parkinson's disease]. / Dosis bajas de amitriptilina frente a dosis bajas de fluoxetina en el tratamiento de la depresión de enfermos con enfermedad de Parkinson.

INTRODUCTION: On average 40% of all patients suffering from Parkinson s disease (PD) undergo bouts of depression. It is thought that this is due to a dysfunction in the orbitofrontal and dorsolateral circuits, together with hypometabolism in the orbital, caudate nucleus and frontal dorsolateral tract regions. AIMS: The aim of this study is to compare the effectiveness of low doses of fluoxetin with that of low doses of amitriptyline in controlling depression in patients with PD. PATIENTS AND METHODS: The study examined a total of 77 patients (34 females and 43 males), with an average age of 68.2 years, who had been suffering from PD (according to the diagnostic criteria of Calne et al, in stage II of Hoehn and Yahr) for an average of 6.9 years. They were divided randomly into two groups which received fluoxetin (37 patients, dosage: 20 40 mg/day) or amitriptyline (40 patients, dosage: between 25 and 75 mg/day). A basal evaluation and four others (at 3, 6, 9 and 12 months of treatment) were performed, including the STMS (Short test of mental status), the Hamilton scale, and extent of functional disability using the UPDRS. A statistical analysis was performed by comparing the variance of the above mentioned parameters and the c2 test with Yates correction or the Fisher exact two tailed test, to evaluate the reasons for dropping out. In both cases a value of p< 0.05 was accepted as significant. RESULTS: 58 patients finished the study. Drop out because of side effects only took place in the group that received amitriptyline (p< 0.02), which was better than fluoxetin at controlling the depression (p< 0.009, 0.001, 0.002 and 0.00006) at 3, 6, 9 and 12 months, respectively. CONCLUSIONS: At an average dosage of 35.2 mg/day, amitriptyline is effective in controlling the depression presented by patients with PD. However, despite the low dosage, the side effects it caused forced 15% of the patients abandon the treatment.

Fluoxetine-induced tremor: clinical features in 21 patients.

We report a cohort of 21 patients (12 females and nine males), with a mean age of 42.4 years, who developed tremor after receiving fluoxetine at a mean dose of 25.7 mg per day. The mean latency period for tremor appearance was 54.3 days. Severity was found to be mild. In all patients, tremor was postural, with P<0.0005, compared to patients with rest tremor and P<0.05 compared to action/intention-tremor patients. The frequency range was 6-12 Hz/s. After fluoxetine was discontinued, tremor disappeared in 10 patients after a mean latency period of 35.5 days. In the remaining 11 patients, tremor persisted up to the end of the observation period (a mean of 449 days). We believe that this tremor phenomenon is due to the involvement of the red nucleus and the inferior olivary nucleus through their projections to the thalamus and the spinal cord.

[Acute mountain sickness: the clinical characteristics of a cohort of 615 patients]. / Mal de montaña agudo: características clínicas de una cohorte de 615 enfermos.

OBJECTIVE: To study the acute mountain sickness (AMS) and the influence the altitude has on individuals according to time of exposure, age and place of residence. Study cohort prospective in the shelters of Cotopaxi and Chimborazo (4,800 and 5,000 m), in the Ecuatorian Andes. SUBJECTS AND METHODS: Tourists from 8 to 51 years of age, residents of the coastal and mountain regions, exposed suddenly to the altitude. Signs and symptoms were recorded at 2, 8, 20 and 24 h of exposure and categorized according to the degree of acute mountain sickness found: AMS 1 [4 to 7 points (light), AMS 2 [8 to 11 points (moderate)] and AMS 3 [more than 12 points (severe)]. RESULTS: The study, consisted of 615 patients, was completed by 564. Neurological symptoms are prevalent (headache in the 81.7% of patients) over cardiopulmonary symptoms (cardiac frequency over 100/min in the 25.6%). At 20 h (after one night), the signs and symptoms are more intense and affect a greater number of people (p < 0.0001). Patients from 8 to 22 years of age and residents of the coast have a greater risk of developing AMS 2 (p < 0.01). Overweight, a sedentary life style and a previous incidence of altitude sickness are factors which contribute to the development of AMS 2 (p < 0.001). CONCLUSIONS: AMS is an important neurological affection. Young people, individuals from sea-level, as well as those whose are overweight, sedentary or who have previously experienced AMS, have a higher risk of developing AMS 2 after a sudden exposure to altitudes between 4,800 and 5,000 meters. Lack of balance and coordination, and shortness of breath at rest imply AMS 3 and the presence of high altitude cerebral or pulmonary edema.

[Acute pharmacological test with clonidine for the tremor in patients with Parkinson disease]. / Prueba farmacológica aguda con clonidina en el temblor de pacientes con enfermedad de Parkinson.

INTRODUCTION: Idiopathic Parkinson's disease has a prevalence of 1/1,000 and in 70-75% of these patients tremor is the commonest symptom. Of all the typical symptoms of this disease, the tremor is the most difficult to control. It is therefore necessary to seek drugs to solve this serious problem. OBJECTIVE: To evaluate the usefulness of clonidine in the acute treatment of resting and postural tremor in patients with idiopathic Parkinson's disease. PATIENTS AND METHODS: Acute pharmacological test (administration of 0.3 mg of clonidine chlorhydrate intramuscularly). The evaluation was done using a clinical protocol before administration and 30, 60, 120 and 240 minutes afterwards. Statistical comparison was done by variance analysis, taking a value of p < 0.0025 as significant. We included 28 patients (15 men and 13 women) of an average age of 66.9 years, and average duration of the disease of 5.53 years. Diagnosis followed the strict criteria of UKDDDSBB. RESULTS: There was no difference in the evaluations before and after the first dose of L-dopa. For both types of tremor, from 60 minutes onwards there were significant differences, with the maximum 120 minutes after administration (p < 0.0001). CONCLUSIONS: Clonidine is useful in the acute treatment of postural and intention tremor in patients with idiopathic Parkinson's disease. Its action is that of reducing the liberation of noradrenaline, synergically with the exciting dopaminergic system. It also seems to reduce the activity of spontaneous discharge at both thalamic and cortical levels.

[Chronic tension-type headache and depression]. / Cefalea tipo tensional crónica y depresión.

INTRODUCTION: Tension-type headache (TTH) is the commonest head pain to be seen in medical practice and is erroneously thought to have a psychogenic origin. OBJECTIVE: To evaluate the presence of depression in a cohort of persons with TTH and compare them with patients with migraine and with a control group. The clinical characteristics of patients with TTH were also noted. PATIENTS AND METHODS: We studied 89 patients with chronic TTH. Their level of depression (on the Hamilton scale) was compared with 31 patients with migraine with typical aura and a control group of 34 asymptomatic volunteers, matched for age, marital and job status. RESULTS: No difference was observed in the index of depression of the group of patients with chronic TTH as compared with the control group with migraine: p < 0.9412 and OR 1.07. Compared with the asymptomatic control group: p < 0.0272 and OR 3.81, which are significant figures. After 11 months of prophylactic treatment with imipramine (50 mg/day), levels of depression persisted in 20.02% of the patients, p < 0.06319 and OR 2.01 even when treatment was optimum in 98.8%. CONCLUSIONS: Patients with chronic TTH showed indices of depression in 33.7%. This figure was similar in those with migraine, 32.2%. Also response to treatment was independent of this figure. In 48% of the patients there was fear of having cerebral vascular disease.

[Parkinson's disease, side affected and depression]. / Enfermedad de Parkinson, hemicuerpo afectado y depresión.

INTRODUCTION: Depression is a state of mind often associated with Parkinson's disease, which is not correlated with the stage of the disease or the response to treatment with L-dopa. It has been suggested that patients with right-sided Parkinsonism have more depression than those with left-sided. OBJECTIVE: To assess whether patients whose dominant side is affected primarily have more depression than those whose non-dominant side is affected; and to evaluate whether when the dominant side is more affected this is accompanied by greater deterioration on the scale of everyday activities (ADLS) and on the motor part of the unified scale for evaluation of Parkinsonism (UPDRSm). PATIENTS AND METHODS: The study group was formed of 63 patients with Parkinsonism at stage 1 or 1.5 (Hoehn and Yahr), with an average age of 66.17 years. They were divided into two groups. Those who received L-dopa (Dopa group) and those who were newly-diagnosed patients (Naive group). They were evaluated on the Hamilton test, UPDRSm and ADLs scale. We used Wilcoxon's nonparametric sum of ranges test taking p < 0.01 as significant. RESULTS: The indexes of depression were greater, in both groups, in the patients whose dominant side was affected (p < 0.001). There were no differences in UPDRSm or ADLs. CONCLUSIONS: The patients with Parkinson's disease whose dominant side is primarily affected have worse depression. The depression seems originate in the dominant hemisphere.

[Hemifacial spasm, quality of life and depression]. / Espasmo hemifacial, calidad de vida y depresión.

INTRODUCTION: Quality of life, a concept which has become increasingly important in recent years, refers to a patient's perception of himself in relation to his illness and its treatment. This is compared with the concept of quantity of life or survival. This approach is in keeping with the concepts of health of the World Health Organization. Hemifacial spasm is a disorder of movement with a prevalence of 7.4 and 14.5 per 100,000 men and women respectively. OBJECTIVE: To evaluate the quality of life of patients with hemifacial spasm, study the occurrence of depression and ascertain whether it correlates with the severity, response to treatment and muscle groups involved. PATIENTS AND METHODS: We present a cohort of 57 patients (average age 53.4 years) with hemifacial spasm, in whom the disorder had been present for an average of 3.7 years. RESULTS: It was found that in these patients the quality of life and index of depression were worse when the severity of the disease was greater, response to treatment poorer and there was generalized hemifacial paralysis, (p < 0.00000) for each parameter. The deterioration in quality of life was correlated with depression (correlation 0.6) for the criteria of severity and muscle groups involved, but not with the response to treatment (correlation 0.3). CONCLUSION: Hemifacial spasm significantly alters the quality of life of patients and is associated with depression. This should be taken into account when treating such patients.

[High altitude pulmonary edema. Study of 21 cases]. / Edema pulmonar de altura. Presentación de 21 casos.

BACKGROUND: The effect of altitude on subjects between 8 to 22 and 23 to 51 years, that resided at sea level, or in the highlands, and developed altitude lung edema, is presented in series of 21 prospective registered patients at 4,800 to 5,000 m altitude in the Andes mountains of Ecuador. PATIENTS MATERIAL AND METHODS: The 21 sick patients were evaluated at 2 h and at 8 hr after exposition to the high altitude. They were immediately evacuated from the high altitudes. Clinical and radiological methods were used. The statistical analysis was performed with chi(2) test with Yates correction and relative risk. RESULTS: The younger patients tended to develop illness with a higher frequency (p < 0.01). The place of residence influenced the development of the illness only for the group of persons between the ages of 23 to 51 years (p < 0.03); and also in comparing all of the subjects from the coast with those from the highlands. CONCLUSIONS: A inverse relationship was found between the age and the possibility of the development of altitude pulmonary edema, possibly due t a basic incrementation of the pressure of the pulmonary artery, or because of a relative immaturity of the adaptative mechanisms. The place of residence was significantly associated with a higher frequency of pulmonary edema in persons between the ages of 23 to 51 years.

[Acute pharmacological test of clonidine in essential tremor]. / Prueba farmacológica aguda con clonidina en el temblor esencial.

Thirty-seven patients with essential tremor were given intramuscular clonidine injections of 0.3 mg. Physical examination and statistical analysis showed that response was highly positive (t = 13.47; p < 0.0001) 60 min after administration. The absence of peripheral alpha-adrenergic receptors for tremor suggest that the drug acts centrally, consistent with the theory that essential tremor originates in a central oscillating pacemaker.

[Transitory cranial dyskinesias and tubercular meningitis. Report of three cases]. / Discinesias craneales transitorias y meningitis tuberculosa. Presentación de 3 casos.

Three patients who suffered transitory (from 18 to 49 days) cranial dyskinesias during the course of tubercular meningitis are described. The diagnosis was confirmed by the presence of acid-alcohol resistant bacilli in spinal fluid. Cranial tomography or magnetic resonance images failed to demonstrate anatomical lesions. The blink reflex and brain stem auditory evoked potentials were abnormal, indicating dysfunction of motor nuclei of the cranial nerves, possibly secondary to changes in their regulation by basal ganglia. No recurrences have been observed during follow-up (from 3 to 7 years).