[Clinical experience in the treatment of motor fluctuations in Parkinson's disease. Delphi consensus of a group of experts in movement disorders]. / Experiencia clínica en el tratamiento de las fluctuaciones motoras en la enfermedad de Parkinson. Consenso Delphi de un grupo de expertos en trastornos del movimiento.

INTRODUCTION: Motor fluctuations are one of the most common complications of Parkinson's disease and their treatment is still a complex matter. Therefore, from the Neurology Movement Disorders Group we present our clinical experience in the treatment of these complications, with the intention of it being useful in decision-making in daily clinical practice. DEVELOPMENT: Nineteen questions were developed based on a literature review and an open survey answered by members of this group. These issues were discussed in two phases, using the Delphi methodology. Considering the results of the survey, levodopa dose adjustment and dopamine agonists are the option with the best efficacy/tolerability ratio in the treatment of motor fluctuations. Rotigotine is useful in the motor fluctuations associated with gastroparesis, and intermittent subcutaneous apomorphine has positive effects in patients with unpredictable off periods. The most relevant adverse effect associated with dopamine agonists is impulse control disorder. Catechol-O-methyltransferase inhibitors are useful in the initial stages of motor fluctuations, especially in wearing off. Monoamine oxidase inhibitors are generally drugs that are well-tolerated and useful in motor fluctuations. If these measures are not effective, second-line treatments should be indicated on a case-by-case basis. CONCLUSION: The clinical profile of patients with Parkinson's disease is paramount in deciding the most appropriate therapy for the treatment of motor fluctuations.

TITLE: Experiencia clínica en el tratamiento de las fluctuaciones motoras en la enfermedad de Parkinson. Consenso Delphi de un grupo de expertos en trastornos del movimiento.Introducción. Las fluctuaciones motoras son una de las complicaciones más frecuentes en la enfermedad de Parkinson y su tratamiento sigue siendo complejo. Por ello, desde el Grupo de Trastornos del Movimiento de la Asociación Madrileña de Neurología presentamos nuestra experiencia clínica en el tratamiento de estas complicaciones, con la intención de que sea de utilidad en la toma de decisiones en la práctica clínica diaria. Desarrollo. Se elaboraron 19 preguntas a partir de una revisión bibliográfica y una encuesta abierta respondida por los miembros de dicho grupo. Dichas cuestiones se debatieron en dos fases, utilizando la metodología Delphi. Considerando los resultados de la encuesta, el ajuste de la dosis de levodopa y los agonistas dopaminérgicos son la opción con mejor relación eficacia/tolerabilidad en el tratamiento de las fluctuaciones motoras. La rotigotina es útil en las fluctuaciones motoras asociadas a gastroparesia, y la apomorfina subcutánea intermitente, en pacientes con off impredecible. El efecto adverso más relevante asociado a los agonistas dopaminérgicos es el trastorno del control de impulsos. Los inhibidores de la catecol-O-metiltransferasa son útiles en las fluctuaciones motoras de inicio, especialmente en el wearing off. Los inhibidores de la monoaminooxidasa son fármacos, en general, bien tolerados y útiles en las fluctuaciones motoras. En caso de que estas medidas no resulten eficaces, se deben indicar terapias de segunda línea de manera individualizada. Conclusión. El perfil clínico del paciente con enfermedad de Parkinson es primordial para decidir la terapia más adecuada en el tratamiento de las fluctuaciones motoras.

Parkinsonismo farmacológico frente a demencia con cuerpos de Lewy / Pharmacological Parkinsonismo opposite to dementia with Lewy's bodies

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Bloqueo bilateral del plexo braquial por vía axilar para ligamentotaxis de fractura bilateral conminuta de extremidad distal del radio en paciente cardiópata con politraumatismo / Bilateral axillary trachial plexus block for ligamentotaxis of comminuted bilateral distal of the radius in a heart failure patient with polytraumatism

Se presenta el caso de un paciente longevo que es llevado al hospital tras una caída casual. Como consecuencia de esta, presenta traumatismo facial y craneal, junto con fractura con minutameta fisaria distal del radio en ambas muñecas, que requieren reducción manual y ligamentotaxis mediante fijación externa ósea (Ebifix®). Debido al trauma craneofacial y al problema cardio vascular del paciente (prótesis aórtica y tres puentes aorto coronarios), se opta por un bloqueo bilateral del plexo braquial por vía axilar. El procedimiento se realiza en el miembro superior derecho mediante electroneuro estimulación múltiple con búsqueda de respuesta motora (nervios: musculo cutáneo, radial, mediano y cubital); y en el miembro superior izquierdo mediante técnica perivascular con inserción de un catéter no estimulante para infusión continua. La cirugía y el postoperatorio transcurren sin incidencias ni complicaciones (AU)

A case of a long-lived patient who is taken to the hospital after a fortuitous fall was presented. As consequence, he presented facial and cranial traumatism, together with fracture conminuta metafisaria distal of the radius in both wrists, which needed manual reduction and ligamentotaxis by means of external bone fixation (Ebifix™).Due to the craniofacial trauma and the cardiovascular problem of the patient (aortic prosthesis and three aorto-coronary bypasses), he was chosen for a bilateral blockade of the brachial plexus by axillary way. The procedure was performed in the right limb by means of multiple electroneural stimulation searching for motor responses (nerves: musculo cutaneous, radial, medium and ulnar); and in the left limb by means of perivascular insertion of a non stimulant catheter for continuous infusion. The surgery and the postoperatory were without incidents (AU)

[Immunotherapy with an oral Alternaria extract in childhood asthma. Clinical safety and efficacy and effects on in vivo and in vitro parameters]. / Inmunoterapia con un extracto oral de Alternaria en el asma infantil. Eficacia clínica, seguridad, repercusiones sobre parámetros in vivo e in vitro.

Studies of immunotherapy with oral Alternaria extracts are scarce. We decided to perform a clinical trial of the clinical safety and efficacy of this extract as well as of its effects on in vivo and in vitro parameters in 39 patients with Alternaria allergy, aged between 7 and 17 years, who are also sensitized extract was used. Allergic activity was determined through RAST inhibition and skin prick test. Quantification of the principal allerten (Alt a 1) was performed through the 2-site binding assay, with a mean content of 34.2 ng Alt a 1/micro g protein. The parameters analyzed were the symptom-medication score, skin prick using the end-point technique, specific bronchial challenge test, peak flow, total and specific IgE and IgG4. Nineteen patiens received active treatment with oral immunotherapy and another 19 received symptomatic treatment. The initial phase of immunotherapy lasted 3 months until the maximum dose was reached. This was maintained for 12 months; the mean accumulated dos was 280,000 PNU. Significant differences were found in reduction in the symptom-medication score in the treated group after 12 months of immunotherapy. No differences were found in the control group. Immunotherapy was well tolerated with 0.42 adverse reactions per 100 doses administered. All adverse reactions were mild-to-moderate. In the treated group, papule size was significantly reduced. Values for the specific bronchial challenge test, expressed through PD20, were significantly higher in the immunotherapy group. Peak flow showed no changes in either group. Values of IgG4 were significantly higher in the immunotherapy group. Total and specific IgE levels showed no significant changes in either group. In conclusion, oral immunotherapy with Alternaria extract is clinically effective in pediatric patients. In general, the therapy was well tolerated. It modified specific cutaneous and bronchial reactivity in our sample and increased levels of specific IgG4, wich are implicated in humoral response.

Inmunoterapia con un extracto oral del Alternaria en el asma infantil. Eficacia clínica, seguridad, repercusines sobre parámetros in vivo e in vitro / Immunotherapy with an oral Alternaria extract in chilhood asthma. Clinical safety and efficacy and effects on in vivo and in vitro

Ante la escasez de trabajos con inmunoterapia oral de Alternaria, planteamos la realización de un ensayo clínico en 39 pacientes, con edades comprendidas entre 7 y 17 años, alérgicos a Alternaria, y sensibilizados también a pólenes y epitelios para evaluar su eficacia clínica y seguridad, así como las repercusiones sobre parámetros in vivo e in vitro. Se empleó un extracto estandarizado, determinando la actividad alérgica mediante RAST inhibición y prick test cutáneo. La cuantificación del alergeno principal (Alt a 1) se llevó a cabo mediante la técnica de fijación en dos lugares, siendo el contenido medio de 34,2 ng Alt a 1/ g de proteína. Los parámetros analizados fueron la puntuación de síntomas-medicación, prick test cutáneo a punto final (TC), test de bronco provocación específico (TBPE), pico de flujo (PF), IgE total y específica e IgG4.Diecinueve pacientes recibieron tratamiento activo con inmunoterapia oral (ITO) y otros diecinueve recibieron tratamiento sintomático. La fase de inicio de la inmunoterapia duró 3 meses, hasta llegar a dosis máxima, que se mantuvo durante 12 meses, alcanzando una dosis acumulada media de 280.000 PNU. Se hallaron diferencias significativas en la disminución de la puntuación de síntomas-medicación en el grupo tratado, tras los 12 meses de inmunoterapia (ITO). No se encontraron diferencias en el grupo control. La inmunoterapia fue bien tolerada, presentando 0,42 reacciones adversas (RA) por 100 dosis administradas, siendo de carácter leve-moderado exclusivamente. Se encontró disminución significativa del tamaño de pápula en el grupo tratado. El TBPE expresado mediante la PD20 mostró cifras significativamente más altas en el grupo con ITO. El pico de flujo no mostró cambios en ninguno de los dos grupos. Los valores de la IgG4 fueron significativamente más altos en el grupo con inmunoterapia. Los niveles de IgE total y específica no mostraron cambios significativos en ambos grupos. En conclusión, la Inmunoterapia Oral con extracto de Alternaria ha demostrado eficacia clínica en pacientes pediátricos, siendo en general bien tolerada, modificando la reactividad específica cutánea y bronquial con incremento de los niveles de IgG4 específica implicados en la respuesta humoral (AU)

Studies of immunotherapy with oral Alternaria extracts are scarce. We decided to perform a clinical trial of the clinical safety and efficacy of this extract as well as of its effects on in vivo and in vitro parameters in 39 patients with Alternaria allergy, aged between 7 and 17 years, who are also sensitized extract was used. Allergic activity was determined through RAST inhibition and skin prick test. Quantification of the principal allerten (Alt a 1) was performed through the 2-site binding assay, with a mean content of 34.2 ng Alt a 1/μg protein. The parameters analyzed were the symptom-medication score, skin prick using the end-point technique, specific bronchial challenge test, peak flow, total and specific IgE and IgG4. Nineteen patiens received active treatment with oral immunotherapy and another 19 received symptomatic treatment. The initial phase of immunotherapy lasted 3 months until the maximum dose was reached. This was maintained for 12 months; the mean accumulated dos was 280,000 PNU. Significant differences were found in reduction in the symptom-medication score in the treated group after 12 months of immunotherapy. No differences were found in the control group. Immunotherapy was well tolerated with 0.42 adverse reactions per 100 doses administered. All adverse reactions were mild-to-moderate. In the treated group, papule size was significantly reduced. Values for the specific bronchial challenge test, expressed through PD20, were significantly higher in the immunotherapy group. Peak flow showed no changes in either group. Values of IgG4 were significantly higher in the immunotherapy group. Total and specific IgE levels showed no significant changes in either group. In conclusion, oral immunotherapy with Alternaria extract is clinically effective in pediatric patients. In general, the therapy was well tolerated. It modified specific cutaneous and bronchial reactivity in our sample and increased levels of specific IgG4, wich are implicated in humoral response (AU)

IgE-mediated downregulation of L-selectin (CD62L) on lymphocytes from asthmatic patients.

BACKGROUND: L-selectin (CD62L) mediates the binding of lymphocytes to high endothelial venules of peripheral lymph nodes and is also involved in leukocyte attachment to the endothelium at sites of inflammation. Although it has been demonstrated that L-selectin is shed after lymphocyte activation, it is unknown whether the expression of L-selectin on the surface of lymphocytes can be modulated by an IgE-dependent mechanism or whether immunotherapy (IT) might affect this mechanism. METHODS: One group of adult allergic asthmatic patients had received IT for the previous 3 years. Another similar group was not treated with IT. We challenged peripheral blood lymphocytes from both groups of asthmatic patients in vitro with an anti-IgE antibody (Ab). Expression of L-selectin on the lymphocyte surface was analyzed by flow cytometry, and the levels of soluble L-selectin (sL-selectin) on culture supernatant by ELISA. RESULTS: L-selectin was downregulated from the surface of lymphocytes in a time- and anti-IgE antibody dose-dependent manner (with a concomitant upregulation of shed L-selectin in the supernatant). When lymphocytes from non-IT asthmatic patients were cultivated with anti-IgE Ab, a statistically significantly greater CD62L downmodulation on the lymphocyte surface was observed compared with lymphocytes from the healthy group (P<0.002) and from the IT-asthmatic group (P<0.001). When lymphocytes from non-IT asthmatic patients were cultivated with anti-IgE Ab, a significantly greater sL-selectin level in the culture supernatant was observed compared with lymphocytes from the healthy group (P<0.001) and with lymphocytes from IT-asthmatic group (P<0.001). CONCLUSIONS: We present evidence that the expression of L-selectin on the surface of lymphocytes can be modulated by an IgE-dependent mechanism. This mechanism can be affected by IT.

Fulminant herpes hepatitis in a healthy adult: a treatable disorder?

Hepatitis due to herpes simplex virus (HSV) is a potentially fatal disorder that is often not considered in the differential diagnosis of acute hepatitis. This disease occurs most often in patients with impaired immunity and is very uncommon in healthy patients. HSV hepatitis presents with a wide clinical spectrum, and the clinical diagnosis is difficult. We describe a case of disseminated herpes virus infection with fulminant hepatitis mimicking an acute human immunodeficiency virus infection in a 33-year-old healthy man. Preliminary studies suggest that early treatment of HSV hepatitis with acyclovir may be beneficial in these patients. A high index of suspicion and the availability of early diagnostic tools, such as HSV DNA detection, may dramatically improve the clinical outcome of severe HSV hepatitis.

Cardioverter desfibrilador automático implantable en un paciente con cardiopatía chagásica crónica y taquicardia ventricular sostenida / Implantable cardioverter defibrillator in a patient with chronic chagasic cardiopathy and sustained ventricular tachycardia

Presentamos el caso de una mujer de 48 años de edad con cardiopatía chagásica crónica, la que se manifestó con cardiomegalia, insuficiencia cardiaca y sincope debido a taquicardia ventricular sostenida (TVS) de dos morfologías (bloqueo de rama izquierda y de rama derecha del haz de His). Durante el estudio electrofisiológico, se reprodujeron ambos tipos de taquicardia ventricular. Se realizó ablación de la rama derecha del has de His en forma exitosa, debido a la sospecha de reentrada de rama a rama durante la taquicardia con imagen de bloqueo de rama izquierda del haz de His. Continuó presentando episodios de TVS, ahora con imagen de bloqueo de rama izquierda del haz de His, por lo que fue necesaria la colocación de un cardiverter desfibrilador automático implantable. Reportamos el presente caso debido a la poca frecuencia con la que se confirma enfermedad de Chagas en nuestro medio, donde puede ser una causa importante de cardiopatía, en razón de que previamente se ha identificado la existencia del parásito (Tripanosoma cruzi) y su vector (Triatoma) en algunas zonas rurales y suburbanas del estado de Aguascalientes

Enhancement of Antigen-specific functional responses by neutrophils from allergic patients.

It has been demonstrated that neutrophils from healthy donors or from patients with inflammatory disorders can bind immunoglobulin (Ig) E proteins through binding to Mac-2/epsilon bp. Functional responses to allergens were assessed by measuring the respiratory burst and intracellular Ca2+ levels, and binding of allergens to neutrophils was assessed by flow cytometry analysis and fluorescence microscopy. In this article, we demonstrate that neutrophils sensitized to specific allergens (from allergic patients), but not from healthy donors, are sensitive to allergens of the same type as those that produce clinical allergic symptoms. The activation of neutrophils was analyzed by the induction of a respiratory burst that was detected with luminol-dependent chemiluminescence. Intracellular Ca2+ levels increased parallel to those of the inducing allergens. In addition, the specific binding of allergens on the cell surface was revealed by flow cytometry and allergen-FITC-labeled staining analyses. The present data suggest a restricted recognition of allergen by sensitive neutrophils, probably associated with the specific binding of the allergen to its corresponding IgE molecule, which is bound to the Mac-2/epsilon bp structure. These findings demonstrate a functional role of allergen-associated neutrophils during the allergic state.

Peripheral blood T lymphocytes in seasonal bronchial asthma.

Variations in T lymphocytes in asthmatic patients are related to disease severity. However, the effects of natural exposure to pollens on peripheral blood T lymphocytes have not been clarified. In this paper, the effects on peripheral blood CD4 and CD8 lymphocytes from pollen-sensitive subjects and from nonatopic donors were studied during and outside the pollen season. In patients who suffer from seasonal asthma, we found an increase in the CD4/CD8 bright ratio and a decrease in the mean number of CD4 receptors per cell during the pollen season. No variation was observed in healthy subjects. These results suggest that CD4 lymphocytes may be causally linked to the pathogenesis of seasonal bronchial asthma.

Variations of the cellular antigens CD4 and CD8 in pollinic patients during the spring.

In order to study the possible variations of CD4 and CD8 antigens in pollinic patients, we have studied 25 individuals (11 rhinoconjunctivitis and 14 rhinoconjunctivitis-asthma) before (T0), in the middle (T1) and after the spring (T2). The number of receptors per cell of CD4 start from values in T0, decrease in T1 and increase at the end of the spring (p < 0.00001), which could represent a mechanism to limit the clonal response to an antigen. An increase in the CD4/CD8 bright ratio could be indicate a higher helper mechanism in T1 with respect to T0 and T2 (p < 0.01). The opposite meaning is to given to the increase of CD8bright receptors in the asthmatic patients, and not only in those who suffer only from a rhinopathy (the only difference between the two groups of patients) during T2 over the T1 (p < 0.00001). The greater number of lymphocytes CD8 dim + during T1 with respect to T2 (p < 0.009) and the increase in the number of receptors of such cells during T1 with respect to T2 (p < 0.00001) suggests a possible intervention of these cells in the regulation of the response of the B and T lymphocytes. Of the two soluble factors CD4 (sCD4) and CD8 (sCD8), only the sCD4 increases during T1 (p < 0.0001) in an inverse manner as occurs with CD4 cell receptors, while the sCD8 remains unchanged during the three periods.(ABSTRACT TRUNCATED AT 250 WORDS)

Plasma kallikrein amidolytic activity in patients with urticaria.

We have studied the plasma kallikrein amidolytic activity in healthy control subjects (inactive), patients with chronic urticaria (active) and patients with acute urticaria (active) from their admission to the emergency room (active) to the time after which their clinical symptomatology had disappeared (inactive). We found statistically significant differences (p < 0.01) in the active groups of urticaria patients. This leads us to believe that kallikrein participates in the development of symptomatology in these patients.

Relationship of blood EG2+ eosinophils in patients with bronchial asthma.

The presence of eosinophils in peripheral blood has been previously associated with different degrees of activity in the evolution of disease in asthmatics. The eosinophil cationic protein is a mediator released by the eosinophils when they are activated due to various stimuli. The monoclonal antibody EG2 binds to human ECP, the epitopes which EG2 recognizes is only present in the secreted form of ECP, hence it only stains eosinophils which are undergoing activation and/or secretion. Flow cytometry was used to measure the level of eosinophils stained by the monoclonal antibody EG2 (eosinophil EG2+) in the peripheral blood of subjects with unstable extrinsic bronchial asthma, stable extrinsic bronchial asthma and healthy control group. A statistically significant higher level of eosinophil EG2+ was found in the group with unstable asthma than in either the group with stable asthma or the group of healthy subjects (p < 0.0002). No difference was found between the patients with stable asthma and the control group. The level of eosinophil EG2+ in peripheral blood, measured by flow cytometry, could be used as an indicator of inflammatory activity in patients suffering from bronchial asthma.