Early treatment of multiple sclerosis: a Latin American experts meeting.

Patients with clinically isolated syndrome (CIS) by definition do not have multiple sclerosis (MS) but are at risk of developing it. While studies show earlier immunomodulating drug use is effective, treatment must consider likely patient prognosis. In this paper we review current diagnosis, prognosis, and treatment literature for patients with CIS within Latin American clinical settings. Latin American MS experts, convened by ACINDES (The Civil Association for Research and Development in Health), reviewed current CIS (and early MS) literature and drew consensus conclusions. Three subgroups addressed separate questionnaires on CIS issues: prognosis, diagnosis, and treatment. MRI can contribute to predicting MS risk in patients with CIS; in Latin America, investigation of haplotype presence associated with CIS would be appropriate. McDonald's criteria and subsequent revisions enable earlier, more accurate MS diagnosis. Type A evidence exists supporting all leading immunomodulating MS drugs for effective treatment of CIS with a high risk of conversion to MS. In conclusion, patients with CIS are usually young, with often-limited symptomatic manifestations, and must be adequately prepared to receive preventive treatment. This consensus review should contribute to the dialogue between physicians and patients.

Movimientos anormales psicógenos a propósito de casos clínicos / Psychohenic movement disorders in relation to medical cases

El presente es un trabajo de revisión y puesta al día de la literatura respecto al tema de los movimientos anormales de etiología psicógeno. Se comunica un caso clínico de distonia psicógena clínicamente establecida, analizando su historia desde el punto de vista neurológico y psiquiátrico, fundamentos el diagnóstico positivo y analizando los diagnóstico diferentes. Concluimos en la necesidad del abordaje neuropsiquiátrico cuando se abordan pacientes que padecen movimientos anormales.

This document is a work revision and an update of the psychogenic etiology of movement disorders’ literature. A medical case of dystonia psychogenia clinically established is reported, the medical history is analyzed from a neurological and psychiatric perspective, the positive diagnosis is explained, and the different diagnosis analyzed. Finally, we conclude the necessity of neuropsychiatric treatment when those patients suffer movement disorders.

[Regional cerebral blood flow changes in Parkinson's disease: correlation with disease duration]. / Cambios de la perfusión cerebral en la enfermedad de Parkinson: relación con la duración de los síntomas.

INTRODUCTION: Changes in regional cerebral blood flow (rCBF) have been reported in idiopathic Parkinson's disease (PD). Nonetheless, their typical pattern still remains controversial regarding some features, such as basal ganglia involvement and the main cortical regions affected. Functional neuroimaging makes it possible to identify the brain dysfunctions of the neural circuits underlying the disease. Voxel-based analysis methods make it possible to increase the reliability of the results. OBJECTIVE: To assess the rCBF changes in patients with PD and their relation with disease duration. MATERIALS AND METHODS: Thirty PD adult patients without dementia underwent evaluation with (99m)Tc-ECD SPECT. SPM5 was used for statistical comparison with 25 normal controls of similar ages. The disease course duration in years was added as a covariate. Additionally, patients with a 6-year evolution or less and those with more than 6 years were compared separately with normal controls. RESULTS: Significant hypoperfusion was detected in bilateral premotor and posterior parietal cortex and increase of perfusion was present in the cerebellum. These changes correlated with the years of evolution of the illness. Patients with longer evolution also presented thalamic, subthalamic and basal ganglia hypoperfusion. CONCLUSIONS: We describe rCBF changes in PD in neural circuits related with control of movements. These changes are more manifest in patients with a longer duration of the disease.

Cambios de la perfusión cerebral en la enfermedad de Parkinson: relación con la duración de los síntomas / Regional cerebral blood flow changes in Parkinson's disease: correlation with disease duration

Introducción: En la enfermedad de Parkinson idiopática (EP) se han observado alteraciones del flujo sanguíneo cerebral regional (FSCr) cuyo patrón característico aún presenta aspectos controvertidos, como la existencia de alteraciones gangliobasales y las áreas corticales más afectadas. La neuroimagen funcional permite observar las disfunciones de circuitos neuronales existentes en estos pacientes. Los métodos de análisis estadístico basado en vóxeles permiten incrementar la validez de los resultados. Objetivo: Investigar los cambios de la perfusión cerebral existentes en pacientes con EP y su relación con la duración de los síntomas. Materiales y métodos: Treinta pacientes adultos con EP sin demencia fueron estudiados mediante SPECT cerebral con 99mTc-ECD. Se utilizó SPM5 para su comparación estadística con un grupo control de 25 sujetos sanos de edades similares. Se introdujo, como covariable en dicha comparación, el tiempo de evolución en años y se analizaron por separado los pacientes con 6 años o menos de evolución y aquellos con más de 6 años. Resultados: Se detectó hipoperfusión significativa en la corteza premotora y parietal posterior bilateral y aumento del flujo en el cerebelo. Estas alteraciones se correlacionaron con los años de evolución de la enfermedad. Los pacientes con evolución más prolongada presentaron además hipoperfusión talámica, subtalámica y gangliobasal. Conclusiones: Describimos alteraciones del FSCr en la EP que se relacionan con los circuitos implicados en el control del movimiento. Las mismas son más evidentes en los pacientes con evolución más prolongada de la enfermedad(AU)

Introduction: Changes in regional cerebral blood flow (rCBF) have been reported in idiopathic Parkinson's disease (PD). Nonetheless, their typical pattern still remains controversial regarding some features, such as basal ganglia involvement and the main cortical regions affected. Functional neuroimaging makes it possible to identify the brain dysfunctions of the neural circuits underlying the disease. Voxel-based analysis methods make it possible to increase the reliability of the results. Objective: To assess the rCBF changes in patients with PD and their relation with disease duration. Materials and methods: Thirty PD adult patients without dementia underwent evaluation with 99mTc-ECD SPECT. SPM5 was used for statistical comparison with 25 normal controls of similar ages. The disease course duration in years was added as a covariate. Additionally, patients with a 6-year evolution or less and those with more than 6 years were compared separately with normal controls. Results: Significant hypoperfusion was detected in bilateral premotor and posterior parietal cortex and increase of perfusion was present in the cerebellum. These changes correlated with the years of evolution of the illness. Patients with longer evolution also presented thalamic, subthalamic and basal ganglia hypoperfusion. Conclusions: We describe rCBF changes in PD in neural circuits related with control of movements. These changes are more manifest in patients with a longer duration of the disease(AU)

[The use of biological markers in the diagnosis and follow-up of patients with multiple sclerosis. Test of five fluids]. / Utilidad de los marcadores biológicos en el diagnóstico y seguimiento de los pacientes con esclerosis múltiple. Test de los cinco humores.

PATIENTS AND METHODS: We studied five biological fluids which were easily accessible to immunological examination (cerebrospinal fluid, plasma, tears, saliva and urine) in 25 patients with multiple sclerosis, clinically definite according to the criteria of Cleveland, Ohio (1991) and tabulated according to the Kurztke's expanded disability status scale. The samples were obtained simultaneously during a clinical bout of the disease before any pharmacological or immunosuppressive treatment had been given. RESULTS: The soluble interleukin-2 levels were significantly raised in at least three of these fluids--always absent from the urine--when compared with normal controls. The sensitivity and specificity of this determination for diagnosis of the condition was greater than that of other immunochemical parameters--oligoclonal distribution of immunoglobulins (specifically of IgG), imbalance of the light Kappa and Lambda chains--and physiological studies (evoked potentials). The dosification and quantification of basic myelin protein of the central nervous system, rich in citruline in the urine, may be a parameter of progressiveness. CONCLUSION: This methodology (five humours test) may be used to establish an earlier, more certain diagnosis of multiple sclerosis and also monitor its biological activity together with nuclear magnetic resonance with intravenous contrast.

Test de los cinco humores / The use of biological markers in the diagnosis and follow-up of patients with multiple sclerosis. Test of the five humours

Pacientes y métodos. Se estudiaron cinco fluidos biológicos de fácil acceso a la exploración inmune (líquido cefalorraquídeo, suero, lágrimas, saliva y orina) en 25 pacientes con esclerosis múltiple clínicamente definida, de acuerdo con los criterios de Cleveland, Ohio (1991), y tabulados según la escala del estado de incapacidad ampliada de Kurtzke. Las muestras se obtuvieron simultáneamente durante un brote de la enfermedad y previo a todo tratamiento farmacológico e inmunosupresor. Resultados. El nivel de receptor soluble de interleucina-2 se encontró significativamente aumentado en, por lo menos, tres de estos fluidos -ausente siempre en la orina- en comparación con el de los controles normales. La sensibilidad y especificidad de su determinación para el diagnóstico de la afección fue mayor que la de otros parámetros inmunoquímicos -distribución oligoclonal de inmunoglobulinas (específicamente de IgG), desequilibrio de cadenas livianas kappa y lambda- y estudios electrofisiológicos (potenciales evocados). La dosificación y cuantificación de proteína básica de mielina del sistema nervioso central, rica en citrulina en orina, puede ser un parámetro de progresividad. Conclusión. Esta metodología (test de los cinco humores) podría utilizarse para establecer un diagnóstico más certero y precoz de la esclerosis múltiple así como también para monitorizar su actividad biológica junto con la resonancia magnética nuclear con contraste intravenoso (AU)

Long-term treatment with Madopar HBS in parkinsonians with fluctuations.

1. Of 22 parkinsonians with fluctuations under long-dating dopatherapy in whom standard Madopar was substituted by the HBS form, 16 who performed the trial longer than 1 year were particularly studied to evaluate some parameters of this long-term follow-up (30-36 months). 2. The outstanding beneficial effects were an enhancement of the antiparkinsonian response, improvement or disappearance of motor oscillations, longer "on" periods, less severe "off" periods, and a more sustained nocturnal antiparkinsonian effect with a reduction of dystonias and pain at night and decreased or absent early morning parkinsonism. 3. The decrease or disappearance of dystonia was observed since the early stages of the trial and can be explained by the more sustained dopaminergic effect. 4. Surprisingly, dyskinesias also decreased in spite of the higher dopaminergic effect. The avoidance of sharp and repeated plasmatic peaks and the lower levels of L-dopa under HBS could explain this phenomenon. 5. The negative aspects of Madopar HBS are a lower bioavailability that means a dosage increase and a longer latency for the therapeutic response in the morning. 6. The dosage increase went up by 80% to 100% in relation to standard Madopar during the long-term treatment. 7. As Madopar HBS is a sustained release preparation, we had to increase the initially reduced the number of intakes, again in order to obtain better results. In the most severe cases with poor or absent response, benefits were achieved only when administering the HBS intake every hour.(ABSTRACT TRUNCATED AT 250 WORDS)

Combination of selegiline and controlled release levodopa in the treatment of fluctuations of clinical disability in parkinsonian patients.

Thirteen parkinsonians with a long duration of the disease and long-term dopa therapy, seven of them showing severe on-off oscillations and 6 an "end-of-dose impairment", were treated with a controlled release (HBS) preparation of L-DOPA/benserazide for more than 3 years. Thereafter, selegiline was added in a progressively increasing dosage up to a maximum of 10 mg/day during 4 months, with the aim of a) further improving the long-term results and b) reducing the doses of the new formula of L-DOPA. A significant decrease of early morning parkinsonism and reduction of motor disability throughout the day were observed; "wearing-off" cases showed better results compared with those presenting "on-off" oscillations. A mean reduction of 20% in the doses of levodopa was achieved. Likewise, a mild reduction of dyskinesias and a mild-moderate enhancement of dystonias were recorded. Only one patient did not tolerate selegiline and two others received lower doses due to side-effects. Selegiline was capable of enhancing the antiparkinsonian effect of the new formula of L-DOPA, while allowing a reduction of the doses administered. It must also be emphasized that such improvement was achieved in complicated patients, most of whom showed some deterioration of response in the late stages of long-term sustained-release levodopa treatment.