Reducción de la tasa de broncoaspiración con el test 2 volúmenes/3 texturas con pulsioximetría en una unidad de ictus / Lowering bronchoaspiration rate in an acute stroke unit by means of a 2 volume/3 texture dysphagia screening test with pulsioximetry

Introducción: En la fase aguda del ictus el 30% de los pacientes presentan disfagia, y de ellos, el 50% experimentarán broncoaspiración. Nuestro objetivo fue evaluar los resultados de mortalidad y broncoaspiración del test del agua comparado con el test 2 volúmenes/3 texturas controlado con pulsioximetría (2v/3t-P) en una unidad de ictus. Pacientes y métodos: Durante 5 años se analizaron de forma prospectiva y consecutiva todos los pacientes con infarto cerebral en la Unidad de Ictus. Del año 2008 al 2010 se utilizó el test del agua (grupo 0 o G0), y del 2011 al 2012, el test 2v/3t-P (grupo 1 o G1). Se recogieron las siguientes variables: demográficas, factores de riesgo vascular, gravedad neurológica con la escala NIHSS, subtipo etiológico según criterios TOAST, subtipo clínico según la clasificación Oxfordshire, prevalencia de disfagia, broncoaspiración y exitus. Resultados: Se analizaron 418 pacientes con infarto cerebral agudo (G0 = 275, G1 = 143). Se detectaron diferencias significativas entre ambos grupos en el porcentaje de pacientes con TACI (17% en G0 vs. 29% en G1, p = 0,005) y en la mediana de NIHSS (4 puntos en G0 vs. 7 puntos en G1, p = 0,003). Con el test 2v/3t-P se detectó un aumento no significativo en el porcentaje de disfagia (22% en G0 vs. 25% en G1, p = 0,4), una menor tasa de mortalidad (1,7% en G0 vs. 0,7% en G1, p = 0,3) y una reducción significativa de broncoaspiración (6,2% en G0 vs. 2,1% en G1, p = 0,05). Conclusiones: El nuevo test 2v/3t-P, comparado con el test del agua, mejoró significativamente los resultados de broncoaspiración en los pacientes con infarto cerebral agudo

Introduction: During acute stroke, 30% of all patients present dysphagia and 50% of that subgroup will experience bronchoaspiration. Our aim was to compare mortality and bronchoaspiration rates associated with the water test compared to those associated with a 2 volume/3 texture test controlled with pulse oximetry (2v/3t-P test) in our stroke unit. Patients and methods. Over a 5-year period, we performed a prospective analysis of all consecutive acute ischaemic stroke patients hospitalised in the Stroke Unit. Dysphagia was evaluated using the water test between 2008 and 2010 (group 0 or G0), and the 2v/3t-P test (group 1 or G1) between 2011 and 2012. We analysed demographic data, vascular risk factors, neurological deficit on the NIHSS, aetiological subtype according to TOAST criteria, clinical subtype according to the Oxfordshire classification, prevalence of dysphagia, percentage of patients with bronchoaspiration, and mortality. Results: We examined 418 patients with acute stroke (G0 = 275, G1 = 143). There were significant differences between the 2 groups regarding the percentage of patients with TACI (17% in G0 vs. 29% in G1, P = .005) and median NIHSS score (4 points in G0 vs. 7 points in G1, P = .003). Since adopting the new swallowing test, we detected a non-significant increase in the percentage of dysphagia (22% in G0 vs. 25% in G1, P = .4), lower mortality (1.7% in G0 vs. 0.7% in G1, P = .3) and a significant decrease in the bronchoaspiration rate (6.2% in G0 vs. 2.1% in G1, P = .05). Conclusions: Compared to the water test used for dysphagia screening, the new 2v/3t-P test lowered bronchoaspiration rates in acute stroke patients

Lowering bronchoaspiration rate in an acute stroke unit by means of a 2 volume/3 texture dysphagia screening test with pulsioximetry. / Reducción de la tasa de broncoaspiración con el test 2 volúmenes/3 texturas con pulsioximetría en una unidad de ictus.

INTRODUCTION: During acute stroke, 30% of all patients present dysphagia and 50% of that subgroup will experience bronchoaspiration. Our aim was to compare mortality and bronchoaspiration rates associated with the water test compared to those associated with a 2 volume/3 texture test controlled with pulse oximetry (2v/3t-P test) in our stroke unit. PATIENTS AND METHODS: Over a 5-year period, we performed a prospective analysis of all consecutive acute ischaemic stroke patients hospitalised in the Stroke Unit. Dysphagia was evaluated using the water test between 2008 and 2010 (group 0 or G0), and the 2v/3t-P test (group 1 or G1) between 2011 and 2012. We analysed demographic data, vascular risk factors, neurological deficit on the NIHSS, aetiological subtype according to TOAST criteria, clinical subtype according to the Oxfordshire classification, prevalence of dysphagia, percentage of patients with bronchoaspiration, and mortality. RESULTS: We examined 418 patients with acute stroke (G0=275, G1=143). There were significant differences between the 2 groups regarding the percentage of patients with TACI (17% in G0 vs. 29% in G1, P=.005) and median NIHSS score (4 points in G0 vs. 7 points in G1, P=.003). Since adopting the new swallowing test, we detected a non-significant increase in the percentage of dysphagia (22% in G0 vs. 25% in G1, P=.4), lower mortality (1.7% in G0 vs. 0.7% in G1, P=.3) and a significant decrease in the bronchoaspiration rate (6.2% in G0 vs. 2.1% in G1, P=.05). CONCLUSIONS: Compared to the water test used for dysphagia screening, the new 2v/3t-P test lowered bronchoaspiration rates in acute stroke patients.

Baja tasa de infarto cerebral, infarto de miocardio y muerte vascular con el diagnóstico y tratamiento etiológico rápido del ataque isquémico transitorio / Rapid diagnosis and treatment of TIA results in low rates of stroke, myocardial infarction and vascular death

Introducción: El riesgo de infarto cerebral dentro de los primeros 90 días tras un ataque isquémico transitorio (AIT) se estima entre un 8-20%. Existe escaso consenso sobre cuál es la estrategia diagnóstica más eficaz. Nuestro objetivo fue evaluar del beneficio del estudio precoz con ecocardiografía transtorácica (ETT) y ultrasonografía carotídea y transcraneal (DTSA/TC) en los pacientes con AIT. Métodos: Evaluamos de forma prospectiva todos los pacientes con AIT atendidos en urgencias durante 24 meses. Recogimos variables demográficas, factores de riesgo vascular y escala ABCD2. La etiología del AIT fue clasificada según criterios TOAST. En todos los pacientes se realizó el estudio vascular precoz (< 72 h) con ETT y DTSA/TC. Los objetivos primarios fueron la recurrencia vascular cerebral, infarto de miocardio (IAM) o muerte vascular durante el primer año. Resultados: Evaluamos 92 pacientes con una edad media de 68,3 ± 13 años y el 61% fueron hombres. La media de la escala ABCD2 fue de 3 puntos (≥ 5 en un 30%). La distribución etiológica fue la siguiente: aterotrombótico de gran vaso 12%; cardioembólico 30%; pequeño vaso 10%; indeterminado 40% e inhabitual 8%. Los hallazgos de la ETT cambiaron el tratamiento en 6 pacientes (6,5%) con exploración física y ECG normal. Al año de seguimiento 3 pacientes (3,2%) sufrieron un infarto cerebral, uno (1%) un IAM y no detectamos ninguna muerte vascular. Conclusiones: El estudio etiológico precoz en los pacientes con AIT y la detección de pacientes con cardiopatía silente puede haber contribuido a la baja tasa de recurrencia vascular

Introduction: The 90-day risk of cerebral infarction in patients with transient ischaemic attack (TIA) is estimated at between 8% and 20%. There is little consensus as to which diagnostic strategy is most effective. This study evaluates the benefits of early transthoracic echocardiography (TTE) with carotid and transcranial Doppler ultrasound in patients with TIA. Methods: Prospective study of patients with TIA in an emergency department setting. Demographic data, vascular risk factors, and ABCD2 score were analysed. TIA aetiology was classified according to TOAST criteria. All patients underwent early vascular studies (< 72 hours), including TTE, carotid ultrasound, and transcranial Doppler. Primary endpoints were recurrence of stroke or TIA, myocardial infarction (MI), or vascular death during the first year. Results: We evaluated 92 patients enrolled over 24 months. Mean age was 68.3 ± 13 years and 61% were male. The mean ABCD2 score was 3 points (≥ 5 in 30%). The distribution of TIA subtypes was as follows: 12% large-artery atherosclerosis; 30% cardioembolism; 10% small-vessel occlusion; 40% undetermined cause; and 8% rare causes. Findings from the early TTE led to a change in treatment strategy in 6 patients (6.5%) who displayed normal physical examination and ECG findings. At one year of follow-up, 3 patients had experienced stroke (3.2%) and 1 patient experienced MI (1%); no vascular deaths were identified. Conclusions: In our TIA patients, early vascular study and detecting patients with silent cardiomyopathy may have contributed to the low rate of vascular disease recurrence

Rapid diagnosis and treatment of TIA results in low rates of stroke, myocardial infarction and vascular death.

INTRODUCTION: The 90-day risk of cerebral infarction in patients with transient ischaemic attack (TIA) is estimated at between 8% and 20%. There is little consensus as to which diagnostic strategy is most effective. This study evaluates the benefits of early transthoracic echocardiography (TTE) with carotid and transcranial Doppler ultrasound in patients with TIA. METHODS: Prospective study of patients with TIA in an emergency department setting. Demographic data, vascular risk factors, and ABCD(2) score were analysed. TIA aetiology was classified according to TOAST criteria. All patients underwent early vascular studies (<72hours), including TTE, carotid ultrasound, and transcranial Doppler. Primary endpoints were recurrence of stroke or TIA, myocardial infarction (MI), or vascular death during the first year. RESULTS: We evaluated 92 patients enrolled over 24 months. Mean age was 68.3±13 years and 61% were male. The mean ABCD(2) score was 3 points (≥5 in 30%). The distribution of TIA subtypes was as follows: 12% large-artery atherosclerosis; 30% cardioembolism; 10% small-vessel occlusion; 40% undetermined cause; and 8% rare causes. Findings from the early TTE led to a change in treatment strategy in 6 patients (6.5%) who displayed normal physical examination and ECG findings. At one year of follow-up, 3 patients had experienced stroke (3.2%) and 1 patient experienced MI (1%); no vascular deaths were identified. CONCLUSIONS: In our TIA patients, early vascular study and detecting patients with silent cardiomyopathy may have contributed to the low rate of vascular disease recurrence.

EDUCA study: Psychometric properties of the Spanish version of the Zarit Caregiver Burden Scale.

OBJECTIVES: The Zarit Caregiver Burden Scale, translated and validated into Spanish, is sensitive to the application of a Psychoeducational Intervention Program (PIP) for the prevention and reduction of burden in caregivers of Alzheimer's disease (AD) patients (EDUCA study). The data obtained in EDUCA was used to reanalyse its psychometric properties and the cut-off points of the Zarit scale. METHODS: The scale was administered to 115 caregivers of patients with AD who were randomised to receive a PIP or standard care for four months. Internal reliability and a factorial analysis of principal components were assessed, and the impact of PIP on each of the subscales was evaluated. A cut-off point was defined for the Zarit scale to identify the caregivers most sensitive to receiving a PIP. RESULTS: A good internal reliability (Cronbach alpha coefficient of 0.92) was obtained, with three principal components (burden, competency and dependence) explaining 54.75% of the variance. The application of PIP showed statistically significant differences versus standard care for the dependence subscale (p = 0.0082) (p = 0.062 for the burden scale). The Zarit scale cut-off points which combine better sensitivity and specificity were 56/57 and 59/60, for the 5/6 and 6/7 cut-off points of the General Health Questionnaire (GHQ-28) scale, respectively. CONCLUSIONS: This study confirms the good psychometric properties of the Zarit scale found in previous studies. The dependence component appeared to be most influenced by the application of a PIP in the clinical trial. Caregivers with a Zarit scale score of 60 or more benefit most from the PIP.

[Cognitive and functional decline in the stage previous to the diagnosis of Alzheimers disease]. / Deterioro cognitivo y funcional en la fase previa al diagnóstico de enfermedad de Alzheimer.

INTRODUCTION: The decline in the phase prior to diagnosis of Alzheimers disease (AD) is not well known, although this knowledge is necessary to evaluate the efficiency of new drugs that can influence in disease course prior to diagnosis. OBJECTIVE: To contribute to better knowledge of the decline prior to diagnosis, we have investigated the cognitive and functional deterioration for 2-3 years before the probable AD diagnosis was established. PATIENTS AND METHODS: We compared results obtained by 17 control subjects and 27 patients at the time of diagnosis of a probable AD with results obtained 2-3 years before (interval of 27.7 4 months). We compared memory functions (logical, recognition, learning and autobiographical memory), naming, visual and visuospatial gnosis, visuoconstructive praxis, verbal fluency and the Mini-Mental State Examination (MMSE), Informant Questionnaire and Blessed's Scale scores. RESULTS: Performance of control subjects did not change. AD patients showed a significant decline in scores, except for verbal fluency. In order of importance, cognitive decline was more marked in scores of learning memory, visuospatial gnosis, autobiographical memory and visuoconstructive praxis. CONCLUSIONS: Decline prior to diagnosis of AD is characterized by an important learning memory impairment. Deterioration of visuospatial gnosis and visuoconstructive praxis is greater than deterioration of MMSE and Informant Questionnaire scores.

Deterioro cognitivo y funcional en la fase previa al diagnóstico de enfermedad de Alzheimer / Cognitive and functional decline in the stage previous to the diagnosis of Alzheimer´s disease

Introducción: El deterioro en la fase previa al diagnóstico de enfermedad de Alzheimer (EA) no es bien conocido, a pesar de que este conocimiento es necesario a fin de evaluar la eficacia de nuevos fármacos que puedan ser capaces de incidir en el curso anterior al diagnóstico de la enfermedad. Objetivos: Con el ánimo de contribuir a un mejor conocimiento del deterioro previo al diagnóstico, hemos investigado el deterioro cognitivo y funcional acaecido en un período de al menos 2-3 años antes de que el diagnóstico de probable EA fuese establecido. Métodos: Comparamos los resultados obtenidos por 17 sujetos control y 27 pacientes en el momento de establecer el diagnóstico de probable EA con aquellos obtenidos de 2 a 3 años antes (intervalo promedio de 27,7ñ4 meses). Comparamos funciones mnésicas (memoria reciente lógica, de reconocimiento, de aprendizaje y autobiográfica), denominación, gnosis visuales y visuoespaciales, praxis visuoconstructivas, fluencias y las puntuaciones del Miniexamen del estado mental (MMSE), el Test del informador y la escala de Blessed. Resultados: Las puntuaciones obtenidas por los sujetos control no variaron. Las puntuaciones en los pacientes con EA empeoraron significativamente a excepción de las fluencias. El grado de deterioro cognitivo fue más acentuado, y por este orden, en las puntuaciones de memoria de aprendizaje, gnosis visuoespaciales, memoria autobiográfica y praxis visuoconstructiva. Conclusiones: El deterioro previo al diagnóstico de EA está caracterizado por una marcada afectación de la memoria de aprendizaje. Funciones como la gnosis visuoespacial y la praxis visuoconstructiva se deterioran en mayor medida que lo que decrece la puntuación global en el MMSE o lo que aumenta la puntuación en el Test del informador (AU)

Antipsicóticos y efectos extrapiramidales / Extrapyramidal effects of antipsychotic drugs

La mayoría de estos efectos son reversibles con la aplicación de una serie de medidas, entre las que se puede incluir la retirada del fármaco precipitante. Los síndromes tarLos antipsicóticos clásicos han constituido durante muchos años armas terapéuticas muy eficaces para el tratamiento de trastornos psiquiátricos y neurológicos. Sin embargo, su efecto beneficioso debe balancearse contra un elevado riesgo de aparición de efectos secundarios, en especial de tipo extrapiramidal. Con la llegada de los llamados neurolépticos atípicos este riesgo se ha reducido de forma considerable aunque no completa, por lo que su uso debe acompañarse de un buen conocimiento de sus características farmacológicas y de su potencial para desarrollar trastornos motores. En este artículo se revisan estos fármacos, sus características farmacológicas, así como la fenomenología de los síndromes extrapiramidales y la actuación terapéutica recomendada. (AU)

[Extrapyramidal effects of antipsychotic drugs]. / Antipsicóticos y efectos extrapiramidales.

Conventional antipsychotics have been used for many years to treat psychiatric and neurological disorders. Nevertheless, their effectiveness is often associated with a high incidence of side effects, especially extrapyramidal ones (EPS). With the entrance of the socalled atypical neuroleptics, this risk has been considerably, although not completely, reduced. Thus, clinicians should have good knowledge about the pharmacological characteristics of the newer anti-psychotics and their associated risk of worsening or developing motor disturbances. This article reviews these drugs, their pharmacological characteristics as well as the phenomenology of the extrapyramidal syndromes ans treatment of the EPS recommended.

Atención sostenida en la fase preclínica de la enfermedad de Alzheimer / Sustained attention in the preclinical phase of Alzheimer´s disease

Introducción. El deterioro atencional en la fase preclínica de la demencia de tipo Alzheimer (DTA) no se conoce bien, ni los estudios disponibles son concluyentes. Objetivo. Planteamos la posibilidad de identificar un trastorno de la atención sostenida en la fase preclínica de la DTA y explorar si este trastorno ayudaría a identificar a aquellos pacientes que, remitidos inicialmente por quejas subjetivas de pérdida de memoria (QSPM), involucionarán en pocos años a DTA. Pacientes y métodos. Comparamos la exploración inicial en una prueba de atención sostenida (CPT) de 70 pacientes remitidos por QSPM, de los cuales 27 involucionaron a DTA en el plazo de 2 años y 43 permanecieron estables. Resultados. Los pacientes que involucionaron presentaron, 2 años antes de su diagnóstico, rendimientos significativamente inferiores a aquellos otros que no involucionaron. Cometieron un mayor número de errores de omisión y obtuvieron un menor número de aciertos. Conclusiones. La prueba de vigilancia tipo CPT es capaz de detectar el deterioro de atención sotenida en la fase preclínica de la DTA y podría ser un indicador objetivo del declinar cognitivo en la fase preclínica de la enfermedad de Alzheimer (AU)

Introduction. Deterioration of attention in the preclinical phase of dementia of Alzheimer’s type (DAT) is not very well-known neither available studies are conclusive. Objective. We outline if would be possible to identify a deficit of sustained attention in preclinical phase of DAT and if this attentional dysfunction could help to identify those patients, referred by subjective memory complaints (SMC), who will progress in a few years to DAT. Patients and methods. We compared basal exploration in a task of sustained attention (CPT) of 70 patients referred by SMC and followed longitudinally for 2 years. Twenty-seven patients developed probable DAT and forty-three remained clinically stable. Results. Patients who will be diagnosed 2 years later with DAT performed significantly more poorly than patients who did not develop DAT. Patients who will be diagnosed 2 years later with DAT made a higher number of omission errors and obtained a lower number of correct responses. Conclusion. CPT paradigm is a vigilance task that detects deterioration of sustained attention in the preclinical phase of DAT and could be an objective indicator of the cognitive decline in the preclinical phase of Alzheimer’s disease (AU)

[Sustained attention in the preclinical phase of Alzheimer's disease]. / La atencion sostenida en la fase preclinica de la enfermedad de Alzheimer.

INTRODUCTION: Deterioration of attention in the preclinical phase of dementia of Alzheimer s type (DAT) is not very well known neither available studies are conclusive. OBJECTIVE: We outline if would be possible to identify a deficit of sustained attention in preclinical phase of DAT and if this attentional dysfunction could help to identify those patients, referred by subjective memory complaints (SMC), who will progress in a few years to DAT. PATIENTS AND METHODS: We compared basal exploration in a task of sustained attention (CPT) of 70 patients referred by SMC and followed longitudinally for 2 years. Twenty seven patients developed probable DAT and forty three remained clinically stable. RESULTS: Patients who will be diagnosed 2 years later with DAT performed significantly more poorly than patients who did not develop DAT. Patients who will be diagnosed 2 years later with DAT made a higher number of omission errors and obtained a lower number of correct responses. CONCLUSION: CPT paradigm is a vigilance task that detects deterioration of sustained attention in the preclinical phase of DAT and could be an objective indicator of the cognitive decline in the preclinical phase of Alzheimer s disease.

Motor circuitry re-organization after pallidotomy in Parkinson disease: a neurophysiological study of the bereitschaftspotential, contingent negative variation, and N30.

The aim of the study was to evaluate the reorganization changes in the motor circuitry of the basal ganglia following unilateral posteroventral pallidotomy in Parkinson disease (PD) patients using neurophysiological paradigms. Eight advanced PD patients received a neurophysiological battery 2 months prior and 6 months after unilateral pallidotomy. Examinations were all performed in the practically defined "off" situation. Bereitschaftspotential (BP) and N30 were recorded for each hand alternately. Contingent negative variation (CNV) was obtained using a visual Go/no-Go paradigm. ANOVAs (electrode position; surgery) were applied for BP and CNV results. N30 data were analyzed using Wilcoxon matched-pair tests. A significant increase in amplitude of the late component (NS') of the BP was evidenced with patient performing with the hand contralateral to pallidotomy. No significant amplitude differences were found in CNV after surgery in any lead, or in any of the time windows tested. A trend toward significance was observed corresponding to a postsurgical numerical increase in amplitude of the N30 peak in the hand contralateral to pallidotomy. These results suggest that neurophysiological changes after pallidotomy are mainly in the last stages of movement preparation and execution.

[Weight gain after functional surgery for Parkinsons disease]. / Ganancia ponderal después de la cirugía funcional en la enfermedad de Parkinson.

BACKGROUND: The origin of weight gain after functional surgery for Parkinson's disease (PD) is incompletely known. We have done a prospective study to determine the possible causes of weight gain after pallidal and subthalamic surgery. PATIENTS AND METHOD: Twenty-seven patients were studied (9 unilateral pallidotomy, 9 bilateral deep brain stimulation (DBS) of palidum, and 9 bilateral DBS of suthalamic nucleus) with a follow-up of 12 months. The relationship between weight gain and changes in motor situation, levodopa dosage, dyskinesias, dysphagia and mood state were analyzed. The patients filled a questionnaire about the severity and etiology of weight gain. RESULTS: Weight gain was noted in 26 patients (mean of 4.7 kg at 12 months). It was found a significant correlation between weight gain and improvement of dyskinesias (AIMS) (r = 0.461; p = 0.023), the scores of the UPDRS part III, (r = 0.479; p = 0.028), and a significant inverse correlation with the pre-operative weight of the patient (r = 0.399; p = 0.050). Weight gain was most pronounced with bilateral than unilateral pallidal surgery (p = 0.021). The majority of patients referred weight gain as an slight adverse event and secondary to the improvement of dyskinesias. CONCLUSION: Functional surgery for PD, independently of the surgical target, provokes weight gain which is benign in the majority of cases. Reduction of energy expenditure with respect to the pre-operative situation would be the responsible of that phenomenon.

Ganancia ponderal después de la cirugía funcional en la enfermedad de Parkinson / Weight gain after functional surgery for Parkinson's disease

FUNDAMENTO: Se ha descrito una ganancia ponderal inesperada después de la cirugía funcional de la enfermedad de Parkinson. Realizamos un estudio prospectivo para determinar las posibles causas del aumento ponderal después de la cirugía palidal y subtalámica. PACIENTES Y MÉTODO: Se estudió a 27 pacientes (9 palidotomías unilaterales, 9 casos de estimulación cerebral profunda [ECP] palidal bilateral y 9 casos de estimulación cerebral profunda subtalámica bilateral) con un seguimiento postoperatorio de 12 meses. Se analizó la relación del aumento ponderal con los cambios de la situación motriz, dosis de levodopa, discinesias, disfagia y estado de ánimo. Asimismo, los pacientes rellenaron un cuestionario sobre la gravedad y las causas del aumento ponderal. RESULTADOS: Se registró un aumento ponderal en 26 pacientes (media, 4,7 kg a los 12 meses). Se halló una correlación significativa entre la ganancia ponderal y la mejora de la escala de discinesias (AIMS) (r = 0,461; p = 0,023) y de la parte motriz de la escala UPDRS (r = 0,479; p = 0,028), así como una correlación inversa significativa con el peso inicial del paciente (r = -0,399; p = 0,050). La ganancia ponderal fue superior con la cirugía palidal bilateral respecto a la unilateral (p = 0,021). La mayoría de los pacientes consideró el aumento ponderal como un efecto adverso leve y secundario a la mejoría de las discinesias. CONCLUSIONES: La cirugía funcional de la enfermedad de Parkinson, con independencia de la diana quirúrgica escogida, provoca un aumento ponderal que es benigno en la mayoría de los casos. La reducción del gasto energético respecto a la situación prequirúrgica sería la causa de este fenómeno. (AU)

[Postural tremor: clinical and neurophysiological study in a consecutive series of 300 patients]. / Temblor postural: estudio clínico y neurofisiológico en una serie consecutiva de 300 pacientes.

BACKGROUND: There are few studies analysing the clinical and neurophysiological characteristics of postural tremor in Spain. PATIENTS AND METHOD: We studied prospectively 300 consecutive patients referred to a Movement Disorders Section because of postural tremor of the upper limbs. Syndromic diagnosis of postural tremor was made according to clinical criteria with the aid of neurophysiological criteria (accelerometric and EMG data). In patients diagnosed with essential tremor (ET), diagnostic sensitivity studies, correlation studies of clinical and neurophysiological data and multivariate analysis were performed. RESULTS: Most frequent syndromic diagnoses were ET (77%), parkinsonian postural tremor (10%) and exaggerated physiological tremor (6%). Fifty percent of ET patients reported having affected relatives, and 7% reported that their tremor improved with alcohol. Mostly specific variables for the diagnosis of ET were: affected relatives (77%), cephalic tremor (80%), alcohol improvement (100%), and synchronous EMG pattern (79%). The presence of affected relatives and a synchronous EMG pattern were significant predictive variables on a multivariate analysis. We found a significant correlation between age at time of consulting and frequency (rs = 0.561; p < 0.0005) and amplitude (rs = 0.470; p < 0.0005) of tremor. CONCLUSIONS: In the present study, ET was the most common cause of reference for postural tremor. Selective clinical data and neurophysiological evaluation are useful for the diagnosis of postural tremor.

Relationship between cerebral perfusion in frontal-limbic-basal ganglia circuits and neuropsychologic impairment in patients with subclinical hepatic encephalopathy.

UNLABELLED: Early detection of neuropsychologic impairment in cirrhotic patients with subclinical hepatic encephalopathy (SHE) is important for their prognosis and quality of life. Abnormal MRI and MR spectroscopy (MRS) findings have been proposed as early markers of brain damage in these patients, but the role of functional neuroimaging in this field still has to be defined. In this study, the SPECT perfusion pattern in patients with SHE was investigated, and the relationship between regional cerebral blood flow (rCBF) and the MRI, MRS, neuropsychologic evaluation and biochemical data of these patients was assessed. METHODS: Data were obtained from 13 cirrhotic patients with SHE and 13 age-matched healthy volunteers. Fasting venous blood ammonia and manganese sampling and a battery of standardized neuropsychologic tests related to basal ganglia function and sensitive to the effects of liver disease were all performed on the same day. MRI and 99mTc-hexamethyl propyleneamine oxime SPECT were performed within 2 wk. RESULTS: A pattern of decreased prefrontal rCBF was found in patients with SHE compared with healthy volunteers. Basal ganglia and mesial temporal rCBF correlated inversely with performance on motor tasks involving speed (Purdue pegboard test) and frontal premotor function (Luria graphic alternances and Stroop tests). Thalamic rCBF correlated positively with T1-weighted MRI signal hyperintensity in the globus pallidus and with abnormal MRS findings. Neither the MRI signal intensity of the globus pallidus nor MRS correlated with neuropsychologic test results. CONCLUSION: Cirrhotic patients with SHE show a SPECT pattern of impaired prefrontal perfusion that does not seem to account for their neuropsychologic deficits. On the other hand, perfusion in some parts of the limbic system and limbic-connected brain regions, such as the striatum and the mesial temporal regions, increased with neuropsychologic impairment. These findings suggest that brain SPECT may be more sensitive than MRI in delineating cirrhotic patients requiring in-depth clinical testing to reveal basal ganglia-related neuropsychologic alterations.

Decerebrate-like posturing with mechanical ventilation in brain death.

Complex spinal cord, spontaneous, or upper limb reflexes are rarely observed in brain death. The authors describe two brain-dead heart-beating cadavers (out of 400 consecutive cases in their hospital in the past 9 years) that, immediately after brain-death diagnosis, exhibited symmetric upper limb movements resembling decerebrate posture that were triggered by each mechanical pulmonary insufflation, and also by superficial pressure and noxious stimuli applied to the arms, thorax, or abdomen. These movements persisted until disconnection from mechanical ventilation.