Consenso de expertos españoles sobre el uso de la safinamida en la enfermedad de Parkinson / Spanish expert consensus on the use of safinamide in Parkinson's disease

La safinamida es un nuevo fármaco para el tratamiento de pacientes con enfermedad de Parkinson (EP) con fluctuaciones como tratamiento complementario a levodopa. Dado que por el momento aún no existen estudios de fase IV postautorización debido a la reciente incorporación de la safinamida a la práctica clínica habitual, el interés de este proyecto radica en el desarrollo de una guía de manejo clínico de la safinamida basada en las opiniones de expertos de trastornos del movimiento. Este proyecto se desarrolló en 2 fases: una primera fase que constó de 16 reuniones locales y una segunda fase que consistió en una reunión nacional. Dichas reuniones siguieron un guion de trabajo preestablecido. Tras la reunión nacional se recopilaron las principales conclusiones de los expertos, que han supuesto la base para redactar la presente guía clínica. Se concluyó que la safinamida es eficaz en la reducción de las fluctuaciones motoras y no motoras. Los pacientes con EP con fluctuaciones leves-moderadas son los que más se benefician del tratamiento, si bien el fármaco puede contribuir a mejorar diversos problemas clínicos en pacientes con EP avanzada. Se ha destacado la posibilidad de reducir la dosis de otros fármacos dopaminérgicos tras la introducción de la safinamida, lo cual contribuiría a reducir efectos adversos como el trastorno de control de impulsos. Se hipotetizó sobre el posible efecto de la safinamida sobre la mejoría de las discinesias a dosis más altas de las habitualmente utilizadas. Se ha consensuado que la safinamida es bien tolerada y presenta un perfil de efectos adversos favorable frente a placebo. (AU)

Safinamide is a new add-on drug to levodopa for the treatment of Parkinson's disease (PD) with motor fluctuations. Due to the recent incorporation of safinamide into routine clinical practice, no post-authorisation phase IV studies on the safety of safinamide have been conducted to date. This study provides clinical management guidelines for safinamide based on the opinion of a group of experts in movement disorders. This project was developed in 2 phases: 16 local meetings in phase 1 and a national meeting in phase 2. The meetings followed a pre-established agenda. The present clinical practice guidelines are based on the main conclusions reached during the national meeting. The group concluded that safinamide is effective in reducing motor and non-motor fluctuations. PD patients with mild-to-moderate fluctuations benefit most from treatment, although the drug may also improve the clinical status of patients with advanced PD. The dose of other dopaminergic drugs may be reduced after introducing safinamide, which would contribute to reducing such adverse reactions as impulse control disorder. At doses higher than those usually prescribed, safinamide may also improve dyskinesia. The experts agreed that safinamide is well tolerated and causes few adverse reactions when compared with placebo. (AU)

Spanish expert consensus on the use of safinamide in Parkinson's disease.

Safinamide is a new add-on drug to levodopa for the treatment of Parkinson's disease (PD) with motor fluctuations. Due to the recent incorporation of safinamide into routine clinical practice, no post-authorisation phase IV studies on the safety of safinamide have been conducted to date. This study provides clinical management guidelines for safinamide based on the opinion of a group of experts in movement disorders. This project was developed in 2 phases: 16 local meetings in phase 1 and a national meeting in phase 2. The meetings followed a pre-established agenda. The present clinical practice guidelines are based on the main conclusions reached during the national meeting. The group concluded that safinamide is effective in reducing motor and non-motor fluctuations. PD patients with mild-to-moderate fluctuations benefit most from treatment, although the drug may also improve the clinical status of patients with advanced PD. The dose of other dopaminergic drugs may be reduced after introducing safinamide, which would contribute to reducing such adverse reactions as impulse control disorder. At doses higher than those usually prescribed, safinamide may also improve dyskinesia. The experts agreed that safinamide is well tolerated and causes few adverse reactions when compared with placebo.

Spanish expert consensus on the use of safinamide in Parkinson's disease. / Consenso de expertos españoles sobre el uso de la safinamida en la enfermedad de Parkinson.

Safinamide is a new add-on drug to levodopa for the treatment of Parkinson's disease (PD) with motor fluctuations. Due to the recent incorporation of safinamide into routine clinical practice, no post-authorisation phase IV studies on the safety of safinamide have been conducted to date. This study provides clinical management guidelines for safinamide based on the opinion of a group of experts in movement disorders. This project was developed in 2 phases: 16 local meetings in phase 1 and a national meeting in phase 2. The meetings followed a pre-established agenda. The present clinical practice guidelines are based on the main conclusions reached during the national meeting. The group concluded that safinamide is effective in reducing motor and non-motor fluctuations. PD patients with mild-to-moderate fluctuations benefit most from treatment, although the drug may also improve the clinical status of patients with advanced PD. The dose of other dopaminergic drugs may be reduced after introducing safinamide, which would contribute to reducing such adverse reactions as impulse control disorder. At doses higher than those usually prescribed, safinamide may also improve dyskinesia. The experts agreed that safinamide is well tolerated and causes few adverse reactions when compared with placebo.

Agonistas dopaminérgicos en la enfermedad de Parkinson / Dopaminergic agonists in Parkinson’s disease

Introducción: Los agonistas dopaminergicos no ergoticos (AD) son tratamientos útiles en la enfermedad de Parkinson (EP). Revisamos la farmacología, el grado de evidencia en cuanto a eficacia y tolerabilidad de pramipexol, ropinirol y rotigotina, y proponemos algunas recomendaciones para su uso en la practica clínica. Desarrollo: En el momento actual se dispone de formas de liberacion prolongada (LP) de pramipexol y ropinirol y de administración transdermica de rotigotina, que contribuyen a una mayor estabilidad plasmatica de los valores del fármaco. En la EP inicial los 3 fármacos mejoran de forma significativa las escalas de incapacidad de los pacientes, retrasan la aparición de discinesias y permiten retrasar la introducción de levodopa. En la EP avanzada reducen el tiempo off, mejoran la Unified Parkinson’s Disease Rating Scale (UPDRS) en on y en off y permiten reducir la dosis total de levodopa. Además, los 3 han sido capaces de inducir una mejora significativa en las escalas de la calidad de vida relacionada con la salud. Las formulas de LP han demostrado la no inferioridad frente a las de liberación inmediata, e incluso una mejor tolerabilidad (ropinirol). A pesar de su buen perfil de seguridad, entre los efectos adversos graves cabe destacar el trastorno de control de impulsos, cuya aparición puede ser precoz, y los accesos de sueño (sleep attacks). Aunque la terapia combinada no ha sido estudiada específicamente, algunas asociaciones (como la de apomorfina y otros AD) pueden ser beneficiosas. El cambio de un AD a otro es factible de un día para otro, aunque en los primeros días puede haber una sumación de efectos adversos dopaminergicos que debe tenerse en cuenta. La suspensión brusca del tratamiento con AD puede inducir un síndrome de deprivacion dopaminergica. La retirada de cualquier AD, en particular pramipexol, se ha asociado a aparición de apatía que puede ser grave. Conclusiones: Los nuevos AD no ergoticos constituyen una opción valida de tratamiento de la EP tanto inicial como avanzada. A pesar de su buen perfil de tolerabilidad, no están exentos de efectos adversos graves, que pueden tener un efecto atoplastico en la EP y que deben monitorizarse

Background: Non-ergoline dopamine agonists (DA) are effective treatments for Parkinson’s disease (PD). This review presents the pharmacology, evidence of efficacy and safety profile of pramipexole, ropinirole, and rotigotine, and practical recommendations are given regarding their use in clinical practice. Results: Extended-release formulations of pramipexole and ropinirole and transdermal continuous delivery rotigotine patches are currently available; these may contribute to stabilizing of plasma levels. In early PD, the three drugs significantly improve disability scales, delay time to dyskinesia and allow a later introduction of levodopa. In late PD they reduced total ’off’-time, improved Unified Parkinson’s Disease Rating Scale (UPDRS) in both ’on’ and ’off’ state and allowed a reduction in total levodopa dosage. A significant improvement in quality of life scales has also been demonstrated. Extended-release formulations have proved to be non-inferior to the immediate release formulations and are better tolerated (ropinirole). Despite a generally good safety profile, serious adverse events, such as impulse control disorder and sleep attacks, need to be routinely monitored. Although combination therapy has not been addressed in scientific literature, certain combinations, such as apomorphine and another DA, may be helpful. Switching from one DA to another is feasible and safe, although in the first days an overlap of dopaminergic side effects may occur. When treatment with DA is stopped abruptly, dopamine withdrawal syndrome may present. Suspending any DA, especially pramipexole, has been linked to onset of apathy, which may be severe. Conclusions: New non-ergotine DAs are a valuable option for the treatment of both early and late PD. Despite their good safety profile, serious adverse effects may appear; these effects may have a pathoplastic effect on the course of PD and need to be monitored

Dopaminergic agonists in Parkinson's disease.

BACKGROUND: Non-ergoline dopamine agonists (DA) are effective treatments for Parkinson's disease (PD). This review presents the pharmacology, evidence of efficacy and safety profile of pramipexole, ropinirole, and rotigotine, and practical recommendations are given regarding their use in clinical practice. RESULTS: Extended-release formulations of pramipexole and ropinirole and transdermal continuous delivery rotigotine patches are currently available; these may contribute to stabilising of plasma levels. In early PD, the three drugs significantly improve disability scales, delay time to dyskinesia and allow a later introduction of levodopa. In late PD they reduced total 'off'-time, improved Unified Parkinson's Disease Rating Scale (UPDRS) in both 'on' and 'off' state and allowed a reduction in total levodopa dosage. A significant improvement in quality of life scales has also been demonstrated. Extended-release formulations have proved to be non-inferior to the immediate release formulations and are better tolerated (ropinirole). Despite a generally good safety profile, serious adverse events, such as impulse control disorder and sleep attacks, need to be routinely monitored. Although combination therapy has not been addressed in scientific literature, certain combinations, such as apomorphine and another DA, may be helpful. Switching from one DA to another is feasible and safe, although in the first days an overlap of dopaminergic side effects may occur. When treatment with DA is stopped abruptly, dopamine withdrawal syndrome may present. Suspending any DA, especially pramipexole, has been linked to onset of apathy, which may be severe. CONCLUSIONS: New non-ergotine DAs are a valuable option for the treatment of both early and late PD. Despite their good safety profile, serious adverse effects may appear; these effects may have a pathoplastic effect on the course of PD and need to be monitored.

[Diagnostic accuracy of FP-CIT SPECT in patients with parkinsonism]. / Utilidad diagnóstica de la SPECT con FP-CIT en el estudio de pacientes con parkinsonismo.

OBJECTIVE: To determine the diagnostic accuracy of FP-CIT SPECT in entities with and without presynaptic involvement of the nigral-striatal dopaminergic pathway in a large group of patients with movement disorders, evaluating the usefulness of quantitative analysis. MATERIALS AND METHODS: A group of 183 consecutive patients clinically diagnosed as either having or not having degenerative Parkinsonism. These results were then contrasted with those of FP-CIT SPECT to determine the diagnostic accuracy of the procedure. The specific binding index was evaluated with ROC curves. RESULTS: FP-CIT SPECT was highly accurate in the diagnosis of neurodegenerative Parkinsonism (sensitivity: 95 %, specificity: 90 %). Most of the false positive results arose in patients with vascular Parkinsonism and the false negative results in patients with Parkinson disease. ROC curve analysis of semiquantitative evaluation had a sensitivity of 83 % and specificity of 82 % with an optimal cut-off of 1.44. The area under the curve was not significantly different between patients 60 years (0.899 vs 0.884) of age. CONCLUSIONS: FP-CIT SPECT has a high degree of diagnostic accuracy for striatal dopaminergic involvement. No significant changes in diagnostic accuracy were seen with respect to patient age.

Utilidad diagnóstica de la SPECT con FP-CIT en el estudio de pacientes con parkinsonismo / Diagnostic accuracy of fp-cit spect in patients with parkinsonism

Diagnostic accuracy of fp-cit spect in patients with parkinsonism Objetivo. Establecer la validez diagnóstica del estudio tomográfico con FP-CIT en entidades que cursan conafectación presináptica de la vía dopaminérgica estriato-nígrica y en otras que no lo hacen, valorando la aportación del análisis cuantitativo.Material y métodos. Se incluyen 183 pacientes que tras un período de seguimiento se establece desde el punto de vista clínico la existencia o no de parkinsonismo degenerativo y seconfronta con el resultado de la tomogammagrafía (SPECT) con FP-CIT, estableciendo la validez diagnóstica de dicho procedimiento. El índice de captación específica se valoró mediante curvas ROC. Resultados. Considerados de forma global se obtuvo una exactitud diagnóstica del 93 % para el diagnóstico de un parkinsonismo de origen neurodegenerativo. La mayor parte deresultados falsos positivos se obtuvieron a partir de pacientes con parkinson vascular (PV) y la de falsos negativos a partir de sujetos con enfermedad de Parkinson (EP). El análisis mediante curva ROC de la valoración semicuantitativa aportó una sensibilidad del 83 % y una especificidad del 82 %, con un punto de corte óptimo de 1,44. El área bajo la curva no se modificó de forma significativa en pacientes ≤60 y >60 años (0,899 frente a 0,884). Conclusiones. El estudio tomográfico con FP-CIT permite poner de manifiesto, con elevada seguridad diagnóstica, la afectación de la vía dopaminérgica nigroestriada en pacientes afectos de un trastorno del movimiento. No se obtuvieron cambios significativos en pacientes ancianos

Objective. To determine the diagnostic accuracy of FP-CIT SPECT in entities with and without presynaptic involvement of the nigral-striatal dopaminergic pathway in a large group of patients with movement disorders, evaluating the usefulness of quantitative analysis.Materials and methods. A group of 183 consecutive patients clinically diagnosed as either having or not having degenerative Parkinsonism. These results were then contrasted withthose of FP-CIT SPECT to determine the diagnostic accuracy of the procedure. The specific binding index was evaluated with ROC curves.Results. FP-CIT SPECT was highly accurate in the diagnosis of neurodegenerative Parkinsonism (sensitivity: 95 %, specificity: 90 %). Most of the false positive results arose inpatients with vascular Parkinsonism and the false negative results in patients with Parkinson disease. ROC curve analysis of semiquantitative evaluation had a sensitivity of 83 % and specificity of 82 % with an optimal cut-off of 1.44. The area under the curve was not significantly different between patients ≤60 and >60 years (0.899 vs 0.884) of age.Conclusions: FP-CIT SPECT has a high degree of diagnostic accuracy for striatal dopaminergic involvement. No significant changes in diagnostic accuracy were seen with respect to patient age

[Hemiparkinsonism secondary to mesencephalic bleeding]. / Hemiparkinsonismo secundario a hemorragia mesencefálica.

Vascular parkinsonism is the second cause of secondary parkinsonism, and can cause a complex clinical syndrome. In spite of this, it is not common to find an isolated vascular injury in the mesencephalic region, and even rarer for it to give rise to clinical parkinsonism. We present the case of a young patient who developed left hemiparkinsonism with a fluctuating clinical evolution and unpredictable response to the treatment after suffering right mesencephalic bleeding. Structural and functional neuroimaging techniques showed injury on the mesencephalic level and no uptake in the right striatal region, respectively.

Validez diagnóstica de la SPECT con FP-CIT en la evaluación de pacientes con síndrome parkinsoniano clínicamente incierto / Diagnostic accuracy of FP-CIT SPECT in the evaluation of patients with clinically uncertain parkinsonian syndrome

Objetivo. Establecer la validez diagnóstica de la SPECT con FP-CIT en un subgrupo de pacientes que presentan clínicamente rasgos no concluyentes o atípicos de parkinsonismo (síndrome parkinsoniano clínicamente incierto [SPCI]), valorando la aportación del análisis cuantitativo en este grupo de pacientes. Pacientes y métodos. Se incluye a 54 pacientes que conforman el grupo con SPCI. Tras un período de seguimiento se establece desde el punto de vista clínico la existencia o no de parkinsonismo degenerativo y se confronta con el resultado de la SPECT con FP-CIT, estableciendo la validez diagnóstica de dicho procedimiento en el grupo de pacientes con SPCI. Resultados. Se obtuvo una elevada validez diagnóstica en el diagnóstico de un parkinsonismo de origen neurodegenerativo en pacientes con SPCI (sensibilidad: 85 %, y especificidad, 93 %). Los resultados falsos positivos se obtuvieron a partir de pacientes con Parkinson vascular (PV) y la mayoría de falsos negativos a partir de sujetos con enfermedad de Parkinson (EP). La valoración cuantitativa no aportó datos de relevancia a la valoración visual. Conclusiones. El estudio tomográfico con FP-CIT permite poner de manifiesto con elevada seguridad diagnóstica la afectación de la vía dopaminérgica nigroestriada, aportando, asimismo, información de relevancia al clínico acerca de la etiología de la sintomatología extrapiramidal en pacientes con síntomas y signos no concluyentes de la existencia de un parkinsonismo

Objective. To determine diagnostic accuracy of FP-CIT SPECT in a subgroup of patients who clinically present nonconclusive or atypical characteristics of parkinsonism (Clinically Uncertain Parkinsonian Syndromes, CUPS), and assess the contribution of the quantitative analysis in this group of patients. Patients and methods. We included 54 patients who make up the CUPS group. After a variable follow-up period, we evaluated the existence of a degenerative parkinsonism and compared it with the result of the FP-CIT SPECT, establishing the diagnostic accuracy of this procedure in the CUPS patient group. Results. We obtained a high diagnostic accuracy of neurodegenerative Parkinsonism in the CUPS patient group (sensitivity: 85 %; specificity: 93 %). False positive results were obtained in patients with vascular parkinsonism and most of the false negative results in patients with Parkinson's disease. The quantitative evaluation did not contribute data of relevance to the qualitative evaluation. Conclusions. FP-CIT SPECT makes it possible to show the involvement of nigrostriatal dopaminergic pathway, also contributing with information of relevance to the clinician about the etiology of the extrapyramidal symptomatology in patients with nonconclusive signs and symptoms of the existence of a Parkinsonism

[Diagnostic accuracy of FP-CIT SPECT in the evaluation of patients with clinically uncertain parkinsonian syndrome]. / Validez diagnóstica de la SPECT con FP-CIT en la evaluación de pacientes con síndrome parkinsoniano clínicamente incierto.

OBJECTIVE: To determine diagnostic accuracy of FP-CIT SPECT in a subgroup of patients who clinically present nonconclusive or atypical characteristics of parkinsonism (Clinically Uncertain Parkinsonian Syndromes, CUPS), and assess the contribution of the quantitative analysis in this group of patients. PATIENTS AND METHODS: We included 54 patients who make up the CUPS group. After a variable follow-up period, we evaluated the existence of a degenerative parkinsonism and compared it with the result of the FP-CIT SPECT, establishing the diagnostic accuracy of this procedure in the CUPS patient group. RESULTS: We obtained a high diagnostic accuracy of neurodegenerative Parkinsonism in the CUPS patient group (sensitivity: 85%; specificity: 93%). False positive results were obtained in patients with vascular parkinsonism and most of the false negative results in patients with Parkinson's disease. The quantitative evaluation did not contribute data of relevance to the qualitative evaluation. CONCLUSIONS: FP-CIT SPECT makes it possible to show the involvement of nigrostriatal dopaminergic pathway, also contributing with information of relevance to the clinician about the etiology of the extrapyramidal symptomatology in patients with nonconclusive signs and symptoms of the existence of a Parkinsonism.

[Application of 123I-FP-CIT in the clinical practice in Parkinsonism patients]. / Aplicación del FP-CIT-I-123 en la práctica clínica de pacientes con Parkinsonismo.

INTRODUCTION: 123I-FP-CIT scan has been supported in the last years by numerous studies as a technique of undeniable value to assess presynaptic integrity of the nigrostriatal pathway. The objective of this study is to perform a descriptive analysis of the main diagnostic aspects obtained from the first 110 studies made with FP-CIT in our center. MATERIAL AND METHODS: The study population consisted of 110 consecutive patients distributed into 5 groups according to the clinical diagnosis, after a follow-up period of at least one year. Qualitative and quantitative scintigraphy was done. RESULTS: A total of 61.8 % (68/110) of the studies were considered abnormal and 38.2 % (42/110) as normal. Among the abnormal examinations there was 88.3 % (60/68) agreement with the clinical diagnosis and agreement was 83.4 % (35/42) in the normal examinations. Inverse significant correlation was assessed between striatal binding and severity according to the H and Y scale (r = -0.4) and between qualitative and quantitative assessment (r = -0.86). There was no significant correlation between the degeneration of dopaminergic function according to age and degree of asymmetry on striatal binding in the different groups. CONCLUSIONS: Generally an adequate agreement between clinical diagnosis and SPECT-FP-CIT was observed. Inverse correlation between striatal binding and H and Y scale and greater asymmetry at striatal binding was obtained among Parkinson patients than in the rest of groups.

Aplicación del FP-CIT-I-123 en la práctica clínica de pacientes con parkinsonismo / Application of 123I-FE-CIT in the clinical practice in Parkinsonism patients

Introducción: La SPECT con FP-CIT-I-123 ha sido avalada en los últimos años por numerosos estudios como una técnica muy valiosa para evaluar la integridad presináptica de la vía estriato nígrica. El presente estudio tiene como objetivo realizar un análisis descriptivo de los principales aspectos diagnósticos extraídos de los 110 primeros estudios realizados con FP-CIT en nuestro centro. Material y métodos: Se incluyeron a 110 pacientes reclutados de forma consecutiva, distribuidos en 5 grupos según el diagnóstico clínico de presunción, con un período de seguimiento de al menos un año. La exploración gammagráfica se valoró tanto cualitativa como cuantitativamente. Resultados: El 61,8 % (68/110) de los estudios fueron considerados como patológicos y el 38,2 % (42/110) no presentaron alteraciones. Entre lo estudios patológicos hubo una concordancia con el diagnóstico clínico del 88,3 % (60/68). En el grupo de exploraciones consideradas normales, la concordancia fue del 83,4 % (35/42). En los pacientes con Enfermedad de Parkinson (EP), se apreció correlación inversa estadísticamente significativa entre captación estriatal y severidad según grado H&Y (r = ­0,4) y entre valoración cualitativa y cuantitativa (r = ­0,86). No se obtuvo significación entre pérdida fisiológica de función dopaminérgica y edad, ni entre grado de asimetría a nivel estriatal en los distintos grupos. Conclusiones: Se observó en general una adecuada concordancia entre diagnóstico clínico y resultado de la SPECT con FP-CIT. En los pacientes con EP se obtuvo correlación inversa entre captación estriatal y grado de H&Y y mayor grado de asimetría a nivel estriatal que en el resto de grupos

Introduction: 123I-FP-CIT scan has been supported in the last years by numerous studies as a technique of undeniable value to assess presynaptic integrity of the nigrostriatal pathway. The objective of this study is to perform a descriptive analysis of the main diagnostic aspects obtained from the first 110 studies made with FP-CIT in our center. Material and methods: The study population consisted of 110 consecutive patients distributed into 5 groups according to the clinical diagnosis, after a follow-up period of at least one year. Qualitative and quantitative scintigraphy was done. Results: A total of 61.8 % (68/110) of the studies were considered abnormal and 38.2 % (42/110) as normal. Among the abnormal examinations there was 88.3 % (60/68) agreement with the clinical diagnosis and agreement was 83.4 % (35/42) in the normal examinations. Inverse significant correlation was assessed between striatal binding and severity according to the H&Y scale (r = ­0.4) and between qualitative and quantitative assessment (r = ­0.86). There was no significant correlation between the degeneration of dopaminergic function according to age and degree of asymmetry on striatal binding in the different groups. Conclusions: Generally an adequate agreement between clinical diagnosis and SPECT-FP-CIT was observed. Inverse correlation between striatal binding and H&Y scale and greater asymmetry at striatal binding was obtained among Parkinson patients than in the rest of groups

Alteración precoz de la función adrenérgica cardíaca en los parkinsonismos con cuerpos de Lewy / Early alteration of adrenergic cardiac function in parkinsonisms with Lewy bodies

Introducción: La gammagrafía miocárdica con 123I-metayodobencilguanidina (123I-MIBG) se emplea para obtener información acerca de la función simpática cardíaca, tanto en cardiopatías como en otras patologías donde existe alteración del sistema nervioso autónomo. En este estudio se analizan las características de la captación miocárdica de 123I-MIBG en la enfermedad de Parkinson (EP), y su posible utilidad para diferenciarla de la enfermedad por cuerpos de Lewy (ECL). Material y métodos: 108 sujetos fueron estudiados, 70 pacientes con EP, 21 con ECL, y 17 sujetos controles. Los parámetros clínicos evaluados fueron la severidad del proceso mediante escala de Hoehn y Yahr, las manifestaciones vegetativas, el tiempo de evolución y el uso de fármacos. La captación miocárdica se analizó tras administración i.v. de 111 MBq de 123I-MIBG, en imágenes planares de tórax a los 15 min y a las 4 h, obteniéndose mediante índices corazón-mediastino (ICM) evaluación cualitativa y semicuantitativa de la misma. Resultados: Los ICM obtenidos en los pacientes con EP y ECL, están significativamente disminuidos en relación con los sujetos controles (p < 0,05), siendo independientes del tiempo de evolución, severidad del proceso, uso de medicación o de la existencia de manifestaciones vegetativas. Los ICM obtenidos en los pacientes de ECL, se encuentran menos disminuidos que en la EP. Conclusión: La gammagrafía de inervación miocárdica con 123I-MIBG detecta tanto en los pacientes con EP como en los de ECL alteraciones de la función simpática cardíaca de una manera clara y precoz

Background: 123I-metaiodobenzylguanidine (123I-MIBG) myocardial scintigraphy is clinically used to estimate myocardial sympathetic damage in some forms of heart disease, autonomic nerve disturbance in diabetic neuropathy, and disturbance of the autonomic nervous system in neurodegenerative disease. In the present study, examinations were performed to clarify the rate and characteristics of cardiac sympathetic disturbance in Parkinson's disease (PD) and usefulness of 123I-MIBG myocardial scintigraphy to differentiate PD from the Lewy Body Disease (LBD). Material and methods: 108 subjects were studied. There were 70 patients with PD, 21 patients with LBD, and 17 age-matched normal subjects without neurological disease. The clinical parameters evaluated were severity of the process (measured by Hoehn and Yahr Scale), vegetative manifestations, development time and use of medication taken. Myocardial adrenergic function was analyzed by imaging with 123I-MIBG. Early (15 min) and delayed (4 h) images of the thorax in the anterior view were obtained after injection of 123I-MIBG (111 MBq). The qualitative and semiquantitative 123I-MIBG uptake was quantified by calculating a heart-to-mediastinum ratio (HMR) and analyzed in a blind manner. Results: The mean H/M ratio in patients with PD and LBD was significantly lower than in controls (p < 0.05). This is independent of development time, process severity, use of medication or vegetative manifestations. The HMR obtained in LBD patients is less clear than in PD. Conclusion: 123I-MIBG myocardial scintigraphy might detect early disturbances of the sympathetic nervous system in PD and LBD

[Early alteration of adrenergic cardiac function in parkinsonisms with Lewy bodies]. / Alteración precoz de la función adrenérgica cardíaca en los parkinsonismos con cuerpos de Lewy.

BACKGROUND: 123I-metaiodobenzylguanidine (123I-MIBG) myocardial scintigraphy is clinically used to estimate myocardial sympathetic damage in some forms of heart disease, autonomic nerve disturbance in diabetic neuropathy, and disturbance of the autonomic nervous system in neurodegenerative disease. In the present study, examinations were performed to clarify the rate and characteristics of cardiac sympathetic disturbance in Parkinson's disease (PD) and usefulness of 123I-MIBG myocardial scintigraphy to differentiate PD from the Lewy Body Disease (LBD). MATERIAL AND METHODS: 108 subjects were studied. There were 70 patients with PD, 21 patients with LBD, and 17 age-matched normal subjects without neurological disease. The clinical parameters evaluated were severity of the process (measured by Hoehn and Yahr Scale), vegetative manifestations, development time and use of medication taken. Myocardial adrenergic function was analyzed by imaging with 123I-MIBG. Early (15 min) and delayed (4 h) images of the thorax in the anterior view were obtained after injection of 123I-MIBG (111 MBq). The qualitative and semiquantitative 123I-MIBG uptake was quantified by calculating a heart-to-mediastinum ratio (HMR) and analyzed in a blind manner. RESULTS: The mean H/M ratio in patients with PD and LBD was significantly lower than in controls (p < 0.05). This is independent of development time, process severity, use of medication or vegetative manifestations. The HMR obtained in LBD patients is less clear than in PD. CONCLUSION: 123I-MIBG myocardial scintigraphy might detect early disturbances of the sympathetic nervous system in PD and LBD.

[Dopamine agonists situation in Parkinson disease]. / Situación de los agonistas dopaminérgicos en la enfermedad de Parkinson.

The development of a variety of side effects associated with long term treatment of Parkinson s disease has prompted the introduction of new drugs and new treatment strategies. The use of dopamine agonists in combination with levodopa has proved to be useful in advanced patients with motor fluctuations. Recent studies indicate that the use of dopamine agonists in monotherapy from the early stages of the disease can be as effective as levodopa for clinical improvement with the added advantage of a significant less presentation of diskinesias. Ropinirol the first dopaminergic agonist demonstrating this effect in a 5 year controlled study, has well tolerance, both in combination or in monotherapy. Although low doses can be useful for individual patients, doses of approximately 15 16 mg/day proved to be safe and effective in long term studies.

[The response of the growth hormone to acute effort is a function of training]. / La respuesta de la hormona de crecimiento al esfuerzo agudo está en función del entrenamiento.

BACKGROUND: The increase of the growth hormone (GH) during exercise is known although the relationship of this response with other hormones, the type and intensity of the exercise, nutritional state and with the degree of training are reasons for discussion. The aim of this investigation was to study the response of the HG on a group of young adults with different degrees of training, according to the maximum consumption of oxygen (VO2 max) achieved over a short period of time. METHODS: Thirty-nine healthy subjects who underwent maximum effort on the treadmill were grouped according to VO2 max reached (less than 3,000 ml/min; 3,000-4,500 ml/min and greater than 4,500 ml/min). Systolic blood pressure (SBP) and diastolic blood pressure (DBP), respiratory quotient (RQ), O2 pulse, cardiac frequency (CF) respiratory equivalence (RE), glycemia, plasma insulin (PI), C peptide, lactic acid, venous pH, plasma renin activity (PRA), plasma aldosterone, thyrotropine (TSH), triodothyronine (T3), thyroxine (T4), adrenocorticotropine (ACTH), cortisol and GH were measured basally and following achievement of VO2 max. RESULTS: The GH was only increased in those subjects with a VO2 max higher than 3,000 ml/min with a significant positive correlation found between the GH and VO2 max and a significant negative correlation was found between the GH and lactic acid at the end of the test. The increase of glycemia at the end of the test correlated with the VO2 max. The PI and C peptide increased at the end of the test in the subjects with greater VO2 max capacity and correlated positively with the VO2 max and with the GH upon completion of the exercise. CONCLUSIONS: These results suggest that the response of the growth hormone to exercise is a function of maximum oxygen consumption although this only explains 24% of the variants of the growth hormone. Despite important hormonal and metabolic mobilization during exercise, no model of multiple regression has been found which substantially improves the association found between the growth hormone and maximum oxygen consumption.