Neuropsychological evaluation in transient ischaemic attack and minor stroke

Summary Two groups of patients with transient ischaemic attack and minor stroke without detectable haemodynamic stenotic lesions were evaluated by neuropsychological tests and compared with a control group. The mean values of the scores adjusted for age and educational background demonstrated that (a) the patients with transient ischaemic attack did not have a worse performance than normal subjects in any of the tests, (b) the patients with minor stroke had a worse performance than normals, particularly in Rey's figure-copying test (P<0.025), and (c) the latter test was not affected by educational background or age of the subjects. The results are discussed with reference to other case series, and the importance of age and cerebral damage in causing intellectual impairment evaluated by neurophysiological tests is stressed.     

Man-to-woman sexual transmission of the human immunodeficiency virus. Risk factors related to sexual behavior, man's infectiousness, and woman's susceptibility. Italian Study Group on HIV Heterosexual Transmission.

To investigate the risk factors for man-to-woman sexual transmission of the human immunodeficiency virus (HIV), we carried out a cross-sectional study of 368 women who were steady partners of HIV-infected men attending 16 Italian clinical centers. Information was collected from the medical records of the infected men and by direct interviews with the women. In a logistic regression analysis, the woman's awareness of her partner's seropositivity (odds ratio [OR], 0.2; 95% confidence interval [CI], 0.0 to 1.1), use of condoms (OR, 0.3; 95% CI, 0.1 to 1), and oral contraceptive use (OR, 0.5; 95% CI, 0.3 to 1.0) were negatively associated with transmission of the HIV infection. An increased risk was found in women having sexual intercourse more than twice a week (OR, 2.4; 95% CI, 1.2 to 4.9) and in women who had been sexually exposed to HIV for between 2 and 5 years (OR, 3.5; 95% CI, 1.8 to 6.7). The transmission rate was higher in couples who engaged in anal sex (OR, 2.8; 95% CI, 1.3 to 6.3); in women reporting vaginitis (OR, 4.9; 95% CI, 2.4 to 10.2) or genital warts (OR, 33.3; 95% CI, 4.5 to 244.1); and in those using intrauterine devices (OR, 3.1; 95% CI, 1.4 to 7.1). The risk for women was also associated with a CD4+ cell count lower than 400/mm3 in their partners. Knowledge of the HIV status of the partner led to increased condom use but did not induce a lower frequency of sexual intercourse or an avoidance of anal sex.     

Levodopa or dopamine agonists, or deprenyl as initial treatment for Parkinson's disease. A randomized multicenter study

Objectives: levodopa improves the quality of life in parkinsonian patients, however long term response is compromised by the emergence of motor fluctuations and dyskinesias. The aim of this study was to compare the occurrence of motor fluctuations and dyskinesias in previously untreated patients assigned to receive levodopa, a dopamine agonist or deprenyl.Thirty-five neurological departments in Italian hospitals participated in this randomized open trial. Patients with Parkinson's disease, who required the initiation of an effective antiparkinsonian treatment, were randomly assigned to receive levodopa, dopamine agonists or deprenyl. The end-points were motor dyskinesias and motor fluctuations occurring in a median follow-up period of about 3years.After a median follow-up of 34months, motor fluctuations and dyskinesias were less frequent in patients assigned to a dopamine agonist or deprenyl than in patients assigned to levodopa (relative risk [RR] 0.5, 95% confidence interval [95% CI] 0.3-0.8, and RR=0.6, 95% CI 0.3-0.9, respectively), but dopamine agonists were less effective and less well tolerated than levodopa. The lower frequency of motor fluctuations in patients assigned to deprenyl was no longer statistically significant when prognostic predictors were considered in a multivariable analysis. Long-term mortality did not differ in the three arms of the study. Dopamine agonists and deprenyl can be considered as an alternative to levodopa for starting treatment in Parkinson's disease patients. However, on clinical grounds, only small advantages are expected over the traditional therapy initiation with levodopa.     

Sympathetic modulation by levodopa reduces vascular risk factors in Parkinson disease

BackgroundSympathetic nervous system hyperactivity promotes vascular disorders by its catabolic effects and by increasing arterial blood pressure. Levodopa-derived dopamine modulates sympathetic overactivity and is known to reduce blood pressure, but its effects on glucose and lipid metabolism have not been studied in large series of patients.MethodsWe retrospectively examined 483 consecutive parkinsonian patients, admitted to a single institute between 1970 and 1987, before statins were available. We compared risk factors for vascular disease in the 305 who were on levodopa with the 178 who had never received the drug.ResultsOn admission levodopa-treated patients had significantly lower plasma levels of triglycerides, total cholesterol and lipids, and lower frequency of diabetes and hypertension than untreated patients. Mean body mass index, resting blood pressure, fasting plasma glucose, and smoking did not differ between the groups. A year after enrolment 160 patients were re-hospitalized; of these 63 had started levodopa during first hospitalization. In these new levodopa users total cholesterol, triglycerides and lipids had reduced to levels comparable with those of longer-term levodopa users.ConclusionLevodopa use in parkinsonian patients is associated with reduced vascular risk factors. In causal terms this finding might be attributed to the inhibitory action of levodopa-derived dopamine on the sympathetic nervous system.     

Mortality associated with early and late levodopa therapy initiation in Parkinson's disease

We evaluated the possible influence of early levodopa treatment on the mortality of Parkinson's disease (PD). One hundred forty-five consecutive parkinsonian patients initiated treatment with levodopa between 1970 and 1983. Ninety-eight of those started levodopa therapy 2 or more years after symptom onset, while 47 received levodopa within the 1st 2 years of the disease. At the end of follow-up, in December 1985, 49 patients had died. Mortality was 2.5 times higher among patients who delayed initiation of levodopa therapy 2 or more years than among those who initiated the therapy earlier. Age and disease severity were the most significant predictors of survival after initiation of levodopa treatment. The risk of death was 10% higher every year of age increase and was 2 and 4 times higher, respectively, for patients at Hoehn and Yahr stages II and III than for patients at Hoehn and Yahr stage I. When we controlled for the effect of age and disease severity on mortality, the cumulative death probability was no longer significantly higher among patients who delayed levodopa treatment than among patients treated within 2 years from disease onset. As far as mortality is concerned, the results show that the time of levodopa treatment initiation during PD has no influence and the drug can be introduced as soon as indicated by the severity of the disease progression.     

Incidence and prognosis of brain abscess in a defined population: Olmsted County, Minnesota, 1935-1981

The incidence of brain abscess was studied on all cases occurring in residents of Olmsted County, Minn., from 1935 through 1981. Thirty-eight cases (9 cases first diagnosed at autopsy) were identified and followed through the Rochester Olmsted County medical record-linkage system at the Mayo Clinic. The incidence rate was 1.3/100,000 person-years (PY), 1.9 in males and 0.6 in females. Incidence decreased from 2.7 in 1935-44 to 0.9 in 1965-81. Rates were higher in children 5-9 years old (2.4) and after age 60 (2.6 PY). An etiologic agent was identified in 29 cases (76%) with streptococci being the most frequently isolated. Case-fatality ratio was 38% (11/29), stable over time. Concurrent bacterial meningitis was the strongest predictor of death. Neurologic sequelae were observed in 8 (44%) of the 18 surviving patients including epilepsy (5 cases), deafness and motor impairment.     

In vivo detection of iron and neuromelanin by transcranial sonography: a new approach for early detection of substantia nigra damage.

Early diagnosis of Parkinson's disease (PD) in nonsymptomatic patients is a key issue. An increased echogenicity of the substantia nigra (SN) was found previously in Parkinsonian patients and in a low percentage of healthy adults. These nonsymptomatic subjects also showed a reduced 18F-dopa uptake in striatum, suggesting a preclinical injury of the nigrostriatal system that could later proceed into PD. To investigate the ability of ultrasonography to detect markers of SN degeneration, such as iron deposition and neuromelanin depletion, we scanned postmortem brains from normal subjects at different ages by ultrasound and measured the echogenic area of the SN. The SN was then dissected and used for histological examinations and determination of iron, ferritin, and neuromelanin content. A significant positive correlation was found between the echogenic area of the SN and the concentration of iron, H- and L-ferritins. Multivariate analysis carried out considering the iron content showed a significant negative correlation between echogenicity and neuromelanin content of the SN. In PD, a typical loss of neuromelanin and increase of iron is observed in this brain area. The finding of a positive correlation between iron and ferritin levels and a negative correlation of neuromelanin content with the area of echogenicity at the SN could therefore provide an interesting basis for diagnosis and therapeutic follow-up studies in PD.