Incidence of Parkinson's disease in Norway: the Norwegian ParkWest study

OBJECTIVE

To present the incidence of Parkinson's disease (PD) in Norway and to explore gender influences on incidence and age at onset, as well as severity and pattern of parkinsonism at the time of diagnosis in a representative drug naïve cohort with newly diagnosed PD.

METHODS

In four Norwegian counties comprising a base population of 1 052 075 inhabitants, multiple sources of case ascertainment and a four step diagnostic procedure were used to establish a representative cohort of patients with incident PD at a high level of diagnostic accuracy. Of a total of 604 subjects referred to the study, 265 individuals fulfilled the clinical research criteria of PD at their latest clinical visit, at a mean 28 months after identification.

RESULTS

The incidence of PD in the study area, age standardised to the 1991 European standard population, was 12.6/10(5yr-1) (95% CI 11.1 to 14.2). The overall age standardised male to female ratio was 1.58 (95% CI 1.22 to 2.06), with a consistent male preponderance throughout all age groups. Clinical onset of PD was later in women than in men (68.6 vs 66.3 years; p = 0.062) whereas severity and pattern of parkinsonism in drug naïve patients was not different between genders at the time of diagnosis.

CONCLUSION

Incidence rates of PD in Norway are similar to those in other Western European and American countries. Female gender was associated with a considerably lower risk of PD and slightly delayed motor onset but had no impact on severity of parkinsonism or clinical phenotype in incident drug naïve PD, suggesting that the female gender influences on the nigrostriatal system are most pronounced in the preclinical phase of the disease.

The spectrum of neuropsychiatric symptoms in patients with early untreated Parkinson's disease

BACKGROUND

Neuropsychiatric symptoms are common in Parkinson's disease (PD) and have important clinical consequences for patients, caregivers and society. Few studies of neuropsychiatric symptoms in early untreated PD exist.

OBJECTIVE

To explore the range, clustering and correlates of neuropsychiatric symptoms in an incidence cohort of untreated subjects with PD.

METHODS

All cases with incident PD identified during a 22 month period in four counties of Western and Southern Norway were included. Standardised criteria were used to diagnose PD. The Neuropsychiatric Inventory (NPI) was administered to 175 PD and 166 healthy control subjects with similar age and sex distributions. Cluster analysis was used to investigate the interrelationship of NPI items.

RESULTS

The proportion with any NPI symptoms was higher in PD (56%) than in controls (22%) (p<0.001). Depression (37%), apathy (27%), sleep disturbance (18%) and anxiety (17%) were the most common symptoms. Clinically significant symptoms occurred in 27% of the PD group compared with only 3% in the control group (p<.001). Subjects with clinically significant neuropsychiatric symptoms had more severe parkinsonism than those without. Two neuropsychiatric clusters were identified, one characterised by mood symptoms and one by apathy.

CONCLUSIONS

Although the majority of patients with early untreated PD do not have clinical significant neuropsychiatric symptoms, these symptoms are more common in patients than in people without PD. Both psychological stress and brain changes associated with PD are likely to contribute to the higher frequencies.

Is fatigue an independent and persistent symptom in patients with Parkinson disease?

OBJECTIVE

To evaluate if mental fatigue is a symptom that appears independently from other clinical features in patients with Parkinson disease (PD), and to study if fatigue is persistent over time in these patients.

METHODS

In 1993, 233 patients with PD were included in a community-based study of fatigue and followed prospectively over 8 years. Fatigue was measured by a combination of a seven-point scale and parts of the Nottingham Health Profile (NHP) at baseline and after 4 and 8 years. In addition, the Fatigue Severity Scale (FSS) was used to evaluate fatigue in 2001. Population-averaged logistic regression models for correlated data were performed to study the relationship between fatigue and various demographic and clinical variables.

RESULTS

In patients who were followed throughout the 8-year study period, fatigue increased from 35.7% in 1993 to 42.9% in 1997 and 55.7% in 2001. Fatigue was related to disease progression, depression, and excessive daytime sleepiness (EDS). However, the prevalence of fatigue in patients without depression and EDS remained high and increased from 32.1% to 38.9% during the study period. For about 44% of the patients with fatigue the presence of this symptom varied during the study period, as it was persistent in 56% of the patients with fatigue.

CONCLUSIONS

The authors confirmed the high prevalence of mental fatigue in patients with Parkinson disease (PD). Fatigue is related to other non-motor features such as depression and excessive daytime sleepiness, but cannot be explained by this comorbidity alone. In more than half of the patients mental fatigue is persistent and seems to be an independent symptom that develops parallel to the progressive neurodegenerative disorder of PD.

Suppressor of fused links fused and Cubitus interruptus on the hedgehog signalling pathway

The Hedgehog (Hh) family of signalling proteins [1] mediate inductive interactions either directly or by controlling the transcription of other secreted proteins through the action of Gli transcription factors, such as Cubitus interruptus (Ci) [2]. In Drosophila, the transcription of Hh targets requires the activation of the protein kinase Fused (Fu) and the inactivation of both Suppressor of fused (Su(fu)) and Costal-2 (Cos-2) [3]. Fu is required for Hh signalling in the embryo and in the wing imaginal disc and acts also as an antitumorigen in ovaries [4]. All fu- phenotypes are suppressed by the loss of function of Su(fu) [5]. Fu, Cos-2 and Ci are co-associated in vivo in large complexes that are bound to microtubules in a Hh-dependent manner [6,7]. Here we investigate the role of Su(fu) in the intracellular part of the Hh signalling pathway. Using the yeast two-hybrid method and an in vitro binding assay, we show that Su(fu), Ci and Fu can interact directly to form a trimolecular complex, with Su(fu) binding to both its partners simultaneously. Su(fu) and Ci also co-immunoprecipitate from embryo extracts. We propose that, in the absence of Hh signalling, Su(fu) inhibits Ci by binding to it and that, upon reception of the Hh signal, Fu is activated and counteracts Su(fu), leading to the activation of Ci.

Excessive daytime sleepiness in Parkinson disease: is it the drugs or the disease?

OBJECTIVE

To examine associated demographic and clinical correlates and the development of excessive daytime sleepiness (EDS) over 8 years in a community-based cohort of patients with Parkinson disease (PD).

METHODS

A total of 232 patients with PD were included in a population-based prevalence study in 1993. Patients were followed prospectively and reexamined after 4 and 8 years. At all study visits, the authors administered semistructured interviews to obtain information on clinical and demographic variables. Standardized rating scales of parkinsonism, depression, and cognitive impairment were used. The diagnosis of EDS was based on a sleep questionnaire and in 2001 also on the Epworth Sleepiness Scale. Population-averaged logistic regression models for correlated data were performed to study the relationship between EDS and various demographic and clinical variables.

RESULTS

Of the 232 patients included at baseline, 138 were available for re-evaluation after 4 years and 89 patients after 8 years. Frequency rates of EDS increased from 5.6% in 1993 to 22.5% in 1997 and 40.8% in 2001, with an 8-year prevalence of 54.2%. In the majority of patients, EDS was a persistent feature. In the logistic regression model, EDS was related to age, gender, and use of dopamine agonists. In those never having used dopamine agonists, hypersomnia was associated with the Hoehn and Yahr stage only.

CONCLUSION

Excessive daytime sleepiness is a frequent and highly persistent feature in Parkinson disease, with multifactorial underlying pathophysiology. The authors' findings indicate that both age and disease related disturbances of the sleep-wake regulation contribute to hypersomnia in PD. Treatment with dopamine agonists also contributed to excessive daytime sleepiness in our patients.

A 12-year population-based study of freezing of gait in Parkinson's disease

INTRODUCTION

Freezing of gait (FOG) is a potentially disabling motor problem in Parkinson's disease (PD) with uncertain etiology. Longitudinal studies of FOG in PD are scarce. We determined the prevalence, incidence, and associated clinical risk factors and concomitants of FOG during prospective long-term follow-up of a population-based PD cohort.

METHODS

A community-based prevalent cohort of 232 PD patients was followed prospectively over 12 years. Reassessments were conducted at 4 and 8 years, and then annually. FOG, as well as severity of parkinsonism, motor complications, and psychotic symptoms were assessed by the Unified PD Rating Scale, and cognitive impairment by the Mini-Mental State Examination. Generalized estimating equations were applied to investigate baseline risk factors and concomitants of FOG over time.

RESULTS

The point prevalence of FOG at baseline was 27% (95% confidence interval (95%-CI) 22-33%). By study end, 63% (95%-CI 56-69%) of patients had developed FOG. The incidence rate of FOG was 124.2 (95%-CI 101.5-152.1) per 1000 person-years. Motor fluctuations (odds ratio (OR) 3.45; p = 0.036) and higher levodopa dose (OR 1.30/100 mg, p = 0.009) at baseline were independent risk factors of incident FOG. Prevalent FOG over time was additionally associated with features thought to reflect extrastrial, non-dopaminergic pathologies, including PIGD (postural instability/gait difficulty, OR 6.30/10 points, p < 0.001) and psychosis (OR 1.85; p = 0.016).

CONCLUSION

These findings demonstrate that FOG affects the majority of patients in the general PD population and provide support to the hypothesis that alterations in both basal ganglia and extrastriatal brain areas are involved in the pathogenesis of FOG in PD.

Modulation of Hedgehog target gene expression by the Fused serine-threonine kinase in wing imaginal discs

The Fused (Fu) serine-threonine kinase and the Suppressor of fused (Su(fu)) product are part of the Hedgehog (Hh) signaling pathway both in embryos and in imaginal discs. In wing imaginal discs, the Hh signal induces Cubitus interruptus (Ci) accumulation and activates patched (ptc) and decapentaplegic (dpp) expression along the anterior/posterior (A/P) boundary. In this paper, we have examined the role of the Fu and Su(fu) proteins in the regulation of Hh target gene expression in wing imaginal discs, by using different classes of fu alleles and an amorphic Su(fu) mutation. We show that, at the A/P boundary, Fu kinase activity is involved in the maintenance of high ptc expression and in the induction of late anterior engrailed (en) expression. These combined effects can account for the modulation of Ci accumulation and for the precise localization of the Dpp morphogen stripe. In contrast, in more anterior cells which do not receive Hh signal, we show that Fu plays a role independent of its kinase function in the regulation of Ci accumulation. In these cells, Fu may be involved in the stabilization of a large protein complex which is probably responsible for the regulation of Ci cleavage and/or targeting to nucleus. We propose that the Fused function is necessary for the activation of full-length Ci and counteracts the negative Su(fu) effect on the pathway, leading to en, ptc and dpp expression.

Occurrence and risk factors for apathy in Parkinson disease: a 4-year prospective longitudinal study

BACKGROUND

Apathy is a common but under-recognised behavioural disorder associated with depression and cognitive impairment in patients with Parkinson disease (PD). However, the longitudinal course of apathy in PD has not been studied.

OBJECTIVE

To examine the occurrence of and risk factors for apathy over time in a representative sample of patients with PD.

METHODS

A sample of 139 patients was drawn from a population-based prevalence study of PD in Rogaland County, Western Norway. Apathy was measured with the Neuropsychiatric Inventory, using a composite score >or=4 to indicate clinically significant apathy. Additional measurements included standardised rating scales for parkinsonism, depression and cognitive impairment. A follow-up evaluation was carried out in 79 patients (78.2% of the survivors) 4 years later.

RESULTS

Of the 79 patients included in this study, 29 patients (36.7%) had never had apathy, 11 (13.9%) had persistent apathy, and a further 39 (49.4%) developed apathy during follow-up. At follow-up, patients with apathy were more frequently depressed and demented than never-apathetic patients. Dementia at baseline and a more rapid decline in speech and axial impairment during follow-up were independent risk factors for incident apathy.

CONCLUSIONS

Apathy is a persistent behavioural feature in PD with a high incidence and prevalence over time. Progression of motor signs predominantly mediated by non-dopaminergic systems may be a useful preclinical marker for incident apathy in PD.

Differential methylation of human LINE-1 retrotransposons in malignant cells

Long interspersed element-1 (LINE-1) retrotransposons from Homo sapiens (L1Hs) are not expressed in normal somatic cells. In malignant cells, there is a direct correlation between the hypomethylation of 5' L1Hs sequences and the presence of L1Hs proteins, suggesting that elements with hypomethylated 5' ends are transcriptionally active. Sequences flanking the 5' ends of hypomethylated L1Hs elements were isolated from the T-47D breast cancer cell line by inverse-PCR and cloning. These flanker clones served as probes for analyzing the loci harboring the hypomethylated L1Hs elements. Sequencing demonstrated that the flankers have no homology with one another and do not appear to contain common short motifs that might serve as recognition sites for regulatory factors. The hypomethylated L1Hs elements are located on many chromosomes, although three of twelve are on chromosome 15. Southern blotting indicates that certain elements are hypomethylated in numerous cell lines, and that elements that are hypomethylated in malignant germ cells comprise a different subset of elements than those that are hypomethylated in non-germ cell malignancies. These results suggest that the subset of L1Hs elements that is hypomethylated in malignant cells is not simply a random collection of L1Hs elements.

Neurologic disorders due to brain manganese deposition in a jaundiced patient receiving long-term parenteral nutrition

BACKGROUND

Neurologic and radiologic disorders have been reported in patients receiving long-term parenteral nutrition (PN). On the basis of elevated serum manganese levels, some of these abnormalities have been attributed to manganese intoxication. Alterations of the basal ganglia signal intensity on T1-weighted magnetic resonance images (MRIs) have been previously reported, but the precise nature of these alterations remains controversial although the deposition of manganese has been suggested in patients with chronic hepatic encephalopathy due to liver failure.

METHODS

We report the case of a patient who was receiving PN and exhibited a chronic cholestasis. Neurologic disorders appeared after several months of PN, when a hypersignal in the basal ganglia and white matter was found on T1-weighted MRIs of the brain in association with elevated serum and manganese levels.

RESULTS

Elevated autopsic concentrations of manganese were found in the radiologic abnormal cerebral areas.

CONCLUSIONS

Our observation is the first demonstration of a relationship between high intracerebral manganese levels, radiologic abnormalities, and neurologic disorders during long-term PN. Moreover, serum manganese levels are not a good indicator of cerebral levels. In fact, in our patient, serum manganese levels returned to normal, whereas those of cerebral manganese remained increased.

The Suppressor of fused gene encodes a novel PEST protein involved in Drosophila segment polarity establishment

Suppressor of fused, Su(fu), was identified as a semi-dominant suppressor of the putative serine/threonine kinase encoded by the segment polarity gene fused in Drosophila melanogaster. The amorphic Su(fu) mutation is viable, shows a maternal effect and displays no phenotype by itself. Su(fu) mutations are often found associated to karmoisin (kar) mutations but two complementation groups can be clearly identified. By using a differential hybridization screening method, we have cloned the Su(fu) region and identified chromosomal rearrangements associated with Su(fu) mutations. Two classes of cDNAs with similar developmental patterns, including a maternal contribution, are detectable in the region. Transformation experiments clearly assigned the Su(fu)+ function to one of these transcription units while the other one can be most likely assigned to the kar+ function. Surprisingly the 5' end of the kar RNA mapped within the 3' untranslated region of the Su(fu) transcribed sequence. The Su(fu) gene encodes a 53-kD protein, which contains a PEST sequence and shows no significant homologies with known proteins. Genetic analysis shows that proper development requires a fine tuning of the genetic doses of fu and Su(fu) both maternally and zygotically. These results, together with previous genetic and molecular data, suggest that fused and Suppressor of fused could act through a competitive posttraductionnal modification of a common target in the hedgehog signaling pathway.

Functional domains of fused, a serine-threonine kinase required for signaling in Drosophila

fused (fu) is a segment-polarity gene encoding a putative serine-threonine kinase. In a wild-type context, all fu mutations display the same set of phenotypes. Nevertheless, mutations of the Suppressor of fused [Su(fu)] gene define three classes of alleles (fuO, fuI, fuII). Here, we report the molecular analysis of known fu mutations and the generation of new alleles by in vitro mutagenesis. We show that the Fused (Fu) protein functions in vivo as a kinase. The N-terminal kinase and the extreme C-terminal domains are necessary for Fu+ activity while a central region appears to be dispensable. We observe a striking correlation between the molecular lesions of fu mutations and phenotype displayed in their interaction with Su(fu). Indeed, fuI alleles which are suppressed by Su(fu) mutations are defined by inframe alterations of the N-terminal catalytic domain whereas the C-terminal domain is missing or altered in all fuII alleles. An unregulated FuII protein, which can be limited to the 80 N-terminal amino acids of the kinase domain, would be responsible for the neomorphic costal-2 phenotype displayed by the fuII-Su(fu) interaction. We propose that the Fu C-terminal domain can differentially regulate the Fu catalytic domain according to cell position in the parasegment.

Genetic imbalances in 26 cases of penile squamous cell carcinoma

To obtain more information on chromosomal changes in the up-to-now poorly studied tumor class of penile squamous cell carcinoma (SCC), we performed a comparative genomic hybridization study of 26 cases of this rare tumor. DNA sequence copy number alterations (CNAs) very similar to those detected in other SCC types, such as oral and esophageal SCC, were noted. The most common copy number gains were found in 8q24, 16p11-12, 20q11-13, 22q, 19q13, and 5p15, and the most common deletions were detected in 13q21-22, 4q21-32, and along the X chromosome. Classifying the patients according to the number of CNAs showed a possible correlation with clinical outcome.

Alpha satellite DNA in neotropical primates (Platyrrhini)

The alpha satellite DNA of Old World (catarrhine) primates usually consists of similar, but not identical, ca. 170 bp sequences repeated tandemly hundreds to thousands of times. The 170 bp monomeric repeats are components of higher-order repeats, many of which are chromosome specific. Alpha satellites are found exclusively in centromeric regions where they appear to play a role in centromere function. We have found that alpha satellite DNA in neotropical (New World; platyrrhine) primates is very similar to its Old World counterpart: it consists of divergent ca. 170 bp subsequences that are arranged in tandem arrays with a ca. 340 bp periodicity. New and Old World alpha satellites share about 64% sequence identity overall, and contain several short sequence motifs that appear to be highly conserved. One exception to the tandemly arrayed 340 bp motif has been found: the major alpha satellite array in Chiropotes satanas (black bearded saki) has a 539 bp repeat unit that consists of a 338 bp dimer together with a duplication of 33 bp of the first monomeric unit and 168 bp of the second monomeric unit.

Early constipation predicts faster dementia onset in Parkinson's disease

Constipation is a common but not a universal feature in early PD, suggesting that gut involvement is heterogeneous and may be part of a distinct PD subtype with prognostic implications. We analysed data from the Parkinson's Incidence Cohorts Collaboration, composed of incident community-based cohorts of PD patients assessed longitudinally over 8 years. Constipation was assessed with the MDS-UPDRS constipation item or a comparable categorical scale. Primary PD outcomes of interest were dementia, postural instability and death. PD patients were stratified according to constipation severity at diagnosis: none (n = 313, 67.3%), minor (n = 97, 20.9%) and major (n = 55, 11.8%). Clinical progression to all three outcomes was more rapid in those with more severe constipation at baseline (Kaplan-Meier survival analysis). Cox regression analysis, adjusting for relevant confounders, confirmed a significant relationship between constipation severity and progression to dementia, but not postural instability or death. Early constipation may predict an accelerated progression of neurodegenerative pathology.

Familial Parkinson's disease: a community-based study

Genetic factors seem to be important in the pathogenesis of Parkinson's disease (PD). It is however, still controversial whether these factors also are reflected in a familial aggregation of PD. The aim of this study was to investigate the frequency of PD patients with a positive PD family history compared with two control groups. The included 245 PD patients were examined by neurologists and information was obtained through a semi-structured interview. The patients and the control groups were examined for the frequency of PD and dementia in their families. The 245 patients with PD were included in this study. A positive PD-family history could be obtained in 53 (21.6%) patients. The frequency was three- and four-fold increased as compared with the control groups (P < 0.001). Age at onset of disease was not different among patients with and without PD in the family. The frequency of dementia did not differ in the family of individuals with and without PD (P > 0.1). As a conclusion our study of PD in a community based population supports previous reports of a three- to fourfold increased risk for PD in the families of patients with the disease. Our results indicate that the familial aggregation of the disease is independent of the age of the proband.

Analysis of the salivary proteome in gingivitis patients

BACKGROUND AND OBJECTIVE

Gingivitis is a disease that is characterized by inflammation of the gingival tissue, which can progress to periodontitis and tooth loss. Although many studies have attempted to identify salivary proteins that are associated with the disease, this is the first study to use a proteomic approach to analyze and compare the proteomic profile of whole saliva from gingivitis patients and healthy controls.

MATERIAL AND METHOD

To analyze the saliva proteome, two-dimensional gel electrophoresis and liquid chromatography were used, followed by mass spectrometry.

RESULTS

The analyses showed that gingival inflammation was associated with increased amounts of blood proteins (serum albumin and hemoglobin), immunoglobulin peptides and keratins. In the control group, salivary cystatins, which were detected using capillary Liquid Chromatography on line to electrospray ionization Quadrupole Time-of-flight mass spectrometry, appeared to be more abundant.

CONCLUSION

This approach provides novel insight into profiles of the salivary proteome during gingival inflammation, which may contribute to improvements in diagnosis.

Comparative karyology and evolution of the Amazonian Callithrix (Platyrrhini, Primates)

Chromosomal studies in three species of Amazonian Callithrix (2n=44) and data in the literature show that this group is karyomonotypic. Moreover, it is characterized by the presence of abundant heterochromatic regions, unlike the situation in congeneric forms of Callithrix of the Atlantic coast with 2n=46, and by the presence of a highly repetitive, exclusive DNA component, with a basic repeat motif of 1528bp. Karyotypic comparisons with other Callitrichids and an outgroup species showed that Callitrichids are karyologically conserved and explained several rearrangements that had presumably occurred during their phyletic radiation. Analyses of karyologic data enabled the construction of two alternative phylogenetic topologies. The lack of derived homoeologies, common to all members of the genus Callithrix grouped at present, and the fact that Amazonian species were more similar to Cebuella pygmaea (2n=44) than to their congeneric forms with 2n=46 suggested that species at present included in the Amazonian Callithrix should be grouped with C. pygmaea.

Circumferential fingernail

We describe a Brazilian girl with a congenital circumferential nail on her left ring finger associated with other bony and soft tissue abnormalities of the affected limb. The tubular nail plate resembling a punch biopsy has been described as a circumferential nail, an extremely rare congenital malformation that can be associated with other congenital anomalies. In our review of the literature, there have only been two previous reports of this unusual condition affecting the fingernails.

The process of implementation of emergency care units in Brazil

OBJECTIVE

To analyze the process of implementation of emergency care units in Brazil.

METHODS

We have carried out a documentary analysis, with interviews with twenty-four state urgency coordinators and a panel of experts. We have analyzed issues related to policy background and trajectory, players involved in the implementation, expansion process, advances, limits, and implementation difficulties, and state coordination capacity. We have used the theoretical framework of the analysis of the strategic conduct of the Giddens theory of structuration.

RESULTS

Emergency care units have been implemented after 2007, initially in the Southeast region, and 446 emergency care units were present in all Brazilian regions in 2016. Currently, 620 emergency care units are under construction, which indicates expectation of expansion. Federal funding was a strong driver for the implementation. The states have planned their emergency care units, but the existence of direct negotiation between municipalities and the Union has contributed with the significant number of emergency care units that have been built but that do not work. In relation to the urgency network, there is tension with the hospital because of the lack of beds in the country, which generates hospitalizations in the emergency care unit. The management of emergency care units is predominantly municipal, and most of the emergency care units are located outside the capitals and classified as Size III. The main challenges identified were: under-funding and difficulty in recruiting physicians.

CONCLUSIONS

The emergency care unit has the merit of having technological resources and being architecturally differentiated, but it will only succeed within an urgency network. Federal induction has generated contradictory responses, since not all states consider the emergency care unit a priority. The strengthening of the state management has been identified as a challenge for the implementation of the urgency network.

Determination of manganese in human brain samples

A method is presented for the determination of manganese (Mn) in human tissue samples (especially brain) by graphite furnace atomic absorption spectrophometry (GFAAS). After complete digestion by a mixture of concentrated nitric acid (HNO3)/concentrated perchloric acid (HClO4) (50:50, v/v), the samples are assayed on a Perkin-Elmer 5100 PC apparatus, equipped with transversal graphite tubes and a Mn-specific hollow cathode lamp. The furnace conditions are as follows (for each step: temperature (degree C)/ramp (s)/duration (s)) dry 120/1/40; char 1200/5/10; atomization 2250/0/4; pyrolysis 2400/1/1. Zeeman correction is employed. The method is linear over the range 0.05 to 5.00 micrograms/g wet tissue, and the limit of detection for Mn is about 0.01 microgram/g wet tissue. This simple and rapid method may be of value for the post-mortem assessment of Mn accumulation in brain structures due to occupational or iatrogenic exposure. An application is presented in which elevated levels of Mn were determined in the brain samples of a 63-year-old female deceased after long-term total parenteral nutrition involving Mn supplementation.

Opinião das mulheres sobre as circunstâncias em que os hospitais deveriam fazer abortos

Pouco se sabe a respeito da opinião que as mulheres brasileiras têm acerca do aborto provocado. Em um estudo realizado na região de Campinas, se quis conhecer, entre outras coisas, o que pensavam as mulheres sobre as circunstâncias em que os hospitais deveriam fazer abortos. Foram entrevistadas 1838 mulheres em idade fértil e que tinham engravidado pelo menos uma vez. Para saber se existiam algumas características das mulheres associadas à sua opinião, foi feita uma análise univariada, seguida por uma multivariada por regressão logística. As mulheres solteiras e as que haviam tido pelo menos um aborto provocado foram as que tiveram opinião mais favorável à realização de abortos pelos hospitais em todas as circunstâncias perguntadas. As circunstâncias de estupro, risco de vida para a mulher e malformação fetal foram as que tiveram maior acordo. A proporção de mulheres que se manifestaram favoráveis foi menor no caso de aborto por razões que trazem conseqüências à mulher mas não podem ser observadas direta e objetivamente por outras pessoas.

Progression of fatigue in Parkinson's disease - a 9-year follow-up

BACKGROUND AND PURPOSE

Although highly disabling, the pathogenesis and evolution of fatigue in Parkinson's disease (PD) is largely unknown, and no sufficiently documented treatment currently exists. The aim of the present study was to investigate the evolution of fatigue during the first 9 years after diagnosis.

METHODS

This study is part of the Norwegian ParkWest collaboration, a prospective population-based longitudinal cohort study. The present study comprised 191 newly diagnosed patients and 170 control participants. Fatigue was assessed by the Fatigue Severity Scale, with examinations at baseline and then every other year up to 9 years of follow-up. Linear mixed models were applied to investigate possible variables associated with fatigue.

RESULTS

It was found that there was a statistically significant increase in the proportion of PD patients with fatigue during the first 9 years after diagnosis. A large proportion of patients had a significant increase or decrease in fatigue score between consecutive visits. In addition, the relative risk of persistent fatigue and ever having fatigue was higher than for controls. There were statistically significant longitudinal associations between higher levels of fatigue and female gender, comorbidity at baseline, depressive symptoms, dependency in activities of daily living and better cognitive functioning. Lower levels of fatigue were associated with the use of dopamine agonists.

CONCLUSION

Fatigue is a common, severely limiting symptom in PD. This study demonstrates associations with other factors that could yield a better understanding of the symptom and thus possible treatment strategies, although further investigations are necessary to establish causal relationships.

[Factors associated with prenatal care among low income women in the State of São Paulo, Brazil]

This paper presents the results of a study carried out in 1988 in the State of S. Paulo, with the purpose of evaluating the Program for Women's Integral Health Care. A total of 3.703 low income women of 15-49 years of age were interviewed using a structured, pre-tested form. The data in this paper relate to 669 women who had been pregnant during 1987 or 1988 and who were asked about pre-natal, delivery and post-partum care. The association between some of their socio-demographic characteristics and the pre-natal care received, months pregnant at the time of first visit and total number of visits, were analysed. Results showed an association between socio-economic characteristics and pre-natal care received. The greatest percentage of pregnant women who had had pre-natal care was found among those with more than elementary education. The highest percentage of women who started prenatal care before the third month of pregnancy was found among those who had no living children (74%), were in union (70%), had at least some high school education (88%) and lived in the interior of the state (71%). The results show that it is necessary to increase the coverage and quality of pre-natal care so as to improve perinatal results.

Detection of cytomegalovirus infections by PCR in renal transplant patients

Cytomegalovirus (CMV) is the single most important infectious agent affecting recipients of organ transplants. To evaluate the incidence and the clinical importance of CMV infection in renal transplants in Brazil, 37 patients submitted to renal allograft transplants were tested periodically for the presence of cytomegalovirus DNA in urine using the polymerase chain reaction (PCR), and for the presence of IgM and IgG antibodies against CMV by enzyme-linked immunosorbent assay (ELISA) and indirect immunofluorescence (IIF). The PCR-amplified products were detected by gel electrophoresis and confirmed by dot-blot hybridization with oligonucleotide probes. Thirty-two of the 37 patients (86.4%) were positive by at least one of the three methods. In six patients, PCR was the only test which detected the probable CMV infection. Ten patients had a positive result by PCR before transplantation. In general, the diagnosis was achieved earlier by PCR than by serologic tests. Active infection occurred more frequently during the first four months after transplantation. Sixteen of the 32 patients (50%) with active CMV infection presented clinical symptoms consistent with CMV infection. Five patients without evidence of active CMV infection by the three tests had only minor clinical manifestations during follow-up. Our results indicate that PCR is a highly sensitive procedure for the early detection of CMV infection and that CMV infection in renal transplant patients is a frequent problem in Brazil.