Long-term levodopa treatment in Parkinson's disease is typically associated with "motor side effects" consisting in dyskinesias and/or fluctuations in motility referred to as the on-off phenomena. The main objective of this prospective, randomized, multi-centre study was to determine to what extent the development of such complications could be prevented by partial substitution of levodopa monotherapy (L-DOPA/benserazide) by bromocriptine in patients with early symptoms of the disease. The basic trial population included 674 newly diagnosed Parkinsonian patients that were randomly allocated to monotherapy with levodopa or a combination therapy based upon a nearly 40% replacement of levodopa by bromocriptine. The two target regimens had to be consistently maintained for 42 months. Parkinsonian symptoms were assessed by means of the Webster rating scale, the Hoehn and Yahr scale, and the Zung Self-Rating Depression scale. Motor side effects and adverse events were recorded at each regular clinic visit. Neurological symptoms improved and stabilized in a similar manner during treatment with both regimens throughout the study period. Motor side effects were observed in more patients on levodopa alone than on combination therapy (28.8 vs 20%; p = 0.008). According to Kaplan-Meier estimates the cumulative probability of experiencing motor side effects was 0.43 on monotherapy, compared to 0.28 on combination therapy, which was equal to a one third reduction of risk (p = 0.025). In regard to motor side effects, the degree of substitution of levodopa proved relevant: patients with> 50% substitution by bromocriptine exhibited half the risk observed in those with < 30% (p = 0.045). The overall burden of motor side effects, as reflected by a sum score based upon the relevance, the severity and the extent of motor dysfunction, was also significantly less on combination therapy (p = 0.046). In conclusion, partial substitution of levodopa by bromocriptine (> 30%) as first-line treatment of Parkinson's disease proves active in the prophylaxis of levodopa associated motor side effects. Early combination therapy therefore extends the period of optimal disease control.
L-Dopa supplemented by a peripheral decarboxylase inhibitor is considered the most potent therapeutic regimen prolonging active life in Parkinsonian patients. The long-term benefit of therapy is limited by adverse effects, such as dyskinesia and on-off phenomena, which can be mitigated by the concomitant administration of dopamine agonists, such as bromocriptine. In order to quantify the beneficial impact of early combination therapy, a controlled clinical trial (PRADO: PRA videl1 + DO pa) in patients with early Parkinson's disease was carried out, whereby L-Dopa monotherapy (in a fixed combination with benserazide (DoBe) was being compared with the same combination plus bromocriptine (DoBeBro). Patients were recruited and treated by 101 practising neurologists in the Federal Republic of Germany and in Hungary. Twenty seven clinical university centers cross-checked the patients at regular intervals. The trial started with 3 months of DoBe monotherapy (median dose of 375 mg L-Dopa for both randomized groups) followed by gradual substitution of DoBe by bromocriptine over 3 months in one of the groups (250 mg L-Dopa/10 mg bromocriptine). The target medication was maintained from study months 6 to 54. Parkinsonian symptoms were classified according to the Webster rating scale, the Hoehn and Yahr scale and the Zung Self-Rating Depression Scale. Adverse events and life status were checked at regular intervals. Special emphasis was given to motor performance tests. 587 patients (302 in the DoBe group and 285 in the DoBeBro group) were available for intention-to-treat analysis. Both groups were homogeneous at baseline in all observed parameters.(ABSTRACT TRUNCATED AT 250 WORDS)
A 50 year old female patient received anaesthesia of the arm by the vertical infraclavicular blockade of the plexus brachialis (VIP). Postoperatively an ipsilateral pneumothorax occurred complicated by pleural effusion and a contralateral bronchopneumonia, which resolved completely after treatment. The blockade of the plexus was performed correctly, failures in determining the correct point of needle insertion could be excluded. Therefore a pneumothorax has to be regarded as a specific complication of the VIP, which might occur despite correct technique, and requires that the patient be informed of this eventuality. Nevertheless, the VIP is an important method due to its high success rate concerning blockade of the musculocutaneous nerve and tolerance of tourniquet. The risk of a pneumothorax is about 0.2 to 0.7%.
We examined the efficacy of the vertical infraclavicular block for plexus brachialis anaesthesia using a nerve stimulator after introducing the method (VIP1) and after three years of clinical experience (VIP2). In two prospective studies we compared the results with each other as well as with the efficacy of the axillary block (AX). At VIP1, we found a complete analgesia in 88% of the patients, whereas in 9% a supplementation was needed. In group AX the results were significantly worse (complete: 70%, supplementation: 24%; p < 0.001). No increase of the rate of efficacy could be found when having some clinical experience with the VIP (VIP2: complete 87%, supplement: 11%). In general, the results of the VIP depended on the motoric answer to the nerve stimulation. There were no complications of the VIP such as nerve lesions or pneumothorax. The VIP using a nerve stimulator is a simple, reliable and uncomplicated method for plexus-brachialis-anaesthesia, which is easy to learn.
In the present study 48 sagittal and transversal magnetic resonance images of volunteers were examined for biometric data concerning risk of pneumothorax at the vertical infraclavicular blockade (VIP) of the brachial plexus. With a correct puncture the plexus can be reached after 3 cm. The shortest way to the lung is 5.3 cm (3.1-8.7 cm) at a incorrect medial angle of puncture of 46.3 degrees (35-58 degrees). While moving the angle of puncture at a minimum of 24.1 degrees (1-51 degrees) in a medial direction, a depth of 6.1 cm (4-8.9 cm) has to be reached for fatal lung puncture. The puncture point has to be determined 2.8 cm (0-4.1 cm) towards the midline of the body to have a pleura connection by a strictly vertical puncture at 6 cm (4-8.9 cm). In asthenic women, shorter distances were obtained. A considerable lower deviation can lead to pleural damage (7.5 degrees; 4.7 cm). The plexus is very close to the skin surface (1.6-3 cm). In one case, the risk for pneumothorax could be measured even with the correct puncture technique. Overall, the VIP is a very safe method for brachial plexus anaesthesia with regard to the risk of pneumothorax. In asthenic women, the risk seems to be higher but can be minimised by reducing the maximum puncture depth.
scite is a Brooklyn-based organization that helps researchers better discover and understand research articles through Smart Citations–citations that display the context of the citation and describe whether the article provides supporting or contrasting evidence. scite is used by students and researchers from around the world and is funded in part by the National Science Foundation and the National Institute on Drug Abuse of the National Institutes of Health.
hi@scite.ai
10624 S. Eastern Ave., Ste. A-614
Henderson, NV 89052, USA
Copyright © 2024 scite LLC. All rights reserved.
Made with 💙 for researchers
Part of the Research Solutions Family.