Search

Parkinson's disease (PD) is a neurodegenerative disorder with an incidence and a prevalence increasing with age, predicted to increase drastically in the next 10 years among the geriatric population aged above 80 in France. There are two distinct groups of patients in which therapeutic issues are different. On the one hand, old to very old patients in which PD started at a late age above 80. These patients present with a more severe PD with earlier onsets of cognitive defects and dopa-resistant axial signs, and more comorbidities needing to be taken into account while treating them. Because of their limited life expectancy, these patients would not likely need second line treatments over their disease course. On the other hand, patients presenting with advanced PD, in which fluctuations and dyskinesia induced by dopamine replacement therapy and dopa-resistant axial symptoms impede patient's daily life. These patients are often treated with multiple antiparkinsonian medications, sometimes at high doses. Some patients will also be treated with advanced therapies such as continuous subcutaneous apomorphine infusion, continuous levodopa-carbidopa intestinal gel or, more rarely, even subthalamic or pallidal deep brain stimulations. Because of the specificities of the old to very old parkinsonian patients, tolerance and efficacy of these treatments can be decreased. What is at stake is to aim for the best motor state possible while limiting iatrogenic adverse events. New emerging, potentially less invasive, techniques, such as gamma knife thalamotomy or high-intensity focused ultrasound thalamotomy or sub-thalamotomy, are also discussed here.

Disulfiram is commonly used in the treatment of alcohol dependence. It induces aversive symptoms after alcohol ingestion: the "acetaldehyde syndrome". Most often "acetaldehyde syndrome" is moderate but severe life-threatening symptoms may occur in specific circumstances. We report the case of a serious "acetaldehyde syndrome" with shock compounded by the initial administration of dopamine. Discussion clarifies the pathophysiology and develops the therapeutic management., (Copyright © 2010 Elsevier Masson SAS. All rights reserved.)

Dopamine is mostly used in patients with cardiogenic or septic shock, but its place in critical care medicine is often questioned. Dopamine, of which pharmacology in children is variable, is prescribed for its inotropic effect, associated with an increase in cardiac output and at a lesser degree blood pressure. Beneficial effects (need for renal replacement therapy and mortality) of low dose in patients at risk of, or with acute renal failure are not demonstrated. Dopamine has numerous potential deleterious effects on local circulations (pulmonary, cerebral, coronary and cutaneous), respiratory function, gastroduodenal motility, endocrine function (further depression of the hypothalamic-pituitary axis induced by stress) and immunity (partially due to decreased production of prolactin). Finally, in shocked adults dopamine infusion might be associated with an increase in mortality rate. Dopamine remains the most prescribed catecholamine, either in adults or children. It still is one of the first line drug included in the recent recommendations for the treatment of septic shock (norepinephrine tends to replace it), cardiogenic shock (dobutamine is the first drug), severe head trauma, and organ donor in cerebral death. In conclusion, if dopamine is today less used, there is no proof that its deleterious effects are associated with an excess of mortality. Thus, dopamine still is part of the stock of drugs that act on the cardiocirculatory system (but for how long?).

Hallucinations (mainly visual), psychosis and excessive daytime sleepiness are potential side-effects of dopaminergic treatment. They may require a reduction or suppression of dopaminergic agonists, and the prescription of atypical neuroleptic agents or vigilance-enhancing drugs. The recent description of narcolepsy-like sleep onset in rapid eye movement sleep periods synchronous with hypnagogic hallucinations in patients with dopaminergic-induced psychosis or excessive daytime sleepiness, suggests that the mesodiencephalic lesions may predispose to the psychic effects of dopaminergic treatment. Disease-related mood disorders, sexual compulsions, gambling or levodopa addiction may also be amplified by the antiparkinsonian treatment. These complications illustrate the neuro-psychic aspect of Parkinson's disease: psychic troubles may result from a subtle balance between the direct effects of drugs, the pre-morbid pathological personality and the cortical and subcortical lesions.

Low dose dopamine is widely used to improve diuresis and renal function. This practice is defended by some and fought by others. Acute renal failure in the ICU is often due to tubular necrosis and is a predictor of worse prognosis. Dopamine at low doses is a delta agonist and stimulation of these receptors leads to diuresis and natriuresis. This natriuresis requires additional ATP consumption by the kidney. Low dose dopamine has also systemic hemodynamic effects and these effects can't be dissociated from direct renal effects. Clinical studies of systematic dopamine use in selected high risk patients fail to show a benefit, and side effects of catecholamine administration may lead to additional cardiovascular morbidity. We conclude that low dose dopamine has a demonstrated renal effect but its systematic use to prevent or treat a renal failure cannot be warranted.

The object of this study is to examine the properties of dopamine at the hemodynamic and renal level in 16 patients with decompensated chronic cardiopathies or very serious cardiogenic shock due to myocardial infarction. The results show an increase in the cardiac index in 75 p. 100 of the cases with a favourable diminution of the arterio-venous difference in O2 and of the pulmonary arterial resistances. The most noticeable and the most constant effect is the recovery and increase of the diuresis. Positive chronotropic and bathmotropic effects were observed which necessitated the limitation of prescription of dopamine in those subjects showing signs of disturbances in ventricular excitability.

The utilisation od dopamine at an average dose of 6 mug/kg/mn, for the treatment of 19 shock states, is proved to be of particular interest. The lapic action, the special amelioration of the left ventricular function suggest that dopamine is an useful drug in the treatment of circulatory failure and myocardial inefficiency. The renal and mesenteric vasodilatation produced, prevent or treat the acute renal failure of shock. The actions of dopamine are different from those of other vasopressive amines (norepinephrine, isoproterenol, glucagon) and make dopamine on the first drug to treat shock states.

Onset of confusion with myoclonus occurred in a 55-year-old patient hospitalized for infectious endocarditis and under intravenous dopamine. The speculative responsibility of dopamine in the occurrence of this myoclonic encephalopathy is discussed. Indeed, although dopamine does not cross the blood-brain barrier, inflammation of the wall of the cerebral vessels (immunologic vasculitis) may have enabled dopamine to reach the central nervous system.