Which clinical risk factors determine a pathological urodynamic evaluation in patients with multiple sclerosis? an analysis of 100 prospective cases.

BACKGROUND: Urinary tract symptoms are an underestimated problem in multiple sclerosis (MS). OBJECTIVE: Hundred urodynamics of MS patients have been evaluated prospectively. DESIGN, SETTING AND PARTICIPANTS: In an inpatient rehabilitation, all persons with MS who also suffered from urinary tract symptoms received a voiding diary, post-void sonography and an urodynamic examination according to International Continence-Society-Standard. RESULTS AND LIMITATIONS: Between 10/2009 and 3/2011, 100 patients (79 women; 21 men; mean EDSS, 4.52 ± 2.26) were examined who had primary progressive MS (9×), relapsing-remitting MS (41×), secondary progressive MS (43×) and CIS (1×). The mean duration of MS was 10.26 ± 10.09 years and mean duration of LUTS, 6.9 ± 7.75 years. Urodynamic testing showed normal findings in 22 patients, detrusor overactivity in 7, increased bladder sensation without detrusor overactivity in 21, detrusor-sphincter dyssynergia in 26, detrusor hypocontractility in 12, detrusor acontractility in 4 and unclear diagnosis in 8 patients. Statistically significant risk factors for pathological urodynamic findings were as follows: wheelchair dependency, use of more than one incontinence pad per day and a MS type other than relapsing-remitting. CONCLUSIONS: The urodynamic investigation at hand showed urinary tract dysfunction in 78 of 100 MS patients with lower urinary tract symptoms (LUTS). The long latency between the occurrence of MS and/or the beginning of LUTS and the first neuro-urological evaluation indicates a deficit in treatment. Beyond national guidelines, all MS patients should at regular intervals be questioned about LUTS and receive urodynamic assessment especially according to the presented risk profile.

Restless legs syndrome--new insights into clinical characteristics, pathophysiology, and treatment options.

We summarize recent advances in the clinical definition of restless legs syndrome (RLS), in understanding the basic mechanisms, and the successful treatments of RLS. New diagnostic instruments and severity scales have been developed for better phenotyping of the individual patient. Iron metabolism related components and the dopaminergic system have been extensively investigated in respect to the pathophysiology of RLS. The presence of mechanical hyperalgesia to pin-prick points towards an involvement of the nociceptive system. Genetic research has reported loci on chromosome 12q and 14q to play a role in the vulnerability to RLS. Placebo-controlled large-scale phase II and III treatment trials have shown that dopamine agonists are safe and efficacious agents for the treatment of this disorder.

[Initial status of patients and effects of rehabilitation after stroke--analysis of a patients' and a physicians' questionnaire in three neurological rehabilitation centres with a follow-up after 6 months]. / Eingangsbelastung der Patient(inn)en und Ergebnisqualität der Rehabilitation nach Schlaganfall--Resultate einer arztseitigen und patientenseitigen Untersuchung in drei neurologischen Kliniken mit Follow-up nach 6 Monaten.

Rehabilitation after stroke has to face specific problems when treating patients with more or less severe disabilities in cognition and communication. Correspondingly, stroke rehabilitation takes a special position within the larger field of rehabilitation, and relatively little is known outside the neurological scientific community about the status of patients at admission, the case mix in the centres and the short- and medium-term effects of rehabilitation. The present study describes in some detail the initial status in unselected samples of consecutive patients (n = 768) from three neurological rehabilitation centres. The description shows a very inconsistent picture in all centres, ranging from patients with no neurological deficits to patients needing intensive care. Across the centres, we found remarkable differences in case mix. In order to measure the effects of rehabilitation after stroke, an instrument was developed that combines a physicians' questionnaire aiming at an assessment of the severely disabled cases with a patients' questionnaire for the less severe cases for which the physicians' questionnaire would show "ceiling effects" so that improvements could no longer be depicted. The application of the instrument showed that about 50 % of the sample were not capable of answering the patients' questionnaire. For the patients with neurological deficits, the functional parameters of the physicians' questionnaire showed significant improvements at discharge that can be interpreted as "strong" effects (effect sizes 1.0-1.3). For the patients with less severe deficits (and usually in later stages of the rehabilitation process), the patients' questionnaire showed "strong" improvements on the somatic and psychosocial scales both at discharge and 6 months later. On the functional scales, however, only small improvements were found. Finally, predictors could be identified that explain a large amount of the variance for length of stay (R(2) =.42) as well as for the effects of rehabilitation (R(2) =.74). When comparing effects across rehabilitation units with differences of case mix, these predictors should be statistically controlled in order to assure fair comparisons.

Breathing and locomotion in patients with Parkinson's disease.

The phase relationship between respiration and locomotion was examined in ten patients with Parkinson's disease (PD, mean age 65, range 51-79 years) and in six healthy subjects (mean age 63, range 58-68 years). Locomotion was measured by means of pressure sensors attached below the subjects' feet. Respiration was measured using respiratory inductive plethysmography. The data were recorded with a battery-driven portable device. We determined the coordination degree as the portion of steps which occurred within 12/50 bins of the respiratory cycle. The mean degree of coordination of PD patients was 45.0%+/-11.9%, for the healthy subjects 85.1%+/-10.8% (P<0.001). Three healthy subjects showed a 2:1 ratio between step and breathing rate, three a 3:2 ratio. Two PD patients showed a coordination of 4:1 and 3:1, respectively, with a larger scatter than in controls. In the other eight patients steps were almost equally distributed over the entire respiratory cycle. We conclude that in patients with PD the coordination between locomotion and breathing is reduced.

Effects of parkinsonian medication on sleep.

Patients suffering from Parkinson's disease (PD) often report about sleep disorders and excessive daytime sleepiness. To some extent, motor disabilities or neural degeneration of sleep modulating structures may be responsible for these effects. Depressive disorders also contribute to the occurrence of insomnia and daytime sleepiness. Nevertheless, dopaminergic, anticholinergic, and other drugs used in PD have a great impact on sleep/wakefulness mechanisms. They may indirectly improve or worsen sleep by changing motor symptoms such as akinesia, hyperkinesia, or tremor. Although their is only little information on the complex regulation of vigilance, it is well known that monoaminergic and cholinergic drugs could influence it directly. Data from animal experiments and clinical experiences led to the hypothesis of a biphasic influence on sleep by dopaminergic substances: small doses of L-Dopa e. g. appear to improve sleep whilst higher doses led to insomnia. Different dopaminergic receptor types or changes in receptor sensitivity may explain these phenomena. Dopaminergic and anticholinergic drugs suppress REM sleep. Recently, initial data on 'sleep attacks' after pramipexole or ropinirole treatment were published. Our preliminary results using 24 h polygraphic recordings showed excessive daytime sleepiness in patients taking ropinirole and L-Dopa which disappeared when changed to ropinirole monotherapy. Sleepiness did never appear as an irresistible attack. Current hypotheses on this topic are reviewed.

Workshop I: Parkinson's disease and sleep--results of the group discussion.

The group agreed on the facts that unwanted sleep onset has been observed after non-ergot as well as ergot dopamine agonists, that patients on these drugs need to be warned, that patients who have experienced sleepiness already must not drive a car unless the dosage is lowered and sleepiness has vanished, that a genetic predisposition for narcoleptic cataplexy has to be ruled out, that predictors of so-called sleep attacks need to be explored individually with the help of sleepiness scales and collectively in a careful study, respectively.

[Obstructive sleep apnea syndrome caused by occupational exposure to solvents]. / Obstruktives Schlafapnoesyndrom durch eine berufliche Lösungsmittelexposition.

HISTORY AND ADMISSION FINDINGS: A 52-year-old man working in a chemical laboratory was referred with the possible diagnosis of toxic encephalopathy. For 17 years he had been exposed to high concentrations of perchlorethylene and n-butanol vapours which every day had caused acute symptoms of organic solvent intoxication. Current complaints were autonomic nervous system symptoms, loss of concentration and memory, and fatigue in the second half of the day. The patient was obese but in good general condition. INVESTIGATIONS: Neuropsychiatric examination confirmed the reported loss of concentration and planning ability at work. The polysomnogram indicated an increased number of largely obstructive apnoea attacks. DIAGNOSIS, TREATMENT AND COURSE: As the patients had an obstructive type of sleep apnoea treatment consisted of positive pressure ventilation at night and weight reduction. The occupational exposure to organic solvents was the likely cause. CONCLUSIONS: As the symptoms of encephalopathy and sleep apnoea syndrome overlap, the latter should be considered before an encephalopathy is diagnosed. Because a rare cause of the sleep apnoea syndrome is prolonged and marked occupational exposure to organic solvents this should be asked about in taking the history. If indeed there has been occupational exposure, it should cease at once and be reported.

[Sleep and breathing disorders in patients with brain stem lesions]. / Störungen von Schlaf und Atmung bei Patienten mit Hirnstammläsionen.

Most information about the structures within the brain stem that modulate respiration and sleep are gathered from animal experiments. Therefore we examined 10 patients several weeks after an infarction of the brain stem by means of polysomnography and tested the chemosensitive drives of respiration. None of these patients complained about symptoms of sleep disordered breathing. In each case polysomnographic measurements and ventilatory response curves revealed pathologic findings. The respiratory response to CO2 was diminished or completely abolished in each patient. In some cases hypoventilation or disturbances of the respiratory rhythmicity could be seen. In several cases missing REM sleep, sleep fragmentation or the reduction of slow wave sleep were observed. The study indicates that on the base of results from animal research the comparison of morphological and pathophysiological data is helpful to gain a better understanding on the coupling of the respiratory system with sleep at the brain stem level as well as on the pathomechanism of sleep related breathing disorder.

Amantadine in Parkinson's disease: pro and contra.

After almost 30 years amantadines have reached a definite position in the therapy of Parkinson's disease. Especially in akinetic crisis and in combination with L-Dops amantadine improves the major symptoms of parkinsonism if L-Dopa alone is no more sufficient. Also in cases where L-Dopa treatment is not effective there is reported of a positive reaction on amantadine (Sandyk, 1987). Another advantage is their low side effects and their fast effectiveness. A monotherapy with amantadine is indicated in the early phase of Parkinson's disease and in cases of slight symptoms. According to Kornhuber and Streifler (1992) two thirds of parkinsonian patients react by such a monotherapy with a global improvement of 20 to 40%. After a long-term treatment amantadines are also still effective. In the beginning of the 1970ies opponent statements were made but now a days no larger amantadine study could show a definite decline in initial response to these drugs. Long-term studies with a larger population of patients indicate effects for many years. With additional knowledge about the pathogenesis of Parkinson's disease and about the role of the neurotoxicity though glutamate amantadines as NMDA-receptor antagonists become a great importance as neuroprotective substances.

[Garcin syndrome. Clinical aspects and diagnosis of a rare cranial nerve syndrome with special reference to computerized tomography and nuclear magnetic resonance image findings]. / Garcin-Syndrom. Klinik und Diagnostik eines seltenen Hirnnervensyndroms unter besonderer Berücksichtigung computer- und kernspintomographischer Befunde.

Garcin syndrome is an ipsilateral step-by-step deterioration of all 12 brain cranial nerves, first described in 1927. The underlying cause is usually a sarcoma or carcinoma of the skull base. The pathogenesis of the Garcin syndrome is chiefly determined by the slow localized growth of these tumors, rather than by their histology and primary localisation. The prognosis is as a rule unfavourable. The findings on computed and magnetic resonance tomography are important for an early diagnosis. Two cases of Garcin syndrome are reported, one of which was probably due to a tonsillar carcinoma, while the other was caused by a mucinous adenocarcinoma of the nasopharynx.

[Migraine and epilepsy in cerebral meningioma]. / Migräne und Epilepsie bei zerebralem Meningeom.

Even though the pathogenesis of migraine is entirely different from that of epilepsy, pointers towards their combined occurrence are frequent. Besides purely coincidental combinations, a variety of reasons is held responsible for this side-by-side occurrence. So far, cerebral meningiomas have been rarely reported for discussion. The following article reports on two cases showing that they, too, can cause the combined incidence of migraine and epilepsy. A woman of 60 years of age and a male patient aged 35 years presented with familial affliction and with a long-standing classical anamnesis of migraine. Epileptic attacks followed with varying latency. After cerebral meningiomas had been removed by surgery, the recurrence of both migraine-like and epileptic attacks ceased completely.

[Results of modifying the standard program of insight and relaxation psychotherapy]. / Ergebnisse von Modifizierungen des Standardprogramms der Einsichts- und Entspannungspsychotherapie (EEP).

The inventory of methods used in insight and relaxation psychotherapy were taken as a basis for elaborating three additional psychotherapy programmes with the aim of better satisfying the needs of groups with different indications in respect of outpatient psychotherapy. The results obtained with these programmes were tested statistically, using groups of appropriate control subjects, by means of the pre- and post-test data of the MMPI, PAULI, d2 and a five-point self-estimation scale. The trend shown by the results achieved so far confirms that this differentiated therapeutic approach is correct. Further tests with large samples are necessary.

[Effect of immunoglobulins on the course of therapy-resistant Klebsiella meningitis]. / Einfluss von Immunglobulinen auf den Verlauf einer therapie-resistenten Klebsiellen-Meningitis.

The case of a 28-year-old patient with refractory Klebsiella meningitis after surgical removal of an angioblastoma in the left cerebellar hemisphere (Lindau's tumour) as described in this article, shows the significance of immunoglobulin therapy in view of the synergistic efficacy increase of antibiotics and immunoglobulin. There were 4 meningitis relapses in a period of 8 months, each time 4 days after discontinuation of antibiotics, the therapy consisting of antibiotics only (penicillin G, gentamycin, lamoxactam, cefotaxim and chloramphenicol). These antibiotics, which were applied in accordance with the antibiogram, were discontinued each 16-32 days after the patient had become afebrile and CSF was free from bacteria. In spite of this, further meningitis relapses followed even when the CSF cell count dropped from 12000/3 to 32/3 cells. An attempt to apply gentamycin suboccipitally failed, since diplopia, nystagmus and headache occurred after a single application. The combination of chloramphenicol orally and immunoglobulin intravenously resulted for the first time in complete freedom from bacteria in the CSF. A single intrathecal application of 1 g immunoglobulin caused a temporary increase in CSF cells to 1200/3 and an anal temperature increase from 37% to 38% C. Urticaria exanthema was observed twice as a side effect of immunoglobulin therapy.

Cortical bone loss and measurements of the second metacarpal bone: II. Hypodense bone in postwar Guamanian children.

Hand-wrist radiographs from 326 Guamanian children (180 boys and 146 girls) were evaluated for total width, medullary width, length, and combined cortical thickness of the second metacarpal. Bone measurements as well as standing height and weight were compared to similar published data from U.S. mainland black, white, and Mexican-American children. The results demonstrated that the second metacarpal bones of Guamanian boys and girls of all age groups (5-17 years) have narrower width and shorter length with less combined cortical thickness than any of the other groups. Guamanian children also weighed less and were of shorter stature than their black, white, or Mexican-American counterparts. These results agree closely with those comparisons between Guamanian and U.S. mainland white adults published earlier. It is not possible from the present data to ascertain whether these differences were due to genetic variability or nutritional deficiency.

On the possible involvement of ascorbic acid and copper proteins in leukemia: II. Electron spin resonance (ESR) and atomic absorption investigations on erythrocyte ghosts and plasma.

The effect of ascorbic acid on white ghosts of erythrocytes and plasma has been investigated by means of ESR spectroscopy. Since the spectra obtained are identical to the one obtained with leukemic blood it is concluded that the receptor for vitamin C has to be searched for in membrane and plasma as well. Determination of Cu and Fe by means of atomic absorption spectroscopy revealed that both of the metals are also present in the membrane. In the case of copper, it must exist there as a protein which has not been identified yet. Oxidizing substances, such as KMnO4, reverse the effect produced by ascorbic acid.

On the possible involvement of ascorbic acid and copper proteins in leukemia. IV. ESR investigations on the interaction between ascorbic acid and some copper proteins.

The interaction between lyophilized samples of ascorbic acid and some copper proteins (ceruloplasmin, cytochrome-c-oxidase, ascorbate-oxidase) has been investigated by means of ESR spectroscopy. The spectra obtained are identical to the one obtained with leukemic blood. The consequences of this for the molecular events occurring in cancer are discussed. The model proposed can explain the experimental findings reported thus far (such as change in spin concentration with the development of cancer, the presence of a high concentration of antioxidants etc.) as well as reconsile the two existing and seemingly contradictory hypothesis. Possible implications for lipid peroxidation and for the respiratory process are discussed.

Some secular changes in the growth of American-born and native Japanese children.

Three hundred and sixteen (35%) of the American-born Japanese children whose height, weight, and skeletal age were recorded in 1956-57 were reexamined as young adults between 1968 and 1974, when they were found to be taller, heavier and shorter legged than men and women in Japan who were born in the same years as they. These differences between the American-born and the native Japanese adults were relatively smaller than they had been during childhood, due to both an acceleration in the growth rate of the native Japanese and a concomitant decline in that of the American-born Japanese during the intervening years. A comparison of our 1956-57 data with Kondo and Eto's findings in Los Angeles in 1971 shows that there has been very little increase in the size of California-Japanese children since 1956. The curves of average heights of native Japanese children 6 to 20 years of age, at 10-year intervals from 1900 to 1970, disclosed the changing rate at which they grew during different decates of that period. Those curves and other data discussed in this paper provide additional evidence of the biological superiority of the human female as compared with the male.

A case of Mongolism in DZ female twins studied at 10 and then at 43 years of age.

A pair of female mongoloid twins was studied when they were ten years old and, again, some thirty years later. A careful comparison was made of the similarities and differences between them in features or traits which have proved to be useful in determining the zygosity of like-sexed twins. Though some of these characters can be, and frequently are, considerably modified in the presence of mongolism and so lose part of their value for that purpose, the differences noted in these twins, both as children and as middle-aged adults, are thought to outweigh their similarities and so warrant the conclusion that they are, indeed, dizygotic.