[Interpersonal behavioral style as predictor of treatment outcome]. / Interpersoonlijke gedragsstijl als voorspeller van behandelresultaat.

BACKGROUND: Interpersonal behavioral style (IPBS) refers to the way in which someone behaves in social contact. IPBS affects the type and quality of different social interactions including the therapeutic relationship. The therapeutic relationship correlates with treatment outcome, IPBS possibly too. The direction of that relationship remains unclear. AIM: To examine the predictive value of IPBS on treatment outcome in group treatment. METHOD: 149 patients were divided in different types of IPBS: degree of affiliation (kindness vs. hostility), degree of dominance (dominant vs. submissive), quadrants (combination of affiliation and dominance) and vector length (strength of IPBS). Treatment outcome was measured in experienced psychopathology, social anxiety and frequency of social contact. Groups were compared by using one-way analysis of variance (ANOVA). Significant differences were analyzed using Tukey's post-hoc analysis. RESULTS: Vector length predicted all treatment outcome measures. The degree of dominance predicted only scores on social anxiety and frequency of social contact. The degree of affiliation did not predict any treatment results. CONCLUSION: Findings suggest that adult patients with stronger IPBS and a more submissive, sub-assertive IPBS experienced lower social anxiety scores and increased frequency of social contact after treatment. A stronger IPBS also predicts lower experienced psychopathology post-treatment. The degree of kindness/hostility does not affect treatment outcome.

Extracellular ATP decreases trophoblast invasion, spiral artery remodeling and immune cells in the mesometrial triangle in pregnant rats.

INTRODUCTION: Preeclampsia is characterized by deficient trophoblast invasion and spiral artery remodeling, a process governed by inflammatory cells. High levels of the danger signal extracellular adenosine triphosphate (ATP) have been found in women with preeclampsia and infusion of ATP in pregnant rats induced preeclampsia-like symptoms such as albuminuria and placental ischemia. We hypothesized that ATP inhibits trophoblast invasion and spiral artery remodeling and affects macrophages and natural killer (NK) cells present in the rat mesometrial triangle. METHODS: Pregnant rats were infused with ATP or saline (control) on day 14 of pregnancy. Rats were sacrificed on day 15, 17 or 20 of pregnancy and placentas with mesometrial triangle were collected. Sections were stained for trophoblast cells, α-smooth muscle actin (spiral artery remodeling), NK cells and various macrophage populations. Expression of various cytokines in the mesometrial triangle was analyzed using real-time RT-PCR. RESULTS: ATP infusion decreased interstitial trophoblast invasion on day 17 and spiral artery remodeling on day 17 and 20, increased activated tartrate resistant acid phosphatase (TRAP)-positive macrophages on day 15, decreased NK cells on day 17 and 20, and decreased inducible nitric oxide synthase (iNOS)-positive and CD206-positive macrophages and TNF-α and IL-33 expression at the end of pregnancy (day 20). DISCUSSION: Interstitial trophoblast invasion and spiral artery remodeling in the rat mesometrial triangle were decreased by infusion of ATP. These ATP-induced modifications were preceded by an increase in activated TRAP-positive macrophages and coincided with NK cell numbers, suggesting that they are involved. CONCLUSION: Trophoblast invasion and spiral artery remodeling may be inhibited by ATP-induced activated macrophages and decreased NK cells in the mesometrial triangle in rat pregnancy.

OS053. Trophoblast invasion in the mesometrial triangle of atp infused pregnant rats.

INTRODUCTION: Poor placentation (disturbed and decreased trophoblast invasion) is a hallmark of preeclampsia (PE), which is a major complication of pregnancy. Unfortunately, the cause and mechanism of disturbed trophoblast invasion is still unknown. OBJECTIVES: The pro-inflammatory agent ATP has been shown to induce PE-like signs, after a single infusion in pregnant rats. These PE-like characteristics include proteinuria and decreased fetal weight. Since purinergic ATP receptors are expressed on trophoblast cells, we aimed to study the effect of ATP infusion on trophoblast invasion in pregnant rats in this pilot study. METHODS: Pregnant rats received a single ATP (n=4) or saline (control,ni=5) infusion via a permanent jugular vein cannula on day 14 of pregnancy. At the time of maximal trophoblast invasion (day 17 of pregnancy) rats were sacrificed and placentas with mesometrial triangle were collected, fixed in zinc-buffer and embedded in paraffin. 4 µm sections were stained with monoclonal α-cytokeratin antibodies. In the mesometrial triangle, the maternal part of the rat placenta, the percentage of surface area of trophoblast invasion was evaluated using computerized image analysis. Also, the depth and width of invasion were analyzed by subdividing the mesometrial triangle in three concentric depth levels of equal width. In addition, trophoblast invaded versus non-invaded spiral arteries in the mesometrial triangle were quantified. RESULTS: In the mesometrial triangle, no changes in percentage of surface area of trophoblast invasion and percentage of invaded spiral arteries were observed after ATP infusion. However, the pattern of trophoblast invasion appeared to be disturbed in ATP infused rats, with a decreased depth of invasion and an increased width of invasion, resulting in a trend towards a decreased depth/width ratio of trophoblast invasion in ATP infused rats. CONCLUSION: In this (pilot) study we showed an altered trophoblast invasion pattern in the mesometrial triangle of the placenta, although no significant differences in the total surface area of trophoblast invasion were seen in experimental versus control pregnant animals. e mechanism by which ATP induces this altered trophoblast invasion pattern and its potential contribution to the pathophysiology of this experimental PE in the pregnant rat awaits further investigation.

Encephalopathic attacks in a family co-segregating myotonic dystrophy type 1, an intermediate Charcot-Marie-Tooth neuropathy and early hearing loss.

OBJECTIVE: To report new disease components in a unique myotonic dystrophy type 1 (DM1) family previously described by us in which all affected members also had a sensorimotor neuropathy that co-segregated with markers flanking the DM1 locus. METHODS: Clinical observations, electrophysiology, audiometry, DNA studies. RESULTS: During a follow-up period of over 25 years, the following were observed: (i) co-segregation of a striking new encephalopathic phenotype. In middle age, five patients were admitted on multiple occasions with attacks of impaired consciousness, psychomotor agitation, fever and, in about half of the cases, focal neurological signs, including unilateral weakness, sensory deficits and dysphasia. Reported onset phenomena consisted of confusion, headache, focal neurological symptoms and nausea; (ii) many patients show an early and severe sensorineural hearing loss; (iii) although they have mothers with the adult onset type, the four affected subjects from the youngest generation do not show any signs or symptoms of childhood or congenital myotonic dystrophy; (iv) the neuropathy meets the criteria of an intermediate type Charcot-Marie-Tooth (CMT), and is more severe in males; and (v) patients presented with an expanded fragment at the DM1 CTG repeat but this allele was refractory to PCR amplification and triplet repeat primed PCR at the 3' end of the array, indicating the existence of an additional lesion at the 3' end. CONCLUSIONS: The phenotype in this unique family extends beyond myotonic dystrophy and CMT to include encephalopathic attacks and early hearing loss, and is associated with an atypical mutation at the DM1 locus.

[Carpal tunnel syndrome: diagnosis, treatment, prevention and its relevance to dentistry]. / Diagnostiek en behandeling van het carpaletunnelsyndroom.

Nocturnal pins and needles and other sensory disturbances in the median nerve innervated fingers are caused by local pressure on this nerve in the carpal tunnel. Carpal tunnel syndrome is the most frequently encountered peripheral nerve entrapment. In The Netherlands, the prevalence of carpal tunnel syndrome is estimated 9% among adult women and 0.6% among adult men. Several risk factors have been identified. For dental professionals, the most relevant seem forceful use of the hand during scaling and extractions, use of vibrating ultrasonic equipment and frequent working with the wrist in flexion or in extension. The diagnosis of carpal tunnel syndrome is based on the characteristic complaints, confirmed preferably by abnormal electrophysiological tests. Depending on the degree of impact on daily functioning, treatment for carpal tunnel syndrome may be expectative, conservative or surgical. Adjustment of the working conditions may prevent the development of a carpal tunnel syndrome.

[Guideline 'Diagnosis and treatment of carpal tunnel syndrome']. / Richtlijn 'Diagnostiek en behandeling van het carpale-tunnelsyndroom'.

--Carpal tunnel syndrome (CTS) is the most frequently encountered peripheral nerve entrapment: about 10% of adult women and less than 1% of adult men in the Netherlands have a clinically and electrophysiologically confirmed CTS. --All medical and paramedical disciplines involved in the diagnosis and treatment of CTS in the Netherlands contributed to the development of a guideline for the diagnosis and treatment ofCTS. --Clinical diagnosis of CTS is based on a history of nocturnal pins and needles, numbeness and/or pain in the median nerve innervated area of the fingers and hand, which often causes the patient to awake. --Provocative tests do not contribute to the clinical diagnosis of CTS. --If invasive therapy is considered, such as corticosteroid injection or surgery, the clinical diagnosis must be confirmed by abnormal findings in electrophysiological tests. --Ultrasound or MRI of the wrist may be of diagnostic value when structural abnormalities in the carpal tunnel are suspected. Given the special expertise needed for ultrasound testing and the limited availability of MRI for CTS diagnostic purposes, these methods are not the first preference. --Depending on the degree of impact on daily functioning, treatment for CTS may be expectative, conservative (wrist splint or local steroid injections) or surgical (endoscopic or open techniques). --If CTS does not restrict daily functioning, adjustment of the working conditions will do. --Furthermore measures aimed at CTS prevention and treatment of an already existing work-related CTS are discussed.

Limb-girdle muscular dystrophy in the Netherlands: gene defect identified in half the families.

Pheno- and genotype correlation is attempted in a Dutch cross-sectional study on limb- girdle muscular dystrophy. Sarcoglycans, caveolin-3, calpain-3, and dysferlin were analyzed on muscle tissue. Mutation analysis of the calpain-3, caveolin-3, and fukutin-related protein gene was executed in successive order for all samples. In 51% of all families a classifying diagnosis was made. Several new mutations in LGMD2A, B, and C patients have been found in this population.

Interobserver variation in the interpretation of SSEPs in anoxic-ischaemic coma.

OBJECTIVE: To study interobserver variation in the interpretation of median nerve SSEPs in patients with anoxic-ischaemic coma. METHODS: SSEPs of 56 consecutive patients with anoxic-ischaemic coma were interpreted independently by 5 experienced clinical neurophysiologists using guidelines derived from a pilot study. Interobserver agreement was expressed as kappa coefficients. RESULTS: Kappa ranged from 0.20 to 0.65 (mean 0.52, SD 0.14). Disagreement was related with noise level and failure to adhere strictly to the guidelines in 15 cases. The presence or absence of N13 and cortical peaks caused disagreement in 5 cases each. For recordings with a noise level of 0.25 microV or more, mean kappa was 0.34; for recordings with a noise level below 0.25 microV mean kappa was 0.74. CONCLUSIONS: Interobserver agreement for SSEPs in anoxic-ischaemic coma was only moderate. Since the noise level strongly influenced interobserver variation, utmost attention should be given to its reduction. If an artefact level over 0.25 microV remains, absence of N20 cannot be judged with sufficient certainty and the SSEP should be repeated at a later stage. SIGNIFICANCE: Because of its moderate interobserver agreement, great care has to be given to accurate recording and interpretation of SSEPs before using the recordings for non-treatment decisions.

Small fiber neuropathy: a common and important clinical disorder.

Small fiber neuropathy (SFN) is a neuropathy selectively involving small diameter myelinated and unmyelinated nerve fibers. Interest in this disorder has considerably increased during the past few years. It is often idiopathic and typically presents with peripheral pain and/or symptoms of autonomic dysfunction. Diagnosis is made on the basis of the clinical features, normal nerve conduction studies (NCS) and abnormal specialized tests of small nerve fibers. Among others, these tests include assessment of epidermal nerve fiber density, temperature sensation tests for sensory fibers and sudomotor and cardiovagal testing (QSART) for autonomic fibers. Unless an underlying disease is identified, treatment is usually symptomatic and directed towards alleviation of neuropathic pain.

Abnormal warm and cold sensation thresholds suggestive of small-fibre neuropathy in sarcoidosis.

OBJECTIVE: A substantial number of sarcoidosis patients report apparently non-specific symptoms such as pain, for which no organic substrate has yet been found. Recently we observed symptoms suggestive of small-fibre neuropathy in a group of sarcoidosis patients. The aim of the present study was to verify this observation using various electrophysiological tests. METHODS: In 74 sarcoidosis patients complaining of symptoms suggestive of small-fibre neuropathy, thresholds for warm (WS) and cold sensation (CS) as well as for heat pain were determined at the thenar eminence and the foot dorsum. Furthermore, sympathetic skin responses (SSR), nerve conduction studies and concentric needle electromyography were performed. In 31 patients, cardiovascular autonomic testing was carried out. RESULTS: Thermal threshold testing (TTT) revealed abnormalities in 51 of the 74 patients. Abnormalities showed an asymmetrical distribution. WS was affected more often than CS and feet more often than hands. Nerve conduction studies in the legs showed slightly abnormal results in 6 patients; all of these had abnormal TTT results. The SSR was absent at the foot in 7 patients. Cardiovascular autonomic testing was abnormal in only a single patient. CONCLUSIONS: In a subgroup of sarcoidosis patients we found TTT abnormalities suggestive of small-fibre neuropathy. SSR and cardiovascular autonomic testing appeared to be of little diagnostic value. Small-fibre neuropathy may be the cause of a number of hitherto unexplained symptoms in sarcoidosis.

[Postsurgical pain and weakness in the shoulder-arm region: iatrogenic or not?]. / Postoperative pijn en krachtsverlies in de schouder-armregio; iatrogeen of niet?

Four patients, one man aged 66 years and three women aged 69, 33 and 55 years, respectively, had postsurgical pain and weakness in the shoulder-arm region. Initially, a peripheral nerve lesion on a mechanical basis was suspected in all patients. However, because of the sharp pain starting after a postsurgical pain-free interval ranging from a few hours to two days, followed after some time by local muscular weakness, the diagnosis 'neuralgic amyotrophy' was made later. The electromyographic findings were in agreement with this diagnosis. The chronological sequence of the symptoms only became clear after targeted questioning. After 6-24 months, the strength was more or less restored. Usually, the prognosis of neuralgic amyotrophy is favourable, although full functional recovery may take two to three years and in a minority of cases recovery remains incomplete. Early diagnosis is important because of the prognostic aspects and to prevent unnecessary investigations or even surgical explorations, as well as legal claims. Therefore, not only neurologists but particularly surgeons and anaesthesiologists should be aware of this postsurgical condition.

Comparison of thermal threshold tests to assess small nerve fiber function: limits vs. levels.

OBJECTIVE: The method of limits (MLI) and the method of levels (MLE) are psychophysical stimulus procedures most commonly applied to quantify warm and cold sensation thresholds in humans. This paper evaluates basic methodological properties of both methods and investigates the correspondence between the method's results. METHODS: Warm sensation threshold was measured in 20 healthy participants using the psychophysical MLIs and MLEs. Two differently shaped kind of levels stimuli were used with triangular (TRIANG) and trapezoid (TRAP) temperature-time profile. RESULTS: A linear model of temperature response, based on threshold level-crossing, quantifies sensation threshold, independent of the MLI inherent 'reaction-time' artifact. It results from modeling MLI responses to warm stimuli with different rates of temperature change. The model also quantifies the reaction-time delay in the physiological system from thermal stimulus presentation until manual response. This study shows that using the reaction-time independent MLE, TRAP should preferably be used for optimal quantification of sensation threshold. CONCLUSIONS: Statistical testing shows that model-based MLI threshold equals MLE threshold provided MLE TRAP stimuli are used. Recommendations for optimal MLI and MLE stimulus configurations and properties are given in relation to application of quantitative sensory testing.

Ankle-foot orthosis has limited effect on walking test parameters among patients with peripheral ankle dorsiflexor paresis.

The aim of this study was to determine the relationship between ankle dorsiflexor strength and performances on several walking tests and to determine the effect of ankle-foot orthosis (AFO) use on walking tests. The following tests were used: 10-metre walking test (with and without three stairs), a complex walking task (6-minute walk with cognitive loading) and a subjective evaluation (SIP68 mobility scale and questionnaire). Isometric strength of the ankle dorsiflexors was measured. All walking tests were performed with and without AFO in random order. When relating torque values to walking performances, the highest correlation was found with the "10 metre" and "10 metre with stairs" test (r = -0.51, i.e. an inverse relationship). No threshold in the degree of paresis was found below which walking disability suddenly increased. No significant improvement could be demonstrated from AFO use on the 10-metre tests. Improvement on the 6-minute test was nearly significant (p = 0.06), the questionnaire revealed a positive opinion on AFO use related to overall walking function and effort. Thus, we have to conclude that these walking tests do not aid the clinician in estimating the severity of (progression of) the paresis nor to detect differences in degree of paresis between subjects.

Neurographic assessment of lesions of single proper digital nerves.

OBJECTIVE: To investigate which strategy should be used to assess lesions of single proper digital nerves by means of nerve conduction studies. METHODS: Comparison of the results of various orthodromic and antidromic tests with surface electrodes and needle electrodes for stimulation and recording in two patients with a lesion of a single proper digital nerve of the middle finger. RESULTS: It is shown that orthodromic and antidromic nerve conduction tests over the wrist-finger segment yield misleading results because of innervation overlap, volume conduction and co-stimulation. These problems could be avoided by selective stimulation of common digital nerves distally in the palm of the hand and recording with ring electrodes around the relevant finger. Efficacy and selectivity of stimulation are verified by simultaneous recordings from the neighbouring fingers. CONCLUSIONS: Lesions of single volar proper digital nerves are by no means rare, but no nerve conduction studies have been published so far to assess such lesions adequately. A novel, simple and reliable technique for this purpose is described.

Evaluation of effect of ankle-foot orthosis use on strength restoration of paretic dorsiflexors.

OBJECTIVE: To assess whether a difference exists in restoration of strength between patients with a recent paresis of the dorsiflexors of the ankle using an ankle-foot orthosis (AFO) and patients without an AFO. DESIGN: Prospective case-control study. SETTING: Patients from regional hospitals, tested in a rehabilitation research center. PARTICIPANTS: Twenty-nine patients with a recent (6wk-1yr) peripheral paresis, alternately assigned to a group using an AFO or a control group. There was no significant difference in duration of the paresis and in torque at entering the study (T0) between the 2 groups. INTERVENTIONS: The use of an ankle-foot orthosis. MAIN OUTCOME MEASURES: Isometric torque production of ankle dorsiflexors, expressed as ratio of paretic and healthy side, in 2 measurement sessions, over a period of 6 weeks (T0-T6) with the ankle in 0 degrees and 30 degrees plantarflexion. RESULTS: Both groups had significant restoration of strength +/- standard deviation between T0 and T6 in 30 degrees flexion: non-AFO group 17% +/- 15%, AFO group 9% +/- 12%. No significant difference existed between the 2 groups (30 degrees p = .56). No significant shift in strength ratio 0 degrees :30 degrees occurred (AFO group p = .82). CONCLUSION: The use of an orthosis does not influence restoration of strength in patients with a recent peripheral paresis of the ankle dorsiflexors.

What is the best way to assess focal slowing of the ulnar nerve?

OBJECTIVE: The study assessed the influence of the length of the across elbow (AE) segment of the ulnar nerve on the true and false positive rates of velocity measurements of the AE segment. Using a short AE length will increase effects of the measurement error (ME), and using a long distance will 'dilute' the slowing due to the focal lesion; it is not known which length is optimal to detect focal slowing. METHODS: A simulation was performed to assess diagnostic yield for AE lengths of 50, 100 and 150 mm, taking into account ME, variation in true velocity, and severity of the lesion. ME of latencies and distances were first determined in a healthy subject. RESULTS: ME proved lower than in a published study. Diagnostic yield was consistently better for an AE length of 50 mm than for 100 or 150 mm. The optimum length is therefore near 50 mm. Yield increased with severity of the lesion, smaller ME, and when interindividual variation in true velocity was small. Judging AE on its own had a slightly better yield than comparing AE velocity to forearm velocity, except for populations with a larger than normal spread in true conduction variability. CONCLUSIONS: The best balance between effects of ME and 'dilution' to detect focal nerve slowing is obtained at nerve lengths of about 50 mm. The need to incorporate all possible compression sites necessitates the use of a suboptimal length of about 80 mm.

Thermal thresholds in complex regional pain syndrome type I: sensitivity and repeatability of the methods of limits and levels.

OBJECTIVES: To study whether the method of levels (MLE) or the method of limits (MLI) is preferable as a method of measuring thermal perception thresholds in patients with complex regional pain syndrome type I (CRPS I). METHODS: Perception thresholds for warmth and cold were measured twice, with both MLE and MLI, at a 1 month interval, both at unaffected and affected wrists (n=33) or feet (n=20) of patients with CRPS I of one extremity. RESULTS: (1) Sensitivity for pathology was equal for both methods. (2) The agreement between thresholds measured by both methods was low at all locations, except for the unaffected wrist. Since thresholds measured with the MLI always contain reaction time artefacts, this lack of agreement favours the MLE. (3) At both unaffected and affected wrists, the MLE showed significantly better coefficients of repeatability as compared to the MLI for both sensations. However, at both unaffected and affected feet, there was no preference for either method as far as threshold measurement repeatability was concerned. CONCLUSIONS: Abnormal thermal perception thresholds occurred in 20% (foot) to 36% (wrist) of the CRPS I patients on the affected side and in 15% (foot, wrist) on the unaffected side. The MLE is considered to be the preferable method to assess thermal perception thresholds in CRPS I.

Progressive resistance training in neuromuscular patients. Effects on force and surface EMG.

In a randomized clinical trial the efficacy of strength training was studied in patients with myotonic dystrophy (n = 33) and in patients with Charcot-Marie-Tooth disease (n = 29). Measurements were performed at the start and after 8, 16 and 24 weeks of progressive resistance training. Surface electromyography (SEMG) of proximal leg muscles was recorded during isometric knee extension at maximum voluntary contraction (MVC) and at 20, 40, 60 and 80% of MVC. Changes in MVC, maximum electrical activity and torque-EMG ratios (TER) were calculated. Fatigue was studied by determining the changes in endurance and in the decline of the median frequency (Fmed) of the SEMG during a sustained contraction at 80% MVC. These parameters showed no significant changes after the training in either of the diagnostic groups. Only the Charcot-Marie-Tooth training group showed a gradual significant increase in mean MVC over the whole training period (21%). After 24 weeks, the increase in mean RMS was similar (25%), but this was mainly due to a sharp rise during the first 8 weeks of training (20%). The findings indicate that the initial strength increase was due to a neural factor, while the subsequent increase was mainly due to muscle hypertrophy.

Surface EMG of proximal leg muscles in neuromuscular patients and in healthy controls. Relations to force and fatigue.

In an effort to find parameters to evaluate patients with neuromuscular disorders, surface electromyography (SEMG) of proximal leg muscles was performed in 33 patients with myotonic dystrophy (MyD), 29 patients with Charcot-Marie-Tooth (CMT) disease and 20 healthy controls. The root mean square (RMS) of the SEMG amplitude (microV) was calculated at different torque levels. Endurance (seconds) and median frequency (Fmed) of the SEMG power spectrum, used as parameters of fatigue, were determined at 80% of MVC. Maximum voluntary contraction (MVC) was found to be decreased in patients; the ratio between RMS values of antagonists and agonists was increased and torque-EMG ratios (Nm/microV) were decreased. These differences with respect to controls were more pronounced in MyD than in CMT. The initial Fmed value was lowest in CMT. The greatest decrease in Fmed was found in MyD. SEMG data in relation to force have not been determined before in groups of MyD or CMT patients. In both disorders, parameters differed from controls, which means that adding SEMG to strength measurements could be useful in studying the progress of the disorder and the effects of interventions.