[Causes of death in amyotrophic lateral sclerosis : Results from the Rhineland-Palatinate ALS registry]. / Todesursachen bei amyotropher Lateralsklerose : Ergebnisse aus dem ALS-Register Rheinland-Pfalz.

BACKGROUND: Amyotrophic lateral sclerosis (ALS) is associated with an increased mortality. Knowledge of possible causes of death could lead to an individualization of the palliative treatment concept and result in a differentiated palliative treatment pathway. Currently, only few systematic data are available on the heterogeneity of causes of death associated with ALS. OBJECTIVE: Analysis of the various causes of death in a prospective population-based German cohort of ALS patients. MATERIAL AND METHODS: Analysis of data of the Rhineland-Palatinate ALS registry in which newly diagnosed patients who had been identified between October 2009 and September 2012 were prospectively enrolled and followed up at regular intervals. From this prospective cohort study the causes of death were elicited based on information provided by the attending physicians, family members and by means of death certificates registered by the regional health authorities in Rhineland-Palatinate. RESULTS: Out of 200 ALS patients registered 148 died between register initiation on 1 October 2009 and the end of follow-up on 30 September 2015 (78 males and 70 females, death rate 74%). The most frequent cause of death was respiratory failure as a consequence of weakness of respiratory muscles (n = 91, 61%). Less frequent causes of death were pneumonia (n = 13, 9%), terminal cachexia (n = 9, 6%) and death from cardiovascular causes including sudden death (n = 9, 6%). Cases of suicide were rare (n = 3, 2%) as were deaths due to concurrent diseases (n = 2). In 21 cases (14%) the exact cause of death could not be clarified. Differences in the causes of death only showed a tendency towards the ALS phenotype. Respiratory failure was the cause of death in all patients with a respiratory phenotype and in 78% of patients with flail arm syndrome. Despite the low number of patients (8%) with additional frontotemporal dementia (FTD) a distinct difference in causes of death between those with and without FTD could be observed. Death due to respiratory failure was less frequent in ALS patients with FTD (33% vs. 65%) while pneumonia was more frequent (27% vs. 7%). CONCLUSION: Respiratory failure was the most frequent cause of death in our cohort of ALS patients. In contrast, pneumonia and nutritional disorders played a less important role as the cause of death. The phenotypic expression of ALS might in part allow the cause of the prospective death to be predicted. Differentiation of ALS phenotypes is an important foundation for patient counseling on the process of dying to be expected and for the determination of an individual palliative concept.

Generalised sensory system abnormalities in amyotrophic lateral sclerosis: a European multicentre study.

BACKGROUND: Amyotrophic lateral sclerosis (ALS) is defined as a disease of the motor neurones, although several studies indicate involvement of the sensory nervous system. AIM: To evaluate the sensory nerve conduction studies (NCS) in 88 patients with ALS as part of a European multicentre study. METHODS: Seven European clinical neurophysiologists examined consecutive series of ALS patients. The examinations were peer reviewed, and the diagnosis of ALS was confirmed clinically. RESULTS: 20 (22.7%) patients with ALS had sensory NCS abnormalities in at least one nerve. Of those, 11 (12.5% of all patients) obtained an additional peer review diagnosis of electrophysiological polyneuropathy. There was no difference between the subgroups of patients with normal versus abnormal sensory NCS findings with respect to age, duration and region of onset. CONCLUSION: The findings support previous reports of sensory involvement in ALS, and raise the question of whether patients with ALS with sensory nerve abnormalities represent a variant of ALS. ALS associated with generalised sensory system abnormalities may be consistent with degeneration of motor neurones and dorsal root ganglion cells.

Persistent unilateral tibialis anterior muscle hypertrophy with complex repetitive discharges and myalgia: report of two unique cases and response to botulinum toxin.

Unilateral enlargement of the tibialis anterior muscle associated with complex repetitive discharges occurred over several months in two patients and was preceded by pain and numbness in the lower leg. Neuroradiologic investigations excluded a compressive radiculopathy, but pharmacologic and neurophysiologic studies suggested a neurogenic basis for the muscle hypertrophy. Botulinum toxin A injection into the hypertrophied muscles led to a decreased muscle volume and cessation of muscle pain.

A sporadic case of rippling muscle disease caused by a de novo caveolin-3 mutation.

OBJECTIVE: To determine the cause of sporadic rippling muscle disease (RMD) in a 24-year-old patient. BACKGROUND: RMD is a rare myopathy characterized by percussion-induced rapid muscle contractions (PIRC), muscle mounding, and rippling waves. We have recently found that autosomal dominant RMD is caused by mutations in the caveolin-3 gene (CAV3) on chromosome 3p25. Possibly, increased activity of neuronal nitric oxide synthase (nNOS) contributes to the clinical characteristics of increased mechanical muscle hyperexcitability. METHODS: Clinical examination, mutational analysis, and immunohistochemistry of muscle tissue were performed in a patient with sporadic RMD. RESULTS: The authors observed a de novo CAV3 missense mutation Arg26Gln. Immunohistochemistry showed reduced caveolin-3 surface expression in a muscle biopsy. In addition, the authors found normal sarcolemmal nNOS expression and a reduced expression of alpha-dystroglycan in muscle fibers. CONCLUSIONS: These data confirm that RMD is caused by CAV3 mutations. Moreover, there is evidence that CAV3 mutations may also be found in patients without a positive family history of RMD.

Electrical stimulation of regenerating nerve and its effect on motor recovery.

The rate of recovery of motor function, after axonotmesis of the motor nerve innervating the soleus muscle in the rabbit, was evaluated. In a chronic study over a period of 4 weeks, contraction parameters and muscle action potentials were recorded. A group of rabbits, whose soleus nerves were stimulated with 4 pps for 24 h daily, was compared with a control group. The electrically stimulated animals showed a faster improvement in motor function and reached their initial values a week earlier than the controls. Electrical stimulation proved to have a positive effect on the regeneration and motor recovery of nerves.

Health-related quality of life in patients with chronic fatigue syndrome: an international study.

OBJECTIVE: Chronic fatigue syndrome (CFS) has been reported worldwide. Our objectives were to determine if patients from different countries have similar profiles of impairments. METHODS: Health-related quality of life (HRQoL) was assessed in 740 CFS patients in the US, 82 in the UK, and 65 in Germany using the eight subscales of the Short-Form General Health Survey (SF-36). To examine the internal structure, factor analyses were performed. RESULTS: Overall, there was a remarkable similarity in HRQoL among all CFS patients, regardless of location. Patients scored two to three standard deviations below normal on six subscales and one standard deviation below normal on the other two subscales. Factor analysis suggested a two-factor model where the same six subscales constitute the first factor and the two others the second factor. CONCLUSION: HRQoL is poor in CFS patients from three countries. This study is a first step towards conducting further comparative cross-cultural and international studies.

Coincidence of uremic and hypertensive encephalopathy with chronic subdural hematoma under hemodialysis. Case report.

In this case report the underlying disease of uremic and hypertensive encephalopathy was complicated by a suspected disequilibrium syndrome under hemodialysis. Examinations proved a coinciding subdural hematoma. The clinical pictures of the different neurological conditions are discussed. Furthermore the importance to eliminate in those conditions primarily the well known but time and again overlooked complication of subdural hematoma is stressed.

Infectious bronchitis virus antibodies in tears and their relationship to immunity.

Antibodies to infectious bronchitis virus (IBV) in chicken tears were investigated to determine if they could be used as an indicator of protective immunity. Antibody production in tears and serum was measured by enzyme-linked immunosorbent assay (ELISA) in specific-pathogen-free (SPF) white leghorn and broiler chickens vaccinated with a live attenuated vaccine containing the Massachusetts (Mass) Connaught strain of IBV. The effect of virulent infectious bursal disease virus (IBDV) infection on antibody production in tears was also evaluated. Immunity was assessed by challenging the chickens with Mass 41 and performing tracheal swabbings 5 days later. In addition, tears were also evaluated for virus-neutralizing (VN) antibodies to IBV. Following eyedrop vaccination, anti-IBV antibodies were consistently detected by ELISA in tears prior to and in higher concentrations than in the sera of SPF white leghorn and broiler chickens. Maternal IBV antibodies were present in the tear secretions of broiler chickens but in lower concentrations than in sera. Infection of SPF chicks with a virulent and immunosuppressive strain of IBDV at 1 day of age greatly reduced IBV ELISA antibody production in tears as well as serum compared with infection of chickens with IBDV at 14 days of age. IBV ELISA and VN antibody levels in tears were not accurate indicators of IBV immunity as determined by challenge with Mass 41. High tear IBV antibody titers were observed in some chickens determined to be susceptible to IBV challenge and low tear titers were detected in some protected chickens. This finding suggests that mechanisms other than antibody-mediated immunity in tears are important in viral clearance following challenge.

Serotype identification of avian infectious bronchitis virus by RT-PCR of the peplomer (S-1) gene.

The S-1 peplomer gene sequences of 31 strains of avian coronavirus infectious bronchitis virus (IBV) from North America, Europe, and Australia were compared to identify common and unique regions for possible diagnostic applications. S-1 sequences that were conserved among serotypes and sequences that were variable between serotypes were identified. Based on conserved S-1 gene sequences, "general" degenerate oligonucleotide primers were designed that amplified IBV genomic RNA by the reverse transcriptase polymerase chain reaction (RT-PCR) procedure regardless of serotype. Primers specific for IBV serotypes Massachusetts, Connecticut, Arkansas, JMK, Delaware (DE/072/92), and California (CA/633/85) were designed from regions of the S-1 gene exhibiting extensive sequence hypervariability. The ability to identify these six serotypes of IBV by RT-PCR was demonstrated by testing the serotype-specific primers on a panel of unknown samples that included 30 reference strains and field isolates previously characterized by virus neutralization (VN). The use of serotype-specific primers in RT-PCR provides a rapid and accurate means of identifying IBV.

Emergence of subtype strains of the Arkansas serotype of infectious bronchitis virus in Delmarva broiler chickens.

Infectious bronchitis virus (IBV) field isolates of the Arkansas (Ark) serotype were identified by reverse transcription-polymerase chain reaction (RT-PCR) as the most common serotype isolated from 1993 to 1997. These isolates were recovered from broiler flocks with respiratory disease raised on the Delmarva peninsula in spite of Ark vaccination in the region. For the purposes of investigating this apparently paradoxical finding, five RT-PCR Ark-positive field isolates recovered in 1995 and 1996 were selected for further characterization. The isolates were compared with Ark reference strains by reciprocal virus neutralization (VN) in embryonated eggs, S-1 gene sequence analysis, and challenge of immunity studies in specific-pathogen-free (SPF) chickens. Antigenic (VN) comparisons and S-1 gene analysis confirmed that the five RT-PCR Ark-positive field isolates were of the Ark serotype but also revealed that the viruses could be readily distinguished from Ark reference strains. Four of the isolates (Ark/213/96, Ark/15C/96, Ark/1529/95, Ark/1534/95) were found to have higher antigenic relatedness percentages to each other (95%-100%) than to Ark reference strains DPI (52%-72%) and Georgia variant (Georgia var) (53%-68%) by VN. Another isolate, Ark/1535/95, was found to differ antigenically from the other four RT-PCR Ark-positive field isolates (34%-61%), Ark DPI (44%), and Georgia var (43%) strains. The trends in the S-1 gene sequencing results were similar to those observed for the VN findings. Isolates Ark/213/96, Ark/15C/96, Ark/1529/95, and Ark/1534/95 demonstrated a higher degree of predicted S-1 amino acid similarity to each other (96.5%-98.7%) than to Ark DPI (92.4%-93.7%), Ark 99 (93.2%-94.7%), and Georgia var (89.3%-90.8%). Ark/1535/95 S-1 amino acid similarity values were lower compared with those of the other four RT-PCR Ark-positive field isolates (93.4%-94.8%), Ark DPI (91.9%), Ark 99 (93.0%), and Georgia var (88.7%). Furthermore, the isolates could be distinguished from the Ark reference strains by a characteristic sequence polymorphism, a six-nucleotide deletion encoding amino acids 57 (Asp) and 58 (Asp) in hypervariable region 1 of S-1. On the basis of the VN and sequencing findings, isolates Ark/213/96, Ark/15C/96, Ark/1529/95, and Ark/1534/95 were considered to be a single subtype of the Ark serotype. The fifth isolate, Ark/1535/95, may constitute another subtype of the Ark serotype. Vaccination of SPF chickens with a high-titering commercially available live vaccine containing the Ark DPI strain provided solid protection (>90%) against challenge with the RT-PCR Ark-positive field isolates. Immunization of SPF chickens with Ark/213/96 produced 100% protection against challenge with the homologous strain, as well as isolates Ark/1535/95 and Ark 99 but lower levels of protection against Ark DPI (58%) and Georgia var (55%). Primers for RT-PCR were designed to distinguish between the Ark subtypes and the Ark reference strains on the basis of the characteristic six-nucleotide deletion identified in the S-1 gene of the Ark subtypes. Retrospective analysis of RT-PCR Ark-positive isolates found that the Ark subtypes existed as early as 1992 in Delmarva broilers and became prevalent by 1995. With RT-PCR, restriction fragment length polymorphism analysis, and DNA sequencing techniques, the presence of Ark subtype viruses was demonstrated in two commercial Ark DPI strain vaccines and in our Ark DPI laboratory stocks that were the original source of the virus used for vaccine development. The demonstration of the Ark subtype and reference strains in the Ark DPI strain is evidence of the existence of IBV quasispecies. Factors possibly influencing the emergence of the Ark subtype in commercial broilers are discussed.

Identification of avian infectious bronchitis virus by direct automated cycle sequencing of the S-1 gene.

Direct automated cycle sequencing (DACS) of a reverse transcription-polymerase chain reaction (RT-PCR) product of the S-1 subunit of the spike peplomer gene was used to identify infectious bronchitis virus (IBV) serotypes. Degenerate primers CK4 and CK2, utilized previously in our laboratory, were selected for DACS because they successfully amplify a wide range of serotypes represented by various reference strains and field isolates and the resulting polymerase chain reaction (PCR) product contains diagnostically relevant S-1 sequences that can be used to identify the serotype of IBV. The S-1 nucleotide sequences generated by DACS were aligned and analyzed with commercial software to determine their relationship to the S-1 nucleotide sequences of IBV strains on deposit in the GenBank and EMBL databases. Reference strains Massachusetts (Mass) 41, Connecticut (Conn), Arkansas (Ark) DPI, JMK, and DE/072/92 were initially tested by DACS to establish the feasibility of the procedure. The DACS procedure was further evaluated with a panel of "unknowns" comprised of IBV reference strains, field isolates, and variant serotypes collected by our laboratory. The DACS procedure provided high-quality and reproducible S-1 sequence for all IBV serotypes tested, including variant serotypes that had not been sequenced previously. The S-1 nucleotide sequences for the amplified PCR products of reference strains Mass 41, Conn, Ark DPI, JMK, and DE/072/92 generated by DACS were highly homologous (>99% nucleotide identity) with their respective GenBank database sequences. In the unknown panel, the nucleotide identities of the DACS S-1 sequences of field isolates of serotypes previously identified by virus neutralization were also found to be very high (> or = 95.5%) after alignment with database sequences. In contrast, the nucleotide identities of S-1 sequences of variant serotypes 37, 3330, and PA/1220/98 and reference strain Clark 333, for which database sequences were not available, ranged from 27.7% to 73.8%, well below the identity values for a homologous serotype. With alignment software, the identities of strains in mixtures of RNAs of two different serotypes were not resolvable. DACS of IBV S-1 RT-PCR products will enable researchers to rapidly identify field strains, including new, previously unrecognized variant virus serotypes.

Antigenic and S-1 genomic characterization of the Delaware variant serotype of infectious bronchitis virus.

A previously unrecognized infectious bronchitis virus (IBV) serotype, referred to hereafter as the Delaware variant (DE var), was isolated from commercial broiler chickens during a severe, widespread respiratory disease epornitic in the Delmarva peninsula region of the United States in January-March 1992. The DE var serotype was found to be antigenically unrelated by virus-neutralization (VN) test to nine reference IBV serotypes from North America. Additional VN tests indicated that the DE var isolates (DE/072/92, DE/121/ 92, DE/152/92, and DE/174/92) from broilers were fully or partially neutralized by monospecific antisera prepared against themselves and against two IBV field isolates (DE/492/90 and DE/903/90) recovered from a Delmarva commercial layer flock experiencing egg production losses in 1990. Antigenic relatedness values determined by VN indicated layer isolate DE/492/90 was more closely related to the broiler DE var isolates than was layer isolate DE/903/90. Cross-challenge tests performed in specific-pathogen-free chickens also demonstrated the antigenic similarity of the broiler (DE/072/92 and DE/174/92) and the layer isolates (DE/492/90 and DE/903/90), with heterologous strain protection values ranging from 55% to 100%. Protection values of DE var isolates vs. Massachusetts 41 and Arkansas DPI were considerably lower (0-60%). The S-1 gene of the US/DE/072/92 isolate of the DE var serotype was amplified by reverse transcription polymerase chain reaction, cloned, and sequenced. The DE var S-1 gene sequence was compared with the S-1 gene sequences of IBV serotypes from North America, Europe, and Australia. A dendrogram based on this analysis supported the conclusion that the DE var serotype is highly novel among IBV. A high degree of similarity (> 88%) was observed between the S-1 genes of the DE var broiler isolates (DE/072/92 and DE/174/92) and layer isolates (DE/492/90 and DE/903/90). These data, taken with the VN and cross-challenge results, establish a genetic as well as an antigenic link between the isolates from layers and broilers and indicate the DE var serotype was responsible for both infectious bronchitis outbreaks.

A computerized re-evaluation of the collision technique.

A computer program is described for the collision technique by which data acquisition and data interpretation is possible. Paired stimuli with varying interstimulus times evoke a muscle action potential. The amplitude or the rectified area integral as a function of interstimulus times was used to define the scatter of conduction velocities within the ulnar nerve. In normal and slightly distorted EMG signals the amplitude and area produces the same scatter. In distorted potentials the integrated area is more sensitive. The technique was furthermore used to separate two different age groups of normal persons. Significant differences were seen as well as in an age matched group of patients with myotonic dystrophy. The collision technique and the computer program proved to be sensitive and applicable in routine examinations.

Seven Strains of Enterovirus D68 Detected in the United States during the 2014 Severe Respiratory Disease Outbreak.

Clusters of severe respiratory disease in the United States were reported to the CDC beginning in August 2014. Enterovirus D68 (EV-D68) was identified from 83% (30/36) of initial severe cases. Investigations in August and September found severe EV-D68 cases to be widespread across the United States. We report seven EV-D68 genomes from the outbreak.

High degree of genetic diversity of non-polio enteroviruses identified in Georgia by environmental and clinical surveillance, 2002-2005.

Enterovirus surveillance data are useful for establishing temporal and geographical patterns of circulation and for virus characterization to determine phylogenetic relationships between strains. Almost no information is available on circulating enteroviruses in Georgia and the surrounding region. To describe enterovirus circulation in Georgia, determine relationships with previously characterized strains and assess the role of environmental and clinical enterovirus surveillance, this study analysed a total of 112 non-polio enterovirus isolates identified during 2002-2005 from sewage and human stool samples. Viruses were isolated in cell culture using standard methods and typed by partial sequencing of the VP1 gene. A total of 20 different non-polio enterovirus serotypes were identified over the 4-year period. The most commonly detected enteroviruses included echovirus (E) 6 (21 isolates; 18.8 %), E20, E3 and E7 (11 isolates each; 9.8 %), E11, coxsackievirus (CV) B4 and CVB5 (seven isolates each; 6.3 %), and E13, E19 and E30 (six isolates each; 5.4 %). Phylogenetic analysis showed that many serotypes were represented by more than one genetic lineage. The present study showed a very high degree of enterovirus diversity in Georgia and demonstrated the added value of environmental enterovirus surveillance, particularly in settings with limited clinical surveillance. Several serotypes would not have been detected without having both clinical and environmental surveillance in place. Several serotypes detected in Georgia were among those rarely reported in the USA and Europe (e.g. E3, E20 and E19). As the emergence of new genetic lineages of enterovirus in a particular area is often associated with large-scale outbreaks, continued monitoring of enterovirus strains by both environmental and clinical surveillance and genetic characterization should be encouraged.

[Indications and value of thymectomy in myasthenia gravis]. / Indikation und Nutzen der Thymektomie bei Myasthenia gravis.

The therapeutic impact of thymectomy on the clinical course of myasthenia gravis is still a matter of debate. Issues in this discussion that are clinically relevant are reviewed. While the surgical procedure is accepted for thymomas its performance is controversial in cases with no thymomatous tissue. Outcome studies show a weak correlation between clinical course and thymus histology, but there is some doubt about the maximum age for thymectomy and about the therapeutic regimen following surgery. Retrospective studies show that thymectomy has a beneficial influence on the natural course of myasthenia. This positive effect is enhanced by appropriate immunosuppressive therapy together with anticholinesterase inhibitor substitution. Unfortunately, the different forms of myasthenia do not all respond in the same manner. Studies have shown that thymoma-associated myasthenia is more difficult to control than non-thymoma-associated myasthenic states. In both groups some patients go into remission after thymectomy alone, and the majority of patients with the institution of additional immunosuppression. In clinically mild cases thymectomy should not immediately be followed by immunosuppression. This will help to identify those patients responding with remission to thymectomy alone. Mostly these are young women with a hyperplastic thymus. Overall, thymectomy is beneficial and should be considered in all patients with generalized myasthenia who are still under 60 years of age.

The effect of low-frequency electrical stimulation on the denervated extensor digitorum longus muscle of the rabbit.

Both extensores digitorum longi (EDL) muscles of rabbits were denervated by crushing the common peroneal nerves. The EDL muscle on one side was directly stimulated at 10-12 Hz via implanted electrodes. This treatment reduced the changes of twitch/tetanus ratios produced by denervation and prevented the slowing of contraction and relaxation that follows denervation. It is concluded that the stimulation reduced the duration of the active state of denervated muscles. These effects of stimulation were reduced after 5 weeks, probably because by that time the slowing effect of low-frequency activity on the fast muscles became apparent.

[What is certain in pain therapy? The analgesic potency of neuroleptics in the treatment of chronic pain. A metaanalysis]. / Haben Neuroleptika eine analgetische Potenz? Eine Metaanalyse.

The wide variety of therapeutic effects make neuroleptics potent drugs in the treatment of pain. Until now there has been no proof of their analgesic potency; in spite of this fact, neuroleptics are used to treat chronic pain states on the assumption that they do have analgesic potency. A metaanalysis was performed and 48 publications reviewed. Thirty-four, the majority of the studies, are case reports, retrospective analyses or non-randomised cohort studies. Most of these reports attest to a positive effect. However, only ten out of fifteen studies with a higher statistical study power describe a possible analgesic effect. None of the studies could differentiate between the effects of analgesia and sedation of the drugs used. The metaanalysis provides no evidence of intrinsic analgesic properties of neuroleptics for their use as adjuvant analgesics.

Effects of intermittent high frequency electrical stimulation on denervated EDL muscle of rabbit.

This study was performed to determine whether electrical stimulation can retard denervation-induced changes. The denervated extensor digitorum longus of the rabbit, a fast-twitch muscle, was stimulated at a rate mimicking its motoneuron firing pattern. The 100-Hz stimulation given intermittently subjected the muscle to a low mean total daily frequency of 1.6 Hz. Four weeks of stimulation resulted in no effect upon the denervated stimulated muscle. This stimulation protocol, therefore, is unable to substitute for the lost neuronal influence of the nerve. The muscle contralateral to the stimulated side showed physiological changes making it unsuitable to serve as a control.

[The plasticity of motor units in change of the activity pattern by electric stimulation--electrostimulation and its possible clinical applications]. / Zum Wandel motorischer Einheiten bei Anderung des Aktivitätsmusters durch elektrische Reizung--Elektrostimulation und ihre klinischen Einsatzmöglichkeiten.

Motoneuron and muscle fibers interact on the motor unit level, whereby discharge characteristics from the neuron imposed on the muscle seem to play a major role. Within the unit all muscle fibers are biochemically homogeneous and display a high degree of plasticity under different functional demands. To distinguish the existing different units rationals are listed that classify the units by physiological and histochemical parameters. Furthermore the review summarizes the available knowledge on the importance of activity patterns--as a biological principle--involved in the control of phenotypic expression of innervated and denervated muscle. The sequelae are shown of electrical stimulation on innervated and denervated animal muscles. In extent to these findings the consequences are discussed for stimulation procedures that can be imposed on normal and diseased human muscles as a therapeutic tool.