Determinants of autonomic dysfunction in idiopathic Parkinson's disease.

OBJECTIVES: To determine demographic or disease-related factors that may influence the severity of autonomic dysfunction in idiopathic Parkinson's disease (IPD). METHODS: 532 patients with IPD aged between 55 and 75 years were included. Severity of autonomic dysfunction was assessed using a 9-item autonomic dysfunction score (ADS). In addition, several demographic factors (e. g. age, gender, comorbidities) and disease- related (e. g. motor stage, disease duration, antiparkinsonian therapy) factors were recorded. A group of 67 age-matched healthy volunteers served as a control group. Demographic and clinical data of this cross-sectional survey were analyzed by a logistic stepwise regression model to determine independent predictors of autonomic dysfunction. RESULTS: IPD patients showed significantly higher ADS values than controls, even in the youngest age groups and in mild disease stages. Hoehn & Yahr (H&Y) stage, disease duration, age at onset and various therapy combinations all showed significant correlations with ADS. However, stepwise logistic regression revealed that age (OR 10.71; CI 7.17-16.0) and arterial hypertension (OR 3.05; CI 1.66-5.58) were the only independent risk factors associated with autonomic dysfunction. Linear regression indicated that ADS increases with age in controls as well as in patients, but with a significantly steeper slope in the latter. CONCLUSIONS: Autonomic dysfunction as an inherent feature of IPD is present already in early disease stages. According to a logistic regression model, the severity of autonomic dysfunction in IPD is primarily related to demographic but not to disease-related factors. This and the differences in predictors for motor versus autonomic decline may indicate at least partly independent neurodegenerative processes.

Short latency afferent inhibition and facilitation in patients with writer's cramp.

Patients with writer's cramp (WC) show abnormalities of sensorimotor integration possibly contributing to their motor deficit. We studied sensorimotor integration by determining short-latency afferent inhibition (SAI) in 12 WC patients and 10 age-matched healthy controls. A conditioning electrical median nerve stimulus was followed 14 to 36 msec later by transcranial magnetic stimulation of the contralateral primary motor cortex, and motor evoked potentials (MEP) were recorded from the relaxed or contracting abductor pollicis brevis muscle (APB). SAI was normal in WC but during APB relaxation SAI was followed by abnormal MEP facilitation, which was absent during APB contraction and in the controls. These findings suggest that somatosensory short-latency inhibitory input into the primary motor cortex is normal in WC, whereas a later excitatory input, which very likely reflects the long-latency reflex II, is exaggerated.

Differences in age at onset and familial aggregation between clinical types of idiopathic Parkinson's disease.

Idiopathic Parkinson's disease (PD) can be subdivided by its patterns of motor symptoms into tremor-dominant (TDT), akinetic-rigid (ART), and mixed type (MT). Our objective was to determine whether age at onset and family history are different in these three types. In total, 366 patients with PD were assigned in a standardized approach to one of the three subtypes. Age at onset and family history were obtained in all patients and all presumably affected family members were examined. Mean ages at disease onset were similar in all three groups, but distribution of age at onset was markedly different: monophasic in TDT with a peak around 60 years, biphasic in ART with two peaks, one in the middle of the sixth decade (earlier onset, ART-EO), another during the first half of the seventh decade (later onset, ART-LO), and increasing with age only in MT patients A positive family history was significantly associated only with TDT (odds ratio = 5.7) and ART-EO (odds ratio = 7.8), but not with MT or ART-LO patients. Segregation analysis suggested an autosomal recessive mode of transmission in ART-EO and an autosomal dominant mode of transmission in TDT.

Functional impairment, disability, and quality of life outcome after decompressive hemicraniectomy in malignant middle cerebral artery infarction.

OBJECT: Whether decompressive hemicraniectomy is an appropriate treatment for space-occupying middle cerebral artery (MCA) infarction is still a controversial issue. Previous studies are in agreement on a reduction of the mortality rate, but the reported functional outcome was highly variable. The authors sought to determine functional impairment, disability, and health-related quality of life (QOL) outcome in long-term survivors who had undergone this procedure, and tried to identify factors related to functional outcome. METHODS: The study included 36 consecutive patients (mean age 58.8 +/- 12.7 years, 20 men and 16 women) who underwent decompressive hemicraniectomy for treatment of malignant MCA infarction (29 on the right and seven on the left side; mean time to surgery 37.8 +/- 20 hours). The survival rate was determined at 6 months: 13.7 +/- 6.7 months after the stroke, a cross-sectional personal investigation of survivors was performed to assess functional impairment, disability, and health-related QOL. Survival rates were 78% at 6 months and 64% at the time of the follow-up investigation; one patient was lost to follow up. Sixteen of 22 long-term survivors lived at home. The median Barthel Index (BI) was 45 (25th and 75th percentile 19 and 71) and the BI correlated negatively with patient age (r = -0.58, p = 0.005). Three patients reached a BI of at least 90. Older age, more severe neurological deficit on admission, and longer duration of intensive care treatment and mechanical ventilation were significantly associated with worse disability (BI < 50). The health-related QOL was considerably impaired in the subscales of mobility, household management, and body care. CONCLUSIONS: Decompressive hemicraniectomy improves survival in patients with malignant MCA infarction when compared with earlier reports of conservative treatment alone. Functional outcome and QOL remain markedly impaired, especially among elderly patients and in those with a severe neurological deficit at admission.

Secondary progressive chronic manganism associated with markedly decreased striatal D2 receptor density.

We describe a patient with chronic manganism due to intoxication 40 years ago. Whereas previous reports on acute or subacute intoxication have shown no or only small reductions in striatal D2 receptor density, we found markedly decreased D2 receptor density using (18)F-methylspiperone PET in this very late stage of chronic manganism, supporting the hypothesis that manganese intoxication may trigger a neurodegenerative disease process.

Single-needle acupuncture alleviates gag reflex during transesophageal echocardiography: a blinded, randomized, controlled pilot trial.

OBJECTIVES: To study the effect of single-needle acupuncture in suppressing gag-reflex in transesophageal echocardiography (TEE). DESIGN: Prospective, blinded trial. Settings/locations: Patients with ischemic stroke or transient ischemic attack undergoing TEE because of presumed cardioembolic origin in a specialized stroke unit of the Johann Wolfgang Goethe-University, Frankfurt/Main, Germany. Subjects/Study interventions: Forty-one (41) patients were studied. Patients received single-needle acupuncture with a 0.2 x 13 mm disposable acupuncture needle (Suzhou Medical Appliances, China), 10-mm deep either at Chengjiang (midline between lower lip and chin) or superficially at a sham point (tip of the chin) during TEE or no acupuncture for alleviating gag reflex. OUTCOME MEASURES: Severity of gagging was rated on a visual-analogue scale. RESULTS: The acupuncture group experienced significantly less gagging than the sham group (p = 0.037) or the nonacupuncture group (p = 0.013). CONCLUSIONS: Acupuncture of CV24 is an easy to apply and effective method to reduce gag reflex during TEE.

Short-interval paired-pulse inhibition and facilitation of human motor cortex: the dimension of stimulus intensity.

Paired transcranial magnetic stimulation has greatly advanced our understanding of the mechanisms which control excitability in human motor cortex. While it is clear that paired-pulse excitability depends on the exact interstimulus interval (ISI) between the first (S1) and second stimulus (S2), relatively little is known about the effects of the intensities of S1 and S2, and the effects of manipulating neurotransmission through the GABA(A) receptor. When recording the motor evoked potential (MEP) from the resting abductor digiti minimi (ADM) muscle, using a fixed ISI of 1.5 ms, and expressing the interaction between S1 and S2 as MEP(S1+S2)/(MEP(S1) + MEP(S2)), then a systematic variation of the intensities of S1 and S2 revealed short-interval intracortical facilitation (SICF) if S1 and S2 were approximately equal to MEP threshold (RMT), or if S1 > RMT and S2 < RMT. In contrast, short-interval intracortical inhibition (SICI) occurred if S1 < RMT and S2 > RMT. Contraction of the ADM left SICI unchanged but reduced SICF. The GABA(A) receptor agonist diazepam increased SICI and reduced SICF in the resting ADM while diazepam had no effect during ADM contraction. Surface EMG and single motor unit recordings revealed that during ADM contraction SICI onset was at the I3-wave latency of S2, whereas SICF typically "jumped up" by one I-wave and started with the I2-wave latency of S2. Findings suggest that SICI is mediated through a low-threshold GABA(A) receptor-dependent inhibitory pathway and summation of IPSP from S1 and EPSP from S2 at the corticospinal neurone. In contrast, SICF originates through non-synaptic facilitation at the initial axon segment of interneurones along a high-threshold excitatory pathway.

Reduced inhibition within primary motor cortex in patients with poststroke focal motor seizures.

BACKGROUND: Following an ischemic brain lesion, the affected cortex undergoes structural and functional changes that may lead to increased cortical excitability or decreased inhibitory neuronal activity, resulting in the occurrence of poststroke epileptic seizures in 6 to 10% of patients with stroke. METHODS: To assess motor cortical excitability, transcranial magnetic stimulation (TMS) was used to determine the silent period (SP) duration in 84 consecutive patients with ischemic stroke. RESULTS: In a subpopulation of six patients (38 to 72 years old) a significant decrease of the SP duration (mean 116 +/- 14 msec) was detected in either the arm or the leg on the affected side as compared to the corresponding unaffected limb (mean 231 +/- 32 msec). This electrophysiologic abnormality was clinically associated with focal motor seizures in five of the six patients, whereas none of the other 76 patients with normal or prolonged SP durations developed seizures or epilepsy. CONCLUSIONS: Silent period shortening in this group reflects decreased inhibitory activity that may partly be related to functional or structural impairment of GABAergic interneurons. TMS may be of value for determining patients with stroke at risk for developing poststroke seizures.

[Laryngocele. The experience with 14 cases]. / Le laryngocèle. Expérience sur 14 cas.

Following a brief introduction regarding the general features and the pathogenic theories of laryngocele, our remarks concern 14 cases observed in the ten year period 1979-1988. The patients are all male, aged between 34-78 years, in eleven cases the laryngocele was monolateral, in seven of a mixed type, five internal and two external. External exeresis was carried out in nine cases. There was a re-occurrence of internal laryngocele, which was treated successfully. The four cases which were not operated on, concerned three occasional outbreaks, which were virtually asymptomatic and a fourth case with serious general contraindications. We encountered one case of laryngopiocele. In conclusion, an elevated number of symptomatic cases has been noted, and the significant fact was that in three cases emergency tracheotomy was required for acute dyspnea. We have noticed the association between cancer and laryngocele in only one case. It has not been possible to draw conclusions about the transition situation between neoplasia and air sac, given the considerable extension of the laryngeal tumour. It is therefore presumed that the laryngocele is secondary, favoured by the increase of intraglottic pressure determined by the laryngeal carcinoma.

[Clinical aspects of vaginal hysterectomy]. / Zur Klinik der vaginalen Uterusexstripation.

From 1971-1982 4,179 hysterectomies have been performed by vaginal route on the department of gynecology and obstetrics of the Klinikum Mannheim. 46.5% of these women were between 20 and 40 years old, 7.2% were older than 60 years. The mean age was 41 years, 5.6% of the patients were nulliparae, 21.0% uniparae and 73.4% multiparae. 4.8% had a history of a previous gynecologic operation, adipositas was present in 8.7%, and a severe varicosis was present in 8%. The most frequent indications were uterus myomatosus (36.2%) and descensus uteri (26.8%). In 62% of all patients only hysterectomy was performed, in 31.4% hysterectomy with an additional colporrhaphy was performed. Morcellation of the uterus was necessary in 3.4%. The most frequent intraoperative complication was the lesion of the bladder in 0.4%. The postoperative morbidity was 15.8%, two third of these patients had an inflammatory disease of the urinary tract. The mortality was 0.07%.