[A patient diagnosed with conversion disorder who did not respond to therapy]. / Een patiënte met de diagnose conversiestoornis die niet verbeterde.

A 61-year-old woman with a conversion disorder (functional neurological symptom disorder) was referred by her neurologist to the outpatient psychiatric clinic for medically unexplained somatic symptoms. She did not respond well to our treatment, which we initially related to a comorbid mood disorder. Eventually, a progression of both motor and cognitive symptoms were found to be consistent with corticobasal degeneration, a rare neurodegenerative disorder. This case report illustrates the importance of a revised neurological examination when a patient with conversion disorder does not improve.

Increased enslaving in elderly is associated with changes in neural control of the extrinsic finger muscles.

Aging has consequences for hand motor control, among others affecting finger force enslaving during static pressing tasks. The aim of this study was to assess whether the extent of finger force enslaving changes with aging during a task that involves both static and dynamic phases. Ten right-handed young (22-30 years) and ten elderly subjects (67-79 years) were instructed to first exert a constant force (static phase) and then flex their index finger while counteracting constant resistance forces orthogonal to their fingertips (dynamic phase). The other fingers (non-instructed) were held in extension. EMG activities of the flexor digitorum superficialis (FDS) and extensor digitorum (ED) muscles in the regions corresponding to the index, middle and ring fingers together with their forces and position of index finger were measured. In both elderly and young, forces exerted by the non-instructed fingers increased (around 0.6 N for both young and elderly) during isotonic flexion of the index finger, but with a different delay of on average 100 ± 72 ms in elderly and 334 ± 101 ms in young subjects. Results also suggest different responses in activity of FDS and ED muscle regions of the non-instructed fingers to index finger flexion between elderly and young subjects. The enslaving effect was significantly higher in elderly than in young subjects both in the static (12% more) and dynamic (14% more) phases. These differences in enslaving can at least partly be explained by changes in neuromuscular control.

Quality of life in elderly patients with an ostomy - a study from the population-based PROFILES registry.

AIM: Ostomies are being placed frequently in surgically treated elderly patients with colorectal cancer (CRC). An insight into the (potential) impact of ostomies on quality of life (QoL) could be useful in patient counselling as well as in the challenging shared treatment decision-making. METHOD: Patients with CRC diagnosed between 2000 and 2009 and registered in the population-based Eindhoven Cancer Registry received a QoL questionnaire (EORTC QLQ-C30) in 2010. In addition, QoL was compared with an age- and sex-matched normative population. RESULTS: The study included 2299 CRC patients, of whom 494 had an ostomy. No differences were found in reported ostomy-related problems between patients aged ≤65, 66-75 and ≥76 years. Ostomy patients aged 66-75 and ≥76 years reported significantly lower physical functioning compared with those without an ostomy. In the elderly (those aged ≥76 years) ostomates reported a worse physical and social functioning compared with the normative population. All these differences were of small clinical relevance. The impact of an ostomy seems to be more prominent in younger (≤75 years old) ostomates, as they experience more functional limitations and a decrease in global health status compared with younger nonostomy patients and the normative population. CONCLUSION: Although elderly (≥76 years old) patients with an ostomy report significantly more limitations in functioning compared with a normative population and elderly CRC patients without an ostomy, the clinical relevance of this finding is limited. In contrast, the impact of an ostomy is more prominent in younger patients. Thus, age itself is not a reason for withholding an ostomy.

Non-uniform displacement and strain between the soleus and gastrocnemius subtendons of rat Achilles tendon.

Achilles tendon (AT) comprises of 3 subtendons arising from the soleus (SOL) and the lateral (LG) and medial (MG) heads of the gastrocnemius muscle. While recent human studies show differential displacement within AT, these displacements have not been attributed to specific subtendons. We tested the hypothesis that the SOL and LG subtendons show differential displacement and strain during various combinations of SOL, LG, and MG excitations. Movement of knots, sutured onto SOL and LG subtendons of 12 Wistar rats, was videotaped, while the muscles were stimulated intramuscularly and ankle torque was assessed. When SOL only was stimulated, the plantar flexion torque was the smallest among the different conditions (P < .001). In this condition, from passive to active state, the displacement (0.57 vs 0.47 mm, P = .002) and strain (8.4% vs 2.4%, P < .001) in the SOL subtendon were greater than in LG subtendon. When LG only was stimulated, a higher ankle torque was measured as compared to SOL stimulation (P < .001); the displacement was similar in both subtendons (~0.6 mm), while the strain was greater in LG than in SOL (4.7% vs 1.7%, P < .001). When all 3 muscles were stimulated simultaneously, ankle torque was highest and the displacement (0.79 vs 0.74 mm, P = .002) and strain (7.7% vs 4.4%, P = .003) were greater in SOL than in LG. These data show that the different subtendons of AT can experience relative displacement and differential strains. Together with anatomical dissections, the results revealed that such uniformities may be due to a lower stiffness of SOL subtendon compared to LG.

An Introduction to Network Psychometrics: Relating Ising Network Models to Item Response Theory Models.

In recent years, network models have been proposed as an alternative representation of psychometric constructs such as depression. In such models, the covariance between observables (e.g., symptoms like depressed mood, feelings of worthlessness, and guilt) is explained in terms of a pattern of causal interactions between these observables, which contrasts with classical interpretations in which the observables are conceptualized as the effects of a reflective latent variable. However, few investigations have been directed at the question how these different models relate to each other. To shed light on this issue, the current paper explores the relation between one of the most important network models-the Ising model from physics-and one of the most important latent variable models-the Item Response Theory (IRT) model from psychometrics. The Ising model describes the interaction between states of particles that are connected in a network, whereas the IRT model describes the probability distribution associated with item responses in a psychometric test as a function of a latent variable. Despite the divergent backgrounds of the models, we show a broad equivalence between them and also illustrate several opportunities that arise from this connection.

Recurrence-free and overall survival among elderly stage III colon cancer patients treated with CAPOX or capecitabine monotherapy.

The aim of this study is to investigate the effects of CAPOX and capecitabine on recurrence-free survival (RFS) and overall survival (OS) among elderly stage III colon cancer patients and to evaluate the effect of (non-)completion. Patients aged ≥70 years who underwent resection only or who were subsequently treated with CAPOX or capecitabine in 10 large non-academic hospitals were included. RFS and OS were analyzed with Kaplan-Meier curves and multivariable Cox regression adjusted for patient and tumor characteristics. 982 patients were included: 630 underwent surgery only, 191 received CAPOX and 161 received capecitabine. Five-year RFS and OS did not differ between capecitabine and CAPOX (RFS: 63% vs. 60% (p = 0.91), adjusted HR = 0.99 (95%CI 0.68-1.44); OS: 66% vs. 66% (p = 0.76), adjusted HR = 0.93 (95%CI 0.64-1.34)). After resection only, RFS was 38% and OS 37%. Completion rates were 48% for CAPOX and 68% for capecitabine. Three-year RFS and OS did not differ between patients who discontinued CAPOX early and patients who completed treatment with CAPOX (RFS: 61% vs. 69% (p = 0.21), adjusted HR = 1.42 (95%CI 0.85-2.37); OS: 68% vs. 78% (p = 0.41), adjusted HR = 1.17 (95%CI 0.70-1.97)). Three-year RFS and OS differed between patients who discontinued capecitabine early and patients who completed treatment with capecitabine (RFS: 54% vs. 72% (p = 0.01), adjusted HR = 2.07 (95%CI 1.11-3.84); OS: 65% vs. 80% (p = 0.01), adjusted HR = 2.00 (95%CI 1.12-3.59)). Receipt of CAPOX or capecitabine is associated with improved RFS and OS. The advantage does not differ by regimen. The addition of oxaliplatin might not be justified in elderly stage III colon cancer patients.

The effect of a geriatric evaluation on treatment decisions for older patients with colorectal cancer.

BACKGROUND: Treating elderly colorectal cancer patients can be challenging. It is very important to carefully weigh the risks and benefits of potential treatments in individual patients. This treatment decision making can be guided by geriatric consultation. Our aim was to assess the effect of a geriatric evaluation on treatment decisions for older patients with colorectal cancer. METHODS: Colorectal cancer patients who were referred for a geriatric consultation between 2013 and 2015 in three Dutch teaching hospitals were included in a prospective database. The outcome of geriatric assessment, non-oncological interventions and geriatricians' treatment recommendations were evaluated. RESULTS: The total number of included referrals was 168. The median age was 81 years (range 60-94). Most patients (71%) had colon cancer and 49% had tumour stage III disease. The reason for geriatric consultation was uncertainty regarding the optimal oncologic treatment in 139 patients (83%). Overall 93% of patients suffered from geriatric impairments; non-oncological interventions that followed after geriatric consultation was mostly aimed at malnutrition. The geriatrician recommended the 'more intensive treatment' option in 69% and the 'less intensive treatment' option in 31% of which 63% 'supportive care only'. CONCLUSION: Geriatric consultation can be useful in treatment decision making in elderly patients with colorectal cancer. It may lead to changes in the treatment plan for individual cases and may result in an additional optimisation of patient's health status prior to treatment.

Altered mechanical interaction between rat plantar flexors due to changes in intermuscular connectivity.

Connective tissue formation following muscle injury and remedial surgery may involve changes in the stiffness and configuration of the connective tissues linking adjacent muscles. We investigated changes in mechanical interaction of muscles by implanting either a tissue-integrating mesh (n = 8) or an adhesion barrier (n = 8) to respectively increase or decrease the intermuscular connectivity between soleus muscle (SO) and the lateral gastrocnemius and plantaris complex (LG+PL) of the rat. As a measure of mechanical interaction, changes in SO tendon forces and proximal-distal LG+PL force differences in response to lengthening LG+PL proximally were assessed 1 and 2 weeks post-surgery. The extent of mechanical interaction was doubled 1 week post-implantation of the tissue-integrating mesh compared to an unaffected compartment (n = 8), and was more than four times higher 2 weeks post-surgery. This was found only for maximally activated muscles, but not when passive. Implanting the adhesion barrier did not result in a reduction of the mechanical interaction between these muscles. Our findings indicate that the ratio of force transmitted via myofascial, rather than myotendinous pathways, can increase substantially when the connectivity between muscles is enhanced. This improves our understanding of the consequences of connective tissue formation at the muscle boundary on skeletal muscle function.

Colorectal Cancer Resections in the Oldest Old Between 2011 and 2012 in The Netherlands.

INTRODUCTION: Adequate decision-making in elderly colorectal cancer patients requires accurate information regarding risks of treatment. We analysed the outcome and survival of colorectal resections in the oldest old (≥85 years). METHODS: An analysis of the 2011-2012 data from two large nationwide registries: the Dutch Surgical Colorectal Audit (DSCA), containing all colorectal cancer resections, and the Netherlands Cancer Registry (NCR), containing survival data for all newly diagnosed malignancies. RESULTS: The study included more than 1200 patients aged ≥85 years (DSCA n = 1232, NCR n = 1206). The postoperative complication rate was 41 % in the oldest old. The frequency of cardiopulmonary complications rose rapidly with age, from 11 % in those <70 years to 38 % for the oldest old (p < 0.001). Postoperative 30-day mortality rate was 10 % in the oldest old. Three-month mortality was 14 % (compared with 3 % of patients <85 years; p < 0.001). One-year mortality was 24 % and 2-year mortality 36 %. After correction for expected mortality in the general population, excess mortality for the oldest old was 12 % in the first year and 3 % in the second year. CONCLUSIONS: In this study of more than 1200 colorectal cancer patients aged ≥85 years undergoing surgical resection, we found high rates of cardiopulmonary complications and excess mortality, particularly in the first year after surgery. We propose that these data could be incorporated into individualized treatment algorithms, which also include detailed information regarding the patients' health status.

Kinds versus continua: a review of psychometric approaches to uncover the structure of psychiatric constructs.

The question of whether psychopathology constructs are discrete kinds or continuous dimensions represents an important issue in clinical psychology and psychiatry. The present paper reviews psychometric modelling approaches that can be used to investigate this question through the application of statistical models. The relation between constructs and indicator variables in models with categorical and continuous latent variables is discussed, as are techniques specifically designed to address the distinction between latent categories as opposed to continua (taxometrics). In addition, we examine latent variable models that allow latent structures to have both continuous and categorical characteristics, such as factor mixture models and grade-of-membership models. Finally, we discuss recent alternative approaches based on network analysis and dynamical systems theory, which entail that the structure of constructs may be continuous for some individuals but categorical for others. Our evaluation of the psychometric literature shows that the kinds-continua distinction is considerably more subtle than is often presupposed in research; in particular, the hypotheses of kinds and continua are not mutually exclusive or exhaustive. We discuss opportunities to go beyond current research on the issue by using dynamical systems models, intra-individual time series and experimental manipulations.

Adaptation of physiological cross-sectional area and serial number of sarcomeres after tendon transfer of rat muscle.

Tendon transfer surgery to a new extensor insertion was performed for musculus flexor carpi ulnaris (FCU) of young adult rats, after which animals were allowed to recover. Mechanical properties and adaptive effects on body mass, bone growth, serial number of sarcomeres, and muscle physiological cross-sectional area were studied. Between the transfer and control groups, no differences were found for body mass and forearm length growth. In contrast, transferred muscles had a 19% smaller physiological cross-sectional area and 25% fewer sarcomeres in series within its muscle fibers than control muscles, i.e., a deficit in muscle belly growth is present. Our present results confirm our the length of previous work showing a limited capability of changing the adapted transferred FCU muscle belly, as the muscle-tendon complex is stretched, so that most of the acute FCU length change must originate from the tendon. This should most likely be attributed to surgery-related additional and/or altered connective tissue linkages at the muscle-tendon boundary. The substantially increased FCU tendon length found, after recovery from surgery and adaptation to the conditions of the transferred position, is likely to be related to such enhanced stretching of the FCU tendon.

Drug dispensings among elderly in the year before colon cancer diagnosis versus matched cancer-free controls.

WHAT IS KNOWN AND OBJECTIVE: The concomitant use of multiple drugs is common among the general population of elderly. The aim of this study was to provide an overview of which drugs are dispensed to elderly in the year before colon cancer diagnosis and to compare this with cancer-free controls. METHODS: Data from the Eindhoven Cancer Registry were linked to the PHARMO Database Network. Patients with colon cancer aged ≥70 years were included and matched with controls on gender, year of birth and postal code. Proportions of cases and controls with ≥1 dispensing of each WHO ATC-2-level drug during the total year and during each quarter of the year were calculated and differences between cases and controls tested. RESULTS AND DISCUSSION: Proportion of cases with ≥1 drug dispensing was highest for drugs for constipation (cases vs. controls 58% vs. 10%), antithrombotics (42% vs. 33%), drugs for acid-related disorders (35% vs. 22%), antibacterials (34% vs. 24%), agents acting on the renin-angiotensin system (33% vs. 27%), beta-blockers (33% vs. 23%), lipid-modifying agents (29% vs. 22%), diuretics (29% vs. 21%), psycholeptics (25% vs. 18%) and antianaemics (23% vs. 6%). The proportion of cases with ≥1 drug dispensing increased from the first to the last quarter of the year for drugs for constipation (7%-53%), drugs for acid-related disorders (16%-27%), antibacterials (12%-16%), beta-blockers (26%-28%), psycholeptics (15%-19%) and antianaemics (6%-18%). Elevated proportions of cases with ≥1 drug dispensing for several drugs are mostly related to comorbidity, although increasing proportions of cases with ≥1 drug dispensing for certain drugs during the year can be attributed to the incidence of colon cancer. WHAT IS NEW AND CONCLUSION: We have provided insight into which drugs are commonly used in the year preceding colon cancer diagnosis. This may trigger general practitioners and medical specialists to further evaluate the patient.

Prediction of disease progression, treatment response and dropout in chronic obstructive pulmonary disease (COPD).

PURPOSE: Drug development in chronic obstructive pulmonary disease (COPD) has been characterised by unacceptably high failure rates. In addition to the poor sensitivity in forced expiratory volume in one second (FEV1), numerous causes are known to contribute to this phenomenon, which can be clustered into drug-, disease- and design-related factors. Here we present a model-based approach to describe disease progression, treatment response and dropout in clinical trials with COPD patients. METHODS: Data from six phase II trials lasting up to 6 months were used. Disease progression (trough FEV1 measurements) was modelled by a time-varying function, whilst the treatment effect was described by an indirect response model. A time-to-event model was used for dropout RESULTS: All relevant parameters were characterised with acceptable precision. Two parameters were necessary to model the dropout patterns, which was found to be partly linked to the treatment failure. Disease severity at baseline, previous use of corticosteroids, gender and height were significant covariates on disease baseline whereas disease severity and reversibility to salbutamol/salmeterol were significant covariates on Emax for salmeterol active arm. CONCLUSION: Incorporation of the various interacting factors into a single model will offer the basis for patient enrichment and improved dose rationale in COPD.

Generating Virtual Patients by Multivariate and Discrete Re-Sampling Techniques.

PURPOSE: Clinical Trial Simulations (CTS) are a valuable tool for decision-making during drug development. However, to obtain realistic simulation scenarios, the patients included in the CTS must be representative of the target population. This is particularly important when covariate effects exist that may affect the outcome of a trial. The objective of our investigation was to evaluate and compare CTS results using re-sampling from a population pool and multivariate distributions to simulate patient covariates. METHODS: COPD was selected as paradigm disease for the purposes of our analysis, FEV1 was used as response measure and the effects of a hypothetical intervention were evaluated in different populations in order to assess the predictive performance of the two methods. RESULTS: Our results show that the multivariate distribution method produces realistic covariate correlations, comparable to the real population. Moreover, it allows simulation of patient characteristics beyond the limits of inclusion and exclusion criteria in historical protocols. CONCLUSION: Both methods, discrete resampling and multivariate distribution generate realistic pools of virtual patients. However the use of a multivariate distribution enable more flexible simulation scenarios since it is not necessarily bound to the existing covariate combinations in the available clinical data sets.

Quality of life more impaired in younger than in older diffuse large B cell lymphoma survivors compared to a normative population: a study from the population-based PROFILES registry.

The objective of this study was to compare health-related quality of life (HRQOL) between diffuse large B cell lymphoma (DLBCL) survivors of different age categories (18-59/60-75/76-85 years) and to compare their HRQOL with an age- and sex-matched normative population. The population-based Eindhoven Cancer Registry was used to select all patients diagnosed with DLBCL from 1999 to 2010. Patients (n = 363) were invited to complete the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire-Core 30 (EORTC QLQ-C30) questionnaire, and 307 survivors responded (85 %). Data from an age- and sex-matched normative population (n = 596) were used for comparison. DLBCL survivors aged 18-59 years scored better on physical functioning, quality of life, appetite loss and constipation than survivors of 76-85 years old (all p < 0.05). Financial problems more often occurred in survivors aged 18-59 years compared to survivors of 76-85 years old (p < 0.01). Compared to the normative population, DLBCL survivors aged 18-59 years showed worse scores on cognitive and social functioning and on dyspnea and financial problems (p < 0.01, large- and medium-size effects). In survivors of the other age categories, only differences with trivial or small-size effects were found. Although younger DLBCL survivors have better HRQOL than older survivors, the differences found between younger survivors and normative population were the largest. This suggests that having DLBCL has a greater impact on younger than older survivors and that the worse HRQOL observed in older DLBCL survivors in comparison with younger survivors is caused mostly by age itself and not by the disease.

The clinical implications of using a low threshold for computed tomography scans in older patients presenting with a proximal femur fracture.

PURPOSE: Current guidelines recommend a low threshold for computerized tomography (CT) scanning in older patients presenting with low-energy trauma (LET). With the ageing of the population, this results in increased use of healthcare resources and costs. We aim to assess (1) the number of CT scans performed as part of the initial trauma screening, (2) their traumatic clinical implications, and (3) their non-traumatic clinical implications. METHODS: A retrospective study in patients ≥ 70 years presenting at a Dutch trauma centre with a proximal femur fracture following a LET between 2021 and 2022. We collected data concerning demographics, Clinical Frailty Scale, Injury Severity Score, number of CT scans and whether the results of these scans altered clinical management. RESULTS: We included 278 patients. Median age was 83.0 years (IQR 77.0-89.0), median ISS was 9 (IQR 9-10) and, most common mechanism of injury was a ground level fall (n = 159, 57.2%). In 49 patients (17.6%) one or more CT scans were performed. These scans did not reveal co-existing traumatic injuries altering clinical management. In 2 patients (0.7%) incidental findings were found that immediately affected treatment. CONCLUSION: Our study concludes that (1) approximately one in five patients with a proximal femur fracture received a CT scan as part of the initial trauma screening, resulting in (2) no traumatic and (3) minimal non-traumatic clinical implications. Therefore, a restrictive policy can be justified in patients with no additional clinical signs or symptoms and admission to the hospital. Further prospective research would be valuable to confirm our results.

Constant force muscle stretching induces greater acute deformations and changes in passive mechanical properties compared to constant length stretching.

Stretching is applied to lengthen shortened muscles in pathological conditions such as joint contractures. We investigated (i) the acute effects of different types of stretching, i.e. constant length (CL) and constant force (CF) stretching, on acute deformations and changes in passive mechanical properties of medial gastrocnemius muscle (MG) and (ii) the association of acute muscle-tendon deformations or changes in mechanical properties with the impulse or maximal strain of stretching. Forty-eight hindlimbs from 13 male and 12 female Wistar rats (13 weeks old, respectively 424.6 ± 35.5 and 261.8 ± 15.6 g) were divided into six groups (n = 8 each). The MG was initially stretched to a length at which the force was 75%, 95%, or 115% of the force corresponding to estimated maximal dorsiflexion and held at either CF or CL for 30 min. Before and after the stretching protocol, the MG peak force and peak stiffness were assessed by lengthening the passive muscle to the length corresponding to maximal ankle dorsiflexion. Also, the muscle belly length and tendon length were measured. CF stretching affected peak force, peak stiffness, muscle belly length, and tendon length more than CL stretching (p < 0.01). Impulse was associated only with the decrease in peak force, while maximal strain was associated with the decrease in peak force, peak stiffness, and the increase in muscle belly length. We conclude that CF stretching results in greater acute deformations and changes in mechanical properties than CL stretching, which appears to be dependent predominantly on the differences in imposed maximal strain.

Treatment and survival of patients with small-cell lung cancer: small steps forward, but not for patients >80.

BACKGROUND: Seventy-five percent of newly diagnosed patients with small-cell lung cancer (SCLC) are aged 60+ and quite a few are treated less aggressively because of fear of toxic effects. We described trends in treatment and survival of unselected SCLC patients. PATIENTS AND METHODS: For the present study, all 13,007 SCLC patients aged 60+ diagnosed in The Netherlands from 1997 to 2007 were included. RESULTS: Among patients with limited disease, the proportion receiving chemoradiation increased from 35% to almost 60% for those aged 60-69, from 28% to 48% in age group 70-74, from 17% to 33% in age group 75-79, but remained <10% for those aged 80+. Among patients with extensive disease, the proportion receiving chemotherapy (CT) decreased from 81% of patients aged 60-64 to 23% of those aged 85+, without substantial changes over time. Survival has only improved for patients <80 years. CONCLUSIONS: CT (+radiotherapy) has improved survival for unselected SCLC patients <80. A better understanding of the impact of frailty on completion of treatment and toxic effects among patients aged 80+ would enable the treating physician to anticipate toxic effects better and to discuss risks and benefits of treatment with the patient.

Chemotherapy in elderly small-cell lung cancer patients: yes we can, but should we do it?

BACKGROUND: Twenty percent of all newly diagnosed patients with small-cell lung cancer (SCLC) are >75 years. Elderly patients may show more toxicity due to co-morbidity. We evaluated motives for adherence to treatment guidelines, completion of treatment and toxicity. PATIENTS AND METHODS: Population-based data from patients aged ≥75 years and diagnosed with SCLC in 1997-2004 in The Netherlands were used (368 limited disease and 577 extensive disease). Additional data on co-morbidity (Adult Co-morbidity Evaluation 27), World Health Organisation performance status (PS), treatment, motive for no chemotherapy, adaptations and underlying motive and grade 3 or 4 toxicity were gathered from the medical records. RESULTS: Forty-eight percent did not receive chemotherapy. The most common motives were refusal by the patient or family, short life expectancy or a combination of high age, co-morbidity and poor PS. Although only relatively fit elderly were selected for chemotherapy, 60%-75% developed serious toxicity, and two-thirds of all patients could not complete the full chemotherapy. CONCLUSIONS: We hypothesise that a better selection by proper geriatric assessments is needed to achieve a more favourable balance between benefit and harm.

[Cyclic episodes of confusion and movement disorders: consider hyopglycemia and insulinoma]. / Cyclische episoden van verwardheid en bewegingsstoornissen: denk aan hypoglykemieën en insulinoom.

Insulinomas are rare neuroendocrine tumours of the pancreas which present with neuroglycopenic and autonomic symptoms induced by hypoglycemic periods. The onset is insidious. Because of atypical symptoms like temporary movement disorders and behavioural disturbances the diagnosis is often made at a late stage. We describe two patients with cyclic behavioural and movement disorders caused by already present but not recognised insulinomas. The treatment options are discussed, in which the most common surgical therapy is not always a first choice in elderly patients with comorbidity. With drug therapy patients can be free of symptoms for a longer period without any significant complications.