[Impact of drug-free care in posterior cortical atrophy: Preliminary experience with a psycho-educative program]

INTRODUCTION

Criteria for the diagnosis of posterior cortical atrophy (PCA) are well established, but little is known about the impact of drug-free care for patients and caregivers.

METHODS

We designed an adapted and specific psycho-educative program for four patients and their caregivers who participated in six sessions, one every 2 months.

RESULTS

Patients and caregivers improved their knowledge about the PCA syndrome; level of anxiety was slightly reduced among caregivers.

CONCLUSION

A specific psycho-educative program can be offered to PCA patients and their caregivers.

[Diffusion-Weighted Imaging infarct volume and neurologic outcomes after ischemic stroke]

BACKGROUND

This study's purpose was to demonstrate a relationship between growth of stroke volume measured on Diffusion-Weighted MRI (DWI) at admission (baseline) and 24 hours later (follow-up) and functional outcome at 90 days evaluated by the modified Rankin Scale (mRS).

METHODS

DWI infarct volumes were calculated, using an Analyze Software. Clinical outcomes were assessed at 90 days by the mRS. Univariate regression analysis was performed to assess the relationship between changes in DWI lesion volume and mRS less or equal to 1.

RESULTS

Sixty-nine cases had serial DWI scans with a measurable lesion at baseline and follow-up. The median baseline National Institutes of Health Stroke Scale (NIHSS) was 10, 5 and 7 at 24 hours. At 90 days, the proportion of patients with Rankin less or equal to 1 was 51.7%. The average baseline volume was 19.7 cm(3) and average follow-up volume was 46.1 cm(3). For each 10 cm(3) of growth in DWI infarct volume, the odds ratio for a mRS less or equal to 1 was 10,1 (IC 95%, 3-33.9).

CONCLUSION

The results of this study provide evidence of a significant inverse relationship between infarct growth measured by DWI and good functional clinical outcome at 90 days.

Alteration of nutritional status at diagnosis is a prognostic factor for survival of amyotrophic lateral sclerosis patients

OBJECTIVES

The aims were to analyse changes in nutritional parameters from diagnosis of amyotrophic lateral sclerosis (ALS) to death and to assess their relationships with survival at the time of diagnosis and during follow-up.

METHODS

92 ALS patients were included and clinically assessed every 3 months (ALS functional rating scale, manual muscular testing, forced vital capacity, weight, BMI, percentage weight loss). Bioimpedance was performed to evaluate body composition (fat-free mass, fat mass and hydration status) and phase angle. Survival analyses were performed from diagnosis to death or censoring date using a Cox model.

RESULTS

The evolution of nutritional parameters in ALS patients was marked by significant decreases in weight, BMI, fat-free mass and phase angle, and increased fat mass. The authors identified an adjusted 30% increased risk of death for a 5% decrease from usual weight at time of diagnosis (RR 1.30; 95% CI 1.08 to 1.56). During follow-up, the authors identified adjusted 34% (95% CI 18% to 51%) and 24% (95% CI 13% to 36%) increased risks of death associated with each 5% decrease in usual weight and each unit decrease in usual BMI, respectively (p<0.0001). Malnutrition during the course was related to a shorter survival (p=0.01), and fat mass level was associated with a better outcome (RR 0.90 for each 2.5 kg fat mass increment).

CONCLUSIONS

Nutritional parameters of ALS patients worsened during evolution of the disease, and worse nutritional status (at time of diagnosis or during the course) was associated with a higher mortality. This study offers some justification for studying the use of therapeutic nutritional intervention to modify the survival of ALS patients.

Causes of death amongst French patients with amyotrophic lateral sclerosis: a prospective study

BACKGROUND AND PURPOSE

To prospectively investigate causes of death and the circumstances surrounding death in 302 patients with amyotrophic lateral sclerosis (ALS). The functional status of patients immediately before death was also determined.

METHODS

Information was obtained from neurologists at ALS centres, patients' files, and, when deaths occurred outside a medical facility, attending physicians.

RESULTS

Most patients (63%) died in a medical facility. The most frequently reported cause of death was respiratory failure (77%), including terminal respiratory insufficiency (58%), pneumonia (14%), asphyxia due to a foreign body (3%) and pulmonary embolism (2%). Ten per cent of patients died from other causes: post-surgical or traumatic conditions (5%), cardiac causes (3.4%), suicide (1.3%) and sudden death of unknown origin (0.7%). The cause of death could not be determined in 13% of cases (6% inside a medical facility and 25% outside). At the time of death, only 55% of patients were receiving riluzole, 33% were undergoing non-invasive ventilation, 3% had a tracheotomy and 37% a gastrostomy.

CONCLUSION

The information provided by this study helps to improve our understanding of the natural history of the disease and may help optimize the quality of care we can offer patients at the end of life.

Rapid cognitive decline in Alzheimer's disease. Consensus paper

The rate of cognitive decline in Alzheimer's disease (AD) varies considerably between individuals, with some subjects showing substantial deterioration and others showing little or no change over the course of the disease. These wide variations support the relatively new concept of Rapid Cognitive Decline (RCD). Patients with an accelerated rate of cognitive decline have showed to present a worse evolution in terms of mortality, loss of autonomy and institutionalisation. The conclusions from RCD studies conducted in the past years remain very heterogeneous and sometimes contradictory. This is possibly due to methodological differences, mainly the different "a priori" definitions of RCD used to identify rapid decliners. Consequently of this, there is considerable variation in reported frequency of patients with RCD which may vary from 9.5% to 54%. The lack of both consensus definition and consensual clinical assessment tools is one of the major barriers for establishing an appropriated management of rapid decliners in clinical practice. Presently, management of rapid decliners in AD remains to be a challenge waiting to better know predictive factors of a RCD. To date no specific guidelines exist to follow-up or to treat patients with this condition. This consensus paper proposes the loss of 3 points or greater in Mini-Mental State Examination (MMSE) during six months as an empirical definition of rapid cognitive decline to be used in routine medical practice and to be relevant for clinical-decision making in patients with mild to moderately-severe AD.

Contribution of electron microscopy to the study of neuropathies associated with an IgG monoclonal paraproteinemia

A typical monoclonal IgG dysglobulinemia whether benign (monoclonal gammopathy of undetermined significance, MGUS) or malignant can give rise to peripheral neuropathy by damaging nerves. At first, neurotoxicity of the chemotherapy if the patient is treated must be ruled out in such cases. Indeed, a variety of other mechanisms have been described: endoneurial deposits of immunoglobulin, infiltration of the immunoglobulin within myelin sheaths, POEMS syndrome, deposits of amyloid, chronic inflammatory demyelinating polyradiculoneuropathy and infiltration of malignant cells. Ultrastructural examination of a nerve biopsy can be decisive in combination with routine histological and immunopathological examinations. Characterization of the mechanism of the neuropathy in a dysglobulinemic context is important as it governs therapeutic options, which in certain cases are particularly beneficial.

Descriptive epidemiology of amyotrophic lateral sclerosis: new evidence and unsolved issues

Amyotrophic lateral sclerosis (ALS) is a relatively rare disease with a reported population incidence of between 1.5 and 2.5 per 100,000 per year. Over the past 10 years, the design of ALS epidemiological studies has evolved to focus on a prospective, population based methodology, employing the El Escorial criteria and multiple sources of data to ensure complete case ascertainment. Five such studies, based in Europe and North America, have been published and show remarkably consistent incidence figures among their respective Caucasian populations. Population based studies have been useful in defining clinical characteristics and prognostic indicators in ALS. However, many epidemiological questions remain that cannot be resolved by any of the existing population based datasets. The working hypotheses is that ALS, like other chronic diseases, is a complex genetic condition, and the relative contributions of individual environmental and genetic factors are likely to be relatively small. Larger studies are required to characterise risks and identify subpopulations that might be suitable for further study. This current paper outlines the contribution of the various population based registers, identifies the limitations of the existing datasets and proposes a mechanism to improve the future design and output of descriptive epidemiological studies.

[One episode of meningoencephalitis, three diagnoses]

Meningo-encephalitis is a set of threatening diseases. The treatment needs to be started quickly for pathogens such as herpes simplex virus type 1 or Listeria monocytogenes. Apart from these classical etiologies, many other diseases may induce meningo-encephalitis. We report the case of a patient, infected with HIV, who presented a history of meningo-encephalitis due to herpes simplex type 1. Three weeks later, he presented an encephalopathy due to aciclovir and then we discovered a chronic meningitis in relation with his HIV infection.

[Announcement of amyotrophic lateral sclerosis diagnosis]

Breaking the news of amyotrophic lateral sclerosis (ALS) is considered as a daunting task in most cases and is not a standardizable procedure. However, proven techniques exist to reduce the trauma to the patient. Announcing ALS falls upen the neurologist who must respect the ethical principle of the patient's independence. After the diagnosis is firmly established, the patient should be informed that he or she has a progressive disease of the motor nerves, for which no curative therapy is available. The name of the disease must be stated and explained. If the family history is negative, it is reassuring for the patient and family to know that their children are unlikely to be at risk. Positive aspects (no pain, no disturbances in sensation, cognition, memory and continence) should be stressed as well as the availability of efficient palliative measures for practically all symptoms. Current research efforts, and when available, the possibility of taking part in clinical studies of new drugs should be pointed out as a means of hope. The answer to the question of prognosis should include the information that there are no sudden worsenings to be expected, that the course of ALS may vary between months and decades, that making a firm statement on prognosis all but impossible for any single patient and that respiratory function may worsen during the disease course. It is therefore mandatory to inform patients and families about the existence of ALS patients'associations. The way the patient is told the diagnosis is of great importance and is considered as a multiple-step procedure. Discussion should take place in a private and quiet room and respect some fundamental objectives such as finding out what the patient already knows or suspects and how much more the patient wants to know, observing and responding to the patient's reactions, reinforcing the information and planning the future. It is proven that communicating the diagnosis of ALS in an empathetic fashion is an important and sensitive step to disease management.

[Nutritional assessment in amyotrophic lateral sclerosis patients]

During ALS, malnutrition may occur. The causes are multiple. A reduction in caloric and protein intakes, due to swallowing disorders, play a major role. Moreover, (2/3) of patients develop an hypermetabolism of unknown cause, leading to an increase in resting energy expenditure. Malnutrition, whose prevalence is 10-55 percent, is an independant significant prognostic factor for survival. Nutritional assessment is recommanded every 3-6 months at least, and more often if needed. After a simple clinical examination, nutritional assessment includes the measurement of weight (W) and height (H), in order to calculate the Body Mass Index (BMI=W/H(2)). BMI<18.5 (age: 18-65ys) or<20kg/m2 (age>65ys) indicates malnutrition. A weight loss more than 5 to 10 percent of usual weight in the last six months is another malnutrition criterion. The measurement of skinfolds and the calculation of mid arm muscle circumference give informations on respectively fat mass and fat-free mass, but their interest is mainly during the follow-up, or for triceps skinfold when included in a validated bioimpedance formula. Bioimpedance analysis (BIA) is a simple bedside technique, recently validated for measurement of fat-free mass in ALS patients. The BIA phase angle could be an easy obtained parameter of severity. Dietary interview is important when patients still use oral route, but is difficult if they have elocution or writing problems. Indirect calorimetry and dual X-ray absorptiometry give reliable informations on respectively energy expenditure and body compartments, but remain scarcely used. Additional methods, like swallowing tests, psychological, digestive or respiratory assessments are often useful for optimal nutritional prescriptions. We recommand as minimal nutritional assessment a systematic clinical examination, anthropometric measurements and bioimpedance evaluation.

Étude des causes du retard au diagnostic de la sclérose latérale amyotrophique

INTRODUCTION

The mean diagnostic delay of amyotrophic lateral sclerosis (ALS) is greater than one year. Its causes are multiple, related to the affection, the patient, or medical practices.

METHODS

An investigation was carried out in 77 consecutive patients, to describe their medical course since the date of the first symptoms until the diagnosis. Interrogation of the private practitioners potentially implied in the diagnostic procedure enabled an evaluation of the degree and origin of their knowledge of the disease.

RESULTS

In the majority of patients, the first consultation was conducted by a general practitioner. Referral to a neurologist occurred on average 7 months after this consultation. A first-intention electrophysiological examination was prescribed in one-third of patients. Practitioners were unknowledgeable about certain clinical signs. Their knowledge on the disease came primarily from medical school training and for two-thirds, their satisfaction concerning their degree of training was low.

CONCLUSION

This observational study shows that medical practices contribute to delayed diagnosis of ALS, particularly delayed referral to a neurologist. To enable earlier diagnosis, general practitioners should be informed of the usefulness of early referral for multidisciplinary care of patients.

Échelles fonctionnelles de la sclérose latérale amyotrophique

Amyotrophic lateral sclerosis (ALS) is a progressive degeneration of the peripheral and central motor neurons. The principal consequence is a loss of motor functions. Evaluation of motor deficit implies an assessment of the resulting deficiency or incapacity and final disability. Many evaluation are proposed for patient follow-up in order to analyze the state of motor function and their consequences on activities of everyday life. Few recommendations can be formulated. Scales must be validated and relatively simple to use and generate ordinate results allowing statistical analysis. The choice of which scale to use depends on the clinical objective. Global scales (ALS Functional rating Scale, ALS Severity Scale, Appel scale, Norris scale and Honda scale) can be used to evaluate progression of the disability. Some of these scales are strongly correlated with patient survival. Other scales (ALS Health State Scale, global clinical impression) are used to classify patients by homogeneous stage of gravity. Still other scales, such as the Sadoul and Borg scales and the Epworth score are designed for more specific evaluation of a given function. The clinician should be aware of these different scales and their relative utility. Knowledge of these scales, their validity, their sensitivity to modification, and their specificity and interpretation pitfalls is a prerequisite to good evaluation in daily practice and clinical research.

Sclérose en plaques et atteinte du système nerveux périphérique

Multiple sclerosis is a demyelinating disease limited to the central nervous system, but the literature has provided recurring evidence which raises the question of associated peripheral nervous system abnormalities. The prevalence of peripheral neuropathy during multiple sclerosis remains controversial without prospective study. Nevertheless, some data have reported well documented case reports describing the co-occurrence of multiple sclerosis and radiculopathy or mononeuropathy or polyneuropathy in the same patients. By contrast, more frequent subtle nerve abnormalities may be found by using electrophysiological and neuropathological examinations. Some hypotheses have been proposed by Waxman to decipher the electrophysiological and neuropathological findings. The mechanisms for demyelinating disease and peripheral nerve pathophysiology may imply the antigenic properties or the presence of diffusing factors between peripheral nervous system and central nervous system myelin and the molecular plasticity of myelinated fibers.

[Review of nutritional and respiratory support in ALS]

During the evolution of amyotrophic lateral sclerosis (ALS), quality of life and survival of patients are related to respiratory and nutritional status. After diagnosis, a multidisciplinary care has to be promptly organized and coordinated by the referring neurologist. The nutritional and respiratory support imply that neurologists know their specific means of evaluation with their sensitivity and sensibility and be able to recognize clinical risk situations. The informations of patients on assisted-ventilation and nutritional support by using gastrostomy may be done early, precisely and trustfully. Well informed patient's choices must be respected. Nutritional and respiratory supports may be based on recommendations established by the American Academy of Neurology. This review will present and discuss their main aspects in patients with ALS.

[Glycogenesis due to adult phosphorylase kinase deficiency]

A 42-year-old man presented exercise-induced muscle pain without myogloburia since the age of 12 years. Histochemistry and electronmicroscopy of a muscle biopsy revealed subsarcolemmal and inter-myofibrillar accumulation of glycogen. Exercise on a bicycle ergometer produced a normal raise of lactate. Biochemical study showed a partial defect in phosphorylase activity.

[Isolated neurosarcoidosis without systemic signs]

Sarcoidosis is a multisystemic disease which involves the nervous system in 5 to 15 p.cent. Neurosarcoidosis without signs of systemic disease is rare and may be difficult to diagnose. We report a case of a 61 year-old patient with a pseudotumoral neurosarcoidosis and along evolution of 25 years without systemic signs. In such cases, histological analysis is rewarding.

[Cranial neuritis with enhancement on post-contrast MRI due to Lyme disease]

We report a case of Lyme disease presenting as an oculomotor nerve palsy and meningitis. T1-weighted postcontrast magnetic resonance images showed marked enhancement of the right third, fifth and sixth nerves. This case illustrates neuroradiological features of cranial nerves during neuroborreliosis.

SMN1 gene study in three families in which ALS and spinal muscular atrophy co-exist

Spinal muscular atrophy (SMA) is caused by SMN1 gene deletions or mutations, and ALS is the most frequent motor neuron condition in adults. The authors describe three families in which ALS and SMA coexist. The authors found that no SOD1 mutation was found within these families; all three ALS cases had at least two SMN1 copies; and an abnormal SMN1 gene locus did not explain the co-occurrence of these two motor neuron disorders in these families.

[Validation of the combined SF36/MSQOL test of evaluation of quality of life in migraine patients in France]

The impact of migraine on patients quality of life is great, even between attacks. The aim of this study was to assess the properties of a French language quality of life questionnaire, which associates the Medical Outcome Study Short Form (MOS SF 36) with the Migraine-Specific Quality of Life (MSQOL). Data were obtained from 110 consultant patients of neurology units located in three University hospitals in the center of France. The results indicated a good acceptability of the association of the two questionnaires with a 84p.cent response rate. The Principal Component Analysis showed no change in both SF-36 and MSQOL structures. It also suggested that the two questionnaires were complementary. The high values of the Cronbach alpha coefficients for each scale indicated a high level of internal consistency. The quality of life scores were correlated with external parameters such as frequency, intensity and length of migraine attacks, and social activity reduction due to these attacks. In conclusion, the association of the SF-36 with the MSQOL has the interest of associating generic and specific questionnaire, in a complementary way. This association has good psychometric properties, and can be used to evaluate migraineurs quality of life in French speaking countries.

Factors correlated with hypermetabolism in patients with amyotrophic lateral sclerosis

BACKGROUND

Amyotrophic lateral sclerosis (ALS) is a severe disease characterized by neurogenic amyotrophy and degeneration of upper and lower motor neurons. Although ALS patients usually experience reductions in fat-free mass (FFM), hypermetabolism via an undetermined source has also been reported.

OBJECTIVE

The objective was to clarify the metabolic level of ALS patients.

DESIGN

We measured the resting energy expenditure (REE) of 62 patients (32 men and 30 women) with ALS and investigated the factors correlated with metabolic level. Nutritional evaluation included bioelectrical impedance analysis, indirect calorimetry, and calculation of the body mass index. Neurologic assessment included an evaluation of peripheral and central neurologic deficit. Forced vital capacity was measured and smoking status was noted. A complete blood cell count was made and thyroid hormone and C-reactive protein concentrations were measured.

RESULTS

Patients were hypermetabolic, by an average of approximately 10% more than in a reference healthy population. FFM, age, and the neutrophil count were significantly associated with REE. The only variable that contributed to the prediction of REE, REE/Z100 kHz (bioimpedance at 100 kHz), REE adjusted for FFM, or the ratio of measured REE to calculated REE was the neutrophil count, which explained only a small percentage of variance in the multiple regression analysis. Hypermetabolism was not associated with a reduction in respiratory function, tobacco use, hyperthyroidism, spasticity and fasciculation intensities, or infection.

CONCLUSIONS

Our study corroborates the surprising finding that ALS patients are hypermetabolic. FFM, age, sex, manual muscular testing, the modified Norris limb score, weight, and an increase in circulating neutrophil counts correlated with the hypermetabolic state. Other factors may play a role in pathophysiologic processes that involve mitochondrial energy production or even sympathoadrenergic activation.

Motor neuron disease after electric injury

The occurrence of motor neuron disease after electrical injury in six patients is reported and compared with patients from the literature. The patients were five men with spinal onset and one woman with bulbar motor neuron disease after electric shock. Two patients were struck by lightning and four by industrial electric shock. For all six of them, the disease started at the site of the electrical trauma. The mean delay for onset of motor neuron disease was 44 months. In four of the spinal patients the disease progressed slowly with mild handicap after several years. For the fifth patient, improvement was noted progressively. The patient with bulbar disease died 26 months after onset. A link between electric shock and motor neuron disease is likely, given the homogenous profile of the patients both in the five spinal cases presented here and in the literature. Bulbar onset has not been reported to date. However, in this patient the long delay between the electrical injury and motor neuron disease, together with the rapid evolution may suggest a chance association.

Parkinson's disease and environmental factors. Matched case-control study in the Limousin region, France

The study included 140 patients with Parkinson's disease (PD) and 280 non-Parkinson age-matched controls to evaluate environmental risk factors associated with PD. The effect of exposure to environmental and dietary factors was determined using conditional logistic regression. This multivariate analysis showed that PD in first-degree relatives and tea drinking were the main risk factors for PD. Smoking appeared to be a protective factor. Exposure to toxic compounds was not a significant risk factor. Further research is needed to validate that tea consumption increases the risk of PD.

Estimation of the amyotrophic lateral sclerosis incidence by capture-recapture method in the Limousin region of France

Amyotrophic lateral sclerosis (ALS) is a rapidly fatal degenerative neurological disease categorized among motor neuron diseases. In the literature, the incidence of ALS varies between 0.7 and 2.4 per 100, 000 inhabitants. A study using the capture-recapture method (multiple records system analysis) was undertaken in Limousin (France) ascertaining all patients having onset of definite or probable ALS during the period 1994-1995. Three information sources able to identify these new ALS cases were selected: the first source was a computerized database of the Neurology Department of the University Hospital of Limoges; the second source consisted of the neurologists of the Limousin region and neighboring provinces (county-sized regions); the third source grouped the hospitals of the Limousin region and neighboring provinces (county-sized regions). During this period, 46 new cases of ALS were seen, corresponding to an observed mean annual incidence of 3.2 (+/-0.6) per 100,000 inhabitants. After standardization for age, the annual incidence was 2.5 per 100,000 inhabitants. The number of new cases estimated by the capture-recapture method was 70, corresponding to an estimated mean annual incidence of 4.9 (+/-1.0) for 100,000 inhabitants. Hence, statistical modeling utilizing partially overlapping information sources permitted a more exhaustive compendium of the new cases of ALS and may be a truer reflection of actual disease incidence than has been previously reported.

In vitro induction of neuronal apoptosis by anti-Fas antibody-containing sera from amyotrophic lateral sclerosis patients

Sera from 26% of patients with sporadic amyotrophic lateral sclerosis (ALS) induced in vitro apoptosis of a human neuroblastoma cell line, as detected by two methods, and most contained anti-Fas autoantibodies. In contrast, Alzheimer sera (studied as controls) very rarely induced apoptosis and did not contain detectable anti-Fas antibodies. Soluble Fas-ligand levels in ALS sera were not different from those in normal sera, except for slightly higher levels in a single case. In mixed cultures of rat embryonic brain and spinal cord cells, ALS sera (and agonistic anti-Fas monoclonal antibodies and soluble Fas-ligand) induced the apoptosis of a subpopulation of neurons. These neurons were motoneurons on the basis of staining with the monoclonal antibody SMI 32 and Fas expression was restricted to these SMI 32-positive neurons. These data are compatible with the hypothesis of the participation of an autoimmune mechanism possibly related to anti-Fas autoantibodies in certain ALS patients.

Prevalence and clinical significance of anti-phospholipid antibodies in multiple sclerosis: a study of 89 patients

The prevalence of serum anti-phospholipid antibodies (aPL) was evaluated in multiple sclerosis (MS) patients to search for a possible association with a distinct form of the disease. Anti-cardiolipin antibodies (Ab) (aCL) and anti-beta 2 glycoprotein I Ab (abeta2GPI) were measured together with antinuclear Ab (ANA), anti-double-stranded DNA Ab (anti-ds DNA) and anti-myelin Ab in 89 patients. Twenty-nine (32.6%) patients had serum aPL, 19xaCL (15 of the IgG and four of the IgM isotype), 14 abeta2GPI (two IgG and 12 IgM) (four of these patients had both Ab). Prevalence of aCL correlated with that of ANA, which were positive in 52 patients (P=0. 005) and with anti-myelin Ab detected in two patients (P=0.046) but not with that of anti-ds DNA (mostly of the IgM class) detected in 28% of case by ELISA. No correlation could be found between aPL and age, sex, duration of the disease from diagnosis, category of MS, clinical course, clinical symptoms, serum IgM levels nor atypical lesions by magnetic resonance imaging. Hence, aCL and abeta2GPI are neither rare in MS nor associated with a specific clinical form of the disease and they cannot be a diagnosis exclusion criteria.

[Interest of a computerized ALS database in the diagnosis and follow-up of patients with ALS]

The aim of the study is to present a computerized database of the Neurology department of Limoges University Hospital and the main results obtained from data of 340 patients suffering from amyotrophic lateral sclerosis (ALS), diagnosed between 1984 and 1997. It is a user friendly and can be accessed by all neurologists at any level of computer knowledge. This database is modular (6 modules) and flexible according to need. The software used, Access 7, is an open relation database, which allows export of data to statistical or other compatible software. One of the reasons, which led to the elaboration of this database was to develop a means of collecting data in an analyzable manner for therapeutic trials. During these trials, a great number of data can be collected during each clinic visit for the evaluation of the degree of impairment, disability, and handicap. We present part of the data from the patients followed, some of whom were treated with riluzole, the current reference molecule for ALS.

Nutritional assessment and survival in ALS patients

Malnutrition, present in 16-50% of ALS patients, is an independent prognostic factor for worsened survival. It is caused primarily by swallowing dysfunction, resulting from involvement of the lower sets of cranial nerves, but hypermetabolism is also implicated. Malnutrition itself can produce neuromuscular weakness and adversely affect patients' quality of life, thereby creating a vicious circle. The nutritional status of ALS patients can be assessed with dietary review and measurements of weight (W) and height (H). A body mass index (BMI = W/H2) below 18.5-20 kg/m2 indicates a state of malnutrition. Dietary counselling is important, but rapidly becomes insufficient, particularly in bulbar-onset ALS, where enteral nutritional support is then necessary. Percutaneous endoscopic gastrostomy tube placement is well tolerated, and provides more efficient enteral nutrition than nasogastric tube feeding. Enteral nutrition support can improve the respiratory status of ALS patients. The effect on survival remains to be confirmed.

[Case study of 199 patients with multiple sclerosis: the use of EDMUS program]

European Database Multiple Sclerosis (EDMUS) is a standardized tool which allows the collection of clinical, biological, radiological and therapeutic data on multiple sclerosis (MS). A descriptive analysis of 199 patients was done using EDMUS (version 2.2). Most data agreed with previous published results, except a low 0.4 sex ratio. At the beginning of MS, 42 p. 100 of MS patients developed pyramidal and sensory involvements and 14 p. 100 retrobulbar optic neuritis. Optic neuritis was the most frequent initial symptom of relapsing-remitting MS (25.9 p. 100) but not in the chronic progressive form (5.5 p, 100; p < 0.01). Surprisingly, relapsing-remitting form occurred more frequently whereas the secondary progressive form was diagnosed less. The concordances between the three disability scales, EGS (EDMUS Grading Scale), EDSS (Expanded Disability Status Score) and AI (Hauser Ambulation Index) were correct. In clinical practice, EDMUS is user-friendly and rapid. The lack of radiological data and the necessary quantification of only one disability scale, EGS may be too restrictive. The analysis of most of clinical data is possible by using integrated selection within the software, but sometimes needs more complex procedures.