Molecular Targeted Therapies in Glioblastoma Multiforme: A Systematic Overview of Global Trends and Findings

This systematic review assesses current molecular targeted therapies for glioblastoma multiforme (GBM), a challenging condition with limited treatment options. Using PRISMA methodology, 166 eligible studies, involving 2526 patients (61.49% male, 38.51% female, with a male-to-female ratio of 1.59/1), were analyzed. In laboratory studies, 52.52% primarily used human glioblastoma cell cultures (HCC), and 43.17% employed animal samples (mainly mice). Clinical participants ranged from 18 to 100 years, with 60.2% using combined therapies and 39.8% monotherapies. Mechanistic categories included Protein Kinase Phosphorylation (41.6%), Cell Cycle-Related Mechanisms (18.1%), Microenvironmental Targets (19.9%), Immunological Targets (4.2%), and Other Mechanisms (16.3%). Key molecular targets included Epidermal Growth Factor Receptor (EGFR) (10.8%), Mammalian Target of Rapamycin (mTOR) (7.2%), Vascular Endothelial Growth Factor (VEGF) (6.6%), and Mitogen-Activated Protein Kinase (MEK) (5.4%). This review provides a comprehensive assessment of molecular therapies for GBM, highlighting their varied efficacy in clinical and laboratory settings, ultimately impacting overall and progression-free survival in GBM management.

Breaking Barriers in Cranioplasty: 3D Printing in Low and Middle-Income Settings-Insights from Zenica, Bosnia and Herzegovina

Background and Objectives: Cranial defects pose significant challenges in low and middle-income countries (LIMCs), necessitating innovative and cost-effective craniofacial reconstruction strategies. The purpose of this study was to present the Bosnia and Herzegovina model, showcasing the potential of a multidisciplinary team and 3D-based technologies, particularly PMMA implants, to address cranial defects in a resource-limited setting. Materials and Methods: An observational, non-experimental prospective investigation involved three cases of cranioplasty at the Department of Neurosurgery, Cantonal Hospital Zenica, Bosnia and Herzegovina, between 2019 and 2023. The technical process included 3D imaging and modeling with MIMICS software (version 10.01), 3D printing of the prototype, mold construction and intraoperative modification for precise implant fitting. Results: The Bosnia and Herzegovina model demonstrated successful outcomes in cranioplasty, with PMMA implants proving cost-effective and efficient in addressing cranial defects. Intraoperative modification contributed to reduced costs and potential complications, while the multidisciplinary approach and 3D-based technologies facilitated accurate reconstruction. Conclusions: The Bosnia and Herzegovina model showcases a cost-effective and efficient approach for craniofacial reconstruction in LIMICs. Collaborative efforts, 3D-based technologies, and PMMA implants contribute to successful outcomes. Further research is needed to validate sustained benefits and enhance craniofacial reconstruction strategies in resource-constrained settings.

A correlation of demographic characteristics, preoperative conservative therapy and timing with postoperative outcome in herniated disc-associated cauda equina syndrome: Do they really matter?

Aim To examine a correlation of demographic characteristics of patients, preoperative modality of conservative therapy and timing on the postoperative outcome of patients six months after the operation. Methods A retrospective, non-randomized, clinical study involved 48 patients of different age and gender with a verified diagnosis of cauda equina syndrome (CES). The inclusion criteria were patients with CES caused by discus hernia. Observed research variables were age, gender, affected vertebral level, conservative modalities of perioperative therapy (nonsteroidal anti-inflammatory drugs - NSAIDs and physiotherapy), duration of symptoms, and outcome parameters (motor and sensory function, sphincter function of the urinary bladder and bowel). Results A statistically significant negative correlation was found between age and postoperative outcome (p<0.05). The affected vertebral level was positively correlated with the motor and sensory outcome (p<0.05). A positive correlation between the use of NSAIDs and the outcome was found (R=0.570; p<0.001), as well as a negative correlation with perioperative physiotherapy (R=-0.201; p= 0.001). Postponement of surgery was negatively correlated with outcome variables (p<0.001). Conclusion The results of the study bring new conclusions that were not previously observed. Possible new characteristics associated with the outcome of cauda equina syndrome were determined.

Morphometric study of the anatomic relationship between large retroperitoneal blood vessels and intervertebral discs of the distal segment of the lumbar spine: a clinical significance

Aim To analyse potential clinical implications of the distance between large retroperitoneal vessels and lower segment of the lumbar spine in the supine and prone position. Methods Prospective, non-randomised study included 40 patients of different age and gender. For all patients magnetic resonance imaging of the lumbar spine was performed in supine and prone position. The level of aortal bifurcation, common iliac vein confluence, the distance from the anterior and posterior aspect of the annulus to the posterior wall of the large retroperitoneal vessels were analysed. Results The study included 40 patients, 22 (55%) males and 18 (45%) females. The level of aortal bifurcation was higher in prone compared to supine position (χ2 = 29.88571; p<0.05). In supine and prone positions, the common iliac veins confluence was most commonly at the level of the lower third of the L4 vertebra (p>0.05). There was a statistically significant difference between the distance from the left common iliac artery to the anterior contour of L4/L5 intervertebral disc (p<0.05). Conclusion Knowledge of the anatomic relationship between iliac vessels and structures of the lower segment of the lumbar spine is very important in the prevention of a potentially severe complication, such as artificial common iliac vessels rupture. Our study showed that the risk of lesions of the common left iliac artery was lesser in the prone position.

CORRELATION OF PERITUMORAL BRAIN EDEMA WITH MORPHOLOGICAL CHARACTERISTICS AND KI67 PROLIFERATIVE INDEX IN RESECTED INTRACRANIAL MENINGIOMAS

The aim of the study was to analyze correlation between morphological characteristics of intracranial meningiomas and Ki67 labeling index (Ki67 LI), and their influence on peritumoral brain edema (PTBE). There were 41 consecutive patients with intracranial meningiomas surgically treated at the Department of Neurosurgery, Zenica Cantonal Hospital, Zenica, Bosnia and Herzegovina, during the period from January 2010 to December 2015. We reviewed clinical data including patient age, gender, magnetic resonance imaging (MRI) characteristics of the tumor and peritumoral edema, tumor margins, intraoperative characteristics, histopathologic grade and Ki67 LI. In all cases, follow up MRI was obtained at about three months after resection and PTBE was analyzed. Our research showed the tumor volume, tumor margins, and intraoperative signs of arachnoidal and pial invasion to be associated with PTBE in intracranial meningiomas. Ki67 LI expression correlated with PTBE. This study showed the resolution of PTBE to depend on invasive behavior of meningioma and KI67 LI. PTBE, pial/cortical and arachnoidal invasion significantly influence the extent of surgical resection.

Impact of timing on surgical outcome in patients with cauda equina syndrome caused by lumbar disc herniation

Aim To analyze the relationship between timing of surgery and outcome in patients with cauda equina syndrome caused by lumbar disc herniation. Methods A retrospective, non-randomized clinical study included 25 consecutive patients with cauda equina syndrome (CES) caused by lumbar disc herniation. All patients were operated within 24 hours after hospitalization at the Department of Neurosurgery, Cantonal Hospital Zenica, Bosnia and Herzegovina, between January 2000 and December 2010. All patients were evaluated before surgery on the basis of complete history, neurological examination and neuroimaging evaluations using CT (computed tomography)and MRI (magnetic resonance imaging). Results Statistically significant difference between preoperative and postoperative bladder (p=0.05) and bowel (p=0.05) function was found. A significant number of patients had bladder and bowel recovery after surgery, nine (36%) and 11 (44%), respectively. Significant recovery of muscle strength was noted with complete recovery(5/5) in 12 (48%) and partial recovery in 13 (52%) patients. Complete sensory recovery was noted in 16 (64%), incomplete in four (16%), and in five (20%) patients there were no changes. Most commonly, patients with complete sensory recovery were operated within 48 hours of symptom onset. In most patients early surgery was associated with better outcome. Conclusion This research showed that early decompression correlated with better outcome. Patients with cauda equina syndrome must be cleared for surgery in optimal conditions and, if it possible within optimal timing for recovery (within 48 hours).

Evaluation of the surgical treatment of diabetic foot

AIM

To examine two modalities of surgical treatment of diabetic foot based on two different approaches, classical and multidisciplinary.

METHODS

A retrospective-prospective study including 120 consecutive patients with diabetic foot treated in the Department of Surgery, General Hospital Tešanj in the period 1999-2006. Since 2003 a new multidisciplinary approach to the treatment of diabetic foot based on a more conservative approach has been introduced. Two groups of patients were analyzed according to two treatment approaches: the first group included patients treated with classical method (in the period 1999-2002), and the second group included patients treated with multidisciplinary approach (in period 2003- 2006). An age distribution, gender, local changes in the extremities, results of microbiological analysis of wound swabs, and modalities of surgical treatment of diabetic foot were analyzed.

RESULTS

Duration of the disease (p=0.24), the level of blood glucose (p=0.52) and glycosylated hemoglobin (p=0.10) had no statistically significant effect to the outcome of the treatment of diabetic foot, while the level of hematocrit (p less than 0.006), fibrinogen (p less than 0.003), cholesterol (p less than 0.000001), and the absence of a pulse in the peripheral arteries (p less than 0.000002), and the outcome of surgical treatment of diabetic foot had the influence to the outcome of the treatment of diabetic foot with statistical significance.

CONCLUSION

Aggressive and appropriate medical and surgical treatment according to a grade of disease could improve the outcome and reduce the morbidity and mortality of diabetic foot. The results of this study showed the importance of proper diabetes treatment, prevention of complications and a multidisciplinary approach to the treatment of diabetic foot.

Bile duct injury during laparoscopic cholecystectomy: risk of procedure or professional negligence?

Laparoscopic cholecystectomy introduced in the late eighties has now become the gold standard and has taken the place of conventional cholecystectomy. Bile duct injury during cholecystectomy is an iatrogenic, but rare catastrophe associated with significant morbidity and mortality. The incidence of bile duct injuries during laparoscopic cholecystectomy is 0.1-0.42%. We have presented a patient who underwent laparoscopic cholecystectomy which got complicated with bile duct injury grade four. The complication was recognized three weeks later. A remediation of complications was performed in a reference center with full involvement of the primary surgeon.

Morphometric changes of the lumbar intervertebral space following discectomy on one or two levels

AIM

To investigate a potential difference in postoperative morphological changes of two-level lumbar disc surgery as compared to one level surgery.

METHODS

The standard lateral radiographs of lumbar spine obtained preoperatively and postoperatively were used in the study . The morphological study included 60 adult patients of both sexes who had undergone the surgery in the period 2002-2006. The first group comprised patients operated on one level (L4/L5 and L5/ S1), and the second included patients operated on two levels (L3/ L4/L5; L4/L5/S1 and L5/S1/S2). Using lateral radiographs, after digitalization, the height of intervertebral disc space (HD), angle between vertebral bodies (A) and translation (T) were measured.

RESULTS

Comparing preoperative and postoperative values, statistically significant difference has been found for HD in the first group and HD and A in the second group. In neither groups there was statistically significant difference for T, which is one of radiological signs of segmental instability. The comparison of postoperative values for both groups has not shown any statistically significant difference.

CONCLUSIONS

The standard lumbar discectomy on two levels has not shown more pronounced morphological changes or changes suggesting an increased risk of segmental instability as compared to one level discectomy.

[Dorsal extrusion of intervertebral disc as a cause of cauda equina syndrome]

We have presented a case of rare dorsally sequestrated lumbar disc herniation manifesting as cauda equina syndrome. The patient was admitted to the Neurological Department of Canton Hospital Zenica due to urinary retention and weakness in both lower extremities. Magnetic resonance imaging showed a compressing mass located in the dorsal extradural space at the L2-L3 level. An extruded intervertebral disc was found intraoperatively. The decompression was followed by good recovery.

[Chronic epidural haematoma mimicking meningioma]

The study presents a rare case of organised chronic epidural haematoma that imitated a meningioma. A patient was admitted to the Department of Neurology of the Cantonal Hospital Zenica due to loss of consciousness and right hemiparesis. Non-contrast Computed Tomography (CT) scan had shown an expansive intracranial process in the left parietal region which was radiologically diagnosed as a meningioma. During the operation a linear skull fracture and organised chronic epidural haematoma were found.

[Psychological, emotional, spiritual and social aspects of pain]

We are used to speak about the organic pain origin. Meanwhile in actual and old definitions of pain the other determinants, besides the organic one, are included. They are changing the pain threshold and the pain tolerance. Dame Cicely Saunders, who started the modern hospice movement of care for those in advanced stage of disease, describes the concept of "total pain" as involving organic, emotional, spiritual and social determinants. Such pain concept fits into the classical division of pain pathogenesis. The basic forms are: nociceptive, neuropathic and according to the old nomenclature psychogenic. The first one is defense reaction, the second one is due to pathology. The third one is very complex and this article is dealing with it. The patient's emotional reactions, especially the fear and anxiousness producing tension increase the pain. Therefore, different kinds of relaxation or attention distraction can help a lot in relieving the pain. Spiritual pain can be a very difficult symptom increasing the physical pain significantly. Everybody has spiritual needs and they are independent of religious orientation. The experience of life's and suffering's senslessness, personal valulessness and situational hopelessness lowers significantly pain tolerance. The selfconfidence, the confidence in other persons, in somebody over us has the opposite effect. And finally the pain is often easier to cope with in the presence of a friendly person. To be able to complain and to describe one's own fears, especially in connection with the significance of the actual pain, helps a lot. The support of the wider community also helps. We ought to approach the patient holistically, that means also observe the person, the human being suffering, hoping and wishing to be heard, and not to be left alone.

[Bioethics of dying]

The bioethical problems related to the dying person might be classified in four groups: 1) those of the society the person is involved in, 2) those of physicians and other health professionals, 3) those of the nursing staff in the broadest sense and 4) those connected with the dying person himself. The society must consider the death as a part and natural end of life. One of the most delicate problems related to patient-physician relationship is adequate information concerning the diagnosis and prognosis of the condition. A very complex problem is stopping or not introducing the treatment which cannot influence significantly the quality and length of life. Palliative therapy, although risky, should be introduced if suffering is great. The duty to alleviate suffering is more important than life prolongation. The nursing staff and family should honour the wishes of the dying. Active euthanasia legalization is too risky, especially for nonautonomous persons unable to express their will. In autonomous persons even the possibility of its realization could be the cause of extreme disturbances in patient/physician relationship. Active euthanasia, due to the involvement of public opinion, is already becoming a sociopolitical problem.

H-reflex, F-wave, transitional and missed response frequency distribution in limb muscles

The late potential analysis was performed in 86 neurologically healthy subjects aged 0 month to 6 years. The following muscles were analyzed: soleus, flexor hallucis brevis, extensor digitorum brevis and abductor pollicis brevis muscle. Late potentials were evaluated according to H, HF, F and Ms (missing potentials) attributes. The potential population in a particular muscle in an age group was considered as 100%; the type frequency for a particular muscle in different age groups is presented as absolute value and percentage. No age specific combination was found. As no age specificity was recorded, attempts were made to differentiate the muscle specificity potential type distribution. The mean (x) of potential type percentages of all age groups in the same muscle was calculated. Thus, in soleus muscle, the following response types were found: 29% H-reflex, 15% HF potentials, 45% F-waves and 11% Ms potentials. Flexor hallucis brevis muscles had: 3% H-reflex, 6% HF potentials, 85% F-waves and 6% Ms potentials. In extensor digitorum brevis, not a single H-reflex or HF potential was found, whereas F-waves were observed in 46% and Ms in 54%. Abductor pollicis brevis produced 1% H-reflex, 2% HF, 66% F-waves and 31% Ms potentials. Therefore, the soleus could be defined as a high percentage of H, HF, F and low Ms responses muscle. Flexor hallucis brevis and abductor pollicis brevis had high F, very low H, HF and low or moderate Ms response muscles. In the latter, the percentage of Ms potentials was significantly higher than in the former. A very high percentage of Ms potentials was found to be an outstanding attribute of extensor digitorum brevis, as it never develops H or HF but only F potentials. The occurrence of H, HF, F and Ms responses in different limb muscles corresponded closely to that found in adults. There was no significant correlation with age. The potential type frequency of occurrence in individual muscles with aging remained more or less constant. There was no correlation with nerve conduction velocities (significantly slower during the first months of life) either. The results appear to favor the genetic determination of the electrophysiological phenomena observed, through motor units structure and function.

H-reflex and F-wave potentials in leg and arm muscles

The systematic analyses of secondary muscle potentials of H-reflex and F-wave type were done in multicentric study. The examinations were carried out in healthy volunteers with 9 muscles analysed on the legs and 9 on the lower arms and hands. The H-reflex potential was found regularly in thigh muscles (vastus medialis 100%, biceps femoris 97%, semitendinosus 93%). Less frequently but still with high incidence it appeared in posterior lower leg muscles (soleus 93%, caput mediale gastrocnemii 73%). In anterior tibial muscle and extensor digitorum brevis it did not appear at all. Only exceptionally it was found in short peroneal muscle (3%) and occasionally, only on proximal nerve stimulation, in flexor hallucis brevis. The similar distribution pattern was found in lower arm and hand muscles with analysis on both sides. In flexor digitorum superficialis (73-70%) and flexor carpi radialis (73-57%) the percentage of H-potential muscles was the highest, in flexor carpi ulnaris (47-40%) lesser but still remarkable. Brachioradialis (37-30%) and extensor digitorum communis (27-27%) percentage decreased further. The even more distal, pronator quadratus (21-20%) and abuctor digiti minimi (17-17%) presented as muscles with low incidence of H-reflex positivity. In extensor indicis proprius (3%) the lowest H-potential incidence was found and in opponens pollicis no H-potential at all. F-waves if evaluated as "F-frequency" follow the similar distribution pattern. The lowest "F-frequency" was found on the legs in anterior tibial, short peroneal and extensor digitorum brevis muscles. In the last one more than one half of stimuli failed to evoke the F-potential. Those are the muscles in which H-potentials almost never appeared. The highest "F-frequency" was recorded in thigh, posterior lower leg muscle and flexor hallucis brevis. Some of the examinees displayed in almost all examined muscles H-potential (6 of 30), the others (9 of 30) had it in neither one or in a single muscle. It looks like as if a kind of H-reflex or F-wave individuals exist. If the H- or F-potentials distribution pattern got projected on the homunculus in quadrupedal position the following idea appears. The thigh muscles, the plantar flexors of the feet and hand and finger flexors are first of all tonic muscles mostly involved in standing or holding. The extensors of the foot/toes, respectively of hand/fingers interrupt phasically the sustained action of standing by lifting the foot/hand from the ground. The muscles with mostly tonic function produce much H-reflexes, transitional forms or at least F-wave with high "F-frequency". Is that a kind of phylogenetical remnants, better developed in the motorically less differentiated legs? Have the H-reflex muscles if compared with F-wave muscles different motor units structure? Have they different motoneurons, with different liability to produce recurrent discharges?

[Carnitine: physiologic role, primary and secondary deficiency]

L-carnitine is essential in fatty acids metabolism, it is synthetized endogenically and supplied by nurishment as well. Ninety eight percent of it is stored in skeletal muscles. Its importance in primary deficiency, either systemic encephalomyopathies or isolated myopathies, is out of discussion. In deficiency states, life itself may be threatened. Numerous investigations point to secondary carnitine deficiencies. Favorable substitution effects are published, first of all, in organic acidurias in children, in ischemic heart diseases of adults, in hyperlipoproteinemias, in peripheral vascular disease, in patients on hemodialysis, and in muscle dystrophy. Favorable results are published also in total parenteral nourishment of newborns and adults. L-carnitine may prevent toxic effects of valoproates and antracyclins. The substance is not toxic and is well tolerated. LD50 values are almost like those of amino acids. Meanwhile, inspite of many reports on favorable results in secondary carnitne deficiencies the additional controlled clinical trials should be done, especially in children.

Steroid responsive familial neuropathy with liability to pressure palsies

Autosomal dominant motor and sensory neuropathy with liability to pressure palsies was studied in three members of the same family. Only one of two monozygotic twin sisters was clinically affected. She developed unilateral peroneal palsy twenty minutes following local pressure. Electromyography revealed a weak intermediate innervation pattern with very rapid action potentials in the right anterior lower leg muscle. A 25-70 per cent reduction of motor and sensory conduction velocity was recorded in the clinically unaffected twin sister and in the father. The electrophysiological findings in the mother were normal. The sural nerve biopsy revealed "sausage-like" formations. The palsy persisted for two months and disappeared after eight weeks of fluocortolon treatment. It is possible that the myelin sheaths acted as antigen.

[Myasthenia gravis in pregnancy]

Twenty-nine patients with myasthenia gravis in pregnancy have been presented. These patients represent a total of 31 deliveries and 33 newborns. Despite that myasthenia gravis is an illness that poses potentially grave complications for both mother and infant, there were no maternal and neonatal deaths. Only two patients experienced significant exacerbation of their disease during pregnancy. Most of patients underwent vaginal delivery. Cesarean section is not indicated unless there are obstetrical reasons. Incidence of cesarean section delivery was 16.1%. Vacuum extractor has been used to shorten the second stage of labor and its incidence was 16.1%. In the seven (22.6%) patients myasthenic signs and symptoms got worse during the postpartal period. Neonatal myasthenia gravis was observed in 13 (39.4%) newborns. Inverse relationship was found between neonatal myasthenia and duration of disease in mothers. Incidence of neonatal myasthenia was higher in newborns born by mothers with short duration of myasthenia gravis.

Electrophysiologic signs of sensory fiber lesion in spinal amyotrophies and the role of physiologic variations of sensory finger innervation pattern

In 33 patients, 30 to 64 years old, with spinal amyotrophy and brachial paresis, the sensory symptoms and electrophysiologic signs were analyzed. The paresthesias were felt most often in the ulnar nerve innervation region. The motor conduction velocities, terminal latency quotient, sensory conduction on direct nerve stimulation were within the limits of normal in both median and ulnar nerve. On percutaneous stimulation normal values were obtained for median nerve, and significantly slower for ulnar nerve innervation region. In four cases no nerve potential was obtained over the ulnar nerve with stimulation of the fifth finger. The nerve potential over the ulnar nerve was elicited mostly by stimulation of median nerve innervated fingers. Congenital variations of sensory innervation pattern were considered, which may increase the liability to destruction.

Secondary evoked muscle potential mapping according to the F, H, HF, FH features of nonexistence in proximal and distal limb muscles. A preliminary communication

In 62 healthy volunteers, a late response analysis was done in 23 leg and arm muscles. The potentials were differentiated according to their H-potential or F-potential features. The total disappearance of secondary potential was estimated also. The H-potential appeared most frequently in the thigh muscles (100%), frequently in the calf and peroneus longus muscles (77%-23%), rarely in the intrinsic foot muscles (20%), and never in the short or long foot and toe extensors. In the arms the H potential was most frequently found in flexor digitorum sublimis (67%). Its appearance in pronator quadratus was 22%. H-potential appeared rarely in the intrinsic hand muscles and never in the extensor digitorum communis. The similarity of H-wave distribution in the lower leg and feet muscles, and the lower arm and hand muscles is pointed out. The question of its phylogenetic determination is raised.

Hereditary increased muscle mechanical irritability and progressive contracture with stretch-induced electromyographic activity

A son and mother are reported with autosomal dominantly transmitted painless, increased mechanical irritability in the limb and trunk muscles and progressive finger contracture. Immediately after a tap, muscle swelling appeared. With light tapping, wavelike muscle surface movements appeared. Progressive contractures developed first in the proximal interphalangeal finger joints and subsequently involving the lower arm muscles. The contractures disappeared in the local curare test. No spontaneous activity was recorded on concentric needle recording. Serial repetitive activity was recorded with fine wire electrode recording, induced by muscle stretch, performed by percussion hammer blows or by prolonged finger grasp. A slight, irritative peripheral nervous lesion could be the cause. The chronic sensorimotor polyneuropathy may be also a part of the syndrome.

Selective ACTH insensitivity associated with autonomic nervous system disorders and sensory polyneuropathy

A 10-year-old boy is described with a syndrome of adrenal insufficiency due to selective ACTH insensitivity associated with autonomic nervous system disorders. In addition to insufficient production of glucocorticoids and adrenal androgens, achalasia, defective lacrimation, anisocoria and hyperkeratosis of palms and soles we also found defective sweating, permanent cutis anserina and sensory polyneuropathy, which have not been reported previously in this rare syndrome.

Rigid spine syndrome associated with tent-like configuration of the thoracic cage, cerebral lesion and delayed sexual maturation in three patients

Three male patients with rigid spine syndrome and predominantly proximal myopathy which developed slowly from childhood are described; two cases were sporadic, one possibly hereditary. All three had the same associated signs and symptoms, differing only in degree. They had tent-like thoracic cages with very steeply sloping ribs, reduced anteroposterior diameter and reduced vital capacity. The EGGs were slightly abnormal. All the patients had some cerebral abnormality, in one case of diffuse demyelinating type. All had the signs and symptoms of slightly delayed puberty.

Acute polyneuropathy with severe generalized rigidity in a child aged 16 months. Preliminary report

A case of acute severe generalized muscle rigidity in a 16-month-old child is described. The arm flexors and leg extensors were the most severely involved, with all stretch reflexes absent. Motor conduction velocities on the arms and legs were very slow and nerve potentials were not elicited. The rigidity and electromyographically recorded spontaneous activity almost disappeared on carbamazepine treatment, with nerve conduction velocities remaining unchanged.

Neuromuscular synapse testing in two cases of suicidal organophosphorous pesticide poisoning

Electromyographic neuromuscular testing was performed for two patients with a very low blood cholinesterase activity due to suicidal poisoning with organophosphorous pesticides. Electromyographic results did not differ significantly from those obtained in healthy nonexposed adults. Neuromuscular synapse functioning was normal, as was determined by electromyography. Neurological signs and symptoms are described in detail.

Long-term ACTH and corticosteroid therapy in two siblings with polyneuropathy due to acute intermittent porphyria

The influence of long-term corticosteroid and ACTH therapy in two sisters was followed up. The periods of observation were 4 and 2 years. The high levels of corticosteroids obviously reversed the fatal progress of the disease. The relapses in the elder sister occurred during longer periods of discontinued corticosteroid therapy. In the younger the therapy was continuous. There was no relapse except for a short one appearing after the tooth extraction and discontinuation of the therapy for 10 days. Some correlation between neurological signs and symptoms and porphobilinogen androporphyrin levels were found. The question arises how it is possible to influence the genetically determined disease by corticosteroids or ACTH.

The reversible flexion contracture as a sign of peripheral nerve lesion

Three cases were observed with the same substantial clinical features: flexion contracture of the third, fourth, and fifth finger and less extensive of the wrist. The contracture appeared after a mechanical injury not related to the involved muscles. In two cases the lesion was situated above or in the elbow region, in the third on the ulnar border of the forearm. In all cases there were some ulnar nerve signs and symptoms but the contracture involved flexor muscles which were co-innervated by the median nerve. The signs and symptoms improved or disappeared entirely after neurolysis. The question is raised, whether the contracture is due to peripheral nerves damage.

Nerve potentials and afferent conduction velocities in the differential diagnosis of amyotrophy of the hand

Nerve action potentials recorded over the elbow after stimulation of the wrist were studied in patients with hand amyotrophy of different origin. In amyotrophic lateral sclerosis the amplitude of nerve action potentials does not change significantly even with extreme muscle wasting and loss of motor units.Studies of multisegmental afferent conduction velocities may demonstrate a strictly localized lesion with normal values above the compression.