Detecting dysphagia in inclusion body myositis

Dysphagia is an important yet inconsistently recognized symptom of inclusion body myositis (IBM). It can be disabling and potentially life-threatening. We studied the prevalence and symptom-sign correlation of dysphagia. Fifty-seven IBM patients were interviewed using a standard questionnaire for dysphagia and 43 of these underwent swallowing videofluoroscopy (VFS). Symptoms of dysphagia were present in 37 of 57 patients (65%). Nevertheless, only 17 of these patients (46%) had previously and spontaneously complained about swallowing to their physicians. Both symptoms of impaired propulsion (IP) (59%) and aspiration-related symptoms (52%) were frequently mentioned. Swallowing abnormalities on VFS were present in 34 of 43 patients (79%) with IP of the bolus in 77% of this group. The reported feeling of IP was confirmed by VFS in 92% of these patients. Dysphagia in IBM is common but underreported by the vast majority of patients if not specifically asked for. In practice, two questions reliably predict the presence of IP on VFS: ‘Does food get stuck in your throat’ and ‘Do you have to swallow repeatedly in order to get rid of food’. These questions are an appropriate means in selecting IBM patients for further investigation through VFS and eventual treatment.

Limb-girdle muscular dystrophy in the Netherlands: gene defect identified in half the families

Pheno- and genotype correlation is attempted in a Dutch cross-sectional study on limb- girdle muscular dystrophy. Sarcoglycans, caveolin-3, calpain-3, and dysferlin were analyzed on muscle tissue. Mutation analysis of the calpain-3, caveolin-3, and fukutin-related protein gene was executed in successive order for all samples. In 51% of all families a classifying diagnosis was made. Several new mutations in LGMD2A, B, and C patients have been found in this population.

Does modafinil enhance activity of patients with myotonic dystrophy?: a double-blind placebo-controlled crossover study

We performed a double-blind placebo-controlled crossover study in 13 patients with myotonic dystrophy to address the question whether modafinil, known to improve hypersomnolence in myotonic dystrophy, may improve levels of activity as well. We used the Epworth Sleepiness Scale as a measure of hypersomnolence and a structured interview of the patient and the partner or housemate as a measure of activity. We additionally used a restricted form of the RAND-36 to relate a possible improvement of activity to perceived general health. We confirmed earlier positive findings of modafinil regarding reduced somnolence (p = 0.015), but no significant effects were seen regarding activity levels (p = 0.2 for patients’ self-reports and 0.5 for partners’ reports).

Associations with autoimmune disorders and HLA class I and II antigens in inclusion body myositis

Whether autoimmune mechanisms play a role in the pathogenesis of inclusion body myositis (IBM) is unknown. Human leukocyte antigen (HLA) analysis in 52 patients, including 17 with autoimmune disorders (AIDs), showed that patients were more likely to have antigens from the autoimmune-prone HLA-B8-DR3 ancestral haplotype than healthy control subjects, irrespective of the presence of AIDs. Patients lacked the apparently protective HLA-DR53 antigen. The results provide further support for an autoimmune basis in IBM.

Necrotising myopathy, an unusual presentation of a steroid-responsive myopathy

OBJECTIVE

To evaluate the clinical features, muscle pathology and response to treatment in patients with a necrotising myopathy, without mononuclear cell infiltrates.

BACKGROUND

Mononuclear cell infiltrates in the muscle biopsy specimen are the diagnostic hallmark of the immune-mediated idiopathic inflammatory myopathies (IIM). In patients with the typical clinical features of IIM, absence of these infiltrates in the muscle biopsy specimen casts doubt on the diagnosis and leads to uncertainty about therapeutical strategies.

METHODS

A detailed description is given of the clinical, laboratory, and histopathological features of eight patients suspected of having an idiopathic inflammatory myopathy, in whom mononuclear cell infiltrates in their muscle biopsy specimens were lacking.

RESULTS

Eight patients (five men, three women, age range 40-69 years) had severe, symmetrical proximal weakness with a subacute onset. There were no skin abnormalities suggesting dermatomyositis. Serum creatine kinase activity was more than 10 times elevated. Repeated muscle biopsy specimens, taken from a symptomatic muscle prior to immunosuppressive treatment showed widespread necrosis, regeneration, and atrophy of muscle fibres, but no mononuclear cell infiltrates. Known causes of necrotising myopathy were excluded. Three patients had a malignancy. Adequately dosed and sustained immunosuppressive treatment eventually resulted in normal or near normal muscle strength in seven patients. One patient showed marked improvement.

CONCLUSION

Occasionally, patients who clinically present as an idiopathic inflammatory myopathy may lack mononuclear cell infiltrates in their muscle biopsy specimens. This subacute-onset progressive necrotising myopathy should not deter the clinician from timely and appropriate treatment as we consider this myopathy to be steroid-responsive with a possible immune-mediated pathogenesis.

Difference in distribution of muscle weakness between myasthenia gravis and the Lambert-Eaton myasthenic syndrome

BACKGROUND

Myasthenia gravis and the Lambert-Eaton myasthenic syndrome (LEMS) may have a similar distribution of muscle weakness. Deciding on a diagnosis of myasthenia gravis or LEMS on clinical grounds may therefore be difficult.

OBJECTIVE

To compare the localisation of initial muscle weakness and the distribution of weakness at the time of maximum severity in patients with myasthenia gravis and LEMS.

SUBJECTS

101 patients with myasthenia gravis and 38 patients with LEMS.

RESULTS

In myasthenia gravis, initial weakness involved extraocular muscles in 59%, bulbar muscles in 29%, and limb muscles in 12% of the patients. In LEMS no patient had ocular weakness, 5% had bulbar weakness, and 95% had weakness of the limbs as the first symptom (p < 0.001). At the point of maximum severity, weakness in myasthenia gravis was purely ocular in 25%, oculobulbar in 5%, restricted to the limbs in 2%, and present in both oculobulbar muscles and limbs in 68%. At this point, none of the LEMS patients had weakness restricted to extraocular or bulbar muscles (p = 0.002). The legs were affected in all LEMS patients, whereas in 12 patients with generalised myasthenia gravis limb weakness was restricted to the arms (p = 0.024).

CONCLUSIONS

In a patient suspected to have a myasthenic syndrome whose first symptom is ocular weakness, LEMS is virtually excluded. Limb weakness confined to the arms is only found in generalised myasthenia gravis and not in LEMS. Muscle weakness in myasthenia gravis tends to develop in a craniocaudal direction, and in the opposite direction in LEMS.

HLA class I and II in Lambert-Eaton myasthenic syndrome without associated tumor

Lambert-Eaton myasthenic syndrome (LEMS) is an autoimmune disorder, in which antibodies against voltage-gated calcium channels located at nerve terminals cause muscle weakness and autonomic dysfunction. In approximately half of the patients the autoimmune process is initiated by a tumor. In the other half of patients no tumor is found and the etiology is unknown. The aims of this study were to investigate the strength of HLA-associations with nontumor LEMS (NT-LEMS) and to study the relation of HLA-haplotypes with age at onset of LEMS and other clinical features. Therefore, typing of HLA class I and II was performed in 19 patients with NT-LEMS, who were clinically evaluated. NT-LEMS was significantly associated with alleles of both HLA-class I (i.e. HLA-B8) as well as -class II (i.e. HLA-DR3 and -DQ2). HLA-B8+ patients had significantly younger age at onset of LEMS and tended to be female. This study shows that HLA-class I haplotype is associated with a distinct phenotype in NT-LEMS.

Neuropathy and IgM M-proteins: prognostic value of antibodies to MAG, SGPG, and sulfatide

BACKGROUND

In polyneuropathy associated with immunoglobulin M (IgM) monoclonal gammopathy, antibodies to myelin-associated glycoprotein (MAG), sulfoglucuronyl paragloboside (SGPG), and sulfatide have been associated with specific clinical and electrophysiologic features. However, it is not known whether the results of antibody tests provide additional information for the individual patient (and the neurologist) in terms of future neurologic deficit or outcome.

OBJECTIVE

To study the independent contribution of potential prognostic factors to the prediction of outcome of neuropathy associated with IgM monoclonal gammopathy.

METHODS

In accordance with the chronology in which prognostic factors are available in clinical practice, the association between prognostic factors and outcome was evaluated by univariate and multivariate logistic regression analysis in 65 patients with polyneuropathy and IgM monoclonal gammopathy.

RESULTS

In univariate analysis, the initial symptoms, the IgM light chain type, electrophysiologic and pathologic studies, the presence of sural nerve IgM deposition, and anti-MAG or anti-SGPG antibodies were significantly associated with outcome. However, multivariate analysis showed that only initial symptoms and electrophysiologic studies are independent prognostic factors: initial sensory symptoms of the feet are prognostic for a slowly progressive disease course and less disability at 4 years, and evidence for demyelination on electrophysiologic examination is prognostic for development of weakness and symptoms of the upper extremities at 4 years. Addition of anti-MAG or anti-SGPG antibody tests did not yield any additional prediction of outcome.

CONCLUSION

These results indicate that in clinical practice, antibody tests in polyneuropathy associated with IgM monoclonal gammopathy do not have a prognostic value in terms of future neurologic deficit or outcome.

[Proximal muscle weakness, depressed tendon reflexes and autonomic dysfunction: the Lambert-Eaton myasthenic syndrome]

Three patients with Lambert-Eaton myasthenic syndrome (LEMS), two men aged 61 and 64 and a woman aged 55 years, all developed proximal weakness, depressed tendon reflexes and autonomic dysfunction. Although this clinical triad is highly suggestive for LEMS, the disorder had not been recognized initially. The woman had a small-cell bronchial carcinoma, treated successfully by chemotherapy, whereafter the LEMS symptoms gradually disappeared. The first man was treated with 3,4-diaminopyridine and azathioprine, whereupon his symptoms diminished. The other man had only slight complaints and refused drug treatment. The three cases illustrate that presentation and course of LEMS can vary between patients. Furthermore, clinical and electrophysiological features can suggest myasthenia gravis, myopathy or axonal polyneuropathy. Therapeutic options and the risk of underlying malignancy make early diagnosis important. In conclusion, in every patient presenting with unexplained proximal weakness, LEMS should be considered, especially if depressed tendon reflexes and autonomic dysfunction are found as well.

Epidemiology of inclusion body myositis in the Netherlands: a nationwide study

Epidemiologic data on inclusion body myositis (IBM) are scarce, and possibly biased, because they are derived from larger neuromuscular centers. The present nationwide collaborative cross-sectional study, which culminated on July 1, 1999, resulted in identification of 76 patients with IBM and the establishment of a prevalence of 4.9 patients with IBM per million inhabitants in the Netherlands. Several discrepancies suggest that this may be an underestimation. The most frequently identified pitfall in diagnosing IBM was an erroneous diagnosis of polymyositis or motor neuron disease.

Acquired slow-channel syndrome: a form of myasthenia gravis with prolonged open time of the acetylcholine receptor channel

A 32-year-old female presented with a 2-year history of fluctuating generalized weakness including extraocular, bulbar, and limb muscles, suggesting myasthenia gravis, but with poor response to pyridostigmine and unusual electromyographic findings. After rest, power increased on repeated maximal contractions, followed by progressive weakness. There were decremental responses at low-frequency stimulation, but incremental responses at high frequencies, and single stimuli evoked repetitive compound muscle action potentials. Plasmapheresis was ineffective. In a conventional assay, antibodies against acetylcholine receptors (AChRs) were borderline. However, in an assay using cells expressing mainly adult-type human AChRs, the patient's serum was positive. Thymectomy revealed a hyperplastic thymus. An intercostal muscle specimen revealed small miniature end-plate potentials, 0.22+/-0.02 mV instead of 0.56+/-0.05 mV in controls. The number of 125I-alpha-bungarotoxin binding sites was normal. The decay time constant of end-plate potentials was increased from 5.3+/-0.6 msec in controls to 23+/-3.6 msec in the patient. Ultrastructurally, there was no destruction of the end plate. Transfer of the patient's plasma to mice in vivo produced similar physiological changes in their diaphragms. We conclude that the patient has an immune-mediated disorder, in which an antibody specific to the adult form of the AChRs alters the channel properties, reducing total current and slowing the closure. We propose the name "acquired slow-channel syndrome" for this variant of myasthenia gravis.

Very long chain acyl-coenzyme A dehydrogenase deficiency with adult onset

Very long chain acyl-coenzyme A (acyl-CoA) dehydrogenase (VLCAD) deficiency is a severe disorder of mitochondrial beta-oxidation in infants. We report adult onset of attacks of painful rhabdomyolysis. Gas chromatography identified strongly elevated levels of tetradecenoic acid, 14:1(n-9), tetradecadienoic acid, 14:2(n-6), and hexadecadienoic acid, 16:2(n-6). Palmitoyl-CoA and behenoyl-CoA dehydrogenase in fibroblasts were deficient. Muscle VLCAD activity was very low. DNA analysis revealed compound heterozygosity for two missense mutations in the VLCAD gene. The relatively mild clinical course may be due to residual enzyme activity as a consequence of the two missense mutations. Treatment with L-carnitine and medium chain triglycerides in the diet did not reduce the attacks of rhabdomyolysis.

['Inclusion body'-myositis]

In 3 patients, a 72-year-old man, a 62-year-old man and a 73-year-old woman with weakness of respectively the quadriceps femoris, the finger flexors and the pharyngeal muscles, the diagnosis of 'inclusion body myositis' was made. This is a rare, slowly progressive skeletal muscle disorder which is more common in men and after the age of fifty. The activity of serum creatine kinase is often 2-5 times the highest normal value. The electromyogram pattern is myopathic, but can also display neuropathic changes (exclusively). Inclusion body myositis is often misdiagnosed, which can lead to an inappropriate treatment or approach. A frozen muscle biopsy is needed to make cryostat sections for demonstration of myositis with rimmed vacuoles.

Vocational perspectives and neuromuscular disorders

The present study analyses the actual occupational situation, vocational handicaps and past labour career of a group of about 1000 Dutch patients suffering from a neuromuscular disorder (NMD). On the basis of the likelihood of a substantial employment history and sufficient numbers of patients, four types of NMD were selected: dystrophia myotonica (DM), hereditary motor and sensory neuropathy, (HMSN), spinal muscular atrophy (SMA) and myasthenia gravis (MG). Results show that a labour career is in reach of most NMD patients, even for those with severe limitations. It is concluded that physical limitations seem not to be decisive in that respect. The loss of the quality of communication, the loss of mental abilities and the effect of the diseases on the facial expression, as with some DM patients, are also important for chances on the labour market. Though the labour participation of NMD patients tends to decrease after the age of 34, the availability of work adaptations makes it possible to prolong the labour career. Analysis of the actual work situation of NMD patients shows that both disorder-related limitations and work characteristics play an important role in the amount of physical work problems encountered. It is argued that physical labour has to be regarded as generally unsuitable for NMD patients. This has implications for the sort and level of education to be attained by NMD patients. Career counselling as a focus point for the choice of an educational programme may improve labour market opportunities as well as quality of employment of NMD patients. Allowing for and accepting the possible effects of the disorder in the work situation are considered to be important in respect to labour participation and work satisfaction of workers with NMD. Reducing time pressure demands and increasing the freedom to organize one's work, are measures to be given especial consideration.

[Gait impairment in the oldest old]

To evaluate senile gait patterns in octogenarians and nonagenarians, we provided a standardized questionnaire on gait disabilities to 153 elderly subjects over 88 years of age. Subjects represented a relatively healthy subgroup of non-institutionalized residents who participated in a gerontological survey of all inhabitants of the city of Leiden who were 85 years or older. Of the 142 subjects who responded to this questionnaire, 87 persons (61%) claimed distinct diseases as a cause of gait impairment. Of the remaining 55 persons, 42 received a standardized gait assessment. Gait was classified as completely normal in 25 persons (18% of all responders), whereas in three other persons gait could not reliably be classified as either normal or abnormal. A wide spectrum of clear gait abnormalities-mainly with ataxic features-was encountered in the remaining 14 persons (10%). It is concluded that some elderly subjects have a mainly ataxic gait disturbance which seems unrelated to the presence of distinct diseases. Although additional investigations might still reveal underlying pathology in these subjects, their gait impairment may represent the "idiopathic senile gait disorder'. In addition, a relatively high number of very old community residents have a completely normal gait.

The clinical spectrum of limb girdle muscular dystrophy. A survey in The Netherlands

A cross-sectional study was performed in the Netherlands to define the clinical characteristics of the various subtypes within the broad and heterogeneous entity of limb girdle muscular dystrophy (LGMD). An attempt was made to include all known cases of LGMD in the Netherlands. Out of the reported 200 patients, 105 who fulfilled strictly defined criteria were included. Forty-nine patients, mostly suffering from dystrophinopathies and facioscapulohumeral muscular dystrophy, appeared to be misdiagnosed. Thirty-four cases were sporadic, 42 patients came from autosomal recessive and 29 from autosomal dominant families. The estimated prevalence of LGMD in the Netherlands was at least 8.1 x 10(-6). The clinical features of the autosomal recessive and sporadic cases were indistinguishable from those of the autosomal dominant patients, although calf hypertrophy was seen more frequently, and the course of the disease was more severe in autosomal recessive and sporadic cases. The pectoralis, iliopsoas and gluteal muscles, hip adductors and hamstrings were the most affected muscles. Distal muscle involvement occurred late in the course of the disease. Facial weakness was a rare phenomenon. The severity of the clinical picture was correlated with a deteriorating lung function. All autosomal dominantly inherited cases showed a mild course, although in two families life-expectancy was reduced because of concomitant cardiac involvement.

Repetitive CMAPs: mechanisms of neural and synaptic genesis

Repetitive compound muscle action potentials (R-CMAPs) occur when a single nerve shock excites muscle fibers repeatedly. "Double discharges" are due to intramuscular nerve reexcitation. "Synaptic" R-CMAPs, due to excess acetylcholine in the neuromuscular synapse, can occur in congenital myasthenia, the slow-channel syndrome, and acetylcholinesterase inhibition. Secondary nerve excitation can reexcite muscle fibers. Synaptic R-CMAPs in a patient consisted of two discharges. The second diminished during repetitive stimulation and began 3.5-4.0 ms after the first, which is slightly longer than the synapse-muscle refractory period. Neural R-CMAPs, due to ectopic nerve activity, occur in neuromyotonia (NMT). R-CMAPs in a patient consisted of about 20 discharges at 200-300 Hz. Studies in healthy subjects showed that such trains represent added single CMAPs. Impulse frequency in the patient lied close to the threshold of refractoriness. Refractoriness of the synapse-muscle cell assembly determines the characteristics of R-CMAPs regardless of the primary cause.

[A patient with Creutzfeldt-Jakob disease following treatment with human growth hormone]

In a 39-year old woman Creutzfeldt-Jakob disease was diagnosed. More than twenty years prior to the first clinical symptoms she had been treated with human pituitary growth hormone. After four months of illness she died of Creutzfeldt-Jakob disease, as was shown by the post-mortem finding of spongiform encephalopathy immunochemically positive for abnormal prion protein. The patient represented the first case of Creutzfeldt-Jakob disease associated with the use of human growth hormone in the Netherlands.

Risk of stroke during long-term anticoagulant therapy in patients after myocardial infarction

Myocardial infarction survivors have an increased risk of stroke, which is reduced with long-term anticoagulant therapy. However, an estimated 10-times increase in risk of bleeding during such treatment has been reported. We evaluated the risk of stroke in patients after a myocardial infarction and examined the relationship of the risk of intracranial hemorrhage or cerebral infarction and the intensity of anticoagulant therapy. The study population consisted of 3,404 post-myocardial infarction patients who took part in a randomized, double-blind, placebo-controlled trial. Patients were randomized to treatment with anticoagulants (international normalized ratio range, 2.8-4.8) or matching placebo. Mean follow-up was more than 3 years. The incidence of stroke analyzed on "intention-to-treat" was 0.7 per 100 patient-years in the anticoagulant patients against 1.2 in placebo, a hazard ratio of 0.60, with 95% confidence interval of 0.40 to 0.90. In the anticoagulation group, 15 patients had cerebral infarction and 17 an intracranial bleeding, 3 of which occurred after withdrawal of treatment. In the placebo group, the numbers were 43 and 2. Of the 14 intracranial bleeds during anticoagulation, 6 occurred at an international normalized ratio between 3.0 and 4.0 and 8 at greater than 4.0. These results confirm that long-term anticoagulant therapy substantially reduces the risk of stroke in post-myocardial infarction patients. The increased risk of bleeding complications associated with anticoagulant therapy is offset by a marked reduction in ischemic events. The risk of intracranial bleeding is directly related to the intensity of anticoagulant treatment.

Acquired neuromyotonia: evidence for autoantibodies directed against K+ channels of peripheral nerves

Acquired neuromyotonia is characterized by hyperexcitability of motor nerves leading to muscle twitching, cramps, and weakness. The symptoms may improve following plasma exchange, and injection of immunoglobulin G (IgG) from 1 neuromyotonia patient into mice increased the resistance of neuromuscular transmission to d-tubocurarine. Here we examine nerves and muscle in vitro from mice injected with plasma or purified IgG from 6 neuromyotonia patients or pooled control subjects, and cultured dorsal root ganglion cells after treatment with IgG. Three of the patients had antibodies against human voltage-gated potassium channels labeled with 125I-alpha-dendrotoxin. The quantal release of acetylcholine (quantal content) at end-plates in diaphragms from mice treated with neuromyotonia IgG preparations was increased by 21% relative to control values (p = 0.0053). With one IgG preparation, the duration of the superficial peroneal nerve compound action currents was increased by 93%. The dorsal root ganglion cells treated with this IgG showed a marked increase in repetitive firing of action potentials. All effects were similar to those obtained with aminopyridines. We conclude that at least some patients with acquired neuromyotonia have antibodies directed against aminopyridine- or alpha-dendrotoxin-sensitive K+ channels in motor and sensory neurons, and they are likely to be implicated in the disease process.

Optimal oral anticoagulant therapy in patients with mechanical heart valves

BACKGROUND

The optimal intensity of oral anticoagulant therapy for patients with mechanical heart valves (i.e., the level at which thromboembolic complications are effectively prevented without excessive bleeding) is not known. We attempted to determine the optimal intensity by calculating the incidence of both complications at different levels of anticoagulation.

METHODS

Data were collected on all patients with mechanical heart valves who have been seen at four regional Dutch anticoagulation clinics since 1985. The primary outcome events were episodes of thromboembolism or major bleeding. The intensity-specific incidence of each type of event was calculated as the number of events that occurred at a certain intensity of anticoagulation (expressed in terms of the international normalized ratio [INR]) divided by the number of patient-years during which the INR was at this level in the total patient population.

RESULTS

A total of 1608 patients were followed during 6475 patient-years. Cerebral embolism occurred in 43 patients (0.68 per 100 patient-years) and peripheral embolism in 2 (0.03 per 100 patient-years). Intracranial and spinal bleeding occurred in 36 patients (0.57 per 100 patient-years) and major extracranial bleeding in 128 (2.1 per 100 patient-years). The optimal intensity of anticoagulation, at which the incidence of both complications was lowest, was achieved when the INR was between 2.5 and 4.9.

CONCLUSIONS

The intensity of anticoagulant therapy for patients with prosthetic heart valves is optimal when the INR is between 2.5 and 4.9. To achieve this level of anticoagulation, a target INR of 3.0 to 4.0 is recommended.

Mutation in DHP receptor alpha 1 subunit (CACLN1A3) gene in a Dutch family with hypokalaemic periodic paralysis

Hypokalaemic periodic paralysis (HypoPP) is characterised by transient attacks of muscle weakness of varying duration and severity accompanied by a drop in serum potassium concentration during the attacks. The largest known HypoPP family is of Dutch origin and consists of 277 members in the last five generations, 55 of whom have HypoPP inherited in an autosomal dominant pattern. Forty-eight persons including 28 patients with a proven diagnosis of HypoPP were used for linkage analysis. Microsatellite markers were used to exclude 45 to 50% of the genome and linkage to chromosome 1q31-32 was found. No recombinants were found between HypoPP and D1S412 and a microsatellite contained within the DHP receptor alpha 1 subunit (CACLN1A3) gene. A previously reported G to A mutation causing an arginine to histidine substitution at residue 528 in the transmembrane segment IIS4 of the CACLN1A3 gene was shown in patients by restriction analysis of genomic PCR products.

Aneurysmal bleeding. A plea for early surgery in good-risk patients

From 1985 onwards we have aimed at operating on good-risk patients, i.e., those graded I-III on the WFNS SAH Scale, within 3 days after the aneurysmal bleed. We report on a series of 100 consecutive operations for saccular aneurysm, covering a period of 5 1/2 years. Early operations (in the above sense) were done in 57 good-risk but otherwise unselected patients. After a one year follow-up, 47 of them (82%) were found to have made a good recovery (Glasgow Outcome Score I). The outcome of (mostly early) surgery in 15 selected poor-risk patients (WFNS SAH Scale IV and V) was much less favourable. Late surgery (4 or more days after SAH) was performed in 28 good-risk patients, most of whom had been admitted several days or weeks after the bleeding. Almost all of these patients had a good outcome. It is argued that the known management results of delayed surgery, which during the deliberately chosen interval exposes the patient to the risk of rebleeding and vasospasm, have by now been surpassed by those of early surgery. However excellent the surgical results of delayed operations may be, early operation should become the treatment of choice in good-risk patients.

Influence of bolus volume on hyoid movements in normal individuals and patients with Parkinson's disease

The swallowing movements of 22 ambulant patients with Parkinson's disease were examined by videofluoroscopy, 15 spouses serving as controls. The relation between bolus volume and movement of the hyoid bone was studied in the lateral view to assess the adaptation of the pharynx musculature. Although movement characteristics of the hyoid varied considerably both intra- and interindividually, mean values followed typical patterns. In controls, the position of the hyoid before the start of the swallow tended to be lower as the bolus volume increased, apparently to create space in the oral cavity by lowering the floor of the mouth. This trend was not seen in the group of Parkinson patients. We suppose that this specific lack of adaptation represents hypokinesia. The amplitude of the hyoid movement did not change with increasing bolus volumes, either in patients or in controls. Moreover, Parkinson patients had many more aborted swallowing movements ("hesitations") than controls, probably representing defective switching from the voluntary phase of swallowing to the involuntary, automatic phase.

Dysphagia in ambulant patients with Parkinson's disease: common, not dangerous

To assess the frequency of subjective and objective dysphagia and its possible pulmonary sequelae, we prospectively studied 22 out-patients with Parkinson's disease; 15 spouses served as controls. All subjects answered a standard questionnaire concerning swallowing and respiratory functions and underwent barium swallow videofluoroscopy. Possible pulmonary infection was investigated by recordings of body temperature, ESR, leucocyte count, and chest X-ray. Patients had significantly more symptoms than controls, especially choking, piece-meal deglutition and regurgitation. Videofluoroscopy revealed tracheal aspiration in one patient, vestibular aspiration in one patient and in one control. Non-fluent swallowing movements were common in patients: abnormal bolus formation, delayed swallowing reflex, vallecular stasis, and piriform sinus residue. None of the subjects had signs of pulmonary infection. Both subjective and objective oro-pharyngeal dysfunction is frequent in ambulant Parkinson patients, but apparently does not produce demonstrable pulmonary infection.

Mitochondrial encephalomyopathy, lactic acidosis and stroke in adults: two cases

Two previously healthy women are described who in their late thirties suffered transient strokelike episodes, consisting of initial headache and vomiting, with various subsequent neurological signs that were only partially reversible. Investigations revealed elevated serum creatine kinase, lactic acidosis, hypertriglyceridaemia, and ragged red fibres in the muscle biopsy specimens. In both patients in vitro studies were performed on intact muscle mitochondria and muscle homogenate. Only in one was a mitochondrial defect found, located at the level of coenzyme Q. We conclude that these patients suffered from adult-onset mitochondrial encephalopathy, lactic acidosis and strokelike episodes (MELAS syndrome). Although the syndrome is often associated with long-standing neurological multisystem disease from childhood onwards, it should also be suspected in adults with strokelike signs of otherwise unexplained origin.

Disruption of sleep-wake rhythmicity and daytime sleepiness in myotonic dystrophy

Ten patients with myotonic dystrophy (MyD) and excessive daytime sleepiness (EDS) were studied. Daytime sleepiness was assessed by means of a subjective alertness rating scale, multiple sleep latency tests and auditory event-related potentials. In addition, the diurnal pattern of daytime sleepiness and ultradian rhythm characteristics of nocturnal sleep were assessed. The multiple sleep latency tests and the P300 component of the auditory event-related potentials gave evidence of EDS, whereas the subjective alertness ratings did not. However, the alertness ratings showed a significantly reduced circadian periodicity as compared with controls. Consistent with this, no time-of-day effect was observed for the multiple sleep latency test outcomes. The ultradian rhythm characteristics of nocturnal sleep indicated a prolonged mean cycle duration and decreased stability of NREM/REM cycle. Moreover, the temporal structure of REM sleep showed a pattern similar to that of subjects who develop free-running rhythms when living in temporal isolation. These findings suggest that EDS in MyD reflects a complex and wide-spread malfunction of the circadian and ultradian timing system.

Muscle fiber conduction velocity in the diagnosis of sporadic hypokalemic periodic paralysis

A 6-year-old girl presented with episodes of profound muscle weakness since the age of 2 years. On the basis of decreased ictal serum potassium level and lack of metabolic disorder, primary hypokalemic periodic paralysis (HPP) was diagnosed. Both parents and 3 sibs were unaffected clinically. In all of them asymptomatic heterozygosity was very unlikely by the finding of normal muscle fiber conduction velocities, whereas in the patient interictal muscle fiber conduction velocity was lowered. Determination of muscle fiber conduction velocity can be helpful in documenting sporadic occurrence of HPP.

Eye movements in myotonic dystrophy

Smooth pursuit eye movements were studied with infrared reflection equipment in 10 patients with myotonic dystrophy and in 10 age- and sex-matched controls. Smooth pursuit gain, measured after correction for catch-up saccades, was decreased in the patient group. Normal latencies of saccadic eye movements made a lack of attention an unlikely explanation for this low gain. Likewise, presence of catch-up saccades and normal fixation made it unlikely that extra-ocular myopathy explained the low smooth pursuit gain. We suggest that periventricular white matter abnormalities represent a more likely explanation.

Investigation of gait in elderly subjects over 88 years of age

To evaluate senile gait patterns in octagenarians and nonagenarians, we provided a standardized questionnaire on gait disabilities to 153 elderly subjects over 88 years of age. Subjects represented a relatively healthy subgroup of noninstitutionalized residents who participated in a gerontological survey of all inhabitants of the city of Leiden who were 85 years of age or older. Of the 142 subjects who responded to this questionnaire, 87 persons (61%) claimed distinct diseases as a cause of gait impairment. Forty-two of the remaining 55 persons were investigated neurologically and received a standardized assessment of gait. Twenty-five persons (18% of all responders) had a completely normal gait, whereas a wide spectrum of gait abnormalities--mainly with ataxic features--was encountered in the remaining persons. It is concluded that a surprisingly high number of very old community residents can have a completely normal gait. Gait disorders in this age group are most frequently associated with common distinct diseases. In addition, many elderly have a gait disturbance of variable clinical nature and unclear pathologic basis, which may represent the "idiopathic senile gait."

Inclusion body myositis: its relative frequency in elderly people

Inclusion body myositis (IBM) is a distinct, steroid resistant, form of inflammatory myopathy. Its recognition is the more important because of the preponderant occurrence in the elderly, in whom steroid treatment is hazardous. Since the relative frequency of IBM among inflammatory myopathies in the elderly is undetermined, we retrospectively studied its frequency among all our patients over 50 years, diagnosed between 1980 and 1991 with inflammatory myopathy. Nine of 15 patients with inflammatory myopathy appeared to suffer from IBM. In a further 2 patients this diagnosis was strongly suspected. We conclude that IBM is the most frequent inflammatory myopathy in the elderly. This observation warrants restraint with steroids in the management of inflammatory myopathy in the elderly.

Paroxysmal kinesigenic choreoathetosis as presenting symptom of multiple sclerosis

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Assessment of autonomic function in myotonic dystrophy

Published reports suggested autonomic nervous system dysfunction in myotonic dystrophy but were inconclusive partly due to small patient numbers and because only a limited number of tests was used. Autonomic nervous system function with noninvasive tests was assessed in ten myotonic dystrophy patients and age and sex matched healthy controls. Statistically significant differences included reduction in the heart rate response to standing and in the blood pressure response to sustained handgrip. Latency of the pupillary light reflex was not different from controls but the time to reach peak velocity of contraction was significantly longer in the myotonic dystrophy group. It is argued that these results reflect dysfunction of voluntary and iris smooth muscle rather than autonomic nervous system dysfunction.

Postinfectious encephalitis in two siblings

A 33-year-old man and his 32-year-old sister developed, with an interval of 2 years, an acute fatal encephalitis following an upper respiratory tract infection of unknown etiology. Autopsy documented postinfectious encephalitis in both. This is the first report of postinfectious encephalitis occurring in first degree relatives, suggesting that specific genetic factors play a role in the pathogenesis of this disease.