[Gastrostomy tubes in patients with amyotrophic lateral sclerosis: indications, safety and experience in a tertiary care centre]

AIM

The aim of this study is the clinical characterisation of patients diagnosed with amyotrophic lateral sclerosis (ALS), who were indicated for the placement of a gastrostomy tube (G-Tube) in the period 2007-2017 in the Complejo Asistencial Universitario de Salamanca, and to find possible associated prognostic factors.

MATERIAL AND METHODS

It is a descriptive study of clinical cases.

RESULTS

Between 2007 and 2017, 139 cases of ALS were assessed and a G-Tube was indicated in 29 of them. Of these 29, on two occasions it was not performed, one due to the patient refusing and the other because of clinical deterioration. Of the total number of G-Tubes, 21 were placed by endoscopy, four by interventional radiology and two by surgery. The main indications were: in 10 cases, for severe dysphagia; in eight cases, for weight loss >10%; and in nine cases, for reduced forced vital capacity <50%. Immediate complications (first 24 hours) included: two intraprocedural desaturations, one ostomy infection, one abdominal pain, one paralytic ileus and one respiratory failure resulting in death. Late complications (first month) include pneumonia, intestinal ischaemia, cellulitis and poor control of secretions. The main cause of death was respiratory failure. The median time elapsed between G-Tube placement and death was 7.89 months. An improvement in analytical nutritional parameters was observed, without showing statistical significance, as a prognostic factor.

CONCLUSION

G-Tube placement is an effective and safe procedure to ensure enteral nutrition in ALS patients.

Speech rate in Parkinson's disease: A controlled study

INTRODUCTION

Speech disturbances will affect most patients with Parkinson's disease (PD) over the course of the disease. The origin and severity of these symptoms are of clinical and diagnostic interest.

PURPOSE

To evaluate the clinical pattern of speech impairment in PD patients and identify significant differences in speech rate and articulation compared to control subjects. Speech rate and articulation in a reading task were measured using an automatic analytical method.

PATIENTS

A total of 39 PD patients in the 'on' state and 45 age-and sex-matched asymptomatic controls participated in the study. None of the patients experienced dyskinesias or motor fluctuations during the test.

RESULTS

The patients with PD displayed a significant reduction in speech and articulation rates; there were no significant correlations between the studied speech parameters and patient characteristics such as L-dopa dose, duration of the disorder, age, and UPDRS III scores and Hoehn & Yahr scales.

CONCLUSION

Patients with PD show a characteristic pattern of declining speech rate. These results suggest that in PD, disfluencies are the result of the movement disorder affecting the physiology of speech production systems.

Paraoxonase 1 (PON1) polymorphisms and risk for essential tremor

BACKGROUND

The polymorphic enzyme human serum paraoxonase 1 (PON1), encoded by the gene PON1 (chromosome 7q21.3), plays a major role in the metabolism of organophosphorus compounds. We investigated the possible association between the PON1 genotype and allelic variants of the polymorphisms Leu55Met and Glu192Arg, and the risk for essential tremor (ET).

METHODS

We studied the frequency of the PON1 genotypes and allelic variants in 201 patients with ET and 220 healthy controls using a PCR-RLFP method.

RESULTS

The frequencies of the PON1 genotypes and allelic variants of the polymorphisms Leu55Met and Gln192Arg did not differ significantly between patients with ET and controls. These polymorphisms were unrelated with the age of onset of ET.

CONCLUSIONS

PON1 polymorphisms are not related with the risk for ET.

Glutathione-S-transferase P1 polymorphism and risk for essential tremor

Glutathione-S-transferases (GST) are polymorphic enzymes that participate in the metabolism of carcinogens (including those of tobacco smoke) and pesticides. We investigated the possible association between the GSTP1 genotype and allelic variants and the risk for essential tremor (ET). We studied the frequency of the GSTP1 genotypes and allelic variants in 200 patients with ET and 220 healthy controls using PCR-RFLP method. The association between GSTP1 polymorphism and the exposure to some environmental factors (agricultural work, pesticides, well-water and smoking-cigarettes habit) was also studied in a subgroup of patients. The frequencies of the GSTP1 genotypes and allelic variants did not differ significantly between patients with ET and controls or between patients with ET exposed to agricultural work, well water and cigarette smoking versus those non-exposed. Mutated allelic variants were significantly more frequent in patients with ET exposed to pesticides versus those non-exposed. GSTP1 polymorphism was unrelated with the age of onset of ET. GSTP1 genotypes and allelic variants were not related with the risk for ET with the possible exception of those patients exposed to pesticides.

[Multiple cranial neuropathy: an atypical variant of the Guillain-Barre syndrome?]

INTRODUCTION

Multiple cranial neuropathy or polineuritis cranealis is rarely seen in everyday clinical practice. It is considered to be a topographically circumscribed form of the Guillain-Barré syndrome. The cases described have a wide range of clinical and biological characteristics. Some of these may be due to infectious agents.

CLINICAL CASE

We present the case of a 50 year old man with acute onset of diplopia, dysphagia, anarthria, cervical and right arm flexor-extensor muscle weakness due to involvement of many motor cranial nerves and superior cervical nerve roots. On neurological examination there was mixed involvement, mainly of the axons of the nerve trunks involved. Studies to determine aetiology did not show any demonstrable agent.

DISCUSSION AND CONCLUSIONS

Different topographical varieties of the Guillain-Barré syndrome have been described, including: Fisher's syndrome, pharyngo-cervico-brachial paralysis, arreflexive paraparesia, bilateral facial paralysis with paraesthesias, hyporeflexia and bilateral lumbar polyradiculopathy. We compare the clinical characteristics of our patient with those described in the literature. We found a degree of heterogenicity in the clinical and biological characteristics of the cases described, which may mean that they had different aetiologies. Therefore, we consider that before labelling these conditions as atypical variants of the Guillain-Barré syndrome, a thorough search should be made for a precise aetiology.

[Central motor conduction evaluation in glycogenosis type III]

We report a 20-year-old man affected by glycogenosis type III with distal muscle weakness, more severe in distal leg muscles. The electromyogram showed myopathic features. Nerve conduction studies and central motor conduction after magnetic stimulation of the brain were normal. Our results suggest that there is no involvement of central motor pathways in this disease.

[Complete axonotmesis of the axillary nerve in relation to microtrauma]

INTRODUCTION

The axillary nerve is injured in many clinical situations, mainly in major surgical or traumatic lesions of the shoulder. Equally, it may be found in the context of microtraumatisms or compressive mechanisms. Amyotrophic neuralgia is a clinical entity with pain and later atrophy of the muscle which affects various nerves and nerve groups, as shown by neurophysiological studies.

CASE REPORT

We present a lesion with complete axonotmesis of the axillary nerve with a time-relationship to microtraumatism. Initially the patient complained of some pain in the shoulder. During follow-up striking atrophy of the deltoid muscle was seen.

CONCLUSIONS

We have reviewed the mechanisms described for lesions of the axillary nerve, which do not include the one we found. We discuss the possibility of our case being included in the clinical group described as having amyotrophic neuralgia, although there are some neurophysiological findings which are not typical of this condition. We suggest a review of the many possible trigger factors described in the genesis of amyotrophic neuralgia. Possibly some cases with atypical histories of trauma, and lesions shown by neurophysiological studies to be particularly severe, may be separated from this group.

Carpal tunnel syndrome and vitamin B6

Twelve patients with carpal tunnel syndrome were studied. Clinical and electrophysiological data were obtained and an estimation of vitamin B6 (pyridoxine) status by an assay of erythrocyte aspartate aminotransferase and coenzyme stimulation assay were done. None of the patients was found to have vitamin B6 deficiency. Patients were treated with 150 mg of pyridoxine daily for 3 months. Erythrocyte aspartate aminotransferase increased significantly (p less than 0.001) in all the patients. In 6 patients there were clinical and electrophysiological improvement and erythrocyte aspartate aminotransferase increased more than in the other 6 patients. The data obtained appear to indicate that although vitamin B6 deficiency is not common in carpal tunnel syndrome patients, pyridoxine supplementation can be recommended as adjuvant treatment in those patients undergoing surgery.

Effect of ischaemia on somatosensory evoked potentials in diabetic patients

The nerve action potential at the elbow and somatosensory evoked potentials (SEPs) at the scalp were recorded over 30 minutes of tourniquet-induced limb ischaemia in 10 diabetic patients and 10 controls. According to the SEP changes, an increased resistance to nerve ischaemia in diabetic patients was observed. The pathways involved in SEP conduction are discussed.

Proximal sensory conduction in diabetic patients

A study of segmental conduction along the peripheral afferent pathway of the upper limbs was carried out in 44 diabetic patients and 44 controls. An abnormal proximal conduction (Erb-cervical) was observed in 9 patients (20.4%). A similar incidence of abnormalities appeared at the most distal segment (digit III-wrist). A significant relationship between the alterations of proximal conduction and the presence of clinical signs of diabetic polyneuropathy was found. A common pathogenic mechanism underlying both these disorders is suggested.