Sadjadi and colleagues show that in IBM, as in most chronic illness,
mood plays a role in QoL. It would be a surprise if mood didn't play a
role in measured QoL. QoL assessment uses subjective measures, for
example "how would you rate your health?", and a patient's response to
such a question is likely to be altered by mood. Hence QoL questionnaires
can also act as mood questionnaires. Indeed, the awkward realisation i...
Sadjadi and colleagues show that in IBM, as in most chronic illness,
mood plays a role in QoL. It would be a surprise if mood didn't play a
role in measured QoL. QoL assessment uses subjective measures, for
example "how would you rate your health?", and a patient's response to
such a question is likely to be altered by mood. Hence QoL questionnaires
can also act as mood questionnaires. Indeed, the awkward realisation is
that if QoL didn't reflect mood then it wouldn't be a subjective scale. A
consequence is that anti-depressant medication or cognitive behavioural
therapy might well improve QoL (by changing the way an individual
perceives and reports their disability) without making any impact on
functional ability. Perhaps the only way around this would be to correct
each patient's QoL result for that individual's mood at the time of
questionnaire completion.
Dear Sir,
We write in response to the rapid response by Kleine et al. The disparity
between the sensitivity of El Escorial in our study (1) and the work by
Boekestein et al (2) and de Carvalho (3), we suggest is as a result of the
differing neurophysiology protocols. Boekestein et al and de Carvalho use
at least 3 times the insertions used in our standard protocols. The
protocol used in our study is tailored for everyday...
Dear Sir,
We write in response to the rapid response by Kleine et al. The disparity
between the sensitivity of El Escorial in our study (1) and the work by
Boekestein et al (2) and de Carvalho (3), we suggest is as a result of the
differing neurophysiology protocols. Boekestein et al and de Carvalho use
at least 3 times the insertions used in our standard protocols. The
protocol used in our study is tailored for everyday clinical diagnosis
rather than the detailed research protocol undertaken by de Carvalho et
al.
We agree with Kleine et al that the Awaji Shima criteria (4) do risk
having a lower sensitivity in patients with UMN disease in one region,
although this was not the case in our study or the study by deCarvalho et
al.
We note that in the study by Boekstein et al in which the sensitivity of
the Awaji criteria was less, that fasciculations were not systematically
sought. As the recognition of complex fasciculations is the major
advantage of Awaji over El-Escorial we suspect this is the reason for the
reported lower sensitivity by Boekstein et al.
We have not evaluated how a modification of the Awaji criteria, allowing
simple fasciculations as evidence of lower motor neuron dysfunction,
affects specificity and therefore can not comment further on this.
References
1. Douglass CP, Kandler RH, Shaw PJ, McDermott CJ. An evaluation
of neurophysiological criteria used in the diagnosis of motor neuron
disease. J Neurol Neurosurg Psychiatry 2010;81:646-9.
2. Boekestein WA, Kleine BU, Hageman G, Schelhaas HJ, Zwarts MJ.
The sensitivity and specificity of the Awaji electrodiagnostic criteria
for amyotrophic lateral sclerosis. Retrospective comparison of the Awaji
recommendations and revised El Escorial criteria for ALS. Amyotroph
Lateral Scler 2010.
3. de Carvalho M, Dengler R, Eisen A, England JD, Kaji R, KimuraJ,
Mills K, Mitsumoto H, Nodera H, Shefner J, Swash M. Electrodiagnostic
criteria for diagnosis of ALS. Clin Neurophysiol 2008;119:497-503.
4. de Carvalho M, Swash M. Awaji diagnostic algorithm increases
sensitivity of El Escorial criteria for ALS diagnosis. Amyotroph Lateral
Scler 2009;10:53-7.
PK Sethi*, A Batra**, L Khanna***
Department of Neurology, Sir Gangaram Hospital, New Delhi - 60, India
While going through the article, The Scan Rule, published in JNNP of
March 2010, Vol; 81 explaining the utility of scan score over conventional
CT scans in diagnosing or ruling out small intra cerebral haemorrhages, we
think that SCAN SCORES cannot score over con...
PK Sethi*, A Batra**, L Khanna***
Department of Neurology, Sir Gangaram Hospital, New Delhi - 60, India
While going through the article, The Scan Rule, published in JNNP of
March 2010, Vol; 81 explaining the utility of scan score over conventional
CT scans in diagnosing or ruling out small intra cerebral haemorrhages, we
think that SCAN SCORES cannot score over conventional CT scans, given such
reasons like the lack of CT scans and neuroinfrastructure facilities.
It may be a useful method to rule out minor intra cerebral bleeds
utilising this score at places where there are scarcity of CT scans, so
that early antiplatelet therapy can be started to prevent early recurrent
ischemic stroke.
However, if we look at all aspects of the discussion, it can be said
that it is unreasonable for a stroke patient to keep waiting for
radiological confirmation for 7-10 days before an intracranial haemorrhage
is diagnosed. It is worth noting that even in a developing country like
India, there is no scarcity of CT scan centres. CT scans are available in
all small diagnostic centres in the city. All this has been started as a
private partnership in healthcare where the CT scan machines are installed
at a huge cost. In India, CT scans are done at reasonable rates which
include the cost of interpreting the scan and a waiting time of less than
12 hours. The cost of each CT scan is not more than $20. The scan centers
earn their revenue not by high charges, but by increasing their numbers of
patients and by working all days in the week. If we compare different
parts of the country, we see that metropolitan cities like Delhi in India
have nearly 90 CT scan centres and smaller cities like Meerut have 26 CT
scans machines.
So, instead of waiting for a CT scan and clinically ruling out an
intracerebral haemorrhage by the SCAN rule it is advisable to start an
entrepreneurship making available more number of CT scans to avoid the
possibility of treating a small intra cerebral haemorrhage with apparently
ZERO SCAN score with the antiplatelet agents.
Also, one could probably avert the dangers of misdiagnosing intracerebral
hemorrhage for infarction caused by the delays in scanning.
*Senior Consultant Neurologist, **Consultant Neurologist, ***Senior
Resident,.
Department of Neurology, Sir Gangaram Hospital, New Delhi - 60, India
Dear Editor,
We read with interest the article by Wong et al (J Neurol Neurosurg Psychiatry published online May 12, 2010) suggesting that antibiotic impregnated ventricular catheters are as effective as systemic antibiotics to prevent nosocomial infections and cerebro-spinal fluid (CSF) infections in patients with external ventricular drain.
Impregnated catheters are designed to prevent specifically CSF catheter related inf...
Dear Editor,
We read with interest the article by Wong et al (J Neurol Neurosurg Psychiatry published online May 12, 2010) suggesting that antibiotic impregnated ventricular catheters are as effective as systemic antibiotics to prevent nosocomial infections and cerebro-spinal fluid (CSF) infections in patients with external ventricular drain.
Impregnated catheters are designed to prevent specifically CSF catheter related infections. However the primary endpoint was the occurrence of any nosocomial infection in this non-double blinded trial. The proportion of patients with nosocomial infection was not significantly different between the impregnated catheter group and the conventional catheter coupled with systemic antibiotic group. There was also no difference between groups for the secondary endpoint, which was the occurrence of a CSF infection.
At our University Hospital, catheter used for CSF shunts are usually clindamycin-rifampicin impregnated catheters (Bactiseal, Codman, Johnson and Johnson, Raynham, MA). A surveillance of CSF infections has been implemented since January, 2007. We were confronted in 2009 to a shortage of impregnated catheters and therefore some patients received non impregnated catheter. We subsequently conducted a survey using the surveillance data in order to assess ventricular catheter related infection incidence and risk factors. We also assessed whether the lack of antibiotic impregnation of the catheter was a risk factor for CSF infection.
The survey took place in a tertiary care, University teaching hospital. All neurosurgery inpatients with a ventricular catheter inserted between January 1, 2009 and June 30, 2009 were included and followed-up until catheter removal, or for the 30 days following catheter insertion if the catheter had not been removed after 30 days. Patients aged less than eighteen, and patients with a medical history of CSF infection or a known CSF infection were excluded from the study.
The surgical procedure was performed in the operating room by a trained neurosurgeon. Patients received either a impregnated ventricular catheter or a non-impregnated catheter depending on availability and did not receive any systemic prophylactic antibiotics.
The following data were prospectively recorded: age, gender, indication for the catheter (intracranial hemorrhage, or other indication), intracranial pressure measurement, ventricular catheter placement duration, hospitalization in Intensive Care Unit (ICU), and catheter antibiotic impregnation.
We used Center for Desease Control definitions of CSF infections: pathogenic bacteria isolated from CSF or at least two clinical criteria (hyperthermia > 38 degree Celsius, consciousness dysfunction or meningeal signs) associated to an antibiotherapy with at least 1 biological abnormalities (leucocytes in CSF, hyperproteinorrachy and hypoglucorrachy, or bacteria found on CSF direct examination, or positive blood culture, or CSF antigens, or IgM antibody detection, or IgG antibodies X 4 on 2 successive samples).
Ventricular catheter-related infection cumulative incidence and incidence density per 1000 catheter-days were calculated with their 95% confidence intervals. Categorical variables were compared by Fisher's exact test. A multivariate logistic regression was performed including age, sex, catheter antibiotic impregnation, measuring of CSF pressure, indication for the catheter, ICU hospitalization, and ventricular catheter placement duration more than 18 days (third quartile of our ventricular catheter placement duration).
Ninety-six ventricular catheters were inserted in 68 patients between January 1 and June 30, 2009. Twenty-nine ventricular catheters were excluded (10 were inserted in patients aged less than eighteen years old, 12 were inserted in patients with an infected ventricular catheter and 7 in patients who had a history of CSF infection). Sixty-seven ventricular catheters were therefore included (66% were antibiotic impregnated). They were inserted in 55 patients (mean age 49.1 years /- 13.9, male-female sex ratio: 1.4) during 945 catheter-days. The mean duration of ventricular catheter was 14 days.
Nine CSF infections occurred, with a cumulative incidence of 13.4% CI95%[6.3%-24.0%] and an incidence density of 9,5/1000 catheter-days. Fifty-six percent of identified bacteria were cocci gram plus (coagulase negative Staphylococcus n=3, Staphylococcus aureus methicillin susceptible n=1, bacillus n=1), and 44 % were gram negative bacilli (Acinetobacter baumanii n=1, Enterobacter cloacae n=1, Escherichia coli n=1, Klebsiella pneumoniae n=1).
On univariate analysis, antibiotic non-impregnated catheter and catheter placement duration >18 days were significantly associated with an increased risk of ventricular catheter-related infection (respectively RR=4.8 CI95%[1.1-13.9] and RR=3.7 CI95%[1.1-12.1]). On multivariate analysis, only ventricular catheter placement duration was a significant risk factor for ventricular catheter-related infection (adjusted OR : 8.1 CI95%[1.1-59.6])
In conclusion, we observed a cumulative incidence of 13.4%, both higher than incidence observed by Korinek et al.1. We found no significant effect of antibiotic impregnated ventricular catheters to prevent CSF infection. This lack of significant protection may be explained by our sample size. Catheter placement duration was the only independent variable associated with ventricular catheter related infection, as previously shown by Arabi et al.2
Impregnated ventricular catheters have been shown to reduce CSF ventricular catheter related colonisation.3 A large randomized essay is required in order to evaluate the effectiveness in reducing CSF infections.
References
1. Korinek AM, Reina M, Boch AL, et al., Prevention of external ventricular drain-related ventriculitis. Acta Neurochir (Wien) 2005;147:39-45.
2. Arabi Y, Memish ZA, Balkhy HH, et al., Ventriculostomy-associated infections: Incidence and risk factors. Am J Infect Control 2005;33:137-43.
3. Zabramski JM, Whithing D, Darouiche RO, et al., Efficacy of antimicrobial-impregnated external ventricular drain catheters: a prospective, randomized, controlled trial. J Neurosurg 2003;98:725-30.
Acknowledgement: The authors thank Richard Medeiros, Rouen University Hospital Medical Editor for editing the manuscript
An one-and-a-half syndrome as first described by C. Miller-
Fisher in 1967 is characterized by an ipsilateral horizontal gaze paresis
or palsy and an internuclear ophthalmoplegia or INO on
contralateral horizontal gaze. An exotropia may be present in primary
position but does not have to be present. The association of exotropia in
the one-and-a-half syndrome is sometimes called "paralytic pontine
exotropia" In addition t...
An one-and-a-half syndrome as first described by C. Miller-
Fisher in 1967 is characterized by an ipsilateral horizontal gaze paresis
or palsy and an internuclear ophthalmoplegia or INO on
contralateral horizontal gaze. An exotropia may be present in primary
position but does not have to be present. The association of exotropia in
the one-and-a-half syndrome is sometimes called "paralytic pontine
exotropia" In addition there may be a concomitant esotropia if there is a
simultaneous involvement of the sixth cranial nerve. The horizontal gaze
palsy may arise from a lesion in the ipsilateral paramedian pontine
reticular formation (PPRF) only; the ipsilateral abducens nucleus alone;
both the ipsilateral PPRF and the abducens nucleus, or lesions of the
fibers from the ipsilateral abducens nucleus to the lateral rectus and to
the contralateral medial longitudinal fasciculus (MLF) producing the INO.
An INO is characterized by paresis or paralysis of adduction of the
ipsilateral eye on attempted horizontal gaze to the contralateral side and
a dissociated horizontal jerk nystagmus in the contralateral abducting
eye. If convergence is intact then the lesion of the MLF does not extend
rostrally to the mesencephalon. Sometimes a vertical deviation from skew
is associated with the above horizontal ocular motor disturbances.
In our patient the ocular motility showed mild left hypertropia (skew
deviation) and a moderate incomitant exotropia. The near reaction and
convergence effort could overcome the adduction deficit in the left eye
consistent with a more caudal left pontine INO. On right gaze, he had a
severe underaction of adduction in the left eye associated with an
abducting dissociated horizontal nystagmus in the right eye and he had a
moderate underaction of abduction in the left eye due to a left sixth
nerve paresis but not a horizontal gaze paresis. Magnetic
resonance imaging showed a focal haemorrhagic lesion in the floor of the
aqueduct in the region of the dorsal pons.Thus the suggested description,
"half and half".
We thank Dr. Aboul-Enein et al. for their interest about our recent
paper. We apologize for the missing references. For the first one
(Bichuetti et al.) we missed it in our pubmed research probably due to a
misclassification of the key words. For the second one (Aboul-Enein et
al.), the paper was not published before our article was in press. We are
a little bit concern to include in our references abstract of posters....
We thank Dr. Aboul-Enein et al. for their interest about our recent
paper. We apologize for the missing references. For the first one
(Bichuetti et al.) we missed it in our pubmed research probably due to a
misclassification of the key words. For the second one (Aboul-Enein et
al.), the paper was not published before our article was in press. We are
a little bit concern to include in our references abstract of posters.
Many mistakes can be include in abstract form of poster that are
frequently submitted quickly due to the deadline of the congress. It was
the case concerning our poster explaining the differences between the
abstract from Multiple sclerosis and our recent paper. Of course the right
number of patients and controls is in the full paper. We think that the
most important fact is that all the three papers are in the similar
direction confirming that normal apparent white and grey matter are really
normal in NMO evaluated by spectroscopy MR.
we have read with great interest the paper by de Seze et al.,
entitled "Magnetic resonance spectroscopy evaluation in patients with
neuromyelitis optica" (1).
Neuromyelitis optica (NMO) is a rare disease and most studies rely on
a small sample size. Calling attention to previous publications on
magnetic resonance spectroscopy (MRS) in patients with NMO might
strengthen the results of de Seze et al. Bi...
we have read with great interest the paper by de Seze et al.,
entitled "Magnetic resonance spectroscopy evaluation in patients with
neuromyelitis optica" (1).
Neuromyelitis optica (NMO) is a rare disease and most studies rely on
a small sample size. Calling attention to previous publications on
magnetic resonance spectroscopy (MRS) in patients with NMO might
strengthen the results of de Seze et al. Bichuetti et al (2) and our group
(3) achieved nearly identical results as found by de Seze et al.
Furthermore we performed chemical shift imaging MRS at 3 Tesla, a
technique able to quantify absolute concentrations of the metabolites in
the normal appearing white matter (NAWM) instead of metabolite ratios
only.
De Seze et al and our group presented their data previously as
posters at the same session of the 23th Congress of the European Committee
for Treatment and Research in Multiple Sclerosis (ECTRIMS) in 2008 (3, 4).
We were therefore aware of their data and find it confusing that
metabolite ratios in the NAWM of NMO patients and healthy controls
presented at ECTRIMS (3) were essentially the same as published in
JNNP(1), while the number of NMO patients changed from 25 to 24, and the
number of healthy controls from 15 to 12.
NMO is a rare disease and the number of patients included in studies
is generally low. To overcome this limitation data for each patient should
be traceable.
We would like to ask the authors to provide detailed information in
order to explain these confusing data.
References:
1. de Seze J, Blanc F, Kremer S, et al. Magnetic resonance
spectroscopy evaluation in patients with neuromyelitis optica. J Neurol
Neurosurg Psychiatry. 2010; 81:409-11.
2. Bichuetti DB, Rivero RL, de Oliveira EM, et al. White matter
spectroscopy in neuromyelitis optica: a case control study. J Neurol.
2008; 255:1895-9. Epub 2009 Jan 22.
3. Aboul-Enein F, Krssak M, Hoftberger R, Prayer D, Kristoferitsch W.
Diffuse white matter damage is absent in neuromyelitis optica. AJNR Am J
Neuroradiol. 2010; 31:76-9. Epub 2009 Sep 12.
4. de Seze J, Blanc F, Kremer S, et al. Magnetic resonance
spectroscopy evaluation in patients with neuromyelitis optica. Multiple
Sclerosis 2008; 14:S101-S101.
5. Aboul-Enein F, Krssak M, Jecel J, et al. Magnetic resonance
spectroscopy in neuromyelitis optica. Multiple Sclerosis 2008; 14:S101-
S101.
I read the article on association of restless legs and migraine
headache by Chen with interest (1).
Probably the two conditions share basic neuronal abnormalities such
as neurotransmitter dysfunction.
Opiates are an effective treatment for restless legs and also for the
pain of migraine headaches.
Morphine has been found to be produced endogenously in the nervous
system (2) and is also a neurotransmitter (3).
Dopamine is an essential chemical intermediate in morphine
biosynthesis (4), indicating even more potential for involvement in both
migraine and restless legs syndrome, since migraine is treated with
dopamine antagonists such as metoclopramide and restless legs syndrome
with dopamine agonists such as ropinirole and pramipexole.
Endogenous/nitric
oxide signaling regulate metabolism, mitochondrial respiration and energy
metabolism (4).
Variants in the nitric oxide synthase gene have been found to be
associated with restless legs syndrome, implicating the nitric oxide
arginine pathway (5).
Impaired production of endogenous morphine through alterations of
dopamine metabolism, or impaired signaling by endogenous morphine/nitric
oxide due to impaired nitric oxide synthase may lead to development of
migraine and restless legs.
If morphine is an endogenous neurotransmitter with impaired
production in the CNS, which may be the case in restless legs syndrome and
migraine, should attempts be made for replacement in a similar manner to
dopamine replacement in Parkinson's disease,
which is characterized by impaired dopamine production?
References:
1. Chen P, Fuh J, Chen S, Wang S. Association between restless legs
syndrome and migraine. JNNP 2010: 81: 524-528.
2. Grobe N, Lamshoft M, Orth RG, Drager B, Kutchan TM, Zenk MH, Spiteller
M, Urinary excretion of morphine and biosynthetic precursors in mice. Proc
Natl Acad Sci USA. 2010; 107: 8147-52.
3. Guarna M, Ghelardini C, Galeotti N, Stefano GB, Bianchi E,
Neurotransmitter role of endogenous morphine in the CNS. Med Sci Monit.
2005; 11: RA190-193.
4. Kream RM, Stefano GB, Endogenous morphine and nitric oxide coupled
regulation of mitochondrial processes. Med Sci Monit 2009. 15: RA 263-
268.
5. Winkelmann J, Lichtener P, Schormair B, Uhr M, Hauk S, Stiasny-
Kolster K et al. Variants in the neuronal nitric oxide synthase (nNOS,
NOS1) gene are associated with restless legs syndrome. Mov Disord. 2008.
15; 23: 350-258.
Editors,
there is a fundamental bias in this study.
In fact, because congenital functional mitochondrial cytopathology is
overlooked, which is the "conditio sine qua non" of numerous
constitutions and thus of the most frequent and dangerous human disorders,
including malignancies, all current researches are fundamentally biased .
That is, authors do not consider the existence or assess the seriousness
as well as the l...
Editors,
there is a fundamental bias in this study.
In fact, because congenital functional mitochondrial cytopathology is
overlooked, which is the "conditio sine qua non" of numerous
constitutions and thus of the most frequent and dangerous human disorders,
including malignancies, all current researches are fundamentally biased .
That is, authors do not consider the existence or assess the seriousness
as well as the location of Congenital Acidosic Enzyme-Metabolic
Histangiopathy, since they overlook such as mitochondrial cytopathology,
all inherited real risks are based (1, 2, 3). In fact, both environmental
risk factors and every drug, suggested as a product reducing breast
cancer risk , "could" influence some human biological functions and/or
bring about different disorders, such as cancers, exclusively in relation
to both the presence and intensity of CAEMH in a well-defined biological
system.
I suggested this overlooked functional mitochondrial cytopathology, I have
called this Congenital Acidosic Enzyme- Metabolic Histangiopathy in
previous papers, as the genetic factor of common human disorders, and
particularly of malignancy (1, 2, 3).
For instance, apart from the well- known in Literature negative influence
diabetes on cerebral function, as well as on arterial disorders, we have
to consider the importance of the genetic predisposition (1-7)
("Oncological Terrain",in: www.semeioticabiofisica.i), as far as the
onset of a lot of disorders is concerned. At this point, I would emphasise
the well-known pathological powerful influence of smoking on tissue oxygen
supply to all biological systems (3, 4). This effect varies notoriously in
prevalence and intensity among individuals in relation to a congenital
mitochondrial cytopathology, i.e. Congenital Acidosic Enzyme-Metabolic
Histangiopathy (2). This both "silent" and dangerous action is easy to
evaluate at the bed-side with the aid of a stethoscope. I suggest first
investigating (i.e., before whatever research) the presence and intensity
of CAEMH in the tested population, and soon thereafter assessing
prevalence and intensity of the Oncological Terrain as well as oncological
Inherited Real Risk, which always develop on the basis of the above-
mentioned congenital cytopathology (1-7). From the above remarks, reader
understands clearly that without brain function Inherited Real Risk,
periodontitis cannot be associated with cognitive impairment among older
adults. In fact, the majority of human beengs suffer from periodontitis
during life span, but fortunately not all show cognitive impairment!
1) Stagnaro Sergio. Reale Rischio Semeiotico Biofisico. I Dispositivi
Endoarteriolari di Blocco neoformati, patologici, tipo I, sottotipo a)
oncologico, e b) aspecifico. Ediz. Travel Factory, www.travelfactory.it,
Roma, Luglio, 2009.
2) Stagnaro S., Stagnaro-Neri M. Una patologia mitocondriale ignorata: la
Istangiopatia Congenita Acidosica Enzimo-Metabolica. Gazz. Med. It. -
Arch. Sci. Med. 149, 67 1990.
3)Stagnaro-Neri M., Stagnaro S. Deterministic Chaos, Preconditioning and
Myocardial Oxygenation evaluated clinically with the aid of Biophysical
Semeiotics in the Diagnosis of ischaemic Heart Disease even silent. Acta
Med. Medit. 13, 109 1997.
4) Stagnaro-Neri M., Stagnaro S., Cancro della mammella: prevenzione
primaria e diagnosi precoce con la percussione ascoltata. Gazz. Med. It.
Arch. Sc. Med. 152, 447 1993
5) Stagnaro-Neri M., Stagnaro S. Introduzione alla Semeiotica Biofisica.
Il Terreno Oncologico. Travel Factory, Roma, 2004.
http://www.travelfactory.it/semeiotica_biofisica.htm
6) Stagnaro S., Stagnaro-Neri M., Oncological Terrain, conditio sine qua
non of Oncogenesis, 2004:
http://www.gutjnl.com/cgi/eletters?lookup=by_date&days=60
7) Stagnaro Sergio. "Genes, Oncological Terrain, and Breast Cancer" World
Journal of Surgical Oncology., 2005,
http://www.wjso.com/content/3/1/45/comments#205475
With great interest we read the retrospective application of the
Awaji criteria (1) by Douglas et al. (2). In this paper the authors
validated the Awaji criteria in a routine clinical setting. A remarkable
finding is that after EMG assessment only one patient could be classified
as probable laboratory supported ALS. Consequently a low sensitivity of
the revised El Escorial criteria was found. This...
With great interest we read the retrospective application of the
Awaji criteria (1) by Douglas et al. (2). In this paper the authors
validated the Awaji criteria in a routine clinical setting. A remarkable
finding is that after EMG assessment only one patient could be classified
as probable laboratory supported ALS. Consequently a low sensitivity of
the revised El Escorial criteria was found. This considerably differs from
previous studies (3) and our own experience.
Recently we came across the strange fact that the Awaji criteria
sometimes decrease diagnostic certainty in individual patients. This is
the result of abandonment of the category "probable laboratory supported
ALS". Probable laboratory supported ALS only requires upper motor neuron
signs in one region and probable ALS in two regions. In our own series we
had 14 patients with probable laboratory supported ALS. (4) Six of them
had upper motor neuron signs in only one region. Therefore those six
patients dropped to the Awaji category possible ALS regardless how many
fibrillations or fasciculation potentials they had. We reviewed the data
from 28 patients with possible ALS. With the new criteria 21 of them would
remain in that category. Upper motor neurons signs in one region only was
the limiting factor in 3 of these patients with fasciculation potentials
without fibrillations in two or more regions.
The loss of sensitivity in patients with upper motor neuron signs in
one region can be avoided by applying both the El Escorial and Awaji
criteria as a diagnostic algorithm (3), but at the cost of increased
complexity.
According to the new criteria, the fasciculation potentials should be
complex, and often this can be demonstrated. However, in muscles with only
a few fasciculation potentials this may be difficult to assess and
validated standards are lacking. Subjectively, we have the strong feeling
that complexity is a redundant feature and accepting any type of
fasciculation potential is sufficient. Obviously, confusion of benign
fasciculations with ALS must be avoided, but signs of re-innervation may
differentiate sufficiently. Therefore, our question is: does specificity
decline if the criterion of complexity is removed?
1. de Carvalho M, Dengler R, Eisen A, England JD, Kaji R, Kimura J,
Mills K, Mitsumoto H, Nodera H, Shefner J, Swash M. Electrodiagnostic
criteria for diagnosis of ALS. Clin.Neurophysiol. 2008;119:497-503.
2. Douglass CP, Kandler RH, Shaw PJ, McDermott CJ. An evaluation of
neurophysiological criteria used in the diagnosis of motor neuron disease.
J.Neurol.Neurosurg.Psychiatry 2010;81:646-9.
3. de Carvalho M, Swash M. Awaji diagnostic algorithm increases
sensitivity of El Escorial criteria for ALS diagnosis. Amyotrophic Lateral
Sclerosis 2009;10:53-7.
4. Boekestein WA, Kleine BU, Hageman G, Schelhaas HJ, Zwarts MJ. The
sensitivity and specificity of the Awaji electrodiagnostic criteria for
amyotrophic lateral sclerosis. Retrospective comparison of the Awaji
recommendations and revised El Escorial criteria for ALS.
Amyotroph.Lateral.Scler. 2010.
Sadjadi and colleagues show that in IBM, as in most chronic illness, mood plays a role in QoL. It would be a surprise if mood didn't play a role in measured QoL. QoL assessment uses subjective measures, for example "how would you rate your health?", and a patient's response to such a question is likely to be altered by mood. Hence QoL questionnaires can also act as mood questionnaires. Indeed, the awkward realisation i...
Dear Sir, We write in response to the rapid response by Kleine et al. The disparity between the sensitivity of El Escorial in our study (1) and the work by Boekestein et al (2) and de Carvalho (3), we suggest is as a result of the differing neurophysiology protocols. Boekestein et al and de Carvalho use at least 3 times the insertions used in our standard protocols. The protocol used in our study is tailored for everyday...
SCAN SCORE VS. SCAN-- WHICH IS JUSTIFIED
PK Sethi*, A Batra**, L Khanna*** Department of Neurology, Sir Gangaram Hospital, New Delhi - 60, India
While going through the article, The Scan Rule, published in JNNP of March 2010, Vol; 81 explaining the utility of scan score over conventional CT scans in diagnosing or ruling out small intra cerebral haemorrhages, we think that SCAN SCORES cannot score over con...
Impregnated catheters are designed to prevent specifically CSF catheter related inf...
An one-and-a-half syndrome as first described by C. Miller- Fisher in 1967 is characterized by an ipsilateral horizontal gaze paresis or palsy and an internuclear ophthalmoplegia or INO on contralateral horizontal gaze. An exotropia may be present in primary position but does not have to be present. The association of exotropia in the one-and-a-half syndrome is sometimes called "paralytic pontine exotropia" In addition t...
We thank Dr. Aboul-Enein et al. for their interest about our recent paper. We apologize for the missing references. For the first one (Bichuetti et al.) we missed it in our pubmed research probably due to a misclassification of the key words. For the second one (Aboul-Enein et al.), the paper was not published before our article was in press. We are a little bit concern to include in our references abstract of posters....
Sir,
we have read with great interest the paper by de Seze et al., entitled "Magnetic resonance spectroscopy evaluation in patients with neuromyelitis optica" (1).
Neuromyelitis optica (NMO) is a rare disease and most studies rely on a small sample size. Calling attention to previous publications on magnetic resonance spectroscopy (MRS) in patients with NMO might strengthen the results of de Seze et al. Bi...
I read the article on association of restless legs and migraine headache by Chen with interest (1).
Probably the two conditions share basic neuronal abnormalities such as neurotransmitter dysfunction.
Opiates are an effective treatment for restless legs and also for the pain of migraine headaches.
Morphine has been found to be produced endogenously in the nervous system (2) and is also a neu...
Editors, there is a fundamental bias in this study. In fact, because congenital functional mitochondrial cytopathology is overlooked, which is the "conditio sine qua non" of numerous constitutions and thus of the most frequent and dangerous human disorders, including malignancies, all current researches are fundamentally biased . That is, authors do not consider the existence or assess the seriousness as well as the l...
Dear Editor,
With great interest we read the retrospective application of the Awaji criteria (1) by Douglas et al. (2). In this paper the authors validated the Awaji criteria in a routine clinical setting. A remarkable finding is that after EMG assessment only one patient could be classified as probable laboratory supported ALS. Consequently a low sensitivity of the revised El Escorial criteria was found. This...
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