Wobbly handwriting

[Diagnostics of Wilson's disease]

Wilson's disease is a rare genetic but treatable metabolic disorder which has a favorable prognosis when diagnosed early and treated adequately. Therefore, knowledge of this rare clinical condition and a reliable diagnosis are indispensable. The diagnostic work-up is initiated in cases of unexplained acute or chronic liver disease and/or an extrapyramidal motor disturbance occurring mostly between the 5th and 45th years of life. Manifestations with initial symptoms have occasionally been observed at an age younger than 1 year and later than 70 years. Immediate biochemical and genetic examinations for early diagnosis are essential. Further test methods, such as liver and transcranial sonography, cerebral magnetic resonance imaging (MRI) and ¹⁸F-fluorodeoxyglucose positron emission tomography (¹⁸F-FDG-PET), ¹²³I-beta-CIT and ¹²³I-iodobenzamide (IBZM) single photon emission computed tomography (SPECT), electrophysiology as well as fine motor tests are unspecific but can be used to test for organ damage and for monitoring of progress. Immediate initiation of a therapy is required and justified on the basis of a confirmed diagnosis.

Wilson's disease with cognitive impairment and without extrapyramidal signs: improvement of neuropsychological performance and reduction of MRI abnormalities with trientine treatment

Extrapyramidal signs are neurological dysfunction commonly associated with Wilson's disease (WD). In addition, cognitive dysfunction has been reported in the early stages of WD. In this report, we describe a 49-year-old woman presenting with memory impairments and without Parkinsonian or extrapyramidal signs. She was diagnosed with WD based on the presence of Kayser-Fleischer rings around the irises of her eyes and two ATP7B gene mutations, R778L at exon 8 and A874V at exdyon 11. Serial magnetic resonance imaging analysis and neuropsychological tests showed improvements following treatment with trientine.

Wilson’s disease: A review of what we have learned

Wilson’s disease (WD), which results from the defective ATP7B protein product, is characterized by impaired copper metabolism and its clinical consequences vary from an asymptomatic state to fulminant hepatic failure, chronic liver disease with or without cirrhosis, neurological, and psychiatric manifestations. A high grade of suspicion is warranted to not miss cases of WD, especially less florid cases with only mild elevation of transaminases, or isolated neuropsychiatric involvement. Screening in first and second relatives of index cases is mandatory, and treatment must commence upon establishment of diagnosis. Treatment strategies include chelators such as D-penicillamine and trientine, while zinc salts act as inductors of methallothioneins, which favor a negative copper balance and a reduction of free plasmatic copper. As an orphan disease, research is lacking in this field, especially regarding therapeutic strategies which are associated with better patient compliance and which could eventually also reverse established injury.

A review and current perspective on Wilson disease

Wilson disease is a rare, inherited autosomal recessive disease of copper metabolism and may be more common where consanguinity is prevalent. Much has been known about the disease after it was first described by Kinnier Wilson as 'progressive lenticular degeneration in 1912. Over 500 mutations of the ATP7B gene has been identified with no clear genotype to phenotype correlation. Loss of ATP7B function leads various grades of reduced biliary excretion of copper and reduced incorporation of copper into ceruloplasmin; accumulation and toxicity of copper in the liver, brain and other tissues results in liver toxicity and other myriad manifestations of the disease. The clinical features may vary from asymptomatic state to chronic liver disease, acute liver failure, neuropsychiatric manifestations and hemolytic anemia. Diagnosis is based on the combination of clinical sign's, biochemical features, histologic findings and mutation analysis of ATP7B gene. Subtle geographical differences exist with a disproportionate proportion of children presenting with acute liver failure. A high index of suspicion is needed for an early diagnosis. Ratios of biochemical indices for early diagnosis need validation across geographical regions and may not be particularly applicable in children. Better biomarkers or the need for tests for early detection of ALF persists. Drugs used in the treatment of Wilson disease include copper chelating agents such as d-Penicillamine, trientine and zinc salt. Untreated Wilson disease uniformly leads to death from liver disease or severe neurological disability. Early recognition and treatment has excellent prognosis. Liver transplantation is indicated in acute liver failure and end stage liver disease. Family screening in order to detect the disorder in the first-degree relatives is warranted. This review provides an overview of different aspects of Wilson disease including geographical differences in presentations and clinical management and the limitations of currently available tests.

[Common problems in the diagnosis and treatment of Wilson's disease]

The present article aims to provide answers to questions frequently asked by physicians attending patients with Wilson's disease (WD) or those with a suspected diagnosis of WD. The article is divided into 2 parts: a first part with answers to questions relating to the diagnosis of this entity and a second with answers to questions concerning treatment. A brief appendix is included with responses to questions not falling into either of these 2 categories.

Wilson's disease

Progressive hepatolenticular degeneration, or Wilson's disease, is a genetic disorder of copper metabolism. Knowledge of the clinical presentations and treatment of the disease are important both to the generalist and to specialists in gastroenterology and hepatology, neurology, psychiatry, and paediatrics. Wilson's disease invariably results in severe disability and death if untreated. The diagnosis is easily overlooked but if discovered early, effective treatments are available that will prevent or reverse many manifestations of this disorder. Studies have identified the role of copper in disease pathogenesis and clinical, biochemical, and genetic markers that can be useful in diagnosis. There are several chelating agents and zinc salts for medical therapy. Liver transplantation corrects the underlying pathophysiology and can be lifesaving. The discovery of the Wilson's disease gene has opened up a new molecular diagnostic approach, and could form the basis of future gene therapy.

Spiral drawing performance as an indicator of fine motor function in people with multiple sclerosis

This study investigated spiral drawing performance as an indicator of fine motor function, as well as to gain insight into adaptive movement strategies used by people with multiple sclerosis (MS). Seven people with MS, nine younger controls (mean age of 20) and eight older controls (mean age of 40) drew spirals on a graphics tablet at a comfortable speed and size. Spirography (i.e., a subjective visual assessment of the static trace) revealed indications of reduced control of the pen for people with MS. Analysis of the movements showed that people with MS tended to draw the spirals slower and with less pen pressure than controls. All groups increased their speed and pressure along with spiral size, but this increase was much steeper for the controls. MS participants drew spirals with more variability around an ideal trajectory, highlighting fine motor control degradation. MS patients tended to use a smaller scaling ratio, resulting in smaller spirals for a given number of revolutions. The younger and older control groups drew the spirals in a similar manner, and age was not a significant factor in any of the analyses. It is argued that the relatively lower pressure used, and slower, smaller movements (particularly during the more difficult outer sections of the spiral) are in part an adaptive strategy used to reduce movement variability. These results demonstrate the utility of the analysis of spiral movements as an objective technique for assessing motor control degradation, which can compliment the subjective rating based on the static pen trace. As such, it can provide further insight into the biomechanical strategies used when performing fine movements.

Correlation and overlapping between nuchal translucency and triple test among Down syndrome-affected pregnancies

OBJECTIVES

To examine the correlation and extent of overlapping between first-trimester nuchal translucency (NT) and second-trimester triple test (TT) results in Down syndrome (DS)-affected pregnancies.

METHODS

Results of both tests were obtained in 28 cases with DS. Inter-test correlation was performed by comparing the likelihood ratios (LRs). Screen-positive rates (risk >1:380) were calculated for different age groups by adjusting age-dependent background risk and tests' LRs. Overlapping referred to ratio between screen-positive cases by both tests simultaneously and total screen-positive cases by either one or both tests.

RESULTS

No correlation was found between the tests' LRs (Pearson correlation test, r = 0.0487). The overlapping between the tests was 25% and 38.5% among young patients of 20 and 35 years of age, respectively. The average overlapping among patients between 25 and 35 years of age was approximately 33%. Only 3 of the 28 DS cases demonstrated LRs <1 by both tests and moreover none exhibited LRs <0.2 by both tests.

CONCLUSIONS

The degree of overlapping of one third, between NT and TT, confirms the assumption that both tests utilized together improves DS detection. Screen- negative result, by both tests simultaneously, may reassure low-risk population and aid to reduce the number of non-indicated invasive tests.

Genotype correlation with fine motor symptoms in patients with Wilson's disease

Wilson's disease, an autosomal recessive disorder of copper metabolism, is caused by about 200 different mutations of the ATP7B gene. Using a genotype-phenotype correlation, 36 patients were examined to see whether the disorder of the automatic handwriting movement depends on the genotype. The findings of this study indicated that no such link exists. Neither the profile of the impairment of the fine motor parameters nor the severity and frequency of pathological findings were different among the three genotype groups (homozygous for H1069Q, compound homozygous for H1069Q and other mutations). By contrast, fine motor disorders were found to correlate with the clinical symptoms recorded when therapy began. The pathophysiology of the basal ganglia and the cerebellar loop therefore cannot be directly attributed to the genotype of the mutation in the ATP7B gene.

Prevention and Detection of Diabetic Embryopathy

Congenital anomalies are more common in the offspring of women with type 1 and type 2 diabetes mellitus. Herein we define those anomalies more commonly found in the offspring of women with diabetes mellitus, and examine the role of hyperglycemia in their pathogenesis. We then discuss methods for the optimal screening and detection of embryopathy. We conclude by presenting evidence in support of preconception diabetes care to lower the risk of fetal anomalies in women with diabetes mellitus.