Podophyllotoxin Intoxication: Toxic Effect of Bajiaolian in Herbal Therapeutics

Bajiaolian ( Dysosma pleianthum), one species in the Mayapple family, has been widely used as a general remedy and for the treatment of snake bite, weakness, condyloma accuminata, lymphadenopathy and tumours in China for thousands of years. However, the textbooks of traditional Chinese medicine mention little about the toxicity of Bajiaolian. Within 1 year, the authors saw five people who manifested nausea, vomiting, diarrhoea, abdominal pain, thrombocytopenia, leucopenia, abnormal liver function tests, sensory ataxia, altered consciousness and persistant peripheral tingling or numbness after drinking infusions made with Bajiaolian. The herb was recommended by either traditional Chinese medical doctors or herbal pharmacies for postpartum recovery and treatment of a neck mass, hepatoma, lumbago and dysmenorrhoea. Podophyllotoxin is one of the main ingredients of the Bajiaolian root. The clinical manifestations observed in our patients were consistent with podophyllum intoxication. Podophyllotoxin intoxication usually results from the accidental ingestion or topical application of podophyllum resin. However, these cases of Bajiaolian intoxication were iatrogenic and results from 'therapeutic doses' of Bajiaolian cited in the textbooks of traditional Chinese medicine.

Brain dysfunction explored by long latency reflex: a study of adrenomyeloneuropathy

OBJECTIVES

We can assess brain function by measuring the cortical relay time (CRT) of long latency reflex (LLR) of hand muscle. We would study if measurement of CRT of LLR can explore the brain involvement of adrenomyeloneuropathy (AMN).

METHODS

Two AMN patients were included in the study. Both of them had spastic gait and mild sensory deficits but normal mental function. The LLRs were provoked at the first dorsal interosseous muscle by electrical stimulation of the middle finger. We measured the latency of LLR and its CRT.

RESULTS

Delayed LLR and prolonged CRT were noted in AMN patients, even though the magnetic resonance imaging of brain did not show any significant abnormalities.

CONCLUSIONS

Measuring CRT of LLR reveals brain involvement of AMN patients, and it is an adjunct in the assessment of brain function though without specific anatomic diagnosis.

Problem-based, small-group tutorial learning in clinical neurology for second-year medical students

BACKGROUND

Problem-based learning (PBL) in small-group tutorials has been a trend in medical education. Chinese students are known to be reserved and passive; thus, they may not be adaptable to PBL. Neuroanatomy, important to clinical neurology, is difficult to learn. We incorporated clinical neurology with PBL, complementary to the traditional neuroanatomy curriculum, to evaluate the feasibility of PBL for Chinese students in Taiwan.

METHODS

Forty-two second-year medical students and seven tutors participated in the clinical neurology PBL small-group tutorials. Twelve case reports were discussed weekly beginning in February, 1999. Each case was designed to meet the progressive curriculum of the neuroanatomy course. The tutors evaluated the students by the degree of their preparation, participation, key-point comprehension and interaction. All tutors and students filled out questionnaires at the end of each session.

RESULTS

The majority of the students and tutors agreed that the case materials were clearly written. Ninety percent of the students agreed that the case materials matched the traditional content of neuroanatomy. Eighty-five percent of students and 71% of tutors were satisfied and found the class rewarding. Ninety-one percent of students and 74% of tutors were in favor of PBL being continued.

CONCLUSIONS

This preliminary PBL, small-group tutorial learning in clinical neurology showed satisfactory results and was, indeed, complementary to a traditional neuroanatomy course. The students, as early as during the second year of their medical school education, were able to learn through the PBL. More integration of basic and clinical sciences by PBL may be considered in future curricula designs.

Automatic breast region extraction from digital mammograms for PACS and telemammography applications

High spatial resolution results in very large digital mammogram file sizes. For telemammography, and picture archiving and communication systems, the large file issue introduces technical difficulties in image transmission, storage, and display. We propose extracting the breast region from the mammogram to reduce the image file size. The challenge is on how to faithfully extract breast regions from digital mammograms generated from different types of acquisition systems that contain various imaged compositions. We report an algorithm to automatically identify the orientation of breast region and extract the breast region from mammograms. Breast regions extracted from full-field digital mammograms reduce file sizes by three to five folds.

Measurement of the urinary lactate:creatinine ratio for the early identification of newborn infants at risk for hypoxic-ischemic encephalopathy

BACKGROUND

Newborn infants with perinatal asphyxia are prone to the development of hypoxic-ischemic encephalopathy. There are no reliable methods for identifying infants at risk for this disorder.

METHODS

We measured the ratio of lactate to creatinine in urine by proton nuclear magnetic resonance spectroscopy within 6 hours and again 48 to 72 hours after birth in 58 normal infants and 40 infants with asphyxia. The results were correlated with the subsequent presence or absence of hypoxic-ischemic encephalopathy.

RESULTS

Hypoxic-ischemic encephalopathy did not develop in any of the normal newborns but did develop in 16 of the 40 newborns with asphyxia. Within six hours after birth, the mean (+/-SD) ratio of urinary lactate to creatinine was 16.75+/-27.38 in the infants who subsequently had hypoxic-ischemic encephalopathy, as compared with 0.09+/-0.02 in the normal infants (P<0.001) and 0.19+/-0.12 in the infants with asphyxia in whom hypoxic-ischemic encephalopathy did not develop (P<0.001). A ratio of 0.64 or higher within six hours after birth had a sensitivity of 94 percent and a specificity of 100 percent for predicting the development of hypoxic-ischemic encephalopathy. The sensitivity and specificity of measurements obtained 48 to 72 hours after birth were much lower. The mean ratio of urinary lactate to creatinine was significantly higher in the infants who had adverse outcomes at one year (25.36+/-32.02) than in the infants with favorable outcomes (0.63+/-1.50) (P<0.001).

CONCLUSIONS

Measurement of the urinary lactate: creatinine ratio soon after birth may help identify infants at high risk for hypoxic-ischemic encephalopathy.

Botulism: heart rate variation, sympathetic skin responses, and plasma norepinephrine

BACKGROUND

Botulism may involve the autonomic nervous system.

METHODS

We assessed the autonomic function of 6 botulism patients with heart rate variations, sympathetic skin responses, and plasma norepinephrine.

RESULTS

Two weeks after onset, all the patients had absent sympathetic skin response in the palm and sole. Compared with controls, the heart rate variation of botulism patients was significantly decreased at rest (3.1 +/- 1.2% vs. 20.9 +/- 2.0%, p = 0.0018) and during deep breathing (4.3 +/- 2.3% vs. 29.7 +/- 2.6%, p = 0.0018). The botulism patients had significantly lower plasma norepinephrine levels (supine 29.2 +/- 10.1 pg/ml vs. 257.5 +/- 65.8 pg/ml, p = 0.0018; standing 40.3 +/- 13.1 pg/ml vs. 498.5 +/- 85.6 pg/ml, p = 0.0018). The heart rate variation and sympathetic skin response was greatly improved 6 months after onset.

CONCLUSIONS

Heart rate variation, absence of sympathetic skin response, and low plasma norepinephrine are all manifestations of autonomic dysfunction in botulism patients.

Use of botulinum toxin A in the treatment of hemifacial spasm and blepharospasm

BACKGROUND

Hemifacial spasm and blepharospasm are both dystonic disorders. They may seriously affect individuals' lifestyle and social activities. In 1990, the Food and Drug Administration of the USA approved botulinum toxin A as a therapeutic agent in the treatment of hemifacial spasm and blepharospasm. We present a therapeutic review of botulinum toxin A in 80 patients in Taiwan.

METHODS

Fifty-eight patients with hemifacial spasm and 22 with blepharospasm. Botulinum toxin A was prepared and injected into the facial and eyelid muscles. Patients were monitored every two weeks and classified into four groups (excellent, moderate, mild and no improvement) according to the clinical improvement scale. Complications were also recorded.

RESULTS

A total of 86.2% of hemifacial spasm patients and 81.8% of blepharospasm patients had excellent improvement on the spasm intensity scale, while 6.8% of hemifacial spasm and 9.0% of blepharospasm patients had moderate improvement. The complication rate was low and included transient mild facial weakness (5%), ptosis (3.8%), eyelid swelling and/or ecchymosis (3.8%), nausea/vomiting (2.5%) and transient severe facial weakness (1.3%).

CONCLUSION

Botulinum toxin A is an excellent therapeutic agent to improve spasm intensity and has a low complication rate.

Heterogeneity of antibody specificity in Taiwanese patients with polyneuropathy and IgM paraproteinemia

About half of the Caucasian patients with chronic polyneuropathy and IgM paraproteinemia show serum anti-myelin-associated glycoprotein (MAG) and anti-sulfoglucuronosyl glycosphingolipid (SGGLs) activities. These antibody activities have been demonstrated to react with a carbohydrate epitope known as the HNK-1 or sulfoglucuronic acid (SGA) epitope. However, in Asian populations the occurrence of serum anti-SGA activities has been reported to be relatively rare. We investigated 5 cases of chronic polyneuropathy with IgM paraproteinemia from Taiwan and found that 3 of them had high-titer serum anti-SGA (SGGL/MAG) antibody activities. The clinical symptoms of these 3 patients were consistent with sensory dominant polyneuropathy with a severer involvement of the lower limbs than of the upper limbs. Electromyography and nerve conduction studies revealed severe sensory nerve involvement (no response in 3 cases) and moderate slowing of motor conduction velocity (MCV) without conduction block. The decrease in MCV correlated well with anti-SGA antibody titer (less than 30 m/s with the titration of 1:12, 800, normal 55-60 m/s). Pathological findings showed active demyelinating polyneuropathy with myelin ovoid and myelinated fiber loss. Our data suggest that anti-SGGL antibody activities may not be very rare among Asian populations. Additionally, there seems an intriguing possibility that the titer of this antibody correlates with the severity of peripheral nerve involvement in patients of demyelinating polyneuropathy with IgM paraproteinemia.

An electrophysiologic and pathologic study of peripheral nerves in individuals with Machado-Joseph disease

BACKGROUND

Machado-Joseph disease (MJD) is characterized by cerebellar ataxia, pyramidal signs, progressive external ophthalmoplegia, and variable degrees of bulging eyes and dystonia. Electrophysiologic and histologic alterations of the peripheral nervous system in patients with MJD have rarely been reported.

METHODS

The peripheral nerves of four patients with MJD who were identified by polymerase chain reaction were subjected to electrophysiologic testing and histologic study. Correlation analyses were made between clinical parameters and the electrophysiologic as well as histologic changes.

RESULTS

Electrophysiologic studies demonstrated a marked reduction of sensory action potential, as well as a decrease in the compound motor action potential. Light microscopy of the sural nerves revealed marked loss of myelinated fibers, and morphometry studies showed a loss of large myelinated fibers. The severity of these pathologic changes was not related to the duration of the disease.

CONCLUSIONS

In MJD, the peripheral nervous system was frequently affected. These findings were similar to those seen in Friedreich's ataxia, suggesting a loss of sensory and motor fibers probably following a lesion of the dorsal root ganglion and the anterior horns in the spinal cord.

Brachial plexus compression due to subclavian pseudoaneurysm from cannulation of jugular vein hemodialysis catheter

Jugular venous cannulation is generally safer than subclavian cannulation. The traumatic complications associated with jugular vein hemodialysis catheters are rare. A jugular vein, therefore, has become the preferred site for hemodialysis catheter insertion. We describe the first case of brachial plexus compression attributable to delayed recognition of a right subclavian pseudoaneurysm as a complication of jugular venous cannulation of hemodialysis catheter. We advocate that any neck swelling, new bruit, and the symptoms of brachial plexopathy after jugular venous cannulation warrant an intensive investigation to exclude arterial injury. Because delayed diagnosis may lead to a worsened prognosis in patients with brachial plexus palsy, physicians should exercise vigilance to detect and manage early the potentially serious and fatal complications of subclavian artery pseudoaneurysm and brachial nerve injury.

Correlation of peripheral nerve fiber loss and trinucleotide repeats in Machado-Joseph disease

BACKGROUND

Machado-Joseph disease (MJD) is a dominantly inherited cerebellar ataxia associated with spasticity, ophthalmoplegia and dystonia. There has been no report of electrophysiological or histological alterations of the peripheral nervous system in patients with MJD.

METHODS

Four patients with MJD were identified by polymerase chain reaction. The peripheral nerves of these patients were subjected to electrophysiological testing and histological study. Correlation analyses were made between various clinical parameters and the electrophysiological and histological changes.

RESULTS

Electrophysiological studies demonstrated a marked reduction of sensory action potential, acute denervation changes on needle EMG, as well as mild decrease in the compound motor action potential. Light microscopy of the sural nerves revealed clear loss of myelinated fibers, and morphometry studies showed a loss of large myelinated fibers. Moreover, the severity of these pathological changes was found to be related to the CAG repeat length in the MJD gene.

CONCLUSION

Our findings indicated that the peripheral nervous system was frequently affected in patients with MJD. These findings were similar to those seen in Friedreich's ataxia, suggesting a loss of sensory and motor fibers probably following a lesion of the dorsal root ganglion and the anterior horns in the spinal cord. Furthermore, the number of CAG repeats seems to have an inverse relationship to the extent of pathological changes of the peripheral nerves.

Estimation of myocardial glucose utilisation with PET using the left ventricular time-activity curve as a non-invasive input function

The validation study is described of a new modelling method that has been developed, using tracer kinetic modelling with positron emission tomography (PET) to achieve non-invasive measurement of myocardial metabolic rate of glucose (MMRGlc). Eight data sets obtained from dynamic cardiac PET 2-[18F]fluoro-2-deoxy-D-glucose (FDG) studies on human subjects are employed, and the estimation of MMRGlc using both the new and traditional methods is compared. The results from all eight human FDG studies are consistent with those from previous computer simulations. With the new method, the estimated mean of K (a parameter directly proportional to MMRGlc) increases by about 8%, and that of k 4 (the rate constant of FDG dephosphorylation) decreases by about 48%. The approach should be more suitable for use in dynamic cardiac PET studies when non-invasive means are used to obtain the plasma time-activity curve from left-ventricle PET images.

Prevalence of headaches in a Chinese elderly population in Kinmen: age and gender effect and cross-cultural comparisons

OBJECTIVE

To investigate the prevalence of headaches in a Chinese elderly population.

BACKGROUND

There are few headache surveys in the elderly. Previous studies have shown a low headache prevalence in Chinese.

METHODS

TARGET POPULATION

eligible registered residents > or = 65 years old (N = 2,003) in two townships of Kinmen Island on August 1, 1993. All participants completed a headache questionnaire and underwent clinical evaluation and examination by a neurologist. Headache diagnoses were made according to the International Headache Society, 1988.

RESULTS

1,533 persons (77%) participated in the study, of whom 584 (38%) had at least one episode of headache in the previous year. One-year prevalence of migraine was 3.0%, and tension-type headache, 35%. The prevalence of migraine, but not tension-type headaches, continued to decline with age in the elderly. Life-time prevalence of "incapacitating headache" was 10%, and that of migraine, 5.2%. Forty-two percent of migraineurs stopped having migraine before this survey. In comparison with "10 years ago" 8% participants felt their current headaches were worse, 25% better, and 67%, no change, with a net improvement of 17%.

CONCLUSIONS

We have reported the highest headache prevalence among different Chinese elderly populations, but these were still lower than those reported from Western series. More than half of the elderly life-time migraineurs still had attacks of migraine. Severe headaches, including migraine but not tension-type headaches, declined with age.

The Kinmen Neurological Disorders Survey (KINDS): a study of a Chinese population

We conducted an epidemiological study of several neurological disorders among the Chinese aged 50 years or older on the islet of Kinmen. All participants were interviewed and examined by neurologists. From the targeted population of 5,061 individuals, 3,915 (77.4%) of them completed the evaluations. Among the 4,087 individuals with whom face-to-face contact was made, the refusal rate was 4.2%. The disorders of interest were dementia, Parkinson's disease, essential tremor, stroke, transient ischemic attacks, and migraine. Among the 3,915 participants, 366 cases were found with 1 or more of the surveyed neurological disorders on the prevalence day, August 1, 1993, yielding a prevalence of 93.5/1,000. The purpose of this study, the general methodology, and some overall findings are presented in this communication in order to provide a common background for detailed findings on each disorder to be reported separately.

Polyneuropathy associated with acute monoblastic leukemia: a case report

Polyneuropathy associated with acute myelocytic leukemia is rare. We report a woman aged 34 years with acute monoblastic leukemia and polyneuropathy in hematology remission. The clinical, electrophysiological and pathological findings revealed acute symmetrical sensorimotor axonal polyneuropathy that differs from previous reports of three cases.

Automated image registration for FDOPA PET studies

In this study, various image registration methods are investigated for their suitability for registration of L-6-[18F]-fluoro-DOPA (FDOPA) PET images. Five different optimization criteria including sum of absolute difference (SAD), mean square difference (MSD), cross-correlation coefficient (CC), standard deviation of pixel ratio (SDPR), and stochastic sign change (SSC) were implemented and Powell's algorithm was used to optimize the criteria. The optimization criteria were calculated either unidirectionally (i.e. only evaluating the criteria for comparing the resliced image 1 with the original image 2) or bidirectionally (i.e. averaging the criteria for comparing the resliced image 1 with the original image 2 and those for the sliced image 2 with the original image 1). Monkey FDOPA images taken at various known orientations were used to evaluate the accuracy of different methods. A set of human FDOPA dynamic images was used to investigate the ability of the methods for correcting subject movement. It was found that a large improvement in performance resulted when bidirectional rather than unidirectional criteria were used. Overall, the SAD, MSD and SDPR methods were found to be comparable in performance and were suitable for registering FDOPA images. The MSD method gave more adequate results for frame-to-frame image registration for correcting subject movement during a dynamic FDOPA study. The utility of the registration method is further demonstrated by registering FDOPA images in monkeys before and after amphetamine injection to reveal more clearly the changes in spatial distribution of FDOPA due to the drug intervention.

Myasthenia gravis complicated with hyperthyroidism, thymoma and serological evidence of systemic lupus erythematosus: a case report

A 55-year-old woman with a several-decade history of thyroid goiter is presented here as a case of myasthenia gravis complicated with hyperthyroidism and thymoma with serological evidence of systemic lupus erythematous (SLE). She had had right eyelid ptosis since July 1992, with a positive tensilon test. The acetylcholine receptor antibody titer was 4.01 nmol/L. A thyroid function test revealed T3: 162 ngidl, T4: 14.98 micrograms/dl, TSH:0.09 microIU/ml and positive anti-microsomal antibody (1:400). An MRI of the chest showed a thymoma in the left thymus. Other autoantibody screenings include ANA (1:320, speckled pattern) and anti-ds DNA (+) suggesting a serological association with SLE. After three courses of plasmapheresis, she received an extended maximal thymomectomy and a subtotal thyroidectomy. She was then treated with prednisolone, Mestinon, Eltroxin and discharged without complications. The coexistence of myasthenia gravis, hyperthyroidism, thymoma and a serological evidence of SLE have not previously been documented in the literature.

A door-to-door survey of Parkinson's disease in a Chinese population in Kinmen

BACKGROUND

Most published studies have shown lower prevalence rates of Parkinson's disease (PD) in Asian and black African than in Western countries, leading to the hypothesis that Asians and blacks might be protected from PD.

OBJECTIVE

To investigate the prevalence of PD in a Chinese population.

DESIGN

Community-based survey.

SETTING

Registered residents 50 years of age or older (N = 5061) on the islet of Kinmen located off the southeastern coast of China [corrected].

METHOD

Single-phase door-to-door survey by neurologists. All participants were administered a questionnaire and received motor examinations of the Unified Parkinson's Disease Rating Scale.

RESULTS

The participation rate was 96% (N = 3915) among 4158 contacted individuals. Twenty-three cases of PD were identified, including three cases with dementia. The crude prevalence rate of PD was 587 (95% confidence interval (CI), 373 to 884) per 100,000 persons 50 years of age or older. Assuming no case of PD among individuals under 50 years of age, the prevalence rate was 119 (95% CI, 80 to 169) per 100,000 for the total population.

CONCLUSIONS

The prevalence rates of PD in Kinmen were much higher than those reported from mainland China, but slightly lower than those reported from more developed countries. The present findings suggest that, instead of genetic factors, differences in case-ascertainment, life expectancy, and the length of survival with PD may be more important contributors to the variations in observed PD prevalence rates.

6-[18F]fluoro-L-DOPA-PET studies show partial reversibility of long-term effects of chronic amphetamine in monkeys

The acute and long-term effects of chronic amphetamine administration on the striatal dopamine system in monkeys were assessed with 6-[18F]fluoro-L-DOPA (FDOPA) and positron emission tomography (PET). Vervet monkeys (Cerecopithecus aethiops) were administered amphetamine doses, i.m., that increased from 4 mg/kg/d to 18 mg/kg/d over a 10 day period. Post-amphetamine FDOPA-PET scans at 1-2, 3-4, and 6 week time points in individual subjects showed persistent decrements in dopamine synthesis capacity as reflected by FDOPA influx rate constant (Ki) values being approximately 30% that of pre-drug assessment. In other animals that were administered the same drug regimen, biochemical analysis of striatal regions at 1-2 weeks post-drug indicated that dopamine concentrations were decreased by approximately 95% throughout caudate and putamen regions, while the homovanillic acid/dopamine level ratio was increased 3-10-fold. Post-drug FDOPA-PET Ki values remained consistently low up to 6 weeks; however, at the 5-6 month time point, relative increases in FDOPA-Ki values (approximately 53% of pre-drug values) were observed for all subjects, indicative of partial recovery of striatal dopamine synthesis capacity. These results demonstrate that FDOPA-PET can reveal temporal activity changes within the striatal dopamine system of individual subjects. The apparent, partial reversibility of amphetamine's neurotoxic effects suggests a plasticity of dopaminergic function that may include regeneration of dopaminergic terminals and compensatory increases in residual dopamine synthesis rates. The persistence of the partial decrement in dopamine synthesis capacity, however, may indicate a long term component of amphetamine's toxic effects.

Performance on a smell screening test (the MODSIT): a study of 510 predominantly illiterate Chinese subjects

The 12-item Modular Smell Identification Test (MODSIT) was administered to 239 male and 271 female Chinese subjects whose age ranged from 50 to 92 years (68.3 +/- 10.9) and whose education ranged from 0 to 20 years (2.5 +/- 4.3). Every participant was examined by a physician and was found to be free of dementia, stroke, and Parkinson's disease. Different from the standard procedures, only one-third of each odor pad was used for each subject, the four odor choices were presented orally for the majority of subjects, and they were not forced to make a selection when they could not detect or identify the odor. The average level of performance was 46% correct. The score was negatively associated with age, positively associated with education and with performance on a dementia screening test, and corroborated with subjects' report of smell deterioration in recent years. Nonsmokers and women performed better than smokers and men. The 12-item MODSIT had an internal consistency reliability of 0.73 and a 7-month retest stability of 0.57 with different examiners. The MODSIT is satisfactory for group studies, even when administered with suboptimal procedures such as those used in the present study.

Intravenous immunoglobulin infusion in multifocal demyelinating motor neuropathy: a case report

The following report is a case of multifocal demyelinating motor neuropathy (MMN) presenting as a gradual development of asymmetric motor weakness without sensory involvement. Electrophysiological studies showed mainly a conduction block with normal or slightly slow nerve conduction velocity. Cerebrospinal fluid (CSF) protein and serum protein electrophoresis were normal, but serum IgM anti-GM1 ganglioside antibody was elevated. The patient had a poor response to steroid, plasmapheresis and chemotherapy with cyclophosphamide, but significant improvement was noted after intravenous immunoglobulin (IVIG) infusion. MMN is a potentially treatable condition which clinically mimics a motor neuron disease; if treatment with steroid, plasmapheresis and cyclophosphamide have failed, IVIG may be effective.

Correction of spillover radioactivities for estimation of the blood time-activity curve from the imaged LV chamber in cardiac dynamic FDG PET studies

In dynamic cardiac PET FDG studies for measurement of myocardial metabolic rate of glucose (MMRGlc), the plasma FDG time-activity curve (input function) is commonly obtained from the left ventricular (LV) region on the PET images. The input function is contaminated by spillover of radioactivity from the surrounding myocardium and this could cause significant error in the estimated MMRGlc. In this study, we determined the effect of myocardial to blood pool spillover on MMRGlc and developed a method to correct for this spillover of activity. The method is based on a reformulation of the FDG model equation in terms of the spillover contaminated input function that includes both the myocardium to blood pool and blood pool to myocardium spillover fractions as variable parameters (Fmb and Fbm). The reformulated model equation can be used to fit the global myocardial tissue activity curve to estimate Fmb and thus yields a spillover corrected input function. The MMRGlc estimate with the corrected input function was within 95% of the true value (compared to 85% using the uncorrected input function) in a set of computer simulation studies. Dynamic PET FDG data were obtained in eight human studies and blood samples were obtained during the study. As compared to the results with the uncorrected input function, the estimates of k4 by the new method were reduced by 69% into a range consistent with in vitro results. The method is effective in correcting Fmb spillover and leads to more accurate estimates of MMRGlc. The method also allows larger regions of interest (up to 150 mm2) to be drawn over the LV in dynamic PET images, thereby reducing the noise level in the input function.

Midbrain hemorrhage presenting as bilateral ptosis without hemiplegia: a case report

A 66-year-old man suddenly developed bilateral ptosis after awaking from a nap. He did not experience nausea, vomiting or headache. In the emergency room, high blood pressure was noted. On examination, his consciousness was clear. Ptosis was present bilaterally and worse on the right side. The pupils promptly constricted to light. He could fully adduct his eyes during conjugate gaze movements, but convergence was impaired in the right eye. There was no diplopia or nystagmus. The assessment of the motor and sensory systems revealed no significant findings. Computed tomographic scanning and magnetic resonance imaging of the brain showed a small hematoma in the midbrain. Six months later, ptosis improved; however, the convergence deficit remained.

Evaluation of cervical radiculopathy by cervical root stimulation

For precise evaluation of cervical radiculopathy, cervical root stimulation (CRS), conventional electromyographic (EMG) studies, nerve conduction velocity (NCV) studies and F responses were done in 32 patients with clinical symptoms and signs of cervical radiculopathy. While performing CRS, a monopolar needle was inserted into the paraspinal muscles, and the compound muscle action potentials (CMAPs) in the biceps, triceps and abductor digiti minimi muscles were recorded. Conventional EMG was abnormal in 18 (56.2%), whereas CRS was abnormal in 25 (78.1%). Among the 25 patients with positive CRS tests, 13 received surgical decompression for cervical root compression caused either by a cervical disc or by foramen narrowing due to spondylosis. Only 10 out of 13 (76.9%) had abnormal conventional EMG findings. CRS provides a sensitive method for making a direct evaluation of proximal root conduction and is a good aid for pre-surgical evaluation of cervical radiculopathy.

Sympathetic skin response and R-R interval variation in chronic uremic patients

Sympathetic skin response (SSR) and R-R interval variation (RRIV) were studied in 36 chronic, nondiabetic uremics to compare with their nerve conduction studies (NCS) and clinical dysautonomia. Abnormal SSR was noted in 5 (13.9%) patients, abnormal RRIV in 14 (38.9%), and abnormal NCS in 26 (72.2%). The patients were classified into three groups: group (GP) 1: "normal," n = 21 (58.3%), normal RRIV and SSR; GP 2: "isolated parasympathetic dysfunction," n = 10 (27.8%), abnormal RRIV and normal SSR; and GP 3: "sympathetic sudomotor dysfunction," n = 5 (13.9%), abnormal SSR. A significant difference in age was found among the three groups (GP 3 > GP 2 > GP 1; P < 0.0001, ANOVA). After controlling the age factor, we still noted a tendency toward increasing NCS disturbances (distal latency and nerve conduction velocity of peroneal nerve; P < 0.05, multiple regression analysis) and frequencies of clinical autonomic symptoms (postural dizziness and impotence; P < 0.05, Mantel-Hanszel test) from GP 1 to GP 3. Patients with abnormal SSR (GP 3) displayed significantly higher frequencies of postural dizziness and impotence, indicating the relationship between an absence of SSR and clinical dysautonomia.

Parkinson's disease in Kin-Hu, Kinmen: a community survey by neurologists

A door-to-door survey by neurologists in Kin-Hu township, Republic of China, of a sample of the Chinese population of 683 persons aged 50 years and over was performed in August, 1992. A total of 482 subjects (70.6%) completed the study. Kin-Hu, a township of Kinmen, is predominantly rural with agriculture as the main occupation. Six subjects (5 men, 1 woman) were diagnosed with Parkinson's disease (PD). Of these six, five were newly diagnosed; one of the five also had dementia. The crude prevalence rate per 1,000 persons over 50 years of age of PD in Kin-Hu was 6.2. The age-specific prevalence rates per 1,000 persons (95% confidence intervals) were 0 for age 50-59, 7.8 (0-22.9) for age 60-69, 17.5 (5.2-29.8) for age 70-79, and 25.4 (10.9-39.9) for age > or = 80. These rates are considerably higher than those reported in the People's Republic of China, and similar to rates found in Western countries. The higher prevalence of PD found in this pilot study suggests that environmental factors may be more important than racial factors in the pathogenesis of PD. If confirmed, the results suggest that epidemiologic studies looking for environmental risk factors might be of value.

Myokymia and neuromyotonia of the tongue: a case report of complication of irradiation

A 51-year-old man has suffered from progressive dysarthria since 1989. He himself noted slight weakness and tightness of the tongue, so that he was unable to perform motor tasks in a normal fashion. He was diagnosed as having nasopharyngeal carcinoma and had irradiation 70 Gy in 32 divided doses in 1979. Neurological examination revealed left-sided tongue atrophy and myokymia sparing of facial muscles involvement. Electrical discharges of myokymia and neuromyotonia were observed in the tongue muscles, suggesting hypoglossal nerve lesion with hyperexcitability of the axon membrance. Computed tomogram of brain did not show any evidence of recurrence of tumor; indicating that irradiation was the pathologic basis. Our report revealed that myokymia and neuromyotonia of the tongue was an unusual complication of irradiation.

Nerve conduction studies in healthy Chinese: correlation with age, sex, height and skin temperature

We consecutively collected 68 normal subjects who assented to receive electrophysiological examination in four limbs. There were 50 men and 18 women, with a mean age of 50.8 +/- 17.9 years (range: 15-88) and a mean height of 162.72 +/- 9.05 cm (range: 138-180). Mean skin temperature was 32.75 +/- 1.51 degrees C (range: 29.4-35.6) at wrist and 30.9 +/- 1.1 degrees C (range: 29-33) at lower leg. The mean values with standard deviation of the nerve conduction parameters such as distal latency, nerve conduction velocity, amplitude, duration and area of compound muscle action potential and sensory action potential, minimal latencies of H reflexes and F responses, and their side-to-side differences were presented. Age was negatively correlated with motor nerve conduction velocity (P < 0.05, r = -0.37 to -0.46), amplitude of compound muscle action potential (P < 0.05, r = -0.32 to -0.43) and sensory action potential (P < 0.05, r = -0.33 to -0.65), but not with sensory nerve conduction velocity (P > 0.05). Height was correlated with minimal latencies of H-reflexes and F-responses (P < 0.05, r = 0.45 to 0.76). Gender and temperature were not correlated with any parameters (P > 0.05).

Relationship between periventricular lucencies on computed tomographic scans and vascular dementia

We evaluated 48 consecutive patients with periventricular lucencies (PVL) on CT scan of brain to determine the clinical significance of this finding. Twenty-one (43.7%) patients were demented; 27 (56.3%) patients had no dementia but had various other diseases. PVL were frequently associated with hypertension and previous stroke. We used a PVL scoring system to evaluate the degree of PVL. When the score was greater than 3.5, the sensitivity and specificity in separating vascular dementia from other diseases with PVL were 78% and 67% respectively (Kappa = 0.42). We conclude that although mild PVL may be a frequent but non-specific finding in patients with hypertension or previous stroke, moderate and severe PVL should raise the possibility of vascular dementia.

Coexistence of Parkinson's disease and myasthenia gravis: a case report

This is a report on a 62-year-old Chinese woman with Parkinson's disease (PD) for 8 years who developed myasthenia gravis (MG) in the last year. In this case, there was no adverse effect of trihexyphenidyl on MG, whereas pyridostigmine worsened the PD.

Lack of cervical paraspinal muscle involvement in juvenile distal spinal muscular atrophy: an electromyographic study on 15 cases

Electromyography (EMG) of the lower cervical paraspinal muscles was performed in 15 young Chinese males with distal spinal muscular atrophy of the upper extremities. The lack of fibrillation and positive sharp waves in all patients, both in early or active and chronic or steady stages, did not correlate with the EMG status in the affected upper extremity on the same side. This finding is in striking contrast with that in amyotrophic lateral sclerosis.

Sympathetic skin response and R-R interval variation in Parkinson's disease

We investigated autonomic function in patients with idiopathic Parkinson's disease (PD) by measuring sympathetic skin response (SSR) and R-R interval variation (RRIV). Sixty-two PD patients and 62 age-matched normal subjects were recruited. Abnormal SSR was noted in nine (14.5%) PD patients, including three in Stage II, three in Stage III, and three in Stage IV, but not in Stage I patients or normal subjects. Four of these nine patients had postural hypotension. Abnormal SSR was correlated with duration of illness and impotence. In PD patients, abnormal SSR may be due to intermediolateral column dysfunction. After logarithmic transformation and age adjustment, 19 (31.6%) of 60 PD patients had abnormal RRIV during rest and deep breathing. Abnormal RRIV was not related to staging or duration of illness. Patients with constipation had significantly lower RRIV, indicating parasympathetic dysfunction. RRIV was not affected by acute or chronic L-dopa treatment. The agreement between RRIV and SSR in PD patients was poor (kappa = -0.07). It appears that abnormal SSR, but not RRIV, may be associated with more autonomic disturbances in PD patients.

Myoclonus associated with hyperthyroidism and thymoma: a case report

Movement disorders associated with hyperthyroidism or thymoma are extremely rare. A 52-year-old woman had developed myoclonus since June, 1989. Hyperthyroidism and thymoma were diagnosed 1 month and 9 months later. Myoclonus improved after thyroid treatment and thymectomy. If the association was not only a coincident phenomenon, autoimmunity should be considered in this previously unrecognized association.

Reversible motor neuron disease

We investigated a 69-year-old male with a clinical syndrome resembling amyotrophic lateral sclerosis characterized by fasciculation, wasting of the limb muscles and increased deep tendon reflexes in the lower limbs. Electromyographic (EMG) studies showed abundant positive sharp waves and fibrillation potentials with decreased recruitment in the limbs and paraspinal muscles. The patient recovered almost completely in approximately 1.5 years, and follow-up EMG studies showed no positive sharp waves or fibrillation potentials in the limb muscles except for some polyphasic motor units in the bilateral intrinsic hand muscles. No known systemic disease, malignancy or heavy metal intoxication was found during the course of his illness. So far, there are only few cases reported with spontaneous remission of motor neuron disease; however, the possibility should always be considered.

Generalized neuropathy in Taiwan: an etiologic survey

From July 1988 to June 1989, the etiology was registered of 520 patients with generalized neuropathy in 5 neurological centers in Taiwan. The neuropathy was diabetic in 256 cases (49.23%), alcoholic in 45 (8.65%), inflammatory in 34 (6.53%; including 21 with acute inflammatory demyelinating polyneuropathy, 12 with chronic inflammatory demyelinating polyneuropathy, and 1 with chronic relapsing polyneuropathy), 12 with associated malignancy (2.31%), 9 with dysproteinemia (1.73%), uremic in 22 (4.23%), hereditary motor and sensory in 22 (4.23%), toxic in 14 (2.69%), ischemic in 12 (2.31%), hypothyroidism in 10 (1.92%), nutritional deficiency and malabsorption in 6 (1.15%), chronic liver disease in 4 (0.77%), other diseases in 11 (2.12%) and unclassified in 63 (12.12%). This survey provided a crude etiological picture of generalized neuropathy on this island.

Immunosuppressive treatment in lower motor neuron syndrome with autoantibodies against GM1 ganglioside

We report the results of immunosuppressive treatment with intravenous cyclophosphamide in 12 patients with lower motor neuron syndrome and elevated titers of serum autoantibodies to GM1 ganglioside. All patients had lower motor neuron dysfunction including proximal or distal weakness, fasciculation and muscle atrophy, but no upper motor neuron dysfunction such as hyperreflexia, spasticity or Babinski's sign. Electrophysiological studies revealed no evidence of conduction block, but EMG findings of acute or chronic denervation in the limbs were present. Serum biochemistry and immunological studies were negative for M protein. After a 6-month follow-up, despite a fall in antibody titer, there was no significant clinical improvement in any of the patients.

Congenital muscular dystrophy of a non-Fukuyama type with white matter hyperlucency on CT scan

The term "congenital muscular dystrophy (CMD)" is used for a group of diseases with heterogeneous clinical and cranial CT scan manifestations. Recently, a distinct subtype, characterized by white matter hyperlucency on CT scan but normal or nearly normal intellectual function, has been recognized in Western peoples and has even been named "occidental-type cerebromuscular dystrophy." Here, we described two Chinese siblings with this type of CMD.

[Motor evoked potentials in patients with cervical spondylotic myelopathy]

We applied somatosensory and motor evoked potential studies to investigate patients with cervical spondylotic myelopathy (CSM) diagnosed clinically and roentgenographically. There were 32 consecutive cases collected, including 25 males and 7 females, at an average age of 62 +/- 8.2 (49-75) years. A control group consisted of 30 healthy subjects matched in body height and age with patients. The normal values of head-to-neck and head-to-lumbar region central motor conduction times (CMCTs) were 7.04 +/- 0.60 (6.1-8.2) and 15.94 +/- 1.23 (14.0-18.7) ms, which were not affected by body height. The somatosensory evoked potential (SEP) findings were related to clinical posterior column signs, levels of cord lesion, and nerves tested. The abnormality rate of median nerve SEP was relatively low, 53% (17/32), particularly for the lesion below C5-6 level in which median nerve SEP was usually normal. The abnormality rates of ulnar and tibial nerve SEPs were up to 84.5% (27/32) and 90.6% (29/32) respectively. However, median, ulnar and tibial nerve SEPs were normal in 3 (9.4%) patients showing normal posterior column function clinically. Only 18 (56.3%) patients had recordable motor evoked potential (MEP) from abductor digiti minimi (ADM) to head stimulation. The head-to-neck CMCT, 9.12 +/- 1.53 (6.3-12.7) ms, was significantly prolonged. Of these 18 cases there were 9 cases of delayed CMCT with reduced MEP amplitude, 4 of delayed CMCT, 3 of reduced MEP amplitude, and 2 of normal CMCT and MEP amplitude. The remaining 14 cases (43.7%) showed absent MEP from ADM to head stimulation. The overall abnormal rate of MEP from ADM was 93.8% (30/32). MEP from tibialis anterior (TA) to head stimulation was recorded only in 6 patients in whom the responses were all abnormal. There was no response recorded from TA in the remaining 26 CSM patients.(ABSTRACT TRUNCATED AT 250 WORDS)

QRS feature extraction using linear prediction

This communication proposes a method called linear prediction (a high performant technique in digital speech processing) for analyzing digital ECG signals. There are several significant properties indicating that ECG signals have an important feature in the residual error signal obtained after processing by Durbin's linear prediction algorithm. This communication also indicates that the prediction order need not be more than two for fast arrhythmia detection. The ECG signal classification puts an emphasis on the residual error signal. For each ECG's QRS complex, the feature for recognition is obtained from a nonlinear transformation which transforms every residual error signal to a set of three states pulse-code train relative to the original ECG signal. The pulse-code train has the advantage of easy implementation in digital hardware circuits to achieve automated ECG diagnosis. The algorithm performs very well in feature extraction in arrhythmia detection. Using this method, our studies indicate that the PVC (premature ventricular contraction) detection has at least a 92 percent sensitivity for MIT/BIH arrhythmia database.