Balance in essential tremor during tandem gait: is the first mis-step an important finding?

Essential tremor (ET) is the most commonly diagnosed movement disorder. ET may cause substantial loss of motor skills and balance with advanced age. We compared abnormalities in tandem gait with daily activity and Fahn-Tolosa-Marin Tremor Rating Scale (FTMTRS) scores in 90 ET patients. All patients performed a 15-step tandem three times. The mean of first mis-steps was accepted as the tandem index (TI). The mean age was 61.4 ± 17 years; the mean duration of tremor was 6.7 ± 4 years; and there were 36 men and 54 women. There was no significant difference for age or sex between patients and controls. Head (24.6%), jaw (5.5%), voice (11%), and tongue tremors (1.5%) were identified in ET patients. Rest (2.5%), postural (95%), and kinetic tremors (54%) were detected in the upper extremities. Postural tremor was found in the lower extremities of 5%. The mean TI was 8.3 ± 4 (median, 8) in ET patients, and 10.6 ± 3.9 (median, 10) in controls (p=0.04). Correlation analysis of TI and FTMTRS scores showed tandem gait was significantly correlated with age, total tremor score, postural and kinetic extremity tremor, writing, drawing, pouring, feeding, and working scores. Linear regression showed a significant effect of age and FTMTRS score on TI. The decrease in balance control is apparent with advancing age. Balance disorders were more pronounced in ET patients. Although first mis-step in tandem gait is not as detailed as dynamic balance tests, it can be a simple method for detecting balance disorders.

Our surgical approach to treatment of congenital, developmental, and acquired breast asymmetries: a review of 30 cases.

BACKGROUND: Peer pressure and the modern definition of beauty have led people to strive for breast perfection. The aim of our study was to emphasize the importance and frequency of nonmastectomy-related breast asymmetry and explain our approach to such patients using a combination of techniques. METHODS: We retrospectively reviewed 30 patients with nonmastectomy breast asymmetry (i.e., patients with Poland's syndrome, tumors, burns, and tuberous breasts) admitted to our clinic between 2001 and 2011. Patients were followed up for a mean of 25 months postoperatively (range 4-72 months). These patients completed a satisfaction questionnaire regarding scarring, size, symmetry, shape, and nipple-areola complex sensation. RESULTS: Patient distribution and preferred treatment method according to etiology were screened. For mild Poland's syndrome, breast implants with symmetrization procedures (when needed) were used. In two patients, however, fat grafting was sufficient to correct the deformity. For severe Poland's syndrome, a tissue expander was first placed and wrapped by regional local flaps, such as the pedicled latissimus dorsi muscle flap, accompanied by fat grafting for infraclavicular depression and an absent anterior axillary fold. After adequate expansion of the skin and muscle flap, a silicone prosthesis replaced the tissue expanders. CONCLUSIONS: Tissue expanders with or without muscle flaps along with fat grafting in multiple sessions are necessary steps in the treatment of breast asymmetry. Knowledge and application of multiple techniques in a step-by-step fashion helps the surgeon to achieve optimal functional and aesthetic results for each patient. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors http://www.springer.com/00266 .

Neurophysiological and morphological responses to treatment with acetyl-L-carnitine in a sciatic nerve injury model: preliminary data.

We investigated the effects of acetyl-L-carnitine (ALCAR) on the recovery of sciatic nerve injuries in rats. Sprague Dawley rats were randomized to two groups: ALCAR treated (for 14 days) and control. Each group was divided into three subgroups: distal transection, proximal transection, and grafted. Distal latencies, amplitudes, and motor nerve conduction velocities were measured. In the third month, biopsies were taken and examined under light microscopy. Electrophysiological measurements demonstrated that regeneration occurred earlier and was better in the ALCAR group, particularly in the distal transection subgroup. Better results were obtained in the distal transection subgroup in terms of axonal regeneration compared with the proximal transection and grafted subgroups because the regenerating segment was shorter. ALCAR enhanced the quality of neural recovery at the different levels and in different types of repair, and led to a decline in nerve death.

Painless burn injury caused by post-traumatic syringomyelia.

BACKGROUND: Syringomyelia, which is generally related to congenital malformations and tumors, may lead to paresthesia and dysfunctions in thermo-algesic perception. Post-traumatic syringomyelia (PTS) is a rare type of this disease characterised by the development of a cystic formation containing cerebrospinal fluid (CSF), which develops inside the spinal cord after spinal trauma. AIM: The description of a case diagnosed as painless burn injury caused by PTS. METHOD: One case report. CONCLUSION: Although there are a number of reports regarding the formation of neuropathic ulcers related to syringomyelia, painless burn injury descriptions are very rare. Despite available limited data related to this subject, it is important to warn patients about traumas-especially burns-after a diagnosis of PTS.

Long term and frequent electrophysiological observation in carpal tunnel syndrome.

AIM: Carpal tunnel syndrome (CTS) is one of the most common compression neuropathies in neurology. Electromyography (EMG) including nerve conduction study (NCS) is the most useful diagnostic technique for CTS. In this study, we aim to demonstrate changes in electrophysiological parameters in different level of CTS patients by frequent EMG studies. METHODS: We prospectively followed patients with CTS regularly once every 12 weeks for 1 year. Fourteen women (28 hands) with EMG/NCS findings of CTS were observed and classified in 3 groups according to electrophysiological severity. All patients were instructed to wear the splint for 12 weeks. At the end of this period, patients were evaluated by electrophysiologic parameters. If findings were still abnormal, they were encouraged to continue wearing the splint. In severe cases, surgical release was carried out. RESULTS: No statistically significant changes were noted in EMG recordings of mild cases repeated every 3 months. It was determined that significant improvements begin to occur in the moderate group in all parameters, except for the amplitude of the median sensory nerve. However, when the mean values were studied in the severe CTS group, it was observed that the preoperative motor and sensory parameters became increasingly impaired, but approached the initial values in the first evaluation in the postoperative period. CONCLUSION: Subjects with CTS, particularly moderate as determined by electrophysiology, may benefit from conservative therapy, with improvements which continue for about one year. In severe cases the main treatment modality seems to be operation. Frequent electrophysiological follow-ups may be useful in guiding treatment.

The electrophysiological findings of subclinical neuropathy in patients with recently diagnosed type 1 diabetes mellitus.

To assess the prevalence of subclinical neuropathy within the first year of type 1 diabetes mellitus, 30 patients and 14 healthy subjects have been studied prospectively. The patients whose diabetes duration was longer than 1 year have been excluded from the study. Control group consisted of healthy volunteers. Subjective neuropathy symptoms, neurological examination, and electrophysiological findings were evaluated. All patients were clinically asymptomatic. At least two abnormal independent neurophysiological nerve parameters, which were required as the criterion of the peripheral nervous system subclinical involvement, were found as in 96.6% of diabetic patients in the first years. The percentages of abnormal electrophysiological parameters in different motor and sensory nerves were 86.7% in sural nerve, 83.3% in peroneal motor nerve, 73.3% in posterior tibial motor nerve, 66.7% in median motor nerve, 63.3% in ulnar motor nerve, 60% in median sensory nerve, and 46.7% in ulnar sensory nerve. While distal motor latency, F conduction time, and minimum F latency were the most frequent abnormal parameters in the upper extremity electrophysiological study; conduction velocity, minimum and mean F latencies, F conduction time were the most frequent abnormal parameters in the lower extremity. In all sensory nerve conduction studies, the most frequent abnormal parameter was the onset latency. In the autonomic sympathetic nerve electrophysiological study, plantar SSR latency was found significantly longer than the control group. In the lower extremity generally somatic motor fibres, sensory large fibres and sympathetic autonomic nerve fibres were found to be more affected. There is a correlation between HbA1c levels and nerve conduction velocity in posterior tibial and peroneal nerves. However, upper extremity nerve conduction dysfunction was not correlated with HbA1c value. Neither the duration of disease nor the age of the subject correlated with the nerve dysfunction.

Evaluation of autonomic nervous system functions in post-stroke patients.

OBJECTIVE: In this study, we aimed to investigate whether there is a sympathetic and parasympathetic system dysfunction in hemiplegic or hemiparetic patients after a cerebrovascular accident. DESIGN: Sympathetic skin response and R-R interval variation were evaluated in a total of 65 subjects: 37 hemiparetic or hemiplegic patients due to a cerebrovascular accident, seven acute (<30 days) and 30 chronic, with a mean age of 59.16 yr (32-76 yr), and 28 healthy subjects with a mean age of 57.07 yr (45-75 yr). Disease duration was 6.89 mo (1-32 mo) in the patient group. Bilateral sympathetic skin responses were recorded with stimulation of median nerves in both affected and unaffected sides. R-R interval variation was evaluated at rest (R%) and during deep breathing (DB%) at six times per minute. RESULTS: Although there was no significant difference between sympathetic skin response latencies of the patient and the control groups, the amplitude values of sympathetic skin response in patients were significantly lower than those in controls (P < 0.05). Both R% and DB% in patients significantly increased as compared with controls (P < 0.001 and P < 0.05, respectively). CONCLUSION: In conclusion, our results suggest that both sympathetic and parasympathetic functions in post-stroke survivors were partially inhibited, and this finding may be useful in the prediction of possible complications during rehabilitation.

Lesion localization in developing poststroke hand dystonia.

Reports of 9 cases with hand dystonia due to stroke are described. The site of the lesion was found to be parietothalamic in 1 patient, posterolateral thalamic in 5 patients, dorsal thalamic in 2 patients and medial thalamic in 1 patient as defined by computerized tomography or magnetic resonance imaging. In addition to the hand dystonia, hemiballism was noted in 1 case, hemichorea in 2 cases, action tremor in 3, anxiety in 3 and pain in 2 cases. The time lapse from the stroke to the manifestation of dystonia was 1 month to 2 years.

Relationship of leukoaraiosis to vascular risk factors and lesion type in stroke patients.

Nonspecific periventricular white matter lucencies on computed tomograms (leukoaraiosis) were found in 49 (55%) of 89 stroke patients. We compared the vascular risk factors and the types of stroke with and without leukoaraiosis. Patients with leukoaraiosis were significantly older than those without it. The duration of hypertension was longer than those without leukoaraiosis. Mean diastolic blood pressure was associated with leukoaraiosis. No association was found with systolic blood pressure, diabetes mellitus, angina pectoris, myocardial infarction, heart failure, valvular disease and intermittent claudication. Patients with leukoaraiosis were significantly more likely to have lacunar infarcts on computed tomograms but were less likely to have cortical infarcts, subcortical infarcts or cerebral hemorrhage.