Chiharu Yamaguchi

Urinary dysfunction in early and untreated Parkinson's disease

Background Urinary dysfunction is common in Parkinsons disease (PD); however, little is known about urinary dysfunction in early and untreated PD patients. Methods Fifty consecutive untreated PD patients (mean age, 66.7; mean disease duration, 23.6 months; and mean Hoehn & Yahr scale, 1.9) were recruited; those with other conditions that might have influenced urinary function were excluded. Patients were evaluated using a urinary questionnaire and urodynamic studies. Results Sixty-four per cent complained of urinary symptoms (storage, 64.0%; voiding, 28.0%). Urodynamic studies showed abnormal findings in the storage phase in 84%, with detrusor overactivity (DO) and increased bladder sensation without DO in 58.0% and 12.0% of patients, respectively. In the voiding phase, detrusor underactivity, impaired urethral relaxation such as detrusor sphincter dyssynergia, and bladder outlet obstruction were present in 50.0%, 8.0% and 16% of patients, respectively. In patients with both storage and voiding phase abnormalities, DO+detrusor underactivity was the most common finding. Few patients experienced urge incontinence and/or quality-of-life impairment owing to urinary dysfunction; none had low-compliance bladder or abnormal anal-sphincter motor unit potential. These urinary symptoms and urodynamic findings were not correlated with gender, disease severity or motor symptom type. Conclusion Urinary dysfunction, manifested primarily as storage disorders with subclinical voiding disorders and normal anal-sphincter electromyography, occurs in early and untreated PD patients. In cases with severe voiding disorder and/or abnormal anal-sphincter electromyography, other diagnoses should be considered.

HOW TO MANAGE OVERACTIVE BLADDER IN ELDERLY INDIVIDUALS WITH DEMENTIA? A COMBINED USE OF DONEPEZIL, A CENTRAL ACETYLCHOLINESTERASE INHIBITOR, AND PROPIVERINE, A PERIPHERAL MUSCARINE RECEPTOR ANTAGONIST

routine CSF analysis, and electroencephalography. Our case is highly unusual, with early neuroimaging abnormalities and near-normal routine CSF findings. PCR confirmed HSE the same day. This case emphasizes the importance of early neuroimaging in elderly patients suspected of having HSE without CSF abnormalities. PCR detection of HSV DNA in CSF is presently considered to be the reference standard but may be negative during the first 24 to 48 hours after onset of symptoms. Also, PCR sensitivity can diminish 5 to 7 days after commencing antiviral treatment. EEGs show temporal lobe involvement as well as characteristic PLEDs and are fairly sensitive, particularly during the first 48 hours, although lacking specificity. Several publications have recently reported on the diagnostic value of diffusion-weighted MRI, suggesting that it is more sensitive than conventional T2weighted sequences in the early detection of HSE, although conclusive studies have not yet been performed. CT scans typically reveal hypodensities in the temporal lobes and frontal lobes (unior bilaterally), rarely with hemorrhagic components, and show gadolinium enhancement only during later stages of the disease. T2-weighted and MRI imaging studies, as well as fluid attenuated inversion recovery and diffusion-weighted sequences, commonly show more-extensive abnormalities corresponding to tissue edema, often including the inferior frontal and medial temporal lobes, and insular cortex and often sparing the basal ganglia. The neuroradiological findings in this patient are typical for HSE, although they appeared unusually early. Diagnostic tools are evolving but presently do not offer high enough sensitivity to exclude the presence of HSV in the early stages of the disease. Our case report suggests that conventional MRI should be performed early in the absence of other diagnostic clues. The efficacy of acyclovir 10 mg/kg given every 8 hours for 21 days has been proven in two randomized clinical trials. The effect of dexamethasone as an adjuvant treatment on survival and neurological sequelae of HSE in adults is being studied in the German trial of Acyclovir and Corticosteroids in Herpes Simplex Encephalitis, which is planned to conclude in 2011. In our patient, early acyclovir treatmentFbefore a pleocytosis appearedFdid not have a significant effect on outcome.

Distinguishing focal fibrotic lesions and non-fibrotic lesions in hypertrophic cardiomyopathy by assessment of regional myocardial strain using two-dimensional speckle tracking echocardiography: Comparison with multislice CT

PURPOSE To distinguish focal fibrotic and non-fibrotic lesions in left-ventricular myocardium (LVM) in hypertrophic-cardiomyopathy (HCM)-subjects, we compared myocardial regional peak-strain values using two-dimensional speckle-tracking transthoracic-echocardiography (TTE) in multislice computed-tomography (CT)-detected fibrotic, non-fibrotic and normal control lesions. METHODS Twenty subjects (10 consecutive HCM-subjects (8-males, mean 63.4-years), 10 healthy controls (5-males, mean 51.5-years)) underwent speckle-tracking TTE (iE-33), and analysis of regional peak-longitudinal (LS) and radial-strain (RS), and corresponding strain rates in each of 17 LVM segments (American-Heart-Association classification). In HCM-subjects, fibrotic lesions were identified by early-phase defective enhancement and late-phase abnormal enhancement by CT (Light-Speed-Ultra-16). Regional peak LS and RS at basal, mid and apical levels were measured in MSCT-detected fibrotic and non-fibrotic LVM lesions. RESULTS In 10 HCM subjects, 143 lesions (84.1%) yielded good tracking on TTE. Twenty lesions showed fibrotic changes in 5 subjects by CT. Regional peak-LS and RS absolute values were significantly lower in both fibrotic and non-fibrotic lesions in HCM subjects than in controls at basal, mid, apical levels (all P<0.05). While peak-LS (%) absolute values were significantly lower in fibrotic than non-fibrotic lesions at basal, mid and apical levels (all P<0.05), regional peak-RS absolute values were significantly lower only at mid levels. LS was a more sensitive indicator than the corresponding rate, with better reproducibility. CONCLUSIONS In HCM, regional peak-LS was significantly lower in fibrotic than non-fibrotic lesions in LVM by CT. Regional peak-LS by speckle-tracking provides useful information noninvasively to distinguish fibrotic from non-fibrotic lesions in LVM in HCM and normal LVM in healthy controls.

Quantitative evaluation of left atrial volumes and ejection fraction by 320-slice computed-tomography in comparison with three- and two-dimensional echocardiography: A single-center retrospective-study in 22 subjects

PURPOSE To evaluate efficacy and reproducibility of 320-slice computed tomography (CT) for measuring left atrial (LA) maximum (LAVmax) and minimum volume (LAVmin) during the cardiac cycle, we compared CT with three- and two-dimensional (3D and 2D) transthoracic echocardiogram (TTE). MATERIALS AND METHODS LAVmax and LAVmin (ml), and LA ejection fraction (LAEF) (%) were assessed in 22 consecutive subjects (15 males, 59.5 ± 15.1 years) using retrospective electrocardiogram gated 320-slice CT (Aquilion One, Toshiba Medical) and 3D-TTE (IE-33, Phillips). LAVmax and LAVmin were selected from the time volume curve. LAEF was calculated as (LAVmax-LAVmin)/LAVmax×100(%). RESULTS Mean ± standard deviation (SD) of LAVmax and LAV min were significantly larger by CT than 3D-TTE or 2D-TTE (both P<0.01). LAEF was 25.3 ± 13.1% by CT, 30.2 ± 6.8% by 3D-TTE (P=NS) and 33.9 ± 8.9% by 2D-TTE (P<0.05). The correlation coefficients (CCs) between CT and 3D-TTE in LAVmax, LAmin, and LAEF were 0.64, 0.68 and 0.57, respectively. Mean difference ± 1.96SD of LAVmax, LAVmin and LAEF by Bland and Altman analysis calculated from CT minus 3D-TTE were 48.8 ± 59.1 ml, 41.1 ± 63.2 ml, and -4.9 ± 21.1%, respectively. The CCs and mean difference ± 1.96SD between CT and 2D-TTE had similar tendencies. The CCs of interobserver variation were (for CT, 3D-TTE, 2D-TTE, respectively): 0.90, 0.95 and 0.94 (LAVmax), 0.97 and 0.97 and 0.93 (LAVmin), and 0.64, 0.77 and 0.34 (LAEF). CONCLUSIONS 320-slice CT enables direct LAV measurements and has high reproducibility and positive correlation with 3D and 2D TTE. Absolute value of LAV by CT was larger than that by 3D and 2D TTE.

Prevalence and mechanism of bladder dysfunction in Guillain-Barré Syndrome.

To examine the prevalence and mechanism of urinary dysfunction in GBS.

Quantitative evaluation of right atrial volume and right atrial emptying fraction by 320-slice computed tomography compared with three-dimensional echocardiography

[3] Miwa K, Fujita M. “Small heart syndrome” in patients with chronic fatigue syndrome. Clin Cardiol 2008;31:328–33. [4] Miwa K, Fujita M. Cardiac function fluctuates during exacerbation and remission in young adults with chronic fatigue syndrome and “small heart”. J Cardiol 2009;54: 29–35. [5] Miwa K, Fujita M. Cardiovascular dysfunction with low cardiac output due to small heart in patients with chronic fatigue syndrome. Inter Med 2009;48: 1849–54. [6] Coats AJ. Ethical authorship and publishing. Int J Cardiol 2009;131:149–50.

Effects of Milnacipran and Paroxetine on Overactive Bladder due to Neurologic Diseases: A Urodynamic Assessment

Aims: To determine the effects of milnacipran hydrochloride, a serotonin-norepinephrine reuptake inhibitor (SNRI), or paroxetine hydrochloride, a selective serotonin reuptake inhibitor, on overactive bladder (OAB) in neurologic diseases, given by objective measures of urodynamic studies. Methods: This is a prospective open trial, and we enrolled 24 patients (16 men, 8 women; mean age, 63.9 years) with OAB in a neurology clinic. They were randomly allocated into two groups: the milnacipran group (11 patients), and paroxetine group (13 patients). We started with 100 mg/day of milnacipran or 40 mg/day of paroxetine. Before and 3 months after the treatment, we performed a urinary questionnaire and urodynamic studies. Results: Milnacipran reduced daytime urinary frequency (average, from 9.4 to 7.1 times, p < 0.001), improved the quality of life index (p = 0.023), and increased bladder capacity (average, from 289 to 377 ml, p = 0.009) as shown in urodynamic studies. No such changes were noted in the other categories of the lower urinary tract symptoms questionnaire or urodynamic studies, or in the paroxetine group. One male patient complained of mild voiding difficulty. Other adverse effects were not seen during the observation period. Conclusion: Milnacipran, an SNRI, increased bladder capacity as shown in urodynamic studies, and thereby ameliorated OAB in patients with neurologic diseases without serious adverse effects.

Real-time measurement of oxyhemoglobin concentration changes in the frontal micturition area: an fNIRS study

To explore brain activity in the frontal micturition area during natural bladder behavior.

Calcium polycarbophil improves constipation in primary autonomic failure and multiple system atrophy subjects

Constipation is a frequent symptom in patients diagnosed with pure autonomic failure (PAF; Table 1) and multiple system atrophy (MSA).1 Calcium polycarbophil is a calcium salt of polyacrylic acid cross-linked with divinyl glycol.2 Unlike prokinetic drugs (e.g., cisapride3 and mosapride), it is chemically inert and not absorbed by means of the intestine, similar to other dietary fibers (e.g., psyllium4 and Macrogol 33505). The aim of our study was to determine the effects of polycarbophil on constipation as measured objectively by transit time (CTT) in 5 patients with PAF or MSA. Studies were carried out before and 12 weeks after the administration of 1.5 g/day (t.i.d.) of polycarbophil. Case 1 had PAF and the other 4 had the cerebellar form of MSA (MSA-C), all diagnosed according to published criteria.6 Two patients needed assistance with walking (Cases 3, 4), while the rest could walk independently. All patients had severe bladder dysfunction; one (Case 3) needed to perform clean, intermittent self-catheterization. Before polycarbophil, four had decreased bowel frequency ( 3 times/week), all had difficulty with defecation, but none had fecal incontinence. All patients had slow CTT1,2 (Fig. 1). Rectoanal videomanometry1 performed in 3 patients (Cases 2, 3, 5) demonstrated decreased spontaneous phasic rectal contractions (SPRC) in Case 5, increased phasic anal contractions in Case 2, and paradoxical sphincter contraction on defecation (PSD, or anismus) in Case 2. No significant abnormalities were documented in Case 3. Blood chemistry and urinalysis were normal in all. None of the patients was taking anticholinergic agents. Statistical analysis was carried out with Student’s t test. Significance was set at P 0.05. All data are presented as means standard deviation. Polycarbophil was tolerated by all patients. None reported abdominal pain or other adverse effects. After the administration of polycarbophil, all patients reported easier defecation and all except Case 4 reported increased bowel movement frequency. None of the patients developed fecal incontinence. Significant group improvement occurred for total CTT (P 0.029) and both right (P 0.019) and left (P 0.23) CTT. Rectosigmoid transit time improved in 3 of 5 patients but the group mean change did not reach statistical significance (P 0.419; Fig. 1). On polycarbophil, milder cases (Cases 3, 4, 5) achieved normal CTT values, whereas the more severe improved but remained in the pathological range. Whereas the exact cause of constipation in PAF is not well known, in MSA patients, both parasympathetic (slow colonic transit, decreased SPRC) and somatic nerve disorders (weak abdominal strain, PSD, and sphincter weakness) underlie this condition.1 Some of these conditions were documented in our patients before polycarbophil treatment. This open trial showed for the first time that polycarbophil improved colonic motility as shown in CTT, and ameliorated constipation in autonomic failure patients without serious adverse effects. Polycarbophil may improve lower gastroin-

Pelvic Organ Dysfunction Is More Prevalent and Severe in MSA-P Compared to Parkinson's Disease

It is usually difficult to distinguish between idiopathic Parkinsons disease (PD) and parkinsonian‐type multiple system atrophy (MSA‐P) in the early stage. However, it is important to make a careful early‐stage diagnosis. Therefore, we determined whether an examination of pelvic organ dysfunction would be helpful to distinguish between PD and MSA‐P.