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This study aimed to elucidate the role of sex in neurocognitive function in patients with Parkinson’s disease (PD). Ninety-four idiopathic PD and 167 healthy elderly as normal controls (NCs) were recruited and underwent comprehensive neuropsychological assessments. The sex difference were found in NCs but not in PD. In male, PD patients had worse performance on the Digit symbol substitution (DSS) (p

BACKGROUND Social functioning is crucial for the determinants of Parkinson's disease (PD) with dementia; however, there is no social functioning scale applicable to PD. OBJECTIVE This study aimed to develop a social functioning scale specific to PD (PDSFS) and provide a cut-off score to improve diagnosis accuracy. METHODS The items were developed through literature, interview patients, and PD expertise. After the pilot study, one hundred fifty-seven patients and 74 healthy participants were enrolled and completed the Mini-Mental State Examination, Clock Drawing Test, Activities of Daily Living, Neuropsychiatric Inventory, Adaptive Behavior Assessment System-Second Edition (ABAS-II) and part III of the Movement Disorder Society-sponsored revision of the Unified Parkinson's Disease Rating Scale (MDS-UPDRS). RESULTS The final PDSFS has 23 items. The exploratory factor analysis revealed three factors, including "Family Life, Hobbies and Self-Care", "Interpersonal Relationship and Recreational Leisure", and "Social Bond". The internal consistency coefficient was 0.883, and the test-retest reliability was 0.774, respectively. The total score of the PDSFS was significantly related to the total score of ABAS-II (r = 0.609, p

Spasticity and pain in the masticatory muscles or mouth opening limitation have been reported as early signs and symptoms of amyotrophic lateral sclerosis (ALS). These signs and symptoms are also frequently seen in, and thus mistaken for, temporomandibular disorders (TMD).The authors report a case of ALS initially presenting with signs and symptoms of TMD. The TMD was followed by dysarthria of insidious onset, leading to the diagnosis of ALS. This case highlights the importance of considering TMD as a potential early form of presentation of ALS, requiring multidisciplinary treatment, especially by dental professionals.A review of the literature was conducted to elucidate the oral and facial signs and symptoms of ALS and to identify ways of improving the quality of life of patients through a multidisciplinary approach.

Patients with parkinsonism or other movement disorders may visit the emergency department due to acute deterioration of neurological status or consciousness disturbance. Under such circumstances, patients may be misdiagnosed as having a hyperacute stroke, i.e. stroke mimic. The purpose of the present study was to explore the clinical features and consequences of patients with parkinsonism or other movement disorders presenting as stroke mimics with activation of a stroke code.In this retrospective case-series study, we reviewed the charts and stroke code registry data in two stroke centers with high volume of stroke codes and thrombolytic therapy in the Southern Taiwan.We found seven male patients (67.0 ± 12.8 years old): one with focal myoclonus, one with focal dystonia, and the other five with parkinsonism. The chief problems for emergency department visit included acute consciousness disturbance in one patient and motor weakness in other six patients. Five of the six patients with motor weakness complained unilateral symptoms. Six patients were evaluated by neurology residents (five by second-year residents, one by a third-year resident) and one by a board-certified neurologist, while a misdiagnosis of a stroke was made in three patients. All patients experienced neurological improvement when follow-up. One patient who received intravenous thrombolytic therapy had no intracranial hemorrhagic complications.Although rare, parkinsonism or other movement disorders may present as a stroke mimic with activation of a stroke code. Consulting neurologists should clarify the etiology for those patients with acute consciousness disturbance or motor weakness and avoid unnecessary thrombolysis. Key Words: Parkinson disease, parkinsonism, movement disorders, stroke code, thrombolysis.

Research has shown that moving targets help Parkinson's disease (PD) patients improve their arm movement while sitting. We examined whether increasing the speed of a moving ball would also improve standing postural control in PD patients during a virtual reality (VR) ball-catching task. Twenty-one PD patients and 21 controls bilaterally reached to catch slow-moving and then fast-moving virtual balls while standing. A projection-based VR system connected to a motion-tracking system and a force platform was used. Dependent measures included the kinematics of arm movement (movement time, peak velocity), duration of anticipatory postural adjustments (APA), and center of pressure (COP) movement (movement time, maximum amplitude, and average velocity). When catching a fast ball, both PD and control groups made arm movements with shorter movement time and higher peak velocity, longer APA, as well as COP movements with shorter movement time and smaller amplitude than when catching a slow ball. The change in performance from slow- to fast-ball conditions was not different between the PD and control groups. The results suggest that raising the speed of virtual moving targets should increase the speed of arm and COP movements for PD patients. Therapists, however, should also be aware that a fast virtual moving target causes the patient to confine the COP excursion to a smaller amplitude. Future research should examine the effect of other task parameters (e.g., target distance, direction) on COP movement and examine the long-term effect of VR training.

Internal responsiveness of HRQoL in the stable patient group. (DOCX 20 kb)

Objectives Generic and disease-specific health-related quality of life (HRQoL) instruments may reflect different aspects of lives in patients with Parkinson’s disease (PD) and thus be associated with different determinants. We used the same cluster of predictors for the generic and disease-specific HRQoL instruments to examine and compare the determinants of HRQoL. Method HRQoL was measured in 92 patients with PD by the 36-item Short-Form Health Survey (SF-36) and the 39-item Parkinson’s Disease Questionnaire (PDQ-39). The predictors included demographic and disease characteristics, and motor and non-motor symptoms. Multiple regression analyses were used to identify HRQoL determinants. Results Depressive symptoms and motor difficulties of daily living were the first two significant determinants for both instruments. The other significant determinant for the SF-36 was fatigue and non-motor difficulties of daily living, and for the PDQ-39 was motor signs of PD. Conclusions The results suggest the importance of the evaluation and intervention focused on depressive symptoms and motor difficulties of daily living in patients with PD. In addition, the SF-36 seems more related to non-motor symptoms, while the PDQ-39 appears more associated with motor symptoms. This information is important for understanding results from these two instruments and for choosing which to use.

Changed scores of measures in three groups. (DOCX 17 kb)

Proprioceptive deafferentation of spinal cord origin can cause pseudoathetosis, sensory ataxic gait, or both. The co-existence of pseudoathetosis and sensory ataxic gait caused by a surgically treatable condition of the spinal cord has been rarely reported. An 80-year-old man with cervical spondylotic myelopathy presented with severe sensory ataxic gait which confined him to a wheelchair. He also had poor control of his hands due to the pseudoathetoid movements of the fingers, which prevented him from sustaining constant muscle contraction. He underwent C3-4 and C4-5 anterior discectomies and anterior fusion. His neurological deficits gradually improved after the decompressive surgery. About 7months postoperatively, he was totally independent in activities of daily living and needed no mobility aid. This case highlights the clinical importance of recognizing a surgically treatable and reversible condition of the spinal cord that causes pseudoathetosis and sensory ataxic gait.

We used a trunk-assisted prehension task to examine the effect of task (reaching for stationary vs. moving targets) and environmental constraints (virtual reality [VR] vs. physical reality) on the temporal control of trunk and arm motions in people with Parkinson's disease (PD). Twenty-four participants with PD and 24 age-matched controls reached for and grasped a ball that was either stationary or moving along a ramp 120% of arm length away. In a similar VR task, participants reached for a virtual ball that was either stationary or moving. Movement speed was measured as trunk and arm movement times (MTs); trunk-arm coordination was measured as onset interval and offset interval between trunk and arm motions, as well as a summarized index-desynchrony score. In both VR and physical reality, the PD group had longer trunk and arm MTs than the control group when reaching for stationary balls (p

BACKGROUND AND PURPOSE The pathological process of Huntington's disease (HD) preferentially targets spiny neurons in the striatum, with later involvement of the substantia nigra and other structures. The purpose of this study is to investigate the nigrostriatal dopaminergic system in a genetically confirmed HD family. METHODS We used single photon emission computed tomography (SPECT) with the radiotracers [99mTc]TRODAT-1 and [123I]IBZM to study the binding potentials of dopamine transporter (DAT) and dopamine D2 receptors in the striatum of 3 symptomatic HD patients, 1 mutation-negative member of the HD family, and 7 healthy controls. Specific binding potentials were calculated as (striatum-occipital lobe)/occipital lobe. RESULTS Reduced binding potential of striatal dopamine D2 receptors was found in the 3 symptomatic HD patients. The DAT binding potential was reduced in 1 symptomatic HD patient. We also found that the more severe the clinical status, the lower the DAT and D2 receptor binding potentials, and the larger the bicaudate ratio. CONCLUSIONS We showed that the postsynaptic part of the nigrostriatal pathway was involved. The presynaptic part is usually not affected but could occur in very advanced cases. Our findings suggest that SPECT imaging of D2 receptors is useful for diagnosing and monitoring HD.

Background/Aims: Intravenous tissue plasminogen activator (tPA) treatment is recommended in acute stroke within 3 h of onset; however, the benefit of its use in the elderly remains uncertain. We assessed the safety and efficacy of tPA treatment in elderly patients. Methods: We recruited 97 elderly Chinese patients aged ≧80 years with cerebral ischemia presenting within 3 h of onset. Favorable outcomes were defined as discharge to home and modified Rankin Scale (mRS) ≤2 at discharge. Results: For moderate to severe patients (NIHSS ≧6), the baseline characteristics between the tPA (n = 30) and non-tPA (n = 41) group were not different. The proportion of patients discharged home was 56.7 and 61%, respectively (p = 0.72). For patients with baseline mRS ≤2, the frequency of discharged mRS ≤2 was not different (27.3% of the tPA group and 26.9% of the non-tPA group; p = 1.00). Symptomatic intracranial hemorrhage was 6.7 and 2.4%, respectively (p = 0.31). For minor stroke patients (NIHSS ≤5), tPA was not considered and the outcome of those discharged home and mRS ≤2 was 73 and 88%, respectively. Conclusion: Elderly patients can be treated safely with intravenous tPA, whereas our data did not support routine thrombolysis. Further randomized trials in the elderly are encouraged.

Objective: To investigate the effect of eating utensil weight on kinematic performance in people with Parkinson’s disease. Design: A counterbalanced repeated-measures design. Setting: A motor control laboratory in a university setting. Subjects: Eighteen adults with Parkinson’s disease and 18 age-matched controls. Experimental conditions: Each participant performed a food transfer task using spoons of three different weights: lightweight (35 g), control (85 g) and weighted (135 g). Kinematic variables of arm movement were derived and compared between conditions. Main measures: Kinematic variables of arm movement, including movement time, peak velocity and number of movement units. Results: Utensil weights significantly affected the movement kinematics of all participants. Both groups had fewer movement units in the lightweight condition (Parkinson’s disease group: 22.18, controls: 19.89) than in the weighted condition (Parkinson’s disease group: 22.68, controls: 21.36), suggesting smoother movement in the former condition. In addition, both groups had higher peak velocity in the lightweight than in the weighted condition. Conclusions: Our findings suggest that a lightweight utensil may facilitate smoother and higher-velocity arm movement than a weighted one in people with Parkinson’s disease.

Objective: To examine, in a dual-task paradigm, the effect of auditory stimuli on people with Parkinson's disease. Design: A counterbalanced repeated-measures design. Setting: A motor control laboratory in a university setting. Subjects: Twenty individuals with Parkinson's disease. Experimental conditions: Each participant did two experiments (marching music experiment and weather forecast experiment). In each experiment, the participant performed an upper extremity functional task as the primary task and listened to an auditory stimulus (marching music or weather forecast) as the concurrent task. Each experiment had three conditions: listening to the auditory stimulus, ignoring the auditory stimulus and no auditory stimulus. Main measures: Kinematic variables of arm movement, including movement time, peak velocity, deceleration time and number of movement units. Results: We found that performances of the participants were similar across the three conditions for the marching music experiment, but were significantly different for the weather forecast experiment. The comparison of condition effects between the two experiments indicated that the effect of weather forecast was (marginally) significantly greater than that of marching music. Conclusions: The results suggest that the type of auditory stimulus is important to the degree of interference with upper extremity performance in people with Parkinson's disease. Auditory stimuli that require semantic processing (e.g. weather forecast) may distract attention from the primary task, and thus cause a decline in performance.

Objective: To examine the effect of spoon-handle size on kinematic performance in people with Parkinson's disease. Design: A counterbalanced repeated-measures design. Setting: A motor control laboratory in a university setting. Subjects: Eighteen individuals with Parkinson's disease and 18 age-matched controls. Experimental conditions: Each participant was instructed to scoop water (simulated soup) using spoons with three different-sized handles. Main measures: Kinematic variables (movement time, peak velocity and number of movement units) of arm movement, size of hand aperture and number of fingers to grasp the spoon. Results: The movement of the participants with Parkinson's disease was faster (shorter movement time) and smoother (fewer movement units) when they used spoons with a small- or medium-sized handle than when using a spoon with a large-sized handle. In contrast, the healthy controls showed no significant differences in movement kinematics between handle sizes. Moreover, the participants with Parkinson's disease had a significantly smaller hand aperture and used more fingers to hold the spoons than the controls did. Conclusions: These results suggest that, for people with Parkinson's disease, a small-to-medium-sized handle is more suitable than a large-sized built-up handle.

The trend toward international cooperation in research projects emphasizes the need to translate existing validated tools into local languages. The purpose of this study was to test the reliability and validity of a Chinese-translated version of the 39-item Parkinson's Disease Questionnaire (PDQ-39). Seventy-three Taiwanese individuals with Parkinson's disease were consecutively recruited. The internal consistency reliability was satisfactory for all domains (Cronbach's alpha = 0.80-0.96), except for the social support, cognition, and bodily discomfort domains (alpha = 0.58-0.63). The convergent validity was also supported by strong correlations between domains measuring related constructs of the PDQ-39 and Unified Parkinson's Disease Rating Scale (r = 0.81-0.86), and between those of the PDQ-39 and SF-36 (r = -0.70--0.93). Except for the bodily discomfort domain, all domains of the PDQ-39 significantly discriminated patients at different stages, as indicated by the Hoehn and Yahr scale. Overall, the results of this study are consistent with the reports of the PDQ-39 in other countries (e.g., UK, Spain, US, and Greece), which suggests that the PDQ-39 is appropriate for use among Taiwanese individuals with PD. This study lays the foundation for future combinations and comparisons of data cross-nationally.

We report the clinical and dopamine transporter/D2 receptor single-photon emission computed tomographic (SPECT) imaging findings in a 39-year-old woman with a 24-year history of dopa-responsive dystonia (DRD). The SPECT imaging of the dopamine transporter with [99mTc]TRODAT-1 is helpful in differentiating DRD from early-onset idiopathic parkinsonism. In the later clinical course, the [123I]IBZM SPECT is also helpful in differentiating these two conditions. The patient showed a dramatic and sustained response to levodopa, and needed a smaller dose of levodopa for symptom control in the later course.

Munksgaard 2001.Objectives – Fatigue is a disabling and dopa-resistant symptom inParkinson’s disease (PD). Pathological studies have shown that bothperipheral and central cholinergic systems are involved in PD.Electrophysiological investigation showed decremental muscleresponses following repetitive nerve stimulation (RNS). We hypothe-sized that fatigue in PD patients may be secondary to cholinergic defectat the neuromuscular level. Material and methods – Twenty PD patientswith disabling fatigue symptoms were enrolled. We used stimulatedsingle fiber electromyography (s-SFEMG) to evaluate the neuromus-cular junction of these patients. For every patient, at least 15 musclefibers were tested at the rate of 10 Hz with the method described byTrontelj et al. The individual mean consecutive difference (i-MCD) wasobtained from 100 constant consecutive single fiber potentials. Thei-MCD values in each patient were averaged to obtain the mean MCD(m-MCD). Results – None of the 20 PD patients with disabling fatiguesymptoms had an m-MCD over 29 ms or more than 10% of the i-MCDvalues over 41 ms. The neuromuscular junction was intact in terms ofnormal jitter (expressed as MCD) and an absence of blocking.Conclusion – Our findings indicate that the cholinergic system at theneuromuscular level is not affected in PD patients with fatiguesymptoms.W. J. Hwang, T. S. Lin

Two experiments were designed to investigate effects of cueing upon aptitude for shifting by patients with Parkinson's disease. Subjects executed in alternation two different components of a task set over successive items in a list. We compared the costs of shifting when the stimulus ensemble remained constant from trial to trial (“uniform” lists), with the case in which a change of stimulus ensemble cued each shift of task (“mixed” lists). Shift costs with mixed lists were significantly smaller than those with uniform lists (Exp. 1, ns=12). This suggests that patients with Parkinson's disease can benefit from cues about the stimulus ensemble in performing tasks. Patients' shifting performance was different from that of controls only in a reversalshift condition of the previously consistent stimulus-response mappings (Exp. 2, ns = 12). This result suggests that patients with Parkinson's disease suffer from a specific but not a general deficit in ability to shift.

Research into Parkinson's disease has made much use of the precuing paradigm developed by Posner to examine patients' ability to shift visuospatial attention. The majority of studies indicate that patients with Parkinson's disease have significantly reduced shift costs when compared with normal controls. This reduction in costs is ascribed to abnormal maintenance of attention resulting from Parkinson's disease. We know that visual attention is not directed to spatial locations alone but that it may also be directed to object representations. To date, however, it has not been clear whether the reduced shift costs apparent in Parkinson's disease patients are evident only on spatial locations or on both spatial locations and object representations. Therefore, in the current study we have adopted a new technique with a view to studying both location-based and object-based attentional components within the same paradigm. Our results with 17 patients with Parkinson's disease suggest, at least in the early stages, patients do not show deficits in maintenance of attention to the miscued source of stimulation as reflected in their normal magnitude of cuing effect related to shifting between locations and between objects. 14 normal persons were control subjects.

BACKGROUND: Blepharospasm can cause transient functional blindness that may cause catastrophic traffic accidents. METHODS: Sixty-six patients in southern Taiwan with idiopathic blepharospasm were enrolled. The incidence of and injuries from traffic accidents from the onset of blepharospasm symptoms to the first injection of botulinum toxin were analyzed. Data were collected from medical records and face-to-face interviews with patients and their families. RESULTS: Twenty-six patients (39.4%) had traffic accidents (21 motorcycle; 5 car). There were 5 incapacitating motorcycle injuries: 1 cervical spine injury with quadriparesis, 1 blunt abdominal injury with internal bleeding, 2 broken limbs, and 1 ligament rupture; 1 incapacitating car injury: broken limb of other person; and 11 non-incapacitating motorcycle injuries (abrasions, bruises, and minor lacerations). Nine patients were uninjured. CONCLUSIONS: Blepharospasm caused incapacitating injuries for motorcyclists themselves and another person in a car accident. Patients with untreated blepharospasm should avoid riding motorcycles and driving cars. Language: en

Orienting attention to visual stimuli was studied in 13 patients with Parkinson's disease whose responses were compared to those of a matched control group using a cued reaction-time task which measured cost and benefit effects of orienting of attention. Both groups were screened to exclude dementia, psychiatric disease, and other neurological abnormalities. Although Parkinson patients showed over-all slow mean reaction time, responses showed a pattern of cost and benefit effects similar to that of the control group. The results suggested that Parkinson patients are not impaired on visuospatial orienting of attention on this task.

The precueing paradigm developed by Posner has been used to examine visuospatial shifting of attention. In the current study, we modified such a paradigm so that it could be studied in nonvisuospatial domains and its component processes of disengagement, movement, and engagement could be analyzed in a similar fashion to the visuospatial domains. 14 patients with Parkinson's disease and 14 normal controls matched for age, sex, handedness, and years of education served as subjects. The speed of shifting attention was measured using the cost and benefit analysis. Analyses showed an over-all slowness in reaction time of patients with Parkinson's disease compared to the control group but without a concomitant slowness to engage, shift, and disengage their attention.

Olanzapine had been reported to be effective in the control of tics in a few adult female patients who had a short follow-up period. The author reports the successful outcome of long-term olanzapine treatment in an adult woman with severe Tourette syndrome.A 33-year-old woman who had severe motor and vocal tics (Modified Rush Videotape Rating Scale: 17/20) showed an excellent response to olanzapine 10 mg/day within 2 months. Her tic symptoms were well controlled with gradual reduction of her dose of olanzapine to 2.5 mg/day during the following 8 years. She was symptom-free without medications in the past 2 years. In addition, she had a normal menstrual cycle and became pregnant during the period of olanzapine treatment.Olanzapine may be the drug of first choice for treating severe Tourette syndrome in pubescent female adolescents and young women who wish to have children.

All published studies on micrographia, a diminution of letter size, examine handwriting in the horizontal direction. Writing horizontally typically requires increased wrist extension as handwriting progresses from left to right. Chinese characters, however, can be written not only horizontally from left to right, but also vertically from top to bottom. We examined the effect of handwriting direction on character size and stroke length. Fifteen participants with Parkinson’s disease (PD) and 15 age-matched controls wrote the same Chinese characters both horizontally and vertically. Handwriting performance was recorded with a digitizing tablet, and a custom-written computer program was used to provide objective data about character size and stroke length. The PD group had a linear decrease in overall character size and horizontal strokes along the writing sequence in the horizontal direction, but not in the vertical direction. The controls had shorter horizontal strokes in the horizontal than the vertical direction, but there was no progressive shortening of stroke length along the writing sequence. The results suggest that traditionally reported progressive micrographia in horizontal writing may not be generalizable to vertical writing. The observed decrease of handwriting size in the horizontal direction suggests that micrographia in PD may be associated with wrist extension. For clinical implications, patients may mitigate their micrographia by changing handwriting direction.

Objective: To investigate whether practising reaching for virtual moving targets would improve motor performance in people with Parkinson’s disease. Design: Randomized pretest–posttest control group design. Setting: A virtual reality laboratory in a university setting. Participants: Thirty-three adults with Parkinson’s disease. Interventions: The virtual reality training required 60 trials of reaching for fast-moving virtual balls with the dominant hand. The control group had 60 practice trials turning pegs with their non-dominant hand. Main outcome measures: Pretest and posttest required reaching with the dominant hand to grasp real stationary balls and balls moving at different speeds down a ramp. Success rates and kinematic data (movement time, peak velocity and percentage of movement time for acceleration phase) from pretest and posttest were recorded to determine the immediate transfer effects. Results: Compared with the control group, the virtual reality training group became faster ( F = 9.08, P = 0.005) and more forceful ( F = 9.36, P = 0.005) when reaching for real stationary balls. However, there was no significant difference in success rate or movement kinematics between the two groups when reaching for real moving balls. Conclusion: A short virtual reality training programme improved the movement speed of discrete aiming tasks when participants reached for real stationary objects. However, the transfer effect was minimal when reaching for real moving objects.

Epileptic seizures presenting as motor phenomena without concomitant conscious change may be confused with one of the paroxysmal movement disorders. Conversely, the attack of paroxysmal movement disorders may be thought to be epileptic due to a number of factors, including its sudden, unpredictable, and transient nature, its response to anticonvulsants, and the premonitory sensations preceding attacks. The distinction between epilepsy and movement disorders is further confused by the reports that these two conditions frequently occur in the same families or even in the same patients. Recent studies show that a few epilepsy and paroxysmal movement disorders are "channelopathies", indicating that they may share some common pathophysiology and a possible "overlap". A good quality of history, a trial to reproduce the motor phenomena, the application of video-EEG, polysomnography, and other electrophysiological recordings, together with regular follow-up are important for differentiating these two conditions.

The good clinical effectiveness of dopamine depleter and receptor antagonists on tics suggests dopaminergic hyperactivity in Tourette syndrome (TS). In this case-control study of 10 TS patients and 15 age-matched healthy controls, we evaluated (i) presynaptic and postsynaptic striatal dopaminergic function using [(99m)Tc]TRODAT-1/[(123)I]IBZM single photon emission computed tomography (SPECT) and (ii) correlations between dopamine transporter (DAT)/D2 receptor binding sites and tic severity scores. Patients 1-5 were pretreated with haloperidol and were drug free for at least 3 months before SPECT imaging. Patients 6-10 were drug-naive. We found no significant difference in DAT and D2 receptor binding sites between TS patients and healthy controls nor any association between striatal DAT or D2 receptor binding sites and tic severity assessed using the Modified Rush Videotape Rating Scale. Our findings provided no direct evidence of abnormally available striatal DAT or dopamine D2 receptors in TS. However, functional abnormalities of the dopaminergic system, e.g., alterations in the synaptic release of endogenous dopamine, cannot be completely ruled out.

Phenytoin is a commonly prescribed antiepileptic drug. Due to its saturation (zero-order) pharmacokinetics, phenytoin carries a special risk of dose-related toxicity that is an important issue in emergency medicine. The purpose of this cross-sectional case-series study was to investigate the causes, symptoms, misdiagnoses, and outcomes of acute phenytoin intoxication. It was based on a retrospective chart review of 30 inpatients (mean age, 41.6 +/- 22.8 years) with 36 episodes of acute phenytoin intoxication at our university hospital in the past 13 years. The average initial serum phenytoin level was 47.3 +/- 9.7 microg/mL (range, 27.9-70.4 microg/mL). Excessive self-medication, misunderstanding of the prescription order, and probable drug interaction were the three leading causes of acute phenytoin intoxication. Unsteady gait, dizziness/vertigo, nausea/vomiting, general weakness, and drowsiness were the most common presenting symptoms. The tentative diagnostic accuracy was 67%. The most common initial misdiagnosis was brainstem or cerebellum stroke (14%). The clinical course in all patients was uneventful under temporary withdrawal of phenytoin and supportive care. We concluded that acute phenytoin intoxication was relatively under-diagnosed in the emergency service. Although acute phenytoin intoxication causes no mortality and has a good outcome, the unsteady gait increases the risk of injuries caused by falls. The management of acute phenytoin intoxication includes temporary withdrawal of phenytoin and supportive care.

Functional medical imaging, such as PET or SPECT, is capable of revealing physiological functions of the brain, and has been broadly used in diagnosing brain disorders by clinically quantitative analysis for many years. In routine procedures, physicians manually select desired ROIs from structural MR images and then obtain physiological information from correspondent functional PET or SPECT images. The accuracy of quantitative analysis thus relies on that of the subjectively selected ROIs. Therefore, standardizing the analysis procedure is fundamental and important in improving the analysis outcome. In this paper, we propose and evaluate a normalization procedure with a standard 3D-brain model to achieve precise quantitative analysis. In the normalization process, the mutual information registration technique was applied for realigning functional medical images to standard structural medical images. Then, the standard 3D-brain model that shows well-defined brain regions was used, replacing the manual ROIs in the objective clinical analysis. To validate the performance, twenty cases of I-123 IBZM SPECT images were used in practical clinical evaluation. The results show that the quantitative analysis outcomes obtained from this automated method are in agreement with the clinical diagnosis evaluation score with less than 3% error in average. To sum up, the method takes advantage of obtaining precise VOIs, information automatically by well-defined standard 3-D brain model, sparing manually drawn ROIs slice by slice from structural medical images in traditional procedure. That is, the method not only can provide precise analysis results, but also improve the process rate for mass medical images in clinical.

We report the clinical and dopamine transporter/D2 receptor single-photon emission computed tomographic (SPECT) imaging findings in a 39-year-old woman with a 24-year history of dopa-responsive dystonia (DRD). The SPECT imaging of the dopamine transporter with [(99m)Tc]TRODAT-1 is helpful in differentiating DRD from early-onset idiopathic parkinsonism. In the later clinical course, the [(123)I]IBZM SPECT is also helpful in differentiating these two conditions. The patient showed a dramatic and sustained response to levodopa, and needed a smaller dose of levodopa for symptom control in the later course.

The purpose of this study was to evaluate the contribution of the postsynaptic mechanism to the development of motor fluctuation in advanced Parkinson’s disease (PD). We used 123I-iodobenzamide single-photon emission computed tomography to measure the striatal dopamine D2 receptor densities in early levodopa-naïve PD, chronic PD with stable levodopa response, and advanced PD with fluctuating levodopa response. The basal ganglia/frontal cortex ratios at both hemispheres were calculated and averaged. PD patients with fluctuating levodopa response showed a significant decrease in striatal dopamine D2 receptor densities compared to those with early (1.57 ± 0.20 vs. 1.77 ± 0.12, p = 0.009) or chronic stable PD (1.57 ± 0.20 vs. 1.77 ± 0.10, p = 0.024). We conclude that the decreased D2 receptor densities in advanced PD reduced the ‘safety factor’ for synaptic transmission and contributed to the development of motor fluctuation.