伴有特殊体征的遗传性肩肱型脊髓性肌萎缩

目的报道一个进展缓慢的显性遗传性肩肱型脊髓性肌萎缩家系,探讨其临床特点和诊断规律.方法对一个家系三代进行调查,对1例先证者进行详细的临床和肌电图检查,及右肱二头肌活检标本进行组织学、组织化学和超微结构检查.结果本家系三代人每代均有发病者,共有4人发病,发病年龄在10～30岁左右,以缓慢进行性的颈肩带及双上肢肌肉萎缩和无力为特点,仅1例出现舌肌束颤,均伴有眼外肌麻痹、抬头困难和神经性耳聋,1例伴有双眼白内障.对其中1例病人行肌电图和肌肉活检结果显示为神经原性损害.结论此例的临床、电生理和肌肉病理检查符合显性遗传性肩肱型脊髓性肌萎缩的诊断,合并出现眼外肌麻痹和听神经损害是此家族的临床特点.     

眼咽远端型肌病一家系的咽喉功能观察以及骨骼肌病理特点

目的 报道1个眼咽远端型肌病家系的病理和电生理改变特点,分析其吞咽功能障碍的变化规律.方法 先证者为24岁女性,出现进行性加重的眼外肌麻痹、吞咽困难、构音障碍及四肢远端无力和萎缩2年.肌酸激酶轻度升高.家族同代人中还有5例在20～30岁出现类似症状.对先证者进行纤维咽喉镜吞咽功能检查和肌电图检查,对胫前肌进行肌肉病理检查.结果 纤维咽喉镜检查发现软腭上抬差,肌电图检查发现胫前肌呈现肌源性损害伴随肌强直现象.肌肉病理改变特点是肌纤维出现肥大、萎缩、间质纤维化,部分肌纤维内可见镶边空泡,电镜检查显示肌纤维的胞质内存在管丝包涵体.结论 临床和病理检查证实眼咽远端型肌病的存在,软腭运动障碍是出现咽喉症状的主要原因,此病存在肌强直的电生理改变特点.     

远端型遗传性运动神经病15例报告

临床资料患者15例,为2001年1月至2004年12月我科收集的15个远端型遗传性运动神经元病（distal hereditary motor neuropathy,dHMN）家系中的先证者,各家系之间均不相关;其中男9例,女6例。发病年龄27～44岁,平均35．4岁。均符合dHMN的诊断标准。4例患者有家族史,均呈常染色体显性遗传。由双上肢起病者11例,表现为双手无力,后出现肌肉萎缩,以远端为主,主要是骨间肌萎缩;双下肢起病者4例,表现为足趾背屈无力,小腿无力,肌肉跳动,并逐渐出现萎缩,病程进一步发展累及四肢,并可出现肢体近端无力。所有患者四肢肌张力均低,肌力Ⅲ～Ⅳ级,均可见肌束震颤,腱反射减退或消失,均无感觉障碍及大小便障碍。15例患者行肌电图检查,均提示神经源性损害,前角细胞病变。8例患者行心肌酶学检查,均未发现异常。     

进行性肌阵挛癫一家系临床与遗传学特征分析

目的 研究一个进行性肌阵挛癫(癎)家系的临床特点、遗传性特征并复习文献.方法 搜集并整理一个进行性肌阵挛癫(癎)家系患者临床表现、辅助检查及影像学资料,分析其临床特点和遗传性特征.结果 该家系呈母系遗传,先证者表现为进行性肌阵挛癫(癎)发作,同时伴有近端肌无力、肌肉萎缩、腱反射减弱.肌电图提示肌源性改变,头颅磁共振提示皮层萎缩,该家系中除先证者外其他患者均在发病后6～8 a死亡,预后差.结论 该进行性肌阵挛癫(癎)家系很可能为线粒体脑肌病的肌阵挛癫(癎)伴破碎红细胞纤维(MERRF)型,确诊有待进一步的肌肉活检和基因诊断.     

眼面咽喉肌受累的一个家系临床及其相关基因的初步研究

目的分析呈常染色体显性遗传，核心症状为眼外肌、面肌、咽喉肌肉瘫痪的一个家系，探讨其分类和病因。方法调查包括先证者在内的5例患者以及该家系中另外26名成员，收集其临床资料，进行电生理、肌肉病理检查，收集血样用PCR法进行基因验证。结果5例接受调查的患者经查体发现：眼睑下垂（5／5），眼外肌麻痹（5／5），面瘫（5／5），吞咽困难、声音嘶哑、咽反射迟钝（5／5），舌肌萎缩（3／5），颞肌萎缩（4／5），咬肌萎缩（4／5），近端肢体无力（3／5），肢体近端肌肉萎缩（4／5），远端肢体无力（3／5），肢体远端肌肉萎缩（4／5）。与眼咽型肌营养不良（OPMD）等疾病进行比较，电生理上确定病灶的性质为肌源性损害，肌肉病理为肌肉萎缩，但没有代谢性病变的表现，因此从电生理和肌肉病理两方支持肌营养不良的诊断。患者和表现健康的成员的PABPN1基因不存在（GCG）。（GCA），GCG的突变。结论该家系临床表现类似OPMD而不同于其他已知疾病，但是基因背景又完全不同于OPMD，可能属于肌营养不良的一种新亚型。     

肢带型肌营养不良症一家系10例报告

肢带型肌营养不良 (ＬＧＭＤ)又称Ｅｒｂ型肌营养不良 ,是一种少见的常染色体隐性遗传性肌病 ,而常染色体显性遗传更少见 ,现报道一家系 10例呈常染色体显性遗传患者如下。1　临床资料1.1　先证者　女 ,2 8岁 ,农民。四肢先后进行性无力 10多年而于 2 0 0 1年 4月 2 7日入院。患者 12岁始感觉右上肢上举无力 ,14岁时出现左上肢上举无力 ,梳头困难。症状缓慢加重 ,4年后感双下肢无力 ,双大腿明显变细。查体 :血压18/ 10ｋＰａ ,智能正常 ,颅神经无异常 ,前臂、上臂和手部肌肉无明显萎缩 ,肌张力低 ,双上肢上举不能过肩。岗上肌和肩胛肌群萎缩…     

常染色体显性遗传性微管聚集性肌病存在SCN4A基因突变(附1家系报告)

目的 探讨显性遗传性微管聚集性肌病的临床、骨骼肌病理和基因改变特点.方法 对显性遗传性微管聚集性肌病1家系进行分析研究,先证者为17岁男性,1岁开始出现发作性面肌、咀嚼肌和四肢肌无力,以及寒冷或活动诱发的肌肉僵硬,发作间期持续性肢体乏力.家族中连续4代10例出现类似临床表现.对先证者及其母亲进行肌肉活检.对母子及家族中无症状者行SCN4A基因序列检测.结果 在先证者和其母亲的Ⅱ型肌纤维肌纤维内均发现异常沉积物,分别占所有肌纤维的10%和3%.免疫组织化学染色见病变肌纤维内tau、dysferlin和泛素阳性表达.电镜检查显示沉积物为大量聚集的微管结构.基因测序发现母子两人的SCN 4A基因第13号外显子存在T704M突变.结论 病理检查证实显性遗传性微管聚集性肌病,该病和SCN4A基因突变有关,出现副肌强直性周期性瘫痪的临床表型.     

Bethlem肌病一家系临床表型及基因突变分析

目的分析Bethlem肌病临床表型和基因突变特点。方法报道一家系3例女性患者临床表型、肌电图、肌肉活检、肌肉病理学和基因检测结果,并结合相关文献进行分析。结果先证者于13岁发病,以进行性四肢近端无力为主要临床表现。血清学肌酸激酶水平显著升高,肌电图呈肌源性损害,肌肉病理学显示骨骼肌局灶坏死等非特异性肌源性损害。基因检测显示,先证者及其母、其妹存在相同基因突变,即COL6A3基因错义突变c.4270C>T。结论该家系Bethlem肌病患者为COL6A3基因突变致病,临床通过基因测序手段可提高诊断率,有助于产前诊断,减少遗传病发生率。     

进行性肌阵挛癫(癎)一家系临床与遗传学特征分析

目的 研究一个进行性肌阵挛癫(癎)家系的临床特点、遗传性特征并复习文献.方法 搜集并整理一个进行性肌阵挛癫(癎)家系患者临床表现、辅助检查及影像学资料,分析其临床特点和遗传性特征.结果 该家系呈母系遗传,先证者表现为进行性肌阵挛癫(癎)发作,同时伴有近端肌无力、肌肉萎缩、腱反射减弱.肌电图提示肌源性改变,头颅磁共振提示...     

眼咽型肌营养不良一家系临床、电生理、病理及基因分析

目的 报道1个出现神经源性骨骼肌损害的眼咽型肌营养不良(OPMD)家系的临床、骨骼肌病理和基因改变特点.方法 先证者为60岁男性,50岁时出现双下肢近端无力,53岁出现吞咽困难和构音障碍,57岁出现双眼睑下垂和眼球突出.肌酸激酶轻度增加,四肢肌电图为神经源性损伤,周围神经传导速度下降20%～43%.家系3代中除先证者外尚有5例在45岁后出现吞咽困难,4～20年后出现眼睑下垂,其中3例有肢体无力.对先证者左肱二头肌做肌肉活体组织检查,标本进行组织学、酶组织化学以及免疫组织化学染色(以抗结蛋白和泛素蛋白抗体作为一抗)和超微病理检查.对先证者和家系中另外18人进行多腺苷酸结合蛋白(PABPN1)基因检查.结果 先证者肌纤维内出现镶边空泡伴泛素阳性沉积物和成组分布的小角状萎缩肌纤维,个别肌纤维出现再生改变伴随结蛋白沉积,可见细胞色素C氧化酶阴性肌纤维.电镜检查发现约3%的肌纤维核内存在栅栏样细丝包涵体.先证者和另外11名家系成员的PABPN1基因存在(GCG)9异常扩增.结论 杂合(GCG).异常扩增性OPMD可先出现咽喉肌无力,伴随脱髓鞘性神经病.我国患者也存在肌纤维核内包涵体.     

Epilepsy and anomalies of neuronal migration: MRI and clinical aspects

Neuronal migration disorders are the result of disturbed brain development. In such disorders, neurons are abnormally located. In diagnosing these conditions, magnetic resonance imaging is superior to any other imaging technique. This enables us to improve our knowledge of the clinical correlates of neuronal migration. With reference to migrational disorder, a retrospective study of all 303 patients with epileptic seizures referred for magnetic resonance imaging during a 3-year period was performed, 13 patients (aged 12-41, mean age 27) were identified. They represent 4.3% of the entire study group. Of the patients with known epilepsy, 6.7% and of the mentally retarded, 13.7% had migrational disorders. Four patients had schizencephaly as the dominant finding, one was classified as hemimegalencephaly, 2 had isolated heterotopias, and 6 had localized pachy- and/or poly-microgyria. The clinical pictures are complex. Ectopias of grey matter are recognised foci of epilepsy, but from an epileptological and a clinical viewpoint little attention has been given to these disorders. The present study shows that malmigration is not rare in epilepsy patients, especially not in the mentally retarded.     

Hepatic Considerations in the Use of Antiepileptic Drugs

Summary: Virtually all of the major antiepileptic drugs (AEDs) can cause hepatotoxicity, although fatal hepatic reactions are rare. The mechanisms, incidences, and risk profiles for such reactions differ from drug to drug. With carbamazepine and phenytoin, hepatotoxicity may be due to drug hypersensitivity. Although the profiles of patients at risk have not been well-defined for these two antiepileptic drugs, it would appear from reports in the literature that older adolescents and adults are at higher risk than children of developing serious or fatal hepatotoxicity. Once hepatotoxicity develops, mortality rates are 10–38% with phenytoin and 25% for carbamazepine. The risk profile for valproate fatal hepatotoxicity has been more clearly defined. Those at primary risk of fatal hepatic dysfunction are children under the age of 2 years who are receiving multiple anticonvulsants and also have significant medical problems in addition to severe epilepsy. The risk is considerably lower for patients over the age of 2 years on valproate monotherapy. In contrast to the risk profile with other AEDs, adults receiving valproate as monotherapy have the lowest risk of hepatotoxicity. Fatal hepatic dysfunction coincident with valproate may be the result of aberrant drug metabolism. Concomitant use of AEDs that induce microsomal P450 enzymes (e.g., phenytoin and phenobarbital) may enhance the production of a toxic metabolite, and hence the greater risk of hepatotoxicity with polypharmacy.     

Vascular Malformations and Epilepsy: Clinical Considerations and Basic Mechanisms

Summary: Vascular malformations (VMs) are associated with epilepsy. The natural history of the various VMs, clinical presentation, and tendency to provoke epilepsy determine treatment strategies. Investigations have probed the mechanisms of epileptogenesis associated with these lesions. Electrophysiologic changes are associated with epileptogenic cortex adjacent to VMs. Putative pathophysiologic mechanisms of epileptogenesis include neuronal cell loss, glial proliferation and abnormal glial physiology, altered neurotransmitter levels, free radical formation, and aberrant second messenger physiology.     

Classification of methods in transcranial Electrical Stimulation (tES) and evolving strategy from historical approaches to contemporary innovations

Transcranial Electrical Stimulation (tES) encompasses all methods of non-invasive current application to the brain used in research and clinical practice. We present the first comprehensive and technical review, explaining the evolution of tES in both terminology and dosage over the past 100 years of research to present day. Current transcranial Pulsed Current Stimulation (tPCS) approaches such as Cranial Electrotherapy Stimulation (CES) descended from Electrosleep (ES) through Cranial Electro-stimulation Therapy (CET), Transcerebral Electrotherapy (TCET), and NeuroElectric Therapy (NET) while others like Transcutaneous Cranial Electrical Stimulation (TCES) descended from Electroanesthesia (EA) through Limoge, and Interferential Stimulation. Prior to a contemporary resurgence in interest, variations of transcranial Direct Current Stimulation were explored intermittently, including Polarizing current, Galvanic Vestibular Stimulation (GVS), and Transcranial Micropolarization. The development of these approaches alongside Electroconvulsive Therapy (ECT) and pharmacological developments are considered. Both the roots and unique features of contemporary approaches such as transcranial Alternating Current Stimulation (tACS) and transcranial Random Noise Stimulation (tRNS) are discussed. Trends and incremental developments in electrode montage and waveform spanning decades are presented leading to the present day. Commercial devices, seminal conferences, and regulatory decisions are noted. We conclude with six rules on how increasing medical and technological sophistication may now be leveraged for broader success and adoption of tES.     

Carbamazepine Efficacy and Utilization in Children

Summary: Carbamazepine is effective for preventing partial and generalized tonic-clonic seizures in children. Although absence epilepsies are more common in children than adults, an estimated 80% of children with epilepsy have seizure types or epilepsies that are potentially responsive to carbamazepine. The differential diagnosis of ictal staring is an especially important issue in children because absence and atypical absence seizures are more prevalent in children than adults. Age-related pharmacokinetic differences and drug interactions are major considerations in children. On average, children have higher clearance rates of carbamazepine, shorter half-lives, and higher ratios of carbamazepine-10, 11-epoxide to carbamazepine than adults. In addition, children with severe epilepsy are more likely to require multiple-drug therapy, which can lead to complex drug interactions. When carbamazepine is administered along with valproate, drug protein binding interactions can cause intermittent side effects.     

Neonatal Seizures: Problems in Diagnosis and Classification

Summary: The clinical identification of neonatal seizures is critical for the recognition of brain dysfunction; however, diagnosis is often difficult because of the poorly organized and varied nature of these behaviors. Current classification systems are limited in their ability to communicate motor, autonomic, and electroencephalo-graphic features of seizures precisely and to provide a basis for uniform effective diagnosis, therapy, and determination of prognosis. Recent investigations of neonates, utilizing bedside electroencephalographic/polygraphic/ video monitoring techniques, have provided the basis for improved diagnosis and classification of seizures in the newborn. These studies have demonstrated that not all clinical phenomena currently considered to be seizures require electrocortical epileptiform activity for their initiation or elaboration. In addition, the specific clinical character of the phenomena considered to be seizures, the clinical state of the infant, and the character of the EEG indicate the probable pathophysiological mechanisms involved and suggest probable etiologies, prognosis, and therapy. Similarities between animal models that demonstrate reflex physiology and neonates with motor automatisms and tonic posturing suggest that these clinical behaviors may not be epileptic in origin but, rather, primitive movements of progression and posture mediated by brainstem mechanisms. Although not all clinical behaviors currently considered to be neonatal seizures may have similar pathophysiological mechanisms, they are clinically significant because they all indicate brain dysfunction.     

Valproate Monotherapy in the Management of Generalized and Partial Seizures

Summary: For decades, therapeutic tradition has promoted the concept of polypharmacy in the management of epilepsy. In recent years, however, studies have shown that, for most patients, monotherapy can provide comparable or better seizure control than administration of multiple anticonvulsants, while diminishing the potential for adverse reactions, drug interactions, and poor compliance. Valproate is an important monotherapeutic agent that is highly effective in the control of idiopathic primary and secondarily generalized epilepsies, and partial seizures that do not generalize. Comparative studies have found that valproate is at least as effective as phenytoin and carbamazepine in the treatment of generalized and partial seizures. Given the similar efficacy, other factors such as pharmacokinetics and side effects may therefore determine anticonvulsant selection for monotherapy.     

Un nouveau cadre conceptuel de travail pour la psychiatrie

In an attempt to place psychiatric thinking and the training of future psychiatrists more centrally into the context of modern biology, the author outlines the beginnings of a new intellectual framework for psychiatry that derives from current biological thinking about the relationship of mind to brain. The purpose of this framework is twofold. First, it is designed to emphasize that the professional requirements for future psychiatrists will demand a greater knowledge of the structure and functioning of the brain than is currently available in most training programs. Second, it is designed to illustrate that the unique domain which psychiatry occupies within academic medicine, the analysis of the interaction between social and biological determinants of behavior, can best be studied by also having a full understanding of the biological components of behavior.