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January 16 Highlights

Filosto et al. evaluated the muscle biopsy findings from 240 patients who had isolated muscle pain and correlated pathologic and clinical data. The probability that a patient has a definitive muscle disease was 2%.

see page 181

The editorial by John T. Kissel notes that muscle pain is among the most common complaints encountered by primary care physicians, and may be the commonest presenting symptom in neuromuscular clinics. Population-based studies have suggested that the incidence of diffuse, persistent muscle pain is approximately 10% of the population. The Filosto et al. report is notable in that 80% of patients had biopsy abnormalities, but only 20% could be given a specific diagnosis and only 6% had a specific myopathy. Future work in this area, exploring both the mechanisms of pain at the muscle level, through gene chip and proteomic technologies, as well as the central events involved in the perception of pain in these patients, is essential.

see page 170

Outcome of noninvasive ventilation in children with neuromuscular disease

Young et al. studied outcome in children managed with long-term noninvasive ventilation for severe neuromuscular diseases. Long-term ventilation improved patient symptoms (daytime sleepiness and headache) and significantly decreased hospitalization rates and health care costs. Quality of life remained stable despite disease progression.

see page 198

Progression of white matter hyperintensities (WMHs)

Sachdev et al. found that WMHs increased in volume by nearly 40% over 3 years in 51 healthy elderly individuals, mean age 71 years, with baseline WMH burden, and not vascular risk factors, being the main predictor of progression.

see page 214

Improved appropriateness of carotid endarterectomy

Halm et al. reviewed a statewide cohort of 9,588 patients who had carotid endarterectomy in 1998–1999. Since publication of RCTs on endarterectomy, the rate of inappropriate carotid surgery dropped from 32% to 8.6%. Three-quarters of operated patients were asymptomatic.

see page 187

Increased risk of stroke Dubinsky and Lai examined the mortality and morbidity of combined CEA and CABG in a large national hospital administrative data set. After correcting for comorbidities an increased risk of death or postoperative stroke remained.

see page 195

The editorial by Feasby and Barnett reviews the effect of clinical trials on carotid endarterectomy, noting that the Halm et al. study raises two concerns: first, almost 1 in 10 procedures is still done for inappropriate reasons. The patients were too sick, had very recent strokes, or had only minor carotid stenosis. Clearly, there is still room for improvement and hospitals and departments of surgery should audit their CE procedures to improve the case selection. The second and more important reason for concern is the trend, documented by Halm et al., toward increasing rates of CE for asymptomatic patients. In their study, about three quarters of patients were asymptomatic, almost double the rate of 34% in the original RAND study. The result of increasing the proportion of asymptomatic cases on the overall effectiveness of CE can be modeled by plotting the absolute risk reduction of various case mixes and the numbers-needed-to-treat against the proportion of cases that are asymptomatic. The number-needed-to-treat to prevent one stroke would be 11 for a case series with only 34% asymptomatic cases, as in the original RAND study, but would be 21 if 72.3% were asymptomatic, as in the Halm study. While reporting a risk of CEA and CABG, it is lower than in some other studies, but caution is suggested in combining these two procedures for what is usually asymptomatic carotid stenosis.

see page 172

Functional recovery after disabling recurrent ischemic stroke

Among 345 patients who experienced disabling recurrent ischemic stroke during the MATCH trial, Hankey et al. assessed that 1/3 recovered functional independence after 12 months (median) follow-up. The rate of recovery was greatest in the first 6 months. Significant predictors of recovery were functional independence before recurrence and increasing severity of the recurrent stroke.

see page 202

Voltage-gated sodium channels in pain syndromes

Voltage-gated sodium channels have a critical role in neuronal function and in the development and maintenance of pain. Benarroch briefly summarizes some of the recent experimental data on the involvement of these channels in pain associated with inflammation, axonal and spinal cord injury, and familial erythromelalgia.

see page 233

HTLV-I-associated myelopathy (HAM/TSP) or MS with HTLV-I?

To differentiate HTLV-I-associated myelopathy and myelopathies of other etiologies from primary progressive MS in HTLV-I endemic areas, Puccioni-Sohler et al. demonstrate the value of quantifying the HTLV-I proviral load in CSF and PBMC combined with HTLV-I antibody index.

see page 206

Fulminant idiopathic intracranial hypertension

Thambisetty et al. reported 16 cases with acute idiopathic intracranial hypertension (IIH) and severe visual loss. These cases are rare (between 2.2 and 2.9% of IIH cases), but emphasize the need for aggressive management of patients with IIH when visual function deteriorates rapidly.

see page 229

Education, cognitive reserve, and AD without dementia

Roe et al. found that education predicts clinical dementia in the year preceding death among individuals with neuropathologic AD, supporting the theory that persons with greater cognitive reserve are better able to cope with AD brain pathology without observable deficits in cognition.

see page 223

Figure. Model of the varying proportions of asymptomatic and symptomatic cases undergoing carotid endarterectomy, using absolute risk reductions over 2 years from NASCET and ACAS.

Related Articles

Muscle biopsy in patients with myalgia: Still a painful decision

John T. Kissel
Neurology 2007 68: 170-171. [Full Text] [PDF]

This Article Full Text (PDF) Correspondence: Submit a response Alert me when this article is cited Alert me when Correspondence are posted Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Alert me to new issues of the journal Download to citation manager Citing Articles Citing Articles via Google Scholar Google Scholar Search for Related Content Related Collections Related Articles