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Objective Diabetes commonly affects the bladder nerves. However, the relationship among bladder, periarterial and somatic neuropathy in diabetes is not well known. In the present study we investigated these relationships. Methods A total of 110 diabetic subjects were enrolled in the study. All were referred for screening for diabetic neuropathy, irrespective of their symptoms. The patients included 61 men and 49 women; the mean age was 59.3 years (31-85 years); the mean disease duration was 14.0 years (5-30 years); and the mean HbA1c value was 10.1% (5.1-16.3%). We performed a nerve conduction study (NCS, A-alpha/beta and B fiber), ultrasound-based measurement of the post-void residual (PVR) volume (abnormal, >50 mL, mainly A-delta/C fiber) and postural blood pressure measurement (abnormal, >-20 mmHg, A-delta/C fiber). Fisher's exact probability test and Student's t-test were used to analyze the significance of differences. Results NCS abnormality, an abnormal PVR volume, and postural hypotension were noted in 74, 19, and 36 of the subjects, respectively. There were clear relationships between NCS and an abnormal PVR volume (p

In this review, we discussed the method and the clinical relevance of bladder sensory abnormality in peripheral nerve diseases. Urodynamic first-sensation-volume increase is the most striking bladder sensory abnormality in peripheral nerve diseases, particularly diabetic polyneuropathy. Decreased bladder sensation might occur unwittingly even by patients. However, bladder sensory abnormality is clinically relevant, since it may lead to overflow urinary incontinence due to retention, secondary pyelonephritis, and kidney dysfunction. A small proportion of patients have increased bladder sensation, which leads to urinary urgency and frequency without detrusor overactivity.

Dear Sir,It is rare that patients with cerebral infarction report disorders of depth, shadow, and color perception. We recently reviewed such a patient.An 88-year-old, right-handed, amateur male ph...

Objectives Dementia with Lewy bodies (DLB) is the second most common degenerative cause of dementia, whereas lower urinary tract (LUT) function in DLB patients has not been fully delineated. We investigated LUT function in DLB by clinical-urodynamic observations. Methods We examined 32 patients with DLB (23 men, 9 women; aged 59-86 [mean, 75.9] years; disease duration, 0.2-17 [3.3] years). All patients underwent an electromyography-cystometry, and 21 patients underwent the sphincter motor unit potential analysis. Results Ninety-one percent of patients had LUT symptoms: nighttime frequency (>8 times), 84%, and urinary incontinence (>1 per week), 50%. Detrusor overactivity was revealed in 87.1%, whereas postvoid residual was minimal. Neurogenic changes were shown in 50%. Conclusion LUT dysfunction is a common feature in DLB, attributable not only to dementia and immobility, but also to central and peripheral types of somato-autonomic dysfunction. © 2014 International Parkinson and Movement Disorder Society

It is rare that amyotrophic lateral sclerosis (ALS) presents with respiratory failure as the sole initial manifestation. A 72-year-old man with mild chronic obstructive pulmonary disease developed exertional dyspnea for 13 months. He then progressed to limb weakness that led to the diagnosis of ALS. Although rare, ALS can present with respiratory failure as the sole initial manifestation more than 1 year prior to limb weakness.

In specific stroke cases, serial diffusion-weighted magnetic resonance imaging (DW MRI) on day 1 was unable to show a lesion, whereas that on day 4 and later clearly revealed a lesion. However, clinical features of this phenomenon ("invisible" brain stem infarction [IBI] at the first day) have not been fully delineated.We retrospectively recruited 212 stroke patients in the Emergency Unit and Neurology Department. Among these, we studied patients with IBI. Definition of IBI is that acute and clear brain stem symptoms/signs on arrival were ameliorated at discharge and appearance of high signal intensity on serial DW images with low apparent diffusion coefficient (ADC) by 1.5 T MRI with 2-mm slices.IBI were found in only 6 patients. Day 1 invisible stroke was found only in the brain stem (17%, 6 of 35) but none (0 of 177) in the hemispheric infarction (P .05). In most patients with IBI, DW MRI turned out visible at the third/fourth day. Before the fourth day, DW/ADC signal changes in patients with IBI were minimal. In IBI, lesion size (mean 2.7 mm(2)) was smaller than that of visible cases (mean 7.3 mm(2)). In IBI, lesion location was mostly at the dorsolateral medulla. In IBI, sensory disturbance was significantly more common (67%) than visible cases (24%; P .05), whereas dysarthria was less common (0%; P .01) than visible cases (66%; P .01).It is likely that patients with smaller stroke volume, sensory disturbance, and medullary location are prone to develop IBI. When evaluating stroke using MRI criteria, recognition of IBI is important to start early management.

Bladder function of patients with Parkinson's disease alters significantly: the majority of patients have overactive bladder (urinary urgency/frequency) with little or no post-void residuals. This seems to be the result of an altered brain-bladder relationship, as in Parkinson's disease, the frontal-basal ganglia D1 dopaminergic circuit that normally suppresses the micturition reflex is altered. The pathophysiology of the bladder dysfunction in Parkinson's disease differs from that in multiple system atrophy; therefore, it might also aid in differential diagnosis. The effects of levodopa, the major drug to treat motor dysfunction, on the bladder in Parkinson's disease vary significantly; therefore, add-on therapy is often required. Anticholinergic drugs are the first-line treatment, with particular care for cognitive function in elderly patients. The second-line treatment includes serotonergics drug, desmopressin and others. Newer modalities include deep brain stimulation that improves the bladder in Parkinson's disease; and botulinum toxin is promising, particularly in difficult cases. These treatments might be beneficial in maximizing the patients' quality of life.

Objective To investigate the relationship between Parkinson's disease (PD) and the cardio-ankle vascular stiffness index (CAVI), a novel non-invasive measurement of vascular stiffness. Methods A total of 63 PD subjects who underwent CAVI measurement were enrolled, including 30 men and 33 women 69.1±7.5 years of age (range: 46-79 years). Sixty-three non-PD subjects (30 men, 33 women, mean age: 68.7±7.6 years [range: 43-79 years]) served as controls. Comparisons between the control and PD subjects were made using Fisher's protected least significant difference, the Bonferroni-Dunn test, Scheffe's test and the unpaired t-test. Results 1) The average CAVI values were as follows: control, 9.3±0.9; PD, 9.0±1.0 (p=0.049). The differences in the CAVI values between the groups and the index values (normative data provided internally in the VaSera system) were as follows: control, 0.4±0.8; PD, 0.03±0.9 (p=0.011). The CAVI values of the PD patients were significantly smaller than those of the control subjects. 2) Among the control subjects, the CAVI values in the subjects with atherosclerotic risk factors (hypertension, dyslipidemia and/or diabetes) were significantly higher than those observed in the subjects without risk factors. In contrast, among the PD patients, the CAVI values in the subjects with atherosclerotic risk factors were equivalent to those observed in the subjects without risk factors. 3) Among the PD patients, the CAVI values did not change with the motor stage. Conclusion The results of the present study show that, compared with control subjects, PD patients exhibit normal CAVI values despite having mild but significant atherosclerotic risk factors, e.g., hypertension and diabetes. These findings suggest that PD patients are less vulnerable to systemic atherosclerosis than their risk factors may suggest.

Background The objective of this work was to perform an open trial of the effects of nizatidine (NZT), a selective histamine H2-receptor antagonist and a cholinomimetic, on gastroparesis in Parkinson's disease (PD) patients, using objective parameters given by a gastric emptying study using a 13C-sodium acetate expiration breath test. Methods Twenty patients with PD were enrolled in the study. There were 13 men and 7 women; aged 68.0 ± 7.72 years; disease duration 5.50 ± 3.62 years. All patients underwent the breath test and a gastrointestinal questionnaire before and after 3 months of administration of NZT at 300 mg/day. Statistical analysis was performed by Student t test. Results NZT was well tolerated by all patients and none had abdominal pain or other adverse effects. NZT significantly shortened Tmax (13C) (the peak time of the 13C-dose-excess curve) (P

Small-vessel disease of the brain affecting the deep white matter characteristically manifests with neurological syndromes, such as vascular dementia and vascular parkinsonism. There is, however, compelling evidence to suggest that white matter disease can cause overactive bladder and incontinence, and in some patients these might be the initial manifestation. As white matter disease increases significantly with age, and preferentially affects the prefrontal deep white matter, white matter disease becomes an anatomical substrate in the brain etiology of overactive bladder. Treatment entails the management of small-vessel disease risk factors and anticholinergic drugs that do not easily penetrate the blood-brain barrier, to improve bladder control. In short, when caring for elderly overactive-bladder patients, we should look at both the brain and the bladder.

Aims Studies of overactive bladder (OAB) have shown urothelial/suburothelial changes and increased bladder afferents, while in the brain the frontal micturition area that normally suppresses the bladder is deactivated. It has been unclear whether anticholinergic medication could reverse this suppression. To address this question, we performed a real-time NIRS (near-infrared spectroscopy)-urodynamic study in OAB patients before and after the administration of an anticholinergic agent, tolterodine. Methods We recruited 13 OAB patients in our outpatient clinic (9 males, 4 female; mean age 73 years). Before and after the administration of 4 mg/day tolterodine for 3 months, all patients completed the OAB-symptom scale and a NIRS-urodynamics examination. Cerebral changes in the oxy-hemoglobin concentration (oxy-Hb) were sampled. Concentration changes in oxy-Hb were calculated based on a modified Beer–Lambert approach. Results Tolterodine significantly reduced the OAB patients' nighttime frequency (P

To explore imidafenacin's effects on bladder and cognitive function in neurologic overactive bladder (OAB) patients.Sixty-two subjects (25 men, 37 women; mean age 70 years (25-86) with OAB due to neurologic diseases) were enrolled in the study. We conducted a urinary symptom survey and cognitive tests (MMSE, FAB, ADAS-cog) in all patients. We performed urodynamics in 35 patients and measured real-time near-infrared spectroscopy (NIRS)-urodynamics in eight patients before and after the administration of imidafenacin, an anticholinergic agent, for 3 months at 0.2 mg/day.Imidafenacin significantly ameliorated urinary urgency, nighttime urinary frequency, and quality of life index (p0.05). Three cognitive measures did not change significantly. Urodynamics showed increased bladder capacity (p0.05) but detrusor overactivity did not change significantly. NIRS showed that the subtraction of oxyhemoglobin between the start of filling and the first sensation increased in the bilateral prefrontal area but without statistical significance.Imidafenacin ameliorated bladder sensation without cognitive worsening, with a trend of prefrontal activation. Regarding cognitive function, imidafenacin is safely used in OAB patients due to neurologic diseases.In order to explore imidafenacin (anticholinergic agent)'s effects on bladder and brain function, we performed urinary questionnaire, cognitive tests, urodynamics and near-infrared spectroscopy (selected cases) in 62 overactive bladder (OAB) patients due to various neurologic diseases. As a result, imidafenacin ameliorated bladder sensation without cognitive worsening, with a trend of prefrontal activation. Imidafenacin seems safe in treating OAB patients due to neurologic diseases.

Objective To describe a case of SCA31 who presented with possible neurogenic voiding dysfunction. Methods A case report. Results A 73-year-old man with a 5-year history of cerebellar ataxia developed partial urinary retention. His father and a sister had cerebellar ataxia. Brain magnetic resonance imaging revealed cerebellar atrophy, and gene analysis revealed TGGAA repeat prolongation, and he was diagnosed with spinocerebellar ataxia 31. Urodynamics revealed normal bladder filling but a slightly weak detrusor and a post-void residual urine volume of 130 mL, whereas his prostate volume was normal (26 mL). External sphincter electromyography revealed neurogenic change in the motor unit potentials. In order to lessen the post-void residual, hewas started on 15mg/day pilocarpine with benefit. The weak detrusor and sphincter electromyography abnormality indicated involvement of the sacral spinal cord in this disorder. Conclusion Neurogenic urinary retention in SCA31 can be listed in the clinical differential diagnosis of cerebellar ataxia. However, possible outflow obstruction in men should always be explored.

Depression and anxiety are common mental illnesses. It is recognized that depression/anxiety causes physical changes, including insomnia, anorexia, and bladder dysfunction. We aimed to delineate bladder dysfunction in patients with depression/anxiety by reviewing the literature. We performed a systematic review of the literature to identify the frequency, lower urinary tract symptoms (LUTS), urodynamic findings, putative underlying pathology, and management of bladder dysfunction in patients with depression/anxiety. From a recent survey of a depression cohort (at a psychiatry clinic), the frequency of bladder dysfunction in depression is lower (up to 25.9%) than that in Parkinson's disease (up to 75%) and stroke (up to 55%), whereas it is significantly higher than that in age-matched controls (around 10%). In both the depression cohort and the psychogenic bladder dysfunction cohort (at a urology clinic), the most common LUTS was overactive bladder (OAB), followed by difficult urination and infrequent voiding. Compared with severe LUTS, urodynamic findings were dissociated; i.e. urodynamic findings were normal except for increased bladder sensation without detrusor overactivity for OAB (50% of all patients), followed by underactive detrusor without post-void residual for difficult urination. The effectiveness of serotonergic or anti-cholinergic medication for ameliorating OAB in the patients awaits further study. In conclusion, although the frequency of LUTS among the depression cohort is not elevated, depression/anxiety is obviously a risk factor for OAB. This finding presumably reflects that the bladder is under emotional control. Amelioration of bladder dysfunction is an important target in treating patients with depression/anxiety.

Bladder dysfunctions are one of the most common features seen in the failure of the autonomic nervous system. Among those, overactive bladder (urinary urgency and frequency) worsens quality of life of the patients, and a large amount of post-voiding residual urine or urinary retention causes urinary tract infection, kidney dysfunction, and may bring renal failure. In the present paper we discussed neural control of micturition and how to assess it. Also, we proposed appropriate management of bladder dysfunction in elderly white matter lesions (a common cause of OAB) and diabetic neuropathy (a usual pathology underlying urinary retention). For OAB, anti-cholinergics are the mainstay, whereas for the pathological post-voiding residual urine or urinary retention, alpha-blockers, cholinergic agents and clean, intermittent self-catheterization are the choice. Treatment of bladder dysfunctions is the important target for maximizing patients' quality of life.

Positional vertigo is a common neurologic emergency and mostly the etiology is peripheral. However, central diseases may mimic peripheral positional vertigo at their initial presentation. We here describe the results of a visual suppression test in six patients with spinocerebellar ataxia type 6 (SCA6), a central positional vertigo, and nine patients with benign paroxysmal positional vertigo (BPPV), the major peripheral positional vertigo. As a result, the visual suppression value of both diseases differed significantly; e.g., 22.5% in SCA6 and 64.3% in BPPV (p < 0.001). There was a positive correlation between the visual suppression value and disease duration, cerebellar atrophy, and CAG repeat length of SCA6 but they were not statistically significant. In conclusion, the present study showed for the first time that visual suppression is impaired in SCA6, a central positional vertigo, but preserved in BPPV, the major peripheral positional vertigo, by directly comparing both groups. The abnormality in the SCA6 group presumably reflects dysfunction in the central visual fixation pathway at the cerebellar flocculus and nodulus. This simple test might aid differential diagnosis of peripheral and central positional vertigo at the earlier stage of disease.disease.

This paper reviews current concepts of psychogenic urinary dysfunction (PUD) in children and adults from a uro-neurologist’s point of view. Although it is not common in urodynamic practice, PUD is an important category that all urologists have to consider. Regarding urologic aspects, PUD is basically a diagnosis of exclusion, particularly from urologic, gynecologic, and neurologic causes. In our patients, the characteristics of lower urinary tract symptoms in PUD are the situational occurrence of overactive bladder and/or difficult urination and, in some patients, extremely infrequent toileting. The characteristics of urodynamics in PUD are increased bladder sensation during bladder filling and underactive/acontractile detrusor during voiding. Regarding neuropsychiatric aspects, PUD is usually accompanied by more obvious psychologic/psychiatric features. In fact, the majority of our patients had hysterical neurosis/conversion disorder and anxiety disorders. Alteration in both emotion and micturition under such conditions most probably originates from the brain, which may reflect functional alteration in γ-aminobutyric acid (GABA)ergic, serotonergic, and corticotropin-releasing factor (CRF)ergic neuronal circuits. In addition, even in cases suggestive of PUD, a possible non-PUD pathology behind the symptoms should always be explored.

Department of Urology, Sakura Medical Center, Toho University, Sakura, JapanAims: A peculiar combination of acute urinary retention and aseptic meningitis has been described. This combinationis referred to as meningitis-retention syndrome (MRS), since patients with this syndrome exhibited no other abnormal-ities, except for mild pyramidal involvement. We aimed to delineate this syndrome by reviewing literatures.Methods: We performed a systematic review of the literature to identify the frequency, clinical symptoms, urody-namic findings, putrative underlying pathology, and management of this syndrome. Results: Patients with MRS havetypical symptoms of fever, headache, stiff neck, and minor pyramidal signs, together with acute urinary retention. Thebladder is initially areflexic, but soon becomes either normal or overactive in the repeated urodynamics during thecourse of the disorder. MRS is thought to be a very mild form of acute disseminated encephalomyelopathy (ADEM),with increased cell count, total protein, and occasional myelin basic protein in the cerebrospinal fluid. Propermanagement of the acute urinary retention is necessary to avoid bladder injury due to overdistension. The effective-ness of immune treatments (e.g., steroid pulse therapy) in shortening the urinary retention period awaitsfurther study. Conclusions: Although rare, MRS is a disorder that both urologists and neurologists may encounter.MRS should be listed in the differential diagnosis of acute urinary retention. Neurourol. Urodynam. 2012 Wiley Periodicals, Inc.Key words: acute disseminated encephalomyelopathy; meningitis-retention syndrome; urinary retention

This paper reviewed two common sources of elderly incontinence with brain etiologies, "vascular incontinence" (a disorder of bladder control resulting from cerebral white matter disease) and normal-pressure hydrocephalus (NPH), from a neurological point of view. Both diseases manifest with gait disturbance, dementia, and urinary incontinence. Urinary frequency/ urgency (overactive bladder, OAB) often precedes urinary incontinence in both diseases, and in some patients may be the initial manifestation. While NPH is less common than vascular incontinence, at approximately one-tenth the prevalence, it is important because the symptoms can be reversed by shunt surgery or endoscopic third ventriculostomy. For vascular incontinence, early identification of risk factors and initiation of secondary prevention are necessary. Detrusor overactivity due to frontal hypofunction may underlie the bladder disorder in both diseases. Treatment options for urinary incontinence include anticholinergics, which do not easily penetrate the blood-brain barrier, or newer drugs that act on the adrenergic beta-3 receptor and other receptors. © 2012 Bentham Science Publishers.

After suffering a brainstem stroke, a 62-year-old man developed locked-in syndrome including loss of horizontal eye movement and increased anal tone. Magnetic resonance imaging (MRI) of the patient revealed a massive stroke in the pons and right cerebellum, which seemed to involve the pontine micturition/defecation center (Barrington's nucleus) and the rostral pontine reticular formation (RPRF). As his increased anal tone was intractable to medical treatment, he required intermittent catheterization with an anal bougie tube. In light of the reported cases, our patient developed increased anal tone presumably due to pontine defecation center and RPRF lesion.

Objectives: During bladder filling, the bladder starts to sense it and the sensation steadily increases. However, little is known concerning volume-sensory correlation in normal bladder and pressure-sensory correlation during detrusor overactivity (DO). We aimed to real-time assess bladder sensation in normal bladder and DO using a five-grade measure. Methods: We enrolled 74 normal individuals and 87 patients with DO (51 terminal, 36 phasic). During slow bladder filling, we instructed individuals to indicate sensation in five grades: 1, first sensation; 2, obviously greater than 1 but less than 3; 3, first desire to void when he or she usually goes to toilet; 4, obviously greater than 3 but less than 5; and 5, strong desire to void. We also instructed individuals to report other sensations, such as pain. Results: The five-grade measure is feasible in all participants, showing a volume and pressure- sensory correlation. Among the five grades, grade 0 to 1 was the longest, followed by grade 4 to 5, in all participants. Grade 0 to 1 in phasic DO and grade 4 to 5 in terminal and phasic DO were shorter than those in normal bladder (P < 0.05). Eighty-six percent of patients with DO reported that the rapidly increased sensory grade is akin to urinary urgency in daily life. Conclusion: The five-grade measure is feasible to assess a volume and pressure-sensory correlation. Using this measure the sensory grade rapidly increased during DO compared with normal bladder, and 86% of the patients with DO reported that it is akin to urinary urgency in daily life.

It is reported that severe bladder disorder in idiopathic normal-pressure hydrocephalus (iNPH) is predicted by right frontal hypoperfusion. However, it is not known whether bladder recovery is predicted by brain perfusion change after shunt surgery. To address this issue, we compared bladder and brain function before and after shunt surgery in iNPH. We enrolled 75 patients in the study. Before and 12 months after shunt surgery, we analyzed brain perfusion by SPECT and bladder disorder by a specialized grading scale. The scale consisted of grade 0, none; grade 1, urinary urgency and frequency; grade 2, urinary incontinence 1–3 times a week; grade 3, urinary incontinence >daily; and grade 4, loss of bladder control. More than one grade improvement is defined as improvement, and more than one grade decrement as worsening; otherwise no changes. Comparing before and after surgery, in the bladder-no-change group (32 cases) there was an increase in blood flow which is regarded as reversal of enlargement in the Sylvian fissure and lateral ventricles (served as control). In contrast, in the bladder-improved group (32 cases) there was an increase in bilateral mid-cingulate, parietal, and left frontal blood flow (p

Objective: The pathogenesis of female urinary retention is not well known. Hence, we systematically investigated the frequency of diseases that underlie female urinary retention in a urodynamic laboratory.Methods: We analyzed data from 450 consecutive female patients. Data registries included the diagnosis, lower urinary tract symptom questionnaires, urodynamic study results, and neurologic exam observations. Complete urinary retention is defined as mean post-void residual (PVR) urine volume > 100 ml with no voluntary void at all; whereas incomplete urinary retention is defined as mean PVR urine volume > 100 ml after voluntary partial void.Results: Sixty of the 450 female patients visiting our lab (13%) had urinary retention with 4 (6.7%) of these having complete retention and 56 (93.3%) having incomplete retention. The most common underlying disease in these 60 patients was lumbar spondylosis (LS), 38.3% (with 16 patients having LS alone and 7 having LS & diabetic distal polyneuropathy [DPN]), multiple system atrophy (MSA), 18.3%, and DPN, 14.4% (with 2 patients having DPN alone and 7 having LS & DPN), followed by drug-induced retention (e.g., by antidepressants), 8.3%, acute myelitis of possible demyelinating origin, 5.0%, and other etiologies. An underactive detrusor was the major urodynamic findings in those patients.Conclusion: The present study revealed that common etiologies for female urinary retention are neurologic, e.g., an underactive detrusor due to MSA, age-related LS, and lifestyle-related DPN. Therefore LS and DPN, both common diseases, should also become major treatment targets in order to maximize patients’ quality of life.

One of the hallmarks in the pathology of multiple system atrophy (MSA) is neuronal loss in the sacral Onuf’s nucleus11,33,37. Onuf’s nucleus plays a key role in urinary and fecal continence12. Neurons in this nucleus receive not only cortical inputs, but also noradrenergic and serotonergic facilitatory inputs via interneurons from various brainstem structures, including the pontine urine-storage center57,68. External anal sphincter (EAS)electromyography (EMG) is an established method to detect neurogenic change in motor unit potentials (MUP), which mostly reflects denervation and reinnervation of the sphincter muscle30. The significance of the EAS-EMG in MSA has been well known30,69,74. Physiologically, external urethral sphincter (EUS) and EAS share sacral pudendal innervation from Onuf’s nucleus20. In this article, we review the normal physiology and pathophysiology of the lower urinary tract and the lower gastrointestinal tract briefly, the current methods and interpretations of EAS or EUS-EMG, and sphincter EMG in autonomic disorders.

article i nfo Objectives: Whereas delayed gastric emptying is believed to be a causative factor for producing delayed-on and motor fluctuation in Parkinson's disease (PD), few studies have directly measured levodopa pharmaco- dynamics and gastric emptying together. In order to determine the relationship, we measured these two pa- rameters in a single PD patients cohort. Methods: Thirty-one patients with PD were enrolled in the study. They were 11 men and 20 women; age, 68.1±7.8 years; disease duration, 4.2±3.8 years; Unified Parkinson's Disease Rating Scale Part 3 Motor Score18.37±8.60;bowelmovementb3timesaweekin20;alltaking301 mg±94 mg/daylevodopa/carbidopa. All patients underwent levodopa pharmacokinetic study and the gastric emptying study using 13 C-octanoic acid expiration breath test. Statistical analysis was performed by Student's t-test and Mann-Whitney's U test. Results: Pharmacokinetic study showed that the plasma levodopa peak was at 2 hours in 42% (13/31 patients) whereas at 1 hour in 58% (18/31 patients), total of 50.7±16.4 min (mean±standard deviation) in all 31 pa- tients. The gastric emptying study showed that Tmax ( 13 C)>60 min was more common in patients with a plas- ma levodopa peak at 2 hours (14/18, 69%) than in those with a plasma levodopa peak at 1 hour (4/13, 22%) (pb0.05), total of 50.7±16.4 min in all 31 patients. Conclusion: We found a significant relationship between levodopa pharmacokinetics and gastric emptying in PD patients, suggesting that delayed gastric emptying is a causative factor for producing delayed-on in PD. There- fore, studies of improved gastric emptying in order to ameliorate delayed-on in PD are warranted.

‘Vascular incontinence’ is a part of elderly incontinence due to cerebral white matter change (WMC). We studied the relationship between performance on several cognitive tasks and urodynamic detrusor overactivity (DO) in patients with vascular incontinence. We recruited 40 patients with lower urinary tract symptoms due to WMC [20 male, 20 female; mean age 77 years (60–89 years)]. Other neurologic, urologic, and systemic causes of LUT dysfunction were excluded. All patients underwent urodynamics tests and two sets of cognitive tasks, i.e., the Mini-Mental State Examination (MMSE) (general cognitive tasks), and the Frontal Assessment Battery (FAB) (frontal lobe tasks). The most common urinary symptom was urinary urgency (27 patients), followed by urinary incontinence (26) and nocturnal urinary frequency (25). The urodynamic testing revealed DO in 22 patients. The cognitive testing revealed that the patients’ mean MMSE score was 25.8 (range 15–30), and their mean FAB score was 13.6 (4–18). There was no relationship between DO and the total MMSE or FAB score, but our analysis of the relationship between DO and the six subdomains of the FAB (conceptualization, mental flexibility, programming, sensitivity to interference, inhibitory control, and environmental autonomy) revealed a significant relationship between DO and the inhibitory control task (p

Downbeat nystagmus (DBN) is a rare neurological disorder characterized by slow upward drifts and fast downward phases [1]. In most cases no anatomical lesion is identified, whereas Arnold-Chiari malformation or spinocerebellar degeneration may underlie this condition [1]. AntiNMDAR (N-methyl-D-aspartate receptor) encephalitis rarely causes DBN [2]. Recently, we observed a young lady showing DBN as the sole initial manifestation. A 21-year-old lady presented with the 5-day history of dizziness that worsened gradually. On examination she had spontaneous DBN, which was occasionally overlapped with ocular flutter-like movement. Smooth pursuit was slightly saccadic, and during horizontal gaze horizontal nystagmus overlapped DBN. Eye movements were otherwise intact. She had no intentional tremor or dysmetria on finger-to-nose and heel-to-shin testing. However, her gait was wide-based and mildly unsteady. The remainder of her examination was normal. However, 4 days later, emotional lability and delirium manifested, gradually followed by involuntary movement (crawl swimming-like, myoclonic), mutism, and hyperpnea/apnea that eventually required mechanical ventilation (Fig. 1). Brain magnetic resonance imaging (MRI) on the admission day showed normal findings throughout the course of disease. Single-photon emission computed tomography (SPECT) on the third day showed decrease cerebral perfusion in the medial frontal cortex. An electroencephalography (EEG) was normal. Routine blood studies showed no abnormalities. Cerebrospinal fluid (CSF) analysis showed mildly increased cell count of 35/mm (mononuclear:polymorphonuclear = 32:3) and normal total protein. Viral antigens were all negative. Although survey for malignancies including ovary and paraneoplastic antibodies including anti-Hu, anti-Yo and anti-GAD was negative, she was suspected to have autoimmune encephalitis. Steroid pulse and high-dose intravenous immunoglobulin (IVIG) therapy was of limited benefit. However, anti-NMDAR antibodies in CSF appeared to be increased significantly. From the 37th day she underwent plasmapheresis, which ameliorated significantly her involuntary movement and mildly her level of consciousness. Repeated CT scans of the pelvis showed a 1.5 cm ovarian mass. On the 69th day she underwent tumor resection, which revealed a 14 mm * 13 mm mature teratoma. This surgery brought her to normal consciousness. Previously, DBN has been seldom reported in paraneoplastic encephalitis except for anti-Ma2 antibody encephalitis (one case) [3], anti-glutamate acid decarboxilase (GAD) antibody encephalitis (one case) [4], and anti-NMDAR encephalitis (one case) with upbeat nystagmus at the plateau stage under mechanical ventilation [2]. Our patient was unique in that she presented with DBN and dizziness as the sole initial manifestation. Experimental and functional neuroimaging studies indicated that DBN is caused by dysfunction of the vestibulocerebellum (flocculus, nodulus of cerebellar vermis) and, rarely, bilateral paramedian brainstem [1]. Although brainstem and cerebellum are not commonly Y. Tsuyusaki R. Sakakibara (&) M. Kishi F. Tateno Neurology, Internal Medicine, Sakura Medical Center, Toho University, 564-1 Shimoshizu, Sakura 285-8741, Japan e-mail: sakakibara@sakura.med.toho-u.ac.jp