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Plasma levels of homovanillic acid (pHVA) following debrisoquine (DBQ) administration may be indicative of central dopaminergic activity. The effect of DBQ (10-20 mg) administration on pHVA in young healthy volunteers was studied to establish a protocol for use in de novo patients with Parkinson's disease. Subsequently, pHVA in de novo patients with Parkinson's disease were measured and compared to young healthy volunteers. Following DBQ (10 mg) administration to healthy volunteers, pHVA fell with time to a maximum of 62% of control values at 6 h. The decrease in pHVA was not affected by loading with DBQ (10 mg) 10 h previously (pHVA: 67.6 +/- 5.8% of preDBQ levels) or increasing the dose to 20 mg (56.1 +/- 11.8% of preDBQ levels) compared to a single 10 mg dose of debrisoquine (66.5 +/- 4.5% of preDBQ levels). pHVA was reduced in both de novo patients with Parkinson's disease and in healthy volunteers following DBQ (10 mg) administration. However, there was no difference in pHVA before or after DBQ administration when comparing the two groups. These results suggest that, following DBQ administration, pHVA does not reflect dopamine neuronal loss in de novo patients with Parkinson's disease, so it is unlikely to detect the disease before the clinical symptoms manifest themselves.

The prognosis of patients with progressive multifocal leukoencephalopathy is poor, with few patients showing remission or surviving. We describe a 37-year-old man who developed progressive multifocal leukoencephalopathy in association with sarcoidosis. Despite treatment with cytarabine and acyclovir, he continued to deteriorate. Shortly following the addition of interferon alfa, he made a dramatic improvement, regaining full functional independence. The use of interferon alfa in addition to cytarabine in such patients offers a new therapeutic approach worthy of further trial.

Summary The characteristics of acute deterioration in truncal movements, posture and gait were studied in patients admitted with acute non-neurological disease. Reversible gait abnormalities with characteristics of a 'lower-half parkinsonism' were associated with a disorder of axial movement, disability (as assessed by an activities of daily living score), and low mental test score. There was no association of gait dysfunction with tests of upper limb apraxia. An 'at risk' sub-group of elderly patients was identified who during an acute illness lose their walking independence, of whom some also have great difficulty performing axial movements. Furthermore, any assessment of locomotor and axial movement in elderly patients must consider that any impairment may be the result of an acute medical illness.

Debrisoquine (DBQ) metabolism was studied in 80 Parkinson's disease (PD) patients, 26 of whom had young onset Parkinson's disease (YOPD), and in 143 controls. There was no significant difference between the proportion of poor metabolisers of DBQ among YOPD patients compared either to other parkinsonians, or to controls. Nor was there a significant correlation between the age of disease onset and DBQ metabolic ratio (MR). The results do not support the suggestion that impairment of DBQ metabolism (and hence cytochrome P450) is a primary defect in YOPD. However, in comparison with controls, MR values were modestly but significantly higher in PD patients, even in those not treated with drugs known to affect DBQ metabolism.

Dyskinesias associated with dopaminergic treatment in idiopathic Parkinson's disease (PD) can be indistinguishable from those arising spontaneously in other conditions involving degeneration of, or damage to, the basal ganglia. However, those due to levodopa treatment of PD disappear on cessation of therapy. We report a patient with a clinical diagnosis of PD who, on levodopa treatment, developed hemiballism and chorea that were originally thought to be drug induced. However, the dyskinesias persisted despite stopping levodopa. Postmortem analysis showed a multisystem degeneration.

Advances in the engineering of Quadrupole Resonance (QR) sensors for landmine detection have resulted in improved performance, as well as massive reductions in power, size and weight. The next generation of vehicle-mounted QR confirmation sensors is over an order of magnitude smaller and more power efficient than the system fielded in 2002 and 2003. Early prototypes have also demonstrated a significant improvement in TNT sensitivity, and similar improvements are anticipated in RDX sensitivity during Q1 2005. Blind test results from 2003 confirm the radio frequency interference and piezo-electric ringing immunity of the Quantum Magnetics QR Confirmation Sensor (QRCS).

Dopaminergic therapy can result in behavioural disturbances, including impulse control disorders, punding and the dopamine dysregulation syndrome, consequences of excessive or aberrant dopamine receptor stimulation. We present two patients with the less recognised entity of hobbyism, a rare association with chronic dopaminergic therapy in Parkinson9s disease and discuss its pathophysiology. Patient 1, a geography teacher, developed Idiopathic Parkinson9s disease (PD) at the age of 47. Ropinirole was started in 2001 and levodopa added in 2003. He produced his first poem in 2007and has since written over 400 poems, published a Children9s book on poetry and sold about 300 copies of his poetry booklet. He is currently working on a novel. Patient 2, an infant school teacher, was diagnosed in 1985 (aged 40) and treated with levodopa from disease onset. In 1993, she received a local prize for the best poem, with coverage in the local media. A book relating her PD experiences as well as containing her poetry was successfully published in 2006. Hobbyism, often arising de novo, may represent the milder end of the punding spectrum and lacks the destructive, disabling elements typically associated with punding. Its pathophysiology is ill understood but dysregulation of the dopamine receptors after prolonged dopaminergic exposure is implicated. Patients need close review for potential development of harmful impulsivity.

A patient presented to the Walton Centre for Neurology and Neurosurgery (WCNN) with non-specific fatigue. A voltage gated potassium channel (VGKC) antibody assay was requested, among other investigations. A titre of 0.151 (normal range: 0–0.1 nmol/l) was detected and subsequent CT) of chest showed a thymoma. This led us to ask the following question: What is the clinical spectrum and incidence of malignancy in positive VGKC antibody patients? We performed a retrospective analysis of patients with positive VGKC antibodies from WCNN between 2001 and 2009 (n=52). Limbic Encephalitis (LE) was seen in 20% (n=10), and Peripheral Nerve Hyperexcitibility (PNH) in 33% (n=17). No cases of Morvan9s syndrome were identified. Other associations included Guillain–Barre Syndrome, Chronic Inflammatory Demyelinating Polyneuropathy, Non-Epileptic Attack Disorder, Relapsing Remitting Multiple Sclerosis (RRMS), Primary Lateral Sclerosis, Chronic Regional Pain Syndrome, and an akinetic rigid syndrome. Titres >0.4 nmol/l were detected in 15 patients; PNH (n=5), LE (n=9), RRMS (n=1). Overall five malignancies were detected (10%); thymoma (n=2), small cell carcinoma lung (n=1), astrocytoma (n=1), and prostatic adenocarcinoma (n=1). The clinical spectrum is intriguing, but raises the question of whether testing was appropriate in all cases. This study highlights the importance of correlating clinical context with VGKC antibody testing.

Despite successful orthoptic liver transplantation some patients develop a recurrent headache that interferes with their quality of life. To estimate the frequency of this symptom 34 patients who had undergone orthoptic liver transplantation were questioned about the history and character of any headache. Six patients described a recurrent headache typical of migraine only since transplantation. In two patients the pain improved after reduction of cyclosporin dosage and thereby plasma cyclosporin concentration.

About 90% of patients with MG develop ocular muscle weakness causing ptosis and diplopia. By contrast, the ocular features of blepharospasm and Meige syndrome (blepharospasm plus oromandibular dystonia) are caused by involuntary, forcible contraction of the orbicularis oculi, causing spasmodic blinking.1,2⇓ We report two patients with MG whose presentation with chronic blinking mimicking blepharospasm led to inappropriate treatment. ### Patient 1. A 73-year-old man presented to an ophthalmologist with a 2-year history of continuous involuntary blinking without symptoms or signs of ptosis or diplopia. Blepharospasm was diagnosed. Periocular injections of botulinum toxin (Botox, Allergan Ltd., Wycombe, UK) caused a complete bilateral ptosis lasting 4 weeks. Blinking returned as the ptosis improved. One year later, we noted frequent blinking and residual, nonfatigable ptosis. There was no frontalis overactivity, abnormality of eye movements, or weakness of eye closure. The rest of the neurologic examination was normal. Bilateral blinking tics were diagnosed, …

For many patients with Parkinson disease and levodopa-related motor fluctuations, the latency to onset of action of a single dose of a levodopa preparation may be both long and variable, In an effort to find a more rapidly acting and reliable preparation of levodopa, we therefore studied the efficacy of single doses of an oral solution of 250 mg of levodopa methyl ester (ME) with benserazide, 50 mg and of a molar equivalent dose of dispersible Madopar (DM) (50/200) in 13 patients in the fasting state after overnight drug withdrawal. The response of seven of these patients was compared to that after two Sinemet 25/100. The latency to "on" was equally fast with ME and DM, and significantly faster than after standard Sinemet. The duration of "on" was similar with all three. Because of this more rapid relief of "off" periods, both ME and DM offer a potential clinical advantage over standard preparations of levodopa.

Our 2-year experience in the therapeutic use of subcutaneous apomorphine has involved 25 patients with Parkinson's disease, 10 of whom continue to use it chronically. On the basis of this experience, we have formulated certain indications for its use, together with suggested approaches to modify patients' oral drug regimes so that apomorphine can best be deployed to improve their quality of life.

Summary Central venous catheterization is not without hazard. Inadvertent placement in the pleural space can occur without the development of a pneumothorax and pressure measurements may appear misleadingly normal. This case report illustrates an effective method of diagnosing and draining an iatrogenic hydrothorax which resulted in this way.