R Quinlivan
email: ros.quinlivan@rjah.nhs.uk

J Buckley

M James

A Twist

S Ball

M Duno

J Vissing

C Bruno

D Cassandrini

M Roberts

J Winer

M Rose

C Sewry

Keywords: McArdle disease, Glycogen Storage Disorder Type V, Glycogen Phosphorylase deficiency, PYGM

The clinical phenotype of 45 genetically confirmed McArdle patients is described.

In the majority of patients (84%), the onset of symptoms was from early childhood, but diagnosis was frequently delayed until after 30 years of age. Not all patients could recognise a second wind, although it was always seen with exercise assessment. A history of myoglobinuria was not universal, and episodes of acute renal failure had occurred in a minority (11%). The condition does not appear to adversely affect pregnancy and childbirth. Clinical examination was normal in most patients, muscle hypertrophy was present in 24% and mild muscle wasting and weakness was seen only in patients over 40 years of age and was limited to shoulder girdle and axial muscles. The serum creatine kinase (CK) was elevated in all but one pregnant patient. Screening for the mutations p.Arg50X (R50X) and p.Gly205Ser (G205S) showed at least one mutated allele in 96% of Caucasian British patients, with an allele frequency of 77% for p.Arg50X in this population. A 12-minute walking test to evaluate patients is described, results demonstrated a wide spectrum of severity with the range of distance walked being 195-1980 metres, the mean distance walked was 512m suggesting significant functional impairment in most patients.

Background

McArdle disease (Glycogen storage disease type V, GSDV) is an inherited disorder of glycogen metabolism affecting only skeletal muscle. Brian McArdle described a patient with exercise intolerance who failed to produce lactate during ischaemic exercise [START_REF] Mcardle | Myopathy due to a defect in muscle glycogen breakdown[END_REF]. Subsequently, a deficiency of muscle glycogen phosphorylase was identified in patients with McArdle disease [START_REF] Mommaerts | A functional disorder of muscle associated with the absence of phosphorylase[END_REF][START_REF] Schmidt | Chronic progressive myopathy with myoglobinuria: demonstration of a glycogenolytic defect in muscle[END_REF]. In most affected people, there is no detectable glycogen phosphorylase activity.

Traditionally, diagnosis is based upon the inability of the patient to produce lactate during a forearm exercise test, lack of muscle glycogen phosphorylase activity on muscle biopsy and more recently DNA studies to look for variants in PYGM. The ischaemic lactate test has been replaced by a non-ischaemic forearm test, which avoids the potential risk of compartment syndrome, although there may be a greater risk of false positive results [START_REF] Hogrel | A non-ischemic forearm exercise test for the screening of patients with exercise intolerance[END_REF][START_REF] Kazemi-Esfarjani | A non-ischaemic forearm exercise test for McArdle disease[END_REF]. A functional cycle test has also been shown to be a useful screening assessment, although the equipment required may not be widely available in an outpatient setting [START_REF] Vissing | A diagnostic cycle test for McArdle's disease[END_REF].

There are three isoenzymes of glycogen phosphorylase, all of which have a high degree of amino acid sequence homology. The muscle isoenzyme is encoded at 11q13 and is a prerequisite for generation of ATP to fuel contracting muscle [START_REF] Beynon | Selected disorders of carbohydrate metabolism[END_REF]. It is found in skeletal muscle and as a hybrid form in the brain and cardiac muscle [START_REF] Crerar | Chimeric muscle and brain glycogen phosphoryalses define protein domains governing isozyme-15[END_REF]. There are also liver and brain isoenzymes encoded by separate genes on chromosomes 14 and 20, respectively [9]. The brain isoenzyme is present in foetal muscle and is expressed in regenerating muscle fibres [10,11], and is also expressed in smooth muscle. The histochemical method used to localise phosphorylase reveals the activity of all three isoforms.

McArdle disease results from homozygous or compound heterozygous mutations in the myophosphorylase gene (PYGM), on chromosome 11q13. By December 2008, more than 100 mutations had been identified in the gene, which spans 20 exons and many of the mutations are population specific [12,13,14].

The most common mutation in Northern Europe and North American patients is a nonsense mutation at p.Arg50X (R50X) in exon 1 (previously referred to as R49X) [15]. A second frequent mutation in the Northern American and Spanish populations is p.Gly205Ser (G205S) [START_REF] Beynon | Selected disorders of carbohydrate metabolism[END_REF]15,[START_REF] Andreu | McArdle Disease: Molecular genetic update[END_REF]. The diagnosis of McArdle disease is confirmed by DNA analysis and/or muscle biopsy with histochemistry and biochemical analysis.

In the resting state and during low-intensity aerobic activity, skeletal muscle primarily utilizes free fatty acids, via oxidative phosphorylation, for energy. Absence of muscle glycogen phosphorylase results in the inability to mobilise muscle glycogen stores. This poses a problem to patients with McArdle disease when there is a need for anaerobic metabolism and a high glycolytic flux for oxidative combustion. Typical symptoms include fatigue, muscle stiffness, myalgia and weakness which is induced by exercise and relieved by rest [START_REF] Dimauro | Metabolic Disorders Affecting muscle; Non Lysosomal Glycogenoses[END_REF]. If exercise is continued despite these symptoms painful muscle cramping and contracture followed by myoglobinuria occurs. In severe cases, rhabdomyolysis will lead to collapse and reversible acute renal failure requiring dialysis. The second wind phenomenon is universal in McArdle disease and occurs due to a switch to alternative fuel substrates required for aerobic metabolism [START_REF] Vissing | A diagnostic cycle test for McArdle's disease[END_REF].

In McArdle disease, a secondary impairment of oxidative phosphorylation occurs due to a virtual absence of pyruvate, which is normally generated from glycolysis [START_REF] Haller | Myophosphorylase activity impairs muscle oxidative metabolism[END_REF]. Without physical training, most individuals will have limited capacity for fatty acid oxidation during exercise [START_REF] Stefano | Impairment of muscle mitochondrial oxidative metabolism in McArdle's Disease[END_REF][START_REF] Haller R G | Aerobic conditioning: an effective therapy in McArdle's disease[END_REF]. The effect of this diminished oxidative phosphorylation is a reduction in oxygen consumption to approximately 35% of normal and a disproportionate exercise-induced increase in heart rate when compared with normal controls [START_REF] Vissing | Sympathetic activation in exercise is not dependent on muscle acidosis direct evidence from studies in metabolic myopathies[END_REF].

There have been no detailed epidemiological studies of McArdle disease and there is little published data on the natural history of the condition, although several authors have published data on the relative frequency of specific mutations occurring in patients in different European countries [START_REF] Bruno | McArdle disease: the mutation spectrum of PYGM in a large Italian cohort[END_REF]12]. An incidence of 1:100,000 has been reported for the Dallas population (USA) [START_REF] Haller | Treatment of McArdle Disease[END_REF],

and a small study of neonatal screening for the p.Arg50X mutation in the Netherlands suggested a frequency of 1:350,000 [START_REF] Van Elfen | The prevalence and genetic characteristics of McArdle's disease in The Netherlands[END_REF]. Amongst affected individuals there is marked heterogeneity in terms of severity, which does not correlate with specific mutations [START_REF] Lucia | The 577X allele of the ACTN3 gene is associated with improved exercise capacity in women with McArdle's disease[END_REF]12,13]. One possible explanation for variability in expression of the condition could be the co-existence of disease modifying genes such as the Angiotensin converting enzyme gene phenotype (ACE), alpha actinin 3 (ACTN3) and C34T muscle adenosine monophosphate deaminase (AMPD1) [START_REF] Gomez-Gallego | The I allele of the ACE gene is associated with improvement in exercise capacity in women with McArdle disease[END_REF][START_REF] Lucia | The 577X allele of the ACTN3 gene is associated with improved exercise capacity in women with McArdle's disease[END_REF][START_REF] Martinuzzi | Phenotype modulators in myophosphorylase deficiency[END_REF][START_REF] Rubio | Genotype modulators of clinical severity in McArdle disease[END_REF]. Differences in life-style including dietary habit and fitness are also likely to play a role in variability [START_REF] Quinlivan | Pharmacological and nutritional treatment of McArdle's disease (Glycogen storage disease V) Cochrane Database Syst[END_REF]. A total of 55 patients previously diagnosed with McArdle disease were referred to the service, however, in ten of these patients the clinical history was not considered typical for the condition and further investigation including: forearm exercise test, muscle biopsy and PYGM studies failed to confirm the diagnosis. In nine of these patients, there had been a previously reported absence of muscle glycogen phosphorylase on muscle histochemistry and in one patient, the diagnosis of McArdle disease had been made on the basis of an ischaemic forearm exercise test which gave a false positive result. Two of these patients were subsequently diagnosed with Becker muscular dystrophy and one child was diagnosed with mini-core myopathy. In the remaining seven patients the diagnosis was revised to chronic fatigue syndrome (CFS/ME) in accordance with the NICE diagnostic criteria for CFS/ME [START_REF]Chronic Fatigue Syndrome/myalgic encephalomyelitis (or encephalopathy): diagnosis and management of chronic fatigue syndrome/myalgic encephalitis (or encephalopathy) in adults and children[END_REF].

Methods

The forty-five remaining patients were included in a prospective clinical evaluation which included a detailed structured and standardised history, clinical examination, functional assessment and investigations including: serum CK, plasma urate and molecular genetic studies for mutations in PYGM, including cDNA studies from whole muscle where appropriate. Structured clinical history included: the patient's first memory of exercise intolerance (where possible this was corroborated by a first degree relative), the age at which diagnosis was confirmed and the predominant symptom which caused the person to first seek medical attention (although this might not necessarily have related to the consultation that led to diagnosis), specific questions relating to the second wind phenomenon, myoglobinuria and acute renal failure were also asked.

Results from previous investigations including forearm exercise tests and muscle pathology were not included in the data collection, these investigations had been performed at many different centres across the UK and at different times (sometimes many years earlier) as a consequence reliable and accurate data might have been difficult to obtain, however, in all subjects the diagnosis was confirmed by molecular analysis.

The resulting information was anonymised and recorded onto a secure database and analysed separately by two individuals. Approval for the clinical evaluation study was given by the Hospital's audit committee. Approval was obtained from the Shropshire ethics committee to develop a novel functional 12minute exercise assessment, and informed written consent was obtained from the participants.

We recognised that a pragmatic functional assessment would be necessary to monitor individual patient progress on a routine outpatient basis, hence the devising of a modified 12-minute walking test to assess functional ability. This was combined with using a Borg's CR-10 scale [START_REF] Lane | A double-blind, placebocontrolled, crossover study of verapamil in exertional muscle pain[END_REF] to rate muscle sensations (fatigue, tightness, discomfort, cramping and pain) on a 10 point scale. We chose the CR-10 scale for rating perceived muscle pain (RPP), rather than Borg's traditional scale of perceived exertion (RPE) for two reasons, firstly it has previously been used in conjunction with a timed walking assessment as a primary outcome measure for a clinical trial in McArdle disease [START_REF] Grant | Reproducibility of the blood lactate threshold, 4mmol-l -1 marker, heart rate and ratings of perceived exertion during incremental treadmill exercise in humans[END_REF] and secondly because the RPE scale was designed to measure the linear responses of overall aerobic body work, whereas the CR-10 scale was designed to have congruence with the psychophysical phenomenon of the curvilinear responses in perceptions to specific muscle sensations during exertion [START_REF] Lane | A double-blind, placebocontrolled, crossover study of verapamil in exertional muscle pain[END_REF][START_REF] Grant | Reproducibility of the blood lactate threshold, 4mmol-l -1 marker, heart rate and ratings of perceived exertion during incremental treadmill exercise in humans[END_REF]. Twenty of the 45 patients were recruited for this study following informed written consent.

Each subject was asked to walk as far as they could in 12 minutes and to rate muscle sensation using the RPP scale, subjects were instructed not to allow their RPP score to exceed level 4 (moderate sensation). Heart rate was recorded via a wireless chest strap transmitter (Polar, Kempele Finland) and the total distance walked was recorded. Walking distance and thus speed, heart rate and RPP were recorded each minute. Differences in minimum and peak values of walking speed, heart rate and muscle pain over the 12 minutes of the test were assessed using a one-way analysis of variance.

Results

Age of onset and age at diagnosis

There was an equal preponderance of males (n=22) and females (n=23).

Their ages ranged from 9-64 years. Table 1 summarises the age of onset of symptoms and the age at which diagnosis was made. The majority (n=38, 84%) of patients recalled symptoms before 10 years of age, whereas only seven (15%) patients were diagnosed by 10 years of age. By contrast, 22 patients (49%) were diagnosed after 30 years of age. Most individuals reported that their symptoms in childhood had been attributed to "growing pains" and not investigated further.

Symptoms

The features identified from patient histories are summarised in table 2.

The most frequent symptom that precipitated 44/45 of the subjects to seek medical attention was painful muscle cramping, with or without contracture, which involved any skeletal muscle including: proximal and distal limb, paraspinal, chest and jaw muscles. One subject presented with recurrent hospital admission due to episodes of unexplained collapse associated with myoglobinuria. He was subsequently diagnosed with juvenile myoclonic epilepsy, his myoglobinuria having been triggered by seizures. He denied any significant muscle symptoms other than a mild discomfort occurring with exercise. A faint trace of glycogen phosphorylase (rather than complete absence) was seen in his muscle histochemistry, there were no regenerating muscle fibres. Genomic DNA studies showed him to have two PYGM sequence variants: p.Arg50X mutation and a previously undescribed variation, c.2430C>T. cDNA studies from whole muscle suggested this novel variant was likely to create an aberrant splice site [START_REF] Duno | High-resolution melting facilitates mutation screening of PYGM in patients with McArdle disease[END_REF]. Cryptic splice mutations can occasionally be leaky allowing a minor fraction of correct splicing, which explains the milder phenotype [START_REF] Vissing | Splice mutations preserve myophosphorylase activity that ameliorates the phenotype in McArdle disease[END_REF].

Recognition by patients of a second wind, although typical for the condition, was absent in 22% (n=10), and severe contracture with myoglobinuria had never occurred in 38% (n=17). At least one episode of acute renal failure necessitating haemodialysis had occurred in five patients (11%). Disabling central and peripheral fatigue with poor memory and concentration, resembling chronic fatigue syndrome, was relatively common, affecting 40% of all patients. A significant proportion of patients (31%) had been treated at some time for anxiety and/or depression.

Two patients had come to medical attention following a reported increase in frequency of muscle cramps after statin treatment had been prescribed for hypercholesterolaemia. It remains unclear whether statin therapy actually worsened symptoms or merely led to the diagnosis being unmasked because of routine CK monitoring. Five patients (11%) had raised plasma urate levels and had been prescribed allopurinol for symptomatic gout; one patient had a single episode of renal calculi secondary to urate nephropathy. Affected adults (both male and female) reported muscle cramps +/-myoglobinuria, as a consequence of sexual intercourse. Most patients reported a sedentary lifestyle due to fear of developing rhabdomyolysis and acute renal failure.

Three patients had been treated with opiates prior to referral; two had become dependent on oral morphine and were unable to withdraw treatment. All three reported severe exercise intolerance due to incapacitating chronic pain, muscle cramps and myoglobinuria despite continuous opioid treatment.

Physical Examination

The majority (71%, n=32) of patients were overweight with a BMI greater than 26. Facial weakness was not seen in any patient. Muscle hypertrophy was seen in eleven patients (24%) affecting all or some of the following muscle groups: deltoid, biceps, calves and thighs. Mild muscle wasting predominantly involving the paraspinal, peri-scapular and proximal upper limb muscles was present in fifteen patients (33%). Mild weakness (grade 4/5 MRC scale) involving axial and shoulder girdle muscles was seen in seven patients (16%), all of whom were over 40 years of age. Lower limb wasting and weakness was not a feature in the McArdle patients, by contrast quadriceps wasting and weakness was seen in the two wrongly diagnosed patients who had Becker muscular dystrophy.

Progressive muscle wasting and limb girdle weakness was seen in one patient with homozygous p.Arg50X mutations. The patient had marked calf hypertrophy and pes cavus, which was not seen in any other McArdle patient. In addition to complete absence of muscle glycogen phosphorylase in most fibres, his muscle biopsy showed atypical pathological features with several regenerating fibres with activity of the brain isoform of phosphorylase and several rimmed vacuoles. Immunolabelling of sarcolemmal proteins affected in various forms of muscular dystrophy was normal (figure 1a, figure 1b shows typical histology for comparison). The patient is thought to also be affected with a limb girdle muscular dystrophy. DNA studies for Xp21, FKRP, SMN, GNE and caveolin 3 showed no abnormality. Further genetic studies are pending.

Investigations

The serum CK was raised in all but one female patient who was 32 weeks pregnant at the time of testing, mean serum CK was 2,471 iu/l (ranging from 85-12,405 iu/l, normal values <190 iu/l). Repeat testing of serum CK in the pregnant patient, two years after the birth of her child was raised at 1384iu/l. Molecular genetic studies undertaken to look only for the mutations p.Arg50X and p.Gly205Ser as an initial screen were undertaken at The Princess Diana Children's Hospital, Birmingham. Forty three patients, all of whom were of British Caucasian origin, carried at least one allele mutated for p.Arg50X (95%) (table 2). This initial screen confirmed the diagnosis in 66% of patients, who were shown to be either homozygous or compound heterozygotes. One father and daughter demonstrated pseudo-dominance; both were homozygous for p.Arg50X mutations. There was no consanguinity, the wife/mother was heterozygous for p.Arg50X.

Full gene sequencing was undertaken on DNA from patients shown to be either heterozygotes or who had neither allele mutated. Two patients did not carry either of the p.Arg50X or p.G205Ser mutations. One was of Pakistani origin and was found to carry a novel homozygous mutation in exon 1 (c.14delT), the other was a caucasian female patient and was found to be a compound heterozygote for p.Leu36Pro and c.1239+1G>A. In the remaining 13 patients the second mutation was scattered across the PYGM gene, nine of which were novel mutations [START_REF] Duno | High-resolution melting facilitates mutation screening of PYGM in patients with McArdle disease[END_REF] and are shown in table 3. A detailed account of the methods used for molecular genetic analysis is reported by Duno et al 2009 [START_REF] Duno | High-resolution melting facilitates mutation screening of PYGM in patients with McArdle disease[END_REF].

Functional testing

Patients own perceptions of exercise tolerance were variable ranging from ability to walk only 10 yards on the flat to normal levels of activity (including regular sporting activities and hill walking). Each subject was asked to walk as far as they could in 12 minutes and to rate muscle sensation using the RPP scale, subjects were instructed not to allow their RPP score to exceed level 4 (moderate sensation). Heart rate was recorded via a wireless chest strap transmitter (Polar, Kempele Finland) and the total distance walked was recorded. Walking speed, heart rate and RPP were recorded each minute. Differences in minimum and peak values of walking speed, heart rate and muscle pain over the 12 minutes of the test were assessed using a one-way analysis of variance.

All 20 patients completed the assessment with no episodes of severe cramp or rhabdomyolysis (assessed by laboratory biochemical analysis for CK and urine myoglobin concentrations). In the first six minutes of assessment, RPP ratings and heart rate (HR) increased significantly from the resting value (p<0.0005), whilst walking speed decreased significantly (p = 0.013) (figure 2a, 2b, 2c). Significantly correlated perturbations in RPP and HR occurred between 1 and 6 min (r = 0.521; p = 0.019) and 6 and 11 min (r = 0.678; p = 0.001).

Between 6 and 11 min, RPP decreased (p = 0.011), walking speed increased (p =0.017), thus demonstrating a second wind phenomenon.

The total distance walked in 12 minutes was highly variable ranging from 195-1980 metres, the mean distance walked was 512m, indicating a wide range of functional variability. There was no significant difference between the median distances walked by p.Arg50x heterozygotes (850m) compared with p.Arg50x homozygous participants (920m) (Wilcoxon rank sum, W = 75.5, n1 = 9, n2 = 11; p =.149), thus suggesting no genotype/phenotype correlation. Figure 2c illustrates that the test was of a suitable intensity in keeping with recommended intensities of aerobic exercise [START_REF] Martin | Exercise capacity in a 78 year old patient with McArdle disease: it is never too late to start exercising[END_REF], where throughout the test, with exception to the first minute, heart rates were above 65% of maximum. Figure 3, additional data from a further 34 patients assessed as part of routine clinic follow up, shows a relatively even distribution of walking distance across a wide range of functional abilities, with a small peak of participants in the 800m category. In this group the range was159m-1180m, with a mean distance of 669.3m, demonstrating similar results to the original research study.

Pregnancy

Data were based upon reported experience from affected females, and suggests that McArdle disease does not significantly increase the risk of complications for pregnancy and delivery. Fourteen women had given birth to 21 children. Two women reported worsening muscle cramps during pregnancy but the rest reported feeling better than usual. There was one twin delivery, normal birth was achieved in 17/ 21; two babies were born by forceps delivery and two by emergency caesarean section, one child was born following elective caesarean section because of a previous section. The rate of interventional delivery was 15%, which does not differ significantly from healthy women [START_REF] Nice | A prospective audit of wound-infection rates after Caesarean section in 5 West-Yorkshire hospitals[END_REF].

One woman recalled 'mild' myoglobinuria following the delivery of her third child, but no specific intervention was required. The commonly used histochemical method is specific for muscle glycogen phosphorylase and in McArdle disease it fails to stain in mature skeletal muscle fibres. In regenerating muscle fibres and smooth muscle fibres present in blood vessels it will stain positive because of presence of the brain isoenzyme, this is a useful indicator that the method has worked. The method relies on activation and utilisation of the enzyme in reverse direction (glycogen synthesis) leading to the accumulation of glycogen, which is visible as iodine-reactive material. The colour development is not stable in aqueous mountants and it is essential to include a control sample in parallel with the test sample and to observe the outcome as soon as possible to prevent a false diagnosis [START_REF] Beynon | Selected disorders of carbohydrate metabolism[END_REF]. If, however, the sections are dehydrated and mounted in resins the colour survives well and this can avoid a false negative result. [START_REF] Beynon | Selected disorders of carbohydrate metabolism[END_REF]. A false diagnosis of McArdle disease can also potentially occur in critically ill patients who have secondary glycogen depletion, muscle histochemistry will appear negative for glycogen phosphorylase [START_REF] Pacheco | False negative histochemical reaction for myophosphorylase activity in fulminant sepsis due to methicillin resistant staphylococcus aureus[END_REF]. On the other hand, diagnosis can be missed if muscle biopsy is undertaken too soon after massive rhabdomyolysis. Although the regenerating fibres express the brain glycogen phosphorylase isoenzyme staining may appear weak. Under such circumstances it is wise to delay muscle biopsy until at least one month after the patient has fully recovered muscle function.

Discussion

The diagnosis of McArdle disease can be confirmed by sequencing PYGM

for mutations, although this is time consuming and costly. Screening for the mutations p.Arg50X and p.Gly205Ser before undertaking full gene sequencing is especially useful for British Caucasian patients; it is cost effective and may prevent the need for a muscle biopsy and full gene sequencing. In this cohort, the allele frequency of the p.Arg50X mutation was 77%. This confirms previous studies, which have shown the p.Arg50X mutation to be most prevalent in British and North American patients [14,15]. In this series, there was an equal preponderance of male and female patients as would be expected for an autosomal recessive condition. However, a previous retrospective review reported a predominance of affected males and concluded that this probably reflected a gender related reporting bias, since males are more likely to undertake strenuous recreational and occupational activities [START_REF] Dimauro | Metabolic Disorders Affecting muscle; Non Lysosomal Glycogenoses[END_REF]. The onset of symptoms most commonly occurred in early childhood, but diagnosis was delayed until after 30 years of age in more than half of the patients. The long delay from onset of symptoms to diagnosis despite patients seeking medical help suggests that primary care physicians are not familiar with the condition.

For many of the patients, memories of school years were unfavourable, their symptoms having been attributed to 'growing pains' and not investigated further. In children, idiopathic leg pains are common, they usually occur at night, are not exercise-related and the serum CK is normal. By contrast, the serum CK is almost always raised in McArdle disease. Any patient presenting with a history of muscle cramps affecting any skeletal muscle during exercise should lead the doctor to suspect a metabolic myopathy. A history of painful cramps that occur within a few minutes of initiating exercise and which subside rapidly with rest in conjunction with a raised serum creatine kinase is highly suggestive of McArdle disease. If the individual continues to exercise to the point of contracture, there will be a history of painful rigidity, which may persist for several hours, this will almost always be accompanied by muscle swelling and myoglobinuria. The history of a second wind should be specifically looked for, but may not always be recognised by patients, however, during exercise assessment the second wind is a universal finding [START_REF] Vissing | A diagnostic cycle test for McArdle's disease[END_REF]. A history of myoglobinuria is not universal, and its absence does not exclude the condition.

In this series, significant muscle hypertrophy was present in 24% of patients; a more frequent finding than previously reported which was 10% in a cohort of 34 patients [13]. The aetiology of this finding is unclear. Mild muscle wasting affecting the paraspinal muscles and shoulder girdle was relatively common. Muscle weakness, when present, was mild (not worse than MRC grade 4) and predominantly involved the shoulder girdle and axial muscles. Muscle weakness was not seen in any patient who was under 40 years of age.

Significant shoulder girdle muscle atrophy and weakness has been previously described in an elderly McArdle patient [START_REF] Vissing | Splice mutations preserve myophosphorylase activity that ameliorates the phenotype in McArdle disease[END_REF]. The presence of significant lower limb wasting and weakness was not a typical feature and alerted us to look carefully for an alternative diagnosis, which in this case, was Becker muscular dystrophy.

As with previous studies we found no genotype-phenotype correlation [12,13]. In our research cohort, the 12-minute walk test demonstrated a wide range of variability (195-1980m), however, the mean distance walked in 12 minutes was 512m. Healthy sedentary individuals would be expected to walk more than 1200m in 12 minutes. McArdle patients who walk less than 500m in 12 minutes are most likely to have significant impairment in performing activities of daily living (ADL). The average walking speed of 41.7m/min (2.5km/ hr) in the research cohort, represents an oxygen uptake of 8-10ml/kg/min (2-3 metabolic equivalents) [START_REF]ACSM's Guidelines for Exercise Testing and Prescription[END_REF], most ADLs range between 2-4 metabolic equivalents [START_REF] Martin | Exercise capacity in a 78 year old patient with McArdle disease: it is never too late to start exercising[END_REF], [START_REF] Haller R G | Aerobic conditioning: an effective therapy in McArdle's disease[END_REF]. The authors concluded that the mechanism of action was likely to be an improvement in mitochondrial metabolism secondary to an increased delivery of blood borne mitochondrial fuels through improved blood flow [START_REF] Haller R G | Aerobic conditioning: an effective therapy in McArdle's disease[END_REF]. Thus, aerobic exercise is safe for people with McArdle disease and should be recommended for all patients, regardless of age or severity [START_REF] Haller R G | Aerobic conditioning: an effective therapy in McArdle's disease[END_REF][START_REF] Mate-Munoz | Favourable responses to acute and chronic exercise in McArdle patients[END_REF][START_REF] Livingstone | McArdle's disease following statin-induced myositis[END_REF]. Advice should be given on how to avoid isometric muscle contraction and anaerobic exercise which are dangerous for patients with McArdle disease and are likely to lead to contracture and rhabdomyolysis.

In this series, three patients taking regular opiate medication were the most disabled and complained of incapacitating chronic pain with frequent episodes of contracture and myoglobinuria. There was no evidence to suggest symptomatic benefit from opiates, in fact it is possible that this strong form of analgesia masks mild to moderate discomfort, the normal warning sign to stop exercising before a cramp occurs, and thus could potentially increase the frequency of episodes of contracture and rhabdomyolysis.

The potential risk for adverse reaction to statins remains uncertain. There are two published case reports of worsening cramps following statin treatment and one case report of acute rhabdomyolysis with Ezetimibe, although the patient had also exercised prior to the episode [START_REF] Livingstone | McArdle's disease following statin-induced myositis[END_REF][START_REF] Barth | The case of stainless statins[END_REF][START_REF] Perez-Calvo | Worsening myopathy associate with ezetimibe in a patient with McArdle disease[END_REF]. In this series, two patients were diagnosed after a statin was prescribed. It remains unclear as to whether or not the condition was made worse by statins or merely unmasked in these patients. When considering statin treatment in people with McArdle disease, cautious introduction of treatment with close monitoring is advisable until further evidence becomes available on the effect of statins in the condition.

In this series there was an increased risk of symptomatic gout. One patient also had a renal calculus, probably secondary to a urate nephropathy. This is probably due to a secondary increase in purine metabolism [START_REF] Mineo | Myogenic Hyperuricaemia. A common pathophysiologic feature of glycogenosis types III, V, VII. New England[END_REF].

The findings suggest that plasma urate levels should be monitored in patients with McArdle disease. Women can be reassured that a normal pregnancy and delivery is possible.

There is no cure for McArdle disease, and as yet no specific treatment can be recommended [START_REF] Quinlivan | Pharmacological and nutritional treatment of McArdle's disease (Glycogen storage disease V) Cochrane Database Syst[END_REF]. Low dose creatine was shown to confer a small benefit in a small number of patients [START_REF] Vorgerd | Creatine therapy in myophosphorylase activity (McArdle's disease). A placebo controlled crossover trial[END_REF]. Ingestion of sucrose prior to planned exercise improves performance [START_REF] Vissing | Effect of oral sucrose on exercise intolerance in patients with McArdle's Disease[END_REF], but is not a useful treatment for routine daily living. In one series, a diet rich in carbohydrate resulted in better exercise performance than a protein rich diet [START_REF] Andersen | Carbohydrate-and protein-rich diets in McArdle disease: Effects upon exercise capacity[END_REF]. Teaching patients a strategy to achieve a second wind enables them to exercise safely.

A functional exercise assessment is necessary to monitor the effectiveness of any future clinical intervention. Traditionally exercise capacity in McArdle disease is assessed using cycle ergometry which has been demonstrated to be reliable for physiological and treatment studies [START_REF] Livingstone | McArdle's disease following statin-induced myositis[END_REF].

However, the lack of availability of sport's equipment in many clinical settings makes this test impractical for widespread routine outpatient use. Furthermore, walking is the most common and functional form of physical activity and it seems sensible to have a simple test that represents this activity. The assessment clearly demonstrated the presence of a second wind between 6 and 10 minutes, in keeping with previous studies [START_REF] Van Elfen | The prevalence and genetic characteristics of McArdle's disease in The Netherlands[END_REF], where walking performance clearly improved either by a reduction in discomfort for a given walking speed or that for any given heart rate, walking speed was increased. This assessment additionally acts as an education tool because it enables patients to experience and clearly see and understand the concept of a second wind. Finally, a record of the total distance walked in 12 minutes can be utilised as both a functional status Mean rating of pain (RPP) to walking speed (m.min -1 ) ratio.

Error bars = standard error of the mean.

Figure 2c

Mean Heart rate during 12 minute walk test expressed as a percentage of peak HR corrected for age

A

  specialist clinic for people with McArdle disease was established at The Robert Jones and Agnes Hunt NHS Hospital Trust in 1998. In this study, we present the results of a prospective clinical evaluation of 45 genetically confirmed British patients referred between July 1998 and December 2007.

Following

  the development of a specialist clinic for McArdle disease an unexpected finding was the relatively high frequency of false diagnosis where 10 out of 55 patients previously diagnosed did not have the condition. Two of the patients wrongly diagnosed with McArdle disease had Becker muscular dystrophy, both had presented with exertional cramps and myoglobinuria. Unlike the McArdle patients they both had quadriceps wasting and significant pelvic girdle weakness. Seven patients had chronic fatigue syndrome, unlike the McArdle patients, none of these individuals complained of exercise related muscle cramps and all had a normal serum CK and ischaemic lactate test. In these patients the diagnosis of McArdle disease had been previously made on the basis of muscle biopsy demonstrating absent phosphorylase activity. A repeat muscle biopsy, however, did not confirm this finding.

  which means that the McArdle patients achieving less than 500m were struggling to sustain what healthy individuals would consider to be a very low exercise intensity. People with McArdle disease are afraid to exercise for fear of developing rhabdomyolysis and acute renal failure, however, acute renal failure was a relatively infrequent event and can be avoided by pacing exercise intensity for the first few minutes of activity. Most patients adapt to their condition by adopting a sedentary life-style, the consequence of which will be de-conditioning and may lead to exacerbation of fatigue and exercise intolerance. Weight gain is common, with the majority of patients being overweight or obese, this is likely to worsen symptoms by increasing dependence on glycolytic metabolism during exercise. Psychological disturbance was a relatively common finding, and may reflect a combination of living with limited exercise intolerance and possibly diagnostic delay. Earlier diagnosis, improved management and a greater awareness of the condition could potentially improve quality of life. In an open study of aerobic exercise training in people with McArdle disease, Haller et al demonstrated a significant improvement in work capacity and no serious untoward effects

  Figarella-Branger D. Molecular characterisation of myophosphorylase

Figure legends: Figure 1a

 1a Figure legends:

Figure 1b Figure 2 Figure 2 A

 1b22 Figure 1b

Graph 1

 1 Figure 1a

Table 2

 2 A summary of presenting history and clinical features

	History	Number Affected Percentage of total (n=45)
	Exercise induced cramps/ myalgia	45	100%
	Recognition by patient of second wind	35	78%
	Myoglobinuria	28	62%
	Acute renal failure	5	11%
	Raised plasma urate / gout	5	11%
	Chronic Fatigue	18	40%
	Anxiety / depression / bipolar disorder	14	31%
	Examination
	Muscle hypertrophy (deltoid, biceps,	11	24%
	quads, calves)
	Muscle wasting (shoulder girdle,	15	33%
	paraspinals)
	Muscle weakness, shoulder girdle, axial 7	16%

Table 3 DNA analysis

 3analysis Relative frequency of mutated PYGM alleles. 96% of patients were found to carry at least one mutated allele for p.R50X or p.G205S.

	p.R50X/	p.R50X/ other mutation	p.R50X/	Other
	p.R50X		p.G205S
	N=27	N=13	N=3	N=2
		c.1466C>G (p.P489R)		c.14delT/ c.14delT (p.L5RfsX20/p.L5RfsX20
		c.999+20C>T
		c.107T>C(p.L36P)		c.107T>C/c.1239A+1G>A (p.L36P/c.1239A+1G>A)
		c.2430C>T(p.G810G)
		c.2386_2387delAG(p.R796RfsX19)
		c.1129A>T (p.N377Y)
		c.808C>T (p.R270X)
		c.1345G>A(p.G449R)
		c.2465C>A (p.A822D)
		c.403G>A (p.GI35R)
		c.280C>T(p.R94W)
	60%	29%	7%	4%

Acknowledgements:

The authors would like to thank Mr Andrew Wakelin of the Association for Glycogen Storage Disorders UK (AGSDUK) who gave feedback on the manuscript and Professors Roger Eston (University of Exeter) and Julius Sim (Keele University) who gave analytical advice. Financial support was given by the AGSD (UK) and The Muscular Dystrophy Campaign

Competing Interests: None declared

Licence for publication:

The Corresponding author has the right to grant on behalf of all authors and does grant on behalf of all authors, an exclusive licence (or non exclusive for Government employees) on a worldwide basis to the BMJ Publishing Group Ltd to permit this article (if accepted) to be published in JNNP and any other BMJPGL products and sublicences such use and exploit all subsidiary rights as set out in our licence. (http://group.bmj.com/products/journals/instructions-forauthors/licence-forms)

Appendix


Dainis Zeps
email: dainis.zeps@lumii.lv

Mathematica Quanta

Instrumentalis

Quanta Mathematica

Keywords: mathematics, theoretical physics, quantum mechanics, field of information, vision, theorem/quantum windows, consciousness

Introduction

Simplest translation and interpretation of Latin phrase Quanta mathematica instrumentalis would be -how much mathematics for applications. It is the classical standpoint for physical science that mathematics serve for physics as application, and this thesis has served good enough for quite a long time, and it worked well without perceivable faults until quantum mechanics. Many scientists tend to think that, after quantum mechanics has appeared, this general statement hasn't changed radically, i.e., mathematics was and remains to be applicational instrumentality for exact sciences.

But after articles of Dirac [START_REF] Dirac | The relation between mathematics and physics[END_REF] and Wigner (2) something has changed, or at least signals for such changes have emerged: an awareness has come that mathematics works as something more independent and significant than simply applicational tool for other sciences. What is that? But before we try to answer such a question we must somehow estimate, are we ready to raise it at all? Maybe we must be aware that just mathematics is that that show us way further and further, and we are only to follow, but not to raise questions or pretend of having ready answers? Yes, maybe we must say -mathematics is more clever than mathematicians. And this to use not simply as form of rhetoric: it must be accepted as working instrument and signpost.

Do we know what is mathematics? May we know what is mathematics?

On nature of mathematics there are many texts written. And usually when enlighted people speak about this topics they have in mind they know what is mathematics. Yes, the problem might be only how to express what they think mathematics is -so think these same people. But is it true that we "know what is mathematics", that we have objective background to claim that we know? What if behind we name mathematics stands something quite unknown and quite weird -much more weird than quantum mechanics, say? In our articles (3; 4; 5; 6) we argue for a new approach on to what could be mathematics actually.

The approach we suggest is to use formula "Mathematics is cleverer than mathematicians". By it we assume that mathematics itself is that shows way for mathematicians and not otherwise. No one could have predicted anything where mathematics are leading us. Always there has been right other way -it is mathematics that has showed and shows further steps for it to develop. And arguing this way we don't use only some rhetoric without consequences. We say that this is general paradigm of research subject we recognize as mathematics. It doesn't matter that after some unpredicted results in mathematics we start to build predictions on next steps. Sooner or later our "theories" where mathematics should lead us break down. Thus, the only way to "communicate" with mathematics as subject is to develop it step by step and find from mathematics itself what there goes where.

But mathematicians would say that just this they are doing. Yes, mathematics develops successfully so that mathematicians have already discovered this peculiarity about mathematics that it as if itself shows where to go further.

But actually there is ways how to characterize objectively what mathematics is, and it is by discovering its character of instrumentality.

Yes, mathematics may be considered as instrumentality where new sets of instruments are developed using already built instruments, and so on. Mathematics fits in this definition of instrumentality because it is self-content, i.e., all facts of mathematics are get in mathematical way. In this way mathematics as if differs from other sciences where no one other science may argue for its self-content nature as purely as mathematics. This fact has raised for mathematics image or percept of not being science at all but only some way of thinking. But arguing in this direction actually leads us to deadlock. We must think other way. Following the way of thinking of linguist Benjamin L. Whorf who said that linguistics can't be separated from consciousness [START_REF] Whorf | Language, Mind and Reality[END_REF] we might be forced to apply this same formula for mathematics too and say -mathematics is not separable from consciousness. The only problem there -how mathematics is connected with consciousness. In (3; 4; 8; 5; 6) we tried to go into problem directly.

Mathematics is not arbitrary reasoning

Might be mathematics considered as cognitive activity? But, considering mathematics as cognitive activity we have some danger that leads aside from real nature of mathematics. And this is because of the use of axiomatic in mathematics. Many mathematicians think that mathematics is too arbitrary with regard axioms are chosen in it and thus mathematics can't be anything except way of reasoning at all. We argue that this way of reasoning about mathematics and its nature is simply misleading and is not confirmed by the history of mathematics itself.

The main argument against mathematics being arbitrary way of thinking we raise by theoretical physics and the role of mathematics there. Dirac (1) turned our attention that behind mathematics could be something quite unknown. Wigner in (2) argues that mathematics with its unreasonable effectiveness is subject of much deeper investigation. But who tried to explain these phenomena raised by Dirac and Wigner? In [START_REF]On quantum windows or theorem windows: new approach to observer principle in physics[END_REF] we try to point out direction for such explanation. Is it too fantastic? How to answer to Dirac and Wigner? We usually speak about mathematics first and then about role of mathematics in physics. But couldn't be more correctly to do this in other direction, namely, ask what is role of physics in mathematics? We usually explain this very simply: yes, of course, mathematics takes its pictures from nature. But we say, no, there is deeper connection, mathematics is connected with physics in so deeply a way that we must apply very simple formula mathematics = physics (4). Or, at least, considering both subjects we must say that mathematics is something that completely depends from physics, not in reverse, and this we deduce from what goes on with mathematics in theoretical physics and in quantum mechanics particularly and not in other way.

But let us continue our argument with mathematics as instrumentality and its selfcontent nature. What we do in mathematics is its extension by discoveries via its instrumentality. This instrumentality is not only of cognitive nature or arbitrary product of cognition, but it manifests the cognition itself as we try to show in [START_REF]On quantum windows or theorem windows: new approach to observer principle in physics[END_REF]. Thus, mathematics is both cognitive and physical science. But, maybe our arguing in this direction is too radical? For that reason it is useful to note that mathematics may be considered as instrumentality in very natural way not appealing to these new approaches we mention in this article. And just this instrumentality aspect of whole mathematical science we are going to use in our argument further. We use in title expression Quanta mathematica instrumentalis to say what these words mean directly in Latin -How much mathematics there that arise in its natural way mathematics being instrumentality for its own development.

But we are going to add some other aspect to this title, scilicet, via role of quantum mechanics. We told about this in [START_REF] Zeps | On science as instrumentality: what changed after quantum mechanics appearing in episetemology. Par zinātni kā instrumentalitāti: kas mainījies pēc kvantu mehānikas ienākšanas epistemoloģijā[END_REF]. We said that most queer aspect of quantum mechanics is what role mathematics plays there. Traditionally quantum mechanics is considered as weird discipline due to its discontent with classical physics. We say that aspect of mathematics in quantum mechanics is much more "weird" and this weirdness is not yet fully recognized by contemporary physicists.

Is mathematics intrinsic part of consciousness and cognition or only product of reasoning?

Traditionally mathematics has been considered only as product of reasoning. If someone has tried to ascribe to mathematics some deeper participation in nature then usually this has been nominated as Platonism, but not much asking how or in what way this implication could have been achieved. Benjamin Lee Whorf on what concerns nature of languages have advanced idea that language activity in human beings are intertwined with consciousness and even with physical reality and can't be separated as independent cognitive activity, but rather it builds the cognition itself [START_REF] Whorf | Language, Mind and Reality[END_REF]. We go further and say the same about mathematics and say even more: mathematics and language ability are built on common base and apparatus, and we call this apparatus theorem windows or quantum windows (5; 9). This apparatus by its nature is both cognitive and natural physical. In this way we try to unite consciousness and material world but in way saying that theorem/quantum windows are primary, and consciousness and material world are derived from, these both being different reference systems, i.e., consciousness being our inner reference system, and material world being our outer reference system. We may add that somewhere outside maybe there is some really material world detached from consciousness, but we access it only via this trinity of theorem/quantum windows with its inner and outer reference systems.

On theorem windows or quantum windows as new observer level

In [START_REF]On quantum windows or theorem windows: new approach to observer principle in physics[END_REF] we suggested to consider as base of both consciousness and observable world these new items -theorem windows or quantum windows. Moreover, we suggest to consider these windows as new observer level that is not accessible directly by human being but only via his cognitive activity and human body functionality. We suggest to use new observer principle in physics, i.e., with saying that theorem/quantum windows are new observer level that differs from the observer used in physics up to now, but, in order to maintain connection with contemporary science and not to appear in some area of scientific phantasy we suggest to apply strong and weak variation of this principle. We say that by weak principle nature behaves as if such observer could exist in nature, but contemporary science doesn't give us possibility to detect its proper nature more closely [START_REF] Zeps | On science as instrumentality: what changed after quantum mechanics appearing in episetemology. Par zinātni kā instrumentalitāti: kas mainījies pēc kvantu mehānikas ienākšanas epistemoloģijā[END_REF]. By strong variation of D. Zeps. Quanta Mathematica Instrumentalis! this principle we remain to assumption of existence of these theorem/quantum windows behind consciousness and what we perceive as nature.

Instrumentality of mathematics as objective reality

The instrumentality that we discover in mathematics is always treated more or less as some objectivity. Otherwise we couldn't explain why we/mathematicians so diligently write books of mathematics, collect already proved theorems and theories, consider all this as proper ground to move more and more deeply in some unknown world where mathematics and its discoveries are leading us. We properly call it world of mathematics. Intuitively we consider mathematical world as some proper world of its own rules and nature, and we don't consider it as some mirage depending only from arbitrary basic assumptions/axioms. Why we tend to think in this way? Who suggests us to think this way? Some say this is intuition that compels us to think like this. There could be other, we would say, deeper explanation. Peripheral knowledge and/or Akashic knowledge is that what prompts us to think properly in this case, although we do not want to recognized this directly/openly. Les us name only one case, i.e., that of four dimensional case in low-dimensional topology. Four color theorem, Hadwiger conjecture and Poincaré conjecture, the hardness to prove these facts is objectivity that has been proved by effort of hundreds of mathematicians that has required time more that hundred years. The solution of these problems and developments into these directions promise to give many very rich new ways in mathematics. Mathematics promises to be more and more interesting and these deeper and deeper interests don't resemble the rambling of insanes and lunatics in the dusk, but most victories of triumphant mind.

From instrumentality in mathematics to instrumentality in whatever else in science

But, once we manage to notice the instrumental nature of mathematics we may go further and observe: in technical progress and technologies we have the samewhatever there is of instrumental nature directly, i.e., simpler instrumentality serve as necessary base for more complex instrumentality.

And one more area is very essential for our building of argumentation of instrumentality, scilicet, experimental physics that builds equipment for physical experiment is completely instrumental, where simpler equipment helps to build more and more complex one. Physics with its interpretational "power" remains somewhere in background: experimental equipment and its ability to fix physical quantity or quality is "absolute truth" there, but physical interpretations, "explanations of what goes on", are of secondhand utility, which physicists sometime relay too much upon.

But let us go further and ask -What about instrumental nature of science in general?

To give simple allusion we suggest to consider science consisting of two partsinstrumental and universalizing/conceptualizing. We may say even simpler: let us separate instrumental part and what remains outside we attribute to that second part of universalization/conceptualization. One may ask what is instrumental part of science: there are indirect ways to establish this -instrumental part of science is that what develops mostly dynamically. Just instrumentality in science goes on and on, and develops as if without obstacles and hindrances with increasing speed if considering development of science in some wider timescale. What don't want to develop so smoothly are our wishes to push science according our whims and fancies, but not where it may develop objectively.

What we may conclude from what we said? If science is really forwarded and developed then this forwarded part necessarily is instrumental part too, because only instrumentality could procure for science its development. Not our any " cleverness" or whatever else we could suggest from our virtues or good qualities, but only step by step development from tools and by tools taken from this same science we are pushing forward.

Why only instrumentality procures progress in science? In article (3) entitled " Our Ability to Research Comes Before Understanding of What We Research" we gave explanation already in the title -we simply don' t understand what we research, but providence gives in our hands (and heads) tools necessary for research, and, if we only give way providence to push us forward in this way, then we see progress in science. But, what concerns understanding of what goes on in our research we didn't have neither in times of Plato and Aristotle, nor today. Why? We gave reasons for that in this same article [START_REF] Zeps | Our Ability to Research Comes Before Understanding of What We Research[END_REF].

But some forms of understanding we gain nevertheless, see [START_REF] Zeps | Our Ability to Research Comes Before Understanding of What We Research[END_REF]. Thus, Aristotle gave name to his logical method Organon [START_REF]Aristotle. Organon[END_REF], what means in Greek instrument. Further, Frances Backon pointed out necessity of experimental support of scientific thought [START_REF] Becon | Novum Organum[END_REF], thus giving us allusion to second instrumentality for science. Tertium Organum tried to give Ouspensky by hinting to numina which shouldn't be ignored by considering phenomena [START_REF] Ouspensky | Tertium Organum. Key to the Enigmas of the World[END_REF]. In (3) we said that now we have Quartum Organum emerged in appearance of quantum mechanics. This fourth step, quantum mechanics, indicates us that we must say farewells to understanding of whatever in science, remaining content with instrumentality that Providence provides for us in abundance. And Providence is not stingy and closefisted, but provides for those devoted in quantum mechanics with abundance in highest precision of data and methods. Now, looking backwards onto science in past from where we are now with our quantum mechanics experience as Tertium Organum we may see that it is easier to explain where we something couldn't understand than where we still have claims about deep understanding asking -maybe all these claims of our knowledge are to be reconsidered? It seems now clearly that we are to distinguish more instruments which have given us what we consider as knowledge, but this knowledge itself should be impeached and queried more and more.

Within two levels of observer or within the well of field of information

In articles (3; 4; 5) we tried to give model of how instrumental nature of science could be explained. We argued that we are to discover new level of observer that is not accessible for us now directly, but we access it indirectly via our research abilities that provides so richly us, human beings, with instrumentality. We have reached level of consciousness and awareness that gave us all we have acquired in physical science due to some understanding of how to build correctly principle of observer, and how to ground on it our physical knowledge. But this all worked with success until quantum mechanics. Now we are to notice that before us is higher level of observer that is not accessible in the way we were used to, say, simply by looking or sensing via our anatomical instruments of our senses. But this higher observer not only provides us with information. After all, why we were to be supplied with such information? But we may guess other way there being around. We gain this information as side effect of something else.

What else?

First. Of how we are built by worlds of higher level. Second. Of existence of field of information that provides us with resources of existence as form of life. Third. Of how we are supported as form of life with respect to this higher observer. Fourth. Of how we are built with respect to this higher observer.

On what level of our guess we must stop? Fourth guess says little except that such level of observer is distinguishable and exists in some assumable sense. Third level says that we are to speak of how life is organized between us and "observable" world. But second guess says something more: that this higher level of observer works on informational levels of much more organized structure than that we recognize in us as anatomical structures with respect to inorganic world. With fourth guess way may want to say that this life organization from above is maybe of hierarchical structure.

In articles (3; 4) we stay on guess of field of information. Actually, we see other way to this guess, scilicet, via our vision. Contemporary science considers sense of vision and what we see via vision as pertaining to two distinct areas of science, i.e., sense of vision is anatomical instrumentality, and what we see, outer world, may be attributed to, say, physics. Now, when we come to our guess of new level of observer, we may notice that vision may be considered quite in other way. First of all it isn't any more dissected into two areas of sciences, anatomical functionality and physical reality, but are now pertaining to some integral functionality on this higher level of observer, but which comes via field of information to us in a dissected way via two functionalities, one that provides us built in functionality of anatomical vision, and other that provides us functionality of what we see as pictures of outer world. Thereby these two functionalities represent actually one common functionality on level of higher observer. For this reason, this level of observer we find adequate to designate as higher, because it is as if more primary of what we perceive on our conventional level of observer.

Coming to this level of understanding we are describing here, some might better understand our wish to speak about well of field of information. First of all, field of information expresses the fact that the functionality that works on this higher level of observer is much more organized than that we may find in our direct observation, and this higher organized information is just this that provides us so richly with scientific instruments if only we are sufficiently diligent to inquire after these instruments. Secondly, we may speak about being in well of field of information because we may with easy guess that we are on the very button of some imaginable well where well's upper part may be on level of this higher observer. Thus, we may imagine us as being living creatures that can't access this upper part of this well of field of information. What if we could? We were as gods? Now, if we have image of well of field of information, then way may assume that this higher observer is actually structured hierarchically, and this well has as if several levels within. With these levels we might associate hierarchical multiplicity of life organization [START_REF]On quantum windows or theorem windows: new approach to observer principle in physics[END_REF]. But here we are not going deeper in such our guesses.

Vision as functionality of field of information of higher observer

How to check rationality of the ideas around this new observer we try to introduce? We mean that easiest way would be to check via vision as integral objectivity, but not consisting from two detached parts -anatomy and physics. Pictures provided by vision and what we see possess aspect of wholeness. Thus, we are to describe them mathematically correspondingly, as holograms or distributions, or find other appropriate way [START_REF]On quantum windows or theorem windows: new approach to observer principle in physics[END_REF]. Discoveries of Pribram might directly show that vision is to be considered more in holographic context than reductional physics is possible to give [START_REF] Prideaux | Comparison between Karl Pribram's[END_REF].

Returnig to mathematics and its role there

Why we started with mathematics when starting this discussion on possible new observer level in nature? According our insight we present here mathematics would be almost the only thing that leads us into these new realms. We might argue otherwise and ask: why we haven't discovered all this before? Our answer would be simple: we are too far from this possible observer to catch it in any way directly. The only way it shows up is via peripheral knowledge or Akashic knowledge or religious reasoning or like way which all are too far from scientific way of thinking as we understand it now. Only after quantum mechanics came into existence we noticed that something radically has changed and something appropriate should be applied to cope with this new situation. And because of this all this argumentation that we have used in this article. But returning to what we started we are to say that mathematics is that instrumentality that shows up something that might directly pertain to this higher level of observer. Mathematical structuring shows the freedom of motion in the most general sense that works on levels not only in this world but in higher too. In [START_REF] Zeps | The Double Rotation as Invariant of Motion in Quantum Mechanics[END_REF] we suggested to designate this freedom of motion as Motion. After all, what we designate as mathematics with our present experience there might be only some start point into some unknown world that should reveal before us with going deeper and deeper in it. For that reason mathematics would be subject that we should research with much more diligence than we are done there before. For that reason next section of our discussion.

Why we should study mathematics more and more, and which risks we have on this way there? Mathematics as independent science develops according its own rules. First of all, mathematics may be developed only by people who are sufficiently talented and even more important, who are sufficiently prepared for this purpose. Moreover, mathematics main discoveries are done by highest gifted people there who are very few in number. But even under these conditions mathematical development may be doomed by some outer aspects which we want to designate as highest risks.

First of all there are not popular theories, say, like our approach, that would prompt to increase development of mathematics by some special efforts. Next, if such theories were or appeared, who would care for procuring of such special efforts? Simply asking, who would pay for all this? To make such efforts there should be very clear reasons for this. We think that we are very far from such cleverness.

And more, there are processes that make worse the actual state of mathematics. We may name two, for example. First is understanding of what is mathematics in context of Gödel like theorems and axiomatic nature of mathematics. These aspects tend to assess mathematics as arbitrary reasoning with diminished sense of accumulating of its facts more and more. Second risk is connected with growing role of programming in all areas. First, programming entices people that would be good mathematicians. Second, programming activity tries, deliberately or directly, replace mathematics with offals produced by programmers.

Mathematics as form of awareness of human being

Mathematics along with linguistics are human faculties, but they differ. Linguistics comes as ability to use language to every human being. What concerns mathematics its faculty don't come to every human being except some basic level with ability to easy acquire skills to count and calculate and understand some basic geometric notions. What we acquire in school is that mathematics that comes to us gratis to all. If we want more mathematics we are to make hard efforts that are made easier only for those who are highly gifted, and so on and so on. Mathematical gifts may be compared with some ladder in higher and higher realms of its understanding, but this same picture of ladder depicts for us levels of awareness that are objectivity of our mind with respect to higher levels of observer. Thus, we have all some base level of awareness that is given us from nature and it consists from language ability and some additional in form of mathematical gift and some developed mathematical ability in our lifetime. Now, knowing this, we might ask: -are we developing or evoluting in a longer time scale as form of life, or staying where we are?

The question is very interesting if we consider in context what had to say us in this respect Rudolf Steiner. He gave us allusion that between states of being alive human beings are in contact what he called animal world, where mathematics was present as some objective functionality [START_REF] Steiner | The Dead are with us[END_REF]. It may be that contemporary science sooner or later would come to point where it might take what said R. Steiner with much seriousness.

Conclusions

Mathematics as paradigmatic case of human activity is considered and suggested to be taken as base for our cognition. Moreover, it prompts us to come to conclusion that higher observer level or levels exist that signals us of its presence via mathematical instrumentality we acquire. Doing this our way presented in this article we go away from traditional physics and its attempts to solve problems in traditional way, say, as in [START_REF] Smolin | The Trouble with Physics. The Rise of String Theory, the Fall of a Science and What Comes Next[END_REF]. But we hope that we conclude way that is already started by series of investigators, say, as, e.g., David Bohm [START_REF] Bohm | Wholeness and the Implicate Order[END_REF], Roger Penrose [START_REF] Penrose | The Road to Reality. A Complete Guide to the Laws of the Universe[END_REF], Kerson Huang [START_REF] Huang | Fundamental Forces of Nature. The Story of Gauge Fields[END_REF], Bernard Haisch [START_REF] Haisch | The God Theory. Universes, Zero-Point Fields, And What's Behind It All[END_REF], Dean Radin [START_REF] Radin | Entangled Minds. Extrasensory Experiences in a Qauntum Reality[END_REF] and G. Dlyasin [START_REF] Dlyasin | Azbuka Germesa Trismegista ili molekularnaja tainopis mishelnija[END_REF]. We hope that we conclude way of many researchers of past (23; 24) who suspected already then the necessity of this way suggested by us.

Quanta Mathematica Instrumentalis has two meanings. Firstly, it says, how much there is mathematics that serve for us as much deeper source to be investigated and to be understood. Secondly, it says that quantum mechanics as instrumentality shows us that all science should be reconsidered and restructured on base of mathematics as indicator of higher form of observer.