Early morning off-medication dyskinesias, dystonia, and choreic subtypes

BACKGROUND

Abnormal involuntary movements (dyskinesias) are common in patients with Parkinson disease (PD) as a consequence of the disease and dopaminergic replacement therapy. Early morning off-medication choreic dyskinesias have been recently reported after fetal dopaminergic cell transplantations in patients with advanced PD.

OBJECTIVE

To determine the frequency and severity of the early morning off-medication dyskinesias in consecutive patients with advanced PD and an insufficient response to medical management before they undergo neurosurgery.

METHODS

Consecutive patients with advanced idiopathic PD were examined and videotaped before undergoing neurosurgery that included pallidotomy, fetal transplantation, or deep brain stimulation. The examination took place in the morning in the practically defined off state, at least 12 hours after the last dose of dopaminergic drugs. Parkinson disease was characterized using the Unified Parkinson's Disease Rating Scale and the Hoehn and Yahr stage. Dyskinesias were rated with the Abnormal Involuntary Movements Scale and the Rush Dyskinesia Rating Scale. Patients' characteristics and medications were compared using the Wilcoxon rank sum and the Fisher exact tests.

RESULTS

Of 68 consecutive patients (44 [65%] men and 24 [35%] women), 11 (16%) had early morning off-medication dyskinesia, with a 95% upper confidence limit of 24%. Focal dystonia was the most common off-medication dyskinesia, and occurred in 10 patients (15%), with a 95% upper confidence limit of 22%; and off-choreic dyskinesia occurred in 1 patient (1.5%), with a 95% upper confidence limit of 4%. There was no difference in PD medications between the patients with and those without dyskinesias.

CONCLUSIONS

The most common form of off-medication dyskinesia seen in patients with advanced PD is dystonia. Early morning off-medication choreic dyskinesias are rare but do occur in patients with advanced PD before surgical intervention. The presence and type of off-medication dyskinesias should be monitored in clinical and surgical studies in patients with PD as part of the safety and evaluation of clinical benefits.

Poor Beard!! Charcot's internationalization of neurasthenia, the "American disease"

OBJECTIVE

To analyze the role of the seminal 19th-century neurologist, Jean-Martin Charcot, in the internationalization of neurasthenia, previously known as "the American disease."

BACKGROUND

The New York neurologist, George Beard, first described neurasthenia in 1869 and considered it a disorder related to the particular stress of modern civilization, most typified in the United States.

METHODS

Charcot's personal files on neurasthenia from the Bibliothèque Charcot, Salpêtrière Hospital, Paris, were studied and his teaching lessons and lectures were examined.

RESULTS

Charcot presented numerous cases of neurasthenia, always crediting Beard with the original name and description. Calling Beard's 1880 work a "remarkable monograph," Charcot emphasized that patients with neurasthenia also comprised the bulk of his own private practice. Focusing on the signs of sexual impotency, fatigue, and a tight band of pressure around the head, Charcot categorically distinguished patients with neurasthenica from patients with hysteria. Like Beard, Charcot concluded that the origin of neurasthenia was psychological stress and felt the European society also fostered the environment to precipitate the disease. Charcot adamantly opposed extrapolations that called for early childhood educational reforms to reduce current classroom stress. Charcot sympathized more with the treating physician than the patient, calling neurasthenics insufferable (insupportables). On the front sheet of his neurasthenia file, he wrote in large script, "Poor Beard!!"

CONCLUSION

By emphasizing the prevalence of neurasthenia and extending Beard's observations, Charcot internationally legitimized the new diagnosis. Adding neurasthenia to the other neurologic descriptions from the United States by Hammond, Mitchell, and Dana, Charcot helped to foster the recognition of the American Neurologic School.

Home alone: methods to maximize tic expression for objective videotape assessments in Gilles de la Tourette syndrome

Our objective was to test whether at-home videotapes yield enhanced information on tics compared to office-based videotapes and a patient questionnaire on the current anatomical distribution of tics. Ten subjects with Gilles de la Tourette syndrome (age range 8-49 years) who were seen for initial evaluation completed a check list of anatomical areas currently affected with tics, and underwent a videotape examination according to the Rush Videotape Protocol. Each patient/family conducted the same protocol at home at the same time of day within 48 hours. We rated two tapes in random order using the modified published scoring method for the Rush Video-based Tic Rating Scale. Two environments were compared, the doctor's office and at home, with videotapes taken in three conditions: patient engaged in relaxed conversation, patient quietly seated with filmer in the room, and patient quietly seated alone in the room. Data were analyzed using a 2-factor repeated-measures analysis of variance (ANOVA), followed by Wilcoxon signed rank tests. All patients provided excellent quality videotapes that could be scored without difficulty. Environment (office vs. home) and Condition (conversation, quiet with observer, quiet and alone) were both highly significant (P < .0001) and did not interact (P = .54). The highest tic scores for total tic impairment occurred at home with the patient alone (mean score 14.5), and the lowest yield occurred in the office with an observer present (mean score 5.4), the setting closest to the clinical neurological examination. The Home/Alone video segments revealed tics not otherwise seen. Patient questionnaires on body regions recorded more areas than observed in the office videotape, but patients were unaware of several tics captured on the Home/Alone segment. Patients can produce videotapes for objective tic assessments. Because at-home videotapes consistently yield higher tic expressions than in-office films and capture tics that are not appreciated by patients, this methodology is well-suited for enhanced retrieval of objective data on tic expression.

Ballistic-choreic movements as the presenting feature of renal cancer

BACKGROUND

The paraneoplastic syndromes can involve multiple areas of the central nervous system and result in a variety of neurological symptoms. To our knowledge, severe, rapidly progressive, and drug-resistant ballistic-choreic movements have not been previously described as the presenting feature of renal cell carcinoma.

PATIENT AND METHODS

A previously healthy 55-year-old man developed limb ballismus and involuntary choreic movements of his face over several weeks. Extensive laboratory, diagnostic, and radiographic studies failed to reveal a cause, until an abnormality on a chest x-ray film prompted a search for a primary neoplasm and a final diagnosis of renal cell carcinoma. High doses of medications traditionally used to treat choreic disorders had no effect on the abnormal movements. A biopsy specimen of the basal ganglia showed focal encephalitic changes but no malignant neoplasm.

CONCLUSIONS

Whereas prior cases of paraneoplastic syndromes with chorea have been reported in other forms of cancer, our case was significant because, to our knowledge, renal cell carcinoma has not been previously reported in association with this syndrome. Furthermore, the chorea was categorically resistant to pharmacological treatment, and the movement disorder was the initial and only focal neurological feature of the primary illness.

Genetic variation analysis in parkinson disease patients with and without hallucinations: case-control study

BACKGROUND

Visual hallucinations in Parkinson disease (PD) occur in approximately one third of patients treated long-term with dopaminergic medications. In Alzheimer disease, hallucinations and psychosis have been linked to increased representations of B2/B2 homozyogotes for the dopamine receptor gene DRD1 and 1/1 or 2/2 homozygotes for DRD3. In addition, a previous study of PD patients with and without hallucinations did not show differences in D2 and D3 polymorphisms, although careful case-control matching was not performed. Another study linked the apolipoprotein E4 (APOE4) allele to hallucinations in PD.

OBJECTIVE

To determine whether the frequency of dopamine receptor genetic variants and APOE alleles in patients with PD with and without chronic visual hallucinations resembles the pattern previously documented in patients with Alzheimer disease.

METHODS

We conducted a case-control study of 44 patients with PD and chronic hallucinations and 44 patients with PD who had never hallucinated. Cases and controls were matched for current age and medications. DNA was isolated from blood samples and assayed for DRD1, DRD2, DRD3, DRD4, and APOE polymorphisms. Receptor polymorphisms were genotyped by polymerase chain reaction. Genotypes in hallucinators and nonhallucinators were compared using Mantel-Haenszel tests stratified by pair, and allele frequencies were compared using Wilcoxon signed rank tests within pairs.

RESULTS

Neither D1 receptor genotypes (P =.37) nor allele frequencies (P =.38) differed, and there was no predominance of B2/B2 homozygotes in the hallucinators. For D3, there was a higher frequency of allele 2 (P =.047), but there was no significant difference between frequencies of homozygotes vs heterozygotes (P =.39) as reported in Alzheimer disease. D4 receptor distribution of long and short alleles did not differ between the 2 patient groups, and there were too few C alleles (3 of 86) to compare D2 allele genotypes or frequencies. For APOE, 12 cases and 12 controls carried E4 alleles (P>.99).

CONCLUSIONS

With careful case-control matching, visual hallucinations in PD are not associated with the pattern seen for patients with Alzheimer disease and visual hallucinations. Furthermore, there was no association between hallucinations and APOE. Similar methods using larger sample sizes might be adapted to test whether specific dopaminergic receptor genetic variants are associated with visual hallucinations in PD. Based on our data, the DRD3 allele 2 may merit further study.

Treatment of tremor and dystonia

Treatment of movement disorders has expanded beyond traditional therapies with oral medications to include injection of drugs like botulinum toxin and the use of surgical interventions in cases that do not respond to medical therapy. This article provides an overview to the diagnosis and treatment of tremor and dystonia. The distinguishing features of rest, postural, and kinectic tremor are detailed with medical and surgical modalities for treatment. A discussion of idiopathic and secondary dystonia with focus on diagnosis and medical and surgical treatments encompasses the second part of the article.

Induction by dopamine D1 receptor agonist ABT-431 of dyskinesia similar to levodopa in patients with Parkinson disease

BACKGROUND

Dyskinesias are a frequent adverse effect of long-term levodopa therapy. The relative contribution of dopamine D(1) and D(2) receptor function to the pathophysiology of levodopa-induced dyskinesias remains a matter of controversy.

OBJECTIVE

To establish whether a selective D(1) dopamine agonist induces more or less dyskinesia than levodopa in primed dyskinetic patients with Parkinson disease.

METHODS

We studied ABT-431, the prodrug of a fully selective D(1) agonist, in 20 subjects with advanced Parkinson disease and a fluctuating response to levodopa complicated by dyskinesias. Eight patients were studied in a double-blind, randomized design (French centers); 12, in an open, randomized design (US centers). We assessed and compared the antiparkinsonian (Unified Parkinson's Disease Rating Scale) and dyskinetic (response induced by an acute challenge of a suprathreshold dose of levodopa and by 4 different ascending doses (5, 10, 20, and 40 mg) of ABT-431 during the 6 hours after the challenge.

RESULTS

The separate analysis of the double-blind and open data led to the same findings, ie, the antiparkinsonian and dyskinetic responses induced by ABT-431 were dose related. At the most effective doses (20 and 40 mg), ABT-431 exhibited similar antiparkinsonian benefit and produced similar dyskinesias as levodopa.

CONCLUSION

Dopamine D(1) agonists can induce a full antiparkinsonian response but do not support previous hypotheses suggesting that D(1) agonists are more or less likely to produce dyskinesias than levodopa.

Estrogen supplementation in the posthypoxic myoclonus rat model

The objective of the study was to investigate the effects of estrogen on severity and duration of myoclonus in the rat cardiac arrest model of posthypoxic myoclonus. Female sex hormones affect a variety of movement disorders and alter dopaminergic and serotonergic pharmacology. Although women represented three-fourths of patients from the original report of Lance and Adams and 80% of the largest published series, the impact of estrogens on myoclonus has never been studied. Twelve previously ovariectomized female rats underwent 8 minutes of mechanically induced cardiac arrest and were resuscitated according to a standardized protocol. On the same day, they were randomly assigned to subcutaneous treatment with a 21-day, 0.5-mg, 17 beta-estradiol or matching placebo pellet. Animals were tested daily with 7 sets of 45 auditory stimuli for 10 days, and myoclonus scores were obtained using a 5-point interval scale. Comparisons were based on two-sample Wilcoxon rank-sum tests. Estrogen treatment significantly enhanced myoclonus intensity and duration: mean peak myoclonus score, 210.2 +/- 18.0 versus 180 +/- 28.5 (p = 0.031); mean number of days above baseline, 9.2 +/- 0.4 versus 5.7 +/- 2.3 (p = 0.004); mean score on day 10, 90.7 +/- 38.7 versus 27.0 +/- 20.6 (p = 0.016). All estrogen-treated animals were above baseline on day 10 compared with none in the placebo group. Estrogen enhances and prolongs posthypoxic myoclonus, suggesting that female gender and estrogen status may play a pivotal role as a risk factor for human posthypoxic myoclonus.