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Aldridge JHR. Botulinum neurotoxin: A therapeutic powerhouse with broad clinical implications. JAAPA 2023; 36:39-41. [PMID: 36976032 DOI: 10.1097/01.jaa.0000921280.56648.da] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/29/2023]
Abstract
ABSTRACT Clostridium botulinum is a Gram-positive bacterium that produces one of the most deadly chemodenervating toxins in the world. To date, six distinct neurotoxins are available for prescription use in the United States. Decades of data across aesthetic therapeutic areas and therapeutic disease states support the safety and efficacy of C. botulinum, providing good symptom management and improved quality of life in appropriately chosen patients. Unfortunately, many clinicians are slow to progress patients to toxin therapy from more conservative measures, and others wrongly interchange the products despite characteristics unique to each. Commensurate with an improved understanding of the complex pharmacology and clinical implications of botulinum neurotoxins is the importance for clinicians to appropriately identify, educate, refer, and/or treat candidate patients. This article provides an overview of the history, mechanism of action, differentiation, indications, and uses for botulinum neurotoxins.
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Affiliation(s)
- Jamie H R Aldridge
- Jamie H. R. Aldridge is a medical science liaison for argenx USA, Inc., in Boston, Mass., and practices at Moses H. Cone Memorial Hospital in Greensboro, N.C. The author has disclosed no potential conflicts of interest, financial or otherwise
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2
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Defazio G, Belvisi D, Comella C, Hallett M, Jinnah HA, Cimino P, Latorre A, Mascia MM, Rocchi L, Gigante AF, Ercoli T, Berardelli A. Validation of a guideline to reduce variability in diagnosing cervical dystonia. J Neurol 2023; 270:2606-2612. [PMID: 36790546 PMCID: PMC10129917 DOI: 10.1007/s00415-023-11585-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2022] [Revised: 01/19/2023] [Accepted: 01/20/2023] [Indexed: 02/16/2023]
Abstract
BACKGROUND Cervical dystonia is characterized by a variable pattern of neck muscle involvement. Due to the lack of a diagnostic test, cervical dystonia diagnosis is based on clinical examination and is therefore subjective. The present work was designed to provide practical guidance for clinicians in confirming or refuting suspected cervical dystonia. METHODS Participants were video recorded according to a standardized protocol to assess 6 main clinical features possibly contributing to cervical dystonia diagnosis: presence of repetitive, patterned head/neck movements/postures inducing head/neck deviation from neutral position (item 1); sensory trick (item 2); and red flags related to conditions mimicking dystonia that should be absent in dystonia (items 3-6). Inter-/intra-rater agreement among three independent raters was assessed by k statistics. To estimate sensitivity and specificity, the gold standard was cervical dystonia diagnosis reviewed at each site by independent senior neurologists. RESULTS The validation sample included 43 idiopathic cervical dystonia patients and 41 control subjects (12 normal subjects, 6 patients with isolated head tremor, 4 with chorea, 6 with tics, 4 with head ptosis due to myasthenia or amyotrophic lateral sclerosis, 7 with orthopedic/rheumatologic neck diseases, and 2 with ocular torticollis). The best combination of sensitivity and specificity was observed considering all the items except for an item related to capability to voluntarily suppress spasms (sensitivity: 96.1%; specificity: 81%). CONCLUSIONS An accurate diagnosis of cervical dystonia can be achieved if, in addition to the core motor features, we also consider some clinical features related to dystonia mimics that should be absent in dystonia.
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Affiliation(s)
- Giovanni Defazio
- Department of Medical Sciences and Public Health, Institute of Neurology, University of Cagliari, 09042, Cagliari, Italy.,Institute of Neurology, Azienda Ospedaliero Universitaria di Cagliari, SS 554 km 4.500, 09042, Monserrato, Cagliari, Italy
| | - Daniele Belvisi
- IRCCS Neuromed, Via Atinense 18, 86077, Pozzilli, IS, Italy.,Department of Human Neurosciences, Sapienza University of Rome, Viale dell' Università, 30, 00185, Rome, Italy
| | | | - Mark Hallett
- Human Motor Control Section, NINDS, NIH, Bethesda, MD, USA
| | - Hyder A Jinnah
- Department of Neurology and Human Genetics, Emory University, Atlanta, GA, USA
| | - Paola Cimino
- Department of Medical Sciences and Public Health, Institute of Neurology, University of Cagliari, 09042, Cagliari, Italy
| | - Anna Latorre
- Department of Clinical and Movement Neurosciences UCL Queen Square Institute of Neurology, University College London, London, UK
| | - Marcello Mario Mascia
- Institute of Neurology, Azienda Ospedaliero Universitaria di Cagliari, SS 554 km 4.500, 09042, Monserrato, Cagliari, Italy
| | - Lorenzo Rocchi
- Department of Medical Sciences and Public Health, Institute of Neurology, University of Cagliari, 09042, Cagliari, Italy.,Institute of Neurology, Azienda Ospedaliero Universitaria di Cagliari, SS 554 km 4.500, 09042, Monserrato, Cagliari, Italy
| | | | - Tommaso Ercoli
- Department of Medical Sciences and Public Health, Institute of Neurology, University of Cagliari, 09042, Cagliari, Italy.
| | - Alfredo Berardelli
- IRCCS Neuromed, Via Atinense 18, 86077, Pozzilli, IS, Italy.,Department of Human Neurosciences, Sapienza University of Rome, Viale dell' Università, 30, 00185, Rome, Italy
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3
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Battistella G, Simonyan K. Clinical Implications of Dystonia as a Neural Network Disorder. ADVANCES IN NEUROBIOLOGY 2023; 31:223-240. [PMID: 37338705 DOI: 10.1007/978-3-031-26220-3_13] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 06/21/2023]
Abstract
Isolated dystonia is a neurological disorder of diverse etiology, multifactorial pathophysiology, and wide spectrum of clinical presentations. We review the recent neuroimaging advances that led to the conceptualization of dystonia as a neural network disorder and discuss how current knowledge is shaping the identification of biomarkers of dystonia and the development of novel pharmacological therapies.
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Affiliation(s)
- Giovanni Battistella
- Department of Otolaryngology - Head and Neck Surgery, Massachusetts Eye and Ear and Harvard Medical School, Boston, MA, USA
| | - Kristina Simonyan
- Department of Otolaryngology - Head and Neck Surgery, Massachusetts Eye and Ear and Harvard Medical School, Boston, MA, USA.
- Department of Neurology, Massachusetts General Hospital, and Harvard Medical School, Boston, MA, USA.
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4
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Benito-Lozano J, Arias-Merino G, Gómez-Martínez M, Ancochea-Díaz A, Aparicio-García A, Posada de la Paz M, Alonso-Ferreira V. Diagnostic Process in Rare Diseases: Determinants Associated with Diagnostic Delay. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:ijerph19116456. [PMID: 35682039 PMCID: PMC9180264 DOI: 10.3390/ijerph19116456] [Citation(s) in RCA: 22] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/30/2022] [Revised: 05/23/2022] [Accepted: 05/24/2022] [Indexed: 02/01/2023]
Abstract
Many people living with rare disease (RD) report a difficult diagnostic process from the symptom onset until they obtain the definitive diagnosis. The aim of this study was thus to ascertain the diagnostic process in RDs, and explore the determinants related with having to wait for more than one year in this process (defined as “diagnostic delay”). We conducted a case–control study, using a purpose-designed form from the Spanish Rare Diseases Patient Registry for data-collection purposes. A descriptive analysis was performed and multivariate backward logistic regression models fitted. Based on data on 1216 patients living with RDs, we identified a series of determinants associated with experiencing diagnostic delay. These included: having to travel to see a specialist other than that usually consulted in the patient’s home province (OR 2.1; 95%CI 1.6–2.9); visiting more than 10 specialists (OR 2.6; 95%CI 1.7–4.0); being diagnosed in a region other than that of the patient’s residence at the date of symptom onset (OR 2.3; 95%CI 1.5–3.6); suffering from a RD of the nervous system (OR 1.4; 95%CI 1.0–1.8). In terms of time taken to see a specialist, waiting more than 6 months to be referred from the first medical visit was the period of time which most contributed to diagnostic delay (PAR 30.2%). In conclusion, this is the first paper to use a collaborative study based on a nationwide registry to address the diagnostic process of patients living with RDs. While the evidence shows that the diagnostic process experienced by these persons is complex, more studies are needed to determine the implications that this has for their lives and those of their families at a social, educational, occupational, psychological, and financial level.
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Affiliation(s)
- Juan Benito-Lozano
- Institute of Rare Diseases Research (IIER), Instituto de Salud Carlos III, 28029 Madrid, Spain; (J.B.-L.); (G.A.-M.); (M.G.-M.); (M.P.d.l.P.)
- Universidad Nacional de Educación a Distancia (UNED), 28015 Madrid, Spain
| | - Greta Arias-Merino
- Institute of Rare Diseases Research (IIER), Instituto de Salud Carlos III, 28029 Madrid, Spain; (J.B.-L.); (G.A.-M.); (M.G.-M.); (M.P.d.l.P.)
| | - Mario Gómez-Martínez
- Institute of Rare Diseases Research (IIER), Instituto de Salud Carlos III, 28029 Madrid, Spain; (J.B.-L.); (G.A.-M.); (M.G.-M.); (M.P.d.l.P.)
| | | | - Aitor Aparicio-García
- The State Reference Center for Assistance to People Living with Rare Diseases and Their Families (CREER), Centro de Referencia Estatal de Atención a Personas con Enfermedades Raras y sus Familias, Dependiente del IMSERSO, 09001 Burgos, Spain;
| | - Manuel Posada de la Paz
- Institute of Rare Diseases Research (IIER), Instituto de Salud Carlos III, 28029 Madrid, Spain; (J.B.-L.); (G.A.-M.); (M.G.-M.); (M.P.d.l.P.)
| | - Verónica Alonso-Ferreira
- Institute of Rare Diseases Research (IIER), Instituto de Salud Carlos III, 28029 Madrid, Spain; (J.B.-L.); (G.A.-M.); (M.G.-M.); (M.P.d.l.P.)
- Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBERER), 28029 Madrid, Spain
- Correspondence: ; Tel.: +34-91-822-2089
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Scorr LM, Cho HJ, Kilic-Berkmen G, McKay JL, Hallett M, Klein C, Baumer T, Berman BD, Feuerstein JS, Perlmutter JS, Berardelli A, Ferrazzano G, Wagle-Shukla A, Malaty IA, Jankovic J, Bellows ST, Barbano RL, Vidailhet M, Roze E, Bonnet C, Mahajan A, LeDoux MS, Fung VS, Chang FC, Defazio G, Ercoli T, Factor S, Wojno T, Jinnah HA. Clinical Features and Evolution of Blepharospasm: A Multicenter International Cohort and Systematic Literature Review. DYSTONIA 2022; 1. [PMID: 36248010 PMCID: PMC9557246 DOI: 10.3389/dyst.2022.10359] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Objective: Blepharospasm is a type of dystonia where the diagnosis is often delayed because its varied clinical manifestations are not well recognized. The purpose of this study was to provide a comprehensive picture of its clinical features including presenting features, motor features, and non-motor features. Methods: This was a two-part study. The first part involved a systematic literature review that summarized clinical features for 10,324 cases taken from 41 prior reports. The second part involved a summary of clinical features for 884 cases enrolled in a large multicenter cohort collected by the Dystonia Coalition investigators, along with an analysis of the factors that contribute to the spread of dystonia beyond the periocular region. Results: For cases in the literature and the Dystonia Coalition, blepharospasm emerged in the 50s and was more frequent in women. Many presented with non-specific motor symptoms such as increased blinking (51.9%) or non-motor sensory features such as eye soreness or pain (38.7%), photophobia (35.5%), or dry eyes (10.7%). Non-motor psychiatric features were also common including anxiety disorders (34–40%) and depression (21–24%). Among cases presenting with blepharospasm in the Dystonia Coalition cohort, 61% experienced spread of dystonia to other regions, most commonly the oromandibular region and neck. Features associated with spread included severity of blepharospasm, family history of dystonia, depression, and anxiety. Conclusions: This study provides a comprehensive summary of motor and non-motor features of blepharospasm, along with novel insights into factors that may be responsible for its poor diagnostic recognition and natural history.
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Affiliation(s)
- Laura M. Scorr
- Department of Neurology, School of Medicine, Emory University, Atlanta, GA, United States
| | - Hyun Joo Cho
- Human Motor Control Section, National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD, United States
| | - Gamze Kilic-Berkmen
- Department of Neurology, School of Medicine, Emory University, Atlanta, GA, United States
| | - J. Lucas McKay
- Department of Neurology, School of Medicine, Emory University, Atlanta, GA, United States
- Department of Biomedical Informatics, School of Medicine, Emory University, Atlanta, GA, United States
- Department of Biomedical Engineering, Emory University and Georgia Tech, Atlanta, GA, United States
| | - Mark Hallett
- Human Motor Control Section, National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD, United States
| | - Christine Klein
- Institute of Neurogenetics and Department of Neurology, University of Luebeck and University Hospital of Schleswig-Holstein, Luebeck, Germany
| | - Tobias Baumer
- Institute of Neurogenetics and Department of Neurology, University of Luebeck and University Hospital of Schleswig-Holstein, Luebeck, Germany
| | - Brian D. Berman
- Department of Neurology, Virginia Commonwealth University, Richmond, VA, United States
| | | | - Joel S. Perlmutter
- Department of Neurology, Radiology, Neuroscience, Physical Therapy and Occupational Therapy, Washington University School of Medicine, St Louis, MO, United States
| | - Alfredo Berardelli
- Department of Human Neuroscience, Sapienza University of Rome, Rome, Italy
- IRCCS Neuromed, Pozzilli, Italy
| | - Gina Ferrazzano
- Department of Human Neuroscience, Sapienza University of Rome, Rome, Italy
- IRCCS Neuromed, Pozzilli, Italy
| | - Aparna Wagle-Shukla
- Fixel Institute for Neurological Disease, Department of Neurology, University of Florida, Gainesville, FL, United States
| | - Irene A. Malaty
- Fixel Institute for Neurological Disease, Department of Neurology, University of Florida, Gainesville, FL, United States
| | - Joseph Jankovic
- Parkinson’s Disease Center and Movement Disorders Clinic, Department of Neurology, Baylor College of Medicine, Houston, TX, United States
| | - Steven T. Bellows
- Parkinson’s Disease Center and Movement Disorders Clinic, Department of Neurology, Baylor College of Medicine, Houston, TX, United States
| | - Richard L. Barbano
- Department of Neurology, University of Rochester, Rochester, NY, United States
| | - Marie Vidailhet
- Paris Brain Institute, Inserm, CNRS, AP-HP, Salpetrière Hospital, Sorbonne University, Paris, France
| | - Emmanuel Roze
- Paris Brain Institute, Inserm, CNRS, AP-HP, Salpetrière Hospital, Sorbonne University, Paris, France
| | - Cecilia Bonnet
- Paris Brain Institute, Inserm, CNRS, AP-HP, Salpetrière Hospital, Sorbonne University, Paris, France
| | - Abhimanyu Mahajan
- Rush Parkinson’s Disease and Movement Disorders Program, Department of Neurological Sciences, Rush University, Chicago, IL, United States
| | - Mark S. LeDoux
- Department of Psychology, Veracity Neuroscience LLC, University of Memphis, Memphis, TN, United States
| | - Victor S.C. Fung
- Movement Disorders Unit, Department of Neurology, Westmead Hospital and Sydney Medical School, University of Sydney, Sydney, NSW, Australia
- Movement Disorders Unit, Department of Neurology, Westmead Hospital, Sydney, NSW, Australia
| | - Florence C.F. Chang
- Movement Disorders Unit, Department of Neurology, Westmead Hospital and Sydney Medical School, University of Sydney, Sydney, NSW, Australia
| | - Giovanni Defazio
- Department of Medical Sciences and Public Health, University of Cagliari, Cagliari, Italy
| | - Tomaso Ercoli
- Department of Medical Sciences and Public Health, University of Cagliari, Cagliari, Italy
| | - Stewart Factor
- Department of Neurology, School of Medicine, Emory University, Atlanta, GA, United States
| | - Ted Wojno
- Emory Eye Center, Emory University, Atlanta, GA, United States
| | - H. A. Jinnah
- Department of Neurology, School of Medicine, Emory University, Atlanta, GA, United States
- Department of Human Genetics, School of Medicine, Emory University, Atlanta, GA, United States
- Correspondence: H. A. Jinnah,
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6
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Handa S, Shaefer JR, Keith DA. Oromandibular dystonia and temporomandibular disorders. J Am Dent Assoc 2021; 153:899-906. [PMID: 34863506 DOI: 10.1016/j.adaj.2021.07.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2021] [Accepted: 07/21/2021] [Indexed: 10/19/2022]
Abstract
BACKGROUND The aim of this study was to characterize clinical features of patients with oromandibular dystonia (OMD) who had temporomandibular disorder (TMD) symptoms. METHODS A retrospective chart review of patients seeking treatment at a tertiary-level orofacial pain clinic from January 2015 through December 2020 was undertaken. The inclusionary criteria consisted of a diagnosis of OMD (International Classification of Diseases, Revision 10 code G24.4), which had been confirmed by a neurologist. RESULTS Eleven patients met the inclusion criteria. Focal dystonia and jaw deviation OMD were the most frequent diagnoses. A dental procedure was a triggering or aggravating factor in 36.4% of patients. All but 2 patients had a sensory trick, or tactile stimulus to a particular body part, and approximately one-half of the patients used an oral appliance as a sensory trick device. All but 1 patient had received a diagnosis of TMD, with myofascial pain of the masticatory muscles being the most prevalent diagnosis. Four patients had received a recommendation for orthodontic treatment. About one-half of the patients had undergone 1 or more invasive dental or maxillofacial surgical interventions to address their dystonia. Anxiety was the most common psychological comorbidity. CONCLUSIONS Because patients with OMD commonly experience TMD symptoms, they can receive a misdiagnosis of TMD while the OMD is overlooked. PRACTICAL IMPLICATIONS Owing to concomitant TMD symptoms, patients most often seek dental consultations and undergo treatments such as orthodontic interventions and temporomandibular joint surgeries. A dentist's competency in recognizing these patients can prevent unnecessary procedures and facilitate appropriate patient care.
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7
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Defazio G, Berardelli A. Is Adult-Onset Dystonia a Rare Disease? Time for Population-Based Studies. Mov Disord 2021; 36:1119-1124. [PMID: 33724530 DOI: 10.1002/mds.28560] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2020] [Revised: 02/18/2021] [Accepted: 02/22/2021] [Indexed: 02/06/2023] Open
Affiliation(s)
- Giovanni Defazio
- Department of Medical Sciences and Public Health, University of Cagliari, Cagliari, Italy
| | - Alfredo Berardelli
- Department of Human Neurosciences, Sapienza University of Rome, Rome, Italy
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8
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Supnet ML, Acuna P, Carr SJ, Kristoper de Guzman J, Al Qahtani X, Multhaupt-Buell T, Francoeur T, Aldykiewicz GE, Alluri PR, Campion L, Paul L, Ozelius L, Penney EB, Stephen CD, Dy-Hollins M, Sharma N. Isolated Cervical Dystonia: Management and Barriers to Care. Front Neurol 2020; 11:591418. [PMID: 33329340 PMCID: PMC7732688 DOI: 10.3389/fneur.2020.591418] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2020] [Accepted: 10/20/2020] [Indexed: 11/22/2022] Open
Abstract
Background: Cervical dystonia (CD) is a rare disorder, and health care providers might be unfamiliar with its presentation, thus leading to delay in the initial diagnosis. The lack of awareness displays the need to highlight the clinical features and treatment in cervical dystonia. In our cohort, we have identified an earlier age of onset in men, despite an overall preponderance of affected women. Objective: We aim to identify the prevalence, age of onset, spread, and treatment modalities of CD in the population. We also highlight the barriers which patients encounter related to diagnosis, follow-up, and treatment. Methods: We reviewed 149 CD patients who attended specialized Dystonia Clinics over a 14-year period. Dystonia severity was rated using the Burke-Fahn-Marsden (BFM), Tsui, and Toronto Western Spasmodic Torticollis Rating Scales (TWSTRS). Mood and quality of life were assessed using Beck Depression Inventory (BDI), Beck Anxiety Inventory (BAI), and 36-Item Short Form Health Survey (SF-36). Results: CD patients were majority White (91.3%) and more commonly female (75.8%). Men had an earlier median age of onset, 40.5 years (p = 0.044). BAI revealed a mean score of 7.2 (±6.4, n = 50) indicating minimal anxiety while BDI revealed a mean score of 7.30 (±7.6, n = 50) indicating minimal depression. The only SF-36 subscales associated with CD severity were physical functioning (p = 0.040) pain (p = 0.008) and general health (p = 0.014). Conclusion: There appear to be gender differences in both the prevalence and age of onset of the disease. There was a 3-fold higher incidence in women than in men. CD patients of both sexes experience barriers to care, which can be reflected in their quality of life and time-to-diagnosis. In addition, males were less likely to experience an objective benefit with botulinum toxin treatment and more likely to discontinue care. Greater awareness of CD by health care providers is important to reduce the time-to-diagnosis.
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Affiliation(s)
- Melanie Leigh Supnet
- Department of Neurology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, United States
| | - Patrick Acuna
- Department of Neurology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, United States
| | - Samuel J Carr
- Department of Neurology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, United States
| | | | - Xena Al Qahtani
- Department of Neurology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, United States
| | - Trisha Multhaupt-Buell
- Department of Neurology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, United States
| | - Taylor Francoeur
- Department of Neurology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, United States
| | - Gabrielle E Aldykiewicz
- Department of Neurology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, United States
| | - Priyanka R Alluri
- Department of Neurology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, United States
| | - Lindsey Campion
- Department of Neurology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, United States
| | - Lisa Paul
- Department of Neurology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, United States
| | - Laurie Ozelius
- Department of Neurology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, United States
| | - Ellen B Penney
- Department of Neurology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, United States
| | - Christopher D Stephen
- Department of Neurology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, United States
| | - Marisela Dy-Hollins
- Department of Neurology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, United States
| | - Nutan Sharma
- Department of Neurology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, United States
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9
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Compagnon C, Labrousse M, Brenet E, Chays A, Bazin A, Kleiber JC, Dubernard X. Efficacy and Complications of Microsurgical Neurovascular Decompression in 55 Patients With Hemifacial Spasm. Otolaryngol Head Neck Surg 2020; 164:1299-1306. [PMID: 33198570 DOI: 10.1177/0194599820969168] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVE To analyze the efficacy and complications of microvascular decompression for hemifacial spasm. STUDY DESIGN Retrospective study. SETTING Regional hospital. METHODS Fifty-five patients with hemifacial spasm were treated by microvascular decompression. All patients with hemifacial spasm who underwent retrosigmoid microvascular decompression from May 2004 to January 2017 were included. Patients with no conflict on preoperative magnetic resonance imaging or with an alternate diagnosis were excluded. RESULTS The overall cure rate was 83.64%, with an average follow-up of 7.4 years. A left-sided hemifacial spasm was a healing-promoting factor (P = .01). The median healing was 0.03 months, and the mean was 6 months. The efficacy remained high in the medium term (88% at 3 years), long term (90.24% at 5 years), and very long term (90.48% at 8 years). The recurrence rate was 9.8%. Favorable criteria included a right-sided spasm (P = .01) and an average age of 62 years (P = .03). The specific complications were permanent facial palsy (3.63%), unilateral deafness (5.45%), and hearing loss (3.63%). No death was reported. Regarding the quality of life of the patients, 94.7% had a modified HFS-8 postoperative score of 0 (Hemifacial Spasm 8 Quality of Life Scale). CONCLUSION Microvascular decompression for hemifacial spasm is an effective and lasting technique. Its low rate of complications and the considerable quality-of-life improvement should lead surgeons to propose it to patients as soon as botulinum toxin injections become ineffective or poorly tolerated.
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Affiliation(s)
- Chloé Compagnon
- Department of Otorhinolaryngology, Head and Neck Pole, Robert Debré Hospital, Reims University Hospital, Grand Est Region, France
| | - Marc Labrousse
- Department of Otorhinolaryngology, Head and Neck Pole, Robert Debré Hospital, Reims University Hospital, Grand Est Region, France
| | - Esteban Brenet
- Department of Otorhinolaryngology, Head and Neck Pole, Robert Debré Hospital, Reims University Hospital, Grand Est Region, France
| | - André Chays
- Department of Otorhinolaryngology, Head and Neck Pole, Robert Debré Hospital, Reims University Hospital, Grand Est Region, France.,Otoneurosurgical Institute of Champagne-Ardenne, Head and Neck Department, Maison Blanche Hospital, Reims University Hospital, Grand Est Region, France
| | - Arnaud Bazin
- Otoneurosurgical Institute of Champagne-Ardenne, Head and Neck Department, Maison Blanche Hospital, Reims University Hospital, Grand Est Region, France.,Department of Neurosurgery, Head and Neck Department, Maison Blanche Hospital, Reims University Hospital, Grand Est Region, France
| | - Jean-Charles Kleiber
- Otoneurosurgical Institute of Champagne-Ardenne, Head and Neck Department, Maison Blanche Hospital, Reims University Hospital, Grand Est Region, France.,Department of Neurosurgery, Head and Neck Department, Maison Blanche Hospital, Reims University Hospital, Grand Est Region, France
| | - Xavier Dubernard
- Department of Otorhinolaryngology, Head and Neck Pole, Robert Debré Hospital, Reims University Hospital, Grand Est Region, France.,Otoneurosurgical Institute of Champagne-Ardenne, Head and Neck Department, Maison Blanche Hospital, Reims University Hospital, Grand Est Region, France
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10
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A microstructural neural network biomarker for dystonia diagnosis identified by a DystoniaNet deep learning platform. Proc Natl Acad Sci U S A 2020; 117:26398-26405. [PMID: 33004625 PMCID: PMC7586425 DOI: 10.1073/pnas.2009165117] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
This research identified a microstructural neural network biomarker for objective and accurate diagnosis of isolated dystonia based on the disorder pathophysiology using an advanced deep learning algorithm, DystoniaNet, and raw structural brain images of large cohorts of patients with isolated focal dystonia and healthy controls. DystoniaNet significantly outperformed shallow machine-learning pipelines and substantially exceeded the current agreement rates between clinicians, reaching an overall accuracy of 98.8% in diagnosing different forms of isolated focal dystonia. These results suggest that DystoniaNet could serve as an objective, robust, and generalizable algorithmic platform of dystonia diagnosis for enhanced clinical decision-making. Implementation of the identified biomarker for objective and accurate diagnosis of dystonia may be transformative for clinical management of this disorder. Isolated dystonia is a neurological disorder of heterogeneous pathophysiology, which causes involuntary muscle contractions leading to abnormal movements and postures. Its diagnosis is remarkably challenging due to the absence of a biomarker or gold standard diagnostic test. This leads to a low agreement between clinicians, with up to 50% of cases being misdiagnosed and diagnostic delays extending up to 10.1 y. We developed a deep learning algorithmic platform, DystoniaNet, to automatically identify and validate a microstructural neural network biomarker for dystonia diagnosis from raw structural brain MRIs of 612 subjects, including 392 patients with three different forms of isolated focal dystonia and 220 healthy controls. DystoniaNet identified clusters in corpus callosum, anterior and posterior thalamic radiations, inferior fronto-occipital fasciculus, and inferior temporal and superior orbital gyri as the biomarker components. These regions are known to contribute to abnormal interhemispheric information transfer, heteromodal sensorimotor processing, and executive control of motor commands in dystonia pathophysiology. The DystoniaNet-based biomarker showed an overall accuracy of 98.8% in diagnosing dystonia, with a referral of 3.5% of cases due to diagnostic uncertainty. The diagnostic decision by DystoniaNet was computed in 0.36 s per subject. DystoniaNet significantly outperformed shallow machine-learning algorithms in benchmark comparisons, showing nearly a 20% increase in its diagnostic performance. Importantly, the microstructural neural network biomarker and its DystoniaNet platform showed substantial improvement over the current 34% agreement on dystonia diagnosis between clinicians. The translational potential of this biomarker is in its highly accurate, interpretable, and generalizable performance for enhanced clinical decision-making.
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LaHue SC, Albers K, Goldman S, Lo RY, Gu Z, Leimpeter A, Fross R, Comyns K, Marras C, de Kleijn A, Smit R, Katz M, Ozelius LJ, Bressman S, Saunders-Pullman R, Comella C, Klingman J, Nelson LM, Van Den Eeden SK, Tanner CM. Cervical dystonia incidence and diagnostic delay in a multiethnic population. Mov Disord 2020; 35:450-456. [PMID: 31774238 PMCID: PMC10683845 DOI: 10.1002/mds.27927] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2019] [Revised: 09/02/2019] [Accepted: 09/12/2019] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Current cervical dystonia (CD) incidence estimates are based on small numbers in relatively ethnically homogenous populations. The frequency and consequences of delayed CD diagnosis is poorly characterized. OBJECTIVES To determine CD incidence and characterize CD diagnostic delay within a large, multiethnic integrated health maintenance organization. METHODS We identified incident CD cases using electronic medical records and multistage screening of more than 3 million Kaiser Permanente Northern California members from January 1, 2003, to December 31, 2007. A final diagnosis was made by movement disorders specialist consensus. Diagnostic delay was measured by questionnaire and health utilization data. Incidence rates were estimated assuming a Poisson distribution of cases and directly standardized to the 2000 U.S. census. Multivariate logistic regression models were employed to assess diagnoses and behaviors preceding CD compared with matched controls, adjusting for age, sex, and membership duration. RESULTS CD incidence was 1.18/100,000 person-years (95% confidence interval [CI], 0.35-2.0; women, 1.81; men, 0.52) based on 200 cases over 15.4 million person-years. Incidence increased with age. Half of the CD patients interviewed reported diagnostic delay. Diagnoses more common in CD patients before the index date included essential tremor (odds ratio [OR] 68.1; 95% CI, 28.2-164.5), cervical disc disease (OR 3.83; 95% CI, 2.8-5.2), neck sprain/strain (OR 2.77; 95% CI, 1.99-3.62), anxiety (OR 2.24; 95% CI, 1.63-3.11) and depression (OR 1.94; 95% CI, 1.4-2.68). CONCLUSIONS CD incidence is greater in women and increases with age. Diagnostic delay is common and associated with adverse effects. © 2019 International Parkinson and Movement Disorder Society.
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Affiliation(s)
- Sara C. LaHue
- Department of Neurology, School of Medicine, University of California, San Francisco, California, USA
- Weill Institute for Neurosciences, Department of Neurology, University of California, San Francisco, San Francisco, California, USA
| | - Kathleen Albers
- Division of Research, Kaiser Permanente Northern California, Oakland, California, USA
| | - Samuel Goldman
- Department of Neurology, School of Medicine, University of California, San Francisco, California, USA
- San Francisco Veteran’s Administration Medical Center, San Francisco, California, USA
- Occupational and Environmental Medicine, School of Medicine, University of California, San Francisco, California, USA
| | - Raymond Y. Lo
- Hualien Tzu Chi Hospital/Tzu Chi University, Hualien, Taiwan
| | - Zhuqin Gu
- Department of Neurobiology, Xuanwu Hospital of Capital Medical University, Beijing, China
| | - Amethyst Leimpeter
- Division of Research, Kaiser Permanente Northern California, Oakland, California, USA
| | - Robin Fross
- Department of Neurology, Kaiser Permanente Hayward Medical Center, Hayward, California, USA
| | - Kathleen Comyns
- Department of Neurology, School of Medicine, University of California, San Francisco, California, USA
| | - Connie Marras
- Morton and Gloria Shulman Movement Disorders Centre and the Edmond J Safra Program in Parkinson’s Research, University of Toronto, Toronto, Canada
| | - Annelie de Kleijn
- Department of Neurology, Radboud University Nijmegen, Nijmegen, Netherlands
| | - Robin Smit
- Department of Neurology, Radboud University Nijmegen, Nijmegen, Netherlands
| | - Maya Katz
- Department of Neurology, School of Medicine, University of California, San Francisco, California, USA
- Weill Institute for Neurosciences, Department of Neurology, University of California, San Francisco, San Francisco, California, USA
- San Francisco Veteran’s Administration Medical Center, San Francisco, California, USA
| | - Laurie J. Ozelius
- Department of Neurology, Massachusetts General Hospital, Charlestown, Massachusetts, USA
| | - Susan Bressman
- Department of Neurology, Mount Sinai Beth Israel, New York, New York, USA
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Rachel Saunders-Pullman
- Department of Neurology, Mount Sinai Beth Israel, New York, New York, USA
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Cynthia Comella
- Department of Neurology, Rush University Medical Center, Chicago, Illinois, USA
| | - Jeffrey Klingman
- Department of Neurology, Kaiser Permanente Walnut Creek Medical Center, Walnut Creek, California, USA
| | - Lorene M. Nelson
- Department of Health Research and Policy, Stanford University, Stanford, California, USA
| | | | - Caroline M. Tanner
- Department of Neurology, School of Medicine, University of California, San Francisco, California, USA
- Weill Institute for Neurosciences, Department of Neurology, University of California, San Francisco, San Francisco, California, USA
- San Francisco Veteran’s Administration Medical Center, San Francisco, California, USA
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Abstract
PURPOSE OF REVIEW This article provides a summary of the state of the art in the diagnosis, classification, etiologies, and treatment of dystonia. RECENT FINDINGS Although many different clinical manifestations of dystonia have been recognized for decades, it is only in the past 5 years that a broadly accepted approach has emerged for classifying them into specific subgroups. The new classification system aids clinical recognition and diagnosis by focusing on key clinical features that help distinguish the many subtypes. In the past few years, major advances have been made in the discovery of new genes as well as advances in our understanding of the biological processes involved. These advances have led to major changes in strategies for diagnosis of the inherited dystonias. An emerging trend is to move away from heavy reliance on the phenotype to target diagnostic testing toward a broader approach that involves large gene panels or whole exome sequencing. SUMMARY The dystonias are a large family of phenotypically and etiologically diverse disorders. The diagnosis of these disorders depends on clinical recognition of characteristic clinical features. Symptomatic treatments are useful for all forms of dystonia and include oral medications, botulinum toxins, and surgical procedures. Determination of etiology is becoming increasingly important because the number of disorders is growing and more specific and sometimes disease-modifying therapies now exist.
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Núñez Medrano JA, Fernández E, Georgescu D, Díaz Díaz AL, Graue Moreno G. Consensus of the Iberoamerican Oculoplastic Society for diagnosis and management of facial dystonia. ACTA ACUST UNITED AC 2019; 94:436-440. [PMID: 31272707 DOI: 10.1016/j.oftal.2019.03.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2019] [Revised: 03/26/2019] [Accepted: 03/29/2019] [Indexed: 10/26/2022]
Abstract
OBJECTIVE To propose guidelines for the diagnosis and treatment of facial dystonia prepared by a group of experts in orbit and oculoplastics from the Iberoamerican Oculoplastic Society. MATERIAL AND METHODS An interactive discussion between the expert panel and those attending the 6th Iberoamerican Society of Oculoplastics Congress, which took place at the Hospital Nuestra Señora de la Luz in Mexico City on 22 October 2018, providing their personal experience based on evidence for diagnosis and treatment of facial dystonia. Around 200 ophthalmologists specialised in oculoplastics from North, Central and South America, Spain, and Portugal were involved. Discussion was focused on the following themes: pathophysiology, diagnosis, medical management, and surgical management. CONCLUSIONS Facial dystonia diagnosis is clinical; therefore, image studies are rarely needed. The ophthalmologist is generally the first physician to be consulted, and is able to be the treating physician, with the exception of specific cases of hemifacial spasm where management with neurosurgery may be beneficial. Botulinum toxin is the treatment of choice. Treatment with oral neuroleptics and myectomy of the orbicularis oculi muscle are reserved for refractory cases, since these do not have an adequate clinical response as first choice treatments. Persistent use of botulinum toxin does not modify the natural course of the disease.
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Affiliation(s)
| | - E Fernández
- Práctica particular, Palma de Mallorca, España
| | - D Georgescu
- Práctica particular, Estados Unidos de América
| | | | - G Graue Moreno
- Departamento de Órbita y Oculoplástica, Hospital Nuestra Señora de la Luz, Ciudad de México, México
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Ceylan D, Erer S, Zarifoğlu M, Türkeş N, Özkaya G. Evaluation of anxiety and depression scales and quality of LIFE in cervical dystonia patients on botulinum toxin therapy and their relatives. Neurol Sci 2019; 40:725-731. [DOI: 10.1007/s10072-019-3719-9] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2018] [Accepted: 01/10/2019] [Indexed: 10/27/2022]
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15
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Oromandibular dystonia screening questionnaire for differential diagnosis. Clin Oral Investig 2018; 23:405-411. [DOI: 10.1007/s00784-018-2449-3] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2018] [Accepted: 04/12/2018] [Indexed: 10/17/2022]
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16
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Deep brain stimulation for dystonia: a novel perspective on the value of genetic testing. J Neural Transm (Vienna) 2017; 124:417-430. [PMID: 28160152 DOI: 10.1007/s00702-016-1656-9] [Citation(s) in RCA: 59] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2016] [Accepted: 11/16/2016] [Indexed: 10/20/2022]
Abstract
The dystonias are a group of disorders characterized by excessive muscle contractions leading to abnormal movements and postures. There are many different clinical manifestations and underlying causes. Deep brain stimulation (DBS) provides an effect treatment, but outcomes can vary considerably among the different subtypes of dystonia. Several variables are thought to contribute to this variation including age of onset and duration of dystonia, specific characteristics of the dystonic movements, location of stimulation and stimulator settings, and others. The potential contributions of genetic factors have received little attention. In this review, we summarize evidence that some of the variation in DBS outcomes for dystonia is due to genetic factors. The evidence suggests that more methodical genetic testing may provide useful information in the assessment of potential surgical candidates, and in advancing our understanding of the biological mechanisms that influence DBS outcomes.
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Abstract
PURPOSE OF REVIEW The dystonias are a family of related disorders with many different clinical manifestations and causes. This review summarizes recent developments regarding these disorders, focusing mainly on advances with direct clinical relevance from the past 2 years. RECENT FINDINGS The dystonias are generally defined by their clinical characteristics, rather than by their underlying genetic or neuropathological defects. The many varied clinical manifestations and causes contribute to the fact that they are one of the most poorly recognized of all movement disorders. A series of recent publications has addressed these issues, offering a revised definition and more logical means for classifying the many subtypes. Our understanding of the genetic and neurobiological mechanisms responsible for different types of dystonias also has grown rapidly, creating new opportunities and challenges for diagnosis, and identifying increasing numbers of rare subtypes for which specific treatments are available. SUMMARY Recent advances in describing the clinical phenotypes and determining associated causes have pointed to the need for new strategies for diagnosis, classification, and treatment of the dystonias.
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Affiliation(s)
- Hyder A Jinnah
- aDepartment of Neurology, Human Genetics & Pediatrics, Emory University, Atlanta, Georgia bDystonia Medical Research Foundation, Chicago, Illinois cNational Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, Maryland, USA
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18
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Bertram KL, Williams DR. Delays to the diagnosis of cervical dystonia. J Clin Neurosci 2015; 25:62-4. [PMID: 26601813 DOI: 10.1016/j.jocn.2015.05.054] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2015] [Revised: 05/07/2015] [Accepted: 05/17/2015] [Indexed: 12/19/2022]
Abstract
The diagnosis of cervical dystonia (CD) is based on physical examination and is therefore reliant on clinician experience. Due to variability of presenting symptoms it may be misdiagnosed, thus delaying the provision of effective treatment. We sought to determine the average time taken to make a diagnosis of CD in our clinical cohort and explore contributing factors to diagnostic delay. Forty-nine patients with a diagnosis of CD attending a movement disorder specialist for treatment completed a questionnaire regarding symptoms and clinical interactions at onset and diagnosis. The mean time from symptom onset to diagnosis was 6.8 years (range 0-53 years). More than 50% of patients sought physical therapies initially, prior to consulting their general practitioner. Only 40% of patients sought medical advice within the first 6 months of symptom onset and only 10% were given an initial diagnosis of CD. The first referral from the general practitioner was to a specialist other than a neurologist in 31% of patients. Patients were seen by a mean of three doctors (range one to nine) before being given the correct diagnosis of CD. Delay to diagnosis of CD may in part be due to lack of awareness of the condition amongst health care professionals. Improved diagnostic skill appears likely to have had a substantial impact on the delivery of appropriate treatment in this population.
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Affiliation(s)
- Kelly L Bertram
- Neurosciences, Alfred Hospital, Level 4 Central Block, Commercial Road, Melbourne, VIC 3004, Australia; Faculty of Medicine Nursing and Health Sciences, Monash University, Melbourne, VIC, Australia.
| | - David R Williams
- Neurosciences, Alfred Hospital, Level 4 Central Block, Commercial Road, Melbourne, VIC 3004, Australia; Faculty of Medicine Nursing and Health Sciences, Monash University, Melbourne, VIC, Australia
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Abstract
The dystonias are a group of disorders characterized by excessive involuntary muscle contractions leading to abnormal postures and/or repetitive movements. A careful assessment of the clinical manifestations is helpful for identifying syndromic patterns that focus diagnostic testing on potential causes. If a cause is identified, specific etiology-based treatments may be available. In most cases, a specific cause cannot be identified, and treatments are based on symptoms. Treatment options include counseling, education, oral medications, botulinum toxin injections, and several surgical procedures. A substantial reduction in symptoms and improved quality of life is achieved in most patients by combining these options.
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Affiliation(s)
- H A Jinnah
- Department of Neurology, Emory University School of Medicine, 6300 Woodruff Memorial Research Building, 101 Woodruff Circle, Emory University, Atlanta, GA 30322, USA; Department of Human Genetics, Emory University School of Medicine, 6300 Woodruff Memorial Research Building, 101 Woodruff Circle, Emory University, Atlanta, GA 30322, USA; Department of Pediatrics, Emory University School of Medicine, 6300 Woodruff Memorial Research Building, 101 Woodruff Circle, Emory University, Atlanta, GA 30322, USA.
| | - Stewart A Factor
- Department of Neurology, Emory University School of Medicine, 6300 Woodruff Memorial Research Building, 101 Woodruff Circle, Emory University, Atlanta, GA 30322, USA
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20
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Diagnostic delay in adult-onset dystonia: data from an Italian movement disorder center. J Clin Neurosci 2015; 22:608-10. [PMID: 25577433 DOI: 10.1016/j.jocn.2014.09.014] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2014] [Revised: 09/01/2014] [Accepted: 09/14/2014] [Indexed: 11/23/2022]
Abstract
Adult-onset dystonia (AOD) may manifest in focal forms (as blepharospasm, oromandibular dystonia, cervical dystonia, laryngeal dystonia, and hand dystonia) or in segmental forms. Time from onset of dystonia to diagnosis can be an indicator of the quality of care received during the diagnosis of AOD, likely reflecting factors associated with both the patient and their health system. Three previously reported single-center studies showed that diagnosis of AOD may be delayed for several years. Here, we examined the time lapse between onset and diagnosis in patients with different forms of AOD from an Italian movement disorder center. We found the time lapse between dystonia onset and diagnosis was very long for patients who developed AOD before 1980; and even in the most recent years reaching a correct diagnosis required more than year in almost half of cases. Our results suggest that the delay in diagnosis of adult-onset focal and segmental dystonia has improved over time, but remains unacceptable. The findings are a promising indicator of improvements in care of this uncommon disorder. However, education of patients and doctors is still needed.
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Defazio G, Jankovic J, Giel JL, Papapetropoulos S. Descriptive epidemiology of cervical dystonia. TREMOR AND OTHER HYPERKINETIC MOVEMENTS (NEW YORK, N.Y.) 2013; 3. [PMID: 24255801 PMCID: PMC3822401 DOI: 10.7916/d80c4tgj] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/27/2013] [Accepted: 09/22/2013] [Indexed: 12/13/2022]
Abstract
Background Cervical dystonia (CD), the most common form of adult-onset focal dystonia, has a heterogeneous clinical presentation with variable clinical features, leading to difficulties and delays in diagnosis. Owing to the lack of reviews specifically focusing on the frequency of primary CD in the general population, we performed a systematic literature search to examine its prevalence/incidence and analyze methodological differences among studies. Methods We performed a systematic literature search to examine the prevalence data of primary focal CD. Sixteen articles met our methodological criteria. Because the reported prevalence estimates were found to vary widely across studies, we analyzed methodological differences and other factors to determine whether true differences exist in prevalence rates among geographic areas (and by gender and age distributions), as well as to facilitate recommendations for future studies. Results Prevalence estimates ranged from 20–4,100 cases/million. Generally, studies that relied on service-based and record-linkage system data likely underestimated the prevalence of CD, whereas population-based studies suffered from over-ascertainment. The more methodologically robust studies yielded a range of estimates of 28–183 cases/million. Despite the varying prevalence estimates, an approximate 2:1 female:male ratio was consistent among many studies. Three studies estimated incidence, ranging from 8–12 cases/million person-years. Discussion Although several studies have attempted to estimate the prevalence and incidence of CD, there is a need for additional well-designed epidemiological studies on primary CD that include large populations; use defined CD diagnostic criteria; and stratify for factors such as age, gender, and ethnicity.
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Affiliation(s)
- Giovanni Defazio
- Department of Basic Medical Sciences, Neuroscience and Sensory Organs, University of Bari, I-70124, Bari, Italy
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Tiderington E, Goodman EM, Rosen AR, Hapner ER, Johns MM, Evatt ML, Freeman A, Factor S, Jinnah HA. How long does it take to diagnose cervical dystonia? J Neurol Sci 2013; 335:72-4. [PMID: 24034410 DOI: 10.1016/j.jns.2013.08.028] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2013] [Revised: 08/19/2013] [Accepted: 08/20/2013] [Indexed: 12/27/2022]
Abstract
BACKGROUND Dystonia is a neurological disorder characterized by involuntary twisting movements and postures. The neck is among the most commonly affected regions, and diagnosis can be made readily through a simple clinical evaluation. The goal of this study was to explore how long it took patients to receive a diagnosis of cervical dystonia after symptom onset. METHODS A structured questionnaire was administered at outpatient clinics of a tertiary care academic medical center to 146 consecutively evaluated patients. The questionnaire addressed the length of time from symptom onset to diagnosis, the numbers and types of providers seen before reaching a diagnosis, and treatments attempted prior to receiving botulinum toxin. RESULTS A total of 108 patients saw a mean of 3.5 providers over a mean period of 44 months from symptom onset to diagnosis. For patients with symptom onset in the last decade only, patients saw a mean of 3.0 providers over a mean of 14 months. CONCLUSIONS Although cervical dystonia is the most common form of dystonia with clinical features readily identifiable by a simple history and examination, patients typically see multiple providers over more than a year before reaching a diagnosis and receiving optimal therapy. Improved awareness of the clinical features will enable patients to obtain appropriate therapy more rapidly.
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Affiliation(s)
- Evan Tiderington
- Department of Neurology, Emory University, Atlanta GA, 30322 USA
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23
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Defazio G, Hallett M, Jinnah HA, Berardelli A. Development and validation of a clinical guideline for diagnosing blepharospasm. Neurology 2013; 81:236-40. [PMID: 23771487 PMCID: PMC3770163 DOI: 10.1212/wnl.0b013e31829bfdf6] [Citation(s) in RCA: 66] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2012] [Accepted: 04/04/2013] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To design and validate a clinical diagnostic guideline for aiding physicians in confirming or refuting suspected blepharospasm. METHODS The guideline was developed and validated in a 3-step procedure: 1) identification of clinical items related to the phenomenology of blepharospasm, 2) assessment of the relevance of each item to the diagnosis of blepharospasm, and 3) evaluation of the reliability and diagnostic sensitivity/specificity of the selected clinical items. RESULTS Of 19 clinical items initially identified, 7 were admitted by content validity analysis to further assessment. Both neurologists and ophthalmologists achieved satisfactory interobserver agreement for all 7 items, including "involuntary eyelid narrowing/closure due to orbicularis oculi spasms," "bilateral spasms," "synchronous spasms," "stereotyped spasm pattern," "sensory trick," "inability to voluntarily suppress the spasms," and "blink count at rest." Each selected item yielded unsatisfactory accuracy in discriminating patients with blepharospasm from healthy subjects and patients with other eyelid disturbances. Combining the selected items, however, improved diagnostic sensitivity/specificity. The best combination, yielding 93% sensitivity and 90% specificity, was an algorithm starting with the item "stereotyped, bilateral, and synchronous orbicularis oculi spasms inducing eyelid narrowing/closure" and followed by recognition of "sensory trick" or, alternatively, "increased blinking." CONCLUSION This study provides an accurate and valid clinical guideline for diagnosing blepharospasm. Use of this guideline would make it easier for providers to recognize dystonia in clinical and research settings.
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Affiliation(s)
- Giovanni Defazio
- Department of Basic Medical Sciences, Neurosciences and Sense Organs, Aldo Moro University of Bari, Italy.
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Jinnah HA, Berardelli A, Comella C, Defazio G, Delong MR, Factor S, Galpern WR, Hallett M, Ludlow CL, Perlmutter JS, Rosen AR. The focal dystonias: current views and challenges for future research. Mov Disord 2013; 28:926-43. [PMID: 23893450 PMCID: PMC3733486 DOI: 10.1002/mds.25567] [Citation(s) in RCA: 148] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2013] [Revised: 05/15/2013] [Accepted: 05/16/2013] [Indexed: 11/11/2022] Open
Abstract
The most common forms of dystonia are those that develop in adults and affect a relatively isolated region of the body. Although these adult-onset focal dystonias are most prevalent, knowledge of their etiologies and pathogenesis has lagged behind some of the rarer generalized dystonias, in which the identification of genetic defects has facilitated both basic and clinical research. This summary provides a brief review of the clinical manifestations of the adult-onset focal dystonias, focusing attention on less well understood clinical manifestations that need further study. It also provides a simple conceptual model for the similarities and differences among the different adult-onset focal dystonias as a rationale for lumping them together as a class of disorders while at the same time splitting them into subtypes. The concluding section outlines some of the most important research questions for the future. Answers to these questions are critical for advancing our understanding of this group of disorders and for developing novel therapeutics.
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Affiliation(s)
- H A Jinnah
- Department of Neurology, Emory University, Atlanta, Georgia 30322, USA.
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Wang L, Hu X, Liu C, Wu Y, Wang C, Wang Z, Chen J. Botulinum toxin clinic-based epidemiologic survey of adults with primary dystonia in East china. J Mov Disord 2012; 5:9-13. [PMID: 24868406 PMCID: PMC4027674 DOI: 10.14802/jmd.12003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2012] [Revised: 04/30/2012] [Accepted: 04/30/2012] [Indexed: 11/24/2022] Open
Abstract
Background and Purpose: Primary focal or segmental dystonia is a rare clinical condition. The clinical features of dystonia have not been evaluated in China. We performed a study to investigate the epidemiology of primary dystonia and its clinical variants in an adult population. Methods: A Botulinum Toxin Clinic-based study was conducted in the period 18 May through 8 October 2010 in East China. We identified 523 dystonia patients from the Movement disorders and Botulinum Toxin clinic Cases. Results: The most common focal dystonia were blepharospasm (59%), cervical dystonia (35%), limb dystonia (3%), oromandibular dystonia (2%) and laryngeal dystonia (1%). Males with primary dystonia were noted to have earlier age of onset. A female predominance was noted for most of the primary dystonias with a male to female ratio (M : F) ranging from 1 : 1.48 to 1 : 3. Conclusions: The epidemiological features of dystonia in East China we collected were similar to the report in Japan which contrasts partly with that reported in Europe.
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Affiliation(s)
- Li Wang
- Department of Neurology, Sir Run Run Shaw Hospital of Zhejiang University School of Medicine, Zhejiang, China
| | - Xingyue Hu
- Department of Neurology, Sir Run Run Shaw Hospital of Zhejiang University School of Medicine, Zhejiang, China
| | - Chunfeng Liu
- Department of Neurology, The Second Affiliated Hospital of Suzhou University, Jiangsu, China
| | - Yiwen Wu
- Department of Neurology, Ruijin Hospital of Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Changqing Wang
- Department of Neurology, The First Affiliated Hospital of Anhui Medical University, Anhui, China
| | - Zhiqiang Wang
- Department of Neurology, The First Affiliated Hospital of Fujian Medical University, Fujian, China
| | - Jun Chen
- Department of Neurology, Nanjing Brain Hospital, Nanjing Medical University, Jiangsu, China
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