Musician's dystonia in a percussionist - clinical video analysis and botulinum toxin intervention: a case report

OBJECTIVE

Musician's focal hand dystonia is a painless task-specific focal dystonia, which presents with involuntary movements, abnormal postures, and loss of fine motor dexterity. We report here the case of a 63-year-old male, percussionist, with african ethnicity, with musician's focal hand dystonia who was treated with botulinum toxin, and describe the results at 4-weeks follow up.

METHODS

Clinical examination and video analysis revealed abnormal flexion of the 3rd finger, followed by flexion of the 4th and 5th fingers while playing the congas. Based on these findings, a diagnosis of musician's focal hand dystonia was established. Ten units of botulinum toxin were injected into the muscle fibres of the flexor digitorum superficialis corresponding to the 4th finger using electromyography and ultrasound guidance. Four weeks later, the patient reported a subjective 60% improvement in his performance. He emphasized the effect of botulinum toxin on performance speed and tension over the forearm and hand.

CONCLUSION

Botulinum toxin is not a definitive treatment for musician's focal hand dystonia, but it may potentiate other definitive rehabilitation techniques. More research is needed to determine the long-term effects of botulinum toxin on function enhancement in musician's focal hand dystonia.

The role of neurohospitalism in a specialized cardiovascular hospital

INTRODUCTION

Cardiology and cardiothoracic surgery are among the specialties that most commonly require neurology inpatient consultations. We aimed to study the neurology referrals by the cardiovascular-specialized hospital included in our tertiary hospital center.

METHODS

Retrospective study of consecutive patients referred for neurology inpatient consultation between 01/01/2020 and 31/12/2022. We analyzed referrals, patients' characteristics, and the approach taken. A detailed subanalysis was performed for patients diagnosed with acute ischemic stroke (AIS).

RESULTS

143 patients were observed [mean age 67.3 years, 46 (32.2%) females]. Most frequent referral reasons were suspected AIS deficits (39.2%), altered mental status (19.6%), suspected seizures (13.3%), and neuroprognostication (11.9%). Mean referral-to-consult time was 2.7 days, and 117 (81.8%) consults were in-person. Additional investigation, treatment changes, and outpatient clinic referral were proposed, respectively in 79.7%, 60.1%, and 19.6% of patients. Most common diagnoses were AIS (45.5%), hypoxic-ischemic encephalopathy (18.9%) and delirium (7.0%). Regarding patients with AIS (n=62), most common stroke causes were post-cardiac procedure (44.6%), infective endocarditis (18.5%), aortic dissection (10.8%), acute myocardial infarction (10.8%) and anticoagulant withdrawal in patients with atrial fibrillation (6.2%). 34 AIS patients were diagnosed less than 24-hours since last seen well, of which four (6.2%) were treated (three with thrombolysis and one with mechanical thrombectomy).

CONCLUSION

AIS is the most common reason for referral in our cardiovascular hospital. Our results highlight the importance of the availability of a neurologist/neurohospitalist with stroke expertise for consultation of inpatients admitted in a specialized cardiovascular hospital.

Proteomics to Identify New Blood Biomarkers for Diagnosing Patients With Acute Stroke

Background Blood biomarkers are a potential tool for early stroke diagnosis. We aimed to perform a pilot and exploratory study on untargeted blood biomarkers in patients with suspected stroke by using mass spectrometry analysis. Methods and Results This was a prospective observational study of consecutive patients with suspected stroke admitted within 6 hours of last being seen well. Blood samples were collected at admission. Patients were divided into 3 groups: ischemic stroke (IS), intracerebral hemorrhage (ICH), and stroke mimics. Quantitative analysis from mass spectrometry data was performed using a supervised approach. Biomarker-based prediction models were developed to differentiate IS from ICH and ICH+stroke mimics. Models were built aiming to minimize misidentification of patients with ICH as having IS. We included 90 patients, one-third within each subgroup. The median age was 71 years (interquartile range, 57-81 years), and 49 participants (54.4%) were women. In quantitative analysis, C3 (complement component 3), ICAM-2 (intercellular adhesion molecule 2), PLGLA (plasminogen like A), STXBP5 (syntaxin-binding protein 5), and IGHV3-64 (immunoglobulin heavy variable 3-64) were the 5 most significantly dysregulated proteins for both comparisons. Biomarker-based models showed 88% sensitivity and 89% negative predictive value for differentiating IS from ICH, and 75% sensitivity and 95% negative predictive value for differentiating IS from ICH+stroke mimics. ICAM-2, STXBP5, PLGLA, C3, and IGHV3-64 displayed the highest importance score in our models, being the most informative for identifying patients with stroke. Conclusions In this proof-of-concept and exploratory study, our biomarker-based prediction models, including ICAM-2, STXBP5, PLGLA, C3, and IGHV3-64, showed 75% to 88% sensitivity for identifying patients with IS, while aiming to minimize misclassification of ICH. Although our methodology provided an internal validation, these results still need validation in other cohorts and with different measurement techniques.

Sleep seasonality in alpha-synucleinopathies: A comparative study with non-neurological sleep disorder patients

INTRODUCTION

It is unknown if seasonal variation in daylight affects sleep in patients with alpha-synucleinopathies. Our objectives were to assess month of the year related changes in polysomnography (PSG) data in patients with Parkinson 's disease (PD), Lewy Body Dementia (LBD) and isolated REM sleep behavior disorder (iRBD).

METHODS

We collected PSG data from 64 PD, 30 LBD and 24 iRBD patients attending a sleep laboratory in Lisbon, Portugal, during 10 years. Each was classified according to the month of the year PSG was performed and compared with a control patient with sleep disorder, but no evidence of other neurological disorder, matched for sex, age group and PSG month. The influence of month in PSG data was assessed with mixed linear regression analysis.

RESULTS

In alpha-synucleinopathies, month showed significant interaction with N2 stage time and percentage (increase from December to April) and N3 time (peak in May). REM sleep percentage increased significantly from Spring to middle Summer. In the control group, there were significant interactions regarding Total Sleep Time and Sleep Efficiency (drop during wintertime), N2 time and REM % (increase in April and May) and Apnea-Hypopnea Index (AHI) (peak in June). There were significant associations between the term group*month and sleep efficiency and AHI, with larger monthly variation in the control group.

CONCLUSION

Seasonality had a larger impact in stage architecture in alpha-synucleinopathies, and in total sleep time, sleep efficiency and the severity of OSA in the control group. Different sleep dysfunction mechanisms could explain differences in seasonal variation.

Early Parkinson's Disease Phenotypes Tailored by Personality, Behavior, and Motor Symptoms

BACKGROUND

Previous studies described a parkinsonian personality characterized as rigid, introverted, and cautious; however, little is known about personality traits in de novo Parkinson's disease (PD) patients and their relationships with motor and neuropsychiatric symptoms.

OBJECTIVE

To investigate personality in de novo PD and explore its relationship with PD symptoms.

METHODS

Using Cloninger's biosocial model, we assessed personality in 193 de novo PD patients. Motor and non-motor symptoms were measured using several validated scales. Cluster analysis was conducted to investigate the interrelationship of personality traits, motor, and non-motor symptoms.

RESULTS

PD patients showed low novelty seeking, high harm avoidance, and normal reward dependence and persistence scores. Harm avoidance was positively correlated with the severity of depression, anxiety, and apathy (rs = [0.435, 0.676], p < 0.001) and negatively correlated with quality of life (rs = -0.492, p < 0.001). Novelty seeking, reward dependence, and persistence were negatively correlated with apathy (rs = [-0.274, -0.375], p < 0.001). Classification of patients according to personality and PD symptoms revealed 3 distinct clusters: i) neuropsychiatric phenotype (with high harm avoidance and low novelty seeking, hypodopaminergic neuropsychiatric symptoms and higher impulsivity), ii) motor phenotype (with low novelty seeking and higher motor severity), iii) benign phenotype (with low harm avoidance and high novelty seeking, reward dependence, and persistence traits clustered with lower symptoms severity and low impulsivity).

CONCLUSION

Personality in early PD patients allows us to recognize 3 patients' phenotypes. Identification of such subgroups may help to better understand their natural history. Their longitudinal follow-up will allow confirming whether some personality features might influence disease evolution and treatment.

Distinct gait dimensions are modulated by physical activity in Parkinson's disease patients

Parkinson’s disease (PD) is the fastest growing neurodegenerative disease, but disease-modifying or preventive treatments are lacking. Physical activity is a modifiable factor that decreases the PD risk and improves motor symptoms in PD. Understanding which dimensions of gait performance correlate with physical activity in PD can have important pathophysiological and therapeutic implications. Clinical/demographic data together with physical activity levels were collected from thirty-nine PD patients. Gait analysis was performed wearing seven inertial measurement units on the lower body, reconstructing the subjects’ lower body motion using 3D kinematic biomechanical models. Higher physical activity scores were significantly correlated with MDS-UPDRS part III scores (r = − 0.58, p value = 9.2 × 10⁻⁵), age (r = − 0.39, p value = 1.5 × 10⁻²) and quality-of-life (r = − 0.47, p value = 5.9 × 10⁻³). Physical activity was negatively associated with MDS-UPDRS part III scores after adjusting for age and disease duration (β = − 0.08530, p value = 0.0010). The effect of physical activity on quality-of-life was mediated by the MDS-UPDRS part III (62.10%, 95% CI = 0.0758–1.78, p value = 0.022). The level of physical activity was correlated primarily with spatiotemporal performance. While spatiotemporal performance displays the strongest association with physical activity, other quality-of-movement dimensions of clinical relevance (e.g., smoothness, rhythmicity) fail to do so. Interventions targeting these ought to be leveraged for performance enhancement in PD through neuroprotective and brain network connectivity strengthening. It remains to be ascertained to which extent these are amenable to modulation.

Progression in Parkinson's Disease: Variation in Motor and Non-motor Symptoms Severity and Predictors of Decline in Cognition, Motor Function, Disability, and Health-Related Quality of Life as Assessed by Two Different Methods

Background

Parkinson's disease (PD) is multi-symptom disease with variable progression.

Objectives

We performed a longitudinal study to address the evolution of motor symptoms (MS) and non-motor symptoms (NMS), predictors of motor-, cognitive-, disability-, and health-related quality of life (HRQL) status and the relative usefullness of a battery of separate NMS scales (BSS) versus the Non-Motor Symptom Scale (NMSS).

Methods

Seventy-two patients were assessed at baseline and 4 years later with the NMSS and BSS. We assessed the following outcomes: cognition (Montreal Cognitive Assessment scale [MoCA]), disability (Unified Parkinson's Disease Rating Scale Part II [UPDRS II], Schwab and England [S&E]), motor dysfunction (Unified Parkinson's Disease Rating Scale Part III [UPDRS III], Hoehn and Yahr [HY]), and HRQL (EuroQol [EQ] EQ-vertical visual analogue scale [VAS] and EQ-Index). Statistical analysis included a comparison between scales scores at both time points and multivariate regression analysis to calculate the impact of each baseline symptom in outcomes. NMSS and BSS were introduced in separate models.

Results

NMSS Domain 4: perception/hallucinations, Parkinson's Psychosis Questionnaire, Apathy Scale, NMSS Domain 7: urinary, S&E, UPDRS II, HY, and MoCA scores worsened significantly. Dementia increased to a 4-year prevalence of 39.8%. In the multivariate model using BSS, cognitive state variation was significantly predicted by baseline HY, EQ-Index, and S&E. Using the NMSS, MoCA change was significantly associated with NMSS Domain 4: perceptions/hallucination score, cognitive status with UPDRS III score, HRQL with NMSS Domain 4: perception/hallucinations score, and S&E.

Conclusion

Our study suggests that NMS progress heterogeneously, BSS approach being more sensitive to change than NMSS. The multivariate analysis has shown that S&E and NMSS Domain 4: perception/hallucinations scores are the stronger predictors of HRQL and cognitive dysfunction variation, favoring NMSS over the BSS approach.

Long-term effect of apomorphine infusion in advanced Parkinson's disease: a real-life study

Long-term effects of continuous subcutaneous apomorphine infusion (CSAI) on health-related quality of life (HRQoL) and predictors of CSAI discontinuation are poorly known. Data from consecutive advanced Parkinson’s disease patients treated in routine care were retrospectively collected over 24 months after CSAI initiation, with a focus on the 39-item Parkinson’s disease questionnaire (PDQ-39). We determined predictors of CSAI discontinuation and HRQoL improvement using multiple regression analysis. Of the 110 subjects evaluated over a 2-year period, 35% discontinued CSAI. Of those who continued treatment, HRQoL remained stable with a sustained reduction in motor fluctuations. The observed effect on dyskinesias was mild and transient. Of note, patients with preexisting impulse control disorders showed an overall good tolerability. PDQ-39 was the only baseline predictor of HRQoL improvement after 2 years of treatment. The presence of dyskinesias, poorer psychological status, shorter disease duration, male sex, and worse OFF state were predictors of discontinuation. Best candidates for CSAI are patients with: (i) poor baseline HRQoL and (ii) marked motor fluctuations.

Do dreams tell the future? Dream content as a predictor of cognitive deterioration in Parkinson's disease

Cross-sectional studies suggest a correlation between alterations in dream content reports and executive dysfunction tests in Parkinson's disease (PD), but this has not been assessed in longitudinal studies. Our objective was to assess the predictive value of dream content for progression of cognitive dysfunction in PD. We prospectively addressed all consecutive, non-demented patients with PD attending an outpatient clinic during a 1-year period. Dream reports were collected at baseline by means of a dream diary and analysed according to the Hall and Van de Castle system. Patients were assessed at baseline for rapid eye movement sleep behaviour disorder, motor stage, mood disorder and psychosis. The Montreal Cognitive Assessment (MoCA) was applied at baseline and 4 years later. Linear regression analysis was used to the test the relation between each dream index (predictors), demographic and other motor and non-motor variables (covariates), and change in MoCA scores (dependent variable). In all, 58 patients were assessed at both time points and 23 reported at least one dream (range 1-27, total 148). Aggression, physical activities, and negatively toned content predominated in dream reports. The MoCA scores decreased significantly from baseline to follow-up. In the multivariate model, negative emotion index was the strongest predictor of cognitive decline. We found a significant positive association between negative emotions in dreams at baseline and subsequent reduction in MoCA scores. These findings suggest that some dream content in patients with PD could be considered a predictor of cognitive decline, independent of other factors known to influence either dream content or cognitive deterioration.

Polysomnographic predictors of sleep, motor and cognitive dysfunction progression in Parkinson's disease: a longitudinal study

OBJECTIVE

To assess the predictive value of polysomnographic (PSG) data in the prospective assessment of cognitive, motor, daytime and nighttime sleep dysfunction in Parkinson's Disease (PD) patients.

METHODS

PD patients were assessed at baseline with video-PSG and with cognitive (MoCA), Sleep (SCOPA-Sleep Nighttime and Daytime scores) and Motor (UPDRSIII) function scales at both baseline and four years later. Linear regression analysis was used to assess the relation between PSG variables at baseline and change in symptoms scores.

RESULTS

We included a total of 25 patients, 12 with rapid eye movement (REM) sleep behavior disorder (RBD) (in 8 PSG was inconclusive, due to lack of REM sleep). MoCA scores decreased significantly at follow-up, while SCOPA-Sleep Daytime and SCOPA-Sleep Nighttime and UPDRSIII did not vary. Lower N3 percentage at baseline was significantly associated with MoCA decrease. Higher Periodic Limb Movements in Sleep index (PLMS) and the presence of RBD were significantly associated with SCOPA daytime score increase. Higher global severity of RBD, tonic RSWA and total number of motor events during REM sleep were associated with SCOPA Nighttime score increase.

CONCLUSIONS

The present work suggests that PSG data could be useful for predicting PD cognitive and sleep dysfunction progression. Reduced SWS could predict deterioration of cognitive function, while baseline PLMS could be useful to predict worsening of daytime sleep dysfunction. Severity of RBD could be used for estimating nighttime sleep symptoms progression.

REM sleep behaviour disorder in essential tremor: A polysomnographic study

Our objectives were to assess the prevalence of REM sleep behaviour disorder in patients with Essential Tremor, using video-polysomnography and to compare REM sleep behaviour disorder features in essential tremor with those of patients with alpha-synucleinopathies. Forty-nine patients with essential tremor were screened with the REM Sleep Behaviour Disorder Screening Questionnaire. Patients scoring positive and those with spontaneous complaints of REM sleep behaviour disorder (n = 6) underwent video-polysomnography. The clinical features of essential tremor were compared between patients with and without REM sleep behaviour disorder. Video-polysomnography data were compared between patients who had essential tremor and Parkinson's disease with REM sleep behaviour disorder and those with idiopathic REM sleep behaviour disorder. Fourteen patients (23.5%) screened positive for REM sleep behaviour disorder, confirmed by video-polysomnography in five (11.6%). All patients with essential tremor and REM sleep behaviour disorder had rest tremor, compared with 13 (34.2%) in the group with essential tremor but without REM sleep behaviour disorder (p = .009). In video-polysomnography, patients with essential tremor and REM sleep behaviour disorder were similar to patients with Parkinson's disease with REM sleep behaviour disorder and presented worse sleep dysfunction and lower severity of REM sleep behaviour disorder compared to those with idiopathic REM sleep behaviour disorder. We found a high prevalence of REM sleep behaviour disorder in patients with essential tremor, associated with a predominance of rest tremor. Polysomnography data from patients with essential tremor and REM sleep behaviour disorder were similar to those in patients with Parkinson's disease. This suggests a relation between this subgroup of patients with essential tremor and the alpha-synucleinopathies.

Late-onset presentation of POLG1-associated mitochondrial disease

Mutations in the nuclear POLG1 gene compromise the integrity of mitochondrial DNA and show great allelic and clinical heterogeneity. Among adult POLG1-associated mitochondrial disease, the main clinical feature is chronic progressive external ophthalmoplegia. Other related clinical manifestations are sensory or cerebellar ataxia, peripheral neuropathy, myopathy or extrapyramidal symptoms. We report the case of a 72-year-old man who presented with a late onset sensory neuronopathy, chronic progressive external ophthalmoplegia, gait ataxia and parkinsonism. Genetic studies showed a compound heterozygosity of known pathogenic mutations in the POLG1 gene (variant T252I/P587 L in cis configuration in allele 1 and variant R807C in allele 2). Late life presentation highlights that mitochondrial disorders should be considered regardless of age of onset of symptoms.