1
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Ditzel RM, Walker RH, Nirenberg MJ, Tetlow AM, Farrell K, Lind-Watson KJ, Thorn EL, Dangoor DK, Gordon R, De Sanctis C, Barton B, Karp BI, Kirby A, Lett DJ, Mente K, Simon DK, Velayos-Baeza A, Miltenberger-Miltenyi G, Humphrey J, Crary JF. An Autopsy Series of Seven Cases of VPS13A Disease (Chorea-Acanthocytosis). Mov Disord 2023; 38:2163-2172. [PMID: 37670483 PMCID: PMC10841393 DOI: 10.1002/mds.29589] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2023] [Revised: 07/29/2023] [Accepted: 08/04/2023] [Indexed: 09/07/2023] Open
Abstract
BACKGROUND Vacuolar protein sorting 13 homolog A (VPS13A) disease, historically known as chorea-acanthocytosis, is a rare neurodegenerative disorder caused by biallelic mutations in VPS13A, usually resulting in reduced or absent levels of its protein product, VPS13A. VPS13A localizes to contact sites between subcellular organelles, consistent with its recently identified role in lipid transfer between membranes. Mutations are associated with neuronal loss in the striatum, most prominently in the caudate nucleus, and associated marked astrogliosis. There are no other known disease-specific cellular changes (eg, protein aggregation), but autopsy reports to date have been limited, often lacking genetic or biochemical diagnostic confirmation. OBJECTIVE The goal of this study was to characterize neuropathological findings in the brains of seven patients with VPS13A disease (chorea-acanthocytosis). METHODS In this study, we collected brain tissues and clinical data from seven cases of VPS13A for neuropathological analysis. The clinical diagnosis was confirmed by the presence of VPS13A mutations and/or immunoblot showing the loss or reduction of VPS13A protein. Tissues underwent routine, special, and immunohistochemical staining focused on neurodegeneration. Electron microscopy was performed in one case. RESULTS Gross examination showed severe striatal atrophy. Microscopically, there was neuronal loss and astrogliosis in affected regions. Luxol fast blue staining showed variable lipid accumulation with diverse morphology, which was further characterized by electron microscopy. In some cases, rare degenerating p62- and ubiquitin-positive cells were present in affected regions. Calcifications were present in four cases, being extensive in one. CONCLUSIONS We present the largest autopsy series of biochemically and genetically confirmed VPS13A disease and identify novel histopathological findings implicating abnormal lipid accumulation. © 2023 International Parkinson and Movement Disorder Society.
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Affiliation(s)
- Ricky M. Ditzel
- Department of Pathology, Molecular, and Cell Based Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
- Department of Artificial Intelligence & Human Health, Icahn School of Medicine at Mount Sinai, New York, New York, USA
- Nash Family Department of Neuroscience, Icahn School of Medicine at Mount Sinai, New York, NY, USA
- Friedman Brain Institute, Ronald M. Loeb Center for Alzheimer’s Disease, Icahn School of Medicine at Mount Sinai, New York, New York, USA
- Neuropathology Brain Bank & Research CoRE, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Ruth H. Walker
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
- James J. Peters Veterans Affairs Medical Center, Bronx, NY, USA
| | - Melissa J. Nirenberg
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
- James J. Peters Veterans Affairs Medical Center, Bronx, NY, USA
| | - Amber M. Tetlow
- Department of Pathology, Molecular, and Cell Based Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
- Department of Artificial Intelligence & Human Health, Icahn School of Medicine at Mount Sinai, New York, New York, USA
- Nash Family Department of Neuroscience, Icahn School of Medicine at Mount Sinai, New York, NY, USA
- Friedman Brain Institute, Ronald M. Loeb Center for Alzheimer’s Disease, Icahn School of Medicine at Mount Sinai, New York, New York, USA
- Neuropathology Brain Bank & Research CoRE, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Kurt Farrell
- Department of Pathology, Molecular, and Cell Based Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
- Department of Artificial Intelligence & Human Health, Icahn School of Medicine at Mount Sinai, New York, New York, USA
- Nash Family Department of Neuroscience, Icahn School of Medicine at Mount Sinai, New York, NY, USA
- Friedman Brain Institute, Ronald M. Loeb Center for Alzheimer’s Disease, Icahn School of Medicine at Mount Sinai, New York, New York, USA
- Neuropathology Brain Bank & Research CoRE, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Kourtni J. Lind-Watson
- Department of Pathology, Molecular, and Cell Based Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
- Department of Artificial Intelligence & Human Health, Icahn School of Medicine at Mount Sinai, New York, New York, USA
- Nash Family Department of Neuroscience, Icahn School of Medicine at Mount Sinai, New York, NY, USA
- Friedman Brain Institute, Ronald M. Loeb Center for Alzheimer’s Disease, Icahn School of Medicine at Mount Sinai, New York, New York, USA
- Neuropathology Brain Bank & Research CoRE, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Emma L. Thorn
- Department of Pathology, Molecular, and Cell Based Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
- Department of Artificial Intelligence & Human Health, Icahn School of Medicine at Mount Sinai, New York, New York, USA
- Nash Family Department of Neuroscience, Icahn School of Medicine at Mount Sinai, New York, NY, USA
- Friedman Brain Institute, Ronald M. Loeb Center for Alzheimer’s Disease, Icahn School of Medicine at Mount Sinai, New York, New York, USA
- Neuropathology Brain Bank & Research CoRE, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Diana K. Dangoor
- Department of Pathology, Molecular, and Cell Based Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
- Department of Artificial Intelligence & Human Health, Icahn School of Medicine at Mount Sinai, New York, New York, USA
- Nash Family Department of Neuroscience, Icahn School of Medicine at Mount Sinai, New York, NY, USA
- Friedman Brain Institute, Ronald M. Loeb Center for Alzheimer’s Disease, Icahn School of Medicine at Mount Sinai, New York, New York, USA
- Neuropathology Brain Bank & Research CoRE, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Ronald Gordon
- Department of Pathology, Molecular, and Cell Based Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Claudia De Sanctis
- Department of Pathology, Molecular, and Cell Based Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
- Department of Artificial Intelligence & Human Health, Icahn School of Medicine at Mount Sinai, New York, New York, USA
- Nash Family Department of Neuroscience, Icahn School of Medicine at Mount Sinai, New York, NY, USA
- Friedman Brain Institute, Ronald M. Loeb Center for Alzheimer’s Disease, Icahn School of Medicine at Mount Sinai, New York, New York, USA
- Neuropathology Brain Bank & Research CoRE, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Brandon Barton
- Rush University Medical Center, Chicago, Illinois, USA
- Jesse Brown Veterans Affairs Medical Center, Chicago, Illinois, USA
| | - Barbara I. Karp
- Human Motor Control Section, National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, Maryland, USA
| | - Alana Kirby
- Jesse Brown Veterans Affairs Medical Center, Chicago, Illinois, USA
| | - Debra J. Lett
- Newcastle Brain Tissue Resource, Newcastle University, Newcastle, UK
| | - Karin Mente
- Departments of Neurology and Pathology, Case Western Reserve University, Cleveland, OH, USA
- Louis Stokes Cleveland VA Medical Center, Cleveland OH, USA
| | - David K. Simon
- Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - Antonio Velayos-Baeza
- Department of Physiology, Anatomy, and Genetics, University of Oxford, UK
- Wellcome Centre for Human Genetics, University of Oxford, Oxford, UK
| | - Gabriel Miltenberger-Miltenyi
- Laboratório de Genética, Faculdade de Medicina, Universidade de Lisboa, Lisbon, Portugal
- Department of Neurology, Ludwig-Maximilians-Universität München, Munich, Germany
- Reference Center on Lysosomal Storage Diseases, Hospital Senhora da Oliveira, Guimarães, Portugal
- Instituto de Medicina Molecular João Lobo Antunes, Faculdade de Medicina da Universidade de Lisboa, Lisbon, Portugal
| | - Jack Humphrey
- Nash Family Department of Neuroscience, Icahn School of Medicine at Mount Sinai, New York, NY, USA
- Friedman Brain Institute, Ronald M. Loeb Center for Alzheimer’s Disease, Icahn School of Medicine at Mount Sinai, New York, New York, USA
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
- Department of Genetics and Genomic Sciences & Icahn Institute for Data Science and Genomic Technology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - John F. Crary
- Department of Pathology, Molecular, and Cell Based Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
- Department of Artificial Intelligence & Human Health, Icahn School of Medicine at Mount Sinai, New York, New York, USA
- Nash Family Department of Neuroscience, Icahn School of Medicine at Mount Sinai, New York, NY, USA
- Friedman Brain Institute, Ronald M. Loeb Center for Alzheimer’s Disease, Icahn School of Medicine at Mount Sinai, New York, New York, USA
- Neuropathology Brain Bank & Research CoRE, Icahn School of Medicine at Mount Sinai, New York, New York, USA
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2
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Miltenberger-Miltenyi G, Jones A, Tetlow AM, Conceição VA, Crary JF, Ditzel RM, Farrell K, Nandakumar R, Barton B, Karp BI, Kirby A, Lett DJ, Mente K, Morgello S, Simon DK, Walker RH. Sphingolipid and Phospholipid Levels Are Altered in Human Brain in Chorea-Acanthocytosis. Mov Disord 2023; 38:1535-1541. [PMID: 37307400 DOI: 10.1002/mds.29445] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2022] [Revised: 04/24/2023] [Accepted: 04/28/2023] [Indexed: 06/14/2023] Open
Abstract
BACKGROUND Chorea-acanthocytosis (ChAc) is associated with mutations of VPS13A, which encodes for chorein, a protein implicated in lipid transport at intracellular membrane contact sites. OBJECTIVES The goal of this study was to establish the lipidomic profile of patients with ChAc. METHODS We analyzed 593 lipid species in the caudate nucleus (CN), putamen, and dorsolateral prefrontal cortex (DLPFC) from postmortem tissues of four patients with ChAc and six patients without ChAc. RESULTS We found increased levels of bis(monoacylglycerol)phosphate, sulfatide, lysophosphatidylserine, and phosphatidylcholine ether in the CN and putamen, but not in the DLPFC, of patients with ChAc. Phosphatidylserine and monoacylglycerol were increased in the CN and N-acyl phosphatidylserine in the putamen. N-acyl serine was decreased in the CN and DLPFC, whereas lysophosphatidylinositol was decreased in the DLPFC. CONCLUSIONS We present the first evidence of altered sphingolipid and phospholipid levels in the brains of patients with ChAc. Our observations are congruent with recent findings in cellular and animal models, and implicate defects of lipid processing in VPS13A disease pathophysiology. © 2023 International Parkinson and Movement Disorder Society. This article has been contributed to by U.S. Government employees and their work is in the public domain in the USA.
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Affiliation(s)
- Gabriel Miltenberger-Miltenyi
- Laboratório de Genética, Faculdade de Medicina, Universidade de Lisboa, Lisbon, Portugal
- Department of Neurology, Ludwig-Maximilians-Universität München, Munich, Germany
- Reference Center on Lysosomal Storage Diseases, Hospital Senhora da Oliveira, Guimarães, Portugal
- Instituto de Medicina Molecular João Lobo Antunes, Faculdade de Medicina da Universidade de Lisboa, Lisbon, Portugal
| | - Attila Jones
- Laboratory of Behavioral Neuroscience, National Institute on Aging, National Institutes of Health, Baltimore, Maryland, USA
| | - Amber M Tetlow
- Department of Pathology, Molecular, and Cell Based Medicine, Icahn School of Medicine at Mount Sinai, New York City, New York, USA
- Department of Neuroscience and Artificial Intelligence & Human Health, Icahn School of Medicine at Mount Sinai, New York City, New York, USA
- Friedman Brain Institute, Ronald M. Loeb Center for Alzheimer's Disease, Icahn School of Medicine at Mount Sinai, New York City, New York, USA
| | - Vasco A Conceição
- Instituto de Medicina Molecular João Lobo Antunes, Faculdade de Medicina da Universidade de Lisboa, Lisbon, Portugal
| | - John F Crary
- Department of Pathology, Molecular, and Cell Based Medicine, Icahn School of Medicine at Mount Sinai, New York City, New York, USA
- Department of Neuroscience and Artificial Intelligence & Human Health, Icahn School of Medicine at Mount Sinai, New York City, New York, USA
- Friedman Brain Institute, Ronald M. Loeb Center for Alzheimer's Disease, Icahn School of Medicine at Mount Sinai, New York City, New York, USA
| | - Ricky Michael Ditzel
- Department of Pathology, Molecular, and Cell Based Medicine, Icahn School of Medicine at Mount Sinai, New York City, New York, USA
- Department of Neuroscience and Artificial Intelligence & Human Health, Icahn School of Medicine at Mount Sinai, New York City, New York, USA
- Friedman Brain Institute, Ronald M. Loeb Center for Alzheimer's Disease, Icahn School of Medicine at Mount Sinai, New York City, New York, USA
| | - Kurt Farrell
- Department of Pathology, Molecular, and Cell Based Medicine, Icahn School of Medicine at Mount Sinai, New York City, New York, USA
- Department of Neuroscience and Artificial Intelligence & Human Health, Icahn School of Medicine at Mount Sinai, New York City, New York, USA
- Friedman Brain Institute, Ronald M. Loeb Center for Alzheimer's Disease, Icahn School of Medicine at Mount Sinai, New York City, New York, USA
| | - Renu Nandakumar
- Biomarkers Core Laboratory, Irving Institute for Clinical and Translational Research, Columbia University Irving Medical Center, New York City, New York, USA
| | - Brandon Barton
- Rush University Medical Center, Chicago, Illinois, USA
- Jesse Brown Veterans Affairs Medical Center, Chicago, Illinois, USA
| | - Barbara I Karp
- Human Motor Control Section, National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, Maryland, USA
| | - Alana Kirby
- Jesse Brown Veterans Affairs Medical Center, Chicago, Illinois, USA
| | - Debra J Lett
- Newcastle Brain Tissue Resource, Newcastle University, Newcastle, United Kingdom
| | - Karin Mente
- Departments of Neurology and Pathology, Case Western Reserve University, Cleveland, Ohio, USA
- Louis Stokes Cleveland VA Medical Center, Cleveland, Ohio, USA
| | - Susan Morgello
- Department of Pathology, Molecular, and Cell Based Medicine, Icahn School of Medicine at Mount Sinai, New York City, New York, USA
- Friedman Brain Institute, Ronald M. Loeb Center for Alzheimer's Disease, Icahn School of Medicine at Mount Sinai, New York City, New York, USA
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York City, New York, USA
| | - David K Simon
- Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - Ruth H Walker
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York City, New York, USA
- James J. Peters Veterans Affairs Medical Center, Bronx, New York, USA
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Hohenschurz-Schmidt DJ, Cherkin D, Rice AS, Dworkin RH, Turk DC, McDermott MP, Bair MJ, DeBar LL, Edwards RR, Farrar JT, Kerns RD, Markman JD, Rowbotham MC, Sherman KJ, Wasan AD, Cowan P, Desjardins P, Ferguson M, Freeman R, Gewandter JS, Gilron I, Grol-Prokopczyk H, Hertz SH, Iyengar S, Kamp C, Karp BI, Kleykamp BA, Loeser JD, Mackey S, Malamut R, McNicol E, Patel KV, Sandbrink F, Schmader K, Simon L, Steiner DJ, Veasley C, Vollert J. Research objectives and general considerations for pragmatic clinical trials of pain treatments: IMMPACT statement. Pain 2023; 164:1457-1472. [PMID: 36943273 PMCID: PMC10281023 DOI: 10.1097/j.pain.0000000000002888] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2022] [Revised: 01/09/2023] [Accepted: 01/12/2023] [Indexed: 03/23/2023]
Abstract
ABSTRACT Many questions regarding the clinical management of people experiencing pain and related health policy decision-making may best be answered by pragmatic controlled trials. To generate clinically relevant and widely applicable findings, such trials aim to reproduce elements of routine clinical care or are embedded within clinical workflows. In contrast with traditional efficacy trials, pragmatic trials are intended to address a broader set of external validity questions critical for stakeholders (clinicians, healthcare leaders, policymakers, insurers, and patients) in considering the adoption and use of evidence-based treatments in daily clinical care. This article summarizes methodological considerations for pragmatic trials, mainly concerning methods of fundamental importance to the internal validity of trials. The relationship between these methods and common pragmatic trials methods and goals is considered, recognizing that the resulting trial designs are highly dependent on the specific research question under investigation. The basis of this statement was an Initiative on Methods, Measurement, and Pain Assessment in Clinical Trials (IMMPACT) systematic review of methods and a consensus meeting. The meeting was organized by the Analgesic, Anesthetic, and Addiction Clinical Trial Translations, Innovations, Opportunities, and Networks (ACTTION) public-private partnership. The consensus process was informed by expert presentations, panel and consensus discussions, and a preparatory systematic review. In the context of pragmatic trials of pain treatments, we present fundamental considerations for the planning phase of pragmatic trials, including the specification of trial objectives, the selection of adequate designs, and methods to enhance internal validity while maintaining the ability to answer pragmatic research questions.
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Affiliation(s)
- David J. Hohenschurz-Schmidt
- Pain Research, Department of Surgery & Cancer, Faculty of Medicine, Imperial College London, London, United Kingdom
| | - Dan Cherkin
- Department of Family Medicine, University of Washington and Kaiser Permanente Washington Health Research Institute, Seattle, WA, United States
| | - Andrew S.C. Rice
- Pain Research, Department of Surgery & Cancer, Faculty of Medicine, Imperial College London, London, United Kingdom
| | - Robert H. Dworkin
- Department of Anesthesiology and Perioperative Medicine, University of Rochester Medical Center, Rochester, NY, United States
| | - Dennis C. Turk
- Anesthesiology and Pain Medicine, University of Washington, Seattle, WA, United States
| | - Michael P. McDermott
- Department of Biostatistics and Computational Biology, University of Rochester, Rochester, NY, United States
| | - Matthew J. Bair
- VA Center for Health Information and Communication, Regenstrief Institute, and Indiana University School of Medicine, Indianapolis, IN, United States
| | - Lynn L. DeBar
- Kaiser Permanente Washington Health Research Institute, Seattle, WA, United States
| | | | - John T. Farrar
- Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania, Philadelphia, PA, United States
| | - Robert D. Kerns
- Departments of Psychiatry, Neurology and Psychology, Yale University, New Haven, CT, United States
| | - John D. Markman
- Neuromedicine Pain Management and Translational Pain Research, University of Rochester School of Medicine and Dentistry, Rochester, NY, United States
| | - Michael C. Rowbotham
- Department of Anesthesia, University of California San Francisco School of Medicine, San Francisco, CA, United States
| | - Karen J. Sherman
- Kaiser Permanente Washington Health Research Institute and Department of Epidemiology, University of Washington, Seattle WA, United States
| | - Ajay D. Wasan
- Departments of Anesthesiology & Perioperative Medicine, and Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States
| | - Penney Cowan
- American Chronic Pain Association, Rocklin, CA, United States
| | - Paul Desjardins
- Department of Diagnostic Sciences, School of Dental Medicine, Rutgers University, Newark, NJ, United States
| | - McKenzie Ferguson
- Department of Pharmacy Practice, Southern Illinois University Edwardsville, Edwardsville, IL, United States
| | - Roy Freeman
- Department of Neurology, Harvard Medical School, Boston, MA, United States
| | - Jennifer S. Gewandter
- Department of Anesthesiology and Perioperative, University of Rochester, Rochester, NY, United States
| | - Ian Gilron
- Departments of Anesthesiology & Perioperative Medicine, Biomedical & Molecular Sciences, Centre for Neuroscience Studies, and School of Policy Studies, Queen's University, Kingston, ON, Canada
| | - Hanna Grol-Prokopczyk
- Department of Sociology, University at Buffalo, State University of New York, Buffalo NY, United States
| | - Sharon H. Hertz
- Hertz and Fields Consulting, Inc, Silver Spring, MD, United States
| | | | - Cornelia Kamp
- Center for Health and Technology (CHeT), Clinical Materials Services Unit (CMSU), University of Rochester Medical Center, Rochester, NY, United States
| | | | - Bethea A. Kleykamp
- Department of Anesthesiology and Perioperative Medicine, University of Rochester Medical Center, Rochester, NY, United States
| | - John D. Loeser
- Departments of Neurological Surgery and Anesthesia and Pain Medicine, University of Washington, Seattle, WA, United States
| | - Sean Mackey
- Department of Anesthesiology, Perioperative, and Pain Medicine, Neurosciences and Neurology, Stanford University School of Medicine, Palo Alto, CA, United States
| | | | - Ewan McNicol
- Department of Pharmacy Practice, Massachusetts College of Pharmacy and Health Sciences, Boston, MA, United States
| | - Kushang V. Patel
- Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, WA, United States
| | - Friedhelm Sandbrink
- Department of Neurology, Washington DC Veterans Affairs Medical Center, Washington, DC, United States
- Department of Neurology, George Washington University, Washington, DC, United States
| | - Kenneth Schmader
- Department of Medicine-Geriatrics, Center for the Study of Aging, Duke University Medical Center, and Geriatrics Research Education and Clinical Center, Durham VA Medical Center, Durham, NC, United States
| | - Lee Simon
- SDG, LLC, Cambridge, MA, United States
| | | | - Christin Veasley
- Chronic Pain Research Alliance, North Kingstown, RI, United States
| | - Jan Vollert
- Pain Research, Department of Surgery and Cancer, Imperial College London, London, United Kingdom
- Division of Neurological Pain Research and Therapy, Department of Neurology, University Hospital of Schleswig-Holstein, Campus Kiel, Germany
- Department of Anaesthesiology, Intensive Care and Pain Medicine, University Hospital Muenster, Muenster, Germany
- Neurophysiology, Mannheim Center of Translational Neuroscience (MCTN), Medical Faculty Mannheim, Heidelberg University, Heidelberg, Germany
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4
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Karp BI, Stratton P. Applications of botulinum toxin to the female pelvic floor: Botulinum toxin for genito-pelvic pain penetration disorder and chronic pelvic pain in women. Toxicon 2023; 230:107162. [PMID: 37201800 DOI: 10.1016/j.toxicon.2023.107162] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Accepted: 05/15/2023] [Indexed: 05/20/2023]
Abstract
Chronic pain conditions like genito-pelvic pain penetration disorder and chronic pelvic pain cause significant morbidity in women worldwide and yet are underdiagnosed and undertreated. While the use of botulinum toxin for pain conditions has expanded, there are few randomized controlled studies of botulinum toxin for pelvic pain conditions in women. This paper provides an update on the current status and context for considering botulinum toxin treatment for these conditions to complement and expand currently available approaches. High quality clinical trials to evaluate safety and efficacy and to determine optimal doses and approaches to injection are urgently needed.
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Affiliation(s)
- Barbara I Karp
- National Institutes of Neurological Disorder and Stroke, National Institutes of Health, Bethesda, MD, 20892, USA.
| | - Pamela Stratton
- National Institutes of Neurological Disorder and Stroke, National Institutes of Health, Bethesda, MD, 20892, USA
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5
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Wandner LD, Bloms-Funke P, Bova G, Domenichiello A, Hoffmann A, Iyengar S, Karp BI, Letzen J, Liedgens H, Mohapatra DP, Nagel J, Pelleymounter MA, Pogatzki-Zahn E, Pogorzala L, Vollert J, Woller SA, Treede RD. INTEGRATE-Pain: a transatlantic consortium to advance development of effective pain management. Pain Med 2023:7084781. [PMID: 36951530 DOI: 10.1093/pm/pnad033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/14/2023] [Revised: 03/01/2023] [Accepted: 03/08/2023] [Indexed: 03/24/2023]
Affiliation(s)
- Laura D Wandner
- National Institute of Neurological Disorders and Stroke (NINDS), National Institutes of Health (NIH), United States
| | | | - Giulia Bova
- National Institute of Neurological Disorders and Stroke (NINDS), National Institutes of Health (NIH), United States
| | - Anthony Domenichiello
- National Institute of Neurological Disorders and Stroke (NINDS), National Institutes of Health (NIH), United States
| | | | - Smriti Iyengar
- National Institute of Neurological Disorders and Stroke (NINDS), National Institutes of Health (NIH), United States
| | - Barbara I Karp
- National Institute of Neurological Disorders and Stroke (NINDS), National Institutes of Health (NIH), United States
| | - Janelle Letzen
- National Institute of Neurological Disorders and Stroke (NINDS), National Institutes of Health (NIH), United States
| | | | - Durga P Mohapatra
- National Institute of Neurological Disorders and Stroke (NINDS), National Institutes of Health (NIH), United States
| | | | - Mary Ann Pelleymounter
- National Institute of Neurological Disorders and Stroke (NINDS), National Institutes of Health (NIH), United States
| | | | - Leah Pogorzala
- National Institute of Neurological Disorders and Stroke (NINDS), National Institutes of Health (NIH), United States
| | - Jan Vollert
- University Hospital Muenster, Germany
- Department of Neurophysiology, Mannheim Center for Translational Neuroscience (MCTN), Heidelberg University, Mannheim, Germany
- Imperial College London, Department of Surgery & Cancer, United Kingdom
- Division of Neurological Pain Research and Therapy, Department of Neurology, University Hospital of Schleswig-Holstein, Campus Kiel, Germany
| | - Sarah A Woller
- National Institute of Neurological Disorders and Stroke (NINDS), National Institutes of Health (NIH), United States
| | - Rolf-Detlef Treede
- Department of Neurophysiology, Mannheim Center for Translational Neuroscience (MCTN), Heidelberg University, Mannheim, Germany
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6
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Karp BI, Stratton P. Endometriosis-associated chronic pelvic pain. Med (N Y) 2023; 4:143-146. [PMID: 36858044 DOI: 10.1016/j.medj.2023.02.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/03/2023]
Abstract
Endometriosis is a heterogeneous disease where neurogenic sensitization can lead to chronic pain within and beyond the pelvis. Coincident pain and comorbidities merit specific attention. We discuss the causes, comorbidities, and management of endometriosis-associated chronic pelvic pain, advocating for a multidisciplinary approach to develop more effective treatments.
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Affiliation(s)
- Barbara I Karp
- Office of the Clinical Director, Intramural Research Program, National Institutes of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD, USA
| | - Pamela Stratton
- Office of the Clinical Director, Intramural Research Program, National Institutes of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD, USA.
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7
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Lungu C, Nmashie A, George MC, Karp BI, Alter K, Shin S, Tse W, Frucht SJ, Wu T, Koo V, Considine E, Norato G, Hallett M, Simpson DM. Comparison of Ultrasound and Electrical Stimulation Guidance for Onabotulinum Toxin-A Injections: A Randomized Crossover Study. Mov Disord Clin Pract 2022; 9:1055-1061. [PMID: 36523503 PMCID: PMC9631842 DOI: 10.1002/mdc3.13546] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2022] [Revised: 07/11/2022] [Accepted: 07/24/2022] [Indexed: 09/09/2023] Open
Abstract
Background Botulinum neurotoxin (BoNT) injection is an established therapy for limb spasticity and focal limb dystonia. Comparative benefits of injection guidance procedures have not been rigorously studied. Objectives We compared 2 targeting techniques for onabotulinumtoxin-A (onabotA) injection for the treatment of focal hand dystonia and upper limb spasticity: electrophysiologic guidance using electrical stimulation (E-stim) and ultrasound (US). Methods This was a 2-center, randomized, crossover, assessor-blinded trial. Participants with focal hand dystonia or upper limb spasticity, on stable onabotA therapy for at least 2 previous injection cycles, were randomly assigned to either E-stim or US with crossover at 3 months. The primary outcome was improvement in dystonia or spasticity severity on a visual analog scale (VAS; 0-100) measured 1 month after each injection. The secondary outcome was participant discomfort assessed on a VAS. Repeated-measures analysis of covariance was used with linear mixed-model covariate selection. Results A total of 19 participants (13 men) completed the study, 10 with upper limb spasticity and 9 with dystonia. Benefit was equivalent between the 2 techniques (VAS least-square mean [LSmean] 51.5 mm with US and 53.1 with E-stim). E-stim was perceived as more uncomfortable by participants (VAS LSmean 34.5 vs. 19.9 for E-stim and US, respectively). Procedure duration was similar with the 2 procedures. There were no serious adverse events related to either approach. Conclusions US and E-Stim localization guidance techniques provide equivalent efficacy in onabotA injections for spasticity and dystonia. US guidance injections are more comfortable for participants. Both techniques are effective guidance methods, with US potentially preferable based on participant comfort.
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Affiliation(s)
- Codrin Lungu
- Division of Clinical Research, National Institute of Neurological Disorders and StrokeNational Institutes of HealthBethesdaMarylandUSA
| | - Alexandra Nmashie
- Department of PediatricsNew York Medical College/NYCHealth Hospitals/MetropolitanNew YorkNew YorkUSA
| | | | - Barbara I. Karp
- Division of Clinical Research, National Institute of Neurological Disorders and StrokeNational Institutes of HealthBethesdaMarylandUSA
| | - Katharine Alter
- Department of Rehabilitation MedicineClinical Center, National Institutes of HealthBethesdaMarylandUSA
| | - Susan Shin
- Department of NeurologyIcahn School of Medicine at Mount SinaiNew YorkNew YorkUSA
| | - Winona Tse
- Department of NeurologyIcahn School of Medicine at Mount SinaiNew YorkNew YorkUSA
| | - Steven J. Frucht
- Department of NeurologyNew York University Grossman School of MedicineNew YorkNew YorkUSA
| | - Tianxia Wu
- Clinical Trials UnitNational Institute of Neurological Disorders and Stroke, National Institutes of HealthBethesdaMarylandUSA
| | - Vivian Koo
- Human Motor Control SectionNational Institute of Neurological Disorders and Stroke, National Institutes of HealthBethesdaMarylandUSA
| | - Elaine Considine
- Human Motor Control SectionNational Institute of Neurological Disorders and Stroke, National Institutes of HealthBethesdaMarylandUSA
| | - Gina Norato
- Clinical Trials UnitNational Institute of Neurological Disorders and Stroke, National Institutes of HealthBethesdaMarylandUSA
| | - Mark Hallett
- Human Motor Control SectionNational Institute of Neurological Disorders and Stroke, National Institutes of HealthBethesdaMarylandUSA
| | - David M. Simpson
- Department of NeurologyIcahn School of Medicine at Mount SinaiNew YorkNew YorkUSA
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Stratton P, Tandon HK, Phan V, Aredo JV, Sinaii N, Shah J, Karp BI. RANDOMIZED, PLACEBO-CONTROLLED TRIAL OF BOTULINUM TOXIN FOR ENDOMETRIOSIS-RELATED CHRONIC PELVIC PAIN. Fertil Steril 2021. [DOI: 10.1016/j.fertnstert.2021.07.148] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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9
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Phan VT, Stratton P, Tandon HK, Sinaii N, Aredo JV, Karp BI, Merideth MA, Shah JP. Widespread myofascial dysfunction and sensitisation in women with endometriosis-associated chronic pelvic pain: A cross-sectional study. Eur J Pain 2021; 25:831-840. [PMID: 33326662 DOI: 10.1002/ejp.1713] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Accepted: 12/12/2020] [Indexed: 01/11/2023]
Abstract
BACKGROUND Chronic pelvic pain persists in some women with endometriosis even after lesion removal and optimized hormonal treatment. OBJECTIVE Characterize the presence and distribution of pain, myofascial dysfunction and sensitisation beyond the pelvis in women with endometriosis-associated chronic pelvic pain. METHODS Cross-sectional study of 30 women prior to participation in a clinical trial. Evaluation included pain-focused abdominopelvic gynaecologic examination with the identification of pelvic floor muscle spasm. Neuro-musculoskeletal examination assessed paraspinal allodynia and hyperalgesia bilaterally and myofascial trigger points in 13 paired muscles. Pressure-pain thresholds were measured over interspinous ligaments and trigger points. Women completed the body territories element of the Body Pain Index. RESULTS All women had a pelvic floor muscle spasm that they self-identified as a major focus of pain. Twenty of 30 women described their pelvic pain as focal. However, all demonstrated widespread myofascial dysfunction with low pressure-pain thresholds and trigger points in over two-thirds of 26 assessed regions. Widespread spinal segmental sensitisation was present in 17/30, thoracic in 21/30 and lumbosacral/pelvic in 18/30. Cervical sensitisation manifested as low pressure-pain thresholds with 23/30 also reporting recurrent, severe headaches and 21/30 experiencing orofacial pain. Those reporting diffuse pelvic pain were more likely to have widespread (p = .024) and lumbosacral/pelvic (p = .036) sensitisation and report over 10 painful body areas (p = .009). CONCLUSIONS Women with endometriosis-associated chronic pelvic pain often have myofascial dysfunction and sensitisation beyond the pelvic region that may be initiated or maintained by on-going pelvic floor spasm. These myofascial and nervous system manifestations warrant consideration when managing pain in this population. Clinicaltrials.gov identifier: NCT01553201. SIGNIFICANCE Women with endometriosis often have pelvic pain persisting after surgery despite hormonal therapies and these women have regional pelvic sensitisation and myofascial dysfunction. Pelvic floor muscle spasm is a major pain focus in this population. Sensitisation and myofascial dysfunction are widespread, beyond the pelvic region. On-going pelvic floor spasm may initiate or maintain sensitisation. Myofascial/sensitisation manifestations warrant consideration when managing pain in this population.
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Affiliation(s)
- Vy T Phan
- Rehabilitation Medicine Department, Clinical Center, National Institutes of Health, Bethesda, MD, USA
| | - Pamela Stratton
- Office of the Clinical Director, Intramural Research Program, National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD, USA
| | - Hannah K Tandon
- Rehabilitation Medicine Department, Clinical Center, National Institutes of Health, Bethesda, MD, USA
| | - Ninet Sinaii
- Biostatistics & Clinical Epidemiology Service, Intramural Research Program, Clinical Center, National Institutes of Health, Bethesda, MD, USA
| | | | - Barbara I Karp
- Office of the Clinical Director, Intramural Research Program, National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD, USA
| | - Melissa A Merideth
- Office of the Clinical Director, National Human Genome Research Institute, National Institutes of Health, Bethesda, MD, USA
| | - Jay P Shah
- Rehabilitation Medicine Department, Clinical Center, National Institutes of Health, Bethesda, MD, USA
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10
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Farrell M, Karp BI, Kassavetis P, Berrigan W, Yonter S, Ehrlich D, Alter KE. Management of Anterocapitis and Anterocollis: A Novel Ultrasound Guided Approach Combined with Electromyography for Botulinum Toxin Injection of Longus Colli and Longus Capitis. Toxins (Basel) 2020; 12:toxins12100626. [PMID: 33008043 PMCID: PMC7650774 DOI: 10.3390/toxins12100626] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2020] [Revised: 09/24/2020] [Accepted: 09/27/2020] [Indexed: 11/16/2022] Open
Abstract
Chemodenervation of cervical musculature using botulinum neurotoxin (BoNT) is established as the gold standard or treatment of choice for management of Cervical Dystonia (CD). The success of BoNT procedures is measured by improved symptomology while minimizing side effects and is dependent upon many factors including: clinical pattern recognition, identifying contributory muscles, BoNT dosage, and locating and safely injecting target muscles. In patients with CD, treatment of anterocollis (forward flexion of the neck) and anterocaput (anterocapitis) (forward flexion of the head) are inarguably challenging. The longus Colli (LoCol) and longus capitis (LoCap) muscles, two deep cervical spine and head flexor muscles, frequently contribute to these patterns. Localizing and safely injecting these muscles is particularly challenging owing to their deep location and the complex regional anatomy which includes critical neurovascular and other structures. Ultrasound (US) guidance provides direct visualization of the LoCol, LoCap, other cervical muscles and adjacent structures reducing the risks and side effects while improving the clinical outcome of BoNT for these conditions. The addition of electromyography (EMG) provides confirmation of muscle activity within the target muscle. Within this manuscript, we present a technical description of a novel US guided approach (combined with EMG) for BoNT injection into the LoCol and LoCap muscles for the management of anterocollis and anterocaput in patients with CD.
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Affiliation(s)
- Michael Farrell
- MedStar/Georgetown University National Rehabilitation Hospital, Washington, DC 20010, USA;
| | - Barbara I. Karp
- National Institutes of Neurological Disorders and Stroke, Bethesda, MD 20892 USA; (B.I.K.); (P.K.); (D.E.)
| | - Panagiotis Kassavetis
- National Institutes of Neurological Disorders and Stroke, Bethesda, MD 20892 USA; (B.I.K.); (P.K.); (D.E.)
| | - William Berrigan
- Emory School of Medicine, Emory University, Atlanta, GA 30322, USA;
| | - Simge Yonter
- Rehabilitation Medicine, Clinical Center, National Institutes of Health, Bethesda, MD 20892-1604, USA;
| | - Debra Ehrlich
- National Institutes of Neurological Disorders and Stroke, Bethesda, MD 20892 USA; (B.I.K.); (P.K.); (D.E.)
| | - Katharine E. Alter
- Functional and Applied Biomechanics Section, Rehabilitation Medicine, Clinical Center, National Institutes of Health, Bethesda, MD 20892-1604, USA
- Correspondence:
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11
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Kassavetis P, Lungu C, Ehrlich D, Alter K, Karp BI. Self-reported benefit and weakness after botulinum toxin in dystonia. Parkinsonism Relat Disord 2020; 80:10-11. [PMID: 32927341 DOI: 10.1016/j.parkreldis.2020.08.035] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2020] [Revised: 08/18/2020] [Accepted: 08/28/2020] [Indexed: 11/27/2022]
Abstract
With this retrospective, single center, chart review study, we investigate the self-reported benefit and weakness after botulinum toxin injections in three different types of dystonia: focal hand dystonia (FHD), blepharospasm and cervical dystonia. We found that the benefit lasts significantly longer in FHD compared to the other two groups.
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Affiliation(s)
| | - Codrin Lungu
- NIH/NINDS, Division of Clinical Research, Bethesda, MD, United States
| | - Debra Ehrlich
- NIH/NINDS, Parkinson's Disease Clinic, Office of the Clinical Director, Bethesda, MD, United States
| | - Katharine Alter
- NIH, Rehabilitation Medicine Department, Clinical Center, Bethesda, MD, United States
| | - Barbara I Karp
- NIH/NINDS, Division of Clinical Research, Bethesda, MD, United States
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12
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Iyengar S, Woller SA, Hommer R, Beierlein J, Wright CB, Tamiz AP, Karp BI. Critical NIH Resources to Advance Therapies for Pain: Preclinical Screening Program and Phase II Human Clinical Trial Network. Neurotherapeutics 2020; 17:932-934. [PMID: 32876848 PMCID: PMC7609631 DOI: 10.1007/s13311-020-00918-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
Opioid-related death and overdose have now reached epidemic proportions. In response to this public health crisis, the National Institutes of Health (NIH) launched the Helping to End Addiction Long-term InitiativeSM, or NIH HEAL InitiativeSM, an aggressive, trans-agency effort to speed scientific solutions to stem the national opioid public health crisis. Herein, we describe two NIH HEAL Initiative programs to accelerate development of non-opioid, non-addictive pain treatments: The Preclinical Screening Platform for Pain (PSPP) and Early Phase Pain Investigation Clinical Network (EPPIC-Net). These resources are provided at no cost to investigators, whether in academia or industry and whether within the USA or internationally. Both programs consider small molecules, biologics, devices, and natural products for acute and chronic pain, including repurposed and combination drugs. Importantly, confidentiality and intellectual property are protected. The PSPP provides a rigorous platform to identify and profile non-opioid, non-addictive therapeutics for pain. Accepted assets are evaluated in in vitro functional assays to rule out opioid receptor activity and to assess abuse liability. In vivo pharmacokinetic studies measure plasma and brain exposure to guide the dose range and pretreatment times for the side effect profile, efficacy, and abuse liability. Studies are conducted in accordance with published rigor criteria. EPPIC-Net provides academic and industry investigators with expert infrastructure for phase II testing of pain therapeutics across populations and the lifespan. For assets accepted after a rigorous, objective scientific review process, EPPIC-Net provides clinical trial design, management, implementation, and analysis.
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Affiliation(s)
- Smriti Iyengar
- Division of Translational Research, National Institutes of Health, National Institute of Neurological Disorders and Stroke, 6001 Executive Blvd, Bethesda, MD, 20852-9535, USA.
| | - Sarah A Woller
- Division of Translational Research, National Institutes of Health, National Institute of Neurological Disorders and Stroke, 6001 Executive Blvd, Bethesda, MD, 20852-9535, USA
| | - Rebecca Hommer
- Division of Clinical Research, National Institutes of Health, National Institute of Neurological Disorders and Stroke, 6001 Executive Blvd, Bethesda, MD, 20852-9535, USA
| | - Jennifer Beierlein
- Division of Clinical Research, National Institutes of Health, National Institute of Neurological Disorders and Stroke, 6001 Executive Blvd, Bethesda, MD, 20852-9535, USA
| | - Clinton B Wright
- Division of Clinical Research, National Institutes of Health, National Institute of Neurological Disorders and Stroke, 6001 Executive Blvd, Bethesda, MD, 20852-9535, USA
| | - Amir P Tamiz
- Division of Translational Research, National Institutes of Health, National Institute of Neurological Disorders and Stroke, 6001 Executive Blvd, Bethesda, MD, 20852-9535, USA
| | - Barbara I Karp
- Division of Clinical Research, National Institutes of Health, National Institute of Neurological Disorders and Stroke, 6001 Executive Blvd, Bethesda, MD, 20852-9535, USA
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13
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Stratton P, Tandon HK, Phan V, Sinaii N, Shah J, Bevans M, Karp BI. Pelvic floor muscle spasm, comorbid pain and mental health conditions in women with endometriosis-associated chronic pelvic pain. Fertil Steril 2019. [DOI: 10.1016/j.fertnstert.2019.07.938] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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14
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Tandon HK, Stratton P, Sinaii N, Shah J, Karp BI. Botulinum toxin for chronic pelvic pain in women with endometriosis: a cohort study of a pain-focused treatment. Reg Anesth Pain Med 2019; 44:rapm-2019-100529. [PMID: 31289238 PMCID: PMC6946887 DOI: 10.1136/rapm-2019-100529] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2019] [Revised: 06/14/2019] [Accepted: 06/19/2019] [Indexed: 12/31/2022]
Abstract
BACKGROUND AND OBJECTIVES Many women with endometriosis continue to have pelvic pain despite optimal surgical and hormonal treatment; some also have palpable pelvic floor muscle spasm. We describe changes in pain, spasm, and disability after pelvic muscle onabotulinumtoxinA injection in women with endometriosis-associated pelvic pain, a specific population not addressed in prior pelvic pain studies on botulinum toxin. METHODS We present an open-label proof-of-concept case series of women with surgically diagnosed endometriosis. Under conscious sedation and with topical anesthetic, 100 units of onabotulinumtoxinA was injected transvaginally into pelvic floor muscle spasm areas under electromyography guidance. Changes in pain intensity, muscle spasm, disability, and pain medication use were assessed at periodic visits for up to 1 year after injection. RESULTS Thirteen women underwent botulinum toxin injection and were followed for at least 4 months. Before injection, 11 of the 13 women had spasm in >4/6 assessed pelvic muscles and reported moderate pain (median visual analog scale (VAS): 5/10; range: 2-7). By 4-8 weeks after injection, spasm was absent/less widespread (≤3 muscles) in all (p=0.0005). Eleven rated their postinjection pain as absent/mild (median VAS: 2; range: 0-5; p<0.0001); 7/13 reduced pain medication. Disability decreased in 6/8 women with at least moderate preinjection disability (p=0.0033). Relief lasted 5-11 months in 7 of the 11 patients followed for up to 1 year. Adverse events were mild and transient. CONCLUSIONS These findings suggest pelvic floor spasm may be a major contributor to endometriosis-associated pelvic pain. Botulinum toxin injection may provide meaningful relief of pain and associated disability. TRIAL REGISTRATION NUMBER NCT01553201.
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Affiliation(s)
- Hannah K Tandon
- Intramural Research Program, Rehabilitation Medicine Department, Clinical Center, National Institutes of Health, Bethesda, Maryland, USA
| | - Pamela Stratton
- Office of the Clinical Director, Intramural Research Program, National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, Maryland, USA
| | - Ninet Sinaii
- Biostatistics and Clinical Epidemiology Service, Intramural Research Program, Clinical Center, National Institutes of Health, Bethesda, Maryland, USA
| | - Jay Shah
- Intramural Research Program, Rehabilitation Medicine Department, Clinical Center, National Institutes of Health, Bethesda, Maryland, USA
| | - Barbara I Karp
- Office of the Clinical Director, Intramural Research Program, National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, Maryland, USA
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15
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Mente K, Kim SA, Grunseich C, Hefti MM, Crary JF, Danek A, Karp BI, Walker RH. Hippocampal sclerosis and mesial temporal lobe epilepsy in chorea-acanthocytosis: a case with clinical, pathologic and genetic evaluation. Neuropathol Appl Neurobiol 2019; 43:542-546. [PMID: 28398599 DOI: 10.1111/nan.12403] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Affiliation(s)
- K Mente
- Human Motor Control Section, National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD, USA
| | - S A Kim
- Laboratory of Pathology, National Cancer Institute, National Institutes of Health, Bethesda, MD, USA
| | - C Grunseich
- Neurogenetics Branch, National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD, USA
| | - M M Hefti
- Departments of Pathology and Neuroscience, Ronald M. Loeb Center for Alzheimer's Disease, Friedman Brain Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - J F Crary
- Departments of Pathology and Neuroscience, Ronald M. Loeb Center for Alzheimer's Disease, Friedman Brain Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - A Danek
- Department of Neurology, Ludwig-Maximilians-Universität München, Munich, Germany
| | - B I Karp
- Human Motor Control Section, National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD, USA
| | - R H Walker
- Department of Neurology, James J. Peters Veterans Affairs Medical Center, Bronx, NY, USA.,Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
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Alter KE, Karp BI. Ultrasound Guidance for Botulinum Neurotoxin Chemodenervation Procedures. Toxins (Basel) 2017; 10:toxins10010018. [PMID: 29283397 PMCID: PMC5793105 DOI: 10.3390/toxins10010018] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2017] [Revised: 12/12/2017] [Accepted: 12/21/2017] [Indexed: 12/28/2022] Open
Abstract
Injections of botulinum neurotoxins (BoNTs) are prescribed by clinicians for a variety of disorders that cause over-activity of muscles; glands; pain and other structures. Accurately targeting the structure for injection is one of the principle goals when performing BoNTs procedures. Traditionally; injections have been guided by anatomic landmarks; palpation; range of motion; electromyography or electrical stimulation. Ultrasound (US) based imaging based guidance overcomes some of the limitations of traditional techniques. US and/or US combined with traditional guidance techniques is utilized and or recommended by many expert clinicians; authors and in practice guidelines by professional academies. This article reviews the advantages and disadvantages of available guidance techniques including US as well as technical aspects of US guidance and a focused literature review related to US guidance for chemodenervation procedures including BoNTs injection.
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Affiliation(s)
- Katharine E Alter
- Functional and Applied Biomechanics Section, Rehabilitation Medicine, Clinical Center, National Institutes of Health, Bethesda, MD 20892-1604, USA.
| | - Barbara I Karp
- Combined Neurosciences IRB, National Institutes of Health, Bethesda, MD 20892-1604, USA.
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17
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Aredo JV, Heyrana KJ, Karp BI, Shah JP, Stratton P. Relating Chronic Pelvic Pain and Endometriosis to Signs of Sensitization and Myofascial Pain and Dysfunction. Semin Reprod Med 2017; 35:88-97. [PMID: 28049214 DOI: 10.1055/s-0036-1597123] [Citation(s) in RCA: 108] [Impact Index Per Article: 15.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Chronic pelvic pain is a frustrating symptom for patients with endometriosis and is frequently refractory to hormonal and surgical management. While these therapies target ectopic endometrial lesions, they do not directly address pain due to central sensitization of the nervous system and myofascial dysfunction, which can continue to generate pain from myofascial trigger points even after traditional treatments are optimized. This article provides a background for understanding how endometriosis facilitates remodeling of neural networks, contributing to sensitization and generation of myofascial trigger points. A framework for evaluating such sensitization and myofascial trigger points in a clinical setting is presented. Treatments that specifically address myofascial pain secondary to spontaneously painful myofascial trigger points and their putative mechanisms of action are also reviewed, including physical therapy, dry needling, anesthetic injections, and botulinum toxin injections.
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Affiliation(s)
- Jacqueline V Aredo
- National Institute of Neurological Disorders and Stroke, Clinical Center, Intramural Research Program NIH, Bethesda, Maryland
| | - Katrina J Heyrana
- Department of Obstetrics and Gynecology, University of Rochester Medical Center, Rochester, New York
| | - Barbara I Karp
- National Institute of Neurological Disorders and Stroke, Clinical Center, Intramural Research Program NIH, Bethesda, Maryland
| | - Jay P Shah
- Rehabilitation Medicine Department, Clinical Center, Intramural Research Program NIH, Bethesda, Maryland
| | - Pamela Stratton
- National Institute of Neurological Disorders and Stroke, Clinical Center, Intramural Research Program NIH, Bethesda, Maryland
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18
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Llaneza Ramos VFM, Considine E, Karp BI, Lungu C, Alter K, Hallett M. Ultrasound as Diagnostic Tool for Diaphragmatic Myoclonus. Mov Disord Clin Pract 2016; 3:282-284. [PMID: 27430001 DOI: 10.1002/mdc3.12295] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Diaphragmatic myoclonus is a rare disorder of repetitive diaphragmatic contractions, acknowledged to be a spectrum that includes psychogenic features. Electromyography has been the diagnostic tool most commonly used in the literature. METHODS To test if we could perform a noninvasive technique to delineate the diaphragm as the source of abnormal movements and demonstrate distractibility and entrainability, we used B-mode ultrasound in a patient with diaphragmatic myoclonus. RESULTS Ultrasound imaging clearly delineated the diaphragm as the source of her abdominal movements. We were able to demonstrate entrainability of the diaphragm to hand tapping to a prescribed rhythm set by examiner. CONCLUSION We recommend the use of ultrasound as a noninvasive, convenient diagnostic tool for further studies of diaphragmatic myoclonus. We agree with previous findings that diaphragmatic myoclonus may be a functional movement disorder, as evidenced by distractibility and entrainability demonstrated on real-time video with ultrasonography.
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Affiliation(s)
| | - Elaine Considine
- Human Motor Control Section, National Institutes of Health, Bethesda, MD
| | | | - Codrin Lungu
- Office of the Clinical Director, National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD
| | - Katharine Alter
- Functional and Applied Biomechanics Section, Rehabilitation Medicine Department, National Institutes of Health, Bethesda, MD and Mount Washington Pediatric Hospital, Washington, DC
| | - Mark Hallett
- Human Motor Control Section, National Institutes of Health, Bethesda, MD
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19
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Karp BI, Fe Marie Llaneza Ramos V, Lungu C, Alter K. 119. Dosing and response to botulinum neurotoxin after deep brain stimulation in generalized dystonia. Toxicon 2015. [DOI: 10.1016/j.toxicon.2014.11.122] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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20
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Ramos VFML, Karp BI, Lungu C, Alter K, Hallett M. Clinical Response to IncobotulinumtoxinA, after Demonstrated Loss of Clinical Response to OnabotulinumtoxinA and RimabotulininumtoxinB in a Patient with Musician's Dystonia. Mov Disord Clin Pract 2014; 1:383-385. [PMID: 27066521 DOI: 10.1002/mdc3.12094] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
Botulinum toxin is a mainstay therapy for dystonia. Formulations available are three types of botulinumtoxinA and one type of botulinumtoxinB.1 Antibodies can develop against the toxin, leading to treatment failure. IncobotulinumtoxinA (Xeomin; Merz Pharmaceuticals GmbH, Frankfurt, Germany) is differentiated from other types of botulinumtoxinA preparations by being free from complexing proteins, speculated to make the product less antigenic.2.
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Affiliation(s)
| | - Barbara I Karp
- CNS, IRB, National Institutes of Health, Bethesda, Maryland, USA
| | - Codrin Lungu
- National Institutes of Health, Bethesda, Maryland, USA
| | - Katharine Alter
- Functional and Applied Biomechanics Section, Rehabilitaion Medicine Department, National Institutes of Health, Bethesda, Maryland, USA; Mount Washington Pediatric Hospital, Washington, District of Columbia, USA
| | - Mark Hallett
- Human Motor Control Section, National Institutes of Health, Bethesda, Maryland, USA
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Abstract
Sensory tricks are various manoeuvres that can ameliorate dystonia. Common characteristics are well known, but their variety is wide, sensory stimulation is not necessarily the critical feature, and their physiology is unknown. To enumerate the various forms of sensory tricks and describe their nature, research findings and theories that may elucidate their neurophysiologic mechanism, we reviewed the literature pertaining to sensory tricks, including variants like motor tricks, imaginary tricks, forcible tricks and reverse sensory tricks. On the basis of this information, we propose a new classification of sensory tricks to include its variants. We highlight neurophysiologic evidence suggesting that sensory tricks work by decreasing abnormal facilitation. We tie this with established dystonia pathogenesis and postulate that sensory tricks decrease abnormally increased facilitation to inhibition ratios in the dystonic brain. It appears worthwhile for patients to search for possible sensory tricks.
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Affiliation(s)
| | | | - Mark Hallett
- Human Motor Control, National Institutes of Health, Bethesda, Maryland, USA
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Lungu C, Karp BI, Alter K, Zolbrod R, Hallett M. Long-term follow-up of botulinum toxin therapy for focal hand dystonia: outcome at 10 years or more. Mov Disord 2011; 26:750-3. [PMID: 21506157 DOI: 10.1002/mds.23504] [Citation(s) in RCA: 63] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2010] [Revised: 07/23/2010] [Accepted: 10/03/2010] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND Previous studies have explored the efficacy and safety of botulinum neurotoxin (BoNT) treatment for Focal hand dystonia (FHD), but none have followed a large number of patients for 10 years or more. METHODS Retrospective study, with benefit and weakness assessed on a 0 to 4 subjective scale. Demographic, clinical and treatment characteristics were analyzed using t tests and Pearson correlations. RESULTS Twenty FHD patients had 10 years or longer treatment. Interinjection intervals were variable. Musicians were more likely to wait longer between injections and had less complex dystonia. There was a trend for larger benefit in women and with shorter intervals. The dose increased over time. Dystonia characteristics did not predict response or side-effects, but benefit magnitude predicted longer compliance. No serious side-effects or antibody-mediated resistance occurred. CONCLUSION This is the longest reported period of BoNT treatment in the largest FHD cohort. BoNT therapy for FHD remains safe and effective after more than a decade of treatment.
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Affiliation(s)
- Codrin Lungu
- Medical Neurology Branch, National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, Maryland, USA
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23
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Goldstein DS, Sharabi Y, Karp BI, Bentho O, Saleem A, Pacak K, Eisenhofer G. Cardiac sympathetic denervation preceding motor signs in Parkinson disease. Cleve Clin J Med 2009; 76 Suppl 2:S47-50. [PMID: 19376983 DOI: 10.3949/ccjm.76.s2.10] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
There is substantial interest in identifying biomarkers to detect early Parkinson disease (PD). Cardiac noradrenergic denervation and attenuated baroreflex-cardiovagal function occur in de novo PD, but whether these abnormalities can precede PD has been unknown. Here we report the case of a patient who had profoundly decreased left ventricular myocardial 6-[(18)F]fluorodopamine-derived radioactivity and low baroreflex-cardiovagal gain, 4 years before the onset of symptoms and signs of PD. The results lead us to hypothesize that cardiac noradrenergic denervation and decreased baroreflex-cardiovagal function may occur early in the pathogenesis of PD.
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Affiliation(s)
- David S Goldstein
- Clinical Neurocardiology Section, NINDS, NIH, 10 Center Drive MSC-1620, Building 10, Room 6N252, Bethesda, MD 20892-1620, USA.
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24
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Goldstein DS, Sharabi Y, Karp BI, Bentho O, Saleem A, Pacak K, Eisenhofer G. Cardiac sympathetic denervation preceding motor signs in Parkinson disease. Clin Auton Res 2007; 17:118-21. [PMID: 17334896 PMCID: PMC4615690 DOI: 10.1007/s10286-007-0396-1] [Citation(s) in RCA: 74] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2006] [Accepted: 01/18/2007] [Indexed: 10/23/2022]
Abstract
There is substantial interest in identifying biomarkers to detect early Parkinson disease (PD). Cardiac noradrenergic denervation and attenuated baroreflex-cardiovagal function occur in de novo PD, but whether these abnormalities can precede PD has been unknown. Here we report the case of a patient who had profoundly decreased left ventricular myocardial 6-[(18)F]fluorodopamine-derived radioactivity and low baroreflex-cardiovagal gain, 4 years before the onset of symptoms and signs of PD. The results lead us to hypothesize that cardiac noradrenergic denervation and decreased baroreflex-cardiovagal function may occur early in the pathogenesis of PD.
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Affiliation(s)
- David S Goldstein
- Clinical Neurocardiology Section, NINDS, NIH, Bethesda, MD 20892-1620, USA.
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25
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Goldbach-Mansky R, Dailey NJ, Canna SW, Gelabert A, Jones J, Rubin BI, Kim HJ, Brewer C, Zalewski C, Wiggs E, Hill S, Turner ML, Karp BI, Aksentijevich I, Pucino F, Penzak SR, Haverkamp MH, Stein L, Adams BS, Moore TL, Fuhlbrigge RC, Shaham B, Jarvis JN, O'Neil K, Vehe RK, Beitz LO, Gardner G, Hannan WP, Warren RW, Horn W, Cole JL, Paul SM, Hawkins PN, Pham TH, Snyder C, Wesley RA, Hoffmann SC, Holland SM, Butman JA, Kastner DL. Neonatal-onset multisystem inflammatory disease responsive to interleukin-1beta inhibition. N Engl J Med 2006; 355:581-92. [PMID: 16899778 PMCID: PMC4178954 DOI: 10.1056/nejmoa055137] [Citation(s) in RCA: 636] [Impact Index Per Article: 35.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Neonatal-onset multisystem inflammatory disease is characterized by fever, urticarial rash, aseptic meningitis, deforming arthropathy, hearing loss, and mental retardation. Many patients have mutations in the cold-induced autoinflammatory syndrome 1 (CIAS1) gene, encoding cryopyrin, a protein that regulates inflammation. METHODS We selected 18 patients with neonatal-onset multisystem inflammatory disease (12 with identifiable CIAS1 mutations) to receive anakinra, an interleukin-1-receptor antagonist (1 to 2 mg per kilogram of body weight per day subcutaneously). In 11 patients, anakinra was withdrawn at three months until a flare occurred. The primary end points included changes in scores in a daily diary of symptoms, serum levels of amyloid A and C-reactive protein, and the erythrocyte sedimentation rate from baseline to month 3 and from month 3 until a disease flare. RESULTS All 18 patients had a rapid response to anakinra, with disappearance of rash. Diary scores improved (P<0.001) and serum amyloid A (from a median of 174 mg to 8 mg per liter), C-reactive protein (from a median of 5.29 mg to 0.34 mg per deciliter), and the erythrocyte sedimentation rate decreased at month 3 (all P<0.001), and remained low at month 6. Magnetic resonance imaging showed improvement in cochlear and leptomeningeal lesions as compared with baseline. Withdrawal of anakinra uniformly resulted in relapse within days; retreatment led to rapid improvement. There were no drug-related serious adverse events. CONCLUSIONS Daily injections of anakinra markedly improved clinical and laboratory manifestations in patients with neonatal-onset multisystem inflammatory disease, with or without CIAS1 mutations. (ClinicalTrials.gov number, NCT00069329 [ClinicalTrials.gov].).
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Affiliation(s)
- Raphaela Goldbach-Mansky
- National Institute of Arthritis and Musculoskeletal and Skin Diseases, National Institutes of Health, Bethesda, Md 20892, USA.
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26
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Abstract
A patient developed restless legs symptoms paralleling the course of interferon-alpha (IFN alpha) therapy for chronic hepatitis C. Symptoms began during a course of IFN alpha, resolved with its suspension, and recurred on rechallenge. Restless legs syndrome may thus be an adverse effect of IFN alpha treatment.
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27
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Dobson-Stone C, Danek A, Rampoldi L, Hardie RJ, Chalmers RM, Wood NW, Bohlega S, Dotti MT, Federico A, Shizuka M, Tanaka M, Watanabe M, Ikeda Y, Brin M, Goldfarb LG, Karp BI, Mohiddin S, Fananapazir L, Storch A, Fryer AE, Maddison P, Sibon I, Trevisol-Bittencourt PC, Singer C, Caballero IR, Aasly JO, Schmierer K, Dengler R, Hiersemenzel LP, Zeviani M, Meiner V, Lossos A, Johnson S, Mercado FC, Sorrentino G, Dupré N, Rouleau GA, Volkmann J, Arpa J, Lees A, Geraud G, Chouinard S, Németh A, Monaco AP. Mutational spectrum of the CHAC gene in patients with chorea-acanthocytosis. Eur J Hum Genet 2002; 10:773-81. [PMID: 12404112 DOI: 10.1038/sj.ejhg.5200866] [Citation(s) in RCA: 94] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2002] [Revised: 06/28/2002] [Accepted: 07/01/2002] [Indexed: 11/09/2022] Open
Abstract
Chorea-acanthocytosis (ChAc) is an autosomal recessive neurological disorder whose characteristic features include hyperkinetic movements and abnormal red blood cell morphology. Mutations in the CHAC gene on 9q21 were recently found to cause chorea-acanthocytosis. CHAC encodes a large, novel protein with a yeast homologue implicated in protein sorting. In this study, all 73 exons plus flanking intronic sequence in CHAC were screened for mutations by denaturing high-performance liquid chromatography in 43 probands with ChAc. We identified 57 different mutations, 54 of which have not previously been reported, in 39 probands. The novel mutations comprise 15 nonsense, 22 insertion/deletion, 15 splice-site and two missense mutations and are distributed throughout the CHAC gene. Three mutations were found in multiple families within this or our previous study. The preponderance of mutations that are predicted to cause absence of gene product is consistent with the recessive inheritance of this disease. The high proportion of splice-site mutations found is probably a reflection of the large number of exons that comprise the CHAC gene. The CHAC protein product, chorein, appears to have a certain tolerance to amino-acid substitutions since only two out of nine substitutions described here appear to be pathogenic.
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Affiliation(s)
- C Dobson-Stone
- The Wellcome Trust Centre For Human Genetics, University of Oxford, UK
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28
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Abstract
Although botulinum toxin is an effective treatment for focal dystonia, the importance of electromyography (EMG) in identifying muscles and guiding injections is unclear. The authors examined the accuracy of muscle localization in 38 muscles in patients with focal hand dystonia without EMG guidance. Only 37% of needle placement attempts reached the target muscles or muscle fascicles. This study demonstrates that EMG guidance is needed for correct localization of desired muscles.
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Affiliation(s)
- F M Molloy
- Human Motor Control Section, National Institute of Neurological Disorders and Stroke, NIH, Bethesda, MD 20892-1428, USA
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Abstract
OBJECTIVE This study evaluated neurologic functioning in adolescents with schizophrenia with onset of psychosis before age 13. METHOD The authors administered a structured neurologic examination to 21 adolescents with early-onset schizophrenia and 27 healthy age- and sex-matched comparison subjects. RESULTS The adolescents with schizophrenia had a high frequency of neurologic abnormalities. Neurologic signs decreased with age in the healthy comparison subjects but not in the subjects with schizophrenia. CONCLUSIONS The adolescents with schizophrenia had a high burden of neurologic impairment and a pattern of abnormalities similar to that of adults with schizophrenia. The persistence of neurologic signs in the adolescents with schizophrenia, which faded with age in the healthy comparison adolescents, supports earlier evidence of a delay in or failure of normal brain development during adolescence.
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Affiliation(s)
- B I Karp
- Child Psychiatry Branch, NIMH, Bethesda, MD 20892, USA.
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30
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Abstract
Pharmacologic treatment of severe dystonia is often unsatisfactory. The atypical antipsychotic medication clozapine appears to improve tardive dystonia associated with conventional neuroleptic use. We studied the efficacy of clozapine for severe dystonia in five patients in an open trial. The patient cohort included four with generalized dystonia and one with Meige syndrome. All patients were evaluated at baseline and at least weekly while on medication with subjective assessment of response by the patient and physician rating using the Burke-Fahn-Marsden Evaluation Scale for Dystonia. All five subjects had significant improvement detected by the Burke-Fahn-Marsden Evaluation Scale as well as subjective improvement while on clozapine. Side effects, such as sedation and orthostatic hypotension, developed in all patients but was only treatment-limiting in one subject who developed persistent symptomatic orthostatic hypotension and tachycardia. Two of the four remaining patients continued clozapine after completion of the study; an additional patient was uncertain if the benefit outweighed the side effects. One patient discontinued treatment because of difficulty obtaining the FDA-required weekly white blood cell counts for patients on clozapine. We conclude that clozapine appears to be effective for generalized and refractory focal dystonia although its use may be limited by the side effects and need for hematologic monitoring.
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Affiliation(s)
- B I Karp
- Human Motor Control Section, Medical Neurology Branch, National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, Maryland 20892, USA
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31
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Abstract
Animal and human studies have shown that nerve stimulation enhances some effects of botulinum toxin (btx A) injection. Voluntary muscle activity might work similarly and would focus the effect of an injection into the active muscles. We studied the effects of exercise immediately after btx A injection in eight patients with writer's cramp with established response to btx A over two injection cycles with a single-blinded, randomized, crossover design. Immediately after the first study injection, they were randomly assigned to write continuously for 30 min or have their hand and forearm immobilized for 30 min. Following the second injection, they were assigned the alternate condition. Patients were assessed just before each injection, and at 2 weeks, 6 weeks, and 3 months post-injection. Assessment included objective strength testing, self-reported rating of benefit and weakness, and blinded evaluation of videotapes and writing samples of the patients writing a standard passage. Strength testing showed that the maximum weakness occurred at 2 weeks post-injection, but the benefit was maximum at 6 weeks post-injection. The "write" condition resulted in greater reduction in strength than the "rest" condition. Btx A treatment led to improvement in self-reported ratings, writer's cramp rating scale scores by blinded raters, and reduction in writing time, but the differences between the "write" and "rest" conditions were not significant. We conclude that voluntary muscle activity immediately after btx A injection leads to greater reduction in muscle strength. Our findings raise the possibility that voluntary muscle activation may allow reduction of btx A doses and favorably alter the balance of benefit and side effects of btx A injections.
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Affiliation(s)
- R Chen
- Human Motor Control Section, National Institute of Neurological Disorders and Stroke, Bethesda, Maryland 20892-1428, USA
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32
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Lenz FA, Suarez JI, Metman LV, Reich SG, Karp BI, Hallett M, Rowland LH, Dougherty PM. Pallidal activity during dystonia: somatosensory reorganisation and changes with severity. J Neurol Neurosurg Psychiatry 1998; 65:767-70. [PMID: 9810954 PMCID: PMC2170350 DOI: 10.1136/jnnp.65.5.767] [Citation(s) in RCA: 137] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
A woman with progressive, medically intractable right upper limb dystonia underwent a pallidotomy with only transient improvement. During the procedure her dystonia became more severe as she repeatedly made a fist to command in order to provoke dystonia transiently (movement provoked dystonia). Comparisons within cells in the internal segment of the globus pallidus (Gpi) disclosed that the firing rate was the same at rest, with making a fist, and during movement provoked dystonia. However, the firing rate compared between cells decreased significantly throughout the procedure as the patient made a fist repeatedly. During the second half of the procedure the firing rate of cells in the Gpi was similar to that in hemiballismus. The proportion of cells in the GPi which responded to sensory stimulation was significantly higher in dystonia (53%) than in hemiballismus (13%). These results suggest that pallidal activity can correlate inversely with the severity of dystonia, perhaps due to activity dependent changes in neuronal function resulting from repeated voluntary movement.
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Affiliation(s)
- F A Lenz
- Department of Neurosurgery, Johns Hopkins University, Baltimore, MD, USA
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33
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Abstract
The authors analyzed retrospectively the results of open-labeled botulinum toxin type F (BTXF) treatment for 1 year or longer in 18 BTXA-resistant patients. All patients except one primary nonresponder to BTXA improved initially with BTXF. Most patients continued to respond to BTXF for 1 year or longer, but four patients became resistant to BTXF. BTXF-resistant patients received a higher dose per treatment and a higher cumulative dose than BTXF-responsive patients. BTXF can be used for long-term treatment of dystonia. It seems prudent to limit BTX doses of all serotypes to the lowest necessary for clinical efficacy.
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Affiliation(s)
- R Chen
- Human Motor Control Section, National Institute of Neurological Disorders and Stroke, Bethesda, MD 20892-1428, USA
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34
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Kumra S, Jacobsen LK, Lenane M, Karp BI, Frazier JA, Smith AK, Bedwell J, Lee P, Malanga CJ, Hamburger S, Rapoport JL. Childhood-onset schizophrenia: an open-label study of olanzapine in adolescents. J Am Acad Child Adolesc Psychiatry 1998; 37:377-85. [PMID: 9549958 DOI: 10.1097/00004583-199804000-00015] [Citation(s) in RCA: 98] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVE Olanzapine, a potent 5-HT2a/2c, dopamine D1D2D4 antagonist with anticholinergic activity, has a profile of known receptor affinity similar to that of clozapine. This pilot study examined the efficacy of olanzapine for treatment-refractory childhood-onset schizophrenia in eight patients who had received 8-week open-label trials. For comparison, data are included from 15 patients who had received 6-week open-label clozapine trials using identical rating instruments (largely by the same raters) in the same treatment setting. METHOD Twenty-three children and adolescents with an onset of DSM-III-R schizophrenia by age 12 for whom at least two different typical neuroleptics had been ineffective participated in the two separate studies. Some of the patients were intolerant of clozapine, although it had been effective (n = 4). Patients receiving olanzapine were evaluated over 8 weeks with the Brief Psychiatric Rating Scale (BPRS), the Scale for the Assessment of Positive Symptoms, the Scale for the Assessment of Negative Symptoms, and the Clinical Global Impressions Scale for Improvement. RESULTS For the eight patients who received olanzapine trials, at week 8 there was a 17% improvement in the BPRS total score, a 27% improvement in the Scale for the Assessment of Negative Symptoms, and a 1% improvement in the Scale for the Assessment of Positive Symptoms, relative to "ideal" admission status on typical neuroleptics. In contrast, the magnitude of the effect sizes for each of the clinical ratings was larger at week 6 of the previous clozapine trial than for an 8-week olanzapine trial, relative to admission status on typical neuroleptics. For the four children who had received both clozapine and olanzapine, BPRS total scores were significantly lower at week 6 of clozapine treatment compared with week 6 of olanzapine treatment (p = .03). CONCLUSION These data provide preliminary evidence for the efficacy of olanzapine for some children and adolescents with treatment-refractory schizophrenia, but they also suggest the need for a more rigorous double-blind comparison of these two atypical antipsychotics.
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Affiliation(s)
- S Kumra
- Child Psychiatry Branch, National Institute of Mental Health, Bethesda, MD, USA
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35
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Kumra S, Jacobsen LK, Lenane M, Smith A, Lee P, Malanga CJ, Karp BI, Hamburger S, Rapoport JL. Case series: spectrum of neuroleptic-induced movement disorders and extrapyramidal side effects in childhood-onset schizophrenia. J Am Acad Child Adolesc Psychiatry 1998; 37:221-7. [PMID: 9473920 DOI: 10.1097/00004583-199802000-00016] [Citation(s) in RCA: 37] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OBJECTIVE Neuroleptic-treated pediatric patients with childhood-onset schizophrenia (COS) are at risk for developing extrapyramidal side effects and involuntary movement disorders. A preliminary examination of the incidence of withdrawal dyskinesias (WD), tardive dyskinesia (TD), and extrapyramidal side effects in these patients is presented. METHOD Thirty-four COS patients (mean age +/- SD, 14.2 +/- 2.1 years) were examined for TD using the Abnormal Involuntary Movements Scale and for extrapyramidal side effects using the Simpson-Angus Neurologic Rating Scale, after a 14- to 28-day drug-free period (n = 33), at week 6 of treatment and 2 to 4 years after completion of the study (n = 14). The mean (+/-SD) number of months of prior neuroleptic exposure for the group was 22.4 (15.0) months. RESULTS Seventeen (50%) of 34 patients were noted to have either WD or TD at some point during their participation in the studies. The majority of patients experienced WD that were mainly in the orofacial region, transient in nature, and diminished with haloperidol and clozapine. Patients with TD/WD had greater levels of premorbid impairment (p = .02), increased severity of positive symptoms of schizophrenia (p < .01), and a trend toward more months of neuroleptic exposure (p = .10, one-tailed). CONCLUSIONS A high proportion of COS patients were found to have TD/WD. The majority of these abnormal movements were not severe and generally improved over time. TD/WD in COS appears to be associated with greater premorbid impairment, severity of illness, and duration of neuroleptic exposure. J. Am. Acad.
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Affiliation(s)
- S Kumra
- Child Psychiatry Branch, National Institute of Mental Health, Bethesda, MD 20892-1600, USA
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36
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Abstract
Myelinolysis is a neurologic disorder that can occur after rapid correction of hyponatremia. Initially named "central pontine myelinolysis," this disease is now known to also affect extrapontine brain areas. Manifestations of myelinolysis usually evolve several days after correction of hyponatremia. Typical features are disorders of upper motor neurons, spastic quadriparesis and pseudobulbar palsy, and mental disorders ranging from mild confusion to coma. Death may occur. The motor and localizing signs of myelinolysis differ from the generalized encephalopathy that is caused by untreated hyponatremia. Experiments have duplicated the clinical and pathologic features of myelinolysis by rapidly reversing hyponatremia in animals. Myelinolysis is more likely to occur after the treatment of chronic rather than acute hyponatremia and is more likely to occur with a rapid rate of correction. The exact pathogenesis of myelinolysis has not been determined. Optimal management of hyponatremic patients involves weighing the risk for illness and death from untreated hyponatremia against the risk for myelinolysis due to correction of hyponatremia. Experiments in animals and clinical experience suggest that correction of chronic hyponatremia should be kept at a rate less than 10 mmol/L in any 24-hour period.
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Affiliation(s)
- R Laureno
- Washington Hospital Center, Washington, D.C., USA
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37
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Jacobsen LK, Hong WL, Hommer DW, Hamburger SD, Castellanos FX, Frazier JA, Giedd JN, Gordon CT, Karp BI, McKenna K, Rapoport JL. Smooth pursuit eye movements in childhood-onset schizophrenia: comparison with attention-deficit hyperactivity disorder and normal controls. Biol Psychiatry 1996; 40:1144-54. [PMID: 8931918 DOI: 10.1016/s0006-3223(95)00630-3] [Citation(s) in RCA: 54] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Abnormalities of the smooth pursuit eye movements of adults with schizophrenia have been well described. We examined smooth pursuit eye movements in schizophrenic children, contrasting them with normal and attention-deficit hyperactivity disorder (ADHD) subjects, to determine whether there is continuity of eye movement dysfunction between childhood- and adult-onset forms of schizophrenia. Seventeen schizophrenic children with onset of illness by age 12, 18 ADHD children, and 22 normal children were studied while engaged in a smooth pursuit eye tracking task. Eye tracking variables were compared across the three groups. Schizophrenic children exhibited significantly greater smooth pursuit impairments than either normal or ADHD subjects. Within the schizophrenic group, there were no significant relationships between eye tracking variables and clinical variables, or ventricular/brain ratio. Childhood-onset schizophrenia is associated with a similar pattern of smooth pursuit abnormalities to that seen in later-onset schizophrenia.
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Affiliation(s)
- L K Jacobsen
- Child Psychiatry Branch, National Institute of Mental Health, Bethesda, Maryland 20892, USA
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38
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Abstract
We reviewed the records and radiologic studies of eight patients who developed new focal neurologic abnormalities while receiving interleukin-2 (IL2)-based immunotherapy for malignancy or HIV infection. Initial confusion and delirium in the patients evolved into coma, ataxia, hemiparesis, seizures, and cortical syndromes including aphasia, apraxia, and cortical blindness. Imaging studies showed multiple white and gray matter lesions with a predilection for the occipital poles, centrum semiovale, and cerebellum. After cessation of IL2 treatment, seven patients improved to normal or near-normal neurologic function paralleled by resolution of the lesions on scans. One patient improved only minimally. Possible etiologies for the lesions include an IL2-induced cerebral vasculopathy, a direct toxic effect of IL2, or immunologically mediated damage.
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Affiliation(s)
- B I Karp
- National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD 20892, USA
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39
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Abstract
Obeso et al reported that simple motor tics in Tourette's syndrome were not associated with premotor potentials, which were present when patients mimicked their tics voluntarily, suggesting that spontaneous tics were not generated in the same manner as voluntary movements. Five patients with simple motor tics were studied using a similar paradigm. Premotor potentials were examined during spontaneous tics and during voluntary imitation of the tics. All patients had premotor negativity with the voluntary movements. As in the study of Obeso et al, spontaneous tics were not preceded by premotor potentials in three patients. However, premotor negativity was present with spontaneous tics in two patients and resembled the NS' segment of the premotor potential seen with self paced, voluntary movements. A similar premotor potential pattern has been reported with voluntary movements performed in response to external triggering stimuli. In patients with Tourette's syndrome, the eliciting signals could be internal sensations.
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Affiliation(s)
- B I Karp
- Medical Neurology Branch, National Institute of Neurological Disorders and Stroke National Institutes of Health, Bethesda, MD 20892, USA
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40
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Abstract
Some tics are intentional movements made in an attempt to diminish uncomfortable sensations. These sensations, sometimes termed sensory tics, are focal and usually arise in the part of the body involved in the subsequent motor act. We report a patient whose sensations associated with tics were felt in other people and in objects. The discomfort associated with his out-of-body sensations was temporarily relieved by touching or scratching the object involved. The definition of premonitory sensations should be expanded to include extracorporeal sensations, and a history of external sensations should be sought in patients with Tourette's syndrome. Theories on the generation of tics must incorporate an explanation for extracorporeal sensations.
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Affiliation(s)
- B I Karp
- National Institute of Neurological Disorders and Stroke, NIH, Bethesda, MD 20892, USA
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Vieweg WV, Karp BI. Severe hyponatremia in the polydipsia-hyponatremia syndrome. J Clin Psychiatry 1994; 55:355-61. [PMID: 8071305] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Affiliation(s)
- W V Vieweg
- Department of Psychiatry, Medical College of Virginia, Virginia Commonwealth University, Richmond
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Abstract
We treated focal hand dystonia in 53 patients with botulinum toxin injections for up to 6 years. Eighty-one percent of the patients improved with at least one injection session. Sixty-five percent of the injections produced transient weakness. We followed 37 of the patients for at least 2 years from the start of treatment, 24 of whom discontinued treatment because of inadequate response, loss of response, inaccessibility of a treatment provider, or the expense of the toxin. Women, who had a greater extent and longer duration of benefit than men, were more likely to continue treatment. The mean interval between injection sessions was 6 months. In most patients, we injected the toxin into the same combination of muscles at each session. The dose of toxin generally fluctuated within a range of 20 units. Side effects were mild and transient and unrelated to the long-term use of botulinum toxin. Botulinum toxin injection is safe and effective for the long-term management of focal hand dystonia.
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Affiliation(s)
- B I Karp
- Human Motor Control Section, NINDS, NIH, Bethesda, MD 20892
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Karp BI, Laureno R. Pontine and extrapontine myelinolysis: a neurologic disorder following rapid correction of hyponatremia. Medicine (Baltimore) 1993; 72:359-73. [PMID: 8231786] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/29/2023] Open
Abstract
Neurologic disorders developing after correction of severe, symptomatic hyponatremia were studied in 14 patients. None had a hypoxic event or other identifiable cause for the neurologic illness. Neurologic deterioration began about 3 days after correction and often followed a period of improvement in hyponatremic encephalopathy. Although the symptoms were as mild as transient confusion in 1 patient, they were more severe in the others. Typically, spastic quadriparesis, pseudobulbar palsy, and impairment in the level of consciousness progressed for up to 7 days. Improvement generally began 2 weeks after correction and continued for up to a year in some patients. Routine spinal fluid analysis was usually normal, but myelin basic protein concentration was elevated in all patients in whom it was measured. Electroencephalograms commonly showed nonfocal slowing. Brainstem auditory evoked potential latencies were prolonged in some patients. Brain imaging was normal in the initial week of illness, while later scans, obtained in 9 patients, showed central pontine and/or symmetric extrapontine lesions. The clinical manifestations and distribution of lesions seen on imaging demonstrate that neurologic illness following correction of hyponatremia is due to myelinolysis. Although this neurologic disorder typically followed an elevation in serum sodium > 18 mEq/L/24 hr, it sometimes followed a rise as slow as 10 mEq/L/24 hr and 21 mEq/L/48 hr. Whenever possible, the rate of correction of hyponatremia should be kept below these values in order to minimize the risk of myelinolysis.
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Affiliation(s)
- B I Karp
- National Institute of Neurologic Disorders and Stroke, National Institutes of Health, Bethesda, MD 20892
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Abstract
Neurologic disorders developing after correction of severe, symptomatic hyponatremia were studied in 14 patients. None had a hypoxic event or other identifiable cause for the neurologic illness. Neurologic deterioration began about 3 days after correction and often followed a period of improvement in hyponatremic encephalopathy. Although the symptoms were as mild as transient confusion in 1 patient, they were more severe in the others. Typically, spastic quadriparesis, pseudobulbar palsy, and impairment in the level of consciousness progressed for up to 7 days. Improvement generally began 2 weeks after correction and continued for up to a year in some patients. Routine spinal fluid analysis was usually normal, but myelin basic protein concentration was elevated in all patients in whom it was measured. Electroencephalograms commonly showed nonfocal slowing. Brainstem auditory evoked potential latencies were prolonged in some patients. Brain imaging was normal in the initial week of illness, while later scans, obtained in 9 patients, showed central pontine and/or symmetric extrapontine lesions. The clinical manifestations and distribution of lesions seen on imaging demonstrate that neurologic illness following correction of hyponatremia is due to myelinolysis. Although this neurologic disorder typically followed an elevation in serum sodium > 18 mEq/L/24 hr, it sometimes followed a rise as slow as 10 mEq/L/24 hr and 21 mEq/L/48 hr. Whenever possible, the rate of correction of hyponatremia should be kept below these values in order to minimize the risk of myelinolysis.
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Affiliation(s)
- B I Karp
- National Institute of Neurologic Disorders and Stroke, National Institutes of Health, Bethesda, MD 20892
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Abstract
The authors report four patients whose initial symptom of tumor recurrence or progression was unilateral numbness of the chin. Two patients had Hodgkin lymphoma, one had malignant melanoma, and one had prostate cancer. Physical examination was notable only for unilateral anesthesia of the chin and lower lip. Diagnostic evaluation, including computed tomography (CT) scan and magnetic resonance imaging (MRI) of the brain, plain radiographs of the mandible, and cerebrospinal fluid analysis for protein, glucose, and cytology were normal. Bone scans revealed osseous lesions in the axial skeleton of all patients, whereas only two patients had abnormal uptake in the mandible. The authors conclude that in the setting of a negative evaluation for central nervous system (CNS) or local mandibular disease, mental neuropathy is associated with recurrent or progressive skeletal disease. In addition, to document relapsed or progressive cancer, the skeletal system may have to be examined at sites distant from the mandible.
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Affiliation(s)
- R K Burt
- Clinical Oncology Program, National Cancer Institute, National Institutes of Health, Bethesda, Maryland 20892
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Alexander RC, Karp BI, Thompson S, Khot V, Kirch DG. A double blind, placebo-controlled trial of demeclocycline treatment of polydipsia-hyponatremia in chronically psychotic patients. Biol Psychiatry 1991; 30:417-20. [PMID: 1912134 DOI: 10.1016/0006-3223(91)90300-b] [Citation(s) in RCA: 28] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Affiliation(s)
- R C Alexander
- Neuropsychiatry Branches, National Institute of Mental Health, Washington, DC
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Karp BI, Vieweg WV. Rapid correction of hyponatremia in psychiatric patients with polydipsia. Am J Med 1991; 90:408-10. [PMID: 2003527] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
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Sterns RH, Laureno R, Norenberg MD, Karp BI. Symptomatic hyponatremia in rats: effect of treatment on mortality and brain lesions. Am J Physiol 1990; 258:F1475-7. [PMID: 2337160 DOI: 10.1152/ajprenal.1990.258.5.f1475] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
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Abstract
Central pontine and extrapontine myelinolysis is caused by the rapid correction of hyponatraemia. Acceptance of this concept has been impeded by recent reports attributing myelinolysis to uncorrected hyponatraemia, overcorrection of hyponatraemia, or hypoxia. Several new names have been proposed for this disease, but all are less specific than pontine and extrapontine myelinolysis. This proliferation of terminology is unnecessary and adds to the confusion surrounding the aetiology of myelinolysis.
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Affiliation(s)
- R Laureno
- Department of Neurology, George Washington University School of Medicine, Washington DC
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