Clinical features of patients with blepharospasm: a report of 240 patients

BACKGROUND AND PURPOSE

To characterize patients with benign essential blepharospasm (BEB) by diagnosis, environmental risk factors, and family history.

METHODS

Two hundred and forty patients with BEB were evaluated through a clinical examination and questionnaire. The questionnaire reviewed personal medical history, demographic factors, risk factors for the development of blepharospasm and family history of dystonia and other neurological conditions.

RESULTS

Benign essential blepharospasm was more commonly found in women (2.8:1) and 93% of the patients were Caucasian. Fifty percent had pure BEB, 31% had BEB/Meige's syndrome, and 4% had BEB and eyelid opening apraxia (+/- Meige's syndrome). A minority of patients reported preceding photophobia (25%) or other eye conditions (22%). The majority were non-smokers, had no exposure to anti-emetic or antipsychotic agents, had a normal birth history, and had no history of head trauma. Seventy-two percent did report a stressful event immediately prior to the development of symptoms. Treatments reported included botulinum toxin (BoNT), oral medications, surgical procedures, and acupuncture. Thirty-two percent of patients reported a family history of focal dystonia, and BEB was the most commonly reported.

CONCLUSION

This study confirms previous reports of usual age, sex, caffeine and tobacco use, and family history in patients with blepharospasm. New findings include a report on occupation, lower reports of preceding eye conditions and photophobia, and higher reported stressful events. Further, this study shows a change in treatment with an increase in BoNT use and decrease in surgical procedures.

A 12-week, placebo-controlled study (6002-US-006) of istradefylline in Parkinson disease

BACKGROUND

The safety and efficacy of istradefylline, a selective adenosine A(2A) receptor antagonist, was evaluated in a 12-week, double-blind study in levodopa-treated Parkinson disease (PD) subjects with motor complications.

METHODS

Levodopa-treated PD subjects (n = 395) received istradefylline 20 mg/day (n = 163), istradefylline 60 mg/day (n = 155), or placebo (n = 77) at 40 sites. The primary efficacy variable was the change in the percentage of time per day spent in the OFF state. Secondary measurements assessed change in ON time, Unified Parkinson's Disease Rating Scale, and Clinical Global Impression. Safety monitoring included clinical laboratory, electrocardiograms, vital signs, physical/neurologic examinations, and adverse events (AEs).

RESULTS

Changes from baseline to endpoint in the percentage OFF time in the active groups compared with placebo were -4.35% (95% CI -8.16 to -0.54; p = 0.026) for istradefylline 20 mg/day and -4.49% (95% CI -8.35 to -0.62; p = 0.024) for 60 mg/day; these changes were significant (analysis of covariance). For total hours, istradefylline demonstrated mean differences from placebo of -0.64 hours (95% CI -1.30 to 0.01) for 20 mg/day and -0.77 hours (95% CI -1.44 to -0.11) for 60 mg/day (p = 0.065; overall treatment effect). Clinical response occurred by the second week and was maintained throughout the study. Istradefylline was well tolerated. The common AEs were dyskinesia, nausea, dizziness, and hallucinations.

CONCLUSIONS

Istradefylline demonstrated a significant reduction in the percentage of awake time per day spent in the OFF state, which resulted in a clinically meaningful reduction in OFF time, without an increase in ON time with troublesome dyskinesia, and was well tolerated as adjunctive treatment to levodopa in Parkinson disease.

Clinico-immunologic aspects of botulinum toxin type B treatment of cervical dystonia

In this multicenter study of 100 patients with cervical dystonia, we examined the immunogenicity of botulinum toxin type B (BTX-B) and correlated the clinical response with the presence of blocking antibodies (Abs) using a novel mouse protection assay. One-third of the patients who were negative for BTX-B Abs at baseline became positive for BTX-B Abs at last visit. Thus, the high antigenicity of BTX-B limits its long-term efficacy.

Development of a Patient Questionnaire to facilitate recognition of motor and non-motor wearing-off in Parkinson’s disease

We previously reported that the use of a specifically designed Wearing-Off Questionnaire (WOQ) identified symptoms of wearing-off more frequently than standard assessments conducted by movement disorder specialists during a routine office visit. In the previous study we used a WOQ of 32 symptoms; however this tool was not designed for daily use. In this paper we describe the retrospective development of a simpler, 19-symptom WOQ more suitable for routine clinical use.

Absence of previously reported variants in the SCNA (G88C and G209A), NR4A2 (T291D and T245G) and the DJ-1 (T497C) genes in familial Parkinson's disease from the GenePD study

Parkinson's disease (PD) is a neurodegenerative disorder in which relatives of the probands are affected approximately 4 times as frequently as relatives of control subjects. Several genes have been implicated as genetic risk factors for PD. We investigated the presence of six reported genetic variations in the SCNA, NR4A2, and DJ-1 genes in 292 cases of familial Parkinson's disease from the GenePD study. None of the variants were found in the GenePD families. Our results suggest that other variants or genes account for the familial risk of PD within the GenePD study.

A haplotype at the PARK3 locus influences onset age for Parkinson's disease: the GenePD study

OBJECTIVE

To identify a haplotype influencing onset age for Parkinson's disease (PD) in the PARK3 region on chromosome 2p13.

METHODS

Single nucleotide polymorphisms (SNP) spanning 2.2 Mb and located in or near potential candidate genes were used to fine map the PARK3 region in 527 patients with familial PD, from 264 families.

RESULTS

TT homozygotes for rs1876487 (G/T) had a 7.4-year younger mean age at onset (p = 0.005) compared to patients with GT and GG genotypes. Furthermore, SNP flanking the sepiapterin reductase (7,8-dihydrobiopterin: NADP+ oxidoreductase) (SPR) gene, rs1876487 (p = 0.02) and rs1150500 (p = 0.04), were associated with younger onset age among persons who did not carry the 174 allele of D2S1394. The SPR gene is implicated in dopamine synthesis. Haplotype analysis of three SNP-rs2421095, rs1876487, rs1561244-revealed an association with onset age (p = 0.023) and a haplotype of A-T-G alleles was associated with younger onset for PD (p = 0.005).

CONCLUSIONS

A haplotype at the PARK3 locus, harboring the SPR gene, is associated with onset age of PD. This may suggest a role for the SPR gene in modifying the age at onset of PD.

Randomized, double-blind trial of glial cell line-derived neurotrophic factor (GDNF) in PD

OBJECTIVE

To assess the safety, tolerability, and biological activity of glial cell line-derived neurotrophic factor (GDNF) administered by an implanted intracerebroventricular (ICV) catheter and access port in advanced PD.

BACKGROUND

GDNF is a peptide that promotes survival of dopamine neurons. It improved 6-OHDA- or MPTP-induced behavioral deficits in rodents and monkeys.

METHODS

A multicenter, randomized, double-blind, placebo-controlled, sequential cohort study compared the effects of monthly ICV administration of placebo and 25, 75, 150, 300, and 500 to 4,000 microg of GDNF in 50 subjects with PD for 8 months. An open-label study extended exposure up to an additional 20 months and maximum single doses of up to 4,000 microg in 16 subjects. Laboratory testing, adverse events (AE), and Unified Parkinson's Disease Rating Scale (UPDRS) scoring were obtained at 1- to 4-week intervals throughout the studies.

RESULTS

Twelve subjects received placebo and seven or eight subjects were assigned to each of the other GDNF dose groups. "On" and "off" total and motor UPDRS scores were not improved by GDNF at any dose. Nausea, anorexia, and vomiting were common hours to several days after injections of GDNF. Weight loss occurred in the majority of subjects receiving 75 microg or larger doses of GDNF. Paresthesias, often described as electric shocks (Lhermitte sign), were common in GDNF-treated subjects, were not dose related, and resolved on discontinuation of GDNF. Asymptomatic hyponatremia occurred in over half of subjects receiving 75 microg or larger doses of GDNF; it was symptomatic in several subjects. The open-label extension study had similar AE and lack of therapeutic efficacy.

CONCLUSIONS

GDNF administered by ICV injection is biologically active as evidenced by the spectrum of AE encountered in this study. GDNF did not improve parkinsonism, possibly because GDNF did not reach the target tissues--putamen and substantia nigra.

Epidemiologic study of 203 sibling pairs with Parkinson's disease: the GenePD study

OBJECTIVE

To examine patterns of familial aggregation and factors influencing onset age in a sample of siblings with PD.

METHODS

Sibling pairs (n = 203) with PD were collected as part of the GenePD study. Standardized family history, medical history, and risk factor data were collected and analyzed.

RESULTS

The mean age at onset was 61.4 years and did not differ according to sex, exposure to coffee, alcohol, or pesticides. Head trauma was associated with younger onset (p = 0.03) and multivitamin use with later onset (p = 0.007). Age at onset correlation between sibling pairs was significant (r = 0.56, p = 0.001) and was larger than the correlation in year of onset (r = 0.29). The mean difference in onset age between siblings was 8.7 years (range, 0 to 30 years). Female sex was associated with increased frequency of relatives with PD. The frequency of affected parents (7.0%) and siblings (5.1%) was increased when compared with frequency in spouses (2.0%).

CONCLUSIONS

The greater similarity for age at onset than for year of onset in sibling pairs with PD, together with increased risk for biological relatives over spouses of cases, supports a genetic component for PD. Risk to siblings in this series is increased over that seen in random series of PD cases; however, patients in this sample have similar ages at onset and sex distribution as seen for PD generally. These analyses suggest that factors influencing penetrance are critical to the understanding of this disease.

Genome-wide scan for Parkinson's disease: the GenePD Study

A genome-wide scan for idiopathic PD in a sample of 113 PD-affected sibling pairs is reported. Suggestive evidence for linkage was found for chromosomes 1 (214 cM, lod = 1.20), 9 (136 cM, lod = 1.30), 10 (88 cM, lod = 1.07), and 16 (114 cM, lod = 0.93). The chromosome 9 region overlaps the genes for dopamine beta-hydroxylase and torsion dystonia. Although no strong evidence for linkage was found for any locus, these results may be of value in comparison with similar studies by others.

Idiopathic cervical dystonia: an overview

Idiopathic cervical dystonia (CD) is the most common of the adult-onset focal dystonias. It manifests as involuntary muscle contractions that cause twisting or turning of the neck. The resulting abnormal head and neck postures are heterogeneous in their presentation. Because of the variable presentation of the disease and the poor recognition of its clinical spectrum of manifestations, CD is frequently misdiagnosed and accurate diagnosis of the disease is commonly delayed. The pathogenesis of CD remains obscure. However, genetic factors, trauma, the sensory system, and impaired basal ganglia function may all play a role in the development of this disease.

A randomized, controlled trial of remacemide for motor fluctuations in Parkinson's disease

BACKGROUND

Preclinical studies suggest that glutamate antagonists help ameliorate motor fluctuations in patients with PD treated with levodopa.

METHODS

In a multicenter, randomized, double-blind, placebo-controlled, parallel-group, dose-ranging study, the authors assessed the safety, tolerability, and efficacy of the glutamate receptor blocker remacemide hydrochloride in 279 patients with motor fluctuations treated with levodopa. The primary objective was to assess the short-term tolerability and safety of four dosage levels of remacemide during 7 weeks of treatment. Patients were also monitored with home diaries and the Unified PD Rating Scale (UPDRS) to collect preliminary data on treatment efficacy.

RESULTS

Remacemide was well tolerated up to a dosage of 300 mg/d on a twice daily schedule and 600 mg/d on a four times daily schedule. The most common dosage-related adverse events were dizziness and nausea, as observed in previous studies of remacemide. The percent "on" time and motor UPDRS scores showed trends toward improvement in the patients treated with 150 and 300 mg/d remacemide compared with placebo-treated patients, although these improvements were not significant.

CONCLUSION

Remacemide is a safe and tolerable adjunct to dopaminergic therapy for patients with PD and motor fluctuations. Although this study had limited power to detect therapeutic effects, the observed improvement is consistent with studies of non-human primates with 1-methyl-4-phenyl-1,2,3,6-tetrahydropyridine-induced parkinsonian signs and symptoms. Additional studies are warranted to confirm these results over an extended period of observation, and to explore the potential neuroprotective effects of remacemide in slowing the progression of PD.

Respiratory function in Parkinson's disease

This article reviews the spectrum of respiratory dysfunction in Parkinson's disease (PD). It includes the primary effects of PD on the ventilation, response to medications, and pulmonary complications of antiparkinson therapy. Primary pulmonary abnormalities include a restrictive change mainly secondary to chest wall rigidity and upper airway obstruction; both are responsive to dopaminergic modulation. Respiratory dyskinesia, a side effect of levodopa therapy, may produce both restrictive and dyskinetic ventilation. Therapy with ergot derivatives may result in pleuropulmonary fibrosis. Lastly, pulmonary infection as a consequence of disordered respiratory mechanics continues to contribute significantly to morbidity and mortality in PD.

Pharmacotherapy for advanced Parkinson's disease

Medical management of Parkinson's disease consists of two strategies. A presynaptic strategy attempts to maintain physiologic synaptic concentrations of dopamine, usually by individualizing delivery of levodopa (or exogenous dopamine) by varying the rate of gastrointestinal absorption or blood-brain barrier passage. A postsynaptic strategy bypasses degenerating nigrostriatal neurons by stimulating striatal neurons directly with dopamine agonists. With advancing disease, motor fluctuations appear, related to physiologic changes that narrow the window of levodopa concentration in which symptoms are under control. Then it becomes necessary to add dopamine agonists to therapy.

Parkinson's disease: therapeutic choices and timing decisions in patient management. Interview by Wayne Kuznar

Parkinson's disease is a progressive neurodegenerative disorder characterized by striatal dopaminergic loss. Carbidopa/levodopa is the most effective drug treatment for disease management. It reduces bradykinesia and rigidity, but is less effective against tremor. Whether carbidopa/levodopa should be used at the time of initial diagnosis or delayed until symptoms become disabling is controversial. A clinical trial is in progress to help resolve this dilemma. As carbidopa/levodopa loses efficacy with continued use, adjunct therapies using catechol-O-methyl-transferase inhibitors or dopamine agonists may be considered. In younger patients exhibiting parkinsonian symptoms, dopamine agonists may be used as first-line therapy. A new, reversible surgical intervention known as deep-brain stimulator placement is being used to control disabling tremor in patients not responding to optimal drug therapy.

Managing late complications of Parkinson's disease

Treatment of parkinsonism becomes more difficult as the disease progresses, and results from increasing neuronal degeneration, side effects from antiparkinsonian medications, or most often, a combination of each. Neurodegenerative parkinson symptoms may result from substantia nigra destruction, or from other areas in the nervous system. These include the cortex (cognitive and psychiatric disorders), brainstem (bulbar abnormalities), intermediolateral cell column (autonomic disturbances), among others. Medication side effects produce motor fluctuations, dyskinesias, delirium, hallucinations, psychosis, orthostatic hypotension, sleep disorders, and a host of other well-recognized complications. This article is divided into sections concerning motor fluctuations, gait difficulty bulbar disturbances, autonomic disturbances, sleep disorders, cognitive disorders, and psychiatric disorders, and is an attempt to provide the reader with strategies for treating common complications in the advanced Parkinson's disease patient.

Comparison of two injection techniques using botulinum toxin in spastic hemiplegia

This study sought to test the hypothesis that injections of botulinum toxin type A (BTX-A) at the mid belly of the gastrocnemius muscle in spastic hemiplegic adults produce superior clinical results to proximal injections directed toward the muscular origin. We designed a randomized, double-blind, placebo-controlled intervention study at a university tertiary care setting. Seventeen subjects with chronic spastic hemiplegic gait were enrolled from a volunteer community sample; time range from acute neurologic insult was 0.75 to 31 yr; age range was 19 to 71 yr; gender consisted of 11 men and 4 women; diagnoses were 12 patients with stroke, 2 with traumatic brain injuries, and 1 with a brain tumor. Two subjects were withdrawn from the study because of (1) acute vascular occlusion before intervention and (2) noncompliance with follow-up visits. After baseline measurements, subjects were injected with 50 units of BTX-A (volume, 0.5 cc) into the medial or lateral gastrocnemius: (1) proximally at one site near the muscular origin; (2) distally at three sites along the mid belly. We measured outcome using the Fugl-Meyer score, Ashworth scale, ankle range of motion, and a timed 50-ft fastest walk. No outcome measures showed a significant effect attributable to site of injections. Confounding variables included physical therapy and varying duration of illness in the study cohort. We conclude that the results failed to support the hypothesis that BTX-A injections at the mid belly of the gastrocnemius produced superior functional improvements to injections located near the muscular origin using localization techniques described. Additional research comparing more precise localization methods for BTX-A injections might further establish the importance of electromyographic guidance using BTX-A in management of spasticity.

Treatment options for early Parkinson's disease

Proper treatment of tremor in any clinical setting depends on correct diagnosis. Essential, or familial, tremor is symptomatic with movement and involves the limbs, head and voice. Parkinson's disease tremor occurs at rest, involves the jaw and limbs and is associated with bradykinesia, rigidity and falling. Parkinson's disease is treated with a number of medications, but levodopa, a dopamine precursor, is considered most effective. Other therapies in the early stages of Parkinson's disease may include neuroprotective agents, dopamine agonists, dopamine reuptake inhibitors, anticholinergics and/or amantadine. Polypharmacy is often necessary to minimize or avoid drug side effects.

Effectiveness of clozapine and a social learning program for severely disabled psychiatric inpatients

OBJECTIVE

This study examined the combined effectiveness of clozapine and a comprehensive inpatient psychosocial rehabilitation program on the clinical functioning and aggressive behaviors of patients with chronic schizophrenia.

METHODS

Two groups of 11 subjects each were selected from among patients being treated in the social learning program at Fulton (Mo.) State Hospital. Group 1 subjects were placed on clozapine at various times after the introduction of the program, while group 2 subjects remained on traditional antipsychotics throughout the study period. Group 1 and group 2 subjects were matched on clinical functioning as measured by the Time-Sample Behavioral Checklist (TSBC). For each subject, scores on six TSBC subscales were examined at five time points. Data were analyzed using repeated-measures multiple analysis of variance and univariate analyses of variance. Data on frequency of aggressive behaviors were aggregated into three six-month time periods and were analyzed using Wilcoxon signed-rank tests.

RESULTS

Both groups demonstrated significant improvement on several measures. However, the addition of clozapine resulted in accelerated improvement for group 1 subjects, especially in aggressive behaviors.

CONCLUSIONS

Comprehensive psychosocial treatment programming resulted in significant improvements in clinical functioning for many inpatients. Clozapine may enhance responsiveness to such programming for some patients.

An open-labelled assessment of adverse effects associated with interferon 1-beta in the treatment of multiple sclerosis

Interferon 1-beta (IFNB) (Betaseron) has been reported to reduce the frequency and severity of exacerbations in relapsing-remitting multiple sclerosis (MS). Adverse effects from this every other day injection are frequent, and most often include injection site reaction or flu-like symptoms. This open-labelled prospective study of MS patients receiving IFNB found that while injection site reactions and flu-like symptoms were seen in 90.0% and 76.7% of patients respectively, only two of 30 patients discontinued therapy for these problems.

Tardive stereotypy and other movement disorders in tardive dyskinesias

We reviewed the medical records and videotapes of 100 patients with tardive dyskinesia (TD) referred to our movement disorders clinic to characterize the spectrum of hyperkinetic movement disorders caused by dopamine receptor blocking drugs (DRBD). Tardive stereotypy, present in 78 patients, was the most common type of TD, followed by tardive dystonia, akathisia, tremor, chorea, and myoclonus. Sixty-four had a combination of these hyperkinesias. In a second study, a "blind" review of videotapes of patients with a variety of movement disorders found that DRBD were the cause of stereotypic movements in 89.3% of patients, and 96.1% of patients with TD had stereotypy. We conclude that stereotypy can be readily differentiated from other hyperkinetic movement disorders and that its presence in an adult is highly suggestive of prior exposure to DRBD.

Current approaches in the treatment of Parkinson's disease

Treatment options for patients with Parkinson's disease have rapidly expanded in the last five years. They now include pharmacologic therapies designed not only to improve parkinsonian symptoms, but also to prevent disease progression. In addition, neurosurgical options and other novel treatment strategies are being developed and may become clinically useful in the next decade. This chapter addresses current and evolving Parkinson's disease medications, future surgical interventions, and specific strategies for maximizing patient motor abilities.

Differential diagnosis of Parkinson's disease and the parkinsonism plus syndromes

Although Parkinson's disease (PD) is thought to represent a specific clinical-pathologic entity, up to 20% of patients diagnosed as having PD will have another disorder at autopsy. Furthermore, pathologic features typically associated with PD can also be observed in patients with other neurodegenerative disorders. This article attempts to point out the difficulties in differentiating PD from progressive supranuclear palsy and other parkinsonism plus syndromes and various causes of parkinsonism associated with cognitive changes. The clinical and pathologic differentiation of these disorders are discussed. These disorders are usually associated with postsynaptic receptor changes and therefore levodopa and dopamine agonists provide limited benefit.

Tardive tremor

A variety of hyperkinetic movement disorders has been associated with the use of neuroleptics (dopamine receptor blocking drugs), but tardive tremor has not been previously documented. We describe five patients in whom tremor occurred after chronic treatment with neuroleptics, was aggravated by and persisted after neuroleptic withdrawal, and improved after treatment with the dopamine depleting drug tetrabenazine. This involuntary oscillatory movement, with a frequency range of 3-5 Hz, was most prominent during maintenance of a posture, but was also present at rest and during a goal-directed movement. The tremor was accompanied by other tardive movement disorders, including akathisia, chorea, dystonia, myoclonus, and stereotypy. There was no family history or other explanation for tremor in these patients. We suggest that this hitherto unreported movement disorder is best termed "tardive tremor."