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Rotstein MS, Zimmerman-Brenner S, Davidovitch S, Ben-Haim Y, Koryto Y, Sion R, Rubinstein E, Djerassi M, Lubiniaker N, Peleg TP, Steinberg T, Leitner Y, Raz G. Gamified Closed-Loop Intervention Enhances Tic Suppression in Children: A Randomized Trial. Mov Disord 2024. [PMID: 38881244 DOI: 10.1002/mds.29875] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2024] [Revised: 05/07/2024] [Accepted: 05/13/2024] [Indexed: 06/18/2024] Open
Abstract
BACKGROUND Gamification of behavioral intervention for tic disorders (TDs) potentially enhances compliance and offers key clinical advantages. By delivering immediate positive feedback upon tic-suppression, games may counteract negative reinforcement, which presumably contribute to tic consolidation by relieving uncomfortable premonitory urges. OBJECTIVES We developed a gamified protocol (XTics), which leverages this potential by combining gamified tic-triggering with immediate feedback, and evaluated its clinical value in enhancing tic suppression. METHODS XTics encompasses two conditions: Immediate and Contingent Reward (ICR), where game progression is contingent upon successful tic suppression, and Delayed Reward (DR), where game events' outcomes are random. Employing a randomized crossover design, 35 participants (aged 7-15 years) underwent daily gaming sessions over a week per condition. Improvements in our primary measures, including the inter-tic interval (ITI) and tic severity assessment by blinded evaluators (Yale Global Tic Severity-Total Tic Score [YGTSS-TTS], Rush), and parents (Parent Tic Questionnaire [PTQ]), were compared between ICR and DR, and assessed across conditions for the 4-week protocol. RESULTS No participant voluntarily left the study before completing its two-phase protocol. As expected, ITI showed significantly larger improvement (Z = 4.19, P = 2.85 × 10-5) after ICR (1442 ± 2250%) versus DR (242 ± 493%) training, increasing at a higher pace (t(67) = 3.15, P = 0.0025). Similarly, Rush tic severity scores reduced more post-ICR versus DR (t(47) = 3.47, P = 0.002). We observed a clinically significant reduction of 25.69 ± 23.39% in YGTSS-TTS following a f4-week protocol including both conditions. Parent-reported tic severity decreased by 42.99 ± 31.69% from baseline to 3 months post-treatment. CONCLUSIONS The combination of gamified tic-triggering with immediate and contingent rewards demonstrates a promising approach for enhancing treatment efficacy in TDs, boosting traditional therapeutic methods. © 2024 The Author(s). Movement Disorders published by Wiley Periodicals LLC on behalf of International Parkinson and Movement Disorder Society.
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Affiliation(s)
- Michael S Rotstein
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Child Development Institute, The Dana-Dwek Children's Hospital, Tel-Aviv Medical Center, Israel
- The Pediatric Neurology Unit, Dana-Dwek Children's Hospital, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | | | | | - Yael Ben-Haim
- School of Psychological Sciences, Tel Aviv University, Israel
| | - Yuval Koryto
- Department of Psychology, The Hebrew University of Jerusalem, Mount Scopus, Jerusalem, Israel
| | - Romi Sion
- Sagol School of Neuroscience, Tel Aviv University, Tel-Aviv, Israel
- Sagol Brain Institute, Tel Aviv Sourasky Medical Center, Tel-Aviv, Israel
| | - Einat Rubinstein
- Sagol Brain Institute, Tel Aviv Sourasky Medical Center, Tel-Aviv, Israel
| | - Meshi Djerassi
- Sagol School of Neuroscience, Tel Aviv University, Tel-Aviv, Israel
- Sagol Brain Institute, Tel Aviv Sourasky Medical Center, Tel-Aviv, Israel
| | - Nitzan Lubiniaker
- Sagol Brain Institute, Tel Aviv Sourasky Medical Center, Tel-Aviv, Israel
| | - Tammy Pilowsky Peleg
- Department of Psychology, The Hebrew University of Jerusalem, Mount Scopus, Jerusalem, Israel
- The Neuropsychological Unit, Schneider Children's Medical Center, Petach Tikva, Israel
| | - Tamar Steinberg
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- The Matta and Harry Freund Neuropsychiatric Tourette Clinic, Department of Child and Adolescent Psychiatry, Schneider Children's Medical Center of Israel, Petach Tikva, Israel
| | - Yael Leitner
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Child Development Institute, The Dana-Dwek Children's Hospital, Tel-Aviv Medical Center, Israel
- The Pediatric Neurology Unit, Dana-Dwek Children's Hospital, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Gal Raz
- Sagol School of Neuroscience, Tel Aviv University, Tel-Aviv, Israel
- Sagol Brain Institute, Tel Aviv Sourasky Medical Center, Tel-Aviv, Israel
- The Steve Tisch School of Film and Television, Faculty of the Arts, Tel Aviv University, Tel-Aviv, Israel
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Zhang A, Liu T, Xu J, Zhao Q, Wang X, Jiang Z, Liang S, Cui Y, Li Y. Efficacy of deep brain stimulation for Tourette syndrome and its comorbidities: A meta-analysis. Neurotherapeutics 2024:e00360. [PMID: 38688785 DOI: 10.1016/j.neurot.2024.e00360] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2023] [Revised: 04/10/2024] [Accepted: 04/11/2024] [Indexed: 05/02/2024] Open
Abstract
Tourette Syndrome (TS) is a neurodevelopmental disorder characterized by multiple motor and vocal tics, often accompanied by comorbid disorders. Optional treatments for patients with TS include behavioral therapy, pharmacotherapy, and neurostimulation techniques. Deep brain stimulation (DBS) has been considered a therapeutic approach for refractory TS and its comorbid symptoms. However, systematic comparison is necessary to understand the therapeutic effect of DBS among patients with TS with various comorbid symptoms, demographic characteristics, or stimulation targets. Consequently, our research aimed to assess the clinical efficacy of DBS in alleviating the symptoms of TS and its comorbidities. A systematic literature search was conducted across five databases: PubMed, Web of Science, MEDLINE, Embase, and PsycINFO. The primary outcome was the mean change in the global score of the Yale Global Tic Severity Scale (YGTSS), which assesses the severity of tics. The secondary outcomes included mean improvement of comorbid symptoms, such as obsessive-compulsive behaviors (OCB), depression symptoms and anxiety symptoms. In total, 51 studies with 673 participants were included in this meta-analysis. Overall, the DBS led to a significant improvement in tic symptoms (p < 0.001), as well as the comorbid obsessive-compulsive, depression, and anxiety symptoms with effect sizes of 1.88, 0.88, 1.04, and 0.76 accordingly. In the subgroup analysis, we found that striatum stimulation led to a more significant improvement in OCB in patients with TS compared to that observed with thalamic stimulation (p = 0.017). The relationship between sex, age, and target with the improvement of tics, depression, and anxiety was not statistically significant (p = 0.923, 0.438, 0.591 for different male proportions; p = 0.463, 0.425, 0.105 for different age groups; p = 0.619, 0.113, 0.053 for different targets). In conclusion, DBS is an efficient treatment option for TS, as well as the comorbid OCB, depression symptoms, and anxiety symptoms. It is important to highlight that stimulating the striatum is more effective in managing obsessive-compulsive symptoms compared to stimulating the thalamus.
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Affiliation(s)
- Anyi Zhang
- Department of Psychiatry, Beijing Children's Hospital, Capital Medical University, National Centre for Children's Health, Beijing, China
| | - Tinghong Liu
- Functional Neurosurgery Department, Beijing Children's Hospital, Capital Medical University, Beijing, China
| | - Jinshan Xu
- Functional Neurosurgery Department, Beijing Children's Hospital, Capital Medical University, Beijing, China
| | - Qing Zhao
- Department of Psychiatry, Beijing Children's Hospital, Capital Medical University, National Centre for Children's Health, Beijing, China
| | - Xianbin Wang
- Department of Psychiatry, Beijing Children's Hospital, Capital Medical University, National Centre for Children's Health, Beijing, China
| | - Zhongliang Jiang
- Department of Psychiatry, Beijing Children's Hospital, Capital Medical University, National Centre for Children's Health, Beijing, China
| | - Shuli Liang
- Functional Neurosurgery Department, Beijing Children's Hospital, Capital Medical University, Beijing, China.
| | - Yonghua Cui
- Department of Psychiatry, Beijing Children's Hospital, Capital Medical University, National Centre for Children's Health, Beijing, China.
| | - Ying Li
- Department of Psychosomatic Medicine, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China.
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Gong H, Du X, Su A, Du Y. Pharmacological treatment of Tourette's syndrome: from the past to the future. Neurol Sci 2024; 45:941-962. [PMID: 37962703 DOI: 10.1007/s10072-023-07172-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2022] [Accepted: 10/30/2023] [Indexed: 11/15/2023]
Abstract
Tourette's syndrome (TS) is a neuropsychiatric disease featuring tics and vocal tics, with a prevalence of approximately 1%, including 75% of the total number of male patients. TS seriously disturbs the patients' career, education, and life and brings a serious and unbearable psychological burden to the patients themselves and their families. At present, there are no specific clinical medications recommended for treating TS. Therefore, it is necessary to select the appropriate medication for symptomatic treatment based on the doctor's personal experience and the patient's symptoms, with the main goal of relieving symptoms, thus improving the patient's social skills and psychological problems. Here we conducted a comprehensive search on PubMed to review and organize the history and current status of the development of drug therapy for TS through a timeline format. We also systematically evaluated the effects of each drug for TS treatment to summarize the current problems and new research directions and to provide some ideas for clinical treatment.
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Affiliation(s)
- Hao Gong
- School of Basic Medical Sciences, Henan University, Kaifeng, People's Republic of China
- Department of General Surgery, West China Hospital Sichuan University, Chengdu, 610041, People's Republic of China
| | - Xiangyu Du
- School of Basic Medical Sciences, Henan University, Kaifeng, People's Republic of China
- Department of General Surgery, West China Hospital Sichuan University, Chengdu, 610041, People's Republic of China
| | - Anping Su
- Department of General Surgery, West China Hospital Sichuan University, Chengdu, 610041, People's Republic of China
| | - Yaowu Du
- School of Basic Medical Sciences, Henan University, Kaifeng, People's Republic of China.
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Bao C, Wei M, Pan H, Wen M, Liu Z, Xu Y, Jiang H. A preliminary study for the clinical effect of one combinational physiotherapy and its potential influence on gut microbial composition in children with Tourette syndrome. Front Nutr 2023; 10:1184311. [PMID: 37781119 PMCID: PMC10541309 DOI: 10.3389/fnut.2023.1184311] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2023] [Accepted: 08/28/2023] [Indexed: 10/03/2023] Open
Abstract
Introduction Tourette syndrome (TS) is a chronic neuropsychiatric disorder with unknown causes and inadequate therapies. Inspired by the important roles of gut microbiota in some mental illnesses, the interactions between gut microbiota and TS via the gut-brain axis have gained more and more attention. This study aimed to characterize the gut microbial profiles in children with TS, and explore the clinical effects of one combinational physiotherapy and its potential influence on gut microbial composition. Methods The gut microbial profiles were depicted based on the sequence data of 32 patients and 29 matched health children by 16S rDNA amplicon pyrosequencing. Thirty of thirty-two patients underwent uninterrupted two 10-day courses of combinational physiotherapy, which included a 60-minute cranial electrotherapy stimulation (CES) training followed by a 30-minute biofeedback training per session, 2 sessions a day. Results Our results indicated that the gut microbial composition in children with TS was different from that in healthy controls. Multiple GBM neurotransmitter modules obtained through Picrust2 functional predictive analysis were significantly increased in patients, including Histamine degradation, Dopamine degradation, and DOPAC synthesis. Moreover, this combinational physiotherapy could significantly diminish tic activity, whose positive effects were first reported in children with TS. Lastly, different gut microbial compositions and predictive metabolic pathways were also observed between patients before and after this treatment, with lower abundances of the genera (e.g., Dorea) and significant decreases of GBM neurotransmitter modules (e.g. dopamine degradation) in patients after this treatment, indicating that improved clinical symptoms might be accompanied by an improvement of intestinal microenvironment. Discussion Children with TS showed a cognizable gut microbial profile, and certain enriched bacteria with pro-inflammatory potential might induce neuroinflammatory responses. This combinational physiotherapy could significantly diminish tic activity, and the gut microbial compositions in patients after this treatment were different from those without any treatment, indicating the existence of bidirectional communication of the gut-brain axis in TS. But studies on the gut microbial characteristics in TS patients, the influences of gut microbiota on tic severity, the efficacy and safety of this treatment, and the bidirectional regulatory mechanism between brain signals and gut microbiota in TS still need to be explored.
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Affiliation(s)
- Chun Bao
- Department of Child Healthcare, Xiangyang No. 1 People’s Hospital, Hubei University of Medicine, Xiangyang, China
| | - Meng Wei
- Department of Child Healthcare, Xiangyang No. 1 People’s Hospital, Hubei University of Medicine, Xiangyang, China
| | - Hongguo Pan
- Department of Child Healthcare, Xiangyang No. 1 People’s Hospital, Hubei University of Medicine, Xiangyang, China
| | - Ming Wen
- Zhangjiang Center for Translational Medicine, Shanghai Biotecan Pharmaceuticals Co., Ltd., Shanghai, China
| | - Ziming Liu
- Zhangjiang Center for Translational Medicine, Shanghai Biotecan Pharmaceuticals Co., Ltd., Shanghai, China
| | - Yue Xu
- Zhangjiang Center for Translational Medicine, Shanghai Biotecan Pharmaceuticals Co., Ltd., Shanghai, China
| | - Huihui Jiang
- Zhangjiang Center for Translational Medicine, Shanghai Biotecan Pharmaceuticals Co., Ltd., Shanghai, China
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Makhoul K, Jankovic J. Real-world experience with VMAT2 inhibitors in Tourette syndrome. J Neurol 2023; 270:4518-4522. [PMID: 37301806 DOI: 10.1007/s00415-023-11769-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2023] [Accepted: 05/07/2023] [Indexed: 06/12/2023]
Abstract
OBJECTIVES We aimed to review our "real-world" experience with the vesicular monoamine transporter 2 (VMAT2) inhibitors tetrabenazine, deutetrabenazine, and valbenazine for treatment of Tourette syndrome, focusing on therapeutic benefits, side effect profile, and accessibility for the off-label use of these drugs. METHODS We performed a retrospective chart review, supplemented with a telephone survey, of all our patients treated for their tics with VMAT2 inhibitors over a period of 4 years from January 2017 until January 2021. RESULTS We identified 164 patients treated with the various VMAT2 inhibitors (tetrabenazine, n = 135; deutetrabenazine, n = 71; valbenazine, n = 20). Data on the mean treatment duration and daily dosages were collected. The response to VMAT2 inhibitors was assessed by a Likert scale by comparing the symptom severity before initiation and while on treatment. Side effects were mild and mostly consisted of depression as the major side effect but there was no suicidality reported. CONCLUSION VMAT2 inhibitors are effective and safe in the treatment of tics associated with Tourette syndrome but are not readily accessible by patients in the United States, partly because of lack of approval by the Food and Drug Administration.
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Affiliation(s)
- Karim Makhoul
- Parkinson's Disease Center and Movement Disorders Clinic, Department of Neurology, Baylor College of Medicine, 7200 Cambridge, Suite 9A, Houston, TX, 77030-4202, USA
| | - Joseph Jankovic
- Parkinson's Disease Center and Movement Disorders Clinic, Department of Neurology, Baylor College of Medicine, 7200 Cambridge, Suite 9A, Houston, TX, 77030-4202, USA.
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Jankovic J, Coffey B, Claassen DO, Jimenez‐Shahed J, Gertz BJ, Garofalo EA, Stamler DA, Wieman M, Savola J, Harary E, Alexander J, Barkay H, Gordon MF. Safety and Efficacy of Long-Term Deutetrabenazine Use in Children and Adolescents with Tics Associated with Tourette Syndrome: An Open-Label Extension Study. Mov Disord Clin Pract 2023; 10:1388-1398. [PMID: 37772282 PMCID: PMC10525047 DOI: 10.1002/mdc3.13849] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2023] [Revised: 06/06/2023] [Accepted: 07/08/2023] [Indexed: 09/30/2023] Open
Abstract
Background Tourette syndrome (TS) is a neurodevelopmental disorder characterized by motor and phonic tics. Objective To assess the safety and efficacy of deutetrabenazine (Teva Neuroscience, Inc, Parsippany, NJ), a vesicular monoamine transporter 2 inhibitor, in children and adolescents with TS. Methods Alternatives for Reducing Tics in TS (ARTISTS) open-label extension (OLE) (NCT03567291) was a 54-week, global, phase 3, open-label extension study of deutetrabenazine (6-48 mg daily) conducted May 28, 2018 to April 3, 2020 with a 2-week randomized withdrawal period. Participants (6-16 years of age) had TS and active tics causing distress or impairment. Safety (primary outcome) was assessed by treatment-emergent adverse events (TEAEs) and clinical laboratory testing. Efficacy was measured by the Yale Global Tic Severity Scale-Total Tic Score (YGTSS-TTS). Results The intent-to-treat population (228 participants; mean age, 12.0 years; 79.8% male; 86.4% white) had a median (range) duration of exposure of 28.4 (0.3-52.9) weeks. Of 227 participants in the safety analysis, 161 (70.9%) reported ≥1 TEAE (exposure-adjusted incidence rate, 2.77/patient-year), of which 95 (41.9%) were treatment related. The most frequently reported TEAEs were headaches, somnolence, nasopharyngitis, weight increases, and anxiety. No additional safety signals were observed. Worsening of YGTSS-TTS after the 2-week randomized withdrawal was not statistically significant (least squares mean difference, -0.4; P = 0.78). Several exploratory measures showed sustained improvement throughout the treatment periods. Conclusions In this long-term, open-label trial, deutetrabenazine was well tolerated with low frequency of TEAEs. There was no significant difference in tics between treatment arms during the 2-week randomized withdrawal period, however, descriptive statistics and comparison with baseline showed a numeric improvement in tics, quality of life, and other measures.
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Affiliation(s)
- Joseph Jankovic
- Parkinson's Disease Center and Movement Disorders Clinic, Department of NeurologyBaylor College of MedicineHoustonTexasUSA
| | - Barbara Coffey
- Department of Psychiatry and Behavioral Sciences, Child and Adolescent PsychiatryUniversity of Miami Miller School of MedicineMiamiFloridaUSA
| | - Daniel O. Claassen
- Department of Neurology, Division of Behavioral and Cognitive NeurologyVanderbilt University Medical CenterNashvilleTennesseeUSA
| | - Joohi Jimenez‐Shahed
- Movement Disorders Neuromodulation & Brain Circuit Therapeutics, Departments of Neurology and NeurosurgeryIcahn School of Medicine at Mount SinaiNew YorkNew YorkUSA
| | | | | | - David A. Stamler
- Teva Branded Pharmaceutical Products R&D, Inc.La JollaCaliforniaUSA
| | - Maria Wieman
- Teva Branded Pharmaceutical Products R&D, Inc.West ChesterPennsylvaniaUSA
| | | | - Eran Harary
- Innovative Medicines, Global Clinical DevelopmentTeva Pharmaceutical Industries Ltd.NetanyaIsrael
| | - Jessica Alexander
- Global Medical AffairsTeva Branded Pharmaceutical Products R&D, Inc.West ChesterPennsylvaniaUSA
| | - Hadas Barkay
- Innovative Medicines, Global Clinical DevelopmentTeva Pharmaceutical Industries Ltd.NetanyaIsrael
| | - Mark Forrest Gordon
- Innovative Medicines, Global Clinical DevelopmentTeva Branded Pharmaceutical Products R&D, Inc.West ChesterPennsylvaniaUSA
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Kroeger MG, Thomsen T, Natteru PA. Adult-Onset Tics After Being Crushed by an Air Conditioner: A Case Report. Cureus 2023; 15:e45741. [PMID: 37876411 PMCID: PMC10591533 DOI: 10.7759/cureus.45741] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/19/2023] [Indexed: 10/26/2023] Open
Abstract
Tics are sudden, repetitive, non-rhythmic movements and/or vocalizations. Generally, tics begin during childhood as a part of Tourette syndrome (TS) and rarely have an onset during adulthood. We describe a 30-year-old male who presented with multiple motor and vocal tics two weeks following a closed head injury with alteration of consciousness as a result of being crushed against the wall by a 4,100-pound air-conditioning unit. He started having motor tics that developed in a rostrocaudal distribution, followed by simple and complex vocal tics. His tics increased in severity over several months following the injury until presentation. He was started on pimozide and received hyperbaric oxygen treatment which improved both motor and vocal tics.
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Affiliation(s)
| | - Teri Thomsen
- Movement Disorders, University of Iowa Hospitals and Clinics, Iowa City, USA
| | - Prashant A Natteru
- Movement Disorders, University of Iowa Hospitals and Clinics, Iowa City, USA
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Abstract
BACKGROUND Previous studies have shown that Tourette syndrome (TS) has an impact on academic achievements. The aim of this study was to investigate the association between the severity of tics and comorbidities and educational outcomes. METHODS From 2005 to 2007, 395 participants were included in a large cohort (314 with TS and 81 controls) and the mean age was 12.60 ± 2.64 years. The cohort was re-examined after 4 to 8 years (median 5.6) where n = 276 participants (223 with TS and 53 controls) were included with a mean age of 18.52 ± 2.73 years. At both time points, severity of tics and the presence and severity of psychiatric comorbidity were assessed. Educational achievements were assessed through structured interviews. RESULTS Children with TS had a lower passing rate at lower secondary and high school compared to healthy controls. More severe vocal tics were associated with fewer passing lower secondary school at a prospective level. At a cross-sectional level, more severe motor tics were associated with fewer passing high school. Tic severity only influenced children with TS without comorbidity. The severity of comorbidity was found to be associated with the educational level at a longitudinal view, but not cross-sectional. CONCLUSION Overall, children with TS had a lower passing rate at lower secondary school and high school compared to healthy controls. We found that this difference was more likely driven by the severity of comorbidities than tic severity. It is important to be aware of academic achievement in children with TS in order to give them the right support and thereby optimize educational opportunities.
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Affiliation(s)
- Josefine Lund
- Department of Pediatrics, Herlev University Hospital, Copenhagen, Denmark
| | - Liv Borch-Johnsen
- Department of Pediatrics, Herlev University Hospital, Copenhagen, Denmark
| | - Camilla Groth
- Department of Pediatrics, Herlev University Hospital, Copenhagen, Denmark
| | - Liselotte Skov
- Department of Pediatrics, Herlev University Hospital, Copenhagen, Denmark
| | - Nanette Mol Debes
- Department of Pediatrics, Herlev University Hospital, Copenhagen, Denmark
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Lin X, Lin F, Chen H, Weng Y, Wen J, Ye Q, Chen C, Cai G. Comparison of efficacy of deep brain stimulation, repeat transcranial magnetic stimulation, and behavioral therapy in Tourette syndrome: A systematic review and Bayesian Network Meta-Analysis. Heliyon 2022; 8:e10952. [PMID: 36281376 PMCID: PMC9587297 DOI: 10.1016/j.heliyon.2022.e10952] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2022] [Revised: 05/19/2022] [Accepted: 09/29/2022] [Indexed: 11/06/2022] Open
Abstract
Background Tourette syndrome (TS) is an incurable neuropsychiatric disorder. Deep brain stimulation (DBS), repeat transcranial magnetic stimulation (rTMS), and behavioral therapy (BT) are all effective treatments. However, the comparison of therapeutic effect of these three therapies is lacking. Methods A systematic literature search was conducted for randomized controlled studies (RCT). A network meta-analysis by R4.04 software according to Bayesian framework were performed. Results were meta-analyzed and network meta-analyzed to evaluate and compare the efficacy of DBS, rTMS and BT in TS patients. Results A total of 18 randomized controlled studies with 661 participants were included. The Yale Global Tic Severity Scale (YGTSS) and the Yale-Brown Obsessive-Compulsive Scale (Y-BOCS) were utilized to evaluate the symptoms of TS. All three treatments improved the tic symptoms of TS [DBS 12.11 (95%CI 7.58-16.65); rTMS 4.96 (95%CI 1.01-10.93); andBT 11.72 (95%CI 10.42-13.01)]; and obsessive-compulsive symptom [DBS 4.9 (95%CI 1.13-8.67); rTMS 5.28 (95%CI 0.21-10.77); and BT 1.61 (95%CI 0.74-2.48)]. The cumulative probability results showed that DBS had the best effect on the improvement of tic symptoms, followed by BT; and rTMS was ranked last. However, in terms of improvement of obsessional symptoms, rTMS was ranked first, DBS was ranked second, and BT was ranked last. In addition, the meta regression analysis of YGTSS in DBS, rTMS and BT has significant difference (P = 0.05). Limitation Due to the lack of quantitative indicators, we did not perform a network meta-analysis of the side effects of the three treatments. Conclusion Our study showed that DBS, rTMS, and BT are effective in TS. DBS causes the best improvement in tic symptoms, and rTMS is the most effective in improving the obsessive-compulsive symptoms.
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Affiliation(s)
- Xiaofeng Lin
- Department of Neurology, Union Hospital, Institute of Neuroscience, Institute of Clinical Neurology, Fujian Medical University, Fuzhou 350001, China,Endocrinology, Fujian Provincial Hospital, Fuzhou 350001, China
| | - Fabin Lin
- Department of Neurology, Union Hospital, Institute of Neuroscience, Institute of Clinical Neurology, Fujian Medical University, Fuzhou 350001, China,Department of Clinical Medicine, Fujian Medical University, Fuzhou 350001, China,Department of Neurosurgery, Fujian Medical University Union Hospital, Fuzhou 350001, China
| | - Huiyun Chen
- Fujian Province Key Laboratory of Environment and Health, School of Public Health, Fujian Medical University, Fujian 35008, China
| | - Yanhong Weng
- Department of Neurology, Union Hospital, Institute of Neuroscience, Institute of Clinical Neurology, Fujian Medical University, Fuzhou 350001, China
| | - Junping Wen
- Endocrinology, Fujian Provincial Hospital, Fuzhou 350001, China,Corresponding author.
| | - Qinyong Ye
- Department of Neurology, Union Hospital, Institute of Neuroscience, Institute of Clinical Neurology, Fujian Medical University, Fuzhou 350001, China
| | - Chunmei Chen
- Department of Neurosurgery, Fujian Medical University Union Hospital, Fuzhou 350001, China,Corresponding author.
| | - Guoen Cai
- Department of Neurology, Union Hospital, Institute of Neuroscience, Institute of Clinical Neurology, Fujian Medical University, Fuzhou 350001, China,Department of Clinical Medicine, Fujian Medical University, Fuzhou 350001, China,Corresponding author.
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Mohammadi MR, Badrfam R, Khaleghi A, Ahmadi N, Hooshyari Z, Zandifar A. Lifetime Prevalence, Predictors and Comorbidities of Tic Disorders: A Population-Based Survey of Children and Adolescents in Iran. Child Psychiatry Hum Dev 2022; 53:1036-1046. [PMID: 33966152 DOI: 10.1007/s10578-021-01186-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/30/2021] [Indexed: 10/21/2022]
Abstract
In this population-based survey, we have evaluated the lifetime prevalence of tic disorders and related sociodemographic factors and comorbidities of them. The data obtained from face-to-face interviews with 29,885 children and adolescents aged 6-18 years. We used the multistage cluster sampling method and a cross-sectional design. Tic disorders and other psychiatric disorders were assessed using the Persian version of the Kiddie Schedule for Affective Disorders and Schizophrenia-Present and Lifetime Version (K-SADS-PL). The lifetime prevalence of tic disorders was 1.5% (95% CI (1.3-1.7%)). The highest prevalence was in the age range of 15-18 years old with 1.9% (95% CI (1.6-2.3%)).57.7% (95% CI 51.8-63.3%) of patients with tic disorders had comorbidity with other psychiatric disorders. Increasing the prevalence of tic disorder with increasing age among Iranian children and adolescents, emphasizes the need to pay more attention to use of pharmacological and non-pharmacological treatments and increase education to families in this regard.
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Affiliation(s)
- Mohammad Reza Mohammadi
- Psychiatry and Psychology Research Center, Roozbeh Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Rahim Badrfam
- Psychiatry and Psychology Research Center, Roozbeh Hospital, Tehran University of Medical Sciences, Tehran, Iran.
| | - Ali Khaleghi
- Psychiatry and Psychology Research Center, Roozbeh Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Nastaran Ahmadi
- Yazd Cardiovascular Research Center, Shahid Sadoughi University of Medical Sciences, Yazd, Iran
| | - Zahra Hooshyari
- Psychiatry and Psychology Research Center, Roozbeh Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Atefeh Zandifar
- Social Determinants of Health Research Center (SDH), Alborz University of Medical Sciences, Karaj, Iran
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Dystonic motor and phonic tics in Tourette syndrome. J Neurol 2022; 269:5312-5318. [PMID: 35567613 DOI: 10.1007/s00415-022-11174-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2022] [Revised: 04/13/2022] [Accepted: 05/02/2022] [Indexed: 10/18/2022]
Abstract
BACKGROUND Dystonic tics differ from clonic tics by their slower and more sustained nature. Dystonic tics are often present in patients with Tourette syndrome (TS) and other tic-disorders. However, their phenomenology and impact on overall impairment have not been extensively studied. MATERIALS AND METHODS We assessed clinical history and tic duration in video-recordings from patients with TS evaluated at our movement disorders clinic. Dystonic tics were defined as those lasting ≥ 1000 ms (ms). RESULTS Of the total of 201 patients with TS, there were 156 with video-recordings suitable for tic duration analysis, of their tics, 57 (36.5%) of whom had dystonic motor tics, including 9 (5.7%) with dystonic phonic tics. Dystonic motor tics had a duration range between 1033 and 15,000 ms and dystonic phonic tics between 1132 and 17,766 ms. Patients with dystonic tics were older 24.4 vs. 16.5 years (P = 0.005) and had an older age at onset 12.9 vs. 7.2 years (P < 0.001), than patients without dystonic tics. The bivariate analysis showed an association between the presence of dystonic tics, greater tic severity and wider body distribution. The multivariate regression analysis showed a statistical association with older age at evaluation (P = 0.001), greater tic severity on video-recordings (P = 0.001) and co-occurrence with complex motor tics (P = 0.020). The presence of dystonic tics increased the risk for being considered for deep brain stimulation therapy, odds ratio: 15.7 (P = 0.002). CONCLUSION Dystonic tics, observed in about a third of patients with TS, are associated with increased severity of TS.
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12
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Medical Cannabis for Gilles de la Tourette Syndrome: An Open-Label Prospective Study. Behav Neurol 2022; 2022:5141773. [PMID: 35310886 PMCID: PMC8926524 DOI: 10.1155/2022/5141773] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2021] [Revised: 01/29/2022] [Accepted: 02/21/2022] [Indexed: 11/18/2022] Open
Abstract
Objectives. Assessing the effectiveness and tolerability of medical cannabis (MC) treatment on Gilles de la Tourette syndrome (GTS) patients. Methods. We report on an open-label, prospective study on the effect of MC on adult GTS patients. MC mode of use was decided by the treating neurologist and the patient. Δ9-Tetrahydrocannabinol (Δ9-THC) and cannabidiol (CBD) content within MC product and monthly dose were titrated during the study. Following treatment initiation, patients were assessed after 4 and 12 weeks for efficacy, tolerability, and side effects. Results. Eighteen patients entered the study. Baseline Yale Global Tic Severity Scale- (YGTSS) Total (range 0-100) was
. Three patients did not reach the end of follow-up period. The most common mode of administration was smoking (80%). Following twelve weeks of treatment, a significant 38% average reduction (
) of YGTSS-Total and a 20% reduction (
) of Premonitory Urge for Tic Scale (PUTS) were observed. Common side effects were dry mouth (66.7%), fatigue (53.3%), and dizziness (46.7%). Three patients suffered from psychiatric side effects including worsening of obsessive compulsive disorder (stopped treatment), panic attack, and anxiety (resolved with treatment modification). Six patients (40%) reported cognitive side effects regarding time perception, visuospatial disorientation, confusion, slow processing speed, and attention. Conclusions. MC treatment demonstrates good efficacy and tolerability in adult GTS patients. Predilection for smoking rather than using oil drops requires further comparative studies to evaluate the efficacy of each. Cognitive and psychiatric side effects have to be monitored and addressed.
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13
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Roessner V, Eichele H, Stern JS, Skov L, Rizzo R, Debes NM, Nagy P, Cavanna AE, Termine C, Ganos C, Münchau A, Szejko N, Cath D, Müller-Vahl KR, Verdellen C, Hartmann A, Rothenberger A, Hoekstra PJ, Plessen KJ. European clinical guidelines for Tourette syndrome and other tic disorders-version 2.0. Part III: pharmacological treatment. Eur Child Adolesc Psychiatry 2022; 31:425-441. [PMID: 34757514 PMCID: PMC8940878 DOI: 10.1007/s00787-021-01899-z] [Citation(s) in RCA: 57] [Impact Index Per Article: 28.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2021] [Accepted: 10/24/2021] [Indexed: 12/18/2022]
Abstract
In 2011, the European Society for the Study of Tourette Syndrome (ESSTS) published the first European guidelines for Tourette Syndrome (TS). We now present an update of the part on pharmacological treatment, based on a review of new literature with special attention to other evidence-based guidelines, meta-analyses, and randomized double-blinded studies. Moreover, our revision took into consideration results of a recent survey on treatment preferences conducted among ESSTS experts. The first preference should be given to psychoeducation and to behavioral approaches, as it strengthens the patients' self-regulatory control and thus his/her autonomy. Because behavioral approaches are not effective, available, or feasible in all patients, in a substantial number of patients pharmacological treatment is indicated, alone or in combination with behavioral therapy. The largest amount of evidence supports the use of dopamine blocking agents, preferably aripiprazole because of a more favorable profile of adverse events than first- and second-generation antipsychotics. Other agents that can be considered include tiapride, risperidone, and especially in case of co-existing attention deficit hyperactivity disorder (ADHD), clonidine and guanfacine. This view is supported by the results of our survey on medication preference among members of ESSTS, in which aripiprazole was indicated as the drug of first choice both in children and adults. In treatment resistant cases, treatment with agents with either a limited evidence base or risk of extrapyramidal adverse effects might be considered, including pimozide, haloperidol, topiramate, cannabis-based agents, and botulinum toxin injections. Overall, treatment of TS should be individualized, and decisions based on the patient's needs and preferences, presence of co-existing conditions, latest scientific findings as well as on the physician's preferences, experience, and local regulatory requirements.
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Affiliation(s)
- Veit Roessner
- Department of Child and Adolescent Psychiatry, TU Dresden, Fetscherstrasse 74, 01307, Dresden, Germany.
| | - Heike Eichele
- Department of Biological and Medical Psychology, Faculty of Psychology, University of Bergen, Bergen, Norway , Regional Resource Center for Autism, ADHD, Tourette Syndrome and Narcolepsy Western Norway, Division of Psychiatry, Haukeland University Hospital, Bergen, Norway
| | - Jeremy S. Stern
- Department of Neurology, St George’s Hospital, St George’s University of London, London, UK
| | - Liselotte Skov
- Paediatric Department, Herlev University Hospital, Herlev, Denmark
| | - Renata Rizzo
- Child and Adolescent Neurology and Psychiatry, Department of Clinical and Experimental Medicine, University of Catania, Catania, Italy
| | | | - Péter Nagy
- Vadaskert Child Psychiatric Hospital and Outpatient Clinic, Budapest, Hungary
| | - Andrea E. Cavanna
- Institute of Clinical Sciences, University of Birmingham, Birmingham, UK
| | - Cristiano Termine
- Child Neuropsychiatry Unit, Department of Medicine and Surgery, University of Insubria, Varese, Italy
| | - Christos Ganos
- Department of Neurology, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Alexander Münchau
- Institute of Systems Motor Science, University of Lübeck, Lübeck, Germany
| | - Natalia Szejko
- Department of Neurology, Medical University of Warsaw, Warsaw, Poland ,Department of Bioethics, Medical University of Warsaw, Warsaw, Poland ,Division of Neurocritical Care and Emergency Neurology, Department of Neurology, Yale School of Medicine, New Haven, CT USA
| | - Danielle Cath
- Department of Psychiatry, University Medical Center Groningen, Rijks Universiteit Groningen, GGZ Drenthe Mental Health Institution, Assen, The Netherlands
| | - Kirsten R. Müller-Vahl
- Clinic of Psychiatry, Social Psychiatry and Psychotherapy, Hannover Medical School, Hannover, Germany
| | - Cara Verdellen
- PsyQ Nijmegen, Parnassia Group, Nijmegen, The Netherlands ,TicXperts, Heteren, The Netherlands
| | - Andreas Hartmann
- Department of Neurology, Sorbonne Université, Pitié-Salpetriere Hospital, Paris, France ,National Reference Center for Tourette Disorder, Pitié Salpetiere Hospital, Paris, France
| | - Aribert Rothenberger
- Clinic for Child and Adolescent Psychiatry and Psychotherapy, University Medical Center Gottingen, Gottingen, Germany
| | - Pieter J. Hoekstra
- Department of Child and Adolescent Psychiatry, University of Groningen, University Medical Center Groningen, Groningen, Netherlands
| | - Kerstin J. Plessen
- Division of Child and Adolescent Psychiatry, Department of Psychiatry, Lausanne University Hospital, University of Lausanne, Lausanne, Switzerland ,Child and Adolescent Mental Health Centre, Mental Health Services, Capital Region of Denmark, Copenhagen, Denmark
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14
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Xi W, Gao X, Zhao H, Luo X, Li J, Tan X, Wang L, Zhao JB, Wang J, Yang G, Liu LY, Wang YY, Peng L, Zou LP, Yang Y. Depicting the composition of gut microbiota in children with tic disorders: an exploratory study. J Child Psychol Psychiatry 2021; 62:1246-1254. [PMID: 33738808 DOI: 10.1111/jcpp.13409] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/30/2021] [Indexed: 12/18/2022]
Abstract
BACKGROUND Symptom improvement in children with tic disorder (TD) following fecal microbiota transplantation led us to investigate the gut microbiota in TD. This exploratory study aims to depict the gut microbial profile in patients with TD and explore the impact of dopamine receptor antagonist (DRA) drugs on the composition and metabolic function of the gut microbiota. METHODS The gut microbiota were profiled in fecal samples of 49 children with TD and 50 matched healthy controls (HC) using shotgun metagenomic sequencing. A random forest (RF) model was constructed using the gut bacterial species to distinguish TD from HC. Associations between clinical metadata and microbial abundance or function were analyzed using MaAsLin2 and Spearman correlation. RESULTS The gut microbiota in children with TD was featured by higher abundances of Bacteroides plebeius and Ruminococcus lactaris (a potential pro-inflammatory taxon) and lower abundances of Prevotella stercorea and Streptococcus lutetiensis compared to HC. The constructed RF model accurately distinguished TD from HC based on the gut microbiota profile, resulting in an AUC of 0.884. Significant correlations were observed between tic symptom severity and the abundances of multiple bacterial species and gut microbiota metabolic functions. Multivariate analysis identified an upregulation of 4-aminobutanoate (GABA) degradation in the gut microbiota associated with TD status. The gut microbiota of DRA-treated TD children showed a distinct gut microbiota compared to the treatment-naïve group, represented by an increase in some potential enteric pathogens such as Escherichia coli, a decline in several species including Akkermansia muciniphila, and alterations in various metabolic functions. CONCLUSIONS Bacterial species promoting inflammatory responses and those modulating neurotransmitters such as GABA may be involved in the pathogenesis of TD. The use of DRA drugs is likely to induce overgrowth of some enteric pathogens and alter the gut microbiota metabolism.
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Affiliation(s)
- Wenjie Xi
- School of Medicine, Nankai University, Tianjin, China.,Department of Gastroenterology and Hepatology, the First Medical Center, Chinese PLA General Hospital, Beijing, China
| | - Xuefeng Gao
- Central Laboratory, Shenzhen Key Laboratory of Precision Medicine for Hematological Malignancies, Shenzhen University General Hospital, Shenzhen, China
| | - Huijun Zhao
- Department of Gastroenterology and Hepatology, the First Medical Center, Chinese PLA General Hospital, Beijing, China
| | - Xi Luo
- Department of Gastroenterology and Hepatology, the First Medical Center, Chinese PLA General Hospital, Beijing, China
| | - Jianfeng Li
- Department of Gastroenterology and Hepatology, the First Medical Center, Chinese PLA General Hospital, Beijing, China
| | - Xinjie Tan
- School of Medicine, Nankai University, Tianjin, China.,Department of Gastroenterology and Hepatology, the First Medical Center, Chinese PLA General Hospital, Beijing, China
| | - Lei Wang
- Department of Gastroenterology and Hepatology, the First Medical Center, Chinese PLA General Hospital, Beijing, China
| | - Jian-Bo Zhao
- Department of Neurology, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China
| | - Jing Wang
- Department of Pediatrics, Chinese PLA General Hospital, Beijing, China
| | - Guang Yang
- Department of Pediatrics, Chinese PLA General Hospital, Beijing, China
| | - Li-Ying Liu
- Department of Pediatrics, Chinese PLA General Hospital, Beijing, China
| | - Yang-Yang Wang
- Department of Pediatrics, Chinese PLA General Hospital, Beijing, China
| | - Lihua Peng
- Department of Gastroenterology and Hepatology, the First Medical Center, Chinese PLA General Hospital, Beijing, China
| | - Li-Ping Zou
- Department of Pediatrics, Chinese PLA General Hospital, Beijing, China.,Center for Brain Disorders Research, Capital Medical University, Beijing Institute for Brain Disorders, Beijing, China
| | - Yunsheng Yang
- School of Medicine, Nankai University, Tianjin, China.,Department of Gastroenterology and Hepatology, the First Medical Center, Chinese PLA General Hospital, Beijing, China
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15
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Jankovic J, Coffey B, Claassen DO, Jimenez-Shahed J, Gertz BJ, Garofalo EA, Stamler DA, Wieman M, Savola JM, Gordon MF, Alexander J, Barkay H, Harary E. Safety and Efficacy of Flexible-Dose Deutetrabenazine in Children and Adolescents With Tourette Syndrome: A Randomized Clinical Trial. JAMA Netw Open 2021; 4:e2128204. [PMID: 34609495 PMCID: PMC8493441 DOI: 10.1001/jamanetworkopen.2021.28204] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] Open
Abstract
IMPORTANCE Tourette syndrome is a neurodevelopmental disorder characterized by childhood onset of motor and phonic tics; treatments for tics are associated with safety concerns. Deutetrabenazine is a selective vesicular monoamine transporter 2 inhibitor approved for the treatment of chorea associated with Huntington disease and tardive dyskinesia in adults. OBJECTIVE To examine whether deutetrabenazine is effective and safe for the treatment of Tourette syndrome in children and adolescents. DESIGN, SETTING, AND PARTICIPANTS This phase 2/3, randomized, double-masked, placebo-controlled, parallel-group, dose-titration study included children and adolescents (aged 6-16 years) with Tourette syndrome with active tics causing distress or impairment (ie, Yale Global Tic Severity Scale-Total Tic Score [YGTSS-TTS] ≥20). The trial was conducted over 12 weeks, with 1 week of follow-up from February 2018 to November 2019 at 36 centers in the United States, Canada, Denmark, Russia, Serbia, and Spain. Data analysis was conducted from January 31 to April 22, 2020. INTERVENTION Patients were randomized (1:1) to receive deutetrabenazine or placebo, titrated during 7 weeks to an optimal level, followed by a 5-week maintenance period. The maximum total daily deutetrabenazine dose was 48 mg/d. MAIN OUTCOMES AND MEASURES The primary efficacy end point was change from baseline to week 12 in YGTSS-TTS. Key secondary end points included changes in Tourette Syndrome-Clinical Global Impression, Tourette Syndrome-Patient Global Impression of Impact, and Child and Adolescent Gilles de la Tourette Syndrome-Quality of Life Activities of Daily Living subscale score. Safety was assessed based on treatment-emergent adverse events, vital signs, questionnaires, and laboratory parameters. RESULTS A total of 119 participants were randomized to deutetrabenazine (59 participants; mean [SD] age, 11.5 [2.5] years; 53 [90%] boys; 49 [83%] White; 3 [5%] Black) and placebo (60 participants; mean [SD] age, 11.5 [2.6] years; 51 [85%] boys; 53 [88%] White; 3 [5%] Black). At week 12, the difference in YGTSS-TTS score was not significant between deutetrabenazine and placebo (least squares mean difference, -0.7; 95% CI, -4.1 to 2.8; P = .69; Cohen d, -0.07). There were no nominally significant differences between groups for key secondary end points. Treatment-emergent adverse events were reported for 38 patients (66%) and 33 patients (56%) receiving deutetrabenazine and placebo, respectively, and were generally mild or moderate. CONCLUSIONS AND RELEVANCE In this study of deutetrabenazine in children and adolescents with Tourette syndrome, the primary efficacy end point was not met. No new safety signals were identified. These results may be informative for future studies of treatments for tics in Tourette syndrome. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT03452943.
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Affiliation(s)
| | - Barbara Coffey
- University of Miami Miller School of Medicine, Miami, Florida
| | | | | | | | | | | | - Maria Wieman
- Teva Pharmaceuticals, West Chester, Pennsylvania
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16
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Coffey B, Jankovic J, Claassen DO, Jimenez-Shahed J, Gertz BJ, Garofalo EA, Stamler DA, Wieman M, Savola JM, Gordon MF, Alexander JK, Barkay H, Harary E. Efficacy and Safety of Fixed-Dose Deutetrabenazine in Children and Adolescents for Tics Associated With Tourette Syndrome: A Randomized Clinical Trial. JAMA Netw Open 2021; 4:e2129397. [PMID: 34661664 PMCID: PMC8524312 DOI: 10.1001/jamanetworkopen.2021.29397] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
IMPORTANCE Tourette syndrome is a neurodevelopmental disorder characterized by childhood onset of motor and phonic tics, often accompanied by behavioral and psychiatric comorbidities. Deutetrabenazine is a vesicular monoamine transporter 2 inhibitor approved in the US for the treatment of chorea associated with Huntington disease and tardive dyskinesia. OBJECTIVE To report results of the ARTISTS 2 (Alternatives for Reducing Tics in Tourette Syndrome 2) study examining deutetrabenazine for treatment of Tourette syndrome. DESIGN, SETTING, AND PARTICIPANTS This phase 3, randomized, double-blind, placebo-controlled, parallel-group, fixed-dose study was conducted over 8 weeks with a 1-week follow-up (June 21, 2018, to December 9, 2019). Children and adolescents aged 6 to 16 years with a diagnosis of Tourette syndrome and active tics causing distress or impairment were enrolled in the study. Children were recruited from 52 sites in 10 countries. Data were analyzed from February 4 to April 22, 2020. INTERVENTIONS Participants were randomized (1:1:1) to low-dose deutetrabenazine (up to 36 mg/d), high-dose deutetrabenazine (up to 48 mg/d), or a matching placebo, which were titrated over 4 weeks to the target dose followed by a 4-week maintenance period. MAIN OUTCOMES AND MEASURES The primary efficacy end point was change from baseline to week 8 in the Yale Global Tic Severity Scale-Total Tic Score (YGTSS-TTS) for high-dose deutetrabenazine. Key secondary end points included changes in YGTSS-TTS for low-dose deutetrabenazine, Tourette Syndrome Clinical Global Impression score, Tourette Syndrome Patient Global Impression of Impact score, and Child and Adolescent Gilles de la Tourette Syndrome-Quality of Life Activities of Daily Living subscale score. Safety assessments included incidence of treatment-emergent adverse events, laboratory parameters, vital signs, and questionnaires. RESULTS The study included 158 children and adolescents (mean [SD] age, 11.7 [2.6] years). A total of 119 participants (75%) were boys; 7 (4%), Asian; 1 (1%), Black; 32 (20%), Hispanic; 4 (3%), Native American; 135 (85%), White; 2 (1%), multiracial; 9 (6%), other race; and 1 (0.6%), of unknown ethnic origin. Fifty-two participants were randomized to the high-dose deutetrabenazine group, 54 to the low-dose deutetrabenazine group, and 52 to the placebo group. Baseline characteristics for participants were similar between groups. Of the total 158 participants, 64 (41%) were aged 6 to 11 years, and 94 (59%) were aged 12 to 16 years at baseline. Mean time since Tourette syndrome diagnosis was 3.3 (2.8) years, and mean baseline YGTSS-TTS was 33.8 (6.6) points. At week 8, the difference in YGTSS-TTS was not significant between the high-dose deutetrabenazine and placebo groups (least-squares mean difference, -0.8 points; 95% CI, -3.9 to 2.3 points; P = .60; Cohen d, -0.11). There were no nominally significant differences between groups for key secondary end points. Treatment-emergent adverse events were reported for 34 participants (65%) treated with high-dose deutetrabenazine, 24 (44%) treated with low-dose deutetrabenazine, and 25 (49%) treated with placebo and were generally mild or moderate. CONCLUSIONS AND RELEVANCE In this fixed-dose randomized clinical trial of deutetrabenazine in children and adolescents with Tourette syndrome, the primary efficacy end point was not met. No new safety signals were identified. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT03571256.
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Affiliation(s)
- Barbara Coffey
- University of Miami Miller School of Medicine, Miami, Florida
| | | | | | | | | | | | | | - Maria Wieman
- Teva Pharmaceuticals, West Chester, Pennsylvania
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17
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Ueda K, Black KJ. A Comprehensive Review of Tic Disorders in Children. J Clin Med 2021; 10:2479. [PMID: 34204991 PMCID: PMC8199885 DOI: 10.3390/jcm10112479] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2021] [Revised: 05/28/2021] [Accepted: 05/31/2021] [Indexed: 01/13/2023] Open
Abstract
Tics are characterized by sudden, rapid, recurrent, nonrhythmic movement or vocalization, and are the most common movement disorders in children. Their onset is usually in childhood and tics often will diminish within one year. However, some of the tics can persist and cause various problems such as social embarrassment, physical discomfort, or emotional impairments, which could interfere with daily activities and school performance. Furthermore, tic disorders are frequently associated with comorbid neuropsychiatric symptoms, which can become more problematic than tic symptoms. Unfortunately, misunderstanding and misconceptions of tic disorders still exist among the general population. Understanding tic disorders and their comorbidities is important to deliver appropriate care to patients with tics. Several studies have been conducted to elucidate the clinical course, epidemiology, and pathophysiology of tics, but they are still not well understood. This article aims to provide an overview about tics and tic disorders, and recent findings on tic disorders including history, definition, diagnosis, epidemiology, etiology, diagnostic approach, comorbidities, treatment and management, and differential diagnosis.
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Affiliation(s)
- Keisuke Ueda
- Department of Neurology, Washington University School of Medicine, St. Louis, MO 63110, USA;
| | - Kevin J. Black
- Department of Neurology, Washington University School of Medicine, St. Louis, MO 63110, USA;
- Department of Psychiatry, Washington University School of Medicine, St. Louis, MO 63110, USA
- Department of Radiology, Washington University School of Medicine, St. Louis, MO 63110, USA
- Department of Neuroscience, Washington University School of Medicine, St. Louis, MO 63110, USA
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18
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Cen SS, Yu J, Wang Q, Deeb W, Wang KL, Shukla AW, Malaty I, Ramirez-Zamora A, Zhang JG, Hu W, Meng FG. Multidisciplinary Telemedicine Care for Tourette Syndrome: Minireview. Front Neurol 2021; 11:573576. [PMID: 33391146 PMCID: PMC7775481 DOI: 10.3389/fneur.2020.573576] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2020] [Accepted: 11/16/2020] [Indexed: 11/24/2022] Open
Abstract
Tourette syndrome (TS) is a childhood-onset, chronic neuropsychiatric disorder characterized by multiple motor and vocal tics. TS poses a considerable burden on both patients and health care providers, leading to a major detriment of educational success, occupation, and interpersonal relationships. A multidisciplinary, specialist-driven management approach is required due to the complexity of TS. However, access to such specialty care is often dramatically limited by the patients' locations and the specialists' geographic clustering in large urban centers. Telemedicine uses electronic information and communication technology to provide and support health care when distance separates participants. Therefore, we conducted this mini-review to describe the latest information on telemedicine in the assessment and management of TS and discuss the potential contributions to care for TS patients with a multidisciplinary approach. We believe that telemedicine could be a revolutionary method in improving medical access to patients with TS.
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Affiliation(s)
- Shan-Shan Cen
- Program in Movement Disorders and Neurorestoration, Department of Neurology, Fixel Institution for Neurological Diseases, University of Florida, Gainesville, FL, United States.,Department of Neurology, Xuanwu Hospital of Capital Medical University, Beijing, China
| | - Jun Yu
- Program in Movement Disorders and Neurorestoration, Department of Neurology, Fixel Institution for Neurological Diseases, University of Florida, Gainesville, FL, United States
| | - Qiao Wang
- Department of Functional Neurosurgery, Beijing Neurosurgical Institute, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Wissam Deeb
- Program in Movement Disorders and Neurorestoration, Department of Neurology, Fixel Institution for Neurological Diseases, University of Florida, Gainesville, FL, United States.,Department of Neurology, University of Massachusetts, Worcester, MA, United States
| | - Kai-Liang Wang
- Department of Functional Neurosurgery, Beijing Neurosurgical Institute, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Aparna Wagle Shukla
- Program in Movement Disorders and Neurorestoration, Department of Neurology, Fixel Institution for Neurological Diseases, University of Florida, Gainesville, FL, United States
| | - Irene Malaty
- Program in Movement Disorders and Neurorestoration, Department of Neurology, Fixel Institution for Neurological Diseases, University of Florida, Gainesville, FL, United States
| | - Adolfo Ramirez-Zamora
- Program in Movement Disorders and Neurorestoration, Department of Neurology, Fixel Institution for Neurological Diseases, University of Florida, Gainesville, FL, United States
| | - Jian-Guo Zhang
- Department of Functional Neurosurgery, Beijing Neurosurgical Institute, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Wei Hu
- Program in Movement Disorders and Neurorestoration, Department of Neurology, Fixel Institution for Neurological Diseases, University of Florida, Gainesville, FL, United States
| | - Fan-Gang Meng
- Department of Functional Neurosurgery, Beijing Neurosurgical Institute, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,Chinese Institute for Brain Research, Beijing, China
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19
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Hull M, Parnes M. Cervical Myelopathy as a Complication of Untreated Motor Tics: A Cautionary Tale. JOURNAL OF PEDIATRIC NEUROLOGY 2020. [DOI: 10.1055/s-0040-1718696] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
AbstractTic disorders are common, affecting approximately 0.5 to 1% of children and adolescents. Treatment is required only when symptoms are bothersome or impairing to the patient, so many do not require intervention. However, on occasion tics may cause significant morbidity and are referred to as “malignant.” These malignant tics have resulted in cervical myelopathy, subdural hematoma secondary to head banging, biting of lips leading to infection of oral muscles, self-inflicted eye injuries leading to blindness, skeletal fractures, compressive neuropathies, and vertebral artery dissection. We describe a case of malignant tic disorder, with accompanying video segment, resulting in cervical myelopathy and quadriparesis in a child. We also discuss aggressive management strategies for neurologists to prevent potential lifelong disability. This case emphasizes that these malignant tics must be treated with all due haste to prevent such complications.
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Affiliation(s)
- Mariam Hull
- Section of Pediatric Neurology and Developmental Neuroscience, Pediatric Movement Disorders Clinic, Blue Bird Circle Clinic for Pediatric Neurology, Texas Children's Hospital
- Baylor College of Medicine, Houston, Texas, United States
| | - Mered Parnes
- Section of Pediatric Neurology and Developmental Neuroscience, Pediatric Movement Disorders Clinic, Blue Bird Circle Clinic for Pediatric Neurology, Texas Children's Hospital
- Baylor College of Medicine, Houston, Texas, United States
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20
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Billnitzer A, Jankovic J. Current Management of Tics and Tourette Syndrome: Behavioral, Pharmacologic, and Surgical Treatments. Neurotherapeutics 2020; 17:1681-1693. [PMID: 32856174 PMCID: PMC7851278 DOI: 10.1007/s13311-020-00914-6] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Tourette syndrome is a heterogeneous neurobehavioral disorder manifested by childhood-onset motor and phonic tics, often accompanied by a variety of behavioral comorbidities, including attention deficit and obsessive compulsive disorder. Treatment must be tailored to the needs and goals of the individual patients and their families. All patients should receive education on the condition and, if possible, engage behavioral therapy targeted towards tics and/or comorbidities. Pharmacological therapies, such as alpha agonists, topiramate, and vesicular monoamine transport type 2 inhibitors, are generally used as first-line therapies in patients with troublesome tics that are not controlled by behavioral therapy or when the latter is not available or accessible. Botulinum toxin injections can be used in patients with bothersome focal tics. Second-line therapy includes antipsychotics, such as fluphenazine, aripiprazole, risperidone, and ziprasidone. These medications are generally efficacious but carry the risk of metabolic syndrome, tardive dyskinesia, and other side effects. Much more research is needed before novel therapies such as cannabis-derived products or transcranial magnetic stimulation can be recommended. There is promise in ongoing clinical trials with D1 receptor antagonist ecopipam and other experimental therapeutics. Patients with tics that are refractory to conventional treatments may be candidates for deep brain stimulation, but further studies are needed to determine the optimal target selection.
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Affiliation(s)
- Andrew Billnitzer
- Parkinson's Disease Center and Movement Disorders Clinic, Department of Neurology, Baylor College of Medicine, 7200 Cambridge, Suite 9A, Houston, TX, 77030-4202, USA
| | - Joseph Jankovic
- Parkinson's Disease Center and Movement Disorders Clinic, Department of Neurology, Baylor College of Medicine, 7200 Cambridge, Suite 9A, Houston, TX, 77030-4202, USA.
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