Dystonia phenomenology and treatment response in migraine

OBJECTIVE

To describe the phenomenology of cervical dystonia (CD) in patients with migraine and the effect of its treatment on migraine frequency.

BACKGROUND

Preliminary studies demonstrate that treatment of CD with botulinum toxin in those with migraine can improve both conditions. However, the phenomenology of CD in the setting of migraine has not been formally described.

METHODS

We conducted a single-center, descriptive, retrospective case series of patients with a verified diagnosis of migraine who were referred to our movement disorder center for evaluation of co-existing, untreated CD. Patient demographics, characteristics of migraine and CD, and effects of cervical onabotulinumtoxinA (BoTNA) injections were recorded and analyzed.

RESULTS

We identified 58 patients with comorbid CD and migraine. The majority were female (51/58 [88%]) and migraine preceded CD in 72% (38/53) of patients by a mean (range) of 16.0 (0-36) years. Nearly all the patients had laterocollis (57/58) and 60% (35/58) had concurrent torticollis. Migraine was found to be both ipsilateral and contralateral to the dystonia in a comparable proportion of patients (11/52 [21%] vs. 15/52 [28%]). There was no significant relationship between migraine frequency and dystonia severity. Treatment of CD with BoTNA reduced migraine frequency in most patients (15/26 [58%] at 3 months and 10/16 [63%] at 12 months).

CONCLUSIONS

In our cohort, migraine often preceded dystonia symptoms and laterocollis was the most described dystonia phenotype. The lateralization and severity/frequency of these two disorders were unrelated, but dystonic movements were a common migraine trigger. We corroborated previous reports that cervical BoTNA injections reduced migraine frequency. Providers treating patients with migraine and neck pain who are not fully responding to typical therapies should screen for possible CD as a confounding factor, which when treated can reduce migraine frequency.

Determining tolerance levels for quality assurance of 3D printed bolus for modulated arc radiotherapy of the nose

Given the existing literature on the subject, there is obviously a need for specific advice on quality assurance (QA) tolerances for departments using or implementing 3D printed bolus for radiotherapy treatments. With a view to providing initial suggested QA tolerances for 3D printed bolus, this study evaluated the dosimetric effects of changes in bolus geometry and density, for a particularly common and challenging clinical situation: specifically, volumetric modulated arc therapy (VMAT) treatment of the nose. Film-based dose verification measurements demonstrated that both the AAA and the AXB algorithms used by the Varian Eclipse treatment planning system (Varian Medical Systems, Palo Alto, USA) were capable of providing sufficiently accurate dose calculations to allow this planning system to be used to evaluate the effects of bolus errors on dose distributions from VMAT treatments of the nose. Thereafter, the AAA and AXB algorithms were used to calculate the dosimetric effects of applying a range of simulated errors to the design of a virtual bolus, to identify QA tolerances that could be used to avoid clinically significant effects from common printing errors. Results were generally consistent, whether the treatment target was superficial and treated with counter-rotating coplanar arcs or more-penetrating and treated with noncoplanar arcs, and whether the dose was calculated using the AAA algorithm or the AXB algorithm. The results of this study suggest the following QA tolerances are advisable, when 3D printed bolus is fabricated for use in photon VMAT treatments of the nose: bolus relative electron density variation within [Formula: see text] (although an action level at [Formula: see text] may be permissible); bolus thickness variation within [Formula: see text] mm (or 0.5 mm variation on opposite sides); and air gap between bolus and skin [Formula: see text] mm. These tolerances should be investigated for validity with respect to other treatment modalities and anatomical sites. This study provides a set of baselines for future comparisons and a useful method for identifying additional or alternative 3D printed bolus QA tolerances.

Can google glass™ technology improve freezing of gait in parkinsonism? A pilot study

PURPOSE

Freezing of gait (FOG) is a disabling phenomenon defined by the periodic absence or reduction of forward progression of the feet despite the intention to walk. We sought to understand whether Google Glass (GG), a lightweight wearable device that provides simultaneous visual-auditory cues, might improve FOG in parkinsonism.

METHODS

Patients with parkinsonism and FOG utilized GG custom-made auditory-visual cue applications: "Walk With Me" and "Unfreeze Me" in a single session intervention. We recorded ambulation time with and without GG under multiple conditions including 25 feet straight walk, dual task of performing serial 7's while straight walking, 180 degree turn after walking 25 feet, and walking through a doorway. FOG and patient experience questionnaires were administered.

RESULTS

Using the GG "Walk With Me" program, improvements were noted in the following: average 25 feet straight walk by 0.32 s (SD 2.12); average dual task of serial 7's and 25 feet straight walk by 1.79 s (SD 2.91); and average walk through doorway by 0.59 s (SD 0.81). Average 180 degree turn after 25 feet walk worsened by 1.89 s (SD 10.66). Using the "Unfreeze Me" program, only the average dual task of serial 7's and 25 feet straight walk improved (better by 0.82 s (SD 3.08 sec). All other tasks had worse performance in terms of speed of completion.

CONCLUSION

This feasibility study provides preliminary data suggesting that some walking tasks may improve with GG, which uses various musical dance programs to provide visual and auditory cueing for patients with FOG.IMPLICATIONS FOR REHABILITATIONFreezing of gait in parkinsonian syndromes is a disabling motor block described by patients as having their feet stuck to the floor leading to difficulty in initiation of gait and increased risk for falls.Wearable assistive devices such as Google Glass™ use visual and auditory cueing that may improve gait pattern in patients with freezing of gait.Augmented reality programs using wearable assistive devices are a home-based therapy, with the potential for reinforcing physical therapy techniques; this is especially meaningful during the COVID-19 pandemic when access to both medical and rehabilitative care has been curtailed.

Left ventricular volumes at baseline and outcome in heart failure patients undergoing cardiac resynchronization therapy

Background

Studies evaluating the relationship between baseline left ventricular (LV) volumes and long-term prognosis in heart failure (HF) patients undergoing cardiac resynchronization therapy (CRT) are lacking.

Purpose

To evaluate the association of LV end-systolic and end-diastolic volumes (ESV and EDV) with long-term prognosis in patients with HF treated with CRT.

Methods

Patients from an ongoing institutional HF registry who received CRT according to contemporary guidelines were included. All patients underwent standard transthoracic echocardiography. LV volumes were measured using the biplane method during off-line analysis. Primary end-point included all-cause mortality, implantation of left ventricular assist device or heart transplantation, which were assessed according to the national death registry and case records.

Results

In total, 1165 patients with feasible LV volume assessment were included (mean age 67±10 years; 74.8% males; 55.3% with non-ischemic aetiology of HF). After a median follow-up of 75 (40; 123) months, the primary end-point occurred in 708 (60.8%) patients. Median baseline LV ESV was 151 (108; 198) ml and EDV was 202 (156; 258) ml. All patients were divided into quartiles according to the baseline EDV and ESV: those with larger volumes were significantly younger, more frequently male and had longer QRS durations (p<0.001). Heart failure aetiology, glomerular filtration rate, quality of life and 6-minute walking test distance did not differ significantly between the groups (p>0.05). To investigate the association between long-term prognosis and baseline LV volumes (EDV and ESV), a Cox proportional hazards model was constructed with variables known to influence the mortality of HF patients (age, gender, aetiology, QRS duration, and estimated glomerular filtration rate). When separately included in a multivariate analysis, baseline LV ESV and LV EDV were both independently associated with the primary end-point (p<0.001). To demonstrate hazard change across the range of LV ESV and EDV as continuous variables, an adjusted (for covariates influencing HF mortality) spline curve was drawn, showing an increased mortality risk when the baseline LV ESV and EDV are larger than 100 ml and 200 ml, respectively (Figure).

Conclusion

LV volumes before CRT implantation are independently associated with prognosis during long-term follow-up. Our findings indicate the importance of taking baseline LV remodelling into consideration to identify patients at high mortality risk after CRT implantation.

Funding Acknowledgement

Type of funding source: Public grant(s) – EU funding. Main funding source(s): The author acknowledges funding received from the European Society of Cardiology in form of an ESC Training Grant

Comorbid neuropsychiatric and autonomic features in REM sleep behavior disorder

Objective

Our aim is to define the extent of comorbidities in order to improve clinical care of patients with idiopathic rapid eye movement sleep behavior disorder (iRBD) utilizing the REM Sleep Behavior Disorder Associations with Parkinson's Disease Study (RAPiDS) cohort.

Methods

Consecutive adult study participants with iRBD confirmed on polysomnogram (PSG) were prospectively recruited from the Weill Cornell Center for Sleep Medicine. Evaluations comprised multiple facets of sleep, neurological, autonomic, and psychiatric function.

Results

Participants evaluated included 30 individuals with iRBD, with mean 1.5 ± 2.3 years from PSG to neuropsychiatric evaluation. Mean age was 59.5 ± 16.0 years at time of PSG, and 6/30 were women. Urinary difficulties were reported in 14/30 (47%): slight 7 (23%), mild 4 (13%), moderate 2 (7%), and severe 1 (3.0%). Ten out of 29 (34%) had abnormal Montreal Cognitive Assessment (MoCA) scores and the mean was 26.5 ± 3.2. The distribution of MoCA scores was significantly associated with urinary problems insofar as the more severe urinary problems were, the lower the MoCA scores (p = 0.04).

Conclusions

In this RAPiDS cohort, we detected an unexpectedly high occurrence of non-motor dysfunction. Our results point to the need for screening patients with iRBD for complaints that are actionable, for example those affecting mood, cognition, urinary function, and bowel function. We propose the term RBD+ to be used to identify such individuals. For the quality of life in patients diagnosed with RBD, a closer look by the clinician should be enacted, with appropriate referrals and workup.

•

Comorbidities in idiopathic rapid eye movement sleep behavior disorder (iRBD) is further defined.

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REM Sleep Behavior Disorder Associations with Parkinson's Disease Study (RAPiDS) cohort

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There was a high occurrence of non-motor dysfunction in this cohort.

•

The need for screening patients with iRBD for complaints that are actionable was demonstrated.

•

We proposed the term “RBD+” to be used to identify such individuals.

Ligand-dependent regulation of retinoic acid receptor alpha in rat testis: in vivo response to depletion and repletion of vitamin A

Male animals are sterile due to testicular degeneration in the absence of retinoic acid (RA) or functional retinoic acid receptor-alpha (RAR alpha). This degeneration can be reversed by injecting retinol, a precursor of RA, into vitamin A-deficient (VAD) rats. To determine the relationship between this ligand-dependent testicular degeneration and regeneration and the expression levels of RAR alpha messenger RNA and protein, testes were depleted and then replenished with retinol in vivo. Results showed that RAR alpha messenger RNA and protein levels declined to VAD amounts after 7 weeks on a VAD diet. This decline was due to decreased RAR alpha levels in early meiotic spermatocytes and the loss of advanced germ cells. Interestingly, the advanced germ cells still contained RAR alpha, but the protein was primarily cytoplasmic instead of nuclear, indicating inactivity as a transcription factor. In VAD testis, RAR alpha levels were low and then increased primarily in Sertoli cells after retinol replenishment. TUNEL analyses showed that most germ cells at the basal aspect of seminiferous tubules were undergoing apoptosis during degeneration. These results indicate that RAR alpha is either down-regulated or inactivated in RA-deficient testis and coincident with that, testes degenerate by apoptosis or selective loss of germ cells.

Cloning and biochemical characterization of LIMK-2, a protein kinase containing two LIM domains

We have isolated human and rat clones of the LIM motif-containing protein kinase, termed LIMK-2. LIMK-2 is related to the neuronally expressed LIM-kinase, whose hemizygous deletion appears to result in cognitive impairment in patients with Williams syndrome. The hallmark of this protein family is the presence of 1 or 2-terminal LIM motifs and an atypical C-terminal protein kinase domain. LIMK-2 mRNA was detected by Northern blot analysis in human tissues, most abundantly in placenta, lung, liver, and pancreas, and also in a variety of cell lines including neuronal, glioblastoma, and mammary carcinoma lines. The LIMK-2 transcript was also induced upon neuroectodermal differentiation of mouse P19 embryonal carcinoma cells. A 65 kDa recombinant LIMK-2 protein was identified in 293 cells stably transfected with a LIMK-2 expression vector. An in vitro kinase assay demonstrates LIMK-2 is autophosphorylated and exhibits serine/threonine kinase activity towards the exogenous substrate MBP. The endogenous 65 kDa LIMK-2 protein was detected in a variety of cell lines, and coprecipitates with a 140 kDa tyrosine phosphorylated protein, but was not itself tyrosine phosphorylated. At the subcellular level, LIMK-2 is localized in both the nucleus and in a Triton X-100 soluble fraction.

Impaired intestinal absorption of vitamin D3 in azotemic rats

Changes in vitamin D metabolism and their effect on calcium and bone metabolism in uremia have been extensively studied. However, the possible effect of uremia on intestinal absorption of vitamin D has not been investigated. We determined the rate of intestinal absorption of vitamin D3 in uremic and normal rats using a well-defined in vivo perfusion technique under identical experimental conditions. The rate of jejunal absorption of vitamin D3 in uremic animals (5.09 +/- 1.87 pmol/100 cm/h) was significantly less (p less than 0.001) than that found in the control animals (11.5 +/- 1.6 pmol/100 cm/h). While the underlying mechanism(s) of the observed reduction in vitamin D absorption in uremia is not known, its recognition adds another dimension to the previously recognized abnormalities of vitamin D metabolism in uremia.